Table 1 DSF tenets, SMI results, and threats to sustainability

Not optimized before implementation (Tenet 1)

✓ Evolving design

Continually improves and ongoing learning (Tenet 2)

Ongoing feedback (Tenet 3)

✓ Evidence-based practices

✓ Sector-wide approach (quality improvements, capacity building, health information systems, knowledge-sharing)

Voltage drop not inevitable (Tenet 4)

✓ Culture of prioritizing healthcare

✓ Policy dialogue

✓ Scale-up of interventions

✓ Possible transient culture of prioritizing healthcare

Fit between program and setting (Tenet 5)

✓ Aligns with national needs

✓ Health systems strengthening

Organizational learning (Tenet 6)

✓ Problem-solving capacity

✓ Personnel turnover

Ongoing stakeholder involvement (Tenet 7)

✓ Partnerships, including regional approach and RBA model

✓ Dissipation of reputational risk and donor-government financial partnerships