Abstract

The sustainability of health infrastructures constitutes a major challenge for health systems in developing countries. Despite significant investments, many facilities experience premature degradation or abandonment. Community governance is increasingly presented as a mechanism capable of strengthening local ownership and project sustainability. This systematic review aims to analyze the scientific knowledge relating to the articulation between community governance and sustainability of health infrastructures, in order to identify convergences, divergences and existing gaps, and to formulate a research problem adapted to the Burundian context. A systematic literature search was conducted between April and June 2026 in the following databases: Google Scholar, Scopus, Web of Science, Cairn.info, Persée, PubMed and ScienceDirect. The selection, guided by the PRISMA method, resulted in the analysis of 43 references, supplemented by institutional reports from WHO and UNICEF. The literature reveals a consensus on the positive role of community participation in project ownership and sustainability. Sustainability appears as a multidimensional concept (economic, social, environmental, institutional and community). Community factors explain nearly 40% of observed outcomes in terms of sustainability. However, the precise mechanisms of this influence remain insufficiently documented, and studies specific to Burundi are almost non-existent. The article proposes a conceptual theoretical model of influence mechanisms, as well as operational recommendations for Burundian decision-makers. This review highlights the need for empirical validation of the relationship between community governance and sustainability of health infrastructures in specific contexts, particularly in Burundi. A field survey is essential to identify local influence mechanisms and inform decision-makers.

Keywords

Parental Absence, Parental Abandonment, Child Vulnerabilities, School Dropout, Community Governance, Community Participation, Sustainability, Health Infrastructure, Burundi, Developing Countries

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1. Introduction

The sustainability of health infrastructures constitutes one of the major challenges facing health systems in developing countries today. Despite considerable investments made by states, technical and financial partners, and non-governmental organizations, many health facilities experience premature degradation, low functionality, or progressive abandonment just a few years after their commissioning (Alabi et al., 2026). This situation compromises not only sustainable access to healthcare, but also the achievement of the Sustainable Development Goals (SDGs), notably SDG 3 on health and well-being and SDG 6 on water and sanitation.

In several African countries, the problem of sustainability of health infrastructures goes beyond purely technical and financial considerations. Recent research shows that governance is now a determining factor in the sustainability of public and community investments (Ketchoua et al., 2026). More specifically, community governance appears as a mechanism capable of strengthening local ownership, beneficiary accountability, mobilization of local resources, and continuity of health services (Seck, 2024; Koriko, 2025).

The concept of community governance is part of the evolution of development paradigms that progressively favor participatory approaches over traditional centralized models (Freire, 1970). This orientation is based on the idea that local communities should no longer be considered as simple beneficiaries of development projects, but as actors capable of participating in the design, implementation, management and evaluation of infrastructures intended for them.

Recent scientific literature thus highlights the importance of community participation, local ownership, transparency, collective accountability, and collaboration between different stakeholders to guarantee the sustainability of development projects (Yang et al., 2025). However, observed results remain contrasting according to institutional, sociocultural, economic and political contexts (Akplogan, 2024).

Burundi presents institutional, sociocultural and economic characteristics that may influence the relationship between community governance and sustainability of health infrastructures. Institutionally, the country has undertaken decentralization reforms since 2005, but their implementation remains partial, with limited transfers of competencies and resources. Socioculturally, traditional community structures, such as the bashingantahe (councils of elders), play an important role in local governance and could constitute levers for community participation, while also carrying risks of hierarchies excluding certain categories (women, youth) (Matabaro & Ildephonse, 2024; Sindayigaya, 2025). Economically, Burundi is ranked among the poorest countries in the world, with a highly constrained health budget, making the sustainability of infrastructures particularly difficult. These specificities justify in-depth empirical investigation (Ntampera & Sindayigaya, 2026b, 2026a; Sindayigaya, 2023).

This literature review aims to analyze the main scientific knowledge relating to community governance and sustainability of health infrastructures in order to identify convergences, divergences and existing gaps. It will then allow the development of a research problem as well as investigation paths that will guide a future empirical study devoted to Burundi.

2. Methods and Methodology

This literature review was conducted according to a systematic and transparent approach, in accordance with good scientific research practices (Mansuri & Rao, 2013). The PRISMA method (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was used to guide the selection process.

2.1. Literature Search Strategy

The literature search was conducted between April and June 2026 using the main scientific databases: Google Scholar (broad coverage), Scopus and Web of Science (peer-reviewed articles), Cairn.info and Persée (French-language literature), PubMed and ScienceDirect (public health and sanitary engineering). OpenEdition and ResearchGate were also consulted for access to theses and research reports.

A complementary search was conducted on the institutional websites of international organizations (WHO, UNICEF, World Bank) as well as on development cooperation agency platforms. Specific searches were also conducted on the websites of the Burundi National Institute of Statistics (INSBU) and the Burundi Ministry of Public Health (Ciza & Sindayigaya, 2023a, 2023b).

2.2. Keywords and Search Equations

Searches were conducted using a combination of keywords in French and English, using Boolean operators (AND, OR, NOT). The main terms used were: community governance, community participation, local ownership, infrastructure sustainability, health infrastructure, project sustainability, local development, Burundi, developing countries, and health services. Combinations such as (“community governance” OR “community participation”) AND (“health infrastructure” OR “healthcare facilities”) AND (“sustainability” OR “durability”) were used.

2.3. Inclusion and Exclusion Criteria

Documents published between 2015 and 2026 were included, with particular attention to the most recent works without excluding earlier foundational references. Empirical studies, systematic reviews, meta-analyses, doctoral theses and institutional reports were prioritized, as were works focusing on developing countries with a focus on Sub-Saharan Africa and Francophone contexts (Mperejimana & Sindayigaya, 2023). Only documents in French or English were retained. Excluded were non-scientific documents, studies focused exclusively on high-income countries without comparative perspective, and documents in languages other than French or English.

2.4. Selection Process and Analysis (PRISMA Flow Diagram)

The selection process followed PRISMA recommendations. The diagram below summarizes the different stages: PRISMA Flow Diagram

Identification

├── Records identified through database searching (n = 172)

│ ├── Google Scholar: 45

│ ├── Scopus: 32

│ ├── Web of Science: 28

│ ├── Cairn.info: 18

│ ├── Persée: 12

│ ├── PubMed: 22

│ └── ScienceDirect: 15

├── Additional records identified through grey literature (n = 8)

│ ├── WHO/UNICEF: 3

│ ├── World Bank: 2

│ ├── INSBU: 1

│ └── Burundi Ministry of Health: 2

├── Total records before duplicates removed (n = 180)

├── Duplicates removed (n = 35)

└── Records after duplicates removed (n = 145)

Screening ├── Titles and abstracts screened (60 excluded)

│ ├── Off-topic: 38

│ ├── High-income countries: 12

│ ├── Non-scientific: 6

│ └── Language: 4

└── Eligible after screening (n = 85)

Inclusion ├── Full-text assessed (42 excluded)

│ ├── Concepts not addressed: 22

│ ├── Methodological quality: 12

│ └── Too old: 8

└── Studies included (n = 43)

├── Journal articles: 17

├── Doctoral theses: 14

├── Institutional reports: 8

├── Book chapters: 2

└── Other: 2

2.5. Grey Literature Sources Mobilized

Beyond academic publications, this review draws on institutional grey literature sources, notably WHO/UNICEF 2025 reports. The Global Progress Report 2025 documents the extent of deficits in essential services. The Country Progress Tracker shows that only 17% of countries have dedicated resources to maintain infrastructures over the long term. Finally, the WASH FIT Global Report analyzes the technical and institutional challenges of sustaining health infrastructures in low-income countries.

2.6. Quality Assessment of Included Studies

The methodological quality of included studies was assessed using a simplified grid adapted from CASP (Critical Appraisal Skills Programme) criteria for qualitative studies and JBI (Joanna Briggs Institute) criteria for quantitative studies. The criteria retained were: (1) clarity of objectives, (2) adequacy of design, (3) sample size, (4) validity of instruments, (5) data triangulation, (6) consideration of context, and (7) generalizability. Each study received an overall rating: ★ (low), ★★ (moderate), ★★★ (high).

2.7. Limitations of the Review

Some relevant works may have been missed due to language barriers or non-indexing in the consulted databases. Furthermore, the rarity of studies specifically devoted to Burundi constrained the analysis to rely mainly on works conducted in comparable contexts.

3. Main Results Analysis

3.1. Conceptual Foundations of Community Governance

The concept of community governance originates from participatory development theories that emerged in the 1980s in reaction to top-down approaches. The foundational works advocated for a reversal of priorities in favor of the most marginalized populations. This perspective was reinforced by Freire (1970) and his emphasis on empowerment. Yang, Hu and Deng (2025) specify that nearly 53% of the effect of governance on well-being operates through participatory mechanisms.

Community participation constitutes a fundamental pillar. Osore, Hassan and Morara (2022) identify benefits such as skills acquisition. However, Chemaou (2023) sharply criticizes forms of “window-dressing participation” that serve to legitimize decisions already made. Syamsiyah and colleagues (2025) confirm that communities participate more in planning than in the effective sharing of benefits, revealing imbalances affecting sustainability.

The literature also establishes a close link between community governance and decentralization. Condé (2021) considers decentralization as an essential lever, while Zhour (2023) shows that bottom-up strategies improve living conditions. Faye (2024) notes, however, a gap between theoretical principles and their concrete application.

3.2. Community Governance and Project Ownership

Community ownership refers to the process by which beneficiaries progressively consider a project as belonging to them. Monnelus (2024) shows that the absence of real involvement frequently leads to project rejection. Souleymane (2022) observes that ownership varies according to geographical contexts. Koriko (2025) affirms that beneficiary involvement and empowerment are the fundamental conditions for sustainability of community projects.

Contextual factors are also determining the role of local leadership and geographical characteristics. Akplogan (2024) concludes that sustainability strongly depends on political, economic and social environments. Etukakpan and colleagues (2024) show that consideration of community interests promotes responsible management practices.

3.3. Sustainability of Health Infrastructures: Determinants and Evaluation Models

The sustainability of health infrastructures refers to the capacity of equipment and services to maintain their functions over the long term. Alabi and colleagues (2026) reveal that infrastructures suffer more from maintenance and management problems than from their initial construction. Manyele and Anicetus (2025) demonstrate that preventive renovation significantly reduces service disruptions.

The literature identifies three fundamental dimensions of sustainability: economic, social and environmental. Hosny, Ibrahim and Eldars (2022) propose a model attributing 50% weight to the economic dimension, 30% to the environmental dimension and 20% to the social dimension. Más-López and colleagues (2023) develop a synthetic indicator integrating these three dimensions. However, several authors recommend adding institutional, technological and community dimensions to better account for realities in developing countries.

The determinants of sustainability fall into several interdependent categories. Technical factors concern design quality and maintenance mechanisms (Kouassi et al., 2023). Financial factors are major: Poulin et al. (2024) speak of “financial illusion” when investments in healthcare financing are not accompanied by adequate investments in infrastructures. Bah (2021) and Ototo (2025) emphasize the importance of post-project financing mechanisms. Institutional factors concern the organization of responsibilities and the quality of governance (Ketchoua et al., 2026; Prabowo et al., 2023). Finally, community factors are receiving increasing attention: Ototo (2025) demonstrates that stakeholder participation explains nearly 40% of observed sustainability outcomes. Seck (2024), Koriko (2025), and Monnelus (2024) converge toward the same conclusion (Table 1).

Table 1. Determinants of sustainability.

3.4. Articulation between Community Governance and Sustainability: Conceptual Theoretical Model

The cross-sectional analysis of reviewed studies allows proposing a **conceptual theoretical model** illustrating the mechanisms by which community governance influences the sustainability of health infrastructures (Figure 1).

Figure 1. Conceptual model of influence mechanisms.

This model highlights four main mechanisms:

1. Ownership promotes regular maintenance and collective vigilance.

2. Transparency and social control reduce embezzlement and improve management.

3. Mobilization of local resources (contributions, in-kind contributions, labor) complements external financing.

4. Early identification of problems enables solutions adapted to local realities.

The experience of Dschang, studied by Temgoua and colleagues (2019), perfectly illustrates these mechanisms.

3.5. Synthesis of Reviewed Studies and Quality Assessment (Table 2)

Table 2. Main reviewed studies, strengths, limitations and methodological quality.

★ = low; ★★ = moderate; ★★★ = high (based on clarity of objectives, adequacy of design, sample size, validity of instruments, triangulation, consideration of context, generalizability).

4. Discussion

4.1. Critical Synthesis of Results and Consideration of Counter-Examples

The literature review reveals several major findings. A significant consensus exists regarding the positive role of community participation in project sustainability (Seck, 2024; Koriko, 2025; Monnelus, 2024). Research unanimously emphasizes the multidimensional nature of sustainability (Hosny et al., 2022; Más-López et al., 2023). Several studies also highlight the importance of local context (Akplogan, 2024).

However, a critical analysis reveals notable methodological limitations. Most research relies on small samples, single case studies without comparison with control situations, and evaluations often conducted by the implementing organizations themselves (Matabaro & Ildephonse, 2024). These potential biases call for caution in generalizing results, particularly for the Burundian context where no empirical validation exists to date.

Counter-examples and limitations of community participation: Although the majority of studies emphasize the benefits of participation, some research warns against its perverse effects. Chemaou (2023) denounces “window-dressing participation” that can generate lasting mistrust. Several studies (not included in the review for criteria reasons) show that participation can be captured by local elites, reinforce existing inequalities, or provoke “participatory fatigue” when communities are repeatedly solicited without tangible results. Furthermore, participation requires time and energy that the poorest populations cannot always afford, which can increase inequalities in representation (Sabiraguha et al., 2023). Finally, in contexts of conflict or high political instability, participatory mechanisms can be instrumentalized or become sources of tension. These limits should be explored in the future empirical study in Burundi (Sindayigaya, 2020, 2025).

Success conditions for community governance: The literature suggests that community participation is only effective if several conditions are met: (1) real delegation of power (not mere consultation), (2) capacity building of local actors, (3) consideration of local power dynamics (gender, age, ethnicity), (4) commitment of local and national authorities, and (5) continuous evaluation of participatory mechanisms.

Furthermore, most research separately analyzes community governance or infrastructure sustainability without explicitly studying their interactions. Very few studies specifically address health infrastructures in the Francophone African context. Research devoted to Burundi remains extremely rare. Finally, the precise mechanisms of influence remain insufficiently documented.

4.2. Research Problem and Hypotheses Specific to Burundi

The literature demonstrates that community participation generally promotes the sustainability of development projects. It also shows that the sustainability of health infrastructures depends on multiple technical, financial, institutional and social factors.

Despite investments made in health infrastructures in Burundi, several facilities experience difficulties in maintenance, management and functioning after commissioning. This situation raises the fundamental question: “To what extent does community governance influence the sustainability of health infrastructures in Burundi?”

Several specific questions stem from this main question:

• How does community governance concretely contribute to the sustainability of health infrastructures in low-income countries?

• Which community mechanisms most strongly influence the sustainability of health infrastructures?

• How do the characteristics of the Burundian context modify this relationship?

Hypotheses specific to Burundi:

• The presence of bashingantahe as mediators could facilitate participation, but also create hierarchies that exclude certain categories (women, youth). This ambivalence should be explored empirically.

• The weakness of fiscal decentralization could limit communities’ capacity to mobilize resources, even if the willingness to participate is strong.

• Inter-community conflicts or political instability could weaken the trust necessary for participatory mechanisms.

4.3. Research Avenues for a Future Empirical Study and Operational Indicators

The findings of this review allow sketching several investigation avenues for future field research in Burundi. These avenues could be validated or invalidated by an empirical survey mobilizing mixed methods (quantitative and qualitative):

1. Avenue 1: Active community participation in planning, implementation, monitoring and management of health infrastructures promotes their ownership and contributes positively to their sustainability.

2. Avenue 2: Transparency, accountability, collaboration between stakeholders and mobilization of community resources strengthen the sustainability of health infrastructures.

3. Avenue 3: Institutional, socio-economic and sociocultural factors influence the relationship between community governance and sustainability of health infrastructures in Burundi.

4.4. Operational Recommendations for Burundian Decision-Makers

Based on the findings of this review, several operational recommendations can be formulated for Burundian decision-makers (Ministry of Public Health, local administrations, technical and financial partners):

4.4.1. Recommendation 1: Create Mixed State-Community Management Committees

-Establish, for each health infrastructure, a management committee composed of representatives from the ministry of health, local authorities and elected representatives of beneficiary communities (ensuring representation of women and youth).

-This committee would be responsible for planning, maintenance monitoring and performance evaluation of the infrastructure.

4.4.2. Recommendation 2: Establish Participatory Maintenance Funds

-Institute a sustainable financing mechanism combining contributions from the state, local authorities and communities (voluntary contributions, micro-contributions, income-generating activities).

-These funds would be managed transparently, with social control exercised by user committees.

4.4.3. Recommendation 3: Develop Community Monitoring Indicators

-Develop with communities a set of simple and understandable indicators (e.g., equipment condition, availability of medicines, user satisfaction, cleanliness of premises) to ensure regular sustainability monitoring.

-These indicators could be collected quarterly by user committees.

4.4.4. Recommendation 4: Strengthen Capacities of Local Actors

-Organize continuous training for management committee members on basic maintenance, financial management, resource mobilization and conflict resolution.

-Involve bashingantahe (councils of elders) as facilitators and mediators in participatory processes, while ensuring inclusion of marginalized groups.

4.4.5. Recommendation 5: Integrate Community Governance into Project Specifications

-Calls for tenders for the construction or rehabilitation of health infrastructures should mandatorily include a “community governance” component that is funded and evaluated, and not treated as an optional addition.

4.4.6. Recommendation 6: Establish a Participatory Monitoring and Evaluation Mechanism

-Implement an annual sustainability evaluation of infrastructures involving communities, local authorities and technical partners, with public feedback sessions.

4.5. Theoretical Implications and Perspectives

Theoretically, the article proposes an original conceptual model of the mechanisms by which community governance acts on sustainability. This model could be empirically tested and enriched by future research. It constitutes a contribution to the theory of participatory governance applied to health infrastructures.

Practically, community governance mechanisms should be integrated from the design stage of health infrastructure projects, and not as a late addition. Politically, strengthening local capacities and effective decentralization of resources constitute indispensable prerequisites.

For research, the identified avenues open the way to an empirical study that could inform decision-makers on the most relevant leverage points. A field survey in Burundi would allow validating or invalidating these avenues and identifying mechanisms specific to this context.

5. Conclusion

This systematic literature review has analyzed current knowledge relating to the articulation between community governance and sustainability of health infrastructures. The results show a scientific consensus on the importance of community participation as a determining factor in project sustainability, but also highlight the absence of studies specific to the Burundian context and the insufficient documentation of precise influence mechanisms.

The proposed conceptual theoretical model identifies four key mechanisms by which community governance acts on sustainability: ownership, transparency/social control, mobilization of local resources, and early identification of problems. This model could serve as an analytical framework for a future empirical study.

The research problem and investigation avenues formulated, as well as the operational recommendations for decision-makers, open the way to an empirical survey that will fill the identified gaps. A field study in Burundi, mobilizing mixed methods (quantitative and qualitative), appears as the logical continuation of this work. It will contribute not only to the advancement of scientific knowledge, but also to informing Burundian decision-makers on the most relevant leverage points to guarantee the sustainability of health infrastructures in a context of limited resources.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References