Bill & Melinda Gates Foundation

Avahan's Transition: A Conversation with Sema Sgaier

July 09, 2013

Like other emerging economies, India faces the prospect of dramatic reductions in foreign aid, a factor that could impact health and development programs originally created with donor funding. This week, Health Affairs published an article on how India has worked in partnership with the Gates Foundation to take over the funding and management of Avahan, an innovative HIV prevention initiative created in 2003 with foundation support. We talked with lead author Sema Sgaier about what it takes to ensure a successful transition to country ownership. To read the full article, click here. It will be available to Impatient Optimists readers for the next 30 days.

Impatient Optimists: Your article focuses on Avahan and HIV prevention, but it's really talking about what it takes to achieve country ownership of health and development programs. Tell us why this issue is so important.

Sema Sgaier: Over the past decade, donor investments in global health have increased, producing impressive results in terms of lives saved and infections prevented. At the same time, the economies of many developing countries have grown by leaps and bounds. This growth has led many donors to scale back their aid commitments to the world’s emerging “middle-income” countries.

But there is still a strong need to ensure that high-performing, donor-supported programs have the resources they need to continue. The current global economic crisis, which has tightened most donor budgets, has made this an urgent challenge.

In our paper, we describe how the government of India has worked closely with the foundation to ensure the successful transition of Avahan's HIV prevention programs. When  Avahan was launched in six Indian states in 2003, the foundation was the primary funder, and it managed day-to-day operations. Today, the government of India has taken over the lead in financing and implementing Avahan. We learned many lessons from this transition that we wanted to share with other donors and countries.

IO: What did you learn?

SS: The Health Affairs article outlines the framework that we used to guide the transition. For me, there have been a two key lessons. The first is that the Government of India and the foundation recognized early on that we needed to design and build the program so that it could be effectively transitioned to India over time.  Transition is something that is rarely built into program design. It’s often considered only toward the end of a program, when it’s often too late. Significant resources were invested in Avahan’s transition from the beginning.

 When Avahan was launched in six Indian states in 2003, the foundation was the primary funder, and it managed day-to-day operations. Today, the government of India has taken over the lead in financing and implementing Avahan.

The second key takeaway is the importance of partnership. The foundation worked under the leadership and guidance of the government of India to base the program's structure on existing national and state-level health systems. This made it easier for India to take the program “in house."

The government’s full buy-in and leadership was essential. Transitions must be collaborative, and they depend on the goodwill and capacity of developing country governments.

IO: What was one of the biggest challenges that the Avahan transition faced?

SS: Perhaps the biggest challenge was convincing Avahan’s staff, and the dozens of implementing NGOs and CBOs that worked with Avahan across India, that “transition” did not mean the end of the program. In its early years, Avahan generated a lot of excitement and enthusiasm as India scaled up its national response to AIDS. Many people were understandably concerned, therefore, when the Government of India and the foundation began phasing out key elements of the foundation’s financial and managerial support. We worked hard to reassure all stakeholders that the program would continue with the same vision and the same commitment to helping those in need.

I can’t emphasize enough how important it was to invest the extra time to create an open dialogue with key officials and to  ensure that they were bought into the need for a successful transition and treated it as a priority.

IO: How do you know that the Avahan transition is working?

SS: We are seeing encouraging signs. Our research shows that the quality of services has stayed consistent over the first two phases of the transition. And I recently met with a group of commercial sex workers in Bangalore, India, Swathi Mahila Sangha, who told me that the quality of the services they receive has remained strong under government management. We are also undertaking a formal evaluation of the process and impact of transition. We hope to share those results over the next year.

IO: So, what’s next?

SS: We remain committed to ensuring a successful transition for Avahan.   While we have transitioned management of prevention programs to the government, we still work closely with populations at risk of HIV infection to help them build community-based organizations that can advocate for the needs of their members.  This is a key priority for us going forward.  We are also sharing lessons from our HIV work in India with other countries.   

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