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 ([5], [6]).

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.

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.

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

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.

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).

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.

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 [10] and his emphasis on empowerment. [35] specify that nearly 53% of the effect of governance on well-being operates through participatory mechanisms.

Community participation constitutes a fundamental pillar. [22] identify benefits such as skills acquisition. However, [4] sharply criticizes forms of “window-dressing participation” that serve to legitimize decisions already made. [32] 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. [7] considers decentralization as an essential lever, while [36] shows that bottom-up strategies improve living conditions. [9] notes, however, a gap between theoretical principles and their concrete application.

Community ownership refers to the process by which beneficiaries progressively consider a project as belonging to them. [18] shows that the absence of real involvement frequently leads to project rejection. [31] observes that ownership varies according to geographical contexts. [13] 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. [1] concludes that sustainability strongly depends on political, economic and social environments. [8] show that consideration of community interests promotes responsible management practices.

The sustainability of health infrastructures refers to the capacity of equipment and services to maintain their functions over the long term. [2] reveal that infrastructures suffer more from maintenance and management problems than from their initial construction. [15] demonstrate that preventive renovation significantly reduces service disruptions.

The literature identifies three fundamental dimensions of sustainability: economic, social and environmental. [11] propose a model attributing 50% weight to the economic dimension, 30% to the environmental dimension and 20% to the social dimension. [16] 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 ([14]). Financial factors are major: [24] speak of “financial illusion” when investments in healthcare financing are not accompanied by adequate investments in infrastructures. [3] emphasize the importance of post-project financing mechanisms. Institutional factors concern the organization of responsibilities and the quality of governance ([12]; [25]). Finally, community factors are receiving increasing attention: [23] demonstrates that stakeholder participation explains nearly 40% of observed sustainability outcomes. [9], [13], and [18] converge toward the same conclusion (Table 1).

Table 1.Determinants of sustainability.

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 [33], perfectly illustrates these mechanisms.

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).

The literature review reveals several major findings. A significant consensus exists regarding the positive role of community participation in project sustainability ([9]; [13]; [18]). Research unanimously emphasizes the multidimensional nature of sustainability ([11]; [16]). Several studies also highlight the importance of local context ([1]).

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 ([17]). 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. [4] 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 ([26]). 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 ([28]).

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.

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.

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.

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.

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.