U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)
Health Resources and Services Administration (HRSA)
HIV/AIDS Bureau - Global HIV/AIDS Program
Clinical Assessment for Systems Strengthening (ClASS)
Transition Readiness assessment RePORT
For
HARVARD/PEPFAR
&
THE BOTSWANA HARVARD AIDS INSTITUTE,
A COMPANY LIMITED BY GUARANTEE (BHP)
ART TRAINING AND SITE SUPPORT PROGRAM
January 25-February 5, 2010
Acknowledgements
Ms. Anne Meegan, Associate Director for TrainingThe Health Resources and Services Administration (HRSA) led and implemented the Clinical Assessment for System Strengthening (ClASS) model for the Botswana Harvard AIDS Institute, a Company Limited by Guarantee (BHP, LLC) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Anti-retroviral therapy (ART) Training and Site Support Program from January 25 – February 5, 2010.
Dr. José Rafael Morales of the HRSA, HIV/AIDS Bureau, Global HIV/AIDS Program, served as team leader in week 1 and, provided technical assistance to BHP-PEPFAR ART Training and Site Support Program (Annex1). Ms. Cheryl Nesbitt, an independent consultant, served as team leader in week 2 and, assessed the administrative systems of the BHP, LLC and administrative support to the BHP-PEPFAR ART Training and Site Support Program. Dr. Anjali Sharma and Ms. Juanita Farrow, external consultants, assessed programmatic and financial systems respectively. Dr. Philippe Chiliade, Mr. Rodrigo Boccanera, and Ms. Christine Lim, from the HRSA, HIV/AIDS Bureau, Global HIV/AIDS Program, provided technical and administrative assistance for the ClASS programmatic and administrative components. All persons mentioned above make the “ClASS team” and are authors of the final report.
Representatives of the Ministry of Health (MoH), Ministry of Local Government (MLG), and the Centers for Disease Control and Prevention (CDC) in Botswana (BOTUSA) joined the ClASS team as appropriate for site visits, interviews, and document reviews. Representatives of the following institutions allowed visits, interviews, and/or observations: the Harvard School of Public Health (HSPH), the BHP-PEPFAR ART Training and Site Support Program, the National Reference Laboratory, and the Princess Marina Hospital in Gaborone; the Deborah Retief Memorial Hospital in Mochudi, the Mochudi clinic, the Morwa Clinic, the Werda Clinic, the Tsabong Primary Hospital, the Tsabong District Health Team, the Middlepits Clinic, the Bokspit Clinic, the Strysendum Health Post, and the Tlokweng Clinic (see Annexes 2-5)University College Hospital (UCH), Ijebu-ode General Hospital, Adeoyo Maternity Hospital, Ogbomoso General Hospital, HRSA, and I-TECH. All participants gave generously of their time, knowledge, views and experiences to provide insights and recommendations for the BHP-PEPFAR ART Training and Site Support Program.
The authors are solely responsible for any errors in representation and interpretation of the data from interviews, observations and document review. We hope that this report reflects the feasibility and utility of the BHP-PEPFAR ART Training and Site Support Program while making recommendations for further improvements.
Acronyms and Abbreviations
ART / Anti-retroviral TherapyBHP / Botswana Harvard AIDS Institute, a Company Limited by Guarantee
BOTUSA / Centers for Disease Control and Prevention in BotswanaAIDS prevention in Nigeria, LLC
ClASS / Clinical Assessment for Systems Strengthening
CEO / Chief Executive Officer
COO / Chief Operating Officer
DHHS / U.S. Department of Health & Human Services
HRSA / Health Resources and Services Administration
HSPH / Harvard School of Public Health
KITSO / Knowledge, Innovation & Training Shall Overcome AIDS
LTOA / Long Term Operating Account
MASA / The National ART Program (English Translation: New Dawn)
M&E / Monitoring and Evaluation
MoH / Ministry of Health
MLG / Ministry of Local Government
NGO / Non-governmental Organization
OGAC / Office of Global AIDS Coordinator
PEPFAR / The U.S. President’s Emergency Plan for AIDS Relief
PD / Project Director
PI / Principal Investigator
PLWHA / People Living with HIV/AIDS
PMTCT / Prevention of Mother to Child Transmission
SAQ / Self-Administered Questionnaires
SOP / Standard Operating Procedures
TA / Technical Assistance
USG / United States Government
Table of Contents
Acknowledgements 1
Acronyms and Abbreviations 2
Executive Summary 6
I. Background 6
II. Implementation of the ClASS Model 6
III. Key Findings 7
The BHP-PEPFAR ART Training and Site Support Program 7
BHP Organizational Administrative Systems, Policies, and Procedures 8
BHP Organizational Fiscal & Grants Management Capacity 9
IV. Main Recommendations 11
The BHP-PEPFAR ART Training and Site Support Program 11
BHP Organizational Administrative Systems, Policies, and Procedures 11
BHP Organizational Fiscal & Grants Management Capacity 12
V. Transition Readiness Conclusions 13
1. Introduction 13
1.1 Purpose 14
1.2 Methodology 15
1.3 Structure of the Report 16
2. Background 17
2.1 The Government of Botswana Response to the HIV/AIDS Epidemic 17
2.2 The Botswana-Harvard AIDS Institute, Company Limited by Guarantee 17
2.3 The BHP-PEPFAR ART Training and Site Support Program 18
3. Main Findings 20
3.1 Main Findings of the Program Review 20
3.1.1 Program Overview 20
3.1.2. Program Strengths 27
3.1.3. Programmatic Areas for Improvement 28
3.2 Main Findings of the Administrative Review 29
3.2.1 Administrative Overview 29
3.2.2. Administrative Strengths 35
3.2.3. Administrative Areas for Improvement 35
3.3 Main Findings of the Fiscal Review 36
3.3.1. Fiscal Overview 36
3.3.2. Fiscal Strengths 41
3.3.3. Fiscal Areas for Improvement 41
4. Main Recommendations 45
4.1. Programmatic Technical Recommendations 45
4.2. Administrative Technical Recommendations 46
4.3. Fiscal Technical Recommendations 48
5. Transition Readiness Summary 51
Annex 1. Assessment Team and Schedule 53
Annex 2. Representatives Present at Various Introductory and Exit Meetings in Gaborone and at Health Care Facilities 55
Annex 4. Sites Visited by the ClASS Team 61
Annex 5. Documents Reviewed 62
Annex 6. BHP, LLC Organogram 64
Annex 7. Conditions of Service Manual Recommendations 65
Executive Summary
I. Background
Since 2004, the Health Resources and Services Administration (HRSA) has provided funds from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) for Botswana to the Track 1.0 grantee, the Harvard School of Public Health (HSPH). The project is implemented by the Botswana-Harvard AIDS Institute (BHP) and the HRSA funded program is called the BHP-PEPFAR ART Training and Site Support Program. The Class Deviation Waiver approved by the DHHS Office of Grants Policy 2007 extended the Anti-retroviral Therapy (ART) Track 1.0 grantees project period until 2012 on condition that the grantees identify local partner organization(s) (as defined by OGAC/HHS) for the transfer of funding and program management. The HSPH has identified the recently formed Botswana Harvard AIDS Institute, A Company Limited by Guarantee (BHP, LLC) as the local organization that can absorb the funds and manage PEPFAR funded programs.
HRSA conducted a transition readiness assessment of the BHP, LLC in Botswana from January 25 – February 5, 2010 in collaboration with expert reviewers, and in-country Government, donor, Track 1.0 grantee, and local partners (Annex 1).
II. Implementation of the ClASS Model
The HRSA transition readiness assessment used the Clinical Assessment for System Strengthening (ClASS) framework, which is designed to assess 1) program strengths and specific areas of improvement and system strengthening, 2) organizational systems, policies, and procedures in place to accomplish program goals and objectives, 3) the organization’s capacity to provide the funded services and manage current funding, and 4) the organization’s capacity for monitoring existing local providers and potential to take on increased responsibility. A pre-assessment meeting with the Centers for Disease Control and Prevention in Botswana (BOTUSA) was followed by a full meeting with Ministry of Health (MoH), Ministry of Local Government (MLG), BHP, and HSPH to learn about the BHP-PEPFAR ART Training and Site Support Program and to introduce the ClASS framework (Annex 2). The ClASS team gathered information through at least 50 document reviews; 10 site visits; and 73 interviews (see Annexes 3-5). Interviews include 5 national-level Government of Botswana, an accounting and financial management company, University of Botswana personnel; 33 health workers from LPTFs, and 35 HSPH and BHP staff. A post-assessment debriefing meeting was held with BOTUSA, HSPH, and BHP (including the BHP-PEPFAR program) respectively.
III. Key Findings
The BHP-PEPFAR ART Training and Site Support Program
The BHP-PEPFAR Master Trainers provide on- and off-site training, site support such as that for recording and reporting practices, and are accessible by phone for problem solving on clinical care and treatment, laboratory, and Patient Information Management System (PIMS) related issues. Trainees and sites expressed satisfaction with their training and high satisfaction with phone access. There were mixed reviews on trainee selection, comprehension of materials, deployment, and length of training. Sites found the site support visits useful and notwithstanding the constraints, wanted more frequent visits.
Program Strengths
1. The program is highly integrated within the MoH.
2. The success of the program lies in its Master Trainers, who are well regarded, topic experts, and highly committed health professionals.
3. The recent nurse prescriber and dispenser training has raised the brand name "Master Trainer" among the nursing cadre.
4. The training materials, prepared for immediate presentation rather than as curriculum, are being refined to meet the National Training Program (KITSO: Knowledge, Innovation & Training Shall Overcome AIDS) training standards.
5. The training is delivered by a large team providing the variations necessary to stimulate different learning styles and to keep the trainees interested.
6. The practice and initial on-site support helps trainees attain and retain new skills.
7. The pharmacy master trainers now have a cadre of 11 pharmacists who can be called upon to help during training. Three of these pharmacists are at Clinical Master Trainers (CMT) level.
8. Trained laboratory technicians have been successful in cross training their fellow laboratory staff in their laboratories.
9. The site support facilitates site-specific technical assistance and innovations.
10. Where possible, the team includes the MoH and MLG in site visits facilitating instant decision-making and problem solving.
11. Phone support is available and used by most trainees.
Potential Areas for Improvement
1. Trained Site Master Trainers cannot train and support other health care workers, as originally envisioned for the Master Trainer model, due to competing tasks and deployment to non-HIV/AIDS related services.
2. This along with the expanding ART roll out and HIV/AIDS related programs has increased the content and geographical coverage expected of the Master Trainers.
3. The Master Trainers have not benefitted from early support and guidance on developing and delivering trainings.
4. 1-2 visits per site per year are perceived as inadequate by the sites and the MoH.
5. Not all trainees are able to take advantage of telephone site support as some ARV sites do not have telephone signal.
6. Trainees need training certificates for prescribing and dispensing.
BHP Organizational Administrative Systems, Policies, and Procedures
The BHP, LLC runs clinical research studies and the BHP-PEPFAR program. The BHP, LLC Board is comprised of two levels of membership, members (9) and directors (5). HSPH proposed to create a committee of the directors, a combination of BHP, LLC and HSPH staff, to provide oversight for the BHP-PEPFAR program. The BHP, LLC Chief Executive officer (CEO), the Deputy CEO, and Chief Operating Officer (COO) manage day to day operations and a staff of more than 200 persons. The BHP, LLC has centralized finance and information management departments. The BHP-PEPFAR Program Director (PD) handles the day to day operational, reporting, and reapplication processes for the program. The PD also serves as the primary marketing person and contact for external constituents for the project and as the liaison to the MoH. Quarterly reports are submitted to the CEO. Meetings for all BHP-PEPFAR staff are held quarterly, while monthly meetings are held with each group of trainers. The HSPH Assistant Country Director and the PD meet at least quarterly and now more frequently. The Assistant Country Director liaises with BHP, LLC management, HSPH, and HRSA.
Organizational Strengths
- BHP has obtained LLC status to meet OGAC/HHS transition criteria for local partners.
- BHP, LLC has initiated a strategic planning process which has already identified priority areas for focus.
- Human resource systems are in place and working well.
- Staff retention in key management positions has been very good.
- Harvard conducted an organization assessment and has identified areas for short and long-term improvements consistent with ClASS findings.
- BHP, LLC has an excellent relationship with the MoH that has brought some benefits to the organization.
Potential Areas for Improvement
1. The constitution of the Board does not provide for the autonomy of the sub-committee to provide oversight for the BHP-PEPFAR program.
2. The temporary membership of the PEPFAR sub-committee does not meet the requirements expected by OGAC/HHS.
3. There is no current formal training or orientation for the Board of Directors, nor Board documents to address organization risk management; there are gaps in documentation of meeting events in the minutes.
4. The COO and PD are both performing duties of multiple staff positions that could result in staff burnout or the loss of staff with considerable historical knowledge and experience.
5. Performance reviews are not being consistently conducted annually or at the time of contract renewals. There are no consequences for supervisor non-adherence.
6. Harvard and BHP’s strategic planning process identified several areas for improvement including communication, quality improvement, and program monitoring.
7. There is not currently a plan to ensure that the HSPH Assistant Country Director management functions of the position that are critical to program operations will continue after transition.
9. There is not a specifically designated person to serve as the back-up for the Project Director and provide a consistent level of oversight and responsiveness to donors and stakeholders at all times.
10. Neither TB education or screening is provided to non-clinical staff (M&E Unit staff during PIMS II rollout training, data entry staff and drivers) that accompany the clinical and laboratory master trainers to the clinic locations during their consultations.
BHP Organizational Fiscal & Grants Management Capacity
The BHP, LLC financial portfolio consists of direct and flow-through funding from a variety of grants and contractual arrangements. The fiscal department does payroll for all staff (≥ 200) and manages the funding for BHP-PEPFAR, clinical research studies, and laboratory programs. The fiscal department has nine staff positions. The financial manager position reports to the COO at BHP, LLC. The current finance manager, who also has grants management responsibilities, recently resigned. His and a newly created grants manager position are yet to be filled. BHP, LLC is in the early stages of developing a grants management process. Fiscal policies and procedures have been developed based on basic accounting principles. An external audit is planned for Fall 2010 and an internal audit is not currently economically feasible.