Periodic Review ccm request template
Compliance with Focus of Proposal Requirement
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- SECTION 5: CURRENT PHASE/IMPLEMENTATION PERIOD PERFORMANCE (PR2 - WCDOH)
- 5.1.2 Grant/SSF Risk Management
- 5.1.3 Grant Performance Rating
6.3 Compliance with Focus of Proposal RequirementDescribe whether the focus of proposal requirement has been met per the threshold based on the income classification for the country. Focus on Key populations Sixty percent of PLHIV are women, and women aged between 15-24 years are up to four times more likely to be infected than their male counterparts. Given the disproportionate impact of the HIV epidemic on women, any attempt to move toward universal access will provide a strong benefit to women. In recognition of the still entrenched gender inequalities, particularly around negotiating sexual dynamics, government has developed policies that address sexual dynamics and in particular this proposal prioritizes access to treatment to allow for implementation of the new treatment and PMTCT guidelines. Aggressive implementation of the guidelines will predominantly benefit women through earlier and more effective treatment of women (including the large numbers of co-infected women), as well as pregnant and breastfeeding women. As shown in a 2012 research study, women appear to be accessing ART at a faster rate than men and children78. The gender policy guidelines for the Public Health Sector are a testimony that Government prioritises gender mainstreaming. In particular the National Department of Health’s policy ensures that development of policies and programmes integrate gender and ensure that developed policies are in line with South Africa’s National Policy Framework for Women’s empowerment and Gender equality. Overall the policies’ objective is ensuring equitable attention to the health needs of women and men and girls and boys and equal access to quality of care at all levels of the health system. With regard to monitoring the utilization of health services, the mainstream District Health Information System provides data by age (adults and children), whilst the ART monitoring system, tier.net can provide data by age and gender. Additional information on utilization of health services by gender is provided through independent research such as the ones referenced above.
In addition to combination prevention, ART is a critical intervention in the fight against HIV/AIDS. The 2012 expanded guidelines where ART eligibility criteria changed to CD4< 350, and all pregnant women regardless of CD4 count and TB patients are being initiated on ART are being rigorously scaled-up. Although the early direct costs of an ART programme during a patient’s initiation phase (diagnosis, first four months of treatment) are substantial, there are significant long-term financial benefits as ARV maintenance costs decline considerably after the initiation phase. It has been shown that patients in SA who have CD4 counts above 350 when they start ARVs spend 80% less days in hospital than those being initiated when their CD 4 count is below 50. In addition, the benefits of ART are two-fold, as a highly effective treatment, ART reduces AIDS related mortality and morbidity, whilst simultaneously reducing the rate of transmission and preventing new infections.
The Grant to the Western Cape Department of Health (WCDOH) is a long-standing one, from Round 3 in 2004 to the end of the Rolling Continuation Channel 1 (RCC 1) in June 2013. The table below reflects on the current performance: Table 23: CBR Programme WCDOH
The original Western Cape GF Grant Programme comprised of four intervention Objectives:
Objective 1: Strengthening and expanding the provision of ARV treatment. 1.1 Number of PLHIV receiving ART funded from the GF Grant GF grant funds were allocated toward 20% of ART service provision in the Province, with the WCDOH incrementally assuming responsibility for percentiles covered in the final three years of the Rolling Continuation Chanel (RCC) phase of funding: RCCII. This approach has ensured that the number of people able to access ART was accelerated within the WC. It is projected that by the end of Phase 2 (March 2016) a total of 36 733 people will be enrolled on ART directly as a result of the investment of the GF in the Khayelitsha sites. Khayelitsha, falling within the Metropole District of the WC, serves as a large contributor to the overall prevalence rate within the province, and hence was selected as the geographical area within which ART service provision funds would be allocated. Despite recorded inroads into combating the pandemic, a gradual increase in HIV prevalence across the province continues. In 2011, the prevalence rate specific to Khayelitsha was a high 37.1%. Whilst evidenced that the HIV epidemic is stabilizing within certain geographical areas, there is a continued need for additional allocations in HIV prevalence areas such as Khayelitsha.79
The overall aim of the PMTCT component of the ART objective is to increase the proportion of HIV-infected pregnant women who receive either dual therapy or HAART to reduce the rate of vertical HIV transmission from mother-to-child. During the first two years of the RCCI period, a PMTCT health systems analysis and strengthening intervention was implemented in order to identify and address current service delivery gaps. It is known that many of the service delivery gaps arise from staffing shortfalls in obstetric and neonatal services. Within the RCC period (2012/13), additional nursing personnel have been hired and placed at the appropriate district obstetric and neonatal facilities. Before PMTCT interventions, early infant mortality specifically amongst 2-3 month old babies was high, with these infant deaths attributed to HIV prevalence amongst pregnant women.80 Interventions have been shown to contribute to the progressive decrease of the vertical HIV transmission rate within the province. However, the need for continually ensuring and increasing intervention remains, as demonstrated by the 2011 WCDOH ANC survey (graphic below). 
Figure 12: HIV+ rate per district amongst young pregnant women Objective 2: Strengthen and expand the peer education programme amongst youth in secondary schools Note: the Peer Education Objective will not continue into next implementation period but is reported upon as it provides evidence of Programmatic Achievement within the WCDOH grant. The joint WCDOH and Western Cape Educations’ (WCED) GF Peer Education Programme focused on educating learners ahead of their sexual debut. The learners were provided with the relevant information to make informed decisions and protect them from being infected with HIV. This was inclusive of HIV prevention and life skills issues. The Performance Level Indicator included to: strengthen and expand the peer education Programme among youth at secondary schools. Targets attained in respect of this indicator are articulated in the bullets that follow:
Additionally the GF showcased the GF WC Peer Education Programme as having shown impact (and thereby value for money) in its 2010 GF publication that includes Stories of Innovation and Impact. Furthermore, the Peer Education Programme has successfully been integrated into the WCED with implementation continuing across secondary schools in the Western Cape. The WCED has indicated that GF funding is no longer required to ensure that the Peer Education programme continues to be implemented in the Province. Objective 3: To Strengthen and expand the provision of palliative and step-down care in-patient 3.1 Number of patients admitted for palliative / step-down care to hospices funded from the GF Grant Palliative Care is defined by the World Health Organization as an approach, which improves the quality of life of patients and their families facing problems associated with life threatening illnesses. It is a holistic approach that provides post-acute, respite, restorative & rehabilitative care as well as end of life care. Palliative care is applicable early in the course of an illness like HIV/AIDS. Palliative Care is in line with the requirements of the SA Patients’ Rights Charter that mandates that every person has the right of access to the “provision for special needs in the case of patients in pain” and access to “palliative care that is affordable and effective in cases of incurable or terminal illness”. The need for Palliative/Step Down Care Programmes is especially relevant in the more rural areas of the WC as budgetary constraints delayed the rollout of these services across the province. During the first two years of Phase I, the GF grant supported the provision of palliative / step-down care services from 77 beds in six rural towns in the province. These services are provided by contracted NGO Service Providers who are Sub-Recipients (SRs) of the WC GF grant. Over the course of the final four years of the RCC phase (2012-2016), the WCDOH will incrementally continue to assume funding responsibility for these services. The performance level indicator for this objective sought to strengthen palliative in-patient and home-based care services. Targets, largely attained, include: Table 25: Performance level indicator on strengthen palliative in-patient and home-based care services WCDOH
Objective 4: To strengthen community-based responses to the HIV and TB epidemics 4.1 Number of sub-district with functional Multi-sectoral Action Teams in place 4.2 Number of CBO projects approved for funding from the GF Grant 4.3 Number of CBO projects approved for funding from the GF Grant 4.4 Number of OVC reached through CBO projects 4.5 Number of people reached through CBO income generation projects HIV/AIDS & TB Community Based Response (CBR) Projects CBR Projects focus on those who are most exposed to the impact of HIV/AIDS & TB: for example, Orphans and Vulnerable Children (OVC) and those unemployed due to their HIV/AIDS infection. Its main aim is to empower communities to address their HIV/AIDS and TB related needs, and to implement projects that mitigate the causes and impact of these diseases within the community. Merging a community-level focus with systems operating perspective strengthens district Health Systems. This is achieved through ‘increased community engagement in health care, advocacy, health promotion and health literacy, health monitoring, home-based and community-based care and wider responses to disease burdens’.81 Multi-Sectoral Action Teams (MSATS) were strengthened and supported, operating at a community level, taking forward community based care, health promotion and literacy etc., and are accountable to the local District Health Offices. Through them, the WC Government is able to reinforce existing structures, linking community and additional stakeholders with the formal health system to improve health outcomes. The MSATS relate directly to the mandate of Chapter 5 of the National Health Act: The establishment and support of the District Health Care System. A functioning MSAT is one of the ways that has proven effective in maintaining fairness in adjudication and minimization of potential discrimination / bias towards a tendered project, as well as to ensuring that projects that speak most to the specific needs within a community. Additionally, the MSATs together with the district officials ensure that existing projects which are re-awarded tenders have a proven track record of good performance. The CBR objective is rolled out through small allocations (generally between R50-55 000) per project. During project implementation MSATs have an M&E function ensuring that the projects adhere to the tenants of performance based funding. The MSATS and successful Non Profit Organizations (NPOs) are capacitated by a service provider (NACOSA) who coordinates networking and provides capacitating training programmes specific to needs within each district and NPO. Additionally, NACOSA provides supplementary monitoring and evaluation of NPO interventions. The CBR allocations are intended as bridge funding to help NPOs start (or continue) projects that directly address vulnerabilities emanating from the prevalence of HIV/AIDs. Linking community systems with different levels (formal and informal) of the health system is important for scaling-up and sustainability of interventions. All targets within the strengthen community based responses to the HIV epidemic through the development and implementation of local support projects within specified focus areas performance level indicator are continuously met: Table 26: Performance for development and implementation of local support projects WCDOH
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 Global Fund 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 Global Fund grant/SSF during the current Phase/Implementation Period. Summary of current M&E systems and capacity challenges: The M&E system used for the GF supported Programme is based on the existing provincial DOH's M&E systems and framework. The M&E system has been further built up in order to provide additional information required by the GF. The University of Cape Town was contracted by the PR to carry out various impact evaluations of specific activities carried out within the framework of the four supported objectives. Further feedback mechanisms between the PR and the SRs will be strengthened by the way of more frequent supervision visits and feedback workshops on the SRs' performance while ensuring the quality of reported results. Despite the efforts put in place by the National Department of Health to harmonize M&E plans for HIV/AIDS across South Africa, the systems that include data reporting mechanisms or a full computerized data collection system are not yet fully functional which pose a significant data reliability challenge. However, the WCDOH has undertaken substantive efforts to face this challenge and provided an innovative approach with the establishment of a computerized and centralized data collection system that cascades down to the lowest level of health facility. Furthermore, during the interim period of formation of the GF CCM the Provincial Aids council has monitored the WCDoH GF grant. This body is comprised of relevant civil society organisations and experts within the HIV/AIDS field in addition to WCDOH officials and the Provincial Ministers of Health, Education and Social Development. To fulfil the Global Fund’s M&E mandate the WCDOH is continuously strengthening the M&E system. Additionally the Office of the Inspector General (OIG) report on the WC recommended that the WC GF M&E systems be strengthened further. As part of this endeavour the WC has embarked on refining monthly and quarterly reports, disseminating best practices as identified by the WC and Local Funding Agent (KPMG) as well as building and strengthening a core M&E team within the WC provincial office. In addition to the above a GF M&E unit has been established. This unit will is principal reporting mechanism for data quality issues, provides quarterly updates to the GF management Executive and thereby to the GF manager. This ensures that there is a coherent channel of communication up to Executive level. The GF M&E is led by the GF M&E coordinator, with closer relationships with the GF manager to ensure management, coordination and alignment of grant activities. The main responsibility of the GF M&E unit within the WCDOH is monitoring and reporting on the programmatic progress for all activities under the WC GF grant, as well as conducting evaluations and/or organizing for such activities to be conducted. The M&E unit is also responsible for providing technical support to the districts and Sub-Recipients with regards to M&E issues.
Major grant/ SSF management risks and issues: The capability of the WCDOH to successfully run the GF performance based grant as well as to mitigate associated risks has been proven over the past 9 years (2004 – 2013). For the majority of this time the WC Grant has had an A1-A2 rating. Results, as reported over the RCC period, confirm that the programme is both achieving its targets and has a demonstrable impact within the WC. One of the primary strengths of the grant is that it is fully integration into the WCDOH district health care platform / system. Thus parallel systems are not created but rather the grant strengthens and builds on existing systems, ensuring maximum impact and accountability at all levels within the WCDOH. Additionally, this fulfils the primary purpose of the WC GF grant which is to “Strengthen, Expand & Sustain the Western Cape HIV/AIDS Prevention, Treatment and Care Programme”. The WC RCC phase I was written with an exit strategy. This was to ensure the continual achievements of targets in the face of incremental decreases of funding. Furthermore, this approach also serves the purpose of increasing the sustainability of the Global Fund’s investment within the WC. Premature exit or decreases in funding in the final phase of the grant would compromise the sustainability of the grants’ achievements, as the WCDOH cannot afford to take over full funding of all objectives at one time or at an accelerated rate. Through the GF Grant Risk Assessment and Action Planning Tool the WC identified risks within their grant. These are listed below together with an explanation and implemented solutions.
Fiduciary austerity; Discussions with both the LFA/KPMG and GF;
Short term use of temporary structures such as park homes; Decanting of patients to lower levels of care, for example, once compliance of required ART treatment regimens is reached; Working closely with the City of Cape Town;
Grant Performance Rating for the current Phase (Phase 1/RCC Phase 1)
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