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Background  Uganda implemented a national ART scale-up program at public and private health facilities between 2004 and 2009. Little is known about  how  and  why  some health facilities have sustained ART programs and why others have not sustained these interventions. The objective of the study was to identify facilitators and barriers to the long-term sustainability of ART programs at six health facilities in Uganda which received donor support to commence ART between 2004 and 2009.    Methods  A case-study approach was adopted. Six health facilities were purposively selected for in-depth study from a national sample of 195 health facilities across Uganda which participated in an earlier study phase. The six health facilities were placed in three categories of sustainability; High Sustainers (2), Low Sustainers (2) and Non- Sustainers (2). Semi-structured interviews with ART Clinic managers ( N  = 18) were conducted. Questionnaire data were analyzed ( N  = 12). Document review augmented respondent data. Based on the data generated, across-case comparative analyses were performed. Data were collected between February and June 2015.    Results  Several distinguishing features were found between High Sustainers, and Low and Non-Sustainers’ ART program characteristics. High Sustainers had larger ART programs with higher staffing and patient volumes, a broader ‘menu’ of ART services and more stable program leadership compared to the other cases.  High Sustainers associated sustained ART programs with multiple funding streams, robust ART program evaluation systems and having internal and external program champions.  Low and Non Sustainers reported similar barriers of shortage and attrition of ART-proficient staff, low capacity for ART program reporting, irregular and insufficient supply of ARV drugs and a lack of alignment between ART scale-up and their for-profit orientation in three of the cases.    Conclusions  We found that ART program sustainability was embedded in a complex system involving dynamic interactions between internal (program champion, staffing strength, M &E systems, goal clarity) and external drivers (donors, ARVs supply chain, patient demand). ART program sustainability contexts were distinguished by the size of health facility and ownership-type. The study’s implications for health systems strengthening in resource-limited countries are discussed.

Accounting for variations in ART program sustainability outcomes in health facilities in Uganda: a comparative case study analysis