To make sustainable change in public health systems, first change your mind

In order to improve equity and access to primary health care for the most under-reached people, public health systems in most countries need massive changes. Today, there are more innovators working toward this end than ever.

But for all the innovation and demonstrated impact in the health sector today, and despite the proliferation of successful pilot programs, only a small fraction of innovations are ultimately sustained. To increase this sustainability rate, social innovators must ultimately transition the management and/or operation of their successfully piloted programs to government teams.

Here, transition is defined as the process of integrating a proven solution into an existing public health care system. Transitioning Well, then, describes an implementation based on current best practices that results in the smooth transition of solutions from social innovators to government. 

Transitioning Well is hard but possible

Transition is, of course, hard; it also takes time and money. The complexity of collaborating with stakeholders across government, the private sector, civil society, funders, and non-governmental implementers—and the changing personnel and priorities thereof—presents a high hurdle for social innovators to clear on their Journey to Scale. This barrier exists alongside others, including funding gaps, status quo thinking, inhibiting regulations, and more. All can be compounded by ineffective governance and historical inequities. 

At VillageReach, we know these challenges well. But we also know they can be overcome. Our Transitioning Well team currently supports more than 21 VillageReach programs; since 2019, we’ve successfully guided three programs through transitions to government, the private sector, and local ownership, respectively. We know technological and organizational innovations have a better chance of reaching sustainability at scale when we shape innovations with their future transition to government in mind. It’s an approach that produces better, more sustainable solutions and also improves the health systems of which they ultimately become a part.

What have we learned along the way? 

Our work with governments, social innovators, and donors throughout the public health sector reveals that realizing a more successful transition requires a shift in deeply-entrenched power dynamics between these different stakeholder organizations. It also requires a shift in mindset.

In order to change health systems for the better, we first have to change how we think about the role of social innovators and their organizations in solving public health problems, and where government, the private sector, and philanthropy fit into successful innovation. 

Insight 1: Feel the fear and do it anyway

One of the biggest barriers organizations face in scaling health care innovations is embracing the fear of letting go. They are often hesitant to cede control of their innovations, worried that they will fall apart in someone else’s hands. They may also be concerned about working themselves out of a job, losing funding, and ultimately losing their own identity and purpose.

Overcoming these fears and maintaining progress on the Journey to Scale requires a mindset shift on the part of an organization: government transition creates more opportunities for growth than risks of stagnation. And in fact, there is risk in standing still—status quo thinking on the part of organizations can result in “continuation bias,” which can undermine innovations’ credibility and stifle their adoption. What’s more, as the funding landscape changes and more funders build government transitions into their global public health strategies, this mindset shift may become a key qualifier for continued funding into the future.

Transitioning Well raises fundamental questions about social innovators’ missions and values, but rather than confronting these questions from a place of fear, organizations need to consider the possibility they present. By aligning missions and working with government to build local capacity, innovators can help to create a sustainable workforce to continue delivering services long after non-profits or technical delivery partners have left. 

Insight 2: Transition is the end goal; start with it in mind

When designing for sustainability, VillageReach proceeds from a simple rubric: “An innovation for the public health system belongs to the government.” It is tempting to think of transition to government as a one-time event that happens at the end of a program, but by planning for transition and co-developing either from the moment of program design or when embarking on conversations with funders, organizations can ensure that their solutions have lasting impact. An organization may have a strong vision for their innovation, but a shared vision with government at the early stage is critical for success down the line.  

When social impact organizations design solutions without an understanding of government health priorities, policies, and structures, the sustainability rate is virtually guaranteed to be zero.

In contrast, social innovators who set out with government ownership as their solution’s end state, and explicitly work toward that goal by embracing government in the role of co-creator, can take advantage of ongoing opportunities to realign their priorities with those of the government and in so doing play an active role in creating a sustainable home for their work.

Insight 3: New practices are needed for social innovators, donors, and governments

• A new measure of success for innovators: If the target end state of a social innovation changes, so too must our definition of its success. Early and ongoing consideration is needed not only of whether a solution is impactful, but whether it can be integrated into a health system within a manageable timeframe and continue having impact. Time to impact at scale needs to become a standard indicator. Reinventing how we define successful innovation, and keeping the government and community’s best interests in mind when doing so, requires agility from funders and delivery organizations to change lanes in line with government expectations. 

• Funders that go beyond pilots and proof of concept efforts to support transition: Transitioning Well requires commitment on the part of funders, placing trust and value in organizations’ relationship with government. Rather than using monitoring and evaluation as a tool of accountability, funders need to also see it as a tool for learning and adapting the interventions they fund. By providing the time and financial resources necessary to transition solutions to government, funders will drive an increased focus on innovations that are truly fit for purpose in the country context. The need for longer-term funding may require tighter cross-donor coordination and pooled funding. 

• Governments willing to answer hard questions early on: Even with visionary innovators and willing donors, government has some tough decisions to make about whether to adopt an innovation. The decision to adopt should come before discussions of scaling and transition. Is there sufficient government motivation and capacity to change regulations, people, and processes to integrate an innovation into a health system? Given scarce resources, can the government afford the ongoing operating costs?  

Ultimately, the ability to develop and prove the best solution possible cannot be our sole focus. But early and on-going consideration must be given to the ability of government to own, manage, and operate that solution.

Shifting mindsets, changing lives

Transitioning health care innovations to government is one of the biggest unresolved issues blocking progress in public health systems, particularly in low- and middle-income countries. The Journey to Scale with government will look different for each innovation and country and will require strong collaboration between donors, implementers, partners, and communities. But by changing mindsets, we can start turning the tide and move from a landscape littered with pilots that stopped when the funding ran out to a new paradigm which enables greater access to health care for all. 

To learn more about the Transitioning Well approach, visit VillageReach.

Carla Blauvelt is the Director of Global Programs at VillageReach. She designed VillageReach’s Transitioning Well initiative. She directly oversaw the transition of two of VillageReach’s flagship solutions to the Malawi MoH and a local NGO when she was the Country Director for VillageReach Malawi. Externally, Carla supports the SDG3 Sustainability Technical Working Group, the WHO Innovation Forum Call to Action Steering Committee, and the HealthTech Hub Africa’s Blueprint for Scaling Innovation. She has guided many governments, donors, and organizations on sustainability approaches.

Joseph Roussel is the Director of Private Sector Engagement at VillageReach. He is a lead developer of Transitioning Well tools. He is also a Transitioning Well coach to VillageReach programs in the DRC, Mozambique, and Côte d’Ivoire. Joseph supports program teams as they engage with private sector firms, donors, government, and technical partners. He has contributed to several global goods for Transitioning Well and led sessions for donors, international agencies, and implementers on how to integrate Transitioning Well into their grant-making, grant management, program planning, and program execution.