摘要：Sustaining important public or grant-funded services after initial funding is terminated is a major public health challenge. We investigated whether tobacco treatment services previously funded within a statewide tobacco control initiative could be sustained after state funding was terminated abruptly. We found that 2 key strategies—redefining the scope of services being offered and creative use of resources—were factors that determined whether some community agencies were able to sustain services at a much higher level than others after funding was discontinued. Understanding these strategies and developing them at a time when program funding is not being threatened is likely to increase program sustainability. PUBLIC FUNDS OFTEN support innovative public health policies and services at the community level, but many times these policies and services are not sustainable when funding is discontinued. Several models have been developed that identify sustainability factors important to funders and community agencies who are considering the long-term institutionalization and sustainability of a program’s services at that program’s inception. 1 – 6 However, if planning efforts are to be better informed, models also are needed to understand the factors most critical to program sustainability at the time when funding is discontinued. In the field of public health, sustainability has been defined as the capacity to maintain program services at a level that will provide ongoing prevention and treatment for a health problem 7 after termination of major financial, managerial, and technical assistance from an external donor. 8 An entire service may be continued under its original or an alternate organizational structure, parts of the service may be continued, or there may be a transfer of some or all services to local service providers. In contrast to the notions of institutionalization and routinization, “sustainability” does not imply either that a service continues within its original organizational structure or that no changes are made in the service. 4 The Massachusetts Tobacco Control Program (MTCP) of the Massachusetts Department of Public Health, launched in 1993, sought to change smoking policies at the community level, to motivate smokers to quit via a statewide media campaign, and to provide tobacco treatment services for smokers who wanted to quit, 9 including community-based individual or group behavioral counseling combined with pharmacological treatment according to the guidelines published by the Public Health Service. 10 , 11 The MTCP also funded “counseling-only” services via a statewide quit line. The MTCP lost 90% of its funding in early to mid-2002 during a nationwide recession, and community-based tobacco treatment programs were defunded beginning in late summer 2002. Immediately after defunding occurred, investigators at the University of Massachusetts Medical School, including ourselves and others on a project team funded by the National Cancer Institute to investigate Massachusetts’ state and community tobacco control initiatives, sought answers to a pair of questions in an effort to explore factors associated with program sustainability: What strategies enhance sustainability of services after public funds have been discontinued, and what variations exist in the ability of organizations to sustain services?
