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ORIGINAL ARTICLE
Open Access

Monitoring and Evaluating the Transition of Large-Scale Programs in Global Health

James Bao, Daniela C Rodriguez, Ligia Paina, Sachiko Ozawa and Sara Bennett
Global Health: Science and Practice December 2015, 3(4):591-605; https://doi.org/10.9745/GHSP-D-15-00221
James Bao
aUniversity of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
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Daniela C Rodriguez
bJohns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD, USA
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Ligia Paina
bJohns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD, USA
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Sachiko Ozawa
bJohns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD, USA
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Sara Bennett
bJohns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD, USA
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    FIGURE

    Conceptual Framework for Large-Scale Global Health Program Transitions

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    TABLE 1 Transition Domains Explained
    Transition DomainExplanation
    LeadershipHigh-level leaders must accept that the transition process is actually occurring, and health sector leaders need to provide political support for transition and for sustaining the program in its new environment post-transition. Political will and commitment are complex and context-specific and need to be built beyond individual leaders, who may be transient. High-level leadership needs to come from both within the health sector and from non-health sector actors, such as the Ministry of Finance.
    FinancingIn order to ensure financial sustainability post-transition, the program recipient will need to identify and secure new sources of funding as prior sources of financial support are eliminated. Funding will likely come from multiple sources, and, as such, activities may include lobbying to secure funding from new sources and creating and altering financial mechanisms for improved sustainability.
    ProgrammingResponsibilities for program management, such as day-to-day operations, as well as staff management, funding, reporting requirements, monitoring and evaluation, and other administrative tasks, must be transitioned, to the extent that such functions were previously provided by donors. Capacity assessments can help diagnose competencies and signal the amount of capacity building and training required to transition programming.
    Service deliveryIn instances where donors, and not local organizations, have been directly responsible for service delivery, the local program recipient may have to take responsibility for the logistics of service delivery, including human resources, commodity procurement, community outreach, and other elements related to the program services itself.
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    TABLE 2 Transition Types and Implications for Monitoring and Evaluation
    Transition Type
    Gavi in Bosnia-HerzegovinaFP in Latin AmericaAvahan in India
    Transition DescriptionFrom 2002 to 2011, Gavi supported the government of BiH to introduce the Hepatitis B and Hib vaccines, which were delivered through the government health system. BiH passed Gavi’s GNI per capita threshold in 2007, making it ineligible for new support, while Gavi fulfilled existing multiyear commitments. The government of BiH assumed funding and planning responsibilities from Gavi when the funding ended, which was before Gavi developed a graduation policy.Through USAID, the USG supported FP activities in LAC through financial and technical assistance beginning in the 1960s. In the mid-2000s, due to shifting donor priorities and improving FP indicators, countries were systematically “graduated” from FP assistance. Transition plans, typically spanning 2–5 years, were developed where funding and procurement was transitioned to local in-country organizations.2 In 2005, the BMGF committed US$350 million to address the spread of HIV/AIDS in India, focusing on prevention for high-risk populations. The programs, in 6 states, offered services through cascading contracts with international and local NGOs. A planned and phased program transition took place between 2009 and 2012.
    Transition Domain
     LeadershipXXX
     FinancingXXX
     ProgrammingXX
     Service deliveryX
    Key M&E Dimensions⟶ INCREASING COMPLEXITY ⟶
    Sustaining a supportive policy environmentXXX
    Creating financial sustainabilityXXX
    Developing local capacityXXX
    Communicating among all stakeholdersXX
    Aligning programsX
    • Abbreviations: BiH, Bosnia-Herzegovina; BMGF, Bill and Melinda Gates Foundation; FP, family planning; GNI, gross national income; Hib, Haemophilus influenzae type B; LAC, Latin America and the Caribbean; M&E, monitoring and evaluation; USAID, US Agency for International Development; USG, United States Government.

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    TABLE 3 Guiding Questions for Monitoring and Evaluating Global Health Program Transitions and Illustrative Indicators by Transition Domain
    DomainGuiding QuestionsSample Indicators (obtained through quantitative and qualitative inquiry)
    CONTEXTUAL FACTORSTo what extent is the political environment ready for a health program transition?
    • Score on World Bank Governance Index

    • % government budget spent on health

    • % government budget spent on health program of interest

    To what extent is the economic situation ready for a health program transition?
    • GNI per capita

    • USD per capita spent on health

    To what extent is there community support for the health program to transition?
    • Civil society engagement in health program

    To what extent is the severity and scope of the health problem addressed by the program to transition?
    • % geographic coverage of program

    • # deaths or cases averted due to health program

    • % service delivery coverage target addressed by health program

    • # vulnerable populations reached by health program

    PRE-TRANSITIONTo what extent has a core set of transition stakeholders been identified?
    • Donor and program recipient have agreed on key stakeholders for transition, including communities/beneficiaries, civil society, etc.

    • Transition team representing key stakeholders has been established

    To what extent has this core set of transition stakeholders agreed on transition objectives?
    • % key stakeholders who have participated in transition planning events

    To what extent have the transition objectives been planned for, including monitoring and evaluation?
    • Transition plan with M&E has been agreed upon and documented, including transition timelines

    To what extent have budget allocations been made for transition, including M&E of transition?
    • % program recipient transition budget that has been funded

    • M&E transition budget available

    TRANSITION
    LeadershipTo what extent is there clear commitment from the political level for program service delivery over the long term?
    • Program is integrated into national policy or health plans

    • % leaders of affected communities who have been informed of transition plans

    To what extent is there transparent government leadership and management?
    • Guidelines allow exceptions to operating norms based on realities on the ground

    • Clear lines of government accountability exist for the health program

    To what extent have local authorities incorporated the demands of program service delivery into their routine operations?
    • % program activities integrated into local operational plans

    To what extent do local stakeholders believe that the health program is a valuable and effective investment of their time and resources?
    • % program implementers who believe that program recipient has the same or higher level of commitment toward the program as the donor

    FinancingTo what extent does the program recipient have transparent systems to develop and maintain budgets and expenditures?
    • % implementers with an audit of their financial records

    To what extent have financial responsibilities been transferred from donor to program recipient?
    • % donor contribution to health program versus government funding

    • Any recent or planned transitions from other donors working in health area

    To what extent has program recipient secured adequate funding to sustain program?
    • % gap between estimated annual program costs and resources available

    ProgrammingTo what extent is there technical, managerial, and financial capacity within the program recipient to effectively deliver key health program services?
    • % of required supervision sessions that occur

    • % health program recipient staff qualified for financial management

    • % supervisory or managerial position vacant at health program recipient

    To what extent have any shortages in capacity been identified?
    • Capacity needs assessment of program recipient has been conducted

    To what extent are training/capacity-building activities occurring or planned to address gaps in capacity?
    • % training activities completed where capacity shortages were identified

    Service deliveryTo what extent are budgetary and financial systems aligned with those of the program recipients?
    • Overall budget and individual line items are reviewed and adjusted for alignment

    To what extent are reporting structures aligned with those of the program recipients?
    • Reporting frequency of government and program recipients are aligned

    • % reports that are complete upon submission

    To what extent are service delivery or procurement guidelines aligned with those of the program recipients?
    • % health facilities employing government procurement guidelines

    To what extent do the program M&E systems align with the host country’s M&E systems?
    • % donor indicators currently being reported to government health monitoring information system

    INSTITUTIONALIZATIONTo what extent are the key features of the original service maintained in the program post-transition?
    • % key features of the health program that continue post-transition

    Is there a regular budget line and allocation to support implementation of this program?
    • Budgets at national/district/facility level reflect funding necessary to support transitioned program

    • Budgeted funds are allocated and disbursed in a timely fashion.

    To what extent is the program reflected in routine norms and guidelines?
    • Government standard operating procedures reflect modalities of the transitioned program

    Is the health program viewed as a success by key administrators and program implementers?
    • % key program administrators and implementers who view the program as a success

    SUSTAINED SERVICES AND OUTCOMESTo what extent is the program recipient controlling and managing delivery of essential program services?
    • % health program services delivered through program recipient facilities

    How has the quality of program services changed?
    • % clients who are satisfied with the program’s services

    • % program administrators and implementers describing same or improved quality of program services post-transition

    How has the coverage of program services changed after transition?
    • # health facilities providing service before, during, and after the transition

    How have key outcome indicators and key health outcome indicators relating to the health program changed?
    • Prevalence and incidence of health condition in question

    • Coverage of vulnerable populations reached by the health program

    How was the transition experience overall?
    • % program administrators and implementers who suggest the overall program changed significantly as compared with pre-transition

    • % program administrators and implementers describing the transition as smooth

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Global Health: Science and Practice: 3 (4)
Global Health: Science and Practice
Vol. 3, No. 4
December 01, 2015
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Monitoring and Evaluating the Transition of Large-Scale Programs in Global Health
James Bao, Daniela C Rodriguez, Ligia Paina, Sachiko Ozawa, Sara Bennett
Global Health: Science and Practice Dec 2015, 3 (4) 591-605; DOI: 10.9745/GHSP-D-15-00221

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Monitoring and Evaluating the Transition of Large-Scale Programs in Global Health
James Bao, Daniela C Rodriguez, Ligia Paina, Sachiko Ozawa, Sara Bennett
Global Health: Science and Practice Dec 2015, 3 (4) 591-605; DOI: 10.9745/GHSP-D-15-00221
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