Concussion is a considerable public health problem in youth. However, identifying, understanding and implementing best evidence informed recovery guidelines may be challenging for families given the vast amount of information available in the public domains (e.g. Internet). The objective of this study was to develop, implement and evaluate the feasibility of an evidence-informed self-management education program for concussion recovery in youth.Synthesis of best evidence, principles of knowledge translation and exchange, and expert opinion were integrated within a self-management program framework to develop a comprehensive curriculum. The program was implemented and evaluated in a children’s rehabilitation hospital within a universal health care system. A retrospective secondary analysis of anonymous data from a program evaluation survey was used to evaluate program feasibility, to identify features of importance to program participants and to assess changes in participants’ knowledge.The program, “Concussion & You” includes a comprehensive, evidence informed, population specific curriculum that teaches participants practical strategies for management of return to school and play, sleep, nutrition, relaxation and energy conservation. A ‘wheel of health’ is used to facilitate participants’ self-management action plan. Results from eighty-seven participant surveys indicate that the program is feasible and participant knowledge increased in all areas of the program with the highest changes reported in knowledge about sleep hygiene, rest and energy conservation.Findings indicate that “Concussion & You” is a feasible program that is acceptable to youth and their families, and fills a health system service gap.The online version of this article (doi:10.1186/s12913-016-1664-3) contains supplementary material, which is available to authorized users. Understanding how to promote recovery in youth following concussion may be a considerable challenge for both parents and youth. Factors that contribute to this challenge include managing post-concussion symptoms, navigating return to school and sports, and developing awareness of evidence-informed policies and procedures . The abuMild traumatic brain injury (mTBI) or concussion is defined as “a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces” (p.250) . ConcussPatient education  and selfKnowledge translation and exchange (KTE) principles can be used to support health education and self-management programs. In a review of knowledge transfer principles as applied to concussion in sport, Provvidenza and Johnston  concludeThe objectives of this study were to: 1) develop a self-management program curriculum for concussion recovery that is specifically targeted to youth and their families; 2) pilot test the program; and 3) evaluate program feasibility and knowledge uptake of participants.This program took place in a children’s rehabilitation hospital operating within a universal health care system in Toronto, Canada. This article describes the program development, implementation and evaluation phases. Ethics approval was received by the Research Ethics Board of Holland Bloorview Kids Rehabilitation Hospital and University of Toronto for retrospective secondary analysis of anonymous survey data previously collected for the purpose of program evaluation.The first phase was to develop a comprehensive evidence-informed concussion curriculum specifically designed for youth and their families. Curriculum development was based on synthesis of best evidence and expert opinion and was integrated within a self-management framework. In line with self-management and KTE principles specifically targeted to youth, the goals of “Concussion & You” are to: 1) provide evidence-informed, best practice guidance regarding concussion recovery; 2) enable participants to build their own concussion recovery ‘tool kit’; and 3) provide a platform for participants to interact and network with one another.Program development also considered the need to address existing gaps in service delivery. Figure The program, “Concussion & You” was designed to serve both the hospital population and the general community at large. With respect to the hospital population, youth may be referred to the Hospital Concussion Clinic by their primary care provider if they have been experiencing post-concussive symptoms for longer than 4 weeks. Following referral, patients are contacted by the Hospital Concussion Clinic intake coordinator who advises them of their appointment and instructs them that the first part of their clinical care is to attend the “Concussion & You” session. Currently, there is a waiting period of approximately four to eight weeks from first point of contact with the intake coordinator until patients are seen by the concussion clinic physician. All patients and their families are directed to attend “Concussion & You” during this waiting period.The program is also open to members of the general community who may attend the program via a self-referral process. “Concussion & You” is advertised through the hospital web page, social media , word of mouth, community outreach activities and posters. If needed, these youth may then seek referral to the Hospital Concussion Clinic from their primary care physician.Demographic data: There were two demographics questions. These questions were included to provide a better understanding of who was attending the sessions. The demographic data collected was limited to: if attendees were children/youth or parents/guardians; and, if attendees had received concussion education previously. As the original purpose of the surveys was to conduct program evaluation, identifiable information  could not be collected.Feasibility data: Seven survey questions addressed feasibility . These questions were included to give the researchers a better understanding of what participants felt was important about the program, and/or what was missing. Practical questions that may affect attendance were also asked.Knowledge uptake data: Three survey questions targeted knowledge uptake . These questions were aimed at identifying how participants’ understanding of concussion related topics changed from pre to post session. Using retrospective self-report, participants were asked to rate their pre- and post-session understanding of concussion recovery topics using a four point rating system .The program was pilot tested from December 2013 to May 2015. A survey-based program evaluation design was used to evaluate feasibility and knowledge uptake. Prior to implementation, the survey was reviewed by concussion experts and a knowledge translation specialist for content and to ensure the survey used language that was easily understood by youth and parents. Surveys were administered at the education sessions and were collected anonymously. The complete survey can be accessed as a Additional file Program participants were youth with concussion and their parents or caregiver, who voluntarily attended the program during the pilot phase and who agreed to complete the program evaluation survey.Descriptive statistics (e.g. frequencies) were used to retrospectively analyze surveys collected in the pilot test period. Data from questions involving a yes/no option or rating scale (closed questions) were analyzed using frequency counts/percentages. Data from open-ended questions were themed, whereby similar responses were grouped and recorded as a percentage of the overall responses.“Concussion & You” is a ninety-minute interactive education session facilitated by occupational therapists and knowledge translation specialists with expertise in clinical concussion care and research. The program is designed for children and youth (ages 5-18) with concussion, and their families. A slide presentation and an accompanying written resource work booklet designed specifically for the program are used during the first hour of each session to guide attendees through the curriculum. While some information in this booklet was specifically written for “Concussion & You” , readily accessible best practice resources are also included . Analogies are offered to explain why youth might not be able to do their usual activities . Using the gas tank analogy, participants are then guided through topics on a visual care plan or ‘wheel of health’ Fig. .Fig. 2ViEach of the six spokes on the wheel addresses a curriculum topic: 1) energy conservation; 2) sleep hygiene; 3) nutrition; 4) relaxation; 5) return to school, activities and sport; and 6) development of a concussion recovery ‘tool kit’. Participants are encouraged to fill in blank spaces on the wheel to build their concussion recovery tool kit; in other words, to identify strategies that they think might help to “keep their gas tank full”. Common risks for prolonged recovery and symptom exacerbation are discussed  and management strategies are identified. The last part of the session is aimed at answering questions, facilitating discussion and information sharing amongst program participants regarding their experiences.A total of 87 surveys were completed by 62 parents and 25 youth who attended the program during the pilot phase. Half  the participants reported no previous concussion education. Of the 48 % (42/87) who reported receiving previous concussion education, this education was primarily received from a health care professional (42 %) or the internet (36 %).An overwhelming majority  reported enjoying the “Concussion &You” session and would recommend the program to others. Of the 60 respondents who indicated why they would recommend this program to others, 60 % (36/60) reported the program content. More specifically, participants reported that receiving comprehensive concussion management information from a credible source was very important. Both youth and parents gave an “excellent” rating for the following components: information presented , delivery and format , length of session , ease of understanding  and online session registration .Results from the knowledge uptake evaluation regarding session content are found in Fig. Survey results indicated that most participants  had intentions of incorporating their new knowledge into their daily routines and safety practices (100 % of parents and 80 % of youth). Of note, of the 50 respondents who identified how they plan to use this knowledge, 62 % (31/50) indicated that they would apply their knowledge to monitoring their child or themselves and 38 % (19/50) indicated that they planned to share program content with teachers and coaches.“Concussion & You”, a self-management concussion education program was developed based on evidence-informed best practices and in alignment with principles of knowledge translation and exchange (KTE) . The proKTE means providing the right information to the right people in the right format at the right time and has been identified as a ‘missing link’ for enhancing concussion education . “ConcusTo prevent development of secondary impairment and delayed recovery post-concussion, the provision of timely and relevant concussion education is paramount , 24. “CoOf the participants who indicated that they had received concussion education prior to attending “Concussion & You”, the most common information source was primary or emergency physicians. Participants reported that the information provided in “Concussion & You” would have been valuable to receive earlier in the recovery journey, to effectively manage concussion soon after injury.As aligned with KTE principles and to promote uptake of information by knowledge users (e.g. youth and their families), delivering information in an understandable, consistent manner is an essential goal , 20, 21.Combining KTE  with thewithin participants. Session content and the work booklet were designed to empower participants to create their own self-management concussion recovery ‘tool-kit’ that can be accessed throughout the post-concussion recovery process to optimally manage their injury. Daily planners, activity logs, and post-concussion symptom scales enable youth and their families to implement these strategies into their daily routines. This process is started in the session by providing participants with an opportunity to formally write out which strategies they will use on the ‘wheel of health’  and accThe current study has limitations. Participants were drawn from individuals who were motivated to, and able to attend an early evening education program and were willing to complete a program evaluation survey following the program. Thus, the sample may not be representative of the general population of youth with concussion. While anecdotal and survey data suggest that participant response to “Concussion & You” has been overwhelmingly positive, a better understanding of the effects of this program on long-term knowledge gains and recovery is warranted. Empirical and qualitative inquiry to understand the effects of the program on recovery outcomes including symptom reduction, return to activity, prevention of secondary morbidity, and self-efficacy is needed. Identifying how this program contributes to recovery over time (i.e. follow up studies) is warranted. Further, although an important initial step in the evaluation and validation of this concussion education program, the retrospective secondary analysis of program evaluation surveys approach to this study resulted in the inability to collect more detailed demographic data  that may be useful in determining the group specific impact of this program. Continued study that includes more rigorous research design is needed.“Concussion & You” is a patient education program that uses knowledge translation and exchange strategies to provide youth and their families with concussion recovery information to promote self-management of concussion. Results from our feasibility and knowledge uptake study indicate that this program is feasible, fills a health system service gap, is acceptable to youth and their families, and results in knowledge increases regarding concussion management.


To evaluate the relationship between the pass rate of the American Board of Internal Medicine (ABIM) certifying exam and the characteristics of residency programs.The study used a retrospective, cross-sectional design with publicly available data from the ABIM and the Fellowship and Residency Electronic Interactive Database. All categorical residency programs with reported pass rates were included. Using univariate and multivariate, linear regression analyses, I analyzed how 69 factors  are related to the pass rate.Of 371 programs, only one region had a significantly different pass rate from the other regions; however, as no other characteristics were reported in this region, I excluded program location from further analysis. In the multivariate analysis, pass rate was significantly associated with four program characteristics: ratio of full-time equivalent paid faculty to positions, percentage of osteopathic doctors, formal mentoring program, and on-site child care (OCC). Numerous factors were not associated at all, including minimum exam scores, salary, vacation days, and average hours per week.As shown through the ratio of full-time equivalent paid faculty to positions and whether there was a formal mentoring program, a highly supervised training experience was strongly associated with the pass rate. In contrast, percentage of osteopathic doctors was inversely related to the pass rate. Programs with OCC significantly outperformed programs without OCC. This study suggested that enhancing supervision of training programs and offering parental support may help attract and produce competitive residents. In 2015, 26,252 residents were admitted to the first year of a residency program. The largest type of residency program – categorical internal medicine – has 6,698 positions  –11 or thBesides location and program size, there is limited evidence on the relationships between pass rate and the characteristics of internal medicine residency programs. Thus, the objective of the present study is to evaluate the relationships between the pass rate of the ABIM certifying exam and the characteristics of three-year categorical internal medicine residency programs. Because the educational environment plays a crucial role in the success of medical education  and crea®), a freely available online database containing self-reported program characteristics. The scope of this study covered all three-year categorical internal medicine residency programs in the United States and Puerto Rico, a US territory. A list of three-year categorical internal medicine programs and their characteristics were extracted from FREIDA® using computerized automation on April 24, 2015. The 2012–2014 pass rates of the ABIM certifying exam, the most recent statistics at the time of the study, were obtained from the ABIM website. Residency programs that did not report their pass rates were excluded from the study.This study used a retrospective, cross-sectional design to evaluate the relationships between pass rate of the ABIM certifying exam and most of the program characteristics available in the Fellowship and Residency Electronic Interactive Database  was 0.05. All statistical analyses were conducted using STATA version 13.0 (StataCorp).First, the descriptive statistics of the program characteristics were calculated. Then, to identify the relationships between pass rate and the program characteristics, univariate, linear regression analyses were performed under the assumption that all variables were normally distributed. Program characteristics with a ® at the time of study; however, only 371 programs (n=371) were included in the analysis because the other programs did not report a pass rate. As shown in p<0.001). However, because the programs in this region did not report any other program characteristics in FREIDA®, I could not analyze any relationships between other characteristics and the pass rate. As such, the factor of location was dropped from further univariate and multivariate analyses.There were a total of 405 three-year categorical internal residency programs in FREIDAβ=0.1348, p<0.001), university-based program , offering preliminary positions , FTP ratio , percentage of doctors of osteopathic medicine , formal mentoring program , and OCC .Among the 371 programs that reported a pass rate, 295 programs (79.51%) reported at least one program characteristic other than location. The baseline characteristics of these programs are summarized in β=1.2541, p=0.015), % DO , FMP , and OCC . The adjusted R2 of this multivariate model was 9.61%.In the multivariate, linear regression model , only foThe study findings are distinct from those of similar studies focusing mostly on location and program size. Although the locations of residency programs have been reported to be significantly related with the pass rate of board certifying exams (ABFM and ABP) , 16, thep<0.001). However, in the multivariate analysis, FTP ratio was considered a better predictor of pass rate, which conforms to the results of one previous study  offered it. Thus, even if a mentoring program in internal medicine is unstructured, under-monitored, or under-evaluated . HoweverInterestingly, the % DO was found to be the only significant negative predictor of the pass rate in the multivariate, linear regression. My findings are perhaps explainable by the fact that higher % DO in a given program is an indicator of lower competition in that program. As shown in the case of general surgery residency programs, more competitive programs are significantly more likely to select applicants with higher USMLE Step 1 scores , which aOnly 34.24% of internal medicine residency programs offered an OCC benefit, despite the fact that parenthood during residency is common together with the rising number of residents having babies during residency training –35. Havi® and the ABIM website could be subject to human error by the data reporters or data gatherers. Second, approximately one-fourth of programs opted out of reporting program characteristics other than location to FREIDA. Although such reporting behavior could lead to further bias in the data, the difference in pass rate between fully opted-in programs and fully opted-out programs in this study was found to be non-significant. Third, the study used data from the FREIDA® at a single point of time, and thus the program characteristics and their relations with pass rate might differ by time period. Fourth, the adjusted R2 of 9.61% means that 90.39% of the variance in pass rates is attributable to factors other than FTP ratio, % DO, FMP, and OCC. Further analysis with a larger dataset would be useful to validate the study results, especially regarding the influence of location using multivariate analysis. Despite the limitations of the data and low adjusted R2, the findings of this study can still be applied to most programs in the United States (except those located in Puerto Rico). Therefore, the results of this study have several implications for improving internal residency programs. First, programs should focus on improving the supervision of training experiences such as enhancing the quality of the mentoring program or balancing the faculty to position ratio. Second, programs should pay more attention to improving parental support during residency, such as implementing OCC or other facilities for supporting parenthood during residency training.Several limitations of this study need to be addressed. First, the data from both the FREIDAAccording to the results, success on board certifying exams is associated with two main factors: the competitiveness of individual residents and the training environment. Doubtlessly these factors are related. Specifically, the significant findings about FTP ratio and FMP supported the benefits of a well-supervised training environment, whereas higher % DO had a negative effect on pass rate. Finally, the OCC was directly related to training environment in terms of quality of life. The result of this study suggested that internal medicine residency programs could better attract competitive residents into programs as well as produce competitive residents by enhancing the supervision of training environments and offering parental support.


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.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.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.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. Recent global policy statements have reinforced the centrality of country ownership and leadership of the HIV/AIDS response,2. ProgrBetween 2009–2013 the Bill and Melinda Gates Foundation (BMGF) transitioned its major HIV/AIDS prevention initiative in India from being a stand-alone program outside of government, albeit coordinated with government, to being a fully government funded, managed and implemented program[The Avahan India HIV/AIDS Initiative funded by BMGF, was started in 2003 and was rolled out in the states of Karnataka, Andhra Pradesh, Tamil Nadu, Maharashtra, Manipur and Nagaland in India. During the first phase (2003–08) the goal of the program was to build and operate an HIV prevention program at scale for high risk groups (HRGs). Avahan was implemented through a “parallel” system of non-governmental organizations (NGOs) and community based organizations (CBOs) that facilitated achievement of scale very rapidly. In totaDuring the second phase (2009–2013) BMGF transferred the programs to the Government of India . Avahan This evaluation aimed to generate practical lessons concerning the transition of Avahan to local ownership, so as to guide implementation strategies throughout the transition process, and inform similar processes elsewhere. Specifically we addressed the following questions:-What was the Avahan transition strategy and how was it implemented?How well prepared were the TI programs for transition?How well institutionalized is the Avahan program post-transition?Were program effects sustained after transition?What are the elements necessary for effective transition of HIV/AIDS prevention programs?This paper synthesizes findings from across the entire evaluation.The logic model for the transition evaluation  posited During 2009–2013 we conducted a mixed methods evaluation with multiple rounds of data collection (corresponding to the different transition rounds) that combined surveys of transitioning TIs both just before they transitioned, and approximately one year after transition, with qualitative case studies of purposively selected TI programs. This paper focuses on the TIs that transitioned in the Southern states of Karnataka, Andhra Pradesh, Tamil Nadu and Maharashtra.A transition readiness survey was conducted among all 27 TI programs that transitioned in 2011 and a sample of 53 of the 155 TI programs that transitioned in 2012. The transition readiness survey was administered just before transition, to the program manager of each TI and captured information about communication, capacity building and alignment. It employed structured questions supported by open-ended explanations. The survey also collected data on service utilization trends pre-transition. Because the evaluation was commissioned only in 2009, the transition readiness survey could not be conducted for the 2009 transition round.An institutionalization survey was implemented approximately 9–12 months after transition. It sought to revisit all 80 of the TIs previously surveyed, however, due to merging of some TIs and late transition of others, only 70 TIs were finally included in the survey. The institutionalization survey, also administered to program managers and employing structured questions supported by open-ended explanations, assessed the extent to which key Avahan practices had beenFifteen case studies of TI programs were conducted approximately 6 months after transition, with 5 being revisited 1–3 years later. Case studies were selected to represent variation in state, key population served, and NGO versus CBO operations. Data collection comprised semi-structured interviews with TI managers, SLP staff overseeing the TI, SACS/TSU staff; and focus group discussions with outreach workers, peer educators and key populations. In total 83 semi-structured interviews, and 45 focus group discussions were conducted. Basic data on service provision and other relevant documents were collected from the TI. Case studies sought to understand the experience of transition and the effects of transition.The study components described above were supplemented by regular interviews and discussions with the national and state level BMGF staff managing the transition. The research team also undertook a related piece of work that explored the role Avahan had played in influencing the Third National AIDS Control Program (NACP III) ,16. ThisFor the transition readiness and institutionalization surveys, responses were translated into English where necessary, and entered into and analyzed in Excel. For measures of alignment three simple response categories were created reflecting full alignment, partial alignment, and no change from Avahan modalities. Analysis of both surveys sought to compare the degree of transition readiness, by round, by state and by population served.For the case studies, interviews and focus group discussions, data collection was conducted in the local language, recorded, then transcribed and translated into English in India. Data were coded in Atlas.ti using a framework approach and analysis was confirmed between researchers in the U.S. and India. For each case study, a separate report was drafted, synthesizing findings from the data available.Data were triangulated within and across study components and early results were used to inform later data collection. Results from the first round of data collection were shared and discussed with Avahan and local counterparts. It should be noted that one component of the Avahan transition strategy  was not addressed in this evaluation.The study was submitted to and exempted by the Internal Review Board of the Johns Hopkins Bloomberg School of Public Health. It was approved by the YR Gaitonde (YRG) Medical, Educational and Research Foundation, Centre for AIDS Research and Education Institutional Review Board in India. Respondents to all components of the study were asked for and provided written consent, with the exception of community participants in focus group discussions in the longitudinal case studies who, for reasons of limited literacy, provided oral consent that was recorded by the enumerator. These consent procedures were approved by the YRG Institutional Review Board.There was very early recognition of the need to transition the Avahan program to local counterparts. In 2005, barely two years after its initiation, the Avahan technical panel and partners discussed the need to move Avahan towards a “truly sustainable” program. At the time this was considered mainly in terms of strengthening community owners and transferring funding and management responsibilities to government. This commitment to transition was formalized in a 2006 Memorandum of Cooperation with government. A 2008 The transition strategy continuously evolved responding to new learning as well as shifts in context, but key elements of the strategy included:Strengthening government systems at national and state level to manage TIs, through the provision of assistance to the Technical Support Unit at NACO, and through funding of state-level Technical Support Units.Building NGO/CBO capacity to run TI programs independently through training for NGO/CBO staff.Enhancing key populations’ capacity to demand and access services and information, and promote their engagement in building an enabling policy and program environment through community mobilization activities conducted by State Lead Partners at TI Program staff.Aligning clinical and non-clinical aspects of the Avahan program with government systems prior to handover. In terms of clinical alignment this involved new clinical protocols (such as for STI syndromic management) and referring clients to government health services such as Integrated Counseling and Treatment Centers (ICTC). Non-clinical dimensions included alignment with NACO norms for budgets, staffing profiles and procurement systems, as well as adoption of the government’s health management information system.Promoting continued government commitment to targeted prevention programs and transition of the Avahan program, through engagement with government in the development of key policies such as the National AIDS Control Program III.The 2009 transition round was problematic. While upper and middle management levels at NGOs/CBOs running the TI programs and state-level organizations were relatively well informed about transition, frequently peer educators were less well informed, notified just prior to the transition or were unaware that transition was taking place. Transition preparation focused on budget and staffing alignment, but failed to anticipate operational challenges TIs would face post-transition, notably shortages of cash and commodities due to delays in initiating budget disbursements and supplies via government systems. While transition was meant to occur in April 2009, frequently government contracts to NGOs/CBOs were not issued until months later. There was no planning for the kind of post–transition support that SLPs might provide after transition, which sometimes resulted in confusion at the TI level with both SACS and SLPs intervening. In one state the SLP was asked by SACS to cease its involvement with TI programs that had transitioned, thus undermining any post-transition support.Informants suggested that one reason for the challenges encountered in the 2009 transition round were the short time frame for planning transition. In our case studies we found efforts to prepare transitioning TI programs only started 1–3 months before transition. In addition a lack of experience in collaboration between Avahan and government sometimes manifested itself in mistrust.By comparison, the 2011 transition round appeared better organized. Relationships between Avahan and government were stronger and communications between these actors were more effective and built on trust. New posts for “transition managers” were established within SLPs, as well as at the central level in BMGF, ensuring a clearly identified point-person with responsibility for the transition. Clear indicators to judge the level of program interventions, and budget lines to support transition were established. There was a longer period of transition preparation, with TIs starting preparation on average 6 months before transition according to the transition readiness survey. In two states, Karnataka and Maharashtra, buffer stocks of condoms, medicines and occasionally funds were built up to address potential gaps in supplies. Further, arrangements for post-transition support, which allowed SLPs to continue to work with TI programs, particularly on community mobilization activities were formally agreed in advance. These improvements were facilitated by the fact that the second transition round came a full two years after the initial round, was relatively small (comprising just 28 TIs), and therefore relatively straightforward to implement.The 2012 transition round appeared to go smoothly despite its large size. This success built on even earlier preparation (starting on average 9 months before transition), ongoing strong collaborations and effective communication between SLPs, SACs and TSUs. Post-transition support packages, especially for community mobilization, were standardized across TIs. Buffers of funding and commodities were established for all TIs. Overall planning and implementation of transition strategies were guided by a Common Minimum Program for transition. Data from the surveys reinforce the positive impression that case study data provide of effective implementation of transition strategies in later rounds: while 79% of TI managers in the 2011 round agreed or strongly agreed that “the transition experience went smoothly”, 93% of TI managers perceived the last round of transition to have gone smoothly.In terms of developing capacity and promoting engagement of TI staff and key populations, there was a gradual increase over time in the amount of staff training provided to help prepare for transition. For example, overall more field staff attended transition trainings in 2012 versus 2011 , and more TI managers received training on changes to TI guidelines in 2012 compared 2011 . However higher-level staff received more training than lower-level staff, and for the April 2012 transition most staff training for transition took place very late in the process.In terms of alignment of clinical aspects of the program, Avahan TIs had previously delivered most clinical services for general health and sexually transmitted infections through TI-run centers or alternatively had contracts with private clinics for services. During transition, the delivery of clinical services shifted away from TIs to government facilities. Typically this also implied a shift from broad services for sexually transmitted infections, and indeed general health services, toward a narrower focus on integrated counseling and testing for HIV and syndromic treatment for STIs.Overall, we found high levels of clinical alignment and very high referral rates to government ICTCs . In a nuAvahan also needed to align managerial and operational aspects of the program prior to transition. We found high alignment of budgets, TI team structure, and reporting and procurement systems . Where pWith respect to government commitment, Avahan was fortunate to be transitioning its program into the context of a highly committed and matured government program, whose policy goals aligned with Avahan HIV prevention objectives. The Third National AIDS Control Program (NACP III) committeA number of key practices that Avahan pursued were identified as critical to the success of the program. These kManagement practices, notably extensive use of data at different levels of the system, strong onsite supervision, use of clinical and operational guidelines, a “common minimum package”, and flexible management;Funding and supplies, including on-time, adequate and uninterrupted flow of funds and commodities to TIs;Peer-educator (PE) support, comprising rigorous performance-based management of PEs, use of pictorial micro-planning tool, and needs based training for PEs.Community engagement, including program oversight by committees made up of community members, strong support to community groups, and community-led crisis-response mechanisms to respond to violence or harassment of community members.The institutionalization survey assessed the persistence of these practices post-transition.Overall, by the time of the institutionalization survey, 9–12 months after transition, there had been significant program changes across these dimensions. 75% of survey respondents from the 2011 transition round and 69% from the 2012 round agreed with the statement that “The overall program has changed significantly as compared to pre-transition.”Over 50% of TI program managers noted changes in key management practices . In genenever had cash flow problems. Further, the transition reduced budgets for 63% (across both rounds) of TIs, which in turn decreased TI staff salaries, travel allowance, and funding for TI events and activities.With respect to funding and supplies, close to 70% of TI programs always had sufficient stocks of condoms and medicines, but the remaining 30% had experienced commodity stock outs within a few months post-transition largely due to changes in the supply source and schedules. In all, 10% of TIs regularly had problems with cash flows and less than half of the TIs peer educators was felt to have changed, largely for the better. There appeared to be closer monitoring of peer educators, with more concrete performance standards, and termination of contracts for those who did not meet standards. Further, 59% of TIs (across both rounds) also thought that peer educator training had changed, though views were mixed on whether this had led to improvement. Due to more restricted budgets, the frequency of training had declined, but training opportunities may have been better targeted than previously. The specific use of a pictorial microplanning tool to map HRGs had also changed for 43% of TIs, which was largely perceived as positive.In 59% of TIs (across both rounds), performance monitoring of Based upon the institutionalization survey, about one third of TIs experienced changes in community engagement across the three activities considered. The majority of TI program managers viewed these to be changes for the better; however, a different perspective emerged from community members who participated in the focus group discussions conducted as part of the longitudinal case studies. Community members perceived that TI programs had shifted away from providing incentives and community recognition activities towards a more narrowly clinical focus. Budget cuts that removed small amounts of funding for tea and refreshments for community members had disproportionately large effects on the motivation and satisfaction of community members. Shifts in the source of clinical services also resulted in mixed feelings: while many community members appreciated the possibility of being mainstreamed into government clinics, and recognized improvements in government provider sensitivity to their needs, they also mourned the loss of general health services at the TI. Many resented the focus on testing to the exclusion of other activities. MSM and transgender communities appeared particularly adversely affected by the shift.Figs While questions of transition and country ownership are of growing importance across a number of major development partners, we are not aware of other prospective evaluations of program transitions. This transition assessment was structured around five questions. Here we summarize our conclusions concerning the first four questions, based upon the evidence presented above. We then address the fifth question: “What are the elements necessary for effective transition of HIV/AIDS prevention programs?”, before describing limitations of the study.With the exception of the first small 2009 round of transition, the Avahan transition appeared to be well implemented. The phased nature of the transition allowed for learning between each tranche, and preparations for and investments in transition increased in scope and complexity over time. Transition preparations were varied, encompassing measures to promote continued high level government commitment to HIV/AIDS prevention activities; adaptations to programs to support budgetary, operational and clinical alignment; and support to the development of capacities among key stakeholders. Our assessment identified relatively high levels of transition readiness across these dimensions. Both the 2011 and 2012 transition rounds occurred without significant disruptions to services, where effective transition preparation stands out as an important explanatory factor.In terms of institutionalization, we found very significant changes to management practices 9–12 months after transition. Many of the adaptations in the program were perceived to be positive ones by TI managers with the clear exceptions of more limited funding, and less flexibility in program management. Transitioning a donor-run program into a government health system will likely create adaptations in the government system as well as compel adaptation in the program itself. This begs the question as to which adaptations are an acceptable, or even necessary part of transition, and which are likely to damage the long-run sustainability of program outcomes.While TI program managers had positive impressions of program transition, the views of community members were much less so and the community mobilization component of the program suffered most as a consequence of transition. This was partially addressed by BMGF through the establishment of 12 month post-transition support agreements between SLPs and the TI programs that provided some ongoing support, particularly to community mobilization. BMGF provided three further years of limited support for community strengthening focusing on specific elements such as fund-raising, but the long-term future of community mobilization is unclear.Finally, our data suggest that core services (condom distribution and peer counseling) provided by TI programs continued at similar coverage levels post transition.Many of the lessons from this evaluation echo those of the program implementers. We idenExtended timeline and phased transition—The extended (2009–2013) timeline allowed for substantial transition preparation. Further, the phased nature of the transition facilitated learning and feedback based on prior transition rounds. We observed increasing investment in and a more standardized approach to transition preparation, as both Avahan and government actors learned what was necessary to support transitioning TI programs and acted upon this learning in later transition rounds. The extended timeline also supported the development of trust between stakeholders and open lines of communication.Substantial investment in transition preparation–Avahan made a major investment in preparing the program for transition, particularly focused on aligning the program, ensuring clear communications and agreements with local stakeholders, and enhancing capacity of local partners to manage the program. Specific transition management strategies emerged after the 2009 transition round and were systematized in a Common Minimum Package for transition ahead of the 2012 transition round.Commitment to transition–Avahan was fortunate to transition to a government that already had strong policy commitments to HIV/AIDS prevention that aligned with Avahan’s own goals. Moreover, the Government of India was prepared and willing to take over the funding and operation of Avahan services. However, this was not purely luck–Avahan sought to shape the policy environment to ensure strong commitment to prevention among HRGs by actively engaging in the development of NACP III. It also signaled a strong commitment to transition, through the memoranda of cooperation that helped convince all actors of the seriousness of transition plans.Communication and trust–communications between key partners at state level , as well those running TI programs were relatively strong and improved over time. Initially, during the 2009 transition round, state level actors demonstrated mutual suspicion, but the need to work together in the transition process meant that gradually trust between actors grew and highly collaborative working relationships were established. Specific activities to build communication and trust between those transitioning the program and those receiving it may be beneficial.Adaptability and willingness to provide additional support in key areas—the initial Avahan transition strategy did not address community mobilization differently from other program elements. However, it became apparent during the transition process that government was less well placed, both in terms of orientation and expertise, to support community mobilization activities than the Avahan program. Avahan demonstrated flexibility by seeking to address this issue which was not part of the original plan. The post-transition support agreements, which had a strong focus on community mobilization helped mitigate, although perhaps only temporarily, some of the negative consequences of transition for community mobilization.suggest that a high degree of transition preparedness contributes to smooth transition and the sustainability of program coverage.There are several limitations to the evaluation. Taking a broad perspective, this evaluation had an adequacy design, and we There were a number of specific design weaknesses in the evaluation. First, while we assessed the amount of training provided, trainings do not necessarily translate into higher capacity, and we have no data on the impact of training on skills. Second, there was limited buy-in to the evaluation from the Government of India and this restricted opportunities for checking interpretation of data with government stakeholders and made it difficult to secure national or state-level data on TI service coverage post-transition. Thus, we were not able to compare the data collected from the transitioning Avahan TI programs with the broader population of TIs. Third, the evaluation did not measure the extent to which key Avahan practices were conducted prior to transition and instead relied on TI manager recall of how things had changed. Fourth, this evaluation collected data from TIs immediately before transition and approximately one year post-transition; however, many program changes were still transpiring at this time, and the Indian health system is also changing rapidly, thus the true long run effects of transition may still be emerging.Finally, some features of the Avahan context including the high-level government policy commitment to HIV/AIDS prevention, the availability of significant government funding to support this commitment and relatively high government capacity  may limit transferability to other contexts.Transitioning a donor-funded and managed program to a country government frequently entails substantive changes in financing, management and clinical services. There is clearly a risk that such transitions disrupt services and undermine program sustainability. The expMultiple donors are currently considering how best to transition or graduate health programs, particularly in middle-income countries. There are very few evaluations similar to the one described here, and our understanding of the factors supporting effective program transitions is still nascent. Further monitoring and evaluation of transitions should be conducted to inform future strategy.S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S3 Table(PDF)Click here for additional data file.


Diarrhea remains a leading cause of death among children under five in India. Public health sector is an important source for diarrhea treatment with oral rehydration salts (ORS) and zinc. In 2010, Micronutrient Initiative started a project to improve service delivery for childhood diarrhea management through public health sector in Gujarat, Uttar Pradesh (UP) and Bihar. This paper aims to highlight feasible strategies, experiences and lessons learned from scaling–up zinc and ORS for childhood diarrhea management in the public sector in three Indian states.The project was implemented in six districts of Gujarat, 12 districts of UP and 15 districts of Bihar, which includes 10.5 million children. Program strategies included capacity building of health care providers, expanding service delivery through community health workers (CHWs), providing supportive supervision to CHWs, ensuring supplies and conducting monitoring and evaluation. The lessons described in this paper are based on program data, government documents and studies that were used to generate evidence and inform program scale–up.140 000 health personnel, including CHWs, were trained in childhood diarrhea management. During three years, CHWs had sustained knowledge and have treated and reported more than three million children aged 2–59 months having diarrhea, of which 84% were treated with both zinc and ORS. The successful strategies were scaled–up.It is feasible and viable to introduce and scale–up zinc and ORS for childhood diarrhea treatment through public sector. Community–based service delivery, timely and adequate supplies, trained staff and pro–active engagement with government were essential for program success. Diarrhea remains one of the leading causes of death among children under 5 in the world, causing 9.2% of total under 5 child deaths . In IndiIt has been found that zinc when given for the treatment of diarrhea reduces diarrhea mortality by 23%, decreases the severity of the initial episode, and may prevent future diarrheal episodes in the 2–3 months following supplementation [ORS is a simple, proven treatment that can be used to prevent and manage dehydration and decrease in diarrhea mortality. In a meta–anlaysis of ORS intervention studies, 69% pooled relative reduction has been noticed in diarrhea mortality in communities in which ORS was promoted compared with comparison areas. Use of ORS also results in 29–89% relative decreases in referrals to health centres in the intervention areas. .To manage childhood diarrhea and reduce diarrhea–related mortality and morbidity, WHO and UNICEF have recommended the use of both ORS and zinc for diarrhea treatment , which hMicronutrient Initiative (MI) has been a pioneer organization in demonstrating childhood diarrhea management with zinc as an adjuvant to ORS among large populations, and understanding its feasibility for scale–up through the public health sector  and anganwadi workers–AWW). MI has implemented childhood diarrhea management projects in the three Indian states of Gujarat, Uttar Pradesh (UP) and Bihar.The programs focused on:• Creating a positive enabling environment, building commitment and sustainability for diarrhea management in the implementation states, and• Improving availability of supplies at the point–of–care for treating childhood diarrheaThe lessons from these projects along with earlier demonstration projects helped to facilitate the scale–up and mainstreaming of therapeutic zinc supplementation and oral rehydration for treatment of childhood diarrhea through public sector channels. In all three states, the care seeking for childhood diarrhea in private sector is high (Our study aims to highlight: 1) feasible program strategies which could be used to strengthen and scale–up childhood diarrhea management program, and 2) key lessons learned in scaling–up of zinc and ORS treatment for childhood diarrhea through the public sector.The methodology adopted includes use of program monitoring data, findings of research studies, government documents and data from government surveys to provide evidences for key achievement and draw lessons and conclusions. The main sources of data used in the paper include program reporting and monitoring through government system, periodic supply audit studies and other research studies carried out through external research organizations under this program such as rapid assessment of treated child diarrhea cases, caregivers practice and acceptability of frontline workers as credible providers and process evaluation of supportive supervision under childhood diarrhea management program.Key strategies and challenges faced under the program have been described to give better understanding of implementing the program at scale.The project was implemented in UP and Gujarat between 2010 and 2014 and in Bihar between 2010 and 2015. In Gujarat and Bihar, the projects were initially implemented in 6 and 15 demonstration districts, respectively and subsequently scaled–up across the entire state by the respective state governments. In UP, the program was implemented in 12 districts under the Diarrhea Alleviation through Zinc and ORS Therapy (DAZT) project  workers,• Extending service delivery to communities through frontline workers and at health facilities,• Ensuring supplies of ORS and zinc at all levels,• Providing supportive supervision to community health workers,• Conducting monitoring and evaluation activities.One of the objectives of the program was to ensure enhanced knowledge of service providers on zinc and ORS. This included enabling providers to prescribe zinc and ORS for treating childhood diarrhea and to undertake necessary counseling of caregivers for using these products. A formative research study was conducted in five demonstration districts of Bihar as a part of the program to better understand issues pertaining to knowledge, attitude and practices (KAP) prevalent in the community and among service providers regarding childhood diarrhea management . The ForAn ‘NGO model’ was utilized for the trainings such that professional trainers from select NGOs were hired to train health providers at district and sub–district levels. This was done since medical officers working in the public sector may not have the time or inclination to conduct a large number of trainings in addition to their routine work, and could not necessarily be expected to carry out trainings on such a large scale. However, medical officers were engaged as an expert resource during training sessions. As a result, 144 246 health providers were trained in the intervention districts of UP, Bihar and Gujarat. These providers included medical officers, auxiliary nurse midwives (ANMs), child development program officers (CDPOs), supervisors and anganwadi workers (AWWs) from ICDS and accredited social health activists (ASHAs). All trainings were completed during 2011–2012 except in four UP districts. Prior to this program, childhood diarrhea management was predominantly carried out at the facility–level and CHWs were largely restricted to conducting community mobilization work.One of the major objectives of the program was to enhance the use of zinc and ORS in the public sector for childhood diarrhea treatment. To achieve this, community level health workers including Accredited Social Health Activists (ASHAs) that work for the health department, and Anganwadi Workers (AWWs) that work for the department of woman and child development were involved in the program as service providers to increase public sector care seeking practices. During the program, ASHAs and AWWs were trained and supplied with zinc and ORS to manage diarrhea cases in communities, in addition to facility–based programs. The roles of CHWs included managing simple cases of diarrhea with ORS and zinc, identifying cases of moderate and severe dehydration for referral, and counseling of caregivers on appropriate diarrhea treatment and feeding practices during illness episodes. Thus, in the three states, service was delivered through a network of 66 418 ASHAs, 75 685 AWWs, 9516 health sub centers (HSCs), 918 primary health centers/community health centers (PHCs/CHCs) and 44 district–level hospitals in 33 demonstration districts.Ensuring adequate and timely supplies of zinc and ORS was one of the major project strategies, which, along with supply chain management, are essential for ensuring continuous availability of zinc and ORS across all levels of the public health system.In the beginning, MI introduced initial supplies in the form of combi–packs of zinc and ORS in 10 of the 15 demonstration districts of Bihar, 4 of the 6 districts of Gujarat and 8 of the 12 districts of UP. A total of 3 157 750 combi–packs were distributed. These combi–packs contained 14 tablets of taste–masked dispersible zinc (20 mg each), 2 packets of ORS, one measuring cup and an instruction leaflet. An additional 600 000 zinc tablets were distributed in the remaining 2 districts of Gujarat to be co–packaged with ORS supplies from the Gujarat government. Subsequently, in all the three states, MI facilitated incorporation of budgets under the National Health Mission (NHM) Project Implementation Plan (PIP) for procurement of ORS and zinc. After the first year, the government, in all three states, procured supplies. In Bihar, the state government procured and distributed zinc syrup for the treatment of childhood diarrhea. MI assisted the states to improve forecasting of zinc and ORS demand in order to strengthen procurement based on the child population estimates, diarrhea incidence, and care–seeking rates. It was ensured that states have rate contracts for zinc and ORS in place.CHWs require continuous support and guidance to sustain their knowledge levels in order to effectively manage diarrhea cases. To this end, a mechanism of supportive supervision was envisaged through a network of supportive supervisors at the sub–district level. A ‘partnership model’ was followed in UP and Gujarat, where supportive supervision was implemented in partnership with NGOs having a state–level presence, whereas in Bihar this support was provided using the existing cadre of government functionaries at PHCs called Block Community Mobilizers (BCMs) . Supportive supervisors visited CHWs and provided one–on–one support to them and interacted with caregivers to understand their level of adherence to zinc treatment. In addition, they also addressed gaps in CHW capacities during group meetings. Supportive supervisors were provided with a checklist to be completed during supportive supervision visits in order to identify existing knowledge gaps. This checklist captured data on CHW knowledge, skills and availability of supplies.During each visit, a supportive supervisor was expected to meet at least three field workers and one or two caregivers who had visited CHWs with sick children. In the three states the number of ANM, ASHA, AWWs and caregivers reached through supportive supervision visits is shown in The sites visited for supportive supervision were planned each month and priority was accorded to poor performing frontline workers. The findings from supportive supervision visits were used to give one–to–one feedback as well as group feedback during monthly meetings with the frontline workers. Data was analyzed and findings were shared at national, state and district levels to understand program issues and to suggest mid–course corrective actions.A Health Management Information System (HMIS) exists in the public health system for all three states in order to report on public health service delivery. However, HMIS captures data reported by ANMs at health sub–centre and above facilities but do not have a formal reporting tools for CHWs who were also involved in service provision under the project. Hence simple pictorial formats were developed to facilitate childhood diarrhea reporting by semi–literate CHWs. In addition, HMIS did not include indicators to track progress of key program aspects, such as dehydration levels and the number of diarrhea cases treated with both zinc and ORS. Therefore, a project reporting mechanism was developed to effectively track performance from all service delivery points, including CHWs using pictorial formats.Trainings were provided to health care providers at all service delivery levels, including the CHWs who received close support through the supportive supervision mechanism previously described. A large number of cases were reported through this system from the beginning of the project in all three states. The Government of Bihar has involved CHWs for service delivery in the scale–up districts and has also introduced simple pictorial reporting tools based on the utility of this program reporting mechanism.In Bihar, the government has added the following new HMIS indicators in that state:• Number of cases of childhood diarrhea with no dehydration,• Number of cases of childhood diarrhea with some dehydration,• Number of cases of childhood diarrhea with severe dehydration,• Number of cases of childhood diarrhea treated with both zinc and ORS,• Number of cases of childhood diarrhea referred,• Number of ASHAs reported ORS stock–out (lack of ORS availability),• Number of ASHAs reported zinc stock–out (lack of zinc availability).Currently the program is attempting to streamline and sustain the government HMIS reporting. In addition to reporting, data collected under supportive supervision and research studies also contributed to overall program monitoring in order to understand its progress and to take corrective actions as required. Program evaluation studies planned under this program were conducted by The Johns Hopkins School of Public Health (JHSPH) and results are reported elsewhere .This section describes key achievements and lessons learned from the programs in three states.Regular supplies increase diarrhea cases appropriately treated. Regular availability of zinc and ORS in the public sector is critical for the treatment of diarrhea cases with both zinc and ORS. Program data report that 593 030 childhood diarrhea cases received treatment in 6 demonstration districts of Gujarat between November 2011 and September 2014. More than 99% of these cases were treated with both zinc and ORS. In 12 demonstration districts of UP, 907 295 diarrhea cases reportedly received treatment between December 2011 and September 2014, and 86% of these cases were treated with both zinc and ORS. In Bihar, 1 796 563 cases were reported to have received treatment in 15 demonstration districts between August 2011 and September 2014, and 77% were treated with both zinc and ORS. Importantly, public sector service providers in intervention districts reported only those cases of childhood diarrhea that were provided with any treatment and cases not given treatment were not reported. In Gujarat, the higher percentage of childhood diarrhea cases treated with both zinc and ORS was largely due to the uninterrupted availability of zinc and ORS in that state compared to UP and Bihar that had supply interruptions  are unable to store supplies required for replenishing unanticipated stock–outs .• Lack of an effective mechanism of tracking availability of supplies with CHWs and timely replenishment of stocks at service delivery points in the case of stock outs: The HMIS and drugs logistic management system (DLMS) does not track CHW supply availability, which is a major impediment for replenishing CHW stocks .Lack of available zinc and ORS weakens caregiver trust and reliance in the quality of public health care services, which adversely affects care–seeking at the public sector. A recent study  on care–These results indicate the importance of regular zinc and ORS availability for increased public sector care seeking by improving the credibility of CHWs among caregivers and boosting confidence of the CHWs to act as well–equipped service providers.A large number of health providers were trained in the program as previously described. These trainings were conducted with the help of external trainers who were supported technically by government medical officers, which facilitated the completion of trainings within the stipulated short timeline and with quality assurance. Though baseline data on CHW knowledge level is not available, data collected during supportive supervision visits provide information on knowledge levels of CHWs. During supportive supervision visits, information on CHW knowledge and capacity was collected using a checklist by block community mobilizers (BCMs) in Bihar and by NGO partners in Gujarat and UP. In Bihar nearly 100 BCMs placed at block level in 10 districts undertook a maximum of four supportive supervision visits each month. In Gujarat and UP, 20 and 27 supportive supervisors, respectively, undertook field visits for approximately 20 days in each month. During each visit, a supportive supervisor was expected to meet and collect data from at least three field workers  and to meet with one or two caregivers who attended CHW services. These data were analyzed on a monthly basis and generally showed sustained CHW knowledge and skills, which indicates the good quality of training provided under the program , 57% in UP (July 2013) and 82% in Gujarat (June 2013) were able to report cases using the standard form, and the remaining were not able to submit the report. CHW report submission can be further improved by streamlining the reporting mechanism, ensuring availability of reporting tools and close supervision to enhance their capacity on case reporting. A review of integrated community case managemnt in sub Sahara African countries also highlights that involvemnt of reporting by CHWs can strngthen HIMS, if CHWs are provided simple reporting tools and have a few selective indicators to report .Enhances caregiver access and reach of public health services for childhood diarrhea management. Involving CHWs in service provision for childhood diarrhea management helps increase caregivers access to services and the reach of the public health system. A rapid assessment study conducted by MI in Gujarat and UP suggested that caregivers prefer receiving free–of–cost services closer to home from CHWs [rom CHWs . Making Probably a component of behaviour change communication as a part of program strategies would have contributed to increase in caregivers’ awareness thereby resulting in greater demand for zinc and ORS for management of childhood diarrhea.In order to ensure government ownership from the program outset, attempts were made to continously engage the government at all levels. At the start of the program, Memoranda of Understanding (MOUs) were signed with the state governments of Gujarat and Bihar. The program was also reviewed regularly at the block, district and state levels, which helped strengthen service delivery. In addition, information on program performance was also shared regularly with districts and state level authorities. This continuous engagement with the government and regular sharing of progress achieved has been important for ensuring government ownership, and has paved the path towards the program scale–up.For the purpose of scale–up, the program have focused since its outset in generating evidence of program performance, ensuring buy–in from the government on program strategies, and enhancing capacity of government functionaries. Generating early evidence on effectiveness and regularly sharing these updates with government counterparts has facilitated the government’s decisions for scale–up of specific program strategies. Despite the challenges in procurement, affecting the program achievements, in UP and Bihar the following strategies have been scaled–up by all the three states to facilitate program expansion across districts :• CHW involvement in service delivery is now implemented across the entire states of UP, Bihar and Gujarat• Estimation of zinc and ORS stocks and supply provision to all service delivery points• Regular reporting mechanisms of cases through the HMIS in Bihar• Service provider trainings in childhood diarrhea treatment using ORS and zincThe state governments have earmarked budgets for the procurement of zinc and ORS across districts in order to scale–up program strategies. Bihar, Gujarat and UP governments have incorporated these program activities in their annual plans and have submitted budget proposals to the Government of India for implementation across all districts. The Government of India has approved these proposed budgets for 2012–2013 and subsequent years .The advocacy efforts undertaken and technical support provided by MI and other development partners at national levels have resulted in the development of operational guidelines by the Ministry of Health and Family Welfare, Government of India . These g• Zinc specifications included in the Indian pharmacopeia: Due to this change more Indian pharmaceutical companies can start production of therapeutic zinc • Zinc included in the essential drug list: The Government of India has included zinc in the list of essential medicines . This wi• Indicators on zinc usage included in large–scale national surveys   and DistInformation on certain aspects of program has been collected only during the implementation of the projects across the three states and detailed information on these aspects, like stock out of zinc and ORS, reporting of the cases treated with zinc and ORS, cases of childhood diarrhea treated by CHWs, knowledge level of CHWs on management of childhood diarrhea is not available prior to the initiation of the project implementation. Since data collected during the evaluation studies is being published as a separate paper on evaluation findings in this same issue of the journal, hence evaluation data has not been used in this paper. This paper is largely based on program monitoring and data collected through government functionaries which may have some limitations.This program shows that management of childhood diarrhea using zinc as an adjuvant to ORS when implemented through CHWs in addition to improved services provided through public health facilities, leads to increased service accessibility by the community and increased credibility of the public health system resulting in increased coverage .Prior to the initiation of these projects, the use of zinc and ORS for management of childhood diarrhea was not a focused intervention under the government system in the program states. The exposure of government functionaries on use of zinc and ORS for management of childhood diarrhea was therefore limited and the overall use of zinc was low in all the three states. Some of the critical strategies which were implemented across the states like facilitating procurement of supplies by government, capacity building of service providers and managers across cadres, introduction of simple reporting tools for CHWs, program monitoring and review helped in improving knowledge of service providers and increasing uptake of zinc and ORS.The professional trainings imparted through the program improve CHW capacities and enhanced their skills and knowledge thereby increasing their acceptance in the community as health service providers. However, such outcomes are possible only if there is government ownership of the program, quality training of health service providers, timely and adequate procurement of quality products, timely distribution, an efficient tracking mechanism to identify stock–outs for replenishment, routine monitoring and critical reviews at all levels regarding quality of training provided to service providers.The strategies adopted under the program have resulted in increased utilization of public health services and use of zinc and ORS for childhood diarrhea treatment. These program outcomes could have further increased if these were supported by activities to generate community awareness on use of zinc and ORS for childhood diarrhea and its availability at public health providers. However, the program did not have any Behaviour Change Communication (BCC) component, other than interpersonal communication, as a part of program strategies. Inclusion of behaviour change communication strategies would have contributed to increase in caregivers’ awareness thereby resulting in greater demand for zinc and ORS for management of childhood diarrhea. This has also been substantiated by an evaluation study on caregiver awareness generation activities carried out in 11 blocks of five districts of Gujarat which reflects increased coverage of zinc and ORS for childhood diarrhea at public sector as a result of caregiver awareness generation activities .This program experiences reflect that it is feasible and viable to introduce and scale–up therapeutic zinc supplementation as an adjuvant to ORS in the management of childhood diarrhea through the public sector. Some of the components which are likely to be sustained beyond the program period under the donor funded childhood dairhoea management program in the three states include knowledge level of service providers, engagement of community health workers for service delivery and reporting through HMIS. It is because some of these components have got included in the government program implementation plan and Government of India has developed and rolled out operational guidelines for childhood diarrhea management and has launched the programs such as India Action Plan for Pneumonia and Diarrhea (IAPPD) and Intensified Diarrhea Control Fortnight (IDCF) which has given significant impetus and brought renewed focus on Childhood diarrhea management.Demonstration projects like the one reported in this paper, play a critical role in generating early evidence to influence government decisions for scale–up of programs and accelerate necessary policy changes.