An overview of civil society organizations’ roles in health project sustainability in Bauchi State, Nigeria

Introduction This study sets out to assess the roles of Civil Society Organizations (CSOs) in post donor health project sustainability in Low and Middle Income Countries (LMICs), the case of the Bauchi State, Nigeria. This study equally investigated the CSOs strategies and roles in health project sustainability. Methods For quantitative data collection, the random, purposive, and convenient sampling techniques were used and 156 respondents selected from relevant organizations operating in Bauchi state, Nigeria, and 15 respondents for Key Informant Interviews (KIIs). A Semi-structured questionnaire was the study instrument, and consent from the participants as well as ethical clearances were duly obtained. Results The study revealed that 87.8% of the respondents indicate un-friendly operational policies, while 88.9% of them identified lack of resources (human, money and machineries) as impediments to project sustainability. Also, 74.3% of the respondents said partnership among key stakeholders and 86.6% of them affirmed that community participation and use of available (local) resources ensure health project sustainability. The study further revealed that CSOs fund health projects, support government efforts and encourage development of project sustainability road map in the state. Conclusion Hence, health project sustainability plan should form part of a project right from inception through the donor period and thereafter. In addition to the above, internal income framework, community involvement, enabling policies and partnership among stakeholders, especially with the host government, should always guide project implementation, because without these in place, project sustainability will remain a mirage.


Introduction
In the Bauchi State of Nigeria, myriads of Civil Society Organizations (CSOs) conduct various roles that improve health system functioning through the implementation of health services, which protect the population against illnesses [1]. The CSOs operate in collaboration with public sectors, usually sponsored by external donors. These In practical terms, most health projects received almost no attention in post-donor era, indicating an obvious lack of concern for project sustainability issues. As such, health project sustainability mechanism is literally the 'life-line‚ of a project. In this study, health project sustainability as a concept denotes project continuity in terms of quality, availability and accessibility at the end of donor intervention. Sustainability refers to the activities that ensure project capacity maintenance after donor support ends, preventing it from being phased out [2,3]. CSOs as key partners in development cooperation conduct activities that ensure project sustainability, these activities include, but not limited to policy support, strategic planning, service implementation, project evaluation etc [4]. Roles of CSOs in health project sustainability are mainly complimentary in support of government efforts [5]. But, the nature of their activities varies, depending on the country and issue in contention. These roles are however not without challenges, in need of support with human and capital resources [6,7] Table 1 shows the distribution of 156 respondents of the study drawn from seven Civil Society Organizations (CSOs) in Bauchi state, Nigeria. The table reveals in proportion the types of organizations involved in the study, and a majority of the respondent (41%) is from the Non-Governmental organizations (NGOs). In Table 2, 51.3% (n=80) of the respondents confirmed that sustainability mechanism is a criterion used by donors to ensure continuity of health programs. Also, 56.4% (n=88) and 25.6% (n=40) agreed and strongly agreed that understanding of a project's pain points ensures sustainability. Also, 42.9% (n=67) of the respondents agreed, while 12.8% disagreed with the statement that sustainable management is grounded on partnership with stakeholders. The findings indicated that 49.4% of the respondents strongly agreed that community participation ensures project sustainability. In a similar manner, 53.8 % (n=84) of the respondents agreed with the statement that uneven work load among staff challenge project sustainability. The results in Table   3indicate that 88.9% of the respondents agreed that sustainability requires sufficient resources to maintain quality, 53.8% supported the claim that sustainability should be tailored towards local needs and available resources. On the assumptions that interventions are required to achieve sustainable outcomes, 51.3% of the respondents agreed. From the study, 16% were undecided on the statement that CSOs dependency on donor funding impede sustainability. The findings revealed that majority of the respondents (87.8%) believed that lack of operation friendly policies hinder program sustainability. Implementation roles: According to the respondents, the CSOs implement services that enhance project sustainability; they monitor service provision, generate data through diseases surveillance and also serve as conduit for community reach.

Results
" They conduct direct service implementation in grassroots' health facilities"(KI 9) "They conduct disease surveillance and reporting activities" (KI 12) "They serve as an entry point to communities by other CSOs" (KI 5) " The support government during outbreak"(KI 1) "They monitor government program implementation"(KI 10). Partnership among the health governance actors; as stipulated by one respondent ensures sustainability. "Sustainability mechanism lies upon partnership between stakeholders" (KI 2) .

Discussion
NGOs emerged as the organization ( stakeholders, which in turn promote project sustainability [12]. However, community participation alone is not enough; community members need to utilize local resources within their disposal as a means of sustaining projects. 78.8 % of the respondents ( Table 2) confirmed that uneven work load among staff challenges project sustainability, which is in conformity with Vamos et al assertion that; uneven workload led to insufficient service provision, delayed job completion, and overtly contribute to workers burn out, thereby hindering sustainability [13]. To address the effect of uneven workload, adequate human capital is a necessity for effective job delivery.
Project sustainability thrived on resources availability for qualitative service provision and maintenance, this claim was in line with La Gargasson et al. [14] findings that insufficient financial resources encountered during introduction of new vaccines found in his study, hampered appropriate cold-chain maintenance and distribution of the vaccine. Also, Rashed et al. [15] cites inadequate resources as a challenge confronted by most health project hindering its sustainability, as such, sufficient resources are central to project maintenance and continuity. Therefore, working with available resources sustains projects beyond donor era; programs tailored on available resources address local needs in sustainable fashion as supported by 86.5% of the respondents ( Humphries et al. [17] which state that infrastructure readiness, and functional project monitoring by advisory committee or board is an important intervention mechanism that maintains sustainability. With respect to CSOs dependency on donor funding impedes sustainability; the claim was accepted by 74.3% of the respondents (Table 3). This means that sustaining financial resources is the upper most priority of achieving project sustainability. Funding Page number not for citation purposes 5 mechanisms of a project is cardinal to a country's health system strengthening pursuit. As such, CSOs projects not targeting a resilient health system, no matter how effective ["successful"] it may look, will always become non-sustainable in the long run.
Therefore, projects should consider alternate financing sources for effective program sustainability, to avoid a pitfall of dependency on donor funding. Concerning the effect of operation friendly policies on program sustainability as reported by 87.8% of the respondents (Table 3), the finding here is in tandem with Ghiron et al [18] assertion that policies that address the need of the marginalized population are needed for sustainable project implementation.
Operation friendly policy includes those that enhance accessibility to information, ease registration, enables freedom of association and expression among others.

Conclusion
CSOs, respond to rising needs of the community they serve, and this provide them the opportunity of conducting activities that promote project sustainability, based on their functional ability. The activities include; information gathering, project monitoring and dialogue with stakeholders on issues bothering project sustainability.

Competing interests
The authors declare no competing interests.