Periodic Review ccm request template

SECTION 5: CURRENT PHASE/IMPLEMENTATION PERIOD PERFORMANCE (PR 1 - NDOH)
5.1 Programmatic Achievements and Management Performance
5.1.1 Programmatic Achievements

Provide an overall assessment of the progress of the PR during the current Phase/Implementation Period based on the key programmatic indicators in the Performance Framework.

The overall programmatic performance for SSF phase 1 (July 2011 to December 2013) is reflected in the table below:

Table 19: Programmatic performance using performance framework indicators NDOH

	Indicator	Target	Achieved	%
1	# of people reached through school-based programmes	425 000	494 385	116.3%
2	# of people reached through community based programmes	184 448	246 720	133.8%
3	# of condoms distributed	64 025 856	28 107 384	43.9%
4	# of Voluntary Counselling & Testing (VCT) counsellors trained	547	982	179.5%
5	# of people receiving HCT, including provision of results	67 000	82 661	123.4%
6	Proportion of pregnant women tested for HIV	100%	98.6%	98.6%
7	% of people tested for TB and who receive TB treatment	100%	90.1%	90.1%
8	# of NGOs and service providers providing HIV/AIDS prevention treatment, care and support services supported	722	1 283	177.8%
9	% of pregnant women assessed for eligibility of antiretroviral therapy	95%	79.1%	83.3%
10	% of HIV pregnant women who received ARVs to reduce the risk of mother to child transmission	95%	80.1%	91.7%
11	% of infants born to HIV-infected women who are started on cotrimoxazole prophylaxis within 2 months of birth	100%	80.1%	80.1%
12	# of health professionals trained	540	422	78.1%
13	# of facilities utilising electronic ARV Register	450	820	182.5%
14	# of adults & children with advanced HIV infection receiving ART	2 246 084	2 205 548	98.2%
15	# of Health Care Professional reporting on Adverse Drug Reactions	342	69	20.2%
16	# of Health Professionals trained on PMTCT and quality improvement	5379	0	0%
17	# of Health workers and managers trained on quality assurance	1000	0	0%
18	# of Community PLHIV support groups established and active	2 500	989	39.6%
19	# of Health and other professionals trained in programme management	2 592	2 624	101.2%
20	# of Support staff (Lay Counsellors, Peer Educators, Treatment Literacy Practitioners, etc.) trained in programme implementation and management	5 500	6 046	109.9%

For the 6 quarters ending on 31 December 2012, cumulative achievement on the grant’s 20 performance indicators is provided in the table below. GF Top Ten indicators are highlighted in yellow.

Please provide a description of the related actions the CCM/RCM/sub-CCM will take, in its oversight capacity, to address these identified performance issues?

Prevention

Phase I of the SSF grant was implemented from July 2011 to December 2012. During this implementation period, five civil society organizations and the principal recipient (PR) implemented programmes at community level through community-based outreach programmes and in health facilities. The implemented Service Delivery Areas (SDAs) under the prevention strategy focused on Community outreach, Condom distribution, PMTCT, Counselling and testing and Strengthening of civil society and institutional capacity. The indicators were developed in line with key prevention strategies in order to track the implementation progress and performance.

Per the table above, five (5) of the performance of prevention strategies indicators exceeded 100%. These are: Number of people reached through school-based programmes (116%), Number of people reached through community based programmes (134%), Number of VCT counsellors trained (179%), Number of people counselled and tested for HIV, including provision of results (123%), Number of NGOs and service providers providing HIV/AIDS prevention treatment, care and support services supported (178%). The above level performance is attributed to the holistic approach by programmes to implement activities using other sources of funding despites the non-disbursement of funds from the Global Fund. Programmes implemented activities through school based media, community outreach and institutions to reach the ultimate goal of reducing new HIV infections.

The indicator, Number of condoms distributed, reported a significant underperformance. The PR only managed to distribute 44% of condoms against the set target. The under achievement was as a result of procurement challenges and shortage of Latex material in East Asia which negatively impacted the production and distribution of condoms in South Africa.

The performance of the PMTCT indicators; Proportion of pregnant women tested for HIV (96.7%); Percentage of pregnant women assessed for eligibility of antiretroviral therapy (79.7%); Percentage of HIV pregnant women who received antiretroviral to reduce the risk of mother-to-child transmission (93.5%) and Percentage of infants born to HIV-infected women who are started on cotrimoxazole prophylaxis within 2 months of birth (84.2%) are within acceptable levels. The programme’s performance in achieving its target has been satisfactorily throughout the grant period due to programme’s intensified efforts in improving the lives of pregnant women and children.

The indicator, Percentage of people tested for TB and who receive TB treatment under the HIV & TB Case finding SDA achieved an acceptable performance level of 90.5%. The programme strengthened TB testing and as a result managed to test a significant percentage of people who were also initiated on treatment.

Care and Support

Only one (1) indicator was developed to measure the performance for this service delivery area. This is “the number of community PLHIV support groups established and active”. One SR implemented this activity and demonstrated an achievement of 40% against the set target of 2 500 support groups. Failure to reach the expected target is associated with the scale down of the activity of TCE Programme by the implementing sites as a result of the delays in the training of caregivers, who are the drivers for this activity. The delay in approval of the training plan exacerbated the situation and slowed down the establishment of PLHIV support groups. This led to the poor performance against the set target.

Treatment

The two implemented Service Delivery Areas (SDAs) under the treatment strategy are ART and monitoring and Pharmacovigilance. The programme on ART performed very well and about 1 900 000 adults and children with advanced HIV infection received ART by the end of December 2012. This translates to 98% of set performance target. The performance of 98% is an indirect measurement of ARVs procured by the PR using its fiscal allocation. By the end February 2013, GF contribution on this activity (ARV drugs) had not reached the intended recipients (patients). The 98% performance signifies commitment of the NDOH in treating patients who are in need of the treatment. It is clear that GF resources will push the performance to higher levels when they finally reach intended clients. However, the achievement made thus far is attributed to the continued stigma reduction strategies, improved care and treatment guidelines and the rollout of the TIER systems, which improves reporting of data.

Health Systems Strengthening (HSS)/Health Workforce

An area where the programmes performed poorly is Health System Strengthening and Training. There has been a delay in the approval of the PRs training plan by the GF secretariat and this severely undermined the performance that the PR aimed for. However, the use of other funders’ monies assisted the programme to implement training activities. The approval of the training plan was only granted in November 2012 and SRs faced a challenge of arranging and conducting trainings.

Although SRs had demonstrated commitment to implement the training activities and meet the set targets through their accelerated implementation plans, the delays have long-term effects. During the implementation period two (2) indicators reported zero achievement. These are: Number of Health Professionals trained on PMTCT and quality improvement and Health workers and managers trained on quality assurance. Two (2) other indicators however achieved performance levels of 100%. The performance was achieved for Number of Health Professionals trained in programme management (101%) and Number of Support staff trained in programme implementation and management (110%). The achievement was made possible with other sources of funding. About 919 of the targeted
1 054 Health Professionals (master trainers and data capturers) were trained on the implementation of the tier system. This is a performance of 87% for this activity that translates to a good performance of the roll out of the Tier system explained above. The Indicator under the Pharmacovigilance (PV) SDA was related to training of Health professionals on reporting Adverse Drug Reactions. The activity has not been implemented optimally due to delays in the establishment of the PV unit. It is expected that the establishment of the PV unit will positively contribute toward the realization of the set target on this indicator during phase 1 extension and phase 2 of the implementation plan.

Despite the funding disbursement interruptions and delays, the programmes managed to implement the prevention strategies well. It is clear that most programmes would have performed exceptionally well if the funding was regular and consistent. Indicators however reflected good performance in relation to the funds allocated to activities. The overall good performance is attributed to co-funding mainly as a result of voted funds in internal programmes, use of other funders in mostly external SRs and the application of holistic and effective strategies in implementing programmes.

Please summarize the current challenges in M&E systems and capacity based on any recent assessment undertaken during the current Phase/Implementation Period, and provide an update on status of implementation of M&E systems strengthening recommendations supported through GF grant/SSFs and other partners during the current Phase/Implementation Period. Please also comment on the expenditures on M&E (variances, if any) against approved funding under the GF grant/SSF during the current Phase/Implementation Period.

Current Challenges in M&E Systems & Capacity

Each year, the Local Funding Agency (LFA) conducts on-site data verification (OSDV) for each grant to ensure the quality of data reported by the PR, to assess the accuracy of the results, and adherence to reporting standards as defined in the M&E Plan as well as national and international standards. OSDV process also examines the reporting structures and adequacy of human capacity in the reporting chain. The OSDV process starts at the service delivery points and focuses on aggregated data from the primary source records and makes comparisons with the results reported in the Progress Update and Disbursement Request (PU/DR) Reports.

In 2012 the GF conducted an OSDV and RSQA and country M&E Profile. The results of all these assessments are not yet released or shared with the PMU or PR. However, in preparation for the phase 2 grant funding and expected role shift of the M&E unit of the PMU, the PMU has identified the need to change M&E approaches and existing gaps that should be focused on in order to achieve the desired goals of effective and robust M&E system which the GF is supporting. The identified gaps and changes are at the level of the PMU and programmes level. These are:

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  Inadequate reporting of data by SRs;
  
• 
  Lack of standardizes reporting tools; and
  
• 
  Poor verification of reported data by SSRs which contribute to poor data quality.
  

Addressing the M & E system and capacity challenges:

1. 
   The PMU through technical support provided by USAID is doing the following:
   

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  Redesigning data aggregation tools at PMU level in order to capture a detailed narrative which justifies both over and under achievements of targets, and which will assist the PMU in writing quarterly reports to the LFA and GF;
  
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  Orientation of PMU M&E unit to understand programmatic indicators and data elements so that they can confidently interrogate the quality aspect of reported data; and
  
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  PMU M&E unit to be orientated on principles of conducting evaluations and special studies so that they can provide guidance to programmes.
  

2. 
   At implementation (programme) level, the need to which the PMU is responding covers the following activities:
   

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  Orientation of internal sub-recipients on GF procedures and requirements for quarterly reporting as well as timelines and data quality issues;
  
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  Provide continued support to roll out of tier.net and ART register in order to enable periodic monitoring of clinical outcomes. This register will assist the country to determine HCT uptake, ART initiation rate, current workload; attrition rates trends in drug resistance. As of February 2013 over 1 302 facilities were utilizing the electronic register. When fully operational, the Tier.net system will improve the incomplete data input coverage and feed the data into the DHIS, thereby eliminating the current parallel indicator reporting; and
  
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  Procurement of supportive equipment (central servers and computers) to ease the data management processes and to improve tier.net reporting.
  

Strengthen the M&E unit and programmes within the NDOH: The NDOH hired around 518 data capturers through a contract firm in order to sustain and improve the functioning of the M&E systems at local levels. The department has also contracted 9 ICT coordinators at provincial levels to provide technical assistance to the data capturers.

M&E activities have a budget of $3,596,295. The expenditure of M & E is currently 8%. Low expenditure in this category is due to major studies that are in progress and have not been paid. These include the HCT evaluation study, Final payment to Midterm evaluation study and ART evaluation study. When these studies are completed the expenditure will improve significantly. It is important to note that most of the budget has not been spent because it has not yet been disbursed by the GF. This is severely affecting the optimal functioning of the M&E unit.

5.1.2 Grant/SSF Risk Management

Please comment on the major grant/SSF management risks and issues, if any, including those attached to the CCM Invitation Letter. Describe how you plan to address those risks and monitor progress in the next Phase/Implementation Period.

Programme Management

The biggest risks in implementation of GF programmes relates to the PR’s management of its SRs. The implementation of GF programmes within the NDOH was through management of its SR. The NDOH has reduced the number of external SRs and going forward it has put in place various policies and procedures to minimize this risk. One of the best ways is to develop SR management capacity is through development of specific manuals and guidelines for SRs. This will be supported through rigorous capacity assessments and value-for-money reviews, before any SR agreements are signed. This will be implemented in an on-going basis during implementation of the next phase.

The NDOH will approach the programme-based system in phase 2 by ensuring that future SRs are well coordinated to report and align reports to national systems. This will be made possible with the current funding NDOH is receiving through the GF for implementation of Tier 3 system throughout all health facilities offering ART.

Delay in cash flows due to outstanding conditions precedent: The PR will ensure that all grant requirements are addressed adequately before signing the agreement to limit conditions precedent.

Inadequate Coordination between PRs and SRs: Coordination between the PRs and SRs will continue through formal quarterly steering committee meetings. There will be a standing order of grant management issues to be addresses as well as other pertinent ones. These meetings will also provide an opportunity for experience sharing amongst the SRs. Coordination between PRs and SRs will further be strengthened through implementation of agreed financial and technical reporting systems that are meant to account for and communicate progress on the management and delivery of the grant supported programme. The SRs will be obliged to submit regular (quarterly) financial and technical progress reports to the PRs. Written feedback will be provided to the SRs upon review of these reports. The progress reporting will be complemented by on-site monitoring, mentoring and supervisory visits in order to follow up on matters addressed in the submitted reports. The on-site visits will provide an opportunity for direct interface with individual SRs on grant management and programme implementation issues.

Financial Management

As indicated under programme management, the risk was on management of SRs. The NDOH is developing a plan to further reduce this risk under which the system of payment methods for SRs will vary according to the assessed risk level of the SR. One of the systems is to introduce monthly financial reporting as compared to quarterly reporting. The payment method will be approached firstly as advance payment, in which NDOH makes direct payments to an SR to implement activities, the second payment going forward will be a direct payment, in which NDOH transfers funds to an SR only after invoices are presented and verified. Expenditure verifications will also be intensified.

Most of the challenges which were of major risks during the phase 1 implementation related to a lack of adherence to guidelines of the GF such as avoiding of lump sums in developing unit costs and allocating costs in the right cost categories. The NDOH will provide guidance to internal sub-recipients on unit costs; the breakdown of lump sums into their component parts; and also how to classify cost items within the various cost categories. Proper planning is required to ensure that correct unit costs are developed. This will ensure that there is no over/under budgeting during development of the work plan. In order to improve financial management, there is a need to strengthen financial management training activities during the next phase of implementation.

5.1.3 Grant Performance Rating

Please answer the following questions if you are submitting the CCM Request for a Phase 2 or RCC Phase 2. If you are submitting the CCM Request for Periodic Review, proceed to section 5.2 ‘Financial Performance’.

Grant Performance Rating for the current Phase (Phase 1 of SSF)

A1

A2

X

B1

B2

C