Periodic Review ccm request template

6.3 Compliance with Focus of Proposal Requirement

With South Africa rated as an upper middle-income country and a G20 Countries Member, the NRASD programme is 100% focused on key populations as per the requirement of the Global Fund.

To this end, the NRASD activities will be aimed at the following key populations as defined by the NSP:

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  People with the lowest socio-economic status (with youth as a subset).
  
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  People living with HIV.
  
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  Orphaned and vulnerable children.
  

SECTION 5: CURRENT PHASE/IMPLEMENTATION PERIOD PERFORMANCE (PR 5 - RTC)

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.

RTC was appointed as the civil society Principal Recipient for the South Africa GFATM Round 10 Application in June/July 2010 and actively participated in the preparation of all aspects of the final application. The application was submitted in August 2010 and was given Technical Review Panel (TRP) approval in December 2010 with some clarifications requested. During January and February 2011 RTC also supported the TRP clarification process – including significant technical support to the replacement of TB diagnostic components to include the adoption of GeneXpert in the GFATM programme of support to South Africa – with final approval of the clarifications and amendments in February/March 2011. RTC was subject to an institutional capacity assessment by the Local Fund Agent (LFA) during March/April with no significant adverse findings. Whilst the process of assessment was on-going, RTC advertised for sub-recipients to implement the programme and these were duly selected.

Contract negotiations for Phase 1 implementation began with a short introductory meeting in July 2011 but only commenced in October 2011 with the participation of the full GF Country Team (GFCT). Significant budget reductions were requested by the GFCT which affected all areas of proposed service delivery. A further negotiation meeting was held in December 2011 and, whilst numerous issues remained unresolved RTC, was requested to sign the grant agreement at the deadline for signature in December 2011 with a retrospective start date of July 2011. Conditions Precedent (CP) were also provided at the time of grant signature.

In March 2012 approval of outstanding issues from the grant negotiations namely the interpretation of the Occupational Specific Dispensation (OSD) for health professionals and the use and value of a fee-for-service for HIV Counselling and Testing (HCT) for most-at-risk-populations (MARPS)) was received. (Note- that since the last proposal was submitted the terminology has changed such that we no longer refer to MARPs but instead to key populations.). At the time of approval, the contract start date was adjusted to 1 January 2011 with the end-date remaining 30 September 2013. During the grant negotiations three identified sub-recipients withdrew from the programme due to the reductions in budget imposed. Overall the RTC budget was reduced from $26m to $16m (38%). Despite these SR withdrawals, replacement SRs were identified and new contractual arrangements were formulated to enable the programme to be implemented. All CPs were met within the prescribed timeframes.

The first tranche of funding was received by RTC from the GFATM on 25 May 2012 but funding could not be disbursed to SRs or other costs incurred until approval by the GFATM of the Training Plan (submitted in March 2012) which was received in July. The programme commenced implementation on receipt of the approval of the Training Plan with first disbursement to the implementing SRs following immediately.

Overall the RTC budget was reduced from $26m to $16m (38%) and from a normal phase 1 implementation period of 24 months to a contractual implementation period of 21 months and an actual implementation period (from approval to disburse funds) of 15 months. Targets were not altered despite the reduced timeframe and budget.

Phase 1 targets were established on the basis that lead times were necessary and included purchase and delivery of equipment and some that refurbishments would be required in some instances.

At the conclusion of the December 2012 reporting period RTC had received funding for two reporting periods and the performance against targets for the first two quarters is shown in the table below.

Table 43: Performance against targets RTC

First Implementation Period Reported Performance
Indicator Name	Target	Actual	%
Number of people who received testing (including first and confirmatory tests) and counselling services for HIV and received their results (excluding Most at Risk Populations).	59,620	15,794	26
Number of most-at-risk people who received testing (including first and confirmatory tests) and counselling services for HIV and received their results.	13,440	37,415	120
Percentage of people in the TB Crisis Districts who tested positive for HIV during HCT, were provided with CD4 test, and who received their CD4 results.	90%	87%	97
Number of TB suspects tested for TB using Xpert machine.	29,580	19,626	66
Percentage of people in the TB Crisis Districts who tested positive for TB who were started on TB treatment.	90%	87%	97
Number of men undergoing medical circumcision.	8000	2669	33
Number of Non-Governmental, Faith-Based and/or Community-Based Organisations receiving financial support and management training	6	6	100

Using the GFATM Grant rating tool methodologies (see section 5.1.3) the average performance across the first two implementing quarters is rated at 77%.Comments on under performance:

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  HCT for non-MARPs populations is significantly lower than anticipated due to:
  

Indicator tied to other donors (e.g. partners with other funding) where need is no longer apparent and/or other donor funding is no longer available

Late/no start (TB Crisis Districts including the CCM decision to no longer support Nelson Mandela Bay Metropole (NMMB) and slower uptake generally

Implementing partners withdrawing due to budget constraints

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  TB suspects tested for TB using GeneXpert machines due to delayed start including a revised DCS facility list.
  
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  Number of men undergoing medical circumcision - Circumcisions commenced following refurbishment of sites and procurement of equipment in late August 2012. MMC demand is highly seasonal with winter being the peak season and low levels of uptake during the summer months.
  

To-date no concerns have been raised by the GFATM or CCM in connection with the reported performance. RTC is in discussions with SRs to address areas of slower performance. However, issues primarily relate to “start-up” and the extended holiday period during December in South Africa.

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:

Two key challenges exist in relation to M&E:

1. 
   Insufficient resource allocation to implement sustained M&E programmatic assessments and support; and
   
2. 
   Despite the restricted budget initial expenditure has been slow owing to the delayed start-up of some site. M&E visits were not justified to sites where implementation had not yet commenced. Whilst this represents an under-spend of budget is represents a false under-spend which will be rapidly utilized as the programme gains momentum.
   

No feedback has been received from the LFA following the onsite M&E assessments undertaken in December 2012. However no substantive issues or problems were reported during the process.

5.1.2 Grant/SSF Risk Management

Major grant management risks and issues:

In September 2012 RTC, together with all GFATM PRs in South Africa, participated in the GFATM Risk Management meeting. This meeting focused on the shared experiences of GFATM implementation and allowed PRs to undertake a risk assessment of their individual programmes.

At the time of preparation (and submission to the GFATM) RTC’s risks were largely based on the very limited timeframe of implementation. Risks were, therefore, typically those of a new programme and especially related to late commencement, the reduced timeframe for implementation and no adjustment in targets.

The figure below shows the risk heat map (September 2012) and presents a summary of identified risk areas.

Figure 14: Risk heat map RTC (September 2012)

Issues identified as “high risk” are identified in the Table below.

Table 44: RTC High Risk matrix

Risk Matrix – High Risk
Ref. #	Risk	Rationale for “high” rating
Programmatic and Performance Risks
1.3	Not achieving grant output targets	Because of the delays in grant signing and first disbursement there is a risk of not being able to achieve performance targets.
1.4	Not achieving grant outcome targets	Availability of data to inform impact is, in part, outside of PR control and other external forces influencing impact. The GFATM fund contribution to the country is quite a small percentage compared to the government contribution and therefore cannot leverage resource to be able to directly measure impact or attribute impact solely to GF support.
Fiduciary and Financial Risks
2.5	Financial non-compliance	There are compliance control measures in place to manage how funds are used by SRs. If they are not compliant SRs have to reimburse the funds.
2.6	Market and macro-economic losses	Exchange rate losses may reduce total available budget and increase the cost of imported goods. Whilst RTC has limited flexibility to manage conversion of Forex, it can still be affected by rate fluctuations.
Health Services and Products
3.2	Substandard quality of health products	There is possibility of the health product quality being compromised once it has been distributed to the sites. Once distribution has happened the PR has very limited control of the conditions that products are stored under. Although there are SOPs related to the storage and distribution of products and SRs storage capacity is assessed there might be some risk at implementation level.
3.3	Poor quality of health services and use of health products	There is a possibility of disruption in the provision of services (HCT, MMC) due to issues related to PSM/health services. The PR is managing health services through forecasting and establishing linkages with other providers within the continuum of care for follow up.
Governance, Oversight and Management Risks
4.4	Inadequate secretariat and LFA management and oversight	Delays in disbursement may have negative impact on PR performance. SSF implications may have a negative effect on document processing.
4.6	Inadequate SR reporting and compliance	The PR has financial and M&E reporting systems. For financial reporting all expenses are reported and supporting documents are required for all expenditure. SRs report programme results on a monthly basis. The PR then reviews all submitted reports checking the quality of submissions and undertaking quarterly onsite verification of data reported.

A further five months of implementation has elapsed since the development of the risk heat map. Initial concerns expressed by RTC in the completion of the original risk assessment have, so far, been largely unfounded, and RTC recommends a down grading of most risks. A revised self-assessment risk heat map summary is shown below. It should be noted that the formulation of the risk map includes a correlation of likelihood and severity. By the nature of the risk associated with NGO funding the impact of the materialisation of any risk has an adverse impact. Thus, whilst the likelihood may be on the lower end of the spectrum when combined with severity the rating is classified as medium risk.



Figure 15: Risk Heat Map – Self Assessment (March 2013)

The significant risk that remains is the attainment of performance targets set with an implementation timeframe of 24 months against an actual period of 15 months. Significant progress towards these targets is, however, expected and some programmatic areas may exceed targets (see sections 5.1.1 and 5.1.3). RTC has instituted regular performance assessment meeting with SRs to monitor progress and find innovative solutions to try and recover lost time. Additional measures include:

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  Quarterly on-site data verification visits by RTC
  
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  Monthly compliance reviews (including a report, supporting documentation and a review by RTC’s Compliance Department to ensure that expenses incurred are reasonable, justified and within budget)
  

5.1.3 Grant Performance Rating

No performance rating has yet been agreed upon and finalized despite numerous discussions between RTC and the GFATM secretariat. The delays in receipt of funding which are exacerbated by the shortened review period brought about by the alignment process, has made a fair analysis and rating difficult.

Grant Performance Rating for the current Phase (Phase 1/RCC Phase 1)

A1

A2

X

B1

B2

C