Periodic Review ccm request template

Please comment on systems to manage quality (quality improvement/quality assurance) that ensure adherence to national guidelines and Standard Operating Procedures (SOPs).

The South African National Department of Health (NDOH) has shown an unwavering commitment to improving the quality of health care. This commitment has been further cast into the spotlight through the publication of the 10 Point Plan for improvement of the health sector (2012-2014) in July 2010. The NDOH’s Strategic Plan for 2010/11-2012/13 states that the department’s vision is to ensure “an accessible, caring and high quality health system”. Its mission is “to improve health status through the prevention of illnesses and the promotion of healthy lifestyles and to consistently improve the health care delivery system by focusing on access, equity, efficiency, quality and sustainability”. This links directly with the 10 Point Plan which has improving quality of health services as one of its objectives, and improved patient care and satisfaction and accreditation of health facilities for quality as key activities and priorities.

In 2008 the Office of Standards Compliance (OSC) within the NDOH developed and piloted a set of National Core Standards (NCS) which form the basic requirements for quality and safe care, while also reflecting existing Government policies and guidelines.20 The NCS set the benchmark for quality improvement in public health establishments’ standards, defined as “an expected level of performance”. The main purposes of the NCS are to:

• 
  develop a common definition of quality of care which should be found in all health establishments in SA as a guide to the public and to managers and staff at all levels;
  
• 
  establish a benchmark against which public health establishments can be assessed, gaps identified and strengths appraised; and
  
• 
  Provide a framework for national certification of public health establishments.⁷⁶

  A revised set of core standards the National Core Standards for Health Establishment in South Africa (2011) has been developed, approved and published for implementation in both the public and private health sectors. These standards provide an overall guide to quality of care and set out a common definition of the type of quality of care that should be found in all health establishments. They establish a benchmark against which health establishments can be assessed, gaps identified and strengths appraised, and provide a national framework to certify health establishments as compliant with standards. The Core Standards consist of seven domains, the first three of which relate to ‘the core business of the health system: delivering quality health care to our users or patients’. These are: Patient Rights; Safety, Clinical Governance and Care; and Clinical Support Services. The remaining four domains are essentially the support systems that ensure ‘this core business is delivered’, with staff seen as key to achieving this. They are: Public Health, Leadership and Corporate Governance, Operational Management, and, Facilities and Infrastructure. For measurement purposes, a set of criteria for each National Core Standard, along with an auditing tool aligned to the District Health Information System (a module of the DHIS) have been designed to assess health facilities’ compliance with these standards. To facilities in implementing self-assessments and quality improvement, the NDOH has developed an ‘implementation guide’ and a ‘database guide’ which will assist teams to incorporate their quality-related assessments as part of the routine DHIS. A baseline assessment process is being progressively rolled-out across the country to enable public establishments to assess their compliance with the National Core Standards and some infrastructure and health technology requirements. These assessments will serve as a baseline, which establishments can use to identify and address critical gaps and benchmark themselves against similar establishments prior to external inspection. ⁷⁷

  
  

Please comment on major quality of services risks which have or could have a negative effect on performance, if any. Describe how you plan to address those risks and monitor progress in the next Phase/Implementation Period.

The following risks have been identified that can have a negative effect on performance in the health system:

• 
  Insufficient coherence between the different initiatives and players within the health system;
  
• 
  Complexity of reforms and policy initiatives that influences quality;
  
• 
  Inadequate recognition to health human resource capacity and lack there of
  
• 
  Inadequate Policy and practice interface; and
  
• 
  Increasing emphasis on regulation and compliance without functional systems at an operational level.
  

If the RSQA (Rapid Service Quality Assessment) assessment was not conducted in your country, please continue to section 4.5 ‘Partnerships’

The RSQA was conducted in South Africa but was only completed in early 2013 and the results are not yet available.

Please refer to the latest available information on quality of services annexed to the CCM Invitation Letter and provide updated information (updated national guidelines/protocols), if available. Note, no such information available.

4.5 Partnerships

Using the table below, please indicate the technical assistance (TA), if any, already received in the current Phase/Implementation Period or confirmed to be conducted in the next Phase/Implementation period by the PR(s) and /or SR(s).

4.5.1 NDOH Partnerships

4.5.1.1 Technical Assistance (received in the current Phase/Implementation Period or confirmed to be conducted in the next Phase/Implementation period)

Table 12: Technical Assistance NDOH

TA source/ TA category	Current Phase/ Implementation Period	Next Phase/ Implementation Period
Bilateral	✓	✓
Multilateral	✓	✓
CSO	□	□
Private Sector	□	□
Academic Inst.	□	□
Mixed/other (specify)	□	□

In July 2011 the Office of the Inspector General (OIG) from the GF visited SA to conduct a review of all GF grants. A preliminary report on the performance of each of the grants was released to SA by GF. The report highlighted several areas of weaknesses in the management of the grants by the NDOH. These weaknesses can be summarized into programmatic and financial management categories. In response to the OIG report findings, PMU unit engaged with President’s Plan for AIDS Relief (PEPFAR) team through GF/PEPFAR collaborative mechanism and this resulted in PEPFAR requesting MSH to provide urgent technical assistance and support to strengthen the PMU through capacity building.

The PMU identified the following priority areas for urgent technical assistance:

• 
  Capacity building for PMU Grant Management Unit staff. The PMU staff had limited experience in the management of GF grants and received no formal orientation to GF Procedures;
  
• 
  Improve the quality and systems for completion of the next quarterly Performance Review Update and Disbursement Request (PUDR);
  
• 
  Improve sub-recipient management, including monitoring, evaluation and data verification of expenses and programme activities; and
  
• 
  Increase the current burn rate by assisting the PMU in unlocking financial flow blockages.
  

4.5.1.2 Current gaps/ needs in capacity building not met by existing TA providers

On-going technical assistance will be required to help address challenges of:

• 
  Inadequate budget management and control systems - sub-recipient reports contain inaccurate information;
  
• 
  Inaccurate sub-recipient cash balances - calculations for sub-recipient cash balances were potentially flawed especially in cases where sub-recipients move funds between their internal accounts; and
  
• 
  Lack of supporting documentation for sub-recipient expenditures.
  

As part of the plan to implement the remedial actions and in view of the expected changing monitoring strategies of the PMU staff, from focusing on external sub-recipients to focus on internal departmental programmes only, the PMU will review the PMU staff responsibilities, workloads and align management and junior level staff functions and responsibilities with both departmental programmes and GF needs. This may include development of standard operation procedures (SOPs) and protocols to improve efficiency and effectiveness of organizational systems and processes including the flow of information within the PMU and between PMU and programmes. Tools that will facilitate active and regular interaction between management and junior team members will be implemented to improve the quality of reporting and ensure regular engagement with the programmes.

In addition, the PMU plans to:

• 
  Align staff roles and responsibilities to the phase 2 programme;
  
• 
  Review the current PUDR processes and develop SOPs for the timely completion of the PUDRs;
  
• 
  Design standardized tools, templates, and guidelines to ensure sub-recipients or programmes are all reporting the same information in format that allows easy consolidation by the NDOH, as principal recipient. The templates will include the following elements:
  

Programmes quarterly financial and programmatic reporting with detail variances;

Quarterly forecasting of programmes financial and programmatic needs;

Programmes training plan and forecasting with justification for scale-up in case of underperformance of activities; and

Monthly performance dashboard which incorporates both programme and financial performance indicators.

Continued TA is needed to ensure that key activities are carried out 1) programmes performance and variance analyses 2) PMU reporting and forecasting, and the PUDR are completed in a timely manner. The grant management process also needs to be revised and enhanced improve its efficiency and effectiveness.

Most of the current PMU staff are new and require orientation/ sensitization to GF regulations and procedures. Phase 2 will have a strong focus on internal sub-recipients or programmes and since most of the PMU staff is new, they will not be familiar with programmes activities. As such, they may have limited ability to critically review the effectiveness and efficiency of these sub-recipient activities and the overall grant performance and with need TA.

4.5.2 WCDOH Partnerships

4.5.2.1 Technical Assistance (received in the current Phase/Implementation Period or confirmed to be conducted in the next Phase/Implementation period)

Table 13: Technical Assistance WCDOH

TA source/ TA category	Current Phase/ Implementation Period	Next Phase/ Implementation Period
Bilateral	□	□
Multilateral	□	□
CSO	□	□
Private Sector	□	□
Academic Inst.	✓	✓
Mixed/other (specify)	□	□

WCDOH is currently engaged in discussions with the UNAIDS Technical Support Facility (TSF). This request for technical assistance relates to the department wanting to implement a uniform system based on existing best practices within the Community Based Service Directorate through which the seed funding to NGOs is delivered in this proposal. By doing this the WCDOH will further strengthen M&E within this directorate in a long term sustainable manner. It has been decided that the successful systems and toolkits developed within the Western Cape GF Peer Education Objective will form the framework around which the Community Based Service’s best practices will be built onto. Thus, the WCDOH will work together with the UNAIDS TSF to ensure that capacity developed within the WCDOH’s GF programme is utilised and expanded upon.

Additionally the WCDOH has been actively engaging with the country’s other Principal Recipients. This has proved fruitful thus far in learning from them as well as sharing resources developed within the WCDOH GF grant.

4.5.2.2 Current gaps/ needs in capacity building not met by existing TA providers

Not Applicable

4.5.3 NACOSA Partnerships

1. 
   Technical Assistance (received in the current Phase/Implementation Period or confirmed to be conducted in the next Phase/Implementation period)
   

Table 14: Technical Assistance NACOSA

TA source/TA category	Current Phase/ Implementation Period	Next Phase/ Implementation Period
Bilateral	□	□
Multilateral	□	□
CSO	✓	□
Private Sector	✓	✓
Academic Inst.	□	✓
Mixed/other (specify)	✓	□

The development of NACOSA’s database is still in process. TSF is assisting NACOSA with the process and the plan is that expert TA provider will finalize the process by end of Phase I in September 2013. 20 days TA providers were included in Phase II for assistance with the implementation of the database and future adaptations that might be necessary.

NACOSA will conduct a follow-up MESST workshop with existing and new SRs in the first month of Phase II. Five (5) days of TA were allocated for preparation, workshop facilitation, report writing and follow-up with SRs during this period. The result will be a finalized Indicator Reference Sheet with clarity on alignment with national M&E systems definitions, data collection methods and tools, and data flow.

One of the PR’s main functions is to facilitate training and mentoring for SRs on a variety of organizational development and programmatic content issues. The PR has to continuously review and update training materials and submit materials for accreditation to support skills and career development for workers in civil society organizations. Twenty (20) days TA is included in Phase II for further development of course materials and accreditation of courses. The PR tries to source materials that are already on the market and to limit high TA cost in this regard. The PR has included 5 days TA in Quarter 1 of Phase II for the recruitment and selection of new SRs.

4.5.3.2 Current gaps/ needs in capacity building not met by existing TA providers

The development of NACOSA’s data base is still in process. TSF is assisting NACOSA with the process and the plan is that expert TA provider will finalize the process by end of Phase I in September 2013. 20 days TA providers were included in Phase II for assistance with the implementation of the database and future adaptations that might be necessary.

NACOSA will conduct a follow-up MESST workshop with existing and new SRs in the first month of Phase II. Five (5) days of TA were allocated for preparation, workshop facilitation, report writing and follow-up with SRs during this period. The result will be a finalized Indicator Reference Sheet with clarity on alignment with national M&E systems definitions, data collection methods and tools, and data flow.

One of the PR’s main functions is to facilitate training and mentoring for SRs on a variety of organizational development and programmatic content issues. The PR has to continuously review and update training materials and submit materials for accreditation to support skills and career development for workers in civil society organizations. Twenty (20) days TA is included in Phase II for further development of course materials and accreditation of courses. The PR tries to source materials that are already on the market and to limit high TA cost in this regard. The PR has included 5 days TA in Quarter 1 of Phase II for the recruitment and selection of new SRs.

4.5.4 NRASD Partnerships

4.5.4.1 Technical assistance (received in the current Phase/Implementation Period or confirmed to be conducted in the next Phase/Implementation period)

Table 15: Technical Assistance NRASD

TA source/ TA category	Current Phase/ Implementation Period	Next Phase/ Implementation Period
Bilateral	✓	✓
Multilateral	□	□
CSO	□	□
Private Sector	□	□
Academic Inst.	✓	✓
Mixed/ other (specify)	□	□

Stellenbosch University (SU) is the technical partner of the NRASD in the implementation of the grant in the current phase and in the next phase. The SU provides technical assistance with access to:

• 
  Academic and technical expertise and experience.
  
• 
  Financial systems.
  
• 
  Procurement and supply management systems.
  
• 
  Information technology infrastructure;
  
• 
  Physical infrastructure (office space);
  
• 
  Provision of management and financial support to strengthen capacity of Sub-Recipients (SR's) by undertaking due diligence assessments of SR's; and
  
• 
  Strengthening of M&E capacity for by undertaking systems strengthening for SR’s.
  

In the current phase of the programme, TA has been and still is contracted for the following purposes:

• 
  NRASD – Development of procurement and supply management plan for health products.
  
• 
  NRASD – Behaviour change (modification) communication (BCC) technical adviser supports programme to improve targeting and effectiveness of behaviour change strategies. This technical assistance forms part of the next phase of the programme;
  
• 
  NRASD – Gender consultant supports programme to increase capacity of PR and SR's to improve gender in all activities, particularly in BCC;
  
• 
  NRASD – Assessment of the HCBC and OVC Programmes based on the latest government policy and guidelines with specific attention to the training courses offered to Care Givers and to the competency level of Care Givers that are deployed to reach PLHIV and OVC;
  
• 
  NRASD – Mid-term review for the GF Programme: A review of the performance in Phase 1 of the programme, including the effect that the negative GF Office of the Inspector General Draft Report had on implementation, as well as the programme’s alignment with the new NSP 2012-2016;
  
• 
  NRASD SR Starfish Greathearts Foundation – Formative evaluation of Phase 1 of Starfish Greathearts Foundation rollout of the GF Programme;
  
• 
  NRASD SR SABCOHA – Case study on collaboration toward sustainable delivery; and
  
• 
  NRASD and NACOSA – Evaluation of Phase 1 of the NACOSA/ NRASD OVC Grant.
  

4.5.4.2 Current gaps/ needs in capacity building not met by existing TA providers

A current need is identified in the requirement on quality assurance of health products. The NRASD is in the process of consulting with Stellenbosch University to address this need.

4.5.5 Right to Care Partnerships