"From me to HIV": a case study of the community experience of donor transition of health programs.

BACKGROUND: Avahan, a large-scale HIV prevention program in India, transitioned over 130 intervention sites from donor funding and management to government ownership in three rounds. This paper examines the transition experience from the perspective of the communities targeted by these interventions. METHODS: Fifteen qualitative longitudinal case studies were conducted across all three rounds of transition, including 83 in-depth interviews and 45 focus group discussions. Data collection took place between 2010 and 2013 in four states: Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu. RESULTS: We find that communication about transition was difficult at first but improved over time, while issues related to employment of peer educators were challenging throughout the transition. Clinical services were shifted to government providers resulting in mixed experiences depending on the population being targeted. Lastly, the loss of activities aimed at community ownership and mobilization negatively affected the beneficiaries' view of transition. CONCLUSIONS: While some programmatic changes resulted in improvements, additional opportunity costs for beneficiaries may pose barriers to accessing HIV prevention services. Communicating and engaging community stakeholders early on in future such transitions may mitigate negative feelings and lead to more constructive relationships and dialogue.

Management practices to support donor transition: lessons from Avahan, the India AIDS Initiative.

BACKGROUND: During 2009-2012, Avahan, a large donor funded HIV/AIDS prevention program in India was transferred from donor support and operation to government. This transition of approximately 200 targeted interventions (TIs), occurred in three tranches in 2009, 2011 and 2012. This paper reports on the management practices pursued in support of a smooth transition of the program, and addresses the extent to which standard change management practices were employed, and were useful in supporting transition. RESULTS: We conducted structured surveys of a sample of 80 TIs from the 2011 and 2012 rounds of transition. One survey was administered directly before transition and the second survey 12 month after transition. These surveys assessed readiness for transition and practices post-transition. We also conducted 15 case studies of transitioning TIs from all three rounds, and re-visited 4 of these 1-3 years later. RESULTS: Considerable evolution in the nature of relationships between key actors was observed between transition rounds, moving from considerable mistrust and lack of collaboration in 2009 toward a shared vision of transition and mutually respectful relationships between Avahan and government in later transition rounds. Management practices also evolved with the gradual development of clear implementation plans, establishment of the post of "transition manager" at state and national levels, identified budgets to support transition, and a common minimum programme for transition. Staff engagement was important, and was carried out relatively effectively in later rounds. While the change management literature suggests short-term wins are important, this did not appear to be the case for Avahan, instead a difficult first round of transition seemed to signal the seriousness of intentions regarding transition. CONCLUSIONS: In the Avahan case a number of management practices supported a smooth transition these included: an extended and sequenced time frame for transition; co-ownership and planning of transition by both donor and government; detailed transition planning and close attention to program alignment, capacity development and communication; engagement of staff in the transition process; engagement of multiple stakeholders post transition to promote program accountability and provide financial support; signaling by actors in charge of transition that they were committed to specified time frames.

Risk Recognition and Multidisciplinary Approach for Non-Cardiac Surgeries in Paediatric Cardiac Patients: A Retrospective Observational Study.

Background Congenital heart disease (CHD), a structural and functional heart disease, is the commonest birth defect with an incidence of one in 125 live births worldwide with ventricular septal defect (VSD), atrial septal defect (ASD) and tetralogy of Fallot (TOF) constituting the majority. Surgery for associated extra-cardiac anomalies (airway, skeletal, genitourinary, and gastrointestinal) may be required in 30% of these patients. Delivery of uneventful anaesthesia in these children requires an understanding of not only paediatric anaesthesia but also of the pathophysiology of the cardiac lesion and its associated risks. Aims The purpose of this retrospective review was to highlight the approach to the anaesthetic management and outcomes of patients with significant cardiac lesions presenting for non-cardiac surgeries. Material and methods A retrospective chart review of all children with congenital heart disease (CHD) (repaired or unrepaired) who were posted for a non-cardiac surgery in this tertiary care Paediatric super-specialty hospital from January 1, 2018 to December 31, 2019 was carried out. Data on demographics, peri-operative management, and clinical course was retrieved. Inclusion criteria were paediatric patients (0-18 years) of either gender with a diagnosis of a CHD (repaired or unrepaired) undergoing any non-cardiac surgeries (NCS) under anaesthesia/Monitored Anaesthesia Care (MAC). Exclusion criteria were procedures only under local anaesthesia (LA) or a minor procedure done solely under sedation not involving an anaesthesiologist. Results During the study period, we found five eligible cases who underwent a total of six procedures. Five procedures were elective and one was an emergency. Preoperative optimization was conducted by a multidisciplinary team including paediatric surgeons, anaesthesiologists, physicians, and cardio-thoracic surgeons. Anaesthesia was conducted by at least a consultant paediatric anaesthesiologist. Overall all patients tolerated anaesthesia well without any adverse events or complications. All six anaesthetic encounters were safe and uneventful.

The Avahan Transition: Effects of Transition Readiness on Program Institutionalization and Sustained Outcomes.

BACKGROUND: With declines in development assistance for health and growing interest in country ownership, donors are increasingly faced with the task of transitioning health programs to local actors towards a path to sustainability. Yet there is little available guidance on how to measure and evaluate the success of a transition and its subsequent effects. This study assesses the transition of the Avahan HIV/AIDS prevention program in India to investigate how preparations for transition affected continuation of program activities post-transition. METHODS: Two rounds of two surveys were conducted and supplemented by data from government and Avahan Computerized Management Information Systems (CMIS). Exploratory factor analysis was used to develop two measures: 1) transition readiness pre-transition, and 2) institutionalization (i.e. integration of initial program systems into organizational procedures and behaviors) post-transition. A fixed effects model was built to examine changes in key program delivery outcomes over time. An ordinary least square regression was used to assess the relationship between transition readiness and sustainability of service outcomes both directly, and indirectly through institutionalization. RESULTS: Transition readiness data revealed 3 factors (capacity, alignment and communication), on a 15-item scale with adequate internal consistency (alpha 0.73). Institutionalization was modeled as a unidimensional construct, and a 12-item scale demonstrated moderate internal consistency (alpha 0.60). Coverage of key populations and condom distribution were sustained compared to pre-transition levels (p<0.01). Transition readiness, but not institutionalization, predicted sustained outcomes post-transition. Transition readiness did not necessarily lead to institutionalization of key program elements one year after transition. CONCLUSION: Greater preparedness prior to transition is important to achieve better service delivery outcomes post-transition. This paper illustrates a methodology to measure transition readiness pre-transition to identify less ready organizations or program components in advance, improving the likelihood of service sustainability. Further research is needed around the conceptualization and development of measures of institutionalization and its effects on long-term program sustainability.

Transitioning a Large Scale HIV/AIDS Prevention Program to Local Stakeholders: Findings from the Avahan Transition Evaluation.

BACKGROUND: Between 2009-2013 the Bill and Melinda Gates Foundation transitioned its HIV/AIDS prevention initiative in India from being a stand-alone program outside of government, to being fully government funded and implemented. We present an independent prospective evaluation of the transition. METHODS: The evaluation drew upon (1) a structured survey of transition readiness in a sample of 80 targeted HIV prevention programs prior to transition; (2) a structured survey assessing institutionalization of program features in a sample of 70 targeted intervention (TI) programs, one year post-transition; and (3) case studies of 15 TI programs. FINDINGS: Transition was conducted in 3 rounds. While the 2009 transition round was problematic, subsequent rounds were implemented more smoothly. In the 2011 and 2012 transition rounds, Avahan programs were well prepared for transition with the large majority of TI program staff trained for transition, high alignment with government clinical, financial and managerial norms, and strong government commitment to the program. One year post transition there were significant program changes, but these were largely perceived positively. Notable negative changes were: limited flexibility in program management, delays in funding, commodity stock outs, and community member perceptions of a narrowing in program focus. Service coverage outcomes were sustained at least six months post-transition. INTERPRETATION: The study suggests that significant investments in transition preparation contributed to a smooth transition and sustained service coverage. Notwithstanding, there were substantive program changes post-transition. Five key lessons for transition design and implementation are identified.