Integration of health solutions into government systems: a tool for assessing readiness

Government partnerships are essential for many health solutions to sustain impact at scale, particularly in low-resource settings where strengthening health systems is critical for Universal Health Coverage. Many non-governmental organizations (NGOs) and funders ultimately want solutions to be integrated into public health systems by transitioning solution ownership, management and/or operation to government. However, NGOs and their government partners have limited guidance on how to effectively determine when a solution is ready to transition in a way that will maintain impact long term. To address this need, VillageReach developed the Transition Readiness Assessment (TRA) based on our transition to government theoretical framework. The framework was developed to define both factors related to a solution, as well as external influences that affect a solution’s success. The framework identifies seven dimensions of solution readiness: the political, economic, and social context; solution design; resource availability; financial management; government strategy; government policy and regulations; and organizational management. The TRA measures those dimensions and assigns each one a readiness score. We developed the framework and TRA for VillageReach solutions, as well as to share with government partners and stakeholders. This Open Letter outlines the TRA development, details empirical examples from applying the tool on two VillageReach solutions, and presents recommendations based on our lessons learned. Stakeholders working to transition solutions to government can utilize both the TRA and our lessons.


Introduction
For many non-governmental organizations (NGOs), transitioning a a solution to government ownership, management, and/or operation is the best way to sustain solution impact at scale.Government partnerships contribute to solution design and implementation through networks and infrastructure to reach more people, fiduciary authority over spending, and an understanding of their population's needs and values 1,2 .Transitioning effective solutions to government can support stronger, more sustainable public health systems, which are necessary for achieving Universal Health Coverage 3 , a critical target in Sustainable Development Goal 3.
Large funders, such as the United States Agency for International Development, have shown increased interest in building country self-reliance.This work has primarily centered on capacity building by transitioning large-scale initiatives from a funder to government [4][5][6][7][8][9][10][11][12] .However, for NGOs looking to transition solutions into public health systems there is little guidance on how to transition a solution or assess solution readiness for transition 3,8 .There are few examples evaluating how transition of solution ownership affects long-term solution impact 4 , and NGOs and their government partners lack guidance on collaborative transition planning and on how to adapt to changing solution maturity and context 2 .
To address this need, VillageReach developed the Transition Readiness Assessment (TRA) based on our transition to government theoretical framework.The TRA helps address the lack of available resources to guide solution transition.We also present two empirical examples of its application on two VillageReach solutions within the same sub-Saharan African country and provide recommendations for future users.

Transition Readiness Assessment description
The TRA was developed based on the transition to government theoretical framework (Figure 1) 13 .The framework is based on the concept that successful solutions require an enabling environment, which includes measurable factors both within and external to a solution.We have identified these factors as the seven dimensions of solution readiness, which we define as an indication that a solution is likely to maintain impact post transition.(Here we define a solution as a combination of processes, products, principles, organization, tools, metrics, and collaboration that provides the functionalities needed to solve a defined problem).These dimensions, identified through a literature review and VillageReach's organizational experience, include: (1) the political, economic, and social context; (2) solution design; (3) resource availability; (4) financial management; (5) government strategy; (6) government policy and regulations; and (7) organizational management 13 .
The TRA was informed by findings from a scoping review, an analysis of existing sustainability and transition tools, and VillageReach's organizational experience [5][6][7][8][9][10]14,15 . ThreeVil-lageReach staff conducted the scoping review by searching both peer-reviewed and grey literature on PubMed, GoogleScholar a VillageReach defines transition as the process of integrating a solution into existing public health care systems.Other terms used to describe this process are adoption, scaling up or institutionalization.  and Eldis.org.The team used several key words in different combinations such as "transition+to+government," "sustainabili ty+of+donor+funded+health," and "Country +ownership + transition +health" to identify articles.From this search, we identified 28 articles for further review, for each article, we noted the author name, journal title, year, region, and focus of paper, dimensions related to transition or sustainability, definitions for each dimension, key results and key takeaways.Existing sustainability and transition tools were identified through this review and through consultations with experts in the field.Identified tools were assessed to understand the most common data collection methods, indicators, and scoring approach each of the tools utilized.For example, all tools had either indicators or categories dedicated to assessing funding stability, presence of a champion and organizational capacity, all of which are reflected in the TRA.This analysis informed the TRA's scoring approach, format, dimensions, sub-dimensions, guiding questions and indicators.
The TRA is an Excel™ based tool that measures at a given point in time 49 indicators assigned across the seven dimensions of readiness, each of which also has several subdimensions that are measured (Extended data 16 ).Each of the 49 indicators are scored by placing them in one of four categories: (1) fully in place, (2) partially in place, (3) not in place, or (4) not applicable (Table 1) 6 .Final solution scores for each dimension and sub-dimension allow NGOs and their government partners to identify transition barriers, and where additional support is needed for transition success.

Approach for applying the TRA
In May 2019, VillageReach applied the TRA on two solutions currently transitioning to government within the same sub-Saharan African country.One is a vaccine delivery solution based on VillageReach's approach to supply chain strengthening (hereafter referred to as solution 1) 11 .The second is a similar solution that integrates vaccines along with other medicines and uses an outsourced transport provider (hereafter referred to as solution 2) 12 .Both solutions were developed and implemented in close partnership with government, but solution 1 currently operates at the national and provincial levels, while solution 2 operates at the provincial level only.
We applied the TRA on both solutions using qualitative data collection methods such as document review, key informant interviews, a modified nominal group technique, and a teambased consensus building approach 17 .This allowed the research and solution management teams (EL, RB, BM, JR, AC, and AL) to agree on final scores for each indicator.The assessment team was led and coordinated by a senior health systems researcher (BM) and supported by a qualitative analyst with a background in health systems research (EL).Other study team members included the solution program staff, who were involved in the development and implementation of the solution and who are currently managing solution transition.
Application of the TRA consisted of six iterative steps following a modified nominal group consensus building technique: 1. Data gathering and review -For each solution, two team members independently reviewed all existing data sources related to the 49 indicators for each solution (solution 1: EL and BM; solution 2: JR and AL).Team members reviewed evidence that supported identified indicators and noted indicators where additional data or clarification was needed.Data sources reviewed included monitoring and evaluation reports, national strategy documents, an external evaluation of government accountability and organization, and budgeting guidelines.
2. Initial scoring -The same two team members, for each solution, collaboratively assigned initial scores for each indicator.This was done through an in-person half day working meeting to discuss each guiding question and associated indicators in the TRA, then reviewing the evidence identified in step 1 to agree on a score of fully in place, partially in place, not in place, or not applicable.Justification of assigned scores was documented in the comments section of the TRA Excel tool (eTable1).When team members disagreed on a score, or did not feel there was sufficient evidence to apply a score, they noted this in the notes section of the TRA Excel tool for further discussion during step 3.

3.
Team based consensus building -The same two team members presented the preliminary TRA findings to each of the larger VillageReach solution teams in a two-hour working meeting.During this meeting, initial TRA results were presented facilitating a discussion and revision for final group consensus on each indicator score.Team members provided critical input that was not possible to obtain through data sources, such as current projects and discussions happening with the government, as well as putting key evidence obtained through the document review into the context of transition.Key points from this discussion and any changes to the indicator score were documented in the comments section of the tool.Through this process, the team also identified indicators where government stakeholder perspectives were needed.The team decided that the best way to obtain this input was through key informant interviews.

Obtaining government input through key informant interviews -
The team obtained government perspectives through key informant interviews with national (n=2) and provincial government staff (n=4) working with VillageReach on solution transition.Key informant interviews focused on the guiding questions and on the indicators where government input and data were deemed necessary to apply an accurate readiness score.
Interviews were conducted by EL and AO.One interview with a national government key informant was conducted in English over Skype, while the rest were conducted in Portuguese in person.Interviews were not recorded, rather the interviewer filled out a detailed interviewee debrief form (Extended data 18 ) following the interview.The debrief form contained questions to help the interviewer quickly summarize the discussion.EL, AO and BM met following each interview to discuss the interview and determine if additional interviews were needed.The team agreed that we reached saturation in our sample, and no additional interviews were carried out.

5.
Consensus building -Two team members summarized (AO and EL) the key informant interviews by solution and question, and then one team member (EL) reviewed selected indicator scores and revised them to reflect interview findings.Changes to indicator scores were documented in the comments section of the tool.The final scored TRA was then sent via email for final review and validation by each VillageReach solution team.
6. Quantification of scores -Lastly, one team member (EL) developed summary scores for each sub-dimension of transition readiness by calculating the proportion of indicators scored as fully in place within each sub-dimension.An indicator was omitted from the denominator of the summary score if it was labeled not applicable.

Key observations
Overall application of the tool for these two situations was a success (Extended data 19,20 ).The tool was easy to use, facilitated group discussion and consensus building, and provided an opportunity to document challenges.Assessing the scores across and between solutions (Table 2) allowed us to pinpoint barriers and enabling factors for solution transition, as well as better understand each solution's strengths and weaknesses.
Solution 1 overall scored worse than solution 2. Solution 1 had an average of 24% of indicators across the seven dimensions as fully-in place, while solution 2 averaged 72%.
Identifying why these solutions' scores were so different provided valuable input not only for existing transition plans for solutions 1 and 2, but also for future VillageReach solution transitions.For example, solution In summary, by reviewing TRA results we better understood where to apply additional time and resources to help ensure successful solution transition to government ownership.

Recommendations for future application
Piloting this tool provided important insights for future applications of the TRA.
First, the TRA should be used in a workshop format.We initially applied the TRA internally and obtained government input only after assigning initial readiness scores.Administering the tool with all relevant stakeholders in a workshop setting would be more beneficial and allow stakeholders to collectively discuss and build consensus around scoring complex indicators for transition readiness.Representatives from all government levels --national, provincial, state, and local should attend the workshop to establish sustainable support in the event of political changes.
Second, detailed user guidance for the tool would help ensure that NGOs and their government partners use the tool accurately and consistently.VillageReach developed an accompanying guidance document (Extended data 16 ) for the TRA tool after this initial application.The guidance provides users of the tool with information on the TRA development process, and on how the tool helps inform transition planning.The guidance document also defines roles and responsibilities for administering the TRA and provides direction on scoring indicators and interpreting results.
Third, the TRA should be used early and often throughout transition.The TRA was developed after the transition process began for both solutions 1 and 2, which gave us limited time for adjusting solution transition plans.While the scores still provided us with useful feedback, ideally stakeholders would apply the TRA tool earlier in the transition process.This will provide stakeholders with adequate time to address all dimensions with low scores and discuss with funders any possible adaptions to timeline or resources.Stakeholders should also consider applying the tool multiple times throughout the transition process to continuously adapt the transition plan to the current political, economic, and social environments.This in turn will improve the solution's readiness to transition and ensure sustainability long term.
Fourth, the TRA should be applied in partnership with the government entity adopting the solution.We gained government feedback after internally assigning scores to each dimension.While this input was utilized to adapt final dimension scores, having a government counterpart to lead or cofacilitate applying the TRA can amplify government voices, and ensure government commitment throughout the transition process.Since the government will ultimately own and operate a solution post transition, working collaboratively with government partners throughout the transition process is critical.Fifth, the TRA can be useful post transition to assess solution sustainability and ongoing impact.To date the TRA tool has been used to inform effective transition planning.In the future we plan to combine the TRA tool with outcome evaluation methods as solutions are fully transitioned to government ownership.This evaluation will measure whether the solution was successfully integrated into government systems and whether the process of transition was effective.The results will help inform future planning for transitioning solutions to government.

Limitations of the TRA
The TRA is an operational tool to help facilitate discussion.
It provides a readiness score at one point in time and does not provide a minimum score required to achieve sustained impact post transition.A minimum score should be determined among key stakeholders and will vary by context.We do not yet understand if certain dimensions are more likely to lead to better outcomes post transition compared to other dimensions.Future applications of this tool, coupled with evaluation of solution impact post transition, will help illustrate whether certain dimension scores can better predict sustained solution impact at scale.Additionally, this assessment is just one of the many steps that are important to the transition process.Others include developing a clear solution description and transition strategy in partnership with funders and government partners.

Conclusion
Transitioning solution ownership to government enables greater likelihood that solutions will be sustained at scale and strengthen, rather than burden, health systems.The TRA is a flexible tool for NGOs, their government partners, and funders to make informed decisions for effectively transitioning solutions.This assessment can be applied to a variety of solutions across development sectors, uses accessible data collection methods, and uses consensus building among key stakeholders to generate actionable results.NGOs and their government partners can find and address transition challenges by measuring the seven dimensions of readiness, as well as adapt solution implementation and transition strategy if necessary.
While we are only beginning to use the TRA to assess our solutions, there is an urgent need for guidance among those who are following a similar path of government-owned solutions.For this reason, we are adding to the growing conversation about solution sustainability and transition by sharing access to a standardized tool to evaluate readiness for transition.We hope others can learn from our experiences testing this tool and can utilize the TRA and our recommendations to improve collaborative transition planning to achieve government-owned solutions that sustain impact at scale.The piece is a useful contribution and is worth indexing.I suggest the authors strengthen a few fairly minor issues:

Open Peer Review
There is quite a lot more literature out there on 'scale-up' and 'sustainability' that looks at government adoption of donor-funded interventions -including frameworks and concepts.And so, the introduction underplays the amount already known of the subject, and how the current paper will contribute to that knowledge.So, I would suggest the authors acknowledge a wider pool of literature and tighten the justification for the paper's addition/contribution.
○ Is the study focused on a particular country -good to clarify that here?○ Section on the TRA -it might be helpful to clarify the relationship between the 'transition to government' framework and the TRA.Was the transition to government framework developed earlier by the same team and published in an earlier paper -and now this current paper is applying it via the TRA Excel based tool?A few words at the beginning of the section guiding the reader through would help a lot.And again, in which country was the work done?
○ Methods -where did the work/data collection take place?And a bit more information is needed on the interviewing -who, selection criteria, where, etc.

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The modified nominal group approach -can the authors add a few words on how this technique was developed (perhaps add a reference if it is described elsewhere and say how the approach was modified?).

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In the key observations -it would help to remind the reader of what solution 1 and solution ○ 2 are when discussing them in this section -and also in Table 2? The Letter is worth publishing in order to give visibility to a well-thought tool, that can usefully help plan transitioning in a rational manner.It offers a series of recommendations for future application; recommendations about when to use the TRA, e.g. at various stages of the planning of the transition and even as a monitoring tool after transitioning, is particularly relevant.The reader is invited to visit a dedicated website where a guideline document is available.
I suggest that the authors add comments on the following points: The theoretical framework that structures the TRA gives equal value to its seven dimensions.Is there a way to modulate the weighing to reflect differences in the relative importance of each dimension?Also, is a low score on only one dimension enough to conclude that the solution is not ready for transition?

Wilson Wong
Department of Government and Public Administration, The Chinese University of Hong Kong, Hong Kong, Hong Kong The article has provided a comprehensive and useful framework, Transition Readiness Assessment (TRA), for assessing the readiness of having a solution to be transited to government as a permanent and institutionalized measure.There is a total of seven dimensions in the framework (political, economic, social context; solution, design, resource availability; financial management; government strategy; government policy and regulations; and organizational management) which become a very comprehensive checklist for evaluating the strengths and weaknesses of a government in implementing and institutionalizing the solution.The main idea is to have it as a pre-testing and also ongoing exercise for facilitating dialogue and communication among major parties in seeking progress and improvement.
While TRA is a very intelligent approach which certainly represents a major step forward in this area of research and practice, the current version of the article does have some blind spots and limitations which should be addressed in a revision.
First of all, it has adopted a more state-led approach which assumes the transition of a solution from NGOs to government would be the ideal end state of the solution.However, while this can be one of the permanent arrangements, it is not sure whether it is possible and desirable to cover all cases and situations.Obviously, NGOs and other members of the civil society often have an indispensable role to play so that having a complete take-over by government may not represent the full spectrum of all scenarios.To resolve this, the article should spell out more clearly and explicitly the assumptions and conditions that need to be met for a complete takeover by government.In short, the authors should make it very clear under what conditions the TRA would be useful and applicable.
Second, in the TRA, such as Figure 1, it is very good that political, economic and social contexts, are mentioned.Unfortunately, there are two problems here.There is no sufficient elaboration of the three contexts in the text on what they mean and how they are going to be evaluated in constructing the final score of the TRA.Besides, it does not seem to make sense to state that these contexts are not specific to a given solution and have no interaction with the integrated solution elements.It should not be difficult to think of situations in which the political context, such as a very closed and corrupted political system, can affect the policy and regulatory element and the organizational capacity of a government.These interactions and connections should be built into the revised TRA.
Third, the role of civil society seems to be treated as only temporary and is replaceable as it is implied that the shift of the solution from civil society to government is the desirable end state.This line of argument is totally inconsistent with the trend of coproduction of public services and policies between state and society, and the major field of collaborative governance in the literature of public policy and administration.Most particularly, during the COVID-19 crisis, there is a bloom of theory-guided and empirical-based literature and studies discussing the important and critical role of civil society in combatting the pandemic.Links to some of the representative works are attached (for example: Wong, 2021 1 and Cai et al., 2021 2 ).
It is strongly recommended that the TRA should include the role of civil society in co-production both in the transition and the post-transition, such as how NGOs and citizens can play a visible and significant role in ensuring the positive attributes of public service such as transparency, openness, and accountability can be maintained in the implementation of the solution after it becomes government-owned.

Figure 1 .
Figure 1.Transition to government theoretical framework.

Peer Review Status: Version 1 Reviewer
Report 25 June 2021 https://doi.org/10.21956/gatesopenres.14399.r30768© 2021 Spicer N.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Neil Spicer Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK

○Figure 1 -
Figure 1 -needs a source ref if published previously?
the rationale for the Open Letter provided in sufficient detail?Yes Does the article adequately reference differing views and opinions?Partly Are all factual statements correct, and are statements and arguments made adequately supported by citations?Partly Is the Open Letter written in accessible language?Yes Where applicable, are recommendations and next steps explained clearly for others to follow?Yes Competing Interests: No competing interests were disclosed.Reviewer Expertise: Health policy analysis; qualitative methods; scale-up and sustainability of health interventions I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.Gilles Dussault Global Health and Tropical Medicine, Universidade Nova de Lisboa, Lisbon, Portugal This Open Letter presents the Transition Readiness Assessment (TRA), a tool developed and tested by Village Reach with a view to encourage other development actors to try it and even improve it.

Table 1 . TRA scoring key.
Not applicableThis can mean either this indicator is not valid for this solution or country or that there is insufficient dataThe solution doesn't need staff to manage or operate the solution

Table 2 . Transition readiness assessment scores by solution.
*Policy and regulatory factors were scored as not applicable by the solution team as they felt actions in this category would not impact the sustainability of the solution post-transition.

the rationale for the Open Letter provided in sufficient detail? Yes Does the article adequately reference differing views and opinions? Yes Are all factual statements correct, and are statements and arguments made adequately supported by citations? Yes Is the Open Letter written in accessible language? Yes Where applicable, are recommendations and next steps explained clearly for others to follow? Yes Competing Interests:
Give information on the expertise required from national counterparts, and on time and financial resources needed to apply the TRA.What are the main facilitators/obstacles to the effective use of the TRA?No competing interests were disclosed.

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Is the rationale for the Open Letter provided in sufficient detail? Yes Does the article adequately reference differing views and opinions? Partly Are all factual statements correct, and are statements and arguments made adequately supported by citations? Partly Is the Open Letter written in accessible language? Yes Where applicable, are recommendations and next steps explained clearly for others to follow? Yes Competing Interests:
1. Wong W: When the state fails, bureaucrats and civil society step up: analysing policy capacity with political nexus triads in the policy responses of Hong Kong to COVID-19.Journal of Asian Public Policy.2021.1-15 Publisher Full Text 2. Cai Q, Okada A, Jeong BG, Kim S: Civil Society Responses to the COVID-19 Pandemic: A Comparative Study of China, Japan, and South Korea.The China Review.2021; 21 (1): 107-137 Reference Source No competing interests were disclosed.