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)
assessment RePORT
For
AIDSRelief-Nigeria
21 June –2 July 2010
ClASS AIDSRelief-Nigeria Final Report 1
TABLE OF CONTENTS
Acronyms and Abbreviations
Executive Summary
I.BACKGROUND
II.IMPLEMENTATION OF THE ClASS MODEL
III.KEY OUTCOMES OF PROPOSED LOCAL PARTNER ASSESSMENTS
A.Catholic Secretariat of Nigeria
B.Christian Health Association of Nigeria (CHAN)
C.Institute of Human Virology-Nigeria (IHV-N)
IV.TRANSITION READINESS SUMMARY
AIDSRelief-Nigeria ClASS Assessment Report
I.INTRODUCTION
II.PURPOSE
III.METHODOLOGY
A.Assessment Team
B.Assessment Report Format
IV.OUTCOME SUMMARY OF PROPOSED LOCAL PARTNER ASSESSMENTS
A.Catholic Secretariat of Nigeria
B.Christian Health Association of Nigeria (CHAN)
C.Institute of Human Virology-Nigeria (IHV-N)
V.OUTCOMES OF LOCAL PARTNER CLINICAL AND TREATMENT FACILITY (LPCF and LPTF) ASSESSMENTS
A.St. Gerard’s Hospital
B.Local Partner Clinical Facilities
Appendix A: AIDSRelief-Nigeria Current and Proposed Partners
Appendix B: AIDSRelief-Nigeria ClASS Assessment Schedule
Appendix C: List of Participants (by site)
Appendix D:Christian Health Association of NigeriaClASS Assessment Report
I.BACKGROUND
II.CLINICAL REVIEW
A.Clinical Strengths
B.Clinical Areas for Improvement and Recommendations
III.ADMINISTRATIVE REVIEW
A.Administrative Strengths
B.Administrative Areas for Improvement and Recommendations
IV.FINANCIAL MANAGEMENT REVIEW
A.Financial Management Strengths
B.Financial Management Areas for Improvement and Recommendations
C.Transition Readiness and Preparation
Appendix E: Catholic Secretariat of Nigeria ClASS Assessment Report
I.BACKGROUND
II.CLINICAL REVIEW
A.Clinical Strengths
B.Clinical Areas for Improvement and Recommendations
III.ADMINISTRATIVE REVIEW
A.Administrative Strengths
B.Administrative Areas for Improvement and Recommendations
IV.FINANCIAL MANAGEMENT REVIEW
A.Financial Management Strengths
B.Financial Management Areas for Improvement and Recommendations
V.TRANSITION READINESS AND PREPARATION
Appendix F:Institute of Human Virology-NigeriaClASS Assessment Report
I.BACKGROUND
II.CLINICAL REVIEW
A.Clinical Strengths
B.Clinical Areas for Improvement and Recommendations
III.ADMINISTRATIVE REVIEW
A.Administrative Strengths
B.Administrative Areas for Improvement and Recommendations
IV.FINANCIAL MANAGEMENT REVIEW
A.Financial Management Strengths
B.Financial Management Areas for Improvement and Recommendations
V.TRANSITION READINESS
Appendix G:St. Anne’s HospitalClASS Assessment Report
I.BACKGROUND
II.CLINICAL REVIEW
A.Strengths
B.Areas for Improvement and Recommendations
III.ADMINISTRATIVE REVIEW
A.Administrative Strengths
B.Administrative Areas for Improvement
IV.FINANCIAL MANAGEMENT REVIEW
A.Financial Management Strengths
B.Financial Management Areas for Improvement and Recommendations
Appendix H:Ijebu-Ode, Orphans and Vulnerable Children(OVC) Program ClASS Assessment Report
I.BACKGROUND
II.OVC PROGRAM REVIEW
A. Program Strengths
B.Program Areas for Improvement and Recommendations
III.ADMINISTRATIVE REVIEW
A.Administrative Strengths
B.Administrative Areas for Improvement and Recommendations
IV. FINANCIAL MANAGEMENT REVIEW
A.Financial Management Strengths
B.Financial Management Areas for Improvement and Recommendations
Appendix I:Federal Medical Center, Keffi,ClASS Assessment Report
I.BACKGROUND
II.CLINICAL REVIEW
A.Clinical Strengths
B.Clinical Areas for Improvement and Recommendations
III. ADMINISTRATIVE AND FINANCIAL REVIEW
A.Administrative and Financial Strengths
B.Administrative and Financial Areas for Improvement and Recommendations
Appendix J:St. Gerard’s Catholic HospitalClASS Assessment Report
I.BACKGROUND
II.CLINICAL REVIEW
A. Strengths
B.Areas for Improvement and Recommendations
III. ADMINISTRATIVE REVIEW
IV. FINANCIAL MANAGEMENT REVIEW
Acronyms and Abbreviations
ANC / Antenatal careART / Antiretroviral therapy
ARV / Antiretroviral
CBO / Community-based organization
CDC / Centers for Disease Control and Prevention
CHAN / Christian Health Association of Nigeria
ClASS / Clinical Assessment for Systems Strengthening
COP / Chief of party, country operational plan
CQI / Continuous quality improvement
CRS / Catholic Relief Services
CSN / Catholic Secretariat of Nigeria
EID / Early infant diagnosis
EQA / External quality assurance
FBO / Faith-based organization
GON / Government of Nigeria
GPS / Grants policy statement
HAB / Health Resources and Services Administration, HIV/AIDS Bureau
HCT / HIV counseling and testing
HHS / US Department of Health and Human Services
HMIS / Health management information system
HRSA / Health Resources and Services Administration
IHV / University of Maryland School of Medicine, Institute of Human Virology
IHV-N / Institute of Human Virology-Nigeria
LOA / Letter of agreement
LPCF / Local partner clinical facility
LPTF / Local partner treatment facility (AIDSRelief sites only)
MARP / Most at risk population
M&E / Monitoring and evaluation
MI / Member institution
MIS / Management information system
MOH / Ministry of Health
MSH / Management Sciences for Health
NEC / National Executive Council
NGO / Nongovernmental organization
NICaB / Nigerian Indigenous Capacity Building Project
OGAC / Office of the US Global AIDS Coordinator
OMB / US Office of Management and Budget
OPD / Outpatient department
OVC / Orphans and vulnerable children
PEPFAR / President’s Emergency Plan for AIDS Relief
PICT / Provider initiated counseling and testing
PLHA / People living with HIV and AIDS
PMTCT / Prevention of mother-to-child transmission
STA / Senior Technical Advisor
TA / Technical assistance
TB / Tuberculosis
USAID / United States Agency for International Development
USG / United States government
VCT / Voluntary counseling and testing
ClASS AIDSRelief-Nigeria Final Report 1
Executive Summary
I.BACKGROUND
The President's Emergency Plan for AIDS Relief (PEPFAR) was initiated in 2003 and is the largest commitment ever by any nation for an international health initiative dedicated to a single disease.Since 2004, the Health Resources and Services Administration (HRSA) has provided funds from PEPFAR to US-based organizations to provide HIV care and treatment in developing countries. The class deviation waiver approved by the Health and Human Services (HHS) Office of Grants Policy 2007 extended the antiretroviral 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 HRSA Nigeria Track 1.0 grantee, Catholic Relief Services (CRS), provides services through the project titled AIDSRelief-Nigeria, which is a consortium supporting lifesaving ART for poor and underserved people.The consortium brings together international expertise in HIV care: Catholic Relief Services (CRS) as prime grantee; the University of Maryland School of Medicine Institute of Human Virology (IHV) as clinical lead for medical care and treatment, and Futures Group Internationalas lead agency for strategic information.
Three proposed local partners have been identified by AIDSRelief-Nigeria to serve as the transition organizations to continue the prime grantee, monitoring, and supportive supervision activities for their local partner treatment facilities (LPTFs).Other partners may be identified as the transition planning process continues.
This executive summary provides an overview of the strengths and areas for improvement of the three proposed local partners.The Clinical Assessment for Systems Strengthening (ClASS) final report contains additional sections on the strengths and areas for improvement of the LPTFs and the local partner clinical facilities (clinics and hospitals of the proposed partners) and separate detailed reports on each local partner organization.
II.IMPLEMENTATION OF THE ClASS MODEL
AIDSRelief-Nigeria’s transition plan proposed the implementation of targeted transition capacity building starting July 1, 2010.HRSA was requested by AIDSRelief-Nigeria to conduct a transition readiness assessment to receive feedback on the capacity of the proposed local partners and the proposed transition plan.
The HRSA transition readiness assessment used the ClASSframework, which is designed toassess 1) program strengths and specific areas of improvement and systems 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.
The HRSA ClASS assessment team consisted of the HRSA project officer and consultants to conduct the clinical, administrative, and financial review.Staff members from the Centers for Disease Control and Prevention (CDC)-Nigeria office also participated in the assessment.A representative from the Ministry of Health also joined the team for some of the visits.
A ClASS assessment was conducted at each of the three proposed local partner facilities. As each of the local partners is currently working with a health facility or health care program, one service delivery site was visited for each of the proposed local partners.One of the LPTFs supported by AIDSRelief-Nigeria was also visited to allow the review team to have a better understanding of the type of monitoring and supportive supervision AIDSRelief-Nigeria provides to their sites.This gave the review team a clearer picture of the level of support the proposed local partners will be expected to provide after transition.This report is a compilation of the review findings.
III.KEY OUTCOMES OF PROPOSED LOCAL PARTNER ASSESSMENTS
A.Catholic Secretariat of Nigeria
1.Clinical Strengths
- The Catholic Secretariat of Nigeria (CSN) has extensive relationships with federal, state, and local government institutions, as well asmember health facilities.
- CSN relies on a strong relationship with community groups and networks of volunteers to support programs.
- The CSN member institutions, religious leadership, and advocacy work place the organization in a position to influence government to change policy and increase direct government support to member institutions.
- CSN has developed a cadre of trained management staff and networks through the orphans and vulnerable children (OVC) programs,whichcan be used as a starting point to scale up care and treatment.
- CSN member institutions are already providing HIV care with support from AIDSRelief-Nigeria and other US government (USG) partners.
2.Clinical Areas for Improvement and Recommendations
Finding 1:CSN clinical oversight capacity is insufficient to monitor care and treatment or to take on additional responsibilities.Recommendation: Capacity in the following technical areas will need to be added before transition: site management, clinical oversight for HIV care and treatment, strategic information systems management, laboratory, and pharmacy.
3.Administrative Strengths
- CSN has a strong historical relationship with AIDSRelief-Nigeria.
- The health unit secretary is very competent atproviding guidance for the program manager and program officers.
- There are comprehensive program monitoring processes carried out every six weeks for current subcontractors.
- The human resources department is well organized and managed.
- There is a centralized model of project management, oversight, and finance for programs co-located with organization management.
- CSN is initiating the separation of community programs from those that are solely church-related under a new organization.
4.Administrative Findings and Recommendations
Finding 1: CSN has insufficient internal management information system (MIS) capability to support or provide supervision for local partner clinical facilities (LPCFs) or any subcontractor providingthis service.Recommendation:Determine how best to acquire the skill sets needed to provide oversight in this area.
Finding 2: Coordination between grants management, program, and finance does not occur for site visits to supplement other monitoring.Recommendation:Where possible, have at least one combined visit to each site annually, where all the departments conduct their visits together.
Finding 3:No written program monitoring policies and procedures were available for review.There are also no guidelines for the narrative contents of site reports beyond data on indicators.Recommendation: Staff may want to use the existing policies and procedures, including the contents required for grantee reports of AIDSRelief-Nigeria as a starting point, modifying them to meet the practices currently being carried out by the CSN staff.
Finding 4: Letters of agreement (LOAs) did not contain a detailed narrative description of the services funded.Recommendation:CSN may want to collect sample documents from AIDSRelief-Nigeria and IHV-N and adapt LOAs to be more comprehensive.
Finding 5:The health unit secretary’s multiple roles may compromise good project management with increased responsibilities.Recommendation: Adeputy health unit secretary or an administrative assistant could provide a significant amount of support and thereby relieve some of the current stress.
5.Financial Management Strengths
- CSN is able to draw on the resources of the organization: the HIV/AIDS program is not solely dependent on US government grant funds.
- The diversification of resources supporting HIV and AIDS services allows the organization to enrich the programs supported by public funds and insulate the services from cash-flow problems, unanticipated expenses, or economic downturns.
- CSN has extensive experience with grants, including several direct US government grants.
- An independent compliance/internal audit functionstrengthens internal controls for the organization.
6.Financial Management Findings and Recommendations
Finding 1:CSN has not implemented fiscal monitoring of the dioceses receiving US government grant funds, as required by Office of Management and Budget (OMB) Circular A-133.Recommendation: As the transition plan activities move forward, CSN should implement fiscal monitoring.
Finding 2:CSN does not prepare or review fiscal reports comparing budgets to actual expenses on a site-specific, department-specific, or organization-wide basis, as required by the Health and Human Services Grants Policy Statement
(HHSGPS) and by OMB Circular A-110.Recommendation:As the transition plan activities move forward, CSN should implement a budget management system that includes review of budget variances at the level of project officer, secretary, director of department, and secretary general.
B.Christian Health Association of Nigeria (CHAN)
1.Clinical Strengths
- CHAN supports an extensive network of primary health care sites with national coverage.
- CHAN has longstanding relationships with member institutions and with the government at the federal, state, and local levels.
- CHAN has established relationships with non-governmental organizations and community-based organizations, some as subcontractors.
- CHAN has successfully completed several health programs that expanded the organization’s profile and expertise.
- CHAN Medi-Pharm, an affiliate organization, has extensive experience and a track record in supply chain management, and supports programs in training, warehousing, and distribution of pharmaceuticals.
- CHAN has supportive supervision capacity at the regional office level.
2.Clinical Areas for Improvement and Recommendations
Finding 1: Existing staffing levels at CHAN headquarters are insufficient to
ensure that clinical and programmatic oversight translate into the intended
outcomes at the facility level.Recommendation: CHAN should assess its
existing capacity to provide the kind of clinical oversight required to supervise
AIDSRelief-Nigerialocal partner treatment facilities (LPTFs).
Finding 2: Program management and monitoring practices do not consistently produce expected results. Recommendation:CHAN needs to demonstrate that intended programs are reflected at the facility level by reviewing its program implementation model and the needs and resources at the site, and matching them to ensure that programs produce intended outcomes.
3.Administrative Strengths
- There has been strong and consistent leadership of the organization.
- The National Executive Council (NEC) supports the organization, particularly in senior management interviewing and procurement approval for large cost items.
- Personnel policies and procedures were found to be very comprehensive and were reviewed and updated last year.
- CHAN demonstrates good ability to attract and secure diverse funding from donors as well as resources from CHAN Medi-Pharm.
- The organization has been able to increase security for the Jos facilities (combination of paid and military) through state- and federal-level relationships.
- The decentralization into regional offices allows more localized support and monitoring of programs at the member institutions.
4.Administrative Areas for Improvement and Recommendations
Finding 1:There is no current process for NEC members to identify conflicts
that might exist with CHAN or to sign confidentiality statements, and no process to
conduct self-evaluations. Recommendation:CHAN should confirm that sample
forms and documents to address the above will be shared with NEC members as
part of the MSH training.
Finding 2:There is no system to verify that clinical staff licenses are current,as copies of licenses are taken at initial hiring, but no further verification is done.Recommendation:HR should consider developing a spreadsheet or database to list the license numbers annually for clinical staff, along with dates of expiration.
Finding 3:The performance appraisal forms provide no explanation of the rating scale for supervisors to use when rating staff and no space for use of job description duties as a basis for the rating.Recommendation: Consider adding space for relevant duties from the job description to be added, or categories on which the supervisor should rate the employee performance.
5.Financial Management Strengths
- CHAN’s detailed organizational budget is supported by historical information and allows input from all departments.
- CHAN has experience with grants, including several direct US government grants.
- CHAN’s fiscal policies and procedures are complete and include internal control features.
- The regional office manages the reports from the sites well and ensures timely reimbursement.
- The regional office conducts regular fiscal monitoring of sites.
- The provisions of the site agreement include the line-item budget and specify that program and fiscal monitoring will be conducted by the regional office and incorporate applicable USG regulations and requirements.
- Employees’ time and effort is accounted for on a project-specific basis at the time of each monthly payroll.
6.Financial Management Areas for Improvement and Recommendations