title: The Avahan Transition: Effects of Transition Readiness on Program Institutionalization and Sustained Outcomes.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
authors.forename: Sachiko
authors.identifier: http://orcid.org/0000-0001-7608-9038
authors.initials: S
authors.lastname: Ozawa
authors.affiliation: Amaltas Consulting Private Limited, New Delhi, India.
authors.forename: Suneeta
authors.initials: S
authors.lastname: Singh
authors.affiliation: Amaltas Consulting Private Limited, New Delhi, India.
authors.forename: Kriti
authors.initials: K
authors.lastname: Singh
authors.affiliation: Amaltas Consulting Private Limited, New Delhi, India.
authors.forename: Vibha
authors.initials: V
authors.lastname: Chhabra
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
authors.forename: Sara
authors.initials: S
authors.lastname: Bennett
mesh_terms: D000328:Adult; D005260:Female; D015658:HIV Infections / Q000517:prevention & control*; D006269:Health Facilities, Proprietary / Q000191:economics; D006801:Humans; D007194:India; D007326:Institutionalization / Q000458:organization & administration*; D008297:Male; D008329:Managed Care Programs / Q000458:organization & administration*; D008875:Middle Aged; D010067:Ownership; D015397:Program Evaluation / Q000191:economics / Q000706:statistics & numerical data*