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Modern Applied Statistics With S

Decision makers and the public are in need of information to guide their decisions about how to strengthen health services. This book pulls together available evidence concerning strategies to improve health services delivery in low- and middle-income countries (LMICs), using current methods to assemble a knowledge base and analyze the findings. It describes the results of reviews of such strategies, and how such strategies can produce gains for the poor. This type of information is intended to help decision makers in LMICs learn from others and from their own experiences, so that they may develop and implement strategies that will improve health services in their own setting. The book provides some suggestions for what works and how to improve implementation, as the evidence does not hold up for 'blueprint' planning. It finds that there are many ways that can succeed in improving health services. But not nearly enough attention has been paid to demonstrating how to improve services for the poor. Approaches that ask difficult questions, use information intelligently, and involve key stakeholders and institutions are critical to 'learning and doing' practices that underlie successful implementation of health services.

Improving Health Service Delivery in Developing Countries: From Evidence to Action

Trends in HIV-1 in young adults in south india from 2000 to 2004 : a prevalence study. Commentary

Objectives. We examined the impact of community mobilization (CM) on the empowerment, risk behaviors, and prevalence of HIV and sexually transmitted infection in female sex workers (FSWs) in Karnataka, India.Methods. We conducted behavioral–biological surveys in 2008 and 2011 in 4 districts of Karnataka, India. We defined exposure to CM as low, medium (attended nongovernmental organization meeting or drop-in centre), or high (member of collective or peer group). We used regression analyses to explore whether exposure to CM was associated with the preceding outcomes. Pathway analyses explored the degree to which effects could be attributable to CM.Results. By the final survey, FSWs with high CM exposure were more likely to have been tested for HIV (adjusted odd ratio [AOR] = 25.13; 95% confidence interval [CI] = 13.07, 48.34) and to have used a condom at last sex with occasional clients (AOR = 4.74; 95% CI =  2.17, 10.37), repeat clients (AOR = 4.29; 95% CI = 2.24, 8.20), and regular partners (AOR = 2.80; ...

https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2014.301911

Community Mobilization and Empowerment of Female Sex Workers in Karnataka State, South India: Associations With HIV and Sexually Transmitted Infection Risk

The South-East Asia region, with 11 member states, has an estimated 35 million people living with HIV (PLHIV) More than 99% of PLHIV live in five countries where HIV prevalence among the population aged 15–49 remains low but is between 2% and 29% among key populations Since 2010, the region has made progress to combat the epidemic Mature condom programmes exist in most countries but opioid substitution therapy, and needle and syringe exchange programmes need to be scaled up HIV testing is recommended nationwide in four countries and is prioritised in high prevalence areas or for key populations in the rest In 2015, PLHIV aware of their HIV status ranged from 26% to 89% Antiretroviral therapy (ART) is recommended for all PLHIV in Thailand and Maldives while six countries recommend ART at CD4 cell counts

HIV/AIDS in the South-East Asia region: progress and challenges.

Background: Sustainability is the holy grail of many development projects, yet there is limited evidence about strategies that effectively support transition of programs from donor funding to national governments. The first phase of Avahan, the India AIDS Initiative supported by the Bill and Melinda Gates Foundation (2003-2009), aimed to demonstrate an HIV/AIDS prevention program at scale, primarily targeted at highrisk groups. During the second phase (2009-2013), this large-scale program will be transitioned to its natural owners: the Government of India and local communities. This paper describes the evaluation design for the Avahan transition strategy. Methods/Design: A detailed logic model for the transition was developed. The Avahan transition strategy focuses on three activities: (1) enhancing capacities among communities, non-governmental organizations (NGOs), and government entities, in line with India’s national AIDS control strategy; (2) aligning technical and managerial aspects of Avahan programs with government norms and standards; and (3) promoting and sustaining commitment to services for most-at-risk populations. It is anticipated that programs will then transfer smoothly to government and community ownership, become institutionalized within the government system, and support a sustained HIV/AIDS response. The research design evaluates the implementation and effectiveness of (1) activities undertaken by the program; (2) intermediate effects including the process of institutionalization and the extent to which key Avahan organizational procedures and behaviors are integrated into government systems; and (3) overarching effects namely the impact of the transition process on the sustained delivery of HIV/AIDS prevention services to high-risk groups. Both qualitative and quantitative research approaches are employed so that the evaluation will both assess outcomes and explain why they have occurred. Conclusions: It is unusual for donor-supported projects in low- and middle-income countries to carefully plan transition processes, and prospectively evaluate these. This evaluation is designed so as to both inform decision making throughout the transition process and answer larger questions about the transition and sustainability of donor programs. Keywords: sustainability; evaluation; HIV/AIDS (Published: 14 December 2011) Citation: Global Health Action 2011, 4 : 7360 - DOI: 10.3402/gha.v4i0.7360

https://www.tandfonline.com/doi/pdf/10.3402/gha.v4i0.7360

Sustainability of donor programs: evaluating and informing the transition of a large HIV prevention program in India to local ownership.

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.

/pdf/transitioning-a-large-scale-hiv-aids-prevention-program-to-1iqkbvdh72.pdf

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

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.

/pdf/management-practices-to-support-donor-transition-lessons-545paaap0l.pdf

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

Monitoring and evaluating transition and sustainability of donor-funded programs: Reflections on the Avahan experience.

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.

/pdf/the-avahan-transition-effects-of-transition-readiness-on-2zgr2jpf4p.pdf

Suneeta Singh

Papers

Sustainability of donor programs: evaluating and informing the transition of a large HIV prevention program in India to local ownership.

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

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

Monitoring and evaluating transition and sustainability of donor-funded programs: Reflections on the Avahan experience.

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