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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 REPORTASSESSMENT REPORT

For

AIDSRELIEF-NIGERIA

21 June –2 July 2010

TABLE OF CONTENTS

Acronyms and Abbreviations................................................................................................ivExecutive Summary................................................................................................................6I. BACKGROUND...........................................................................................................6II. IMPLEMENTATION OF THE ClASS MODEL.........................................................6III. KEY OUTCOMES OF PROPOSED LOCAL PARTNER ASSESSMENTS..............7

A. Catholic Secretariat of Nigeria.............................................................................7B. Christian Health Association of Nigeria (CHAN).............................................10C. Institute of Human Virology-Nigeria (IHV-N)..................................................12

IV. TRANSITION READINESS SUMMARY.................................................................15AIDSRelief-Nigeria ClASS Assessment Report..................................................................17I. INTRODUCTION.......................................................................................................17II. PURPOSE....................................................................................................................17III. METHODOLOGY......................................................................................................18

A. Assessment Team...............................................................................................19B. Assessment Report Format.................................................................................20

IV. OUTCOME SUMMARY OF PROPOSED LOCAL PARTNER ASSESSMENTS.20A. Catholic Secretariat of Nigeria...........................................................................20B. Christian Health Association of Nigeria (CHAN).............................................23C. Institute of Human Virology-Nigeria (IHV-N)..................................................26

V. OUTCOMES OF LOCAL PARTNER CLINICAL AND TREATMENT FACILITY (LPCF and LPTF) ASSESSMENTS....................................................................................30

A. St. Gerard’s Hospital..........................................................................................31B. Local Partner Clinical Facilities.........................................................................34

Appendix A: AIDSRelief-Nigeria Current and Proposed Partners......................................38Appendix B: AIDSRelief-Nigeria ClASS Assessment Schedule.........................................39Appendix C: List of Participants (by site)............................................................................40Appendix D: Christian Health Association of Nigeria ClASS Assessment Report.............43I. BACKGROUND.........................................................................................................44II. CLINICAL REVIEW..................................................................................................44

A. Clinical Strengths...............................................................................................45B. Clinical Areas for Improvement and Recommendations...................................45

III. ADMINISTRATIVE REVIEW...................................................................................46A. Administrative Strengths....................................................................................49B. Administrative Areas for Improvement and Recommendations........................49

IV. FINANCIAL MANAGEMENT REVIEW.................................................................50A. Financial Management Strengths.......................................................................53B. Financial Management Areas for Improvement and Recommendations...........54C. Transition Readiness and Preparation................................................................54

Appendix E: Catholic Secretariat of Nigeria ClASS Assessment Report............................55I. BACKGROUND.........................................................................................................56II. CLINICAL REVIEW..................................................................................................56



ClASS AIDSRelief-Nigeria Final Report i

IV. FINANCIAL MANAGEMENT REVIEW.................................................................62A. Financial Management Strengths.......................................................................64B. Financial Management Areas for Improvement and Recommendations...........64

V. TRANSITION READINESS AND PREPARATION................................................65Appendix F: Institute of Human Virology-Nigeria ClASS Assessment Report..................66I. BACKGROUND.........................................................................................................67II. CLINICAL REVIEW..................................................................................................67




V. TRANSITION READINESS......................................................................................80Appendix G: St. Anne’s Hospital ClASS Assessment Report.............................................81I. BACKGROUND.........................................................................................................82II. CLINICAL REVIEW..................................................................................................82

A. Strengths.............................................................................................................84B. Areas for Improvement and Recommendations.................................................85

III. ADMINISTRATIVE REVIEW...................................................................................86A. Administrative Strengths....................................................................................86B. Administrative Areas for Improvement.............................................................87


Appendix H: Ijebu-Ode, Orphans and Vulnerable Children (OVC) Program ClASS Assessment Report...............................................................................................................88I. BACKGROUND.........................................................................................................89II. OVC PROGRAM REVIEW........................................................................................89

A. Program Strengths..............................................................................................90B. Program Areas for Improvement and Recommendations..................................90


IV. FINANCIAL MANAGEMENT REVIEW....................................................................92A. Financial Management Strengths.......................................................................92B. Financial Management Areas for Improvement and Recommendations...........92

Appendix I: Federal Medical Center, Keffi, ClASS Assessment Report.............................94I. BACKGROUND.........................................................................................................95II. CLINICAL REVIEW..................................................................................................95


III. ADMINISTRATIVE AND FINANCIAL REVIEW.....................................................98A. Administrative and Financial Strengths.............................................................99B. Administrative and Financial Areas for Improvement and Recommendations. 99

Appendix J: St. Gerard’s Catholic Hospital ClASS Assessment Report...........................100

ClASS AIDSRelief-Nigeria Final Report ii

I. BACKGROUND.......................................................................................................101II. CLINICAL REVIEW................................................................................................101

A. Strengths..........................................................................................................103B. Areas for Improvement and Recommendations...............................................103

III. ADMINISTRATIVE REVIEW....................................................................................105IV. FINANCIAL MANAGEMENT REVIEW..................................................................108

ClASS AIDSRelief-Nigeria Final Report iii

Acronyms and Abbreviations

ANC Antenatal careART Antiretroviral therapyARV AntiretroviralCBO Community-based organizationCDC Centers for Disease Control and PreventionCHAN Christian Health Association of Nigeria ClASS Clinical Assessment for Systems Strengthening COP Chief of party, country operational planCQI Continuous quality improvementCRS Catholic Relief ServicesCSN Catholic Secretariat of NigeriaEID Early infant diagnosisEQA External quality assuranceFBO Faith-based organizationGON Government of NigeriaGPS Grants policy statementHAB Health Resources and Services Administration, HIV/AIDS BureauHCT HIV counseling and testingHHS US Department of Health and Human ServicesHMIS Health management information systemHRSA Health Resources and Services AdministrationIHV University of Maryland School of Medicine, Institute of Human

VirologyIHV-N Institute of Human Virology-NigeriaLOA Letter of agreementLPCF Local partner clinical facility LPTF Local partner treatment facility (AIDSRelief sites only)MARP Most at risk populationM&E Monitoring and evaluationMI Member institutionMIS Management information systemMOH Ministry of HealthMSH Management Sciences for HealthNEC National Executive CouncilNGO Nongovernmental organizationNICaB Nigerian Indigenous Capacity Building ProjectOGAC Office of the US Global AIDS CoordinatorOMB US Office of Management and BudgetOPD Outpatient department OVC Orphans and vulnerable childrenPEPFAR President’s Emergency Plan for AIDS Relief PICT Provider initiated counseling and testingPLHA People living with HIV and AIDS

ClASS AIDSRelief-Nigeria Final Report iv

PMTCT Prevention of mother-to-child transmissionSTA Senior Technical AdvisorTA Technical assistanceTB TuberculosisUSAID United States Agency for International DevelopmentUSG United States government VCT Voluntary counseling and testing

ClASS AIDSRelief-Nigeria Final Report v

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 International as 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 ClASS framework, which is designed to assess 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.

ClASS AIDSRelief-Nigeria Final Report 6

http://www.pepfar.gov/

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 as member 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, which can 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 at providing 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 providing this 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: A deputy 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 function strengthens 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)


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.


Finding 1: Existing staffing levels at CHAN headquarters are insufficient toensure that clinical and programmatic oversight translate into the intendedoutcomes at the facility level. Recommendation: CHAN should assess its existing capacity to provide the kind of clinical oversight required to superviseAIDSRelief-Nigeria local 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.


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 conflictsthat 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 aspart 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.


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

Finding: CHAN 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 HHSGPS and by OMB Circular A-110 Uniform Administrative Requirements. Recommendation: As the transition plan activities move forward, CHAN should implement a budget management system that includes review of budget variances by management.

C. Institute of Human Virology-Nigeria (IHV-N)


IHV-N currently manages one of the largest comprehensive multidisciplinary treatment programs in Nigeria, accounting for 60,000 patients on treatment.

The IHV-N program works collaboratively with traditional birth attendants some of whom have been trained in HCT and provided with test kits.

IHV-N has a strong didactic training program that includes follow-up with onsite mentoring and supportive supervision.

The IHV-N program works with tertiary hospitals, turning them into centers of excellence and using their geographical proximity and relationships to support satellite sites.

Multidisciplinary teams use local experiences, including patient feedback, to drive continuous quality improvement.

Treatment initiation is guided by standardized protocols. IHV-N has integrated nutrition into its program. IHV-N has provided leadership in task shifting to alleviate some health care

worker shortages, especially in remote sites and other primary health care facilities.


Finding 1: There is no local data to determine what proportion of patients on first-line treatment need second-line. Recommendation: IHV-N may consider working with in-country partners who have viral load data to determine treatment change criteria and also use switch committees.


Finding 2: Pediatric care enrollment is a challenge for the program. Recommendation: IHV-N should look at its data for testing and enrollment in care and use it to estimate the need for pediatric ART and plan scale-up.

Finding 3: High loss to follow-up rates (as much as 30%) have been recorded in the program data from recent analyses. Recommendation: IHV-N should develop plans to support sites to verify the actual patient status and to determine whether clients are deceased, have moved from the area, or transferred to another provider.

Finding 4: Sites are not using quality improvement to improve patient flow and reduce staff workload and patient follow-up adequately. Recommendation: Improvements and lessons that IHV-N may have after interventions to reduce loss to follow-up should be documented and shared across all sites to enable them to implement best practices.

Finding 5: There is no system to link mother and child information within the same site to track success or failure of prevention of mother-to-child transmission (PMTCT) efforts. Recommendation: IHV-N needs to explore how early infant diagnosis (EID) data can be linked to maternal interventions to determine its performance in preventing new HIV infections through PMTCT.


IHV-N has experienced leadership and open communication up and down the staff levels.

Regional offices provide decentralization of program oversight. The organization has grant writing-capacity that is resulting in increased

funding for sustainability. The human resources conditions of service policies are very comprehensive. The organization has information technology systems and expert staffing to

provide oversight for sites and subcontractors.


Finding 1: IHV-N does not currently meet all the OGAC local partner definitions, and there are other local autonomy concerns:

a. The three leadership positions in the organization are not paid employees of IHV-N.

b. The current board of directors is composed entirely of University of Maryland (UMD) staff, for whom it is inappropriate to approve organizational policies, as they are the staff required to implement the same.

c. The majority of funding for the organization comes from within the UMD payment system (discussed more under finance).

d. There is no document indicating the willingness of IHV-UMD to allow IHV-N to be completely autonomous and continue affiliations with the university.

Finding 2: Written program monitoring policies and procedures were not available. Recommendation: IHV-N should review the current monitoring processes and


jdonahue, 10/12/10,

Note: This finding was not included in the HRSA debrief PPT of 2 July; however, it was discussed with AR and IHV/N CEO during the assessment and the points in this finding are consistent with that discussion.

determine whether they are achieving the desired results, then document and share with staff and all sites.

Finding 3: Regional project officers conduct crisis management rather than proactive and preventive monitoring based on management team meeting minutes. Recommendation: Management with the regional manager and project officers should determine if this philosophy is consistent with the donor requirements, and what site issues could have been avoided with more proactive monitoring.

Finding 4: There is a lack of coordination between program monitoring, compliance, and finance in conducting reviews of sites and sharing findings and follow-up. Recommendation: The regional manager and finance manager should develop a schedule to ensure that staff meet at least quarterly to share findings from visits and determine where there are crossover issues that may be appropriate for a joint site or monitoring visit.

Finding 5: Human resources does not document the status of clinical staff licenses. Recommendation: HR should consider developing a spreadsheet or database to list the license numbers annually for clinical staff, along with dates of expiration, either through viewing of the original documents or maintaining copies of licenses annually in employee files.


IHV-N has established independent grants management and compliance/internal audit functions that strengthen internal control. Also, IHV-N thoroughly reviews the documentation supporting the sites’ monthly expenditures.

IHV-N’s plans for the implementation of Accpac software will improve the fiscal management system, especially budget management and allocation of revenue and expenses.

The organization is committed to correcting problems: all recommendations from the management controls report for fiscal year ending March 31, 2008, have been either fully or partially implemented.

IHV-N seeks to increase and diversify revenue by pursuing other grant opportunities.


Finding 1: IHV-N has not implemented fiscal monitoring of the sites receiving US government grant funds, as required by the Office of Management and Budget (OMB) Circular A-133. Recommendation: As the transition plan activities move forward, IHV-N should implement fiscal monitoring.

Finding 2: IHV-N 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 HHSGPS and by OMB Circular A-110. Recommendation: IHV-N should implement a budget management system that includes review of budget variances at the level of grant, department, and top management.


Finding 3: IHV-N does not track time and effort associated with grants, as required by OMB Circular A-122 and the HHSGPS. Recommendation: IHV-N should implement a system to track time and effort reporting by employees and to use these reports as supporting documentation for the allocation of labor costs to the grant.

Finding 4: IHV-N does not have fiscal policies and procedures that have been approved by the board of directors. Recommendation: As the transition plan activities move forward, IHV-N should work with the board to finalize the fiscal policies and procedures.

Finding 5: The LOA with the sites receiving funds for salaries for employees working on US government grants includes a restriction that these funds will not continue for the same employee for longer than twelve months. Recommendation: IHV-N may be able to work with the United States Agency for International Development (USAID) and other stakeholders to develop a solution that allows for continued funding of employees working on the grant.

Finding 6: Sites receiving PEPFAR funds from IHV-N are permitted to pay bed fees for patients who are hospitalized. Recommendation: PEPFAR funds may not be used to support the cost of inpatient services. IHV-N should modify the LOA to prohibit the payment of bed fees.

IV. TRANSITION READINESS SUMMARY

1. IHV-N has the capacity and some of the operational processes to work effectively as a local partner, given its current expertise in grant funding.

2. IHV-N needs to meet the OGAC governance criteria and autonomy expectations.3. IHV-N should determine the resources needed to ensure that proactive ongoing

program monitoring will be provided to AIDSRelief-Nigeria sites after transition.4. IHV-N should identify clinical best practices across their sites for use as quality

improvement opportunities for other sites to consider.5. CHAN has the operational processes to solicit and manage grants and monitor

grantee programs administratively. With the support of MSH as a subcontractor, CHAN has the ability to monitor program areas currently through many of their staff.

6. CHAN has a very strong chief of party for the Nigerian Indigenous Capacity Building Project (NICaB) project, but should she leave, then a significant portion of the organization’s program strengths will depart with her.

7. CHAN has the capability to attract diverse funding streams within Nigeria and internationally.

8. CHAN currently is managing 12 NICaB program sites. 9. Written program monitoring policies and procedures need to be developed at

CHAN to support the current practices. 10. CHAN needs to outline which project officer staff members are employed directly

by CHAN versus those provided by subcontract relationship with MSH, to allow


HRSA, AIDSRelief-Nigeria and CDC to know the “true” staffing capacity of the organization.

11. CSN has extensive relationships through the provincial and diocese offices of the church to extend outreach to health facilities in the community.

12. CSN needs technical assistance to learn the monitoring requirements for ART versus OVC programs and staff experience that will be required to conduct this new role.

13. CSN has been successful in acquiring diverse sources of funding supported by internal grant-writing and fundraising capability.

14. The CSN health unit needs technical assistance to ensure that current practices are sufficient to monitor ART sites and determine what reporting will be needed.

15. The CSN health unit, grants management, and finance should develop processes to share results of visits and when possible conduct joint visits to sites.

16. CSN has the capacity to work effectively as a local partner, given its current expertise in grant funding and strong fiscal position.

17. CSN should optimize the use of QuickBooks and/or Excel to facilitate aggregation of fiscal information for the purposes of budget management and fiscal reporting.

18. Establish appropriate roles, coordination of effort and working relationships of project officers, grants manager and project accountants in the areas of reviewing the reviewing budget variances, making plans for reallocation of funds, fiscal monitoring, and corrective actions.


AIDSRelief-Nigeria ClASS Assessment Report

I. INTRODUCTION

The Health Resources and Services Administration (HRSA) has provided funds from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) to US-based organizations to provide HIV care and treatment in developing countries since 2004. In 2007, funding for antiretroviral therapy (ART) was extended until 2012 on condition that the existing US-based grantees identify local in-country partner organization(s) (as defined by the Office of the US Global AIDS Coordinator (OGAC) and the US Department of Health and Human Services (HHS)) and provide capacity building support for the transfer of funding and program management. The class deviation waiver, approved by the HHS Office of Grants Policy, expanded HRSA’s responsibilities to monitor and support their funded projects in addition to ensuring quality management efforts are implemented and used by funded agencies.

Catholic Relief Services (CRS) provides HIV care and treatment in ten countries with PEPFAR funding. CRS is the HRSA Nigeria Track 1.0 grantee and provides services through AIDSRelief-Nigeria, a three-member consortium that supports lifesaving ART for poor and underserved people. The consortium brings together international expertise in HIV care: 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 International as lead agency for strategic information.

The Christian Health Association of Nigeria (CHAN), the Catholic Secretariat of Nigeria (CSN) and the Institute of Human Virology-Nigeria (IHV-N) are the three proposed local transition partners. No specific roles had been assigned to any of the organizations prior to the assessment.

II. PURPOSE

HRSA’s Global HIV/AIDS Program has developed the Clinical Assessment and Systems Strengthening (ClASS) framework, an assessment approach to determine an organization’s capacity and identify capacity building needs. The framework is meant to serve the following purposes:

To provide HRSA with an approach to assess the administrative, clinical, and financial capacity of US government-supported HIV/AIDS programs;

To inform HRSA and relevant partners of existing technical assistance needs, identify available resources to address these needs, and enable technical and organizational strengthening at the international partner, local partner, and clinic site levels;

To facilitate a process for HRSA and relevant partners to determine readiness and ensure a successful and sustainable transition of programs to local leadership; and

To inform the Track 1.0 partner of the most appropriate roles and responsibilities the proposed local partners will be able to assume for transition planning.


The assessment approach involves the use of tools that support reviewers in:

Assessing the local partner’s capacity to provide and manage the funded services and the quality of services and care provided to patients;

Ensuring that organizational systems, policies, and procedures are in place to accomplish program goals and objectives;

Identifying program strengths and weaknesses and provide appropriate consultation to enhance their capacity to provide high quality, cost-competitive health care and services;

Specifying areas of systems strengthening to enable organizations to enhance and sustain their HIV service delivery; and

Identifying model programs or program components that can be replicated in other communities or organizations.

Assessments focused on three areas:

CLINICAL: Facility structure, policies and procedures, project work plan, continuous clinical quality improvement/quality assurance, supply chain management and medical record reviews.

FINANCIAL: Income and expenditures, charges and fees, billing and collections, accounting system, accounts payable and cash flow, fixed assets, inventory and purchasing, payroll, revenue, cost allocation and grants management

ADMINISTRATIVE: Organization and structure, governance and leadership, strategic and short term planning, and program monitoring, human resource management, personnel policies and procedures, clinical personnel licenses and certifications, risk management and liability protection, quality assurance, collaboration, linkages, and management information systems.

III. METHODOLOGY

The AIDSRelief-Nigeria consortium members and the proposed new AIDSRelief-Nigeria consortium partners participated in the assessment held 21 June – 2 July 2010. Discussions to orient the team to the transfer of roles and responsibilities were held with AIDSRelief-Nigeria, Futures Group, and IHV.

Clinical Assessment for Systems Strengthening (ClASS) reviews were conducted at CHAN, CSN, and IHV-N, the three proposed local partners. A diagram illustrating the AIDSRelief-Nigeria post-transition plan is provided in Appendix A. 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 local partner treatment facilities (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.


A copy of the AIDSRelief-Nigeria assessment schedule is provided in Appendix B.

Each assessment visit began with an entrance meeting held with the organization leadership to review the purpose of the visit and gather broad knowledge of the organization systems and challenges. The review process included interviews with staff members and a review of organization policies and procedures, meeting minutes, and reporting documents. A list of all staff by organization who participated in the AIDSRelief-Nigeria assessment is provided in Appendix C.

Several of the local sites visited during the assessment did not receive a complete ClASS review due to the limited time available onsite. Reports from these sites all contain strengths and areas for improvement and as much information as the team was able to collect.

The HRSA ClASS assessment team consisted of the HRSA project officer and consultants to conduct the clinical, administrative, and financial review. AIDSRelief-Nigeria staff participated as members of the review team and as observers of the process. Staff members from the Centers of 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.

At the end of each assessment visit, findings were shared first with AIDSRelief-Nigeria, and CDC observers, before sharing those same findings with key local organization staff. At the exit meeting held with the organization leadership and staff, the review team shared strengths as well as any areas for improvement and recommendations that might be helpful for staff to consider. This multi-tiered reporting process allowed for a more informed discussion of how to prioritize findings and identify how technical assistance could be provided to address findings by the Track 1.0 grantee without having to wait for a written report.

Debriefing sessions with AIDSRelief-Nigeria and CDC-Nigeria were held on July 2, 2010. Each of the local partners met separately with the HRSA team to hear the initial findings specific to transition readiness

A. Assessment Team

The ClASS assessment team for the AIDSRelief-Nigeria visit included representatives from the HRSA HIV/AIDS Bureau (HAB) and consultants for the areas of clinical, administrative, and financial review. Team members included:

HRSA HAB Global AIDS Program StaffJohn Oguntomilade, BDS, MPH, co-project officer

ConsultantsMoses Bateganya, MBChB, MMed, MPH, I-TECHCheryl Nesbitt, administrative reviewer and team leaderKathleen Wolf, CPA, financial management reviewerStefania Slabyj, team support and administrative, I-TECH


HRSA gratefully acknowledges the valuable contributions of the CDC-Nigeria team, especially Jerry Gwamna and Becky Iyoke, who accompanied the HRSA team and actively participated in the ClASS assessment.

B. Assessment Report Format

The results of the AIDSRelief-Nigeria ClASS assessments are in two primary areas of the report. Area number one provides the findings and recommendations related to each of the proposed local partner organizations, CHAN, CSN, and IHV-N. Transition planning conclusions and a summary of the findings and recommendations related to the local partner clinical facilities (LPCFs) and the AIDSRelief-Nigeria LPTFs are provided. Each of the proposed partner, LPCF, and LPTF reports, including details of information gathered during the visit, strengths, followed by findings and recommendations, are provided in Appendixes D–H.

IV. OUTCOME SUMMARY OF PROPOSED LOCAL PARTNER ASSESSMENTS

A. Catholic Secretariat of Nigeria


The Catholic Secretariat of Nigeria (CSN) has extensive relationships with federal, state, and local government institutions, and member 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 that can 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 USG partners.


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 at providing 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 MIS capability to support or provide supervision for LPCFs or any subcontractor providing this service. Recommendation: Determine how to best 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 and modify 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: A deputy health unit secretary or an administrative assistant could provide a significant amount of support and thereby relieve some of the current stress.


CSN is able to draw on the resources of the organization and the HIV/AIDS program is not solely dependent on US government grant funds.

The diversification of resources supporting the HIV/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 function strengthens 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 the 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.

Finding 3: CSN has not ensured timely liquidation of advances. Recommendation: CSN should implement a system whereby the Project Officer and the Project Accountant review expenditures by the dioceses and reallocate funds from underperforming sites to over-performing sites.

7. Transition Readiness Summary

CSN has extensive relationships through the provincial and diocesan offices of the church to extend outreach to health facilities in the community.

CSN needs technical assistance to learn the monitoring requirements for ART versus OVC programs and staff experience that will be required to conduct this new role.

CSN has been successful in acquiring diverse sources of funding supported by internal grant-writing and fundraising capability.

The CSN health unit needs technical assistance to ensure that current practices are sufficient to monitor ART sites and determine what reporting will be needed.

The CSN health unit, grants management, and finance should develop processes to share results of visits and when possible conduct joint visits to sites.

CSN has the capacity to work effectively as a local partner, given its current expertise in grant funding and strong fiscal position.

CSN should optimize the use of QuickBooks and/or Excel to facilitate aggregation of fiscal information for the purposes of budget management and fiscal reporting.

Establish appropriate roles, coordination of effort, and working relationships of project officers, grants managers, and project accountants in the areas of reviewing the reviewing budget variances, making plans for reallocation of funds, fiscal monitoring, and corrective actions.


B. Christian Health Association of Nigeria (CHAN)


The Christian Health Associate of Nigeria (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 nongovernmental organizations (NGOs) and community based organizations (CBOs), 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.


Finding 1: Existing staffing levels at CHAN headquarters are insufficient toensure that clinical and programmatic oversight translate into the intendedoutcomes at the facility level. Recommendation: CHAN should assess its existing capacity to provide the kind of clinical oversight required to superviseAIDSRelief-Nigeria 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.


There has been strong and consistent leadership of the organization. The National Executive Council 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.



Finding 1: There is no current process for National Executive Council (NEC) members to identify conflicts that might exist with CHAN or to sign confidentialitystatements, and no process to conduct self-evaluations. Recommendation: CHAN should confirm that sample forms and documents to address the above will beshared with NEC members as part of the Management Sciences for Health (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.


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.


Finding 1: CHAN 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 HHSGPS and by OMB Circular A-110, Uniform Administrative Requirements. Recommendation: As the transition plan activities move forward, CHAN should implement a budget management system that includes review of budget variances by management.


7. Transition Readiness Summary

CHAN has the operational processes to solicit and manage grants and monitor grantee programs administratively. With the support of MSH as a subcontractor, CHAN currently has the ability to monitor program areas through many of their staff.

CHAN has a very strong chief of party for the (NICaB) project, but should she leave, then a significant portion of the organization’s program strengths will depart with her.

CHAN has the capability to attract diverse funding streams within Nigeria and internationally.

CHAN is currently managing twelve Nigerian Indigenous Capacity Building Project (NICaB) program sites.

Written program monitoring policies and procedures need to be developed at CHAN to support the current practices.

CHAN needs to outline which project officer staff members are employed directly by CHAN versus those provided by subcontract relationship with MSH, to allow HRSA, AIDSRelief-Nigeria, and CDC to know the true staffing capacity of the organization.

C. Institute of Human Virology-Nigeria (IHV-N)


IHV-N currently manages one of the largest comprehensive multidisciplinary treatment programs in Nigeria, accounting for 60,000 patients on treatment.

The IHV-N program works collaboratively with traditional birth attendants some of whom have been trained in HIV counseling and testing (HCT) and provided with test kits.

IHV-N has a strong didactic training program that includes follow-up with onsite mentoring and supportive supervision.

The IHV-N program works with tertiary hospitals, turning them into centers of excellence and using their geographical proximity and relationships to support satellite sites.

Multidisciplinary teams use local experiences, including patient feedback, to drive continuous quality improvement.

Treatment initiation is guided by standardized protocols. IHV-N has integrated nutrition into its program. IHV-N has provided leadership in task shifting to alleviate some health care

worker shortages especially in remote sites and other primary health care facilities.


Finding 1: There is no local data to determine what proportion of patients on first-line treatment need second-line. Recommendation: IHV-N may consider working with in-country partners who have viral load data to determine treatment change criteria and also use switch committees.


Finding 2: Pediatric care enrollment is a challenge for the program. Recommendation: IHV-N should look at its data for testing and enrollment in care and use it to estimate the need for pediatric ART and plan scale-up.

Finding 3: High loss to follow-up rates (as much as 30%) has been recorded in the program data from recent analyses. Recommendation: IHV-N should develop plans to support sites to verify the actual patient status and to determine if clients are deceased, have moved from the area, or transferred to another provider.

Finding 4: Sites are not using quality improvement to improve patient flow and reduce staff workload and patient follow-up adequately. Recommendation: Improvements and lessons that IHV-N may have after interventions to reduce loss to follow-up should be documented and shared across all sites to enable them to implement best practices.

Finding 5: There is no system to link mother and child information within the same site to track success or failure of prevention of mother-to-child (PMTCT) efforts. Recommendation: IHV-N needs to explore how early infant diagnosis (EID) data can be linked to maternal interventions to determine its performance in preventing new HIV infections through PMTCT.


IHV-N has experienced leadership and open communication up and down the staff levels.

Regional offices provide decentralization of program oversight. The organization has grant-writing capacity that is resulting in increased

funding for sustainability. The human resources conditions of service policies are very comprehensive. The organization has information technology systems and expert staffing to

provide oversight for sites and subcontractors.

4. Administrative Areas for Improvement and RecommendationsFinding 1: IHV-N does not currently meet all the OGAC local partner definitions, and there are other local autonomy concerns:


b. The current board of directors is composed entirely of UMD staff, for whom it is inappropriate to approve organization policies, as they are the staff required to implement the same.


d. There is no document indicating the willingness of IHV UMD to allow IHV-N to be completely autonomous and continue affiliations with the university.


Finding 2: Written program monitoring policies and procedures were not available. Recommendation: IHV-N should review the current monitoring processes and determine whether they are achieving the desired results, then document and share with staff and all sites.


Finding 4: There is a lack of coordination between program monitoring, compliance, and finance in conducting reviews of sites and sharing findings and follow-up. Recommendation: The regional manager and finance manager should develop a schedule to ensure that staff meet at least quarterly to share findings from visits and determine where there are crossover issues that may be appropriate for a joint site or monitoring visit.

Finding 5: Human resources does not document the status of clinical staff licenses. Recommendation: HR should consider developing a spreadsheet or database to list the license numbers annually for clinical staff, along with dates of expiration, either through viewing the original documents or maintaining copies of licenses annually in employee files.


IHV-N has established independent grants management and compliance/internal audit functions that strengthen internal control. Also, IHV-N thoroughly reviews the documentation supporting the sites’ monthly expenditures.

IHV-N’s plans for the implementation of Accpac software will improve the fiscal management system, especially budget management and allocation of revenue and expenses.

The organization is committed to correcting problems: all recommendations from the management controls report for the fiscal year ending March 31, 2008, have been either fully or partially implemented.

IHV-N seeks to increase and diversify revenue by pursuing other grant opportunities.


Finding 1: IHV-N has not implemented fiscal monitoring of the sites receiving US government grant funds, as required by OMB Circular A-133. Recommendation: As the transition plan activities move forward, IHV-N should implement fiscal monitoring.

Finding 2: IHV-N 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 HHSGPS and by OMB Circular A-110. Recommendation: IHV-


N should implement a budget management system that includes review of budget variances at the level of grant, department, and top management.

Finding 3: IHV-N does not track time and effort associated with grants, as required by OMB Circular A-122 and the HHSGPS. Recommendation: IHV-N should implement a system to track time and effort reporting by employees and to use these reports as supporting documentation for the allocation of labor costs to the grant.

Finding 4: IHV-N does not have fiscal policies and procedures that have been approved by the board of directors. Recommendation: As the transition plan activities move forward, IHV-N should work with the board to finalize the fiscal policies and procedures.

Finding 5: The LOA with the sites receiving funds for salaries for employees working on US government grants includes a restriction that these funds will not continue for the same employee for longer than twelve months. Recommendation: IHV-N may be able to work with USAID and other stakeholders to develop a solution that allows for continued funding of employees working on the grant.

Finding 6: Sites receiving PEPFAR funds from IHV-N are permitted to pay bed fees for patients who are hospitalized. Recommendation: PEPFAR funds may not be used to support the cost of inpatient services. IHV-N should modify the LOA to prohibit the payment of bed fees.

7. Transition Readiness Conclusions

IHV-N has the capacity and some of the operational processes to work effectively as a local partner, given its current expertise in grant funding.

IHV-N needs to meet the OGAC governance criteria and autonomy expectations.

IHV-N should determine the resources needed to ensure that proactive ongoing program monitoring will be provided to AIDSRelief-Nigeria sites after transition.

IHV-N should identify clinical best practices across their sites for use as quality improvement opportunities for other sites to consider.


V. OUTCOMES OF LOCAL PARTNER CLINICAL AND TREATMENT FACILITY (LPCF and LPTF) ASSESSMENTS

One LPTF (St. Gerard’s Hospital), and three LPCFs (St Anne’s Hospital, Ibadan; Ijebu-Ode, OVC program office; and the Federal Medical Center, Kefi), were assessed. Crosscutting feedback is provided below.

A. St. Gerard’s Hospital


St. Gerard’s hospital offers a comprehensive set of services with very good integration of HIV care with general hospital services.

HIV clinic staff members collaborate with their colleagues on the medical wards to manage admitted patients, including HCT.

Regular clinical meetings within the clinic and involving other hospital staff improve coordination of care services. Mortality and morbidity meetings are one such avenue.

Onsite training with materials developed locally increases local capacity, and minimizes time spent away from delivering services.

Physicians play a big role in prevention with positives, while nurses and triage staff screen patients for TB.

Referrals are well documented and coordinated through referral staff. This hospital and the HIV clinic building designs minimize TB transmission. A therapeutic drug committee has enabled many eligible patients to be switched

to second-line treatment in a timely manner. Several continuous quality improvement (CQI) activities have been locally

implemented based on data collected onsite.


Finding 1: Staffing in the laboratory is insufficient to run all required procedures efficiently. Recommendation: Consider increasing the number of staff in the laboratory. A professional laboratory audit should help identify where additional support should be placed.

Finding 2: Scheduling patients for repeat CD4 remains a challenge. A recent external quality assurance (EQA) has identified that up to 40% of patients were not getting timely CD4 testing, and a few completely missed their repeat CD4. Recommendation: The staff has already put in place mechanisms to minimize delays in CD4 testing. Regular chart reviews are one of the ways of ensuring proper documentation of processes.

Finding 3: Many needlestick injuries have been reported at this facility.Nursing students seem to be the ones at highest risk. It was not possible to determine whether all those reported had access to timely post-exposure prophylaxis. Recommendation: Urgent interventions should be implemented to


minimize the number of needlestick injuries. Several suggestions are provided in the site-specific report.

Finding 4: Only about 4% of those on ART are children. Recommendation: Efforts should be scaled up to ensure that entry points for pediatric care are maximized. Sites should use their testing data and other family demographics to estimate the number of children that need testing and explore ways to get them tested. Consider integration of pediatric and adult care, testing children (especially those under 5 years old) of HIV-positive women, and moving PICT into maternal and child health services.

Finding 5: HCT is mostly provided at the HIV clinic located several blocks from the outpatient department (OPD). Patients who require testing in OPD are referred to the HIV clinic. Recommendation: HCT should be provided at a place most convenient to patients. Even though HCT staff provide testing to the antenatal (ANC) clinic (twice a week) and to inpatients, testing should be provided at all times in the OPD and in the ANC clinic.

Finding 6: Male enrollment in care and treatment has not exceeded 30%. In the ANC department where uptake of PMTCT and other services depends on involvement of men, inadequate male involvement was a challenge staff acknowledged. Recommendation: Reasons for low uptake of services by men should be determined.

Finding 7: PMTCT program outcomes have been difficult to evaluate. The challenges include many mothers delivering at home, and the lack of linkage between mothers’ and exposed infants’ medical records. Recommendation: Care for the mother (families) and infants should be linked through data and providers. Timely EID and prompt return of results and their linkage with the mothers’ records may help minimize loss of exposed infants from care. Observed differences in the two sites mean that there are lessons that sites can learn from each other.


Hospital management provides good oversight and support for the ART program.

The community advisory board provides input and support to the program. The public relations officer secures corporate support and donations and

community input for the hospital and program. Management and departments meeting documentation indicates good problem

resolution and communication.


Finding 1: There is no HR staff person and duties are carried out by the hospital director and administrator. Recommendation: The hospital should determine what companies in the area would be able to second an HR person to help the hospital


once a month or coordinate a similar arrangement with AIDSRelief-Nigeria until a part-time or full-time person can be hired.

Finding 2: There is no process to document the status of staff clinical licenses.Recommendation: The hospital should consider developing a spreadsheet or database to list the license numbers annually for clinical staff, along with dates of expiration, either through viewing of the original documents or maintaining copies of licenses annually in employee files.

Finding 3: There is no process for administrative and fiscal monitoring of satellites. Recommendation: The Administrator or the Public Relations Officers should develop a schedule for the two staff to alternate visits to the satellites at least once per quarter.


The procurement process includes appropriate provisions for competitive bidding and independent selection on the basis of quality, price, and reliability.

The project finance officer has developed a strong system of accountability for the AIDSRelief-Nigeria funds. She designed a set of linked Excel spreadsheets that include a customized feature to prepare the monthly expenditure report. She has also made good progress in the implementation of QuickBooks in a short time.

The monthly expenditure report that was reviewed by the fiscal consultant included all supporting documentation and bore the necessary signatory approvals.

The participatory approach to budget development tends to ensure that program needs are identified and prioritized.


Finding 1: The audit of the hospital for the fiscal year ending December 31, 2008, did not include the AIDSRelief-Nigeria project, although the hospital is the recipient of the grant. Recommendation: For the 2009 audit, inform the auditor about the grant and determine if the grant’s transactions should be included in the financial statements of the hospital or if a footnote disclosing the grant is sufficient.

Finding 2: The accounting systems of the hospital and the AIDSRelief-Nigeria project are not integrated. Because the audit report of the hospital disregarded the grant and did not disclose that the grant was received, the hospital financial statements are not complete. Recommendation: Develop procedures to prepare and post summary journal entries for the AIDSRelief-Nigeria Project in the hospital accounting system.

Finding 3: The AIDSRelief-Nigeria project is carrying a deficit relating to disallowed costs from a prior period. Consequently the monthly advance does not cover monthly expenditures and the AIDSRelief-Nigeria project has delayed payment of salaries and vendors’ invoices to remain within the available cash.


Recommendation: Continue to work with AIDSRelief-Nigeria to resolve the matter of the disallowance.

Finding 4: The hospital does not have fiscal policies and procedures. Recommendation: Formulate fiscal policies and procedures and have them approved by the board of directors.

Finding 5: The management of St. Gerard’s Hospital does not prepare or review fiscal reports comparing budgets to actual expenses either for the AIDSRelief-Nigeria project or on a hospital-wide basis, as required by the HHSGPS and by OMB Circular A-110. Recommendation: St. Gerard’s Hospital should prepare and review budget variance reports for both the AIDSRelief-Nigeria project and on a hospital-wide basis.

B. Local Partner Clinical Facilities


All sites provide a comprehensive range of services for HIV care and treatment. Where treatment is not available onsite (for the OVC), appropriate referrals are made in a timely fashion.

Each site has integrated HIV services in different degrees based on the size and degree of specialization of each of the program components.

HIV care and treatment at each of the two hospital sites are supported by laboratories that provide the tests required to monitor HIV care and treatment.

All the sites enjoyed uninterrupted supply of ARVs and other consumables. Staff at all sites have been trained, receiving mentoring onsite or through

visiting multidisciplinary teams that provide supportive supervision. Cross-training of different staff has facilitated task shifting, which has alleviated

critical staff shortages.


Finding 1: CQI activities are not locally driven and do not address unique site-specific problems. Recommendation: Sites should be provided training and mentoring to enable them to develop regular patient chart review processes, electronic databases, or paper registers to track patient progress. Both cross-sectional and cohort analysis would inform the clinical team on patient outcomes.

Finding 2: The high rate of loss to follow-up in the sites visited needs urgent review. Loss to follow-up of patients who initiate ART is high (up to 40%). Sites did not have reliable data on those lost to follow-up pre-ART. Recommendation: Sites should consider one or more of the following:

a. Implement a series of three pretreatment counseling sessions for all patients prior to starting ART so patients can be committed to lifelong care.

b. Implement contact tracking with the use of cell phones, active involvement of people living with HIV and AIDS (PLHA), volunteers, and a peer treatment program.


c. Enroll those who test positive into care on the same day of testing to minimize pre-enrollment loss to follow-up.

Finding 3: The proportion of patients who are on second-line treatment was low in all sites. Missing scheduled repeat CD4, or doing them at infrequent intervals, was observed from the few charts we reviewed. Recommendation: Proposed local partners and respective facilities should investigate whether patients who need second-line treatment are receiving it through regular chart reviews to check whether CD4s are routinely ordered, completed, and documented or setting up switch committees.

Finding 4: Prevention with positives activities have not been prioritized in the sites that were visited. Recommendation: Prevention with positives activities should be integrated into HIV care through the promotion of support groups, partner testing, and condom use among discordant couples. AIDSRelief-Nigeria should share with proposed local partners its successes in integrating prevention in its sites.

Finding 5: Tracking of PMTCT outcomes remains a challenge in most sites. The lack of unique identifiers for mother and infant on client files and EID results makes it impossible to link families. Recommendation: Care for the mother (families) and infants should be linked through data and providers.

Finding 6: Staffing is a challenge for critical services (laboratory, pharmacy) and may impact service delivery significantly. The pharmacy and lab were found to be bottlenecks in patient flow. Recommendation: Staffing needs to be improved in the two areas to reduce obstacles to patient flow and improve the quality of service. Task shifting and use of volunteers for non-critical roles such taking patient samples, returning results, and directing patients may be helpful, but hiring of trained staff is also recommended.

Finding 7: Pediatric enrollment appears low in almost all sites. It was not clear whether the sites or relevant partners had set pediatric targets. Children constituted not more than 5% of all patients on ART, a figure less than appropriate per AIDSRelief-Nigeria and global targets. Recommendation: Efforts should be scaled up to ensure that entry points for pediatric care are maximized. Sites should use their testing data and other family demographics to estimate the number of children that need testing and explore ways to get them tested.


Hospital administration supporting program with resources Governance and management oversight Strong linkages with community (donations, advocacy, sustainability) LP support outside of site funding (generators, vehicles support, renovations) Acceptance of all technical assistance Commitment to serve the community despite few resources and space



Finding 1: Medical records were found to be insecure; file contents were easily lost and staff not well trained. Recommendation: Monitoring organizations should provide capacity building support to train staff, procure secure locations to store files, and review filing options that will bind file contents to reduce loss of documents.

Finding 2: Program managers often do not have backups identified and prepared to take over duties in preparation for promotions or changes in staffing. Recommendation: Program managers should identify staff who can serve as stand-ins with full authority to make management decisions as needed.

Finding 3: Confidentiality was found to be discussed, but no written policies were found. Recommendation: AIDSRelief-Nigeria should provide samples of LPTF confidentiality policies as starting points for sites to consider.

Finding 4: Tertiary facilities have not developed processes for administrative monitoring of satellites. Recommendation: If tertiary facilities are expected to be mentors for the satellite sites, then criteria to support this role should be developed and guidelines implemented on how and when such activities are expected to be implemented.


Dedicated accounting staff to support the project Good allocation processes in place with program staff Detailed monthly reports and documentation for all expenditures submitted with

program signatories Appropriate controls for purchasing and payment functions Sound procedures for program staff to request needed equipment and supplies,

consistent with the budget Good procurement policies and processes


Finding 1: The accounting systems of the hospitals and the ART project are not integrated. Recommendation: Develop procedures to prepare and post summary journal entries for the AIDSRelief-Nigeria Project in the hospital accounting system.

Finding 2: Site monitoring organizations do not prepare or require fiscal reports comparing budgets to actual expenses on a site-specific, department-specific, or organization-wide basis, as required by the HHSGPS and by OMB Circular A-110. Recommendation: As the transition plan activities move forward, local partner organizations 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.


Finding 3: Sites’ submissions of monthly reports are not consistently timely and accurate to ensure sufficient cash to implement the project. Recommendation: Sites should ensure an appropriate cash flow by submitting timely expenditure reports, enabling the site to pay project allowances when they are due.

Finding 4: Some procurement policies and procedures did not include basic elements of competitive bids and independent review.

Finding 5: Cross-training of employees is not done and work flow could be interrupted during staff vacancies and leave. Recommendation: Cross-training of employees is advisable so that work flow is not interrupted during staff vacancies.

Finding 6: Petty cash procedures do not include reasonable safeguards, e.g., locked box, periodic cash counts, regular reconciliations of petty cash funds. Recommendation: Petty cash procedures should include reasonable safeguards.The site should ensure an appropriate cash flow by submitting timely expenditure reports, enabling the site to maintain sufficient petty cash funds.


Appendix A: AIDSRelief-Nigeria Current and Proposed Partners


Appendix B: AIDSRelief-Nigeria ClASS Assessment Schedule

Date Site/Organization Name

Mon. 21 June 10

Briefing meeting with CDC-Nigeria

Briefing meeting with AIDSRelief-Nigeria, Futures Group, and UMD/IHV (transition update discussion)

Tues. 22 June 10CSN (Abuja)

Wed. 23 June 10IHV-N (Abuja)

Thurs. 24 June 10 IHV-N (Abuja)—administrative, finance only

CHAN ART (Lagos)

Fri. 25 June 10 CSN (Abuja)—administrative, finance only

OVC site (Lagos)

Mon. 28 June 10 St. Gerard’s Catholic Hospital (Kaduna)

Tues. 29 June 10 CHAN (Jos)

Wed. 30 June 10CHAN (Abuja)

IHV-N (Abuja) —Federal Medical Center

Thurs. 1 July10ClASS Team Meetings, debrief preparation

Kubwa/OLA Akwanga (HRSA project officer only )

Fri. 2 July 10 Debriefing meeting with CDC-Nigeria

Debriefing meeting with AIDSRelief-Nigeria

Appendix C: List of Participants ClASS AIDSRelief-Nigeria Final Report 36

Catholic Relief Services, NigeriaZebiwa Maikin, Senior Program ManagerDon Rogers, Country RepresentativeLeia Isanhart Lalima, Regional Technical AdvisorDrew Rogers, Chief of PartyJohn Donahue, Sustainability CoordinatorJoanna Nwosu, Program Quality ManagerOnne Adah-Ogoh, Health Systems StrengtheningMartin Oluoch, Manager—ICDJudith Adimorah, Program Manager

Catholic Secretariat of NigeriaCelestine Aharamwe, Chief AccountantOgbaisi Folakemi, Project AccountantColumbia Ejukwa, Finance Analyst—ComplianceOkoh Jerry Kaka, Care & Support OfficerVincent Oyewde, Procurement OfficerArit Enwang, Project AccountantFr. Evaristus Bassey, Executive SecretaryChristian Eshiet, Project AccountantMiriam Ifoma Ezekwe, Health SecretaryMichael Tomori, M&E OfficerOrame Ngozi, M&E OfficerSr. Bernadine Ikeji, Personnel OfficerRev. Fr. Zacharia Samjumi, DirectorRev. Fr. Peter Okonkwo, Deputy Secretary GeneralB.O. Ovwigbo, National HIV CoordinatorFelix A. Oso, Program Manager—HIV/AIDSChris Njoku, Provincial Program ManagerDasula Odunaya, Provincial AccountantQueen Egun, M&E OfficerChristian Antanwu, Diocesan AccountantEmmanuel E. Okogwu, Administrative AssistantAnthony Ogunniyi, Home-Based CareAbraham E. Ben, Program AssistantAdelaya Oluwakemi, Diocesan SecretaryAdeloya Adekunle, Diocesan Driver

Centers for Disease Control and Prevention (CDC) NigeriaKate Antyi, Sr. Program Specialist—HIV CareSani Gwargo N., Medical EpidemiologistAday Adelosoyce, Associate Director—Program ManagementJerry Gwamna, Program Specialist—HIV PreventionBecky Iyoke, Financial AnalystSubroto Banerji, Deputy DirectorVindi Singh, Assistant Director—Clinical Programs


Stanley Amadiegwu, Program Specialist—M&EAbiola Tubi, Program Specialist—TB/HIVTapdiyel Telpe, Senior Lab SpecialistJason Houhek, ASPH/CDC Program Management FellowTerfa Kene, Program Specialist—Medical PreventionAdegoke Dickson, Lab Systems SpecialistAnthony Okwuosah, Senior Program Specialist—HIV TreatmentAhmed M. Luna, Senior Program Specialist—HMISSamuel Ngobua, Program SpecialistAhmad Aliy, Program Specialist—SI

Christian Health Association of Nigeria (CHAN), Nigeria Indigenous Capacity Building (NICaB) ProjectKunle Atofarati, Hospital CoordinatorAde Adetunji, Clinical CoordinatorZupporah Kpamo, Chief of PartyPatrick KwalefulN.D. Gobgab, Program Director

Futures GroupD.S. Dandar, SI Advisor

HRSA/ClASS TeamPhilippe Chiliade, HRSA, Medical Officer & Track 1.0 Team LeaderJohn Oguntomilade, HRSA, Project OfficerCheryl Nesbitt, Team Leader and Administrative Reviewer, ConsultantKathleen Wolf, Fiscal Reviewer, ConsultantMoses Bateganya, Clinical Reviewer, I-TECHStefania Slabyj, Team Support, I-TECH

Institute of Human Virology, NigeriaPatrick Dakum, Chief of Party and Project DirectorCharles Mensah, Deputy Chief of PartyKolawole Falayajo, Director—M&EFredrick Hayes, Director—AdministrationSam Peters, Head—Molecular VirologyDebo Olateju, Head—Finance DepartmentGambo Mahmud, Acting Head—Clinical Services DepartmentChuji Olimze, Manager—CommoditiesEmilia Iwu, Senior Technical Advisor—Community MedicineAvong Yohanna Kambai, Head—Pharmacy Gideon T. Ishaya, Senior Program Officer—LabAbdullahi Abubacar, Senior Program Officer—LabMeshak Panwal, Program Officer—LabGrace Adama, Program Officer—PediatricsHaroun Omeiza, Program Officer—PMTCT

Institute of Human Virology, University of Maryland School of Medicine


Michael Obiefune, Country Medical DirectorMercy Niyang, Lead—Quality Improvement

Management Sciences for Health (MSH)Jennifer Brinkerhoff, Deputy Chief of Party

Nigerian Federal Ministry of HealthMrs. O.F. Adegoke, Asst. Director—IPCIjaodola Gbenga, Program OfficerJamiu Ganiyu, Infection, Prevention & Control

Nigerian National Agency for the Control of HIV/AIDS (NACA)Akudo Ikpeazu, Director—Program Coordination John Idoko, Director GeneralPatrick Abah, Director—AdministrationNsikak Ebong, Director—Finance & AccountsHajia Maimunah Mohammed, Director—Partnerships CoordinationGreg Ashefor, Manager—Capacity Building & Systems StrengtheningMercy N. Egemba, Program Officer

St. Anne’s Anglican Hospital—IbadanOlasode Olagbeyu, Medical OfficerKunle Atofarati, Hospital CoordinatorAde Adetunji, Clinical Coordinator


Appendix D: Christian Health Association of Nigeria ClASS Assessment Report


AIDSRelief-Nigeria ClASS Assessment for Systems Strengthening (ClASS)Christian Health Association of Nigeria (CHAN)

June 30, 2010

I. BACKGROUND

The Christian Health Association of Nigeria (CHAN) was formed in 1973 as a multidenominational, not-for- profit service organization by the Catholic Bishops’ Conference of Nigeria (CBCN), the Christian Council of Nigeria (CCN), and the Northern Christian Medical Advisory Council of Nigeria. The organization provides advocacy services and conducts capacity building for member institutions (MIs) to meet the health care needs of Nigeria. CHAN has over 358 registered MIs representing over 4,000 health facilities operated by 15 church denominations to strengthen their capacities to meet the needs of the community.

CHAN has the mission of reaching the most rural and poor through the MIs with high quality, affordable, and client-friendly health services. CHAN has an extensive network of MIs and has supported their delivery of care to many underserved areas. The network is said to be responsible for as much as 40% of the health care delivery in the country.1 This varies by state, with the Plateau state being one where CHAN supports about 70% of the health care delivered across the state.

CHAN is one of the three proposed local partner organizations for the transition of PEPFAR programs from AIDSRelief-Nigeria. CHAN Medi-Pharm is a subsidiary and the drug supply and distribution arm which has been in operation since 1979. CHAN has a diverse funding history, including Family Health International, World Bank, US Agency for International Development, Department for International Development, and Global AIDS Fund.

II. CLINICAL REVIEW

Clinical and Technical Capacity

CHAN supports member institutions to provide many primary health care services, but does not directly run the health programs. Among the services CHAN supports are primary health and HIV and AIDS care, maternal and child health, reproductive health, health systems strengthening (through training and capacity building), health management information systems, and pharmaceuticals procurement and distribution through CHAN Medi-Pharm.

CHAN has run several projects over the years, including the Interfaith Project and Action AID. CHAN is currently completing a three-year USAID-funded project, Nigerian Indigenous Capacity Building (NICaB), implementing care and treatment programs in sites across twelve states of Nigeria. On this project, CHAN has subcontracted with Management Sciences for Health, Inc., to provide capacity building for NGOs to enable them respond to HIV and AIDS in their communities. The NICaB project relies on zonal

1 World Health Organization estimate.


teams comprising clinical, pharmacy, laboratory, and network coordinators. At supported care and treatment sites, a hospital coordinator employed by NICaB provides onsite mentoring. For small sites the coordinator may support more than one site.

Clinical Program Management and Oversight

CHAN operates a decentralized system of administration and clinical program support through zonal/regional offices established in four locations in the country. The zonal teams provide onsite support to the MIs as well as facilitating collaboration with different ministry levels from federal to local government. The northeast zone A has seven states and a CHAN office in Numan, the northwest/central zone B covers twelve states and has a regional CHAN office in Jos, the southeast zone C covers nine states with an office in Owerri, and the southwest zone D covers eight states with an office in Ibadan. These offices manage the relationships with MIs and provide them onsite support.

Most of the sites provide primary health care in hard to reach areas, using a model that supports integration of HIV care into other primary health care services at health centers and other points of service. This model supports task shifting and allows for efficient use of scarce human and other resources and would also potentially minimize loss to follow-up.

The program oversight capacity that exists currently is within the different projects that CHAN oversees or has been seconded by the different partners. Each of these projects has different funding, with different partnership and end dates. It’s not clear what plans CHAN has made to ensure that some of that capacity remains in house as the different programs end. The transition period should allow time to evaluate whether program plans are implemented to completion at the sites, and if not, what the challenges are and how they will be addressed.

A. Clinical Strengths

1. CHAN supports an extensive network of sites with almost national coverage. 2. CHAN has longstanding relationships with MIs and with various levels of

government: federal, state, and local. 3. CHAN has established relationships with NGOs and CBOs, some of whom have

served as subcontractors. These relationships place CHAN in a strategic position to further close the gap between tertiary and primary health care.

4. CHAN has successfully completed several health programs that expanded the organization profile and expertise.

5. 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.

6. Supportive supervision capacity at the regional office level potentially reduces costs of monitoring and puts capacity building efforts close to where they are needed.

B. Clinical Areas for Improvement and Recommendations

Finding 1: Existing staffing levels at CHAN headquarters seem insufficient to ensure that clinical and programmatic oversight translate into the intended outcomes at the


facility level, either now or when more responsibilities are assumed after transition. Recommendation: CHAN should use the transition period to assess its existing capacity to provide the kind of clinical oversight required to supervise AIDSRelief-Nigeria local partner treatment facilities (LPTFs). Options to consider are:

Work closely with AIDSRelief-Nigeria to study how the consortium works. Identify the competencies required to provide clinical leadership in a care and

treatment management grant. If these competencies are within the projects currently being implemented, CHAN should determine which need to be retained and how to support additional roles as a prime grantee.

Identify partners able to support and sustain a care and treatment program.

Finding 2: Program management and monitoring practices do not consistently produce expected results. For example, at the single site visited, challenges were observed in reaching targets, in appropriate documentation and standards in the pharmacy, and in quality improvement, indicating that program management oversight needs to be strengthened. This will be a further challenge when CHAN takes over large sites for which demands are greater. 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. Additionally CHAN should consider the following:

Is the capacity building model appropriate to the site-specific needs? What is the ideal combination of clinical and programmatic expertise needed for

a site coordinator? What is the best way to address staffing challenges at its sites? Should CHAN

second staff or fund time and let the facilities hire their own staff?

Finding 3: CHAN’s expertise and strengths are more suited to supporting primary health care. CHAN should consider what will happen when the organization is expected to take over a government site or a large site currently managed on a different model. Recommendation: CHAN should consult with AIDSRelief-Nigeria and other partners on how large sites are managed, documenting challenges and collecting best practices from AIDSRelief-Nigeria sites.

III. ADMINISTRATIVE REVIEW

Governance

CHAN has two levels of governance providing oversight for organization activities. The board of trustees has six members, two representing each of the three founding bodies of the organization. This is the primary oversight body of the organization. Operationally, the activities of CHAN are initiated from the headquarters based in Jos, Plateau State. The National Executive Council (NEC) serves as the administrative oversight body for the organization. The NEC is composed of thirteen members, three representatives from each of the founding organizations and one representative from each of the four zonal regions covering all the Nigerian states. The NEC meets four times per year.


The NEC approves all the organization policies and procedures. The secretary general and the administrator attend meetings and ensure that detailed minutes are kept of the NEC and committee meetings. Minutes of the meetings and committees were reviewed and found to provide comprehensive descriptions of discussions and staff reports. The administrator sends out meeting reminder notices about six weeks prior to each meeting with agendas and reports or documents for discussion. Board files contained copies of all handouts.

Management Sciences for Health, Inc. (MSH), a subcontractor on the NICaB project, is working with CHAN in providing training for the board of trustees and the National Executive Committee. Two areas where governance members were identified as needing additional guidance include advocacy and fundraising.

Strategic Planning and Fundraising

The CHAN Strategic Plan is very comprehensive and was developed with the assistance of MSH. Initial strategic planning meetings were held with the NEC in August 2009 and concluded with a final document in December 2009. The four goals of the strategic plan for

2010–2015 were as follows:

1. To improve the health status of Nigeria by building the capacity of members to render health services;

2. To develop a financially sustainable organization by expanding the donor base;3. To expand and enhance the quality of CHAN membership; and4. To establish a health maintenance organization to strengthen CHAN’s operation.

The plan provides an outline of actions and projected funding needed to accomplish the desired outcomes. Several organization positions are identified to be added to enhance the organization’s capacity, including that of an internal auditor to conduct quality improvement for the entire organization, not just finance. An information technology officer position was also identified.

CHAN has the capability to attract diverse funding and has done so over the last ten years very successfully. CHAN has developed relationships with NGOs and FBOs that have helped to acquire and disseminate funding to many communities in Nigeria. CHAN has not developed strategies to maintain capabilities that are grant funded after the funding periods have ended. Many of the current clinical capacities of CHAN are through the relationship with MSH. This is certainly an acceptable option, but must be fully disclosed to current and prospective donors

Organization Management and Structure

The secretary general is responsible for the day-to-day operations of the National Secretariat and reports to the NEC. Below the secretary general are a team of directors, who have responsibility for the various departments and units. The National Secretariat has four support service units; primary health care services and programs helps to coordinate all primary health care services and implement projects. The remaining three departments are the advocacy and management information system (AMIS), finance, and administrative.


The management team (secretary general and department/unit heads) is expected to meet monthly. On a quarterly basis, the management team includes the zonal coordinators in joint management team meetings. All managers and zonal coordinators are to submit written reports to the secretary general. General staff meetings are scheduled for three times per year (January, July, and December), when possible. Department meetings are to be held monthly.

MSH is also working with CHAN management using the Leadership Development Program series of trainings to help enhance strategic planning, proposal development, and management and finance systems. MSH is also providing skill building support to the member institutions and to NGOs and FBOs.

Human Resources and Personnel

A new human resources manager has been recently hired due to the growth of the organization, and is in the process of reorganizing personnel files. The administrator supervises the human resources department. The human resources management policy manual is very comprehensive.

Opportunities are available for internal posting of vacancies prior to external advertisement. If positions are for senior management, then the NEC is requested to have members participate in the screening and interview of candidates. CHAN provides loans to staff for rental of houses and cars, and sets up repayment agreements. The probationary period for all employees is twelve months. Suggestions were made to consider having staff sign and disclose outside work on an annual basis rather than just at initial employment with the organization.

Performance reviews are required annually and HR staff reported having few problems receiving such documents from supervisors in a timely manner. A review of the performance assessment tool found that there were no guidelines for use of the rating scale. Management indicated that the tool was currently under review. It was also suggested that training be considered for both managers and employees on the new tool once approved. Five personnel files were reviewed and it was found that licenses for clinical personnel are copied at initial employment, but no system exists to track the status of licenses annually.

Grants Management, Program Management and Monitoring

CHAN has a very comprehensive grants management manual that outlines all the processes to be carried out prior to and after grant awards are made. Pre-award visits are conducted for proposed sites once their applications have been reviewed and make the “best and finals” list. For the NICaB project, representatives from MSH, USAID, and the two national NGOs were included in the pre-award visits.

The CHAN grants management manual provides a brief section on general site monitoring. The Abujah regional director acknowledged that this document does not identify all the current monitoring processes and practices currently being carried out by staff. NICaB


Project officers are expected to conduct a minimum of quarterly visits to each of the twelve (12) sites.

The NICaB chief of party is currently the regional office director for Abuja reporting to the public health department director and provides monthly written reports summarizing the accomplishments of program sites that is then sent to donors upon review and approval. Weekly meetings are held between the regional manager and the project officers in the regional office. A sample of staff meeting minutes was reviewed and found to include reviews of program status and the quarterly and monthly action plans. Where possible, project officers are encouraged to conduct visits to sites jointly unless there are emergency reasons for separate visits. At the time of the ClASS assessment, CHAN monitoring visits were being conducted together due to a shortage of vehicles.

A. Administrative Strengths

1. There has been strong and consistent leadership of the organization.2. The National Executive Council supports the organization, particularly in senior

management interviewing and procurement approval for large-ticket items.3. The minutes for the NEC and management team meetings were very detailed,

showing how information is shared and problems are addressed.4. Board materials contained all notices, advance materials, management and financial

reports shared at meetings.5. Personnel policies and procedures were found to be very comprehensive and were

reviewed and updated last year.6. Human resources is in the process of developing an employee handbook.7. CHAN demonstrates good ability to attract and secure diverse funding from donors

as well as resources from CHAN Medi-Pharm.8. The organization has been able to increase security for the Jos facilities

(combination of paid and military) through state- and federal-level relationships.9. The decentralization into regional offices allows more localized support and

monitoring of programs at the member institutions.

B. Administrative Areas for Improvement and Recommendations

Governance

Finding: 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. Training for the NEC had been scheduled and is in the process of being rescheduled. Recommendation: As MSH reschedules the training, CHAN should confirm that sample forms and documents to address the above will be shared.


Human Resources

Finding 1: There is no standardized table of contents for the personnel files. Recommendation: Develop a checklist of required contents and establish the desired order for the contents of each personnel file.

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, either through viewing the original documents or maintaining copies of licenses annually in employee files.

Finding 3: The performance appraisal forms provide no explanation of the rating scale for supervisors to use when rating staff. Current forms also provide 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.

IV. FINANCIAL MANAGEMENT REVIEW

CHAN’s fiscal year is January 1 through December 31. CHAN’s 2010 budget includes the following:

US Dollars (estimated) Naira

Member Dues 872,051 6,014

EED 19,080,937 131,592

USAID 309,440,046 2,134,069

Rent Income 8,200,000 56,552

Sundry 2,596,333 17,910

Other Donors 23,480,000 161,931

Total Income 363,669,367 2,508,068

Expenses 375,349,938 2,588,620

Surplus (Deficit) (11,680,571) (80,556)

USAID Grant

On October 1, 2007, the United States Agency for International Development awarded $5.6 million to CHAN to implement the Nigeria Indigenous Capacity Building (NICaB) project for the three-year period ending September 30, 2010. Pannell Kerr Forster, Chartered Accountants (PKF), audited the fund accountability statements for the period October 1, 2007, through December 31, 2008. Expenditures for that period were $1.5 million and a fund balance of $467,707 was carried forward.


Based on PKF’s audit, the regional inspector general made the recommendations shown below. The following table presents the recommendations and the status of each.

Recommendation Status

Recover $787 in ineligible questioned costs related to telephone allowance.

PKF audit reports that this item was repaid.

Recover $87,980 in ineligible questioned costs related to payments made before a contract was approved.

Regional office verbally reports that the amount was eventually approved by USAID; fiscal consultant was not able to verify status.

Recommendation Status

Recover $92,571 in unsupported questioned costs related to advances paid without supporting documentation.

Regional office verbally reports that most documentation was submitted and/or amounts were recovered; fiscal consultant was not able to verify status.

Recover $233,074 related to line items exceeding the budget by 10% or more and/or unbudgeted line items.

PKF audit reports that these items were approved by USAID in the reverse work plan.

Correct internal control deficiencies including lack of internal audit function, donated items not documented, control over vehicle usage, supporting documentation maintained by subrecipients, lack of timely appointment letters for new employees, gaps in the Accounting and Procedure Manual, insufficient detail in invoices from MSH.

PKF audit noted some specific corrections; fiscal consultant review of P&P indicates several additional corrections have been made; not able to verify the detail on the MSH invoices; position of internal auditor is currently vacant.

Recover $143,154 shortfall in cost sharing. Regional office tracks cost sharing requirement for sites and accumulated figures through 2009 exceed the requirement.

Financial Management

CHAN uses Tally as its accounting software. Each grant is maintained as a separate company within Tally. Reports can be prepared for each grant or company. Also, Tally allows consolidated, organization level reports to be prepared. The chart of accounts provides for the allocation of revenue and expenses to projects or grants. Employees use timesheets to report actual time worked. The timesheets are approved by the supervisors. Time and effort is allocated based on the percentages assigned to each employee within the project or grant.


Budget Management

CHAN has a participatory budget process. The director of finance and administration schedules a budget retreat which is attended by all heads of departments. Proposals are developed and submitted to the budget committee. Heads of departments meet with the budget committee to explain and defend their proposals. The budget committee finalizes the budget and makes its recommendation for approval to the NEC. After the budget is approved, it is circulated to the heads of departments for implementation.

CHAN’s policy and procedure manual requires that the finance department prepare monthly, quarterly and annual budget reports. The budget reports present the actual figures and cumulative figures for the period and identify variances. In addition, the finance department is to investigate and explain budget variances. However, the chief accountant advised the fiscal consultant that posting is not current and that the budget reports have not been prepared.

Fiscal Policies and Procedures

CHAN has comprehensive fiscal policies and procedures which cover accounting systems, budget management, audit, internal audit, fixed assets and depreciation, inventory, cash management, and fiscal reporting.

Grants Management

CHAN’s regional office manages twelve sites for the USAID grant. The finance and administration officer at the regional office uses an imprest fund to make advances and record expenditures of the sites. (An imprest fund reserves a fixed amount which is replenished on a regular basis or when the cash has been expended. An imprest fund, such as a petty cash fund, usually continues indefinitely, but it can be closed at the end of a fiscal period or when the funds are fully exhausted.) The sites receive an advance of one twelfth of the budget at the beginning of the funding period. Then, the sites are expected to submit monthly reports of actual expenditures when requesting funds for the subsequent month. The fiscal consultant reviewed examples of the sites’ monthly expenditure reports and found that all expenditures were supported by documentation and included signatory approval and notations of the payment issued.

The regional office finance and administration manager uses an Excel spreadsheet to track the advances and payments to the sites. Based on a review of this spreadsheet, all monthly expenditure reports except one are current.

The regional office finance and administration manager provides monthly consolidated reports to the CHAN’s Chief Accountant who records the advances and payments in the accounting system; this process correctly accounts for the advances and the liquidation or retirement of the advances.


Procurement and Contracts

CHAN’s procurement policies specify that the organization shall engage in ethical and responsible practices, make procurement decisions based on acquiring the best value available, provide free and open competition, avoid conflicts of interest, and comply with the terms and conditions of the contract, regulations of the funding source, and any applicable laws. The policies call for competitive bidding based on a combination of price and quality, review by a procurement committee, and signatory approval of selections.

Program Monitoring

The regional office finance and administration manager and the project accountant conduct regular fiscal monitoring visits of the sites. During monitoring visits a comprehensive tool is used that assesses accounting systems, staffing and human resources, budget management, and cash management, as well as the supporting documentation for the grant expenditures. The fiscal consultant reviewed examples of the completed tools and found that they were fully annotated and included evidence that the findings had been discussed with the site and approved by the regional office.

The fiscal monitoring tool includes a review of the sites’ in-kind contribution or cost sharing requirement. The regional office finance and administration manager reviews these figures and tracks the accumulation of cost sharing in an Excel spreadsheet. Based on a review of this spreadsheet, CHAN has exceeded the cost sharing requirement.

A. Financial Management Strengths

1. CHAN’s detailed organizational budget is supported by historical information. The budgetary process is participatory and receives input from all departments. Also, appropriate approval of the budget is documented.

2. CHAN has experience with grants, including several direct US government grants. 3. CHAN’s fiscal policies and procedures are complete and include internal control

features. 4. CHAN is committed to correcting problems; all recommendations from the audit

report of the USAID grant for the 15-month period ending December 31, 2008, have been either fully or partially implemented.

5. The regional office manages the reports from the sites well and ensures timely reimbursement (one week from the receipt of an accurate, complete report from the site).

6. The regional office conducts regular fiscal monitoring of sites.7. 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.

8. Employees’ time and effort is accounted for on a project-specific basis at the time of each monthly payroll.


B. Financial Management Areas for Improvement and Recommendations

Budget Management

Finding: CHAN 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 HHSGPS and by OMB Circular A-110, Uniform Administrative Requirements. Recommendation: As the transition plan activities move forward, CHAN should implement a budget management system that includes review of budget variances by management.

C. Transition Readiness and Preparation

1. CHAN has the operational processes to solicit and manage grants and monitor grantee programs administratively. With the support of MSH as a subcontractor, CHAN has the ability to monitor program areas currently through many of their staff.

2. CHAN has a very strong chief of party for the NICaB project, but should she leave, then a significant portion of the organization’s program strengths will depart with her.

3. CHAN has a strategic plan that includes activities to increase organizational systems and staffing to support expanded programs. CHAN also has the capability to attract diverse funding streams within Nigeria and internationally.

4. CHAN currently is managing twelve NICaB program sites. It is unclear what the largest number of sites the organization could manage is and how quickly CHAN could increase staff with their current resources. It is clear that the relationship with MSH will need to continue for some period of time to support the current organization capacity.

5. Written program monitoring policies and procedures need to be developed within the next ninety days to support the current practices.

6. CHAN also needs to clearly outline which project officer staff members are employed directly by CHAN, versus those provided by subcontract relationship with MSH, to allow HRSA, AIDSRelief-Nigeria and CDC to know the “true” staffing capacity of the organization.

7. CHAN should consult with AIDSRelief-Nigeria to determine the levels of staffing needed to continue the current monitoring and capacity building being provided currently to the LPTFs.


Appendix E: Catholic Secretariat of Nigeria ClASS Assessment Report


AIDSRelief-Nigeria Clinical Assessment for Systems Strengthening

Catholic Secretariat of Nigeria (CSN)June 22 and 25, 2010

I. BACKGROUND

The Catholic Secretariat of Nigeria (CSN) is the administrative headquarters of the Catholic Bishops’ Conference of Nigeria (CBCN). CSN provides education, human development, health care, and pastoral ministries to the communities in Nigeria and supports the 9 provinces and 52 dioceses and parishes of the country. There are an estimated 30 million Catholics in Nigeria. The secretariat implements the decisions of the conference along with facilitating the missionary, educational, and human development work of the bishops, priests, and other male and female religious and lay people engaged with the church in Nigeria.

CSN, one of the proposed partners for AIDSRelief-Nigeria, was founded in 1965 by the Catholic Bishops’ Conference of Nigeria (CBCN) as its administrative arm. Its main role is to guide policy and advocacy for Catholic health facilities and manage the development work on behalf of CBCN. CSN is administered through its headquarters in Abuja.

II. CLINICAL REVIEW

The health unit, under the Department of Church and Society, is headed by a medical doctor and provides general oversight to all the health programs. The health secretary provides this oversight through provincial and diocesan health coordinators. In preparation for transition and to better support the different programs, CSN has decided to register a separate organization called Catholic Social Services of Nigeria (CSSN)2. Although the new organization has not yet been registered, some positions and staff have been identified to fill them.


There is a small number of clinical staff able to provide oversight for health facilities. Most of the oversight in HIV has been provided for prevention programs and orphans and vulnerable children (OVC). The OVC program, one of CSN’s largest, does not provide direct clinical care requiring less clinical oversight. OVC programs refer children who need clinical care to respective member health institutions. To implement OVC, CSN partnered with AIDSRelief-Nigeria in the Scaling Up Nigeria Community Based Response to HIV/AIDS (SUN). Staff who oversee these programs include those in M&E, nurses and pharmacists.

The proposed local organization CSSN will have a team lead or head of programs who will coordinate with program heads for HIV, malaria and TB respectively. These positions have not been filled and the job descriptions were not seen by the assessment team.

2 Since the ClASS review was completed in June 2010, the proposed Catholic Social Services of Nigeria (CSSN) was renamed as the Catholic Caritas Foundation of Nigeria (CCFN).


Joanna Nwosu, 11/08/10,

Comments from Fr Zachariah: 1. The decision to register a different outfit to better manage programs was not taken “in preparation for transition” The decision was taken before CSN started discussing the AIDSRelief transition. 2. The new organization has now been named Catholic Caritas Foundation of Nigeria (CCFN)


1. CSN has extensive relationships with federal, state, and local government institutions, member health facilities that provide direct care, and many other faith- and community-based organizations. These relationships will support future programming and advocacy.

2. CSN relies on a strong relationship with community groups and networks of volunteers to support programs. These relationships can be used very effectively in linking future treatment programs to its existing structures in OVC and prevention programs.

3. 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. One example is getting expert clinical staff from the ministry to support some of the mission hospitals.

4. Oversight of the USG-supported OVC programs has allowed CSN to develop a cadre of trained management staff and networks that can be used to scale up care and treatment.

5. Some of CSN’s member institutions are already providing HIV care with support from AIDSRelief-Nigeria and other USG partners. Their experience could be used in the future to support new sites that CSN may take on after transition.


Finding 1: Clinical oversight capacity for care and treatment is insufficient to take on additional responsibilities. The leadership provided by the health secretary is commendable, but due to the breadth of health programs that CSN is currently involved in, there is need for additional support, especially with the additional demands that will come when CSN takes on local partner roles. Recommendation: Capacity in the following technical areas will need to be added before transition.

Clinical oversight for HIV care and treatment Strategic information systems management Laboratory Pharmacy

Finding 2: Capacity building and other organizational plans for the new organization have not been fully articulated. Recommendation: CSN should share written plans for the new organization, particularly on how it plans to address capacity building and clinical or program oversight. CSN should carefully study what capacity it will require to be competitive as a local organization overseeing a care and treatment grant. This self-study will allow CSN to identify gaps and strengths in supervising the following AIDSRelief-Nigeria areas, for which it currently has no or insufficient capacity.

Site management Clinical support Strategic information Supply chain

The transition period should be a time for CSN to identify competencies required for local partner and address them in a written plan. The partnership forum offered by


AIDSRelief is one such opportunity to learn the model currently used and adapt it for more sustainable programming.


Governance

There are two tiers to the CSN governance structure. The plenary is composed of the 66 bishops in Nigeria who meet twice per year in March and September. The constitution details the duties of each officer, how elections should be handled, and voting by secret ballot. Each unit of the organization has an assigned secretary, who is appointed by the plenary for a minimum three-year period. Reports and minutes for the last two meetings were reviewed.

The plenary relies on receiving information from the administrative board, which is composed of the president and secretary of the conference, bishop chairs of the departments, the secretary general, the directors of each department and the unit secretaries appointed by the plenary. This group of fifteen members meets four times per year, with two of those meetings at the same time frames of the plenary meetings.

The new organization’s (CSSN) governance body will be composed of the secretary general of CSN, the CSN director of church and society, the executive secretary of CSSN (ex-officio), a legal advisor, and three community advisors. Recruitment of the community advisors is in progress. The draft constitution of the new organization was reviewed and suggestions for reorganization provided for consideration.


Organization Structure and Management

CSN is headed by the secretary general assisted by the deputy secretary general. Both of these individuals are priests. The secretariat operates through four departments (pastoral affairs, pastoral agents, church and society, and mission and dialogue), , the directorate of social communications, and the national Catholic service centre. Each department has a director and units that are managed by a secretary. The secretaries of the units are appointed by the administrative board for a three-year term.

CSN managers are expected to conduct meetings at every level and documentation was found to support all levels of meetings. Meeting minutes for each level of management were found to be very detailed, focusing on decision-making and follow-up on past issues. Department directors and the management team meet with the secretary general at least three times per year. Each department is expected to hold their meetings every month. Every Friday there are administrative meetings where changes in policies or other important information for staff are shared after morning prayers. Staff are encouraged to share their feedback and suggestions for improvement in their department and unit meetings. Staff shared several changes that had been made over the last year in their units based on feedback.

CSN holds its annual retreat for all staff each year in January. This five day event includes a day for spiritual renewal and two days for department planning for the year. As each department shares their new plans, they also share highlights of their accomplishments from the previous year. The first director’s meeting is also held at the retreat.

The Christian Organization Research and Advisory Trust of Africa (CORAT Africa) conducted a feasibility study supported by AIDSRelief-Nigeria in 2009 to determine what current programs could be transferred to an NGO of CSN to improve donor reporting and community programs from those focused specifically on the church. CSN has filed paperwork with the government of Nigeria for this new organization and are waiting application acceptance and approval of the new organization name, either Catholic Center for Social Action or Nigeria Catholic Foundation. An executive secretary has been hired to lead the new organization and has developed a draft constitution and strategic plan. The membership categories desired for the board have been identified and approved by the CSN administrative board.


Strategic Planning

The strategic plan for the new organization, CSSN, was reviewed as this was identified as the potential organization to serve as the local grantee for community programs. The draft plan is very detailed and included all the current CSN staff in the planning process along with the newly hired executive secretary of CSSN. CORAT Africa was the facilitator the planning sessions.

The new organization will continue to be governed by the plenary body of CSN, but will have its own board of directors. It will be critical for the new organization to describe and continue its affiliation with CSN for some number of years until able to identify independent experience. This will be a very important consideration for any Track 1.0 transition related application.

Human Resources and Personnel

The human resources (HR) department is managed by one of the sisters for the current sixty-nine employees. There are very detailed processes for placing vacancy announcements, interview panels and questions as well as selection and approval of final candidates. Exit interviews are conducted and it has been found that the most staff leave for positions with higher salaries. The HR policies and procedures are very detailed and shared with each employee during orientation and when policy changes are approved.

The CSN HR department will carry out these same functions for the new CSSN organization until there is enough staff to justify one of their own. Challenges facing the HR department include having access to laptops for staff that must travel around the country to document their work and access email. Six-month probationary performance reviews are required for new staff and annually for all other staff.

Personnel files were reviewed for seven employees. Files were found to be complete with the exception of licenses for clinical staff. A copy of the license is taken upon employment, but there is no process to verify that licenses are current every year, as the employee is responsible for paying for the renewals on their own. It was suggested that CSN develop a database or spreadsheet to track the license numbers for each year if the organization does not want to increase the personnel file size with copies.

Program Management and Monitoring

The health unit currently provides oversight for 40 orphans and vulnerable children’s (OVC) project sites under a subcontract with AIDSRelief-Nigeria. CSN also has the Circle project in five states.

The unit has a single health secretary who provides all the coordination for the HIV, Safe Motherhood and malaria programs. This person is also responsible for coordinating with the diocese and provincial offices any programs that are in their areas.


The unit has one program manager and seven program officers. There are processes in place for conducting visits to the sites and coordinating visits by the project managers, grants and compliance officers, and project officers. There are checklists specific to a project, but there are no written policies for the steps and processes of monitoring and conducting visits that will guide staff and help the sites understand the preparations needed for a successful monitoring visit.

Projects are expected to be visited every six weeks, minimum. Staff is requested to complete a field visit planning document to help managers coordinate visits to sites. It was not clear whether there is joint discussion of the results of visits by the different departments when visits are not conducted together or when there are crossover issues. A field visit report is to be completed within three days of return and reviewed by the team leader within seven days of receipt. Two field reports were reviewed and found to provide good detail on the visit. A chart of the strengths, needs, and outcomes achieved was attached to the narrative report.

Copies of reports sent from the sites did not include enough information to know the outcomes of the project. Reports appeared to only address indicators which do not say how well the OVC services are being provided or whether there are staffing or administrative issues.

Grants Management

Reviewers had an opportunity to assess the processes used to solicit applications from parishes under the SUN project related to OVC. Grant review criteria used to determine the final grantees with scoring was available for review. CSN includes representatives from their project partners and funders on the review committee.

In reviewing the documents submitted from the parishes, it appears that the forms provided were completed and submitted, but very few parishes provided detailed descriptions of projects, outcomes, objectives, or staff members who work with the project. The documents received from applicants did not include detailed narrative project descriptions.

The letters of agreement issued to the ten parishes with the best applications contain requirements for reporting and invoicing. There was not enough detail on what each parish had proposed to provide for monitoring follow-up.


1. There is a strong historical relationship with AIDSRelief-Nigeria.2. CSN has extensive relationships with the diocese to help provide support to local

facilities.3. The health unit secretary is very competent at providing guidance for the program

manager and program officers. 4. There are comprehensive program monitoring processes carried out every six

weeks.5. The human resources department is well organized and managed.


6. There is a centralized model of project management, oversight, and finance for programs co-located with organization management.

7. CSN is initiating the separation of community programs from those that are solely church-related under a new organization.


Management Information Systems (MIS)

Finding: In order to serve as a prime grantee, there is insufficient internal MIS capability to support or provide supervision for local partner clinical facilities (LPCFs) or any subcontractor providing this service. Recommendation: Determine how to best acquire the skill sets needed to provide oversight in this area with AIDSRelief-Nigeria; this might include seconding of staff, pairing for mentoring, or subcontracting to carry out specific functions and gain the expertise needed.

Program Monitoring

Finding 1: 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. Decide how each individual review report can be shared throughout the project after individual visits are conducted and staff share ideas to resolve findings.

Finding 2: No written program monitoring policies and procedures were available. 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.


Grants Management

Finding: Solicitations for the USAID/SUN project did not include enough narrative descriptions and measurable objectives for desired services. Letters of agreement (LOAs) did not contain detailed narrative descriptions of the services funded. Recommendation: CSN may want to collect sample solicitations that have been used for small grants and those of AIDSRelief-Nigeria for LPTF sites in preparation for transition readiness capacity building. Review the current LOAs and decide how to improve the level of detail in the final document for future efforts.

Personnel and Staffing

Finding: Determine whether the health unit secretary’s multiple roles may compromise good project management and how additional support can be provided. Recommendation: The health unit secretary identified that a deputy health unit secretary or an administrative assistant would provide a significant amount of support and thereby relieve some of the current stress.


CSN’s fiscal year is November 1 through October 31. CSN’s audit of the financial statements for the fiscal year ending October 31, 2009, reports significant improvement over the prior year, as follows:

2009Naira

2009 US $

2008Naira

2008 US $

Net Assets 271,191,646 2,008,827 245,179,039 1,816,141

Gross Revenue 327,049,356 2,422,588 95,479,975 707,259

Net Increase (Decrease) in Assets

26,012,607 192,686 (7,603,928) (56,325)

Net Cash from Operations 105,458,375 781,173 (74,189,834) (549,554)

Cash Balance at Year End 303,943,742 2,251,435 81,573,922 604,251

Financial Management

CSN uses QuickBooks as its accounting software. The chart of accounts provides for the allocation of revenue and expenses to projects or grants. CSN has more than thirty projects or grants, including several direct from USG agencies.

Each project or grant is established as a separate company within QuickBooks. Project accountants are assigned to specific projects and handle all full-charge accounting responsibility for the projects to which they are assigned. The project accountants report to the chief accountant. A separate bank account is maintained for each project or grant. Expenses that are specifically related to the project or grant are charged directly. Indirect costs are pooled and allocated to each project or grant on a monthly basis.


The financial analyst, who reports to the secretary general, performs internal audit functions. Employees use timesheets to report actual time worked. The timesheets are approved by the supervisors. Time and effort is allocated based on the percentages assigned to each employee within the project or grant.

Budget Management

The directors of the departments submit requests and estimates for the annual budget and for specific projects or grants. These requests and estimates are reviewed and discussed in an annual budget meeting convened by the secretary general. Based on this review, the secretary general submits the annual budget to the Bishops’ Conference for approval.

Because CSN uses a separate company within QuickBooks to account for each project or grant, the budget management process is cumbersome, entailing the need to export company files to Excel and to roll up information to the project, department and organization-wide level. As a result, no budget management reports, e.g., budget variance analysis, are prepared.


CSN has comprehensive fiscal policies and procedures that cover accounting systems, budget management, cash management, general ledger, accounting for receipts and payments, accounting records, inventories of fixed assets, and fiscal reporting. The report of the audited fund accountability statements for the Scale Up of the Catholic Community Based Outreach in Response to HIV/AIDS (SUCCOUR) grant for the fiscal year ending October 31, 2008, noted that several of the fiscal policies were not implemented or enforced. (The report of the audited fund accountability statements for the SUCCOUR grant for the fiscal year ending October 31, 2009, had not been completed at the time of the site visit.)

Grants Management (Procurement and Contracts)

CSN’s procurement policies specify that the officers responsible should make every effort to find the best vendor, with the best price and with the best product. The policies call for competitive bidding based on a combination of price and quality, review by a panel and signatory approval of selections.

Most project or grant funds are distributed to the dioceses on the basis of contracts or agreements specifying the work to be performed and the line-item budget. The dioceses receive an advance of one-twelfth of the budget at the beginning of the funding period. Then the dioceses are expected to submit monthly reports of actual expenditures when requesting funds for the subsequent month. Advances are recorded in the accounting system and the actual expenses per the monthly reports are recorded; this process correctly accounts for the advances and the liquidation or retirement of the advances.

However, the report of the audited fund accountability statements for the SUCCOUR grant for fiscal year ending October 31, 2008, noted that several monthly reports were late and that advances were not liquidated in a timely manner.


Program Monitoring

The project accountants do not make fiscal monitoring visits to the dioceses receiving project or grant funds. For example, CSN receives USG funds for the SUCCOUR grant. Project officers make monitoring visits to the seven dioceses receiving these funds, but there were no funds allocated for project accountant travel expenses to do the same. CSN intends to include funds in the budget for this purpose in the next year so that the project accountants can make fiscal monitoring visits in the future.

In preparation for this effort, the financial analyst presented a detailed training on fiscal monitoring procedures. The procedures require a detailed review of supporting documentation of all expenses charged to the project or grant.


1. CSN is able to draw on the resources of the organization and the HIV and AIDS program is not solely dependent on US government grant funds.

2. The diversification of resources supporting the 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.

3. CSN has extensive experience with grants, including several direct US government grants.

4. An independent compliance/internal audit function strengthens internal controls for the organization.

5. CSN is committed to correcting problems; all recommendations from the report of the audited fund accountability statements for the SUCCOUR grant for the fiscal year ending October 31, 2008, have been either fully or partially implemented.


Fiscal Monitoring

Finding: 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.

Budget Management

Finding: 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 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.

Management of Advances


Finding: CSN has not ensured timely liquidation of advances. Recommendation: CSN should implement a system whereby the project officer and the project accountant review expenditures by the dioceses and reallocate funds from underperforming sites to over-performing sites.

V. TRANSITION READINESS AND PREPARATION

1. CSN is a current subcontractor to AIDSRelief-Nigeria, providing oversight for OVC services in Nigeria.

2. CSN has extensive relationships through the provincial and diocesan offices of the church to extend outreach to health facilities in the community.

3. CSN has one program monitoring structure that can be expanded to accommodate additional sites and responsibilities. The reporting requirements for OVC sites should be more than just the status of indicators. CSN needs technical assistance to understand the monitoring requirements for ART versus OVC programs and staff experience that will be required to conduct this new role.

4. CSN has been successful in acquiring diverse sources of funding supported by internal grant-writing and fundraising capability.

5. The health unit will need some technical assistance to ensure that current practices are sufficient to monitor ART sites and determine what additional reporting will be required.

6. The health unit, grants management, and the finance department should develop processes to share results of visits, and when possible conduct joint visits to sites.

7. CSN should consult with AIDSRelief-Nigeria to determine the levels of staffing needed to continue the current monitoring and capacity building currently being provided to the LPTFs.

8. CSN has the capacity to work effectively as a local partner, given its current expertise in grant funding and strong fiscal position. It will be critical for AIDSRelief to provide technical assistance in the following areas:

Optimize use of QuickBooks and/or Excel to facilitate aggregation of fiscal information for the purposes of budget management and fiscal reporting.

Establish appropriate roles, coordination of effort and working relationships of project officers, grants manager and project accountants in the areas of reviewing the reviewing budget variances, making plans for reallocation of funds, fiscal monitoring, and corrective actions.


Appendix F: Institute of Human Virology-Nigeria ClASS Assessment Report


AIDSRelief-Nigeria Clinical Assessment for Systems Strengthening (ClASS)Institute of Human Virology-Nigeria (IHV-N)

June 23–24, 2010

I. BACKGROUND

Institute of Human Virology-Nigeria (IHV-N) is a locally registered corporation, limited by guaranty, and an affiliate of the Institute of Human Virology, University of Maryland (UMD), College Park, USA. The organization was established in 2004 to provide treatment and care services in Nigeria for persons with HIV and their families. IHV-N has also coordinated the AIDS Care and Treatment in Nigeria (ACTION) for the past six years in 139 antiretroviral treatment (ART) and Prevention of Mother-to-Child Transmission (PMTCT) sites. IHV-N also serves as the local support for a Global Fund Health and Systems Strengthening program and a National Malaria Control Program with the Federal Ministry of Health. IHV-N also performs research evaluation projects funded by NIH, CDC, and the Doris Duke Foundation.

The IHV-University of Maryland School of Medicine (UMSOM) serves as a consortium member and subcontractor to Catholic Relief Services (AIDSRelief-Nigeria) to provide clinical lead mentoring and training for the forty-four ART local partner treatment facilities (LPTFs). The offices for the IHV-UMSOM are located in the same building, but on a different floor.

II. CLINICAL REVIEW

Nigeria has a lower national HIV prevalence than other PEPFAR countries, and has the third-largest number of people living with HIV (2.6 million, 1.2 million female and 1.4 million male) with about 8.5% being children. The national adult prevalence is estimated at 3.6%.3 There is no national medical record system and no national or state identifiers: hence different partners use different systems.

Nigeria’s health care is guided by the Federal and/or State Ministries of Health. Partners have to coordinate with these simultaneously as they implement programs. Faith-based organizations contribute significantly to health care delivery, especially in rural and hard to reach areas. Fifty percent of the population is rural based.4 Because of religious and cultural reasons in parts of Nigeria, there is a high rate of male circumcision. About 90%5 of Nigerian males aged 15 years or older are circumcised for non-religious reasons.

In diversifying the program more, IHV-N has applied as a subrecipient for the GFATM (Global Fund to fight AIDS, Tuberculosis, and Malaria) Nigeria round 9 application (with National Agency for the Control of AIDS-NACA as the principal recipient) for systems strengthening in the following areas: PMTCT roll-out; care and treatment; prophylaxis and

3 UNAIDS. Adult (aged 15–49) HIV prevalence in (sub-) national population-based surveys thatincluded HIV testing, 2001–2008.

4 United Nations Population Division.

5 UNAIDS/WHO Male circumcision: global trends and determinants of prevalence, safety and acceptability. http://whqlibdoc.who.int/publications/2007/9789241596169_eng.pdf.


treatment of opportunistic infections; malaria and TB/HIV. IHV-N has invested heavily in laboratory training for systems strengthening and will use their track record to support multidrug-resistant TB in the Global Fund collaboration.

Nigeria has had insecurity related to tribal and religious differences in different parts of the country. These factors may affect the form and frequency of supportive supervision of different facilities.

Clinical and Technical Capacity

IHV-N has developed a track record in Nigeria as one of the largest providers of HIV care, with an estimated 60,000 patients on ART, mainly through the PEPFAR-funded AIDS Care and Treatment in Nigeria (ACTION) Project. The care is provided through 34 main sites, each with several satellites bringing services closer to the population.

The IHV-N program involves ARV care focused on strategic information, supportive care, PMTCT, laboratory infrastructure, TB/HIV, and HIV counseling, and develops strong community involvement that relies on treatment support specialists. Each of the IHV-N departments is led by competent Nigerian staff with extensive national and international expertise. Their skills have been exploited to build significant Nigerian capacity to manage HIV. This expertise and capacity has been passed on to several staff in the collaborating sites, translating into hundreds to thousands of health care workers trained. IHV-N reported that fourteen sites have full conversion to electronic records, and some of the centers use Axios for quality assurance. Structured clinical forms are used and entered into an electronic database for documentation.

IHV-N has built a research infrastructure that can be used to improve care and encourage the practice of evidence based decision-making. Specifically, IHV-N has provided leadership in early infant diagnosis (EID) through the development of several polymerase chain reaction (PCR) laboratories and a TB culture laboratory.

IHV-N has integrated nutrition into its program. A nutritional product has been patented for adults, and one that is vitamin-A fortified has been developed for children. Both products are made with local food products. Over 15,000 individuals from programs in the country have attended different trainings, with the majority in ART and palliative care and support.

Quality improvement has been a focus in various departments, including the laboratory where both internal and external controls have been set. For sites, once an external quality assurance score drops to <97%, staff are retrained to improve performance.


The IHV-N program management and oversight involves site identification in collaboration with the MOH. Once identified, site activation proceeds with a five-day didactic training followed by ongoing support and mentoring by a multidisciplinary team and linkage with community support specialists. Mentoring continues, and when a site accrues over 2,000 patients, full-time clinical staff is seconded or employed to provide onsite TA.


Adult Care and Treatment

High loss to follow-up rates (as much as 30%) have been recorded in the program data from recent analyses. Although the figure falls within the average (17%-30%) for the nearly 270 sites in Nigeria providing ART, it still warrants investigation, as IHV-N sites are large-volume sites which provide training and mentorship to smaller sites. Staff also reported that some of those lost to follow-up may actually have died or be seeking care elsewhere, but may just be misclassified as lost to follow-up. The Nigerian definition of lost to follow-up6 requires frequently updating registers to minimize those that have died or transferred to other treatment programs. IHV-N recognizes this as a challenge and has started addressing it. Improvements and lessons that IHV-N may have after interventions to reduce loss to follow-up should be documented and shared across all sites to enable them to implement best practices. IHV-N should also consider using electronic databases and updating them frequently to minimize misclassification of treatment status.

Of all patients on ART, only about 3% were reported to be on second-line treatment. There is no local data to determine what proportion of patients on first-line need second-line treatment. In the absence of viral load monitoring, the diagnosis of first-line failure may be delayed, contributing to clinical disease progression and antiretroviral resistance. Recent viral load studies done by AIDSRelief as part of quality of care studies could be used to inform this process. While IHV-N plans to implement viral load testing to address the low proportion of patients on second-line treatment, the cost effectiveness of this in the setting of flat funding and capping of new ART slots should be considered. IHV-N may also consider doing the following:

a. Work with in-country partners who have viral load data in their cohort to develop estimates and targets.

b. Use switch committees, which have been documented to be very effective in some sites. They could be promoted as best practices until plans to do routine viral loads are finalized.

Survival data and clinical outcomes of those switched at various sites should be analyzed and compared to those not switched. This mini-research project may be useful to determine the timeliness of switching.

Pediatric Care and Treatment

Pediatric care enrollment is a challenge for the IHV-N programs. By March 31 2010, 68,820 persons were on ART, of whom 3,413 (5%) were children. This figure (5%) is below the global PEPFAR pediatric access target of 8%7 for fiscal year 2009 and only half of the global target of 10%. IHV-N should look at its data for testing and enrollment in care and use it to estimate the need for pediatric ART. This data should be used to set targets and benchmarks for each site. Site-specific performance should be studied to identify best

6 “A registered ART patient who has not reported to an ART service point for 3 months since his/her last visit AND it is not known if the patient has died or transferred out or stopped treatment for documented medical/social reasons.” HIVQUAL 2010 International Update http://www.hivqual.org/files/9645/HQI%20Update%20-%20Retention%20-%20May%202010.pdf

7 http://www.pepfar.gov/press/sixth_annual_report/


http://www.hivqual/

practices. AIDSRelief should share some of the lessons learned from its global programs where pediatric access is higher and work with IHV-N to increase pediatric access to ART.

Prevention of Mother-to-Child Transmission (PMTCT)

Many sites are using manual methods for patient tracking. These methods of data collectiondo not allow PMTCT and other outcomes to be determined. The model used by IHV-N inthe site visited does not facilitate the integration of care data when care for the mother and her exposed infant are in two different departments. Delays have also been reported in the delivery of EID results to sites.

Other factors that may be compromising evaluation of PMTCT are the lack of a unique identifier for patients receiving care and the lack of linkage of the infant-mother pair through a database. Some sites, including those with over 5,000 patients in care, are still using manual systems for reporting and program monitoring. IHV-N has reviewed the EID process (preanalytic, analytic, or post-analytic) in its sites and identified some bottlenecks that it plans to address.


1. IHV-N currently manages one of the largest comprehensive multidisciplinary treatment programs in Nigeria.

2. The program has accounted for 60,000 patients on treatment and more reached through care and prevention.

3. Unique strengths of the IHV-N program include:a. Community involvement through linkages of treatment support specialists who

are close to the patients’ environs.b. Working collaboratively with traditional birth attendants, some of whom have

been trained in HCT and provided with test kits and other technical assistance.c. Working with tertiary hospitals, turning them into centers of excellence and

using their geographical proximity and relationships to support satellite sites.d. Reaching out to Most at Risk Populations (MARPs), including commercial sex

workers, long distance drivers, discordant couples, and sexually transmitted infection patients.

e. Using multidisciplinary teams that use local experiences, including patient feedback, to drive continuous quality improvement.

f. Treatment initiation is guided by standardized protocols.4. IHV-N has created various liaisons with MOH at the federal and state levels. These

relationships have enabled IHV-N to work very effectively with government facilities. This strength is key to transition and sustainability of the program.

5. IHV-N has integrated nutrition into its program. 6. IHV-N has a strong didactic training program that includes follow-up with onsite

mentoring and supportive supervision. 7. IHV-N has also provided leadership in task shifting that will help alleviate some

health care worker shortages especially in remote sites and other primary health care facilities.

8. Quality improvement has been a focus in various departments.



Quality Improvement

Finding 1: There is no local data to determine what proportion of patients on first-line treatment need second-line treatment. Recommendation: IHV-N may consider working with in-country partners who have viral load data to determine treatment change criteria and also use switch committees, which could be promoted as best practices until plans to do routine viral loads are finalized.

Finding 2: Pediatric care enrollment is a challenge for the program. Recommendation: IHV-N should look at its data for testing and enrollment in care and use it to estimate the need for pediatric ART. It will also be beneficial to identify strategies that sites can use to improve pediatric enrollment in programs.

Finding 3: High loss to follow-up rates (as much as 30%) have been recorded in the program data from recent analyses. Recommendation: IHV-N should develop plans to support sites to verify the actual patient status, to determine whether clients are deceased, have moved from the area, or transferred to another provider. This is an area where it is important to develop strategies to be shared with other programs that the organization may be asked to monitor during transition.

Finding 4: Sites are not using quality improvement to impact patient flow, staff workload, or patient follow-up adequately. Data collected is not used to address unique site-specific issues, such as quality of care and patient outcomes, due to several challenges. Best practices do not appear to be shared across sites. Recommendation: Improvements and lessons that IHV-N may have after interventions to reduce loss to follow-up should be documented and shared across all sites to enable them to implement best practices. Innovations in patient flow would be useful to minimize waiting times and potential loss to follow-up in large sites.

Prevention of Mother-to-Child Transmission

Finding: There is no system to link mother and child information within the same site to track success or failure of PMTCT efforts. Recommendation: IHV-N needs to explore how EID data can be linked to maternal interventions to determine its performance in preventing new HIV infections through PMTCT. In sites where the PMTCT, pediatric and adult ART are running in different buildings and by different staff, IHV-N should facilitate communication between the different staff and timely updating of registers. Different models of care that facilitate integration, for example by using family based care with services being provided by the same provider or team, should be reviewed.



Governance

The current board of directors was established in August 2004 specifically for the organization Articles of Incorporation. The membership consisted of the principal investigator, the chief and deputy chief of party (COP and DCOP), and Dr. Farley Joseph. All the board members receive their salaries from UMD, which poses a conflict of interest. The board operates under the general guidelines of the Nigerian Articles of Incorporation. No constitution or by-laws have been developed to date, as IHV-N was awaiting approval of UMD to move ahead with establishing an independent board.

As of March 2009, the board minutes show four additional members: the Senior Technical Advisor (STA)-Lab, Deputy COP, STA SI, and the STA Community Medicine. These individuals also are not considered as appropriate members as they are staff on the IHV-N organization chart with paid salaries from UMD. Separate from the membership, the board meets quarterly and minutes of each meeting document the discussions and shows the approval of organization policies and procedures.

A legal firm in Abuja has been engaged to vet candidates for the new board of directors. It is unclear whether the firm was hired by UMD or IHV-N. Membership is expected to be constituted by October 2010. Board orientation training is expected to take place within two months of finalizing board membership. Additional autonomy concerns are raised by the UMD having a leading role in the development of the strategic plan in the February 9, 2009, management team meeting minutes and the development of the mission and vision statements as indicated in the February 12, 2009, expanded management meeting minutes.


The three individuals in leadership and management positions of IHV-N are employees of UMD. This was needed when the organization started in order to ensure oversight for UMD faculty working on projects in Nigeria. Discussions have been under way with UMD to agree on benefits packages that would allow either the COP or DCOP to become at least 50% employees of IHV-N.

The organization has three divisions; research, training, and treatment and care. The division directors, the COP, the DCOP, and the principal investigator form the executive management committee that meets monthly now, and expect to move to quarterly in 2011. The management team is composed of the heads of departments and offices and meets on a monthly basis. The department staff should be meeting twice per month. Each department also has technical working groups that meet on a weekly basis. Minutes for each of the meetings are maintained. Copies of the minutes for the management and the expanded management team were reviewed. A new compliance department has been added, but is only focused on finance-related issues for ART and PMTCT sites. All staff meetings are held quarterly, but recently they have been less frequent due to the schedules of staff and management.


An expanded management team was created to ensure the sharing of information along all channels of the organization, particularly when there have been quick scale-ups needed with the addition of new staff in a short time frame. Employees have the chance to share comments in a suggestion box. Five staff in the administration department identified being very comfortable sharing areas for improvement with their supervisors.

The administrative department consists of information technology, security, human resources, financial management, office management, and transportation and logistics.

Information Technology

Every employee has access to voice, video, and email in the IHV-N offices and housing units. There is real-time video conferencing. All regional offices have the same IT capabilities and there are microwave links with all remote sites. Security updates are done for all computer equipment and desktops on a weekly basis. All internet access is firewalled and the organization IP address can only be accessed by security code. IT needs assessments are conducted at each clinical facility when they become a part of the program. IHV-N will link contractors to the sites if needed and if the work is more than in-house staff can complete.

Security and Transportation

IHV-N has security agreements with EIM Services, an Israeli company that provides services for all the housing facilities. EIM develops and coordinates evaluation procedures as needed at regional offices. Additional security has been provided for the warehouse facilities.

The COP and DCOP have their own vehicles and drivers. There are time use restrictions (6 PM) : all vehicles except the two above must be returned to the HQ facility each evening. When overnight travel is approved outside Abuja, then vehicle requests must be approved by the administrative director. A maintenance contract is in place for all vehicles and regular service logs are maintained. There are 46 vehicles in the current fleet. All drivers must pass an IHV-N driving test prior to employment along with a driver’s license verification. Training is currently being scheduled for the regional office staff and drivers on road safety.

All IHV-N facilities are fire alarmed and safety processes for evacuation are in place. The IHV-N office has a sick bay for employees at headquarters and there are contracts with hospitals for staff to receive services.

Human Resources

IHV-N has comprehensive employee conditions of service. Policies identify processes for both internal and external advertisement of vacancies. When internal staff members are interested in the position, they get first preference in the interview process. If the candidate is appropriate, then there may not be any external notice. Policies require that at least three candidates be interviewed when there are many applicants.


A suggestion box is available in the waiting room areas of the headquarters offices, although HR identified that many staff send their concerns and suggestions by the internal office email system. Performance appraisals are required twice per year. The employee completes the first part of the appraisal on their own performance and then the supervisor completes the second portion. New guidelines have been recently developed to help supervisors in completing the process. The review team suggested that the same training to be provided to supervisors be given to employees so that all parties know what is expected and how the communication process should include the employee and supervisor.

Personnel files are kept under double locks. Copies of current licenses for clinical staff were not found in the files and no system exists to verify that staff licenses are current.When employee duties change, a letter is generated by HR and sent to the employee and the supervisor indicating the change. When there is no salary change to accompany the duty change, the letter does not address this issue. It was suggested that HR may want to cover their bases and include such statements in the future.

Staff training opportunities are available. Each employee is expected to develop a personal growth plan. Managers can make recommendations for organization support for trainings.

Program Monitoring and Management

IHV-N has a regional office in Abuja that is responsible for the coordination of project monitoring activities and reporting for 32 sites (nineteen ART & PMTCT and thirteen PMTCT). The office is staffed with eleven project officers (POs), seven program assistants, three network coordinators, three clinical officers, and six drivers. Each program area has a project officer who is responsible for making a visit at least once per quarter to each site. February 12, 2009, management team meeting minutes request that all visits to the sites be related to problems rather than proactive monitoring.

Depending on the specialty area, the staff check the patient registers and conduct some of the service delivery, such as pre- and post-test counseling for PMTCT if it is a booking day. POs work with the focal area person to check equipment and conduct quality tests in the laboratory. Regional staff members complete monthly reports that are compiled by the regional manager into reports to the DCOP and COP. A new template is being implemented for regional staff reporting. Each of the sites also generates a monthly report that helps the PO decide what the next month site support should include. A clinical officer (CO) is assigned to a site after it reaches 2,000 patients on ART. The CO spends all or part of their time onsite helping to proactively address any issues as they arise and to provide mentoring and training for clinical staff. When there are laboratory equipment failures, the POs are able to have sites share resources when possible until solutions are identified.

Network coordinators work with support groups at the sites and meet with community organizations to share information about hospital or clinic services and to determine how testing can be expanded into the community. The coordinators also help find volunteers to help locate patients who have missed appointments. POs use the larger facilities to link with the satellite sites and help facilitate linkages to be able to expand services into the rural areas.


Challenges facing the POs at the sites include: missing patient files, frequent staff turnover and shortages, backlogs of data entry forms, and poor medical record storage areas. Remote sites constantly have challenges submitting reports on time, particularly when data is collected by hand and paper reports are the only option. The PO staff identified the need for more vehicles to allow staff to make the visits to sites at the required time frames.


1. IHV-N has experienced leadership and open communication up and down the staff levels.

2. Regional offices provide decentralization of program oversight.3. The organization has grant-writing capacity that is resulting in increased funding for

sustainability.4. The human resources employee conditions of service policies are very

comprehensive.5. The organization has information technology systems and expert staffing to provide

oversight for sites and subcontractors.


Finding 1: IHV-N does not currently meet all the OGAC local partner definitions, and there are other local autonomy concerns:


b. The current board of directors is composed entirely of UMD staff, for whom it is inappropriate to approve organization policies, as they are the staff required to implement the same.


d. There is no document indicating the willingness of IHV UMD to allow IHV-N to be completely autonomous and continue affiliations with the university.

Finding 2: Written program monitoring policies and procedures were not available. Recommendation: IHV-N should review the current monitoring processes and determine whether they are achieving the desired results, then document and share with staff and all sites.


Finding 4: There is a lack of coordination between program monitoring, compliance, and finance in conducting reviews of sites and sharing findings and follow-up. Recommendation: The regional manager and finance manager should develop a meeting schedule to ensure that staff meet at least quarterly to share findings from visits


and determine where there are crossover issues that may be appropriate for a joint site or monitoring visit.

Finding 5: Human resources processes do not document status of clinical staff licenses.Recommendation: HR should consider developing a spreadsheet or database to list the license numbers annually for clinical staff, along with dates of expiration, either through viewing the original documents or maintaining copies of licenses annually in employee files.


IHV-N’s fiscal year was April 1 through March 31 until 2008; the organization converted its fiscal year to July 1 through June 30 beginning in 2009.

The report on the audit of fund accountability statements for the USAID grant for the fiscal year ending March 31, 2008, reports the following:

2008 US Dollars

Grants Received 16,701,857 Interest Income 56,606 Other Income 10,906 Total Income 16,769,369

Support Services Expenditure 5,916,931 Program Services Expenditure 11,127,970 Total Expenditure 17,044,901

Excess of Expenditure Over Receipt (275,532)

Net Cash from Operation (712,337)

Audit reports on IHV-N’s financial statements for the fiscal year ending March 31, 2008, and for the fifteen month period ending June 30, 2009 were not provided to the fiscal consultant during the site visit.

IHV-N’s budget for the period April 1, 2009, through March 31, 2010, includes $45 million in income. Approximately 90% of IHV-N’s grant income flows from the University of Maryland Baltimore, based on a verbal estimate from the finance department,. Financial Management

IHV-N uses Peachtree as its accounting software. IHV-N plans to replace Peachtree with Accpac on July 1, 2010. Accpac includes modules for budget management, general ledger, payroll, human resources management and timekeeping. IHV-N selected Accpac to replace Peachtree because Accpac has the capability of accounting for multiple currency transactions, tracking expenditures by grant, and reporting aggregated and disaggregated


fiscal information. IHV-N will continue to operate Peachtree as a dual system until it is verified that Accpac is fully operational.

Expenses that are specifically related to a grant are charged directly. Indirect costs are pooled and allocated to each grant on a monthly basis via journal entry. Employees do not record time and effort. Labor cost is allocated based on the percentages assigned to each employee within the grant.

Budgets are prepared for the departments (community medicine, clinical, laboratory, strategic information, and research and corporate operations.) Departments managing grants that are directly awarded to IHV-N prepare the grant budget. Grants and budgets that are awarded to the University of Maryland Baltimore are handled by the prime grantee. Payments (not subcontracts) to IHV-N are determined by the prime grantee and included in those grants’ budgets.

Because Peachtree does not have the capability to track actual expenditures by grant or by site, no budget variance reports are prepared. Instead, IHV-N uses an Excel spreadsheet to track the balance of funds advanced and retired. The University of Maryland provides an advance of a portion of the grant funds at the beginning of the funding period. Then IHV-N submits monthly reports of actual expenditures to retire the advance. For example, IHV-N’s I-ClASS account report for May 2010 shows a beginning balance of $8,856,072 and expenditures of $7,925,557.


IHV-N has established standard operating procedures that cover areas such as signatory approval on purchases and shipments of supplies, controls in the information technology department, procedures for new hires, and supporting documentation required for payments. The compliance/internal audit division tests compliance with the standard operating procedures, notes exceptions, and submits a regular report to the chief of party.

At present, IHV-N does not have comprehensive fiscal policies and procedures that have been approved by a board of directors. The finance department and others having responsibility for fiscal management are in the process of developing and finalizing these policies and procedures.

Grants Management (Procurement and Contracts)

IHV-N’s procurement policy calls for approval of contracts by the administrative director, by the chief of party, and/or by the procurement committee, depending on the amount of the contract. Also, the procurement policy calls for a minimum of three bids for most purchases and appropriate justification for sole source procurements. In addition, IHV-N establishes list of approved vendors, based on price, quality and reliability.

The grants management division manages the awards to the sites. Grant funds are distributed to the sites on the basis of letters of agreement (LOAs) specifying the work to be performed and the line-item budget. The LOA is signed by the site representative and by IHV-N’s chief of party.


The LOA provides that positions are supported for a period of twelve months and that the site must assume responsibility for the salary cost after that. Also, the sites’ budgets include overhead which is based on N200 per patient per month for patients actively receiving ARVs. The sites may use the overhead for the following:

1. Contribution towards utility bills2. Providing non-funded needed services to improve quality at sites:

a. Temporary staffb. Communications for staff who have not been provided for in LOAc. Recreational items in clinics (tea, water, etc.)

3. Contribution towards card & consultation fee for patients4. Appropriate compensation for extra time spent outside of work hours

Payments to the sites are managed as an imprest fund, which is a cash fund of a fixed amount established through an advance of funds to the site to support expenditures in accordance with the line-item budget. The sites receive an advance of one-twelfth of the budget at the beginning of the funding period. Then the sites are expected to submit monthly reports of actual expenditures when requesting funds for the subsequent month. The monthly reports are approved by the site director and the regional office before submission.

The compliance/internal audit division is responsible for the review of the monthly expenditure reports to verify that the supporting documentation is complete and accurate. Advances and the actual expenses per the monthly reports are tracked on an Excel spreadsheet maintained by the compliance/internal audit division. After the compliance/internal audit division approves the monthly report, an approved request for payment is forwarded to the finance department. The finance department issues the payment and records it as a lump sum amount in the Peachtree system.

The fiscal consultant reviewed the Excel spreadsheet that tracked monthly reports through March 31, 2010. Seven of the thirty-five sites were missing one or more reports and, therefore the reported expenditures were not aligned with the budget. Expenditures for the remaining sites were aligned with the budget. The compliance/internal audit division follows up with sites by telephone or email to resolve the matter of missing reports or other errors. In two cases this year, the compliance/internal audit division visited the site to provide technical assistance to correct specific deficiencies related to the monthly reports.

Program Monitoring

Fiscal monitoring of the sites is strictly problem-focused. No regular fiscal monitoring visits are made to the sites by grants management or by the compliance/internal audit divisions.



1. IHV-N has established independent grants management and compliance/internal audit functions that strengthen internal control. Also, IHV-N thoroughly reviews the documentation supporting the sites’ monthly expenditures.

2. IHV-N’s plans for the implementation of Accpac software will improve the fiscal management system, especially budget management and allocation of revenue and expenses.

3. The organization is committed to correcting problems: all recommendations from the management controls report for the fiscal year ending March 31, 2008, have been either fully or partially implemented.

4. IHV-N seeks to increase and diversify revenue by pursuing other grant opportunities.


Fiscal Monitoring

Finding: IHV-N has not implemented fiscal monitoring of the sites 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, IHV-N should implement fiscal monitoring.

Budget Management

Finding: IHV-N 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 HHSGPS and by OMB Circular A-110. Recommendation: As the transition plan activities move forward, IHV-N should implement a budget management system that includes review of budget variances at the level of grant, department, and top management.

Time and Effort

Finding: IHV-N does not track time and effort associated with grants, as required by OMB Circular A-122 and the HHSGPS. Recommendation: As the transition plan activities move forward, IHV-N should implement a system to track time and effort reporting by employees and to use these reports as supporting documentation for the allocation of labor costs to the grant.


Finding: IHV-N does not have fiscal policies and procedures that have been approved by the board of directors. Recommendation: As the transition plan activities move forward, IHV-N should work with the board to finalize the fiscal policies and procedures.

Limitation on Funding for Salaries


Finding: The LOA with the sites receiving funds for salaries for employees working on US government grants includes a restriction that these funds will not continue for the same employee for longer than twelve months. Recommendation: IHV-N may be able to work with USAID and other stakeholders to develop a solution that allows for continued funding of employees working on the grant.

Use of Funds

Finding: Sites receiving PEPFAR funds from IHV-N are permitted to pay bed fees for patients who are hospitalized. Recommendation: PEPFAR funds may not be used to support the cost of inpatient services. IHV-N should modify the LOA to prohibit the payment of bed fees.

V. TRANSITION READINESS

1. IHV-N should identify clinical best practices across their sites for use as quality improvement opportunities for other sites to consider.

2. IHV-N needs to meet the OGAC governance criteria and autonomy expectations.

3. Proactive program monitoring, rather than problem-oriented monitoring, is the HRSA and AIDSRelief-Nigeria preferred process. IHV-N should determine the resources needed to ensure this is the model used when planning for transition.

4. IHV-N has the capacity to work effectively as a local partner, given its current expertise in grant funding. It will be critical for AIDSRelief-Nigeria to provide technical assistance in the following areas: establishing appropriate roles, coordination of effort and working relationships of project officers and project accountants in the areas of reviewing the reviewing budget variances, making plans for reallocation of funds, fiscal monitoring, and corrective actions.

5. It is also recommended that AIDSRelief-Nigeria request a status report from IHV-on the matters of the twelve-month restriction on funding for salaries and the payment of bed fees after three months.


Appendix G: St. Anne’s Hospital ClASS Assessment Report


AIDSRelief-Nigeria Clinical Assessment for Systems Strengthening (ClASS)St Anne’s Hospital, Molete

June 24, 2010

I. BACKGROUND

St Anne’s Hospital is a 15-bed hospital located in Molete on the outskirts of Ibadan City in Oyo state. It is located adjacent to a church and school by the same names in a low income, high density suburb of Ibadan. The hospital registered with the government in 2000 and renews its registration on a yearly basis.

II. CLINICAL REVIEW

St. Anne’s was initially started in 2000 to cater to priests’ and their families’ medical needs. Family and church members constitute a significant proportion of the hospital’s clientele. The hospital has expanded over the last decade and is open to all inhabitants of the area. The hospital management is increasing efforts to inform the public about services available at the hospital.

Clinical Services

This hospital is a site of the Christian Health Association of Nigeria (CHAN) Nigeria Indigenous Capacity Building Project (NICAB). The primary site selection criteria was to not have an existing ART program. The CHAN provincial health coordinator is housed at this hospital and provides administrative support to the project. The entire hospital staff meets on a monthly basis.

The hospital offers outpatient and inpatient services, and has a laboratory, pharmacy and other support services. TB services (sputum and X-ray) are available at a government facility a few blocks away. The hospital attendance is small; at the time of the visit there were no outpatients in the waiting area and none of the 15 inpatient beds were occupied.

Clinic Facility and Staffing

The ART clinic and other HIV services are integrated with the hospital’s testing, clinical rooms, the laboratory and pharmacy. All share the general outpatient facilities and staff. There are two medical doctors: the medical director, who is also a priest at the adjacent church, and a second who is employed by CHAN/NICaB to support capacity building for HIV care for St. Anne’s and another site. At the time of the visit he had just joined the facility. He spends most of his time at St. Anne, but travels to another site to provide technical assistance. Other staff are five nurses, a dispenser (actually a nurse who has been trained in dispensing), a clerk and five maids. Many of the staff have been cross-trained: for example, the triage nurse manages the HIV records and runs the PMTCT clinic.


Counseling and Testing

The hospital has dedicated counselors, but testing is offered in the laboratory. The laboratory technologist has been trained as a counselor and performs this role regularly when he is not conducting laboratory work. Although staff mentioned that HCT is offered to all patients who come to the hospital, inspection of the laboratory logs indicated that the majority of the testing was client initiated. This is an indication that either patients offered testing refused or that provider-initiated testing and counseling has not been fully implemented at the hospital. Provider-initiated counseling and testing should be scaled up and entry points maximized at the facility and in the community.

The medical records and outpatient department do not have any way to track what proportion of patients are offered testing. A mechanism should be put in place to track offer of HCT. Cumulatively, just over 2,000 patients have been tested (2,313).

HIV Care and Treatment

At the time of this review, 51 patients were in care and 26 on ART. Reasons for the low uptake have not been determined. It’s likely and acknowledged by the hospital director that the public may not be not be fully aware of the services provided at the hospital. The hospital’s original clientele (priests and church members) were not high risk groups. Many patients in the same catchment area may be attending other sites in the area. The hospital has also appealed to church members to market the program and provide community support.

HIV is integrated with other clinics and patients are attended to every day of the week as they present to the reception desk. The medical director and the NICaB physicians see patients.

This reviewer raises the following questions for consideration: (1) Does the medical director’s roles and responsibility in the church and community where most of his clients would come from create a conflict that may not encourage getting tested or receiving HIV care from the same facility where he is the main HIV provider? (2) Will the promotion of the current medical director to a deacon in the church prevent parishioners and others in the community from seeking or accepting HCT? (3) Should the medical director concentrate on administration and leave patient care to other colleagues?

There is no home care team, but the hospital has partnered with two community-based organizations and is able to use their volunteers.

Pharmacy documentation processes are not sufficient to support the hospital and patient care. There were no bin cards in the pharmacy and the method described for tracking supplies and minimizing waste were not adequate. For example the system used did not identify that some of the medication on the shelf were about to expire. Secondly, the “PUSH” system employed by the hospital, if not supported by good consumption data, may promote waste of different drugs.


TB screening based on symptoms or identification of those who are coughing is not consistently done. When done, it is usually done by the clinician and not at the first point of contact or at triage. Screening at the first point of contact has advantages in minimizing transmission of TB. Actual TB diagnostic services are not available onsite, but are provided at the TB clinic nearby. If the existing process of referring TB suspects (based on symptoms) is acceptable to the national TB program and does not result in multiple visits and waiting time for patients, it should be maintained.

Quality Improvement (QI)

There is no QI team; however, a CHAN/NICaB regional staff person previously conducted chart reviews. There is no regular schedule for such reviews. There were no examples of site-initiated CQI activities.

The Coulter manual CD4+ count kit and system used is not supported by a reliable external quality control process. Initially samples were taken to a nearby hospital, but this has not been done consistently. As the hospital uses flow cytometry, it is not clear if this would constitute an acceptable QA/QC system. The team acknowledged the challenges that a small site has with doing CD4 testing feasibly and cost effectively. Manual methods are cheaper and equally accurate8,9 but should be supported by a reliable QA/QC process.

Medical Records and Chart Review

All HIV patient care charts are paper and kept separate from other general hospital charts in a lockable cabinet in one of the doctor’s consultation rooms. They are retrieved once a patient arrives for their appointment. Within individual patient charts, papers and laboratory results were not filed very well and critical areas such as the enrollment process, TB screening, referrals, family screening, and psychosocial assessment were not consistently documented. Please see the crosscutting strength and areas for improvement that are common to all the sites. Those listed here are unique to this site.

A. Strengths

1. St. Anne has achieved a level of integration of HIV services which is commendable and is a best practice scenario.

2. Staff have been cross-trained and can backstop each other when needed. 3. Staff who attend outside trainings are required to share with others through a step-

down process when they return. 4. The presence of an assigned NICaB staff person at the site supports mentoring in

clinical care.

8 Balakrishnan P. et al. An inexpensive, simple and manual method of CD4 T-cell quantitation in HIV-infected individuals for use in developing countries. J Acquir Immune Defic Syndr 2004;36:1006–1010.

9 Karcher H. et al. Comparison of two alternative methods for CD4+ T-cell determination (Coulter manual CD4 count and Cyflow) against standard dual platform flow cytometry in Uganda. Cytometry 2006;70:163–169.


5. The hospital has initiated a mobile outreach aimed at getting more people tested. This together with twinning with other facilities and referral networks that have been established with CBOs may address getting more people in care and on ART.

6. Storing HIV charts separately is an additional safeguard for confidentiality.

B. Areas for Improvement and Recommendations


Finding 1: The site has not met any of its targets for HCT, HIV care, or ART. Recommendation: CHAN should explore reasons why this site has not met its targets for HIV care, but also why patient attendance in general is low for other services. In a local partner role, CHAN should review its site selection process to ensure that the investment in the sites it chooses is cost effective.

Finding 2: Pharmacy documentation processes are not sufficient to support the hospital and patient care. Recommendation: The following interventions could help to address this.

Training the staff working in the pharmaceutical processes and equipping them with the necessary tools to quantify and keep accurate stocks.

Provide ongoing training and mentoring and closer supervision onsite. Move from the “PUSH” to the “PULL” system for ARVs and other

consumables. This should be based on accurate consumption data to get supplies. With the few patients that the facility has currently this method will lead to less waste through expiry.

Finding 3: The Coulter manual CD4+ count kit and system is not supported by a reliable external quality control process. Recommendation: CHAN should review and establish a suitable EQA at this hospital. In addition, it should consider whether transporting samples is a better option than doing them onsite, especially if there is no EQA. If taking samples to the nearby hospital is an acceptable system, the process should be formalized and supported by a written standard operating procedure


Finding 1: The existing model of support to this site for clinical oversight and capacity building is not the most cost effective. CHAN supports a full-time staff for this clinic for technical assistance. Additionally, teams from the regional office come to address other needs. Recommendation: Without clear plans for scale-up, the existing investment in a full-time medical doctor is not justified. Alternatives could be to fund the hospital to employ their own staff who would be supported with additional technical assistance from CHAN. It may be more appropriate for a program manager to be considered, who would develop systems, rather than a practicing clinician, who may not possess the broader system skills.

Finding 2: There was no system for storing or retrieving medical records and care documentation was not consistently found in reviewed charts. Recommendation: Patient records should be streamlined, with regular chart reviews to improve on


completion of records. Records should also be filed either by serial number or by name to facilitate retrieval.

Quality Improvement

Finding: There is no CQI committee and no CQI processes were evident. Recommendation: CHAN should support the staff to develop a team that would use local data to address challenges already identified, namely increasing HCT and enrollment into care and treatment.

TB Screening

Finding: TB screening is not being done at the first point of contact to minimize transmission. Recommendation: A system should be developed to identify coughing patients likely to have TB as soon as they enter the facility, addressing their problems before referral for other TB diagnostic services at the TB facility nearby. The hospital should explore whether to add sputum smear microscopy in the interest of providing patients with all services at the same time and place. With microscopy, only those with confirmed TB would be referred.


The Anglican Archdiocese owns the hospital. There is a two-tiered governance body. The parish church council (PCC) is comprised of 20 people elected by the church. The PCC must approve all major capital equipment purchases. The hospital management committee, which reports to the PCC, is made up of eight individuals, including the chairman of the PCC, and meets monthly. Minutes of all meetings are maintained. Reports are provided to the State Action Committee on AIDS and CHAN each month. There is also a HIV/AIDS Committee at the hospital, which meets every two weeks.

Staff are recruited through a competitive process. Initially job openings are advertised in the church bulletin, and if a suitable candidate is not found, an advertisement is put into the newspaper. A committee interviews candidates. Employees are employed by CHAN, except for the hospital director, who is employed by the diocese. Employees are given a letter of employment and there is an employment manual. No performance evaluations are conducted, although the director would like to institute this practice.

The project does link to other CHAN institutions and works with PLHA groups. There are also two CBOs who are located at the project site.


1. The project has very dedicated staff, especially a director who has several responsibilities inside and outside the project and hospital.

2. There is a strong relationship with the NICaB project and the diocese, both of which provide support to the site.


B. Administrative Areas for Improvement

Finding: The hospital does not have sufficient staffing expertise in human resources and record keeping. Both areas will be particularly important if the site were to have additional services or responsibilities added. Recommendation: CHAN should link this site with any available technical assistance under the NICaB project or other administrative and operations support available from the Ministry of Health or other community-based organizations.


The hospital accounts clerk functions as the site accountant. She handles accounting functions for both the hospital and the NICaB project.


1. Fiscal records are in good order. 2. The project staff are committed and dedicated. 3. The accounts clerk has received appropriate training from the hospital and has

good skills. 4. The procurement process complies with USG requirements. Three quotes are

obtained for an item to be purchased; there are appropriate signatory approvals; the item is delivered before payment is made; documentation is maintained and filed, item delivered before payment is made; and documents are properly filed.


Project Allowances

Finding: The site does not submit timely expenditure reports and, consequently, payments of the grant funds are delayed. Although the site has paid salaries regularly, project allowances are not paid on a timely basis. Recommendation: The site should ensure an appropriate cash flow by submitting timely expenditure reports, enabling the site to pay project allowances when they are due.

Petty Cash

Finding: The petty cash fund is set at N10,000, which is usually exhausted within a week. When the petty cash is exhausted, hospital funds are used for purchases. Recommendation: The site should ensure an appropriate cash flow by submitting timely expenditure reports, enabling the site to maintain a sufficient petty cash fund.

Cross-training of Employees

Finding: The accounts clerk is the only employee who is knowledgeable about the functions she performs. She will be on maternity leave soon and there is no one to pick up her duties in her absence. Recommendation: Cross-training of employees is advisable so that work flow is not interrupted during staff vacancies.


Appendix H: Ijebu-Ode, Orphans and Vulnerable Children (OVC) Program ClASS Assessment Report


AIDSRelief-Nigeria Clinical Assessment for Systems Strengthening (ClASS)Ijebu-Ode, Orphans and Vulnerable Children (OVC) Program

June 25, 2010

I. BACKGROUND

The facility visited at Ijebu-Ode is not a health facility, but one of the project implementation sites for the CSN USAID-funded OVC program. The findings provided here summarize the discussion held with technical staff at the project office and health secretaries or coordinators from the diocese and province. No project sites were visited and no direct beneficiaries of services were interviewed. The focus of the discussion was to establish the different roles technical staff played and to assess whether the program had mechanisms to ensure that OVCs with HIV could be identified and referred for care and treatment. The discussion also sought to find out what the unique needs of the project site were and how CSN addressed them.

II. OVC PROGRAM REVIEW

What services are provided by the program?

The project office supports several activities in the area for OVC. Using a tool, project staff identify eligible children through a network of volunteers and other community-based organizations. Children who satisfy criteria are enrolled and provided with an array of services, including home-based care, counseling, OVC support groups, and linkage to a community care giver.

The program office also directs school clubs, gives small grants to build capacity of CBOs, identifies health facilities, establishes relationships to facilitate referrals for care and treatment, trains out-of-school youth in life skills, pays school fees, trains caregivers, and establishes networks of parish action volunteers (PAVs). The monitoring and evaluation staff visit PAVs and partner CBOs to provide training and collect data which is analyzed and shared with staff. Monthly reports on activities are sent to the headquarters.

How is HCT offered or the HIV status of children identified?

The processes used by the program to identify children who were HIV positive were not clear. Even though the hospital provided HIV care, it was not clear whether OVCs are provided enough opportunities for testing. Staff could not estimate what proportion of registered OVCs were offered testing, were tested, and are in care.

Do OVCs who need HIV care have access?

The Ijebu-Ode OVC project office has partnered with St. Joseph Catholic Hospital, a CSN member health facility, to provide HIV care and treatment services to children who are HIV positive. The hospital receives a bulk grant to provide comprehensive care for a predetermined number of OVC. There were contradictory reports on whether project staff carried out HIV testing. Children with any medical needs are identified by the volunteers at each visit. Volunteers log the services provided to each child on organization forms. The


form included spaces for psychosocial support, nutrition, health and other services. Referrals are made when indicated on the form.

What oversight is provided by CSN?

Monthly monitoring visits are conducted by individual teams from the diocese and the provincial offices as well as periodically from CSN headquarters in Abuja. What demographic information is collected?

An OVC enrollment form is used to collect demographic and contact information, eligibility criteria and needs. There is no unique identifier on the form. The form is kept at the project office. A. Program Strengths

1. Program staff have established very strong relationships and referral networks in the community, particularly with the local hospital, volunteers, the church, and entire community.

2. The program works to sustain itself with proceeds from a fish pond and training and mentorship efforts.

3. Support to individual OVCs and the community is based on a needs assessment.4. Program staff are trained and information is shared with all staff through a step-

down process.5. The program office has reached and exceeded its targets for OVC.

B. Program Areas for Improvement and Recommendations

Finding 1: No clear processes are used by the program to identify children who are HIV-positive. Recommendation: Opportunities for HIV testing and counseling should be provided to all OVCs, and testing information should be tracked at the program level. The visit form for volunteers should be revised to include specific symptoms for HIV and TB that would trigger timely referral for testing and/or care.

Finding 2: OVC enrollment forms kept in the office give the HIV status of the OVC. The staff interviewed were not very familiar with the Catholic Church’s confidentiality policy (a copy of the policy was shown to us during the interview), and had not signed any confidentiality agreements when hired. Recommendation: The office should review its procedures regarding confidentiality. Signing a confidentiality agreement at the time of employment would be one way of ensuring that staff were fully aware of the implications. Similar procedures should apply to volunteers. In the future CSN should consider using codes for the HIV status on any form that are handled by non-medical staff and volunteers.

Finding 3: The targets set for OVC by the headquarters have already been exceeded, with many more OVC in the community not reached. Therefore there is a waiting list of OVC.


Recommendation: CSN should review and compare current status with set targets for all sites. Existing relationships with state and federal agencies should be maximized and used to lobby more government funding or identification of other donors. Additionally, the capacity of supported faith-based organizations should be enhanced to enable them to compete for other grants.

Finding 4: Several trainings have been conducted in schools and for out-of-school youths, but no outcome evaluations have been conducted. There was no information to determine what impact program or individual interventions have had on participants. Recommendation: CSN should consider evaluating its interventions to determine short and long-term outcomes.


The SUCCOUR Project is a national-level CSN program and planning and budgeting are completed on a yearly basis at country-level meetings at which all dioceses participate. At this meeting the Ijebu-Ode diocese creates its own workplans and budgets, along with a first quarter detailed workplan. There is a subcontract agreement document with CSN, which includes reporting responsibilities, staffing, procurement and financial policies.

CSN at the national and provincial levels provides support to the project and arranges for various trainings. CSN and the SUCCOUR project offer trainings on specific technical areas, such as OVC or youth. CSN at the national level determines who should attend the sessions.

The OVC project staff meets weekly for planning and information sharing purposes. There are very general, handwritten minutes from these meetings.

All the project staff are employees of the diocese. Job descriptions were viewed for staff, although they were generic. The project staff do not have performance appraisals. The project manager reports to the diocesan director of health, and meets every Monday with staff. He has a financial spending limit of 50,000 Naira. He monitors the financial expenditure against the budget at the end of every month.

The project has strong ties and links to other organizations at the local, state, and national levels. These groups include the LACA (Local Action Committees on AIDS), Civil Society of Nigerian AIDS Organizations, CHAN, Christian Rural and Orphan Development of Nigeria, Association of OVC and the Interfaith Network. It also works closely with a local pediatrics hospital and other health institutions.

If new staff needs to be hired, the project manager meets with the diocesan health secretary for approval. An advertisement is put in the local newspaper and the health secretary reviews the CVs against the needed skills. Interviews are conducted by a panel including the director, provincial health secretary and accountant. The final approval is made by the panel.



1. The project receives strong support from CSN and the diocese.2. There is a strong approach in place for planning and reporting.


Finding 1: There does not appear to be a process for feedback from CSN national or the diocese to inform program implementation changes or decisions. Recommendation: CSN, along with the OVC program sites, may want to review the reporting formats and the type of content requested. Programs should share their needs and indicate the type of feedback and support that would be more helpful from the national, diocese and provincial offices.

Finding 2: Program meetings do not appear to offer staff a mechanism to help improve the services. Recommendation: Staff is very busy in the field and could use meetings in a more robust way to guide project implementation. Minutes could be in greater detail and put into a format that is easier to follow.



1. The qualifications, experience and education of the fiscal staff are commensurate with responsibilities.

2. The budget management system entails quarterly forecasts and analyses of monthly expenditure reports. Also, fiscal employees participate in the budget process and, consequently, are able to make reliable forecasts and allocations.

3. CSN’s grants management director visits the site frequently. Also, the site has been reviewed by the external auditor. The diocese’s new internal auditor is also preparing to visit the site this year.


Petty Cash Fund

Finding: The project accountant also acts as the cashier but does not have a safe. Cash is kept in the safe controlled by the provincial accountant. As a consequence, more than one person has access to the cash. Also, the same person who has access to the cash is also responsible for reviewing the work of the cashier. Recommendation: Petty cash procedures should include reasonable safeguards, e.g., locked box, periodic cash counts, regular independent reconciliations of petty cash funds.


Supporting Documentation

Finding: Documentation supporting the expenditures related to the grant could not be found. Recommendation: Supporting documentation should be organized for ease of review and verification.

Procurement Policy

Finding: The procurement policy does not comply with USG requirements. Cash is taken to the market to purchase items or supplies from the hospital vendor. There was no evidence of competitive bids for these purchases. Recommendation: The site should formulate a procurement policy that entails competition based on price, quality and reliability, review by a procurement committee and signatory approval of selections.

Monitoring Reports

Finding: Reports of the CSN monitoring visit were not given to the fiscal staff. Recommendation: The fiscal staff should review these reports and participate in the development of plans for corrective action.


Appendix I: Federal Medical Center, Keffi, ClASS Assessment Report


AIDSRelief-Nigeria ClASS Assessment for Systems Strengthening (ClASS)Federal Medical Center, Keffi

June 30, 2010

I. BACKGROUND. Federal Medical Center (FMC), one of the Institute for Human Virology-Nigeria (IHV-N) sites, is a tertiary 100-bed hospital located in the Keffi local government area (LGA) but serving a larger catchment area covering four local government areas (Keffi, Karu, Kokona and Nasarawa) in Nasarawa State. The hospital’s clientele is mostly rural, and includes those from other states, such as Benue, Kaduna, Plateau, Kogi, and Niger, as well as from FCT Abuja, which is only about 50 kilometers away. Nasarawa State ranks second after Benue (10.6%) in HIV prevalence (10%)10 (much higher than the national prevalence of 4.6%11) and also ranks second after Benue in TB prevalence.

A full ClASS assessment was not possible in the three hours spent onsite, but components critical to clinical and ART services oversight and program and financial management were assessed.

II. CLINICAL REVIEW

HIV care and treatment started in late 2005, and with IHV-N help in 2006, the facility has enrolled over 7,000 persons living with HIV (PLHA) in care and put almost 5,000 on ART. A strike by resident doctors had caused severe staff shortages and difficulty seeing all patients at the hospital during the ClASS visit.


PEPFAR care and treatment–supported activities in FMC are implemented in three areas: the adult ART clinic, run separately from other outpatient services, the pediatric ART services, integrated within the general pediatric outpatient clinic, and the PMTCT clinic, integrated within the ANC and located a few blocks from the ANC clinic. Despite the adults and pediatric clinic being in different parts of the hospital, staff reportedly schedule appointments for parents and their exposed or infected children to coincide, thus minimizing hospital visits for affected families. The hospital general laboratory and X-ray services support HIV activities. The recently refurbished TB clinic is co-located with the ART clinic, but has different waiting areas for patients and different staff. Staff reported that HIV patients are referred to all relevant clinics as needed.

HIV clinical services are overseen by the hospital’s acting chief medical officer (ACMD) who is also the ART project coordinator, while three other doctors see patients. The project coordinator provides day-to-day clinical oversight for the clinic. The ACMD has identified an infectious disease physician in the facility who has worked with the ART program over the last few years to serve as his replacement. As the site has more than 2,000 patients on

10 HIV prevalence among pregnant women attending ANC by state in Nigeria, 2008. From 2010 UNGASS Progress Report.

11 FMOH (2008) ANC 2008 Report HIV estimates and projection.


ART, there is an assigned clinical officer from IHV-N providing additional support and TA. There are other experienced ART providers with equivalent training. The IHV-N doctor links the facility to the IHV-N program and coordinates additional TA. The clinic was crowded by the time of the visit with patients in both the inside and outside waiting areas with a few clinicians and nurses who were not participating in the strike attending to them. Every day about 100 patients are seen. The recent strike by residents had also affected the clinic services and by 4 PM nurses were still struggling to clear the backlog.


HCT is provided at the ART clinic as well as ANC and in OPD, but those tested elsewhere are only recruited into care on specific clinic days at the ART clinic


About 5,000 patients are on ART at the facility. Children are seen by the pediatric department in another part of the hospital. The pediatric clinic had closed by the time of our visit and the team was not able to talk to any staff there or get access to patient records to determine current operations. Quality Improvement

A quality improvement team exists with an ART provider, nurse, and HCT staff as some of the key members. A. Clinical Strengths

1. The clinic is providing services to a large catchment area where the need is very high. Cumulatively 7,000 patients have been enrolled in care.

2. The FMC laboratory is well integrated and responding to the clinic needs.3. Task shifting has enabled other staff to provide HIV care and alleviate staff

shortages.4. Community outreaches have been conducted and supported satellites bring care

closer to patients.



Finding: With 7,000 patients in care and about 5,000 on ART, this facility is understaffed. This has resulted in the few staff being overworked, and patients waiting longer in a small physical space. The space is particularly inadequate for the pharmacy and HCT services. Recommendation: IHV-N should work closely with the hospital to identify ways of decongesting the clinic. The following should be considered: Better scheduling of patients to improve patient flow. For example, patients could

come in two hourly appointment groups instead of at the same time in the morning as is the current practice. Implementing these changes would be easier if conducted as a CQI exercise with active involvement of PLHA or their representatives.


Consider employing more staff or lobbying the hospital to allow other hospital staff to participate in the clinic activities when general clinics close (usually in the afternoon).

Improve patient flow to ensure that barriers to patient flow and inconveniences to staff are minimized. Conduct an assessment of clinic operations on a typical day to determine where bottlenecks occur in order to smooth patient flow and collectively address them.

Maximize the use of satellites and give patients an opportunity to get treatment from a site close to their homes.


Finding 1: The current patient load and the poor ventilation at the clinic may increase the risk of TB. This issue needs urgent attention. Recommendation: Maximize use of the outer waiting area for the patients prior to being seen by clinicians. Consider minor modifications to increase airflow within the building and ensure that consulting rooms and other spaces are cross-ventilated and that staff adopt seating arrangements that minimize the risk of TB to themselves. For staff working in restricted places, keeping windows open while serving patients would be a useful way to maximize natural airflow. The facility should also draw up a TB infection control plan to address other issues.

Finding 2: Enrollment into care is done only two days a week. Patients tested or referred enrolled only on selected days. Staff explained that the limitation is due to the CD4 testing capacity of the lab. However, the laboratory department disclaimed ever giving the clinic any quotas or limitations on enrollment. Recommendation: Patients tested or referred should be enrolled into care every day to minimize loss of patients between HCT and care.

Records and Data Management System

Finding 1: The manual patient monitoring system currently used in the clinic does not allow the clinic to analyze and use the information to improve the quality of patient care. Individual records are stored in paper files that are not securely stored. Within individual files, papers were loose and not filed in a systematic manner to enable continuity of care or tracking of progress. The summary page was not always updated after every patient encounter. Recommendation: Paper files should be secured to ensure confidentiality. Given the number of patients cared for, this site urgently needs an electronic database. The database will facilitate analysis, scheduling and quick identification of missed appointments. Regular chart reviews should be encouraged and results shared with the care team.

Finding 2: The facility has had significant loss to follow-up, but actual numbers may not be known due to the lack of an efficient database. Recommendation: See general crosscutting recommendations regarding loss to follow-up.


Finding 3: Pediatric and adult care is provided by different teams. Recommendation: More integration between these two departments should be encouraged to minimize multiple visits by families.

PMTCT

Finding 4: PMTCT outcomes have not been evaluated due to the challenges of linking mothers’ records to those of the exposed infants. Recommendation: Care for the mother (families) and infants should be linked through data and providers. Timely EID, prompt return of results, and their linkage with the mothers’ records may help minimize loss of exposed infants from care.

III. ADMINISTRATIVE AND FINANCIAL REVIEW

IHV-N provides funds to support two treatment support specialists, one pediatric adherence counselor, one network coordinator, and one doctor. The budget also includes funds to support transportation for staff to reach patients who missed appointments, transport patients to appointments, and attend the support groups once a month. IHV-N also funds two M&E staff and one clinical officer, which does not come from the project budget.

The program director is now serving as the acting chief medical officer for the hospital and is in the process of identifying a replacement director. Each of the care or support areas has a focal person who serves as the local contact for the IHV-N project officer. The administrator for the hospital serves this role for the project, which includes facility oversight, ordering supplies, staffing, and coordination of any other areas as requested by the program director.

Staff identified the following challenges facing the project:

Space—the patients in the ART clinic have outdoor space to wait, but onceinside the facility, there is insufficient room to see patients and move along the hallways. Eight new rooms have been renovated by IHV-N and will provide some additional consulting rooms starting in a few weeks.

Training —there has been no training for finance or administrative staff in the last year. Everything has been focused on the clinical team.

The project accountant is new and has been with the project for one month, although he has worked with the organization for many years. All accounting for the project is completely separate from that of the hospital. It is kept manually. Staff indicated that a request for a computer had been made for finance, but had been told they were available for M&E only. The accountant has signature requirements for every request from the program staff. Each month the organization receives one-twelfth of the budget. The hospital supports the clinic when reimbursements are late arriving.

The center can comment on the budget only once it is sent out from IHV-N, but there is no process for center staff to request reallocation of funds in the budget line items in advance.


Recently, IHV-N has talked with staff about creating their budgets, but staff was not clear on exactly what new authority this will provide.

A. Administrative and Financial Strengths The hospital supports the program with the absorption of one or more project

positions each year. The hospital provides “gap” funding when program funds are late arriving. The project accountant has signature requirements for all staff requests and

expenses. Staff is required to provide step-down training to fellow workers when they return

from training sessions.

B. Administrative and Financial Management Areas for Improvement and Recommendations

Finding 1: The ART and PMTCT program finances are kept manually and have no connection to the hospital finance systems. Recommendation: IHV-N and the hospital should work for the project finances to be on the same electronic software as the hospital. Hospital financial statements should include the name of the program.

Finding 2: Medical records are not maintained in a way that provides security and ensures patient confidentiality. Files were on the floor in every hallway where they could be removed or read by anyone entering the facility. Recommendation: IHV-N and the hospital should identify space where secure cabinets can be placed to hold the patient files.


Appendix J: St. Gerard’s Catholic Hospital ClASS Assessment Report


AIDSRelief-Nigeria Clinical Assessment for Systems Strengthening (ClASS)St. Gerard’s Catholic Hospital

June 28, 2010

I. BACKGROUND

St. Gerard’s Catholic Hospital began in 1957 as a missionary dispensary. Located in Kaduna, the hospital has 230 beds, a total of 233 staff, and three satellite health units. The hospital is a local partner treatment facility funded by AIDSRelief-Nigeria. The hospital has a relationship with the Catholic Secretariat of Nigeria (CSN), which provides capacity building training and works with the diocese and provincial offices. The hospital also works with the Christian Health Association of Nigeria (CHAN) through archdiocesan meetings that help share information with the Ministry of Health (MOH) on the needs of the faith-based organizations (FBOs).

II. CLINICAL REVIEW

HIV prevalence in the St. Gerard’s catchment area is at 7%, with a population of about six million in the state: thus the burden on facilities is great. The hospital has expanded over the years to provide a range of services that include: primary health care through its general outpatient department (OPD), specialist clinics, X-ray, pharmacy, and laboratory services. The HIV program, supported by AIDSRelief-Nigeria, currently has over 5,000 cumulative patients in care and slightly over 2,000 currently on ART.

Clinic Facility and Staffing and Operations

The antiretroviral treatment (ART) clinic and other HIV services are provided in a separate part of the hospital but are functionally integrated through shared duties in the inpatient wards (for clinicians working in the ART clinic) and in the ART clinic (for staff clinicians working in the other parts of the hospital). The laboratory is integrated and PMTCT services are provided within the hospital antenatal clinic (ANC) department. The waiting areas are open and consulting rooms are cross-ventilated to maximize airflow. HIV patients are routinely screened for TB using questionnaires. The clinic has six full-time doctors, two pharmacists, six nurses, one monitoring and evaluation (M&E) officer, two record clerks, two home-based care (HBC) coordinators, and a referral coordinator.

Monthly clinical meetings for all staff and weekly mortality meetings ensure that services are coordinated with the hospital and further ensure functional integration with HIV care. Educational sessions offering continuing professional education credits are held twice a month. Physical facilities seem adequate for the number of patients.


HIV counseling and testing (HCT) is conducted at the HIV clinic. Counselors go to ANC twice a week and provide services when required on medical wards. Other staff in ANC are trained to provide HCT. Most of the new patients entering into care are through OPD referrals and HCT.



Cumulatively over 5,000 patients are in care, with a little over 2,000 on ART. With these numbers, the clinic has reached its year 5 targets. Of those on ART about 30% are male, and 4% are children (<14 years). Patients on ART are seen daily. An AIDSRelief-Nigeria program manager coordinates programs onsite. The clinic has very qualified staff and AIDSRelief-Nigeria TA is available on request and for periodic updates. The pharmacy plays a big role in maintaining an uninterrupted supply of drugs to patients by keeping proper records and generating lists of patients who miss appointments in a timely manner. These lists are shared with the home-based care (HBC) team for eventual tracking. Referrals are well documented and coordinated through a referral officer who coordinates both internal (within hospital) and external referrals. The tracking system only works when the patient returns a referral slip to show they received the services for which they were referred. A list of community resources is kept by the referral coordinator. Continuous Quality Improvement (CQI)

A multidisciplinary CQI team meets regularly. Data quality assessments have been done recently and have focused on identifying adherence to CD4 testing schedules as a key problem area. Recent efforts in this area have reduced the number of those who miss their scheduled CD4 testing. Other CQI activities have been locally implemented based on data collected onsite. Data has been used or shared in staff meetings and the most recent exercise has resulted in improvement of documentation of patient information.

Medical Records and Chart Review

Patient records are neatly stored and easy to retrieve and track through a file tracking form. The clinic has an electronic database and intends to make all patient records, including the patient-physician encounters, paperless. Backup plans are followed. A unique identifier is used at the facility, and also identifies which satellite the patient is attached to. A recent data quality assessment has led to improvements in documentation. Data entry officers check completeness of medical records and give feedback to the clinical team.

Continuing Education Training

The training strategies used have resulted in very competent and functioning multidisciplinary teams. Onsite training with materials developed locally by the staff increases local capacity, increases opportunities for all staff to get skills, and minimizes time spent away from care delivery. Several staff are cross-trained and have overlapping skills. For example, physicians play a big role in prevention with positives, while nurses and triage staff screen patients for TB. Step-down training as a method of sharing of clinical updates is commendable. Certification in HIV care through collaboration with IHV-N is a motivating factor for HIV providers.


A. Strengths

1. St. Gerard’s hospital offers a comprehensive set of services with very good integration of HIV care with general hospital services.

2. HIV clinic staff collaborate with their colleagues on the medical wards to manage admitted patients. Similarly, staff members who work in the outpatient get opportunities to manage HIV patients.

3. HIV clinic staff provide HCT on medical wards and link those tested to care and support.

4. Regular clinical meetings within the clinic and involving other hospital staff improve coordination of care services. Mortality and morbidity meetings are one such avenue.

5. The training strategies used have resulted in very competent and functioning multidisciplinary teams.

6. Onsite training with materials developed locally increases local capacity, and minimizes time spent away from delivering services. Several staff members are cross-trained and have overlapping skills. For example, physicians play a big role in prevention with positives, while nurses and triage staff screen patients for TB.

7. Referrals are well documented and coordinated through referral staff.8. This hospital and the HIV clinic building designs minimize TB transmission. 9. Using the therapeutic drug committee has enabled many eligible patients to be

switched to second-line treatment in a timely manner (actual number or proportion of patients on second-line treatment was not established by the review team to corroborate this fact).

10. Several CQI activities have been locally implemented based on data collected onsite.

B. Areas for Improvement and Recommendations


Finding 1: Staffing in the laboratory is insufficient to run all required procedures efficiently. The current staff is struggling to address the large number of samples from the entire hospital. Recommendation: Consider increasing the number of staff in the laboratory. A professional laboratory audit should help identify where additional support should be placed.

Finding 2: Scheduling patients for repeat CD4 remains a challenge. A recent data quality assessment has identified that up to 40% of patients were not getting timely CD4 testing and a few completely missed their repeat CD4. Recommendation: The staff has already put in place mechanisms to minimize delays in CD4 testing. These strategies should be reviewed frequently to ensure that patients get a CD4 and that medical records are updated in a timely manner to enable clinicians to act on the results. Regular chart reviews are one of the ways of ensuring proper documentation of processes.

Finding 3: Many needlestick injuries have been reported at this facility. Nursing students seem to be the ones at highest risk. It was not possible to see if all those


reported had access to timely PEP. Recommendation: Urgent interventions should be implemented to minimize the number of needlestick injuries. The following should be considered:

a. The facility policy on infection control should be reviewed.b. All staff should be urgently trained in infection control and those already trained should have refreshers regularly. A training log should be kept to document all new and repeat training and participants.c. Students should be particularly oriented in infection control procedures before they start their clinical placements in the clinics. Clinic staff should collaborate with the student tutors to ensure training is conducted. d. Assess whether all those who reported needlestick injuries had access to PEP.

Finding 4: Only about 4% of those on ART are children. Recommendation: See crosscutting recommendation on this.

Finding 5: HCT is mostly provided at the HIV clinic located several blocks from the outpatient department. Patients who require testing in OPD are referred to the HIV clinic. It is not known whether all those referred honor the referral. Recommendation: HCT should be provided at a place most convenient to patients. Even though HCT staff provide testing to the ANC clinic (twice a week) and to inpatients, testing should be provided at all times in the OPD and in the ANC clinic. Where it is not possible for dedicated HCT staff, staff in other departments should be facilitated to provide testing. Staff in the ANC department who have already been trained should be able to conduct testing if required, and if their schedules and the patient load allow. In the meantime offering of HIV testing and its immediate outcomes (testing) should be tracked as this is the main entry into care.

Finding 6: Male enrollment in care and treatment has not exceeded 30%. In the ANC department where uptake of PMTCT and other services depends on involvement of men, inadequate male involvement was a challenge staff acknowledged. For care and treatment men seem to be missing crucial interventions. Recommendation: Reasons for low uptake of services by men should be determined. If unique to this site, this area should be part of the next CQI agenda. If not unique, AIDSRelief-Nigeria should consider sharing success stories from its global program and support the sites to implement them as best practices.

Finding 7: PMTCT program outcomes have been difficult to evaluate. The challenges include many mothers delivering at home, and the lack of linkage between mothers’ and exposed infants’ medical records. Recommendation: Care for the mother (families) and infants should be linked through data and providers. Timely EID and prompt return of results and their linkage with the mothers’ records may help minimize loss of exposed infants from care. Observed differences in the two sites mean that there are lessons that sites can learn from each other.



Governance

The hospital has established an advisory board to provide local support for the organization. The group held its first meeting on June 23, 2009. The group includes the archbishop, the medical director, a legal representative, and representatives of the medical community who are appointed for three-year terms. This group develops and reviews the annual budget and the financial statements. Strategic planning is done by the advisory board and receives input from the staff and the community.

There is also a community health facility committee that is composed of persons from the police and fire departments, schools, local companies, and the community. The group meets quarterly and serves as a way to solicit support for the hospital, including donations from corporations.


The hospital administrator provides oversight for all the staff and programs. Monthly meetings are held at each level of the organization, departments, and units. The hospital management meetings also take place quarterly, while the management team meets monthly, in the form of the program management and clinical management meetings.

The AIDSRelief-Nigeria program manager visits the site monthly to support the needs of the facility. Recently a new scheduling system was implemented to ensure that those patients who live the furthest from the facility are given the early appointments and seen first, followed by those closer, and last those in the surrounding neighborhoods.

The hospital receives funds from fees charged to the users and some small pots of dollars from grant-writing efforts. Reuters International is providing support with bore holes for wells; and the Catholic Agency for Overseas Development (CAFOD), is providing staff capacity building assistance. The hospital receives many in-kind donations, such as diesel for the generator from a transport company,

The SI department consists of six staff member who are responsible for coordinating the measurement and evaluation, data entry, and records management.

A public relations coordinator has been instrumental in the coordination of the community health facility committee. This position facilitates the group meetings and meets with patients to hear their feedback and suggestions for improving all services of the hospital.

Challenges facing the hospital were identified as the following:

The organization wants to have more trainings onsite, which any staff can attend, to allow for more task-shifting opportunities. When IHV trainings are provided onsite, allow the organization to invite as many staff as needed, rather than limiting invitations to those funded by PEPFAR.

There is no staff person to perform the human resources duties.


The old generator is costing more to maintain than buying a new generator. ealth outreach workers (HOWs) are unable to reach patients who live very long

distances away. Motorbikes would help HOWs to track more patients.

Human Resources

The HR functions are carried out by the administrator along with the hospital administrator. There were nine vacancies at the time of the visit. Salaries are not that different from those at the MOH, but the rural location of the site still poses some challenges in recruiting staff. Retention of staff is not a major problem, once they are hired.

The HR policies and procedures and personnel files were reviewed. Staff are verbally informed of the confidentiality requirements and expectations, but there is no written policy on the topic.

Administrative Strengths

1. Hospital management provides good oversight and support for the ART program.2. The community advisory board provides input and support to the program.3. The public relations officer secures corporate support and donations and community

input for the hospital and program.4. Management and departments meeting documentation indicates good problem

resolution and communication.

Administrative Areas for Improvement and Recommendations

Finding 1: There is no HR staff person; duties are carried out by the hospital director and administrator. Recommendation: The hospital should determine what companies in the area would be able to second an HR person to help the hospital once a month, or coordinate a similar arrangement with AIDSRelief-Nigeria until a part-time or full-time person can be hired.

Finding 2: There is no process to document the status of staff clinical licenses. Recommendation: The hospital should consider developing a spreadsheet or database to list the license numbers annually for clinical staff, along with dates of expiration, either through viewing the original documents or maintaining copies of licenses annually in employee files.

Finding 3: There is no process for administrative and fiscal monitoring of satellites. Recommendation: The administrator or the public relations officers should develop a schedule for the two staff to alternate visits to the satellites at least once per quarter. At least two of the visits should be conducted alongside the clinical visit.



Nature and Effectiveness of Funds Flow

St. Gerard’s Hospital is working with AIDSRelief-Nigeria to resolve a disallowance from a prior period which has resulted in the project having insufficient cash to cover expenses in subsequent periods. Until this matter is resolved, the site has tried to limit spending to remain within the available cash balance and consequently has delayed payment of salaries to employees and payments to vendors.

The site submits timely monthly expenditure reports which are due by the fifth day following the end of the month. Assuming that the monthly expenditure reports are accurate and complete, AIDSRelief-Nigeria reimburses the site within three to four weeks.

Procurement Processes

Project employees submit a request to purchase needed items of supplies or equipment to the AIDSRelief-Nigeria team leader. If there are sufficient funds in the budget, the team leader approves the request and calls for three vendors to submit bids. The selection of the vendor with the best combination of price, quality, and reliability is made by the procurement committee for purchases or contracts greater than 50,000 Naira. St. Gerard’s Hospital maintains a list of approved vendors.

Budget

The budget is developed by the AIDSRelief-Nigeria team leader after receiving input from project staff. The team leader submits the budget to the hospital administrator for approval before it is submitted to AIDSRelief-Nigeria. Then the team leader works with AIDSRelief to finalize and secure approval for the budget.

The project finance officer has developed a set of linked Excel spreadsheets to track the expenditures against the budget. She uses these spreadsheets to prepare the monthly report of expenditures to AIDSRelief-Nigeria.

The site plans to begin using QuickBooks to record AIDSRelief-Nigeria transactions. The software was installed on the project finance officer’s computer one week before the site visit. She has set up the chart of accounts and is quickly becoming proficient in the use of the new software. AIDSRelief-Nigeria will continue to provide assistance to implement QuickBooks. The project finance officer will continue to use the Excel spreadsheets until QuickBooks is fully implemented and operating well.

For the long term, the site plans to integrate the hospital accounting system into QuickBooks.


Accounts

The project maintains one bank account. Hospital funds are held in separate bank accounts and are not commingled with AIDSRelief funds. The project finance officer reconciles the bank statements, which are reviewed by the hospital accountant.

The project finance officer maintains a petty cash fund for expenditures of 5,000 Naira or less. Expenditures exceeding this amount are paid by check. The hospital accountant performs a regular cash count.

Payroll

Nearly all ART employees are dedicated 100% to the project. Some employees, e.g., the hospital accountant, have shared salary allocations. Separate payrolls are prepared for AIDSRelief-Nigeria and for the hospital. Employees who have shared allocations receive two wire transfers, one from each payer source.

The project finance officer prepares the payroll, using the percentages of time and effort specified in the employment letters issued by human resources. The hospital accountant reviews and approves the payroll, confirming that the deductions and the calculations are correct.

Policies and Procedures

St. Gerard’s Hospital does not have fiscal policies and procedures. The hospital accountant has obtained some examples from other organizations and plans to draft a set of policies and procedures.

Audit

Deloitte completed the audit of the AIDSRelief-Nigeria project fund accountability statements and supplemental information for the year ending February 28, 2007. The auditor’s report, dated November 4, 2008, noted exceptions as follows:

Some expense line items were incurred during the year without prior budgetary approval.

Acknowledged copies of the reports submitted to AIDSRelief are not maintained by the site.

Cash books were not updated and some petty cash vouchers were missing. Supporting documentation was not properly filed. The amount of some payment vouchers did not agree with the supporting

documentation.

Management agreed with these recommendations and stated that the matters would be corrected. It was not possible to verify the status of the corrective action during the site visit.


The audit of the hospital for the fiscal year ending December 31, 2008, did not include the revenue or the expenses related to the AIDSRelief-Nigeria project in the financial statements. There was no footnote disclosing that the hospital received the grant. The hospital accountant explained that he had instructed the auditor to exclude the grant because the grant was reviewed separately by Deloitte, as described above.

In addition, the hospital employs an internal auditor who is responsible for verifying daily collections, tracing payments from the books to the bank statements and reviewing supporting documentation. However, the internal auditor does not perform any duties for the ART project, as there are no funds available in the grant budget.


1. The procurement process includes appropriate provisions for competitive bidding and independent selection on the basis of quality, price, and reliability.

2. The project finance officer has developed a strong system of accountability for the AIDSRelief-Nigeria funds. She has designed a set of linked Excel spreadsheets that include a customized feature to prepare the monthly expenditure report. She has also made good progress in the implementation of QuickBooks in a short time.

3. The monthly expenditure report that was reviewed by the fiscal consultant included all supporting documentation and bore the necessary signatory approvals.

4. The participatory approach to budget development tends to ensure that program needs are identified and prioritized.


Accounting System

Finding: The accounting systems of the hospital and the AIDSRelief-Nigeria project are not integrated. Because the audit report of the hospital disregarded the grant and did not disclose that the grant was received, the hospital financial statements are not complete. Recommendation: Develop procedures to prepare and post summary journal entries for the AIDSRelief-Nigeria Project in the hospital accounting system. These summary journal entries will have the effect of including the project revenue and expenses on the hospital financial statements. Also, summary journal entries to pick up the balances, payments and receipts from the bank accounts and petty cash fund should be posted in the hospital accounting system. After the AIDSRelief-Nigeria project has fully implemented QuickBooks, the hospital should convert its accounting system to QuickBooks and use the class feature to distinguish AIDSRelief-Nigeria accounts from hospital accounts.

Audit

Finding: The audit of the hospital for the fiscal year ending December 31, 2008, did not include the AIDSRelief-Nigeria project, although the hospital is the recipient of the grant. Recommendation: For the 2009 audit, inform the auditor about the grant and determine if the grant’s transactions should be included in the financial statements of the hospital or if a footnote disclosing the grant is sufficient.


For the 2010 audit and the future, the grant’s transactions should be included in the financial statements of the hospital.

Disallowance

Finding: The AIDSRelief-Nigeria project is carrying a deficit relating to disallowed costs from a prior period. Consequently, the monthly advance does not cover the monthly expenditures and the AIDSRelief-Nigeria project has delayed payment of salaries and vendors’ invoices to remain within the available cash. Recommendation: Continue to work with AIDSRelief-Nigeria to resolve the matter of the disallowance.


Finding: The hospital does not have fiscal policies and procedures. Recommendation: Formulate fiscal policies and procedures and have them approved by the board of directors.

Budget Management

Finding: The management of St. Gerard’s Hospital do not prepare or review fiscal reports comparing budgets to actual expenses, either for the AIDSRelief-Nigeria project or on a hospital-wide basis, as required by the HHSGPS and by OMB Circular A-110. Recommendation: St. Gerard’s Hospital should prepare and review budget variance reports for both the AIDSRelief-Nigeria project and on a hospital-wide basis.


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