RENEWAL SCORECARD Haiti Malaria

1. SCORECARD SUMMARY GENERAL PROGRAM INFORMATION RENEWAL RECOMMENDATION SUMMARY

2. COMPONENT PORTFOLIO OVERVIEW 2.1 PROGRAM CONTEXT Epidemiological Situation and Program Objectives Programmatic and Funding Gap Analysis Counterpart Financing Compliance Partnerships 2.2 CURRENT IMPLEMENTATION PERIOD PERFORMANCE Progress Towards Impact / Outcome Financial Performance and Programmatic Achievements 2.3 NEXT IMPLEMENTATION PERIOD REQUEST

3. RECOMMENDATION BY PRINCIPAL RECIPIENT 3.1 PRINCIPAL RECIPIENT 1

4. DETAILED REVIEW BY PRINCIPAL RECIPIENT 4.1 PRINCIPAL RECIPIENT 1 STEP 1: Programmatic Achievements STEP 2: Quality of Data and Services STEP 3: Grant Management and Compliance STEP 4: Progress towards Impact /Outcome STEP 5: Operational Risk Management STEP 6: Programmatic achievements and financial performance STEP 7: Financial Recommendation

2 2 2

2 2 2 4 5 6 7 7 9 12

16 16

21 21 21 23 25 28 28 33 34

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1.

SCORECARD SUMMARY

GENERAL PROGRAM INFORMATION Applicant

CCM

Country and Income Level

Haiti/Low income country

Component

Malaria

Renewal cut-off date

30/06/2012

Renewal Review date

12/2012

Implementation Period start date

01/02/2011

Implementation Period end date

31/12/2012

RENEWAL RECOMMENDATION SUMMARY Please insert a table from Excel file, Financial Template-Program. Grant number

HTI-811G07-M

PR name

PSI

Performan ce Rating

Recommendatio n Category

B2

GO

Total Recommended Incremental Amount (all PRs) Total Adjusted TRP clarified Amount (all PRs)

2.

Recommended Incremental Amount

7,152,429

% of Adjusted TRP clarified amount

% saving

Within Investment Range?

69%

31%

NO

69%

31%

NO

7,152,429 10,438,182

COMPONENT PORTFOLIO OVERVIEW 2.1 PROGRAM CONTEXT

Epidemiological Situation and Program Objectives Please describe the goals and objectives of the program and how these correspond to the epidemiological context. The Global Fund contribution for fighting malaria in Haiti started in July 2004 in a context with high political uncertainty and social and economic unrest that unfortunately deteriorated with the devastating earthquake in January 2010. At the end of 2009, the cumulative investment in malaria reached US$ 12.8 million with a number of programmatic results that were achieved in an environment with very limited epidemiological information: 377,000 Long-lasting insecticide-treated nets (LLINs) were distributed in 5 years; 494 health facilities with established surveillance system, including availability of chloroquine and bed net distribution; 2,200 health personnel and community health care agents were trained in case management. The grant under review, a Round 8 Malaria grant approved by the Global Fund Board in August 2009, is executing the final aspects of Phase 1 implementation (up to month 24). The Global Fund Board granted a six-month signing extension in August 2010 due to the complex post-disaster context: the consequences of the 2010 earthquake, the resignation of Fondation Sogebank as the Principal Recipient (PR) for Global Fund grants, the audit report of the Office of the Inspector General (OIG) and the application of the Additional Safeguards Policy (ASP) in Haiti in the same year. The OIG conducted the abovementioned Audit of the Global Fund's Grants to the Republic of Haiti in November 2009. The final report was published on 1 October 2010. It highlighted mismanagement in the area of PR procurement, Sub-recipients (SRs) and other important elements. After complex negotiations throughout 2011 and 2012, and with the strong direct support of the Global Fund Top Management, an agreement was reached in October 2012 between the Global Fund and Fondation Sogebank for the settlement of balances and the closure of the four Global Fund grants managed by Fondation Sogebank, including the Round 8 malaria grant. Considering the context described above, the selection of the alternative PR, Population Services International (PSI), its requisite PR assessment, and the finalization of the Malaria grant agreement negotiations took a significant amount of time, and the grant was finally signed in early 2011. The first disbursement was transferred to PSI and reached Haiti in May 2011, many months after the last

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disbursement under the previous grant/PR which occurred in September 2009. This situation created a gap in the continuation of effective malaria services in the country and the implementation of the new grant was challenged by multiple administrative and control situations that impeded the immediate contracting of goods, services and overall SRs until the end of 2011. As a result of the time lapsed since Global Fund Board approval, the strategy implemented under Phase 1 was limited and did not effectively take into account the latest research, the latest methods of diagnostic and treatment, nor the most recent studies of the epidemiological situation in the country. For example, there were no Rapid Diagnostic Tests (RDTs) budgeted for in Phase 1 and very limited surveillance activities, even though both of these items are now considered as crucial for the success of the Program in Haiti. Therefore, even though the Phase 2 Program is consistent with the original proposal’s goals and objectives, some adjustments have been included in order to optimize interventions, cover those activities that were not reached because of the grant start delay, increase impact, and achieve better value for money for the requested investment. 1

According to data reported in the WHO Malaria Report 2011, 100% of the Haitian population is living in malaria prone areas, with 47% of the population living in low transmission areas and 53% in high transmission zones. The predominant parasite is Plasmodium falciparum (100%), with handful Plasmodium vivax cases reported in the past years. A prevalence household survey undertaken in 2011 shows a prevalence of 0.9% among sampled general population that the Country Coordinating Mechanism (CCM) compares to a 2007 result of 4.9%. However, these numbers are not directly comparable data as the methodologies to sample the slides were different: in 2007 the Programme Nationale Contre la Malaria (PNCM) national malaria prevalence survey systematically tested all fever cases presenting in randomly selected health clinics across several districts during a fixed time period, whereas the 2011 survey samples were taken in randomly selected households. The 2007 survey might suggest a higher positivity rate as the slides were taken among people already requesting health care and might not represent the situation for the whole population. The same 2011 survey shows low baseline knowledge about the risk that malaria represents for pregnant women and children under 5 year old. Centers for Disease Control and Prevention (CDC)-supported calculation of the number of confirmed cases at sentinel sites for 2011 indicates that the Annual Parasite Index is 1.45/1000 population and WHO reported 84,153 microscopy confirmed cases in 2010. Deaths attributed to malaria have decreased to six reported deaths in 2009 from 17 in 2008. The Health Management Information System presents weaknesses regarding consistency, timeliness and completeness in the reporting received from the 10 Health Directorates covering the country, which suggests that data reported to WHO shows only a partial insight of malaria in Haiti. Therefore, case trends are difficult to interpret in view of increasing microscopy testing, however, WHO trend estimates indicate that Haiti may not be reaching the MDR targets for 2015. In line with the National Malaria Strategy, the original CCM proposal aims at reducing the morbidity and mortality due to malaria in the whole country by i) reducing the incidence and prevalence of malaria with 75% decrease of positivity in diagnosis, ii) an 80% of ownership and use of ITN and iii) increasing the provision of adequate treatment to confirmed malaria cases. To reach these goals, Phase 1 included activities aimed at “raising awareness” of the populations on the causes, symptoms, modes of transmission, prevention and treatment, delivering LLINs through a mass campaign, investing in improving microscopy diagnosis, providing treatment, setting up sentinel sites to support the weak surveillance system and fostering inter-border collaboration between Haiti and the Dominican Republic. While keeping the focus on case management, and in line with partners’ recommendations for the following years, the CCM suggests in phase 2 some programmatic enhancement to support diagnostics and focus treatment through the introduction and scale up of the use of RDTs, improved coordination with partners, and a strong investment for the improvement of national monitoring and reporting systems.

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Total population in Haiti is 10.1 million, World Bank data, 2011

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Programmatic and Funding Gap Analysis Please summarize the programmatic needs in terms of planned targets/coverage for key services. Targets/coverage Key services

End previous implementation period

Year 1

Year 2

Year 3

Increase awareness of malaria and treatment seeking behaviors Number of people reached by small group community outreach activities (Top Ten) Reduce malaria mosquito vector populations by targeted and vector control strategies

971,401

150,000 (excluding mass media)

100,000 (excluding mass media)

100,000 (excluding mass media)

Number of LLINs distributed to target population (Top Ten) Improve coordination and partnership development Number of counties on the border with joint prevention and control activities (Top Ten) Establish a robust surveillance system % of health facilities reporting confirmed malaria cases into surveillance systems (Top Ten) Diagnose and treat every case as per national guidelines Number of suspected cases receiving antimalaria treatment (Top Ten) Percentage of all suspected malaria cases that received a parasitological test

1,988,030 (expected 3.1M by the end of Phase 1

0

1

2

4

4

New indicator

90%

95%

100%

148,534

150,000

125,000

100,000

0

80%

90%

100%

Please summarize financial needs, current and planned sources of funding and financial gap for the fight against this disease by all domestic and external sources. Next Implementation Period Funding Source

Year 1 amount

Overall needs costing Program Investment public Private sector contributions (national) Total domestic sources Global Fund grants CDC

17,797,076 2,433,240 2,433,240 4,583,615

Year 2 % 100% 13.7%

amount 19,576,784 2,433,240

0.0% 13.7% 25.8% 4.6%

Year 3 % 100% 12.4%

amount 21,534,462 2,433,240

0.0% 2,433,240 5,116,937

12.4% 26.1% 0.0%

% 100% 11.3% 0.0%

2,433,240

11.3%

4,874,753

22.6% 0.0%

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820,000 OPS/OMS Total external sources Total resources available Unmet need gap CCM Funding Request

169,000 5,572,615 8,005,855 9,791,221 6,673,938

0.9% 31.3% 45.0% 55.0% 37.5%

5,116,937 7,550,177 12,026,607 6,780,228

0.0% 26.1% 38.6% 61.4% 34.6%

-

0.0%

4,874,753

22.6%

7,307,993

33.9%

14,226,469

66.1%

6,500,969

30.2%

Comments: The assessment of funding needs for the National Program for Malaria Control (PNCM) is made by the Ministry of Health with the support of partners working in the field (CDC and WHO). The period covered by the current strategic plan expires in December 2013. A cost estimate of the actual plan was conducted in 2008. A workshop was held 21-22 August 2012 to review the actual plan and discuss the extension of the National Strategic Plan for 2014-2018. An outcome of the workshop is a rough draft of the revised national strategic plan and costs are not yet quantified. The revised plan will be available at the end of 2013. Overall, the plan keeps the same objectives with a focus on an increase in coverage in diagnosis / treatment, reinforcement of the surveillance system, development of targeted vector control activities, reinforcement of the coordination and partnership, and development of bi-national efforts towards elimination of malaria on the island.

Counterpart Financing Compliance Does the country currently comply with the counterpart financing requirements 2 based on the income classification for the country

Yes

The Phase 2 total estimated funding needs for the National Program for the Control of Malaria (PNCM) is US$ 58,908,322. The analysis presented by the CCM shows that the government of Haiti, the Global Fund, CDC and WHO shall cover US$ 29,490,637. The Haitian government contributes 12.5% of the overall needs of the PNCM (and 25% of the expected funds available for the proposal) whereas 5% is required as minimum threshold. The contribution was similar for Phase 1 (12.9%). To date there is no earmarked budget line in the National Budget to support the PNCM and this situation is similar to tuberculosis and HIV programs. The government is funding mostly salaries and part of operating and investment costs through the work of (1) several government agencies, (2) the offices of the departmental directorates that are coordinating the implementation of the program, and (3) at local level through all public and mixed health facilities which are providing the diagnosis and treatment to all malaria cases and implementing all other operational activities linked to the program. Information on contribution for salaries is gathered through the Ministry of Finance database. To estimate the amount spent on PNCM, the CCM estimated the average time spent on malaria activities by government employees. Similar estimates have been done on infrastructure and operation contribution using the list of facilities that are involved in the PNCM. Through these estimates the government contribution amounts to US$ 7,299,720 for Phase 2 with 66% for salaries, 18% for infrastructure and 16% for operations. In 2010, US$ 464 million was spent on health care in Haiti which corresponds to US$ 46 per capita. 40% of

2

http://www.theglobalfund.org/en/application/applying/ecfp/eligibility/

5

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this is spent by households, the government contributed with 21%, while other sources cover 38% . The health system in Haiti is funded 62% by domestic funding and 38% by funding from abroad.

Partnerships Please briefly summarize key partners and their role in supporting the program implementation. The key partners that have participated in direct support to Phase 1 will also be supporting the program implementation during Phase 2, even if at the moment both the CDC and the WHO have committed funds only for 2013. In addition to the direct financial support, these two partners sit in the CCM and work directly with Gthe Haitian government and key SRs. During Phase 1, the CDC provided technical assistance to the grant through a household survey, a health facility survey and quality assurance for malaria diagnosis. In Phase 2 the contribution is expected for a net efficiency survey, in-vivo therapy efficacy trials, an insecticide efficiency survey, a health facility survey, and for integrating malaria in the national surveillance system. WHO technical assistance contributed expertise to technical working groups and the Commission de Development des Propositions (CDP). CDC and WHO strongly support the CCM and participate directly as members of their respective constituencies. They regularly attend meetings and workshops and participate to the (CDP). In addition both partners provided technical inputs during the preparation of Phase 2 and have officially endorsed the CCM Request for Renewal (CCM Request), through supporting letters. Experts from both organizations are offering on-going technical collaboration to the Secretariat, through regular contacts during the implementation of Phase 1 and recently for the review of the Phase 2. CDC confirmed to the Global Fund Secretariat their main views regarding key elements of the CCM Request resulting inadjustments to the original CCM proposal. WHO and CDC recognize the efforts of Haitian authorities in implementing the National Malaria Strategy (the “Strategy”) and they participated as technical partners in its review which started in the summer of 2012 and will be completed in 2013. Some updates to the Strategy have already being shared and are included in the CCM Request. CDC and WHO acknowledge that the review includes the same approaches supported by both organizations for malaria control and pre-elimination strategies, with emphasis on diagnostic confirmation, surveillance and prevention. The United States Government, USAID and PEPFAR are also closely following up on the implementation of the grant and facilitate information sharing and contacts on the ground with CDC in the United States. The support to the Global Fund Secretariat from the health advisors of the US Government based in Port au Prince has been essential to maintain a very effective communication with all malaria actors. Recently increased interest for collaboration has been shown by the French Government through its Embassy in Haiti to share knowledge resources in the malaria field. From 2013 their availability will be further explored. The Clinton Foundation (CHAI) has been actively supporting Global Fund initiatives as a CCM member and directly supporting the development of key initiatives for the Ministry of Health to improve its managerial capacities. After the completion of a complex analysis for budgeting the national strategic plan for HIV, including the application of a comprehensive methodology of linking the strategic plan to real unit costs, CHAI informed the Global Fund that they are currently seeking funding to complete a malaria feasibility assessment in Hispaniola which would have a full costing of elimination versus control scenarios over a number of years, but this would be a separate document from the malaria strategic plan and would probably be available by the end of 2013. CHAI is coordinating with the Global Fund Secretariat the definition of an exercise similar to the one prepared for HIV. The first estimate is approximately six months for development, to include a costing study at a limited number of medical institutions offering malaria and TB treatment and care, and of organizations

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Health System Financing Country Profile, Haiti 2010, WHO World Health Atlas, 2010

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doing vector control to establish the real unit costs of these activities, which are the two areas for which information is limited. The political situation in Haiti has been marked by a protracted electoral process in the recent years along with Prime Minister change. General elections were held in November 2010 and presidential elections in April 2011, when Michel Martelly won the presidency. The appointed PM, Mr Conille, resigned after a few months and was replaced by Mr Lamothe. The Minister of Health, Dr Florence D. Guillaume, who is also a Board member of the Global Fund, has tried to push ahead the health agenda to include it in the priorities of the Government. In 2011, the CCM was reformed and new members elected. The first Lady of Haiti, Mme Sophia Martelli, assumed the role of CCM chair and representatives from PLWHA and the press sector were elected vice-chairs. The involvement of the First Lady has been crucial to get the support from different government entities and organizations and to improve the relations with the former PR, Fondation Sogebank. The political influence of the First lady has facilitated the terms of the agreement with Sogebank and as a result, funds have been reimbursed to the Secretariat, the settlement of balances with SRs is in process, and four grants are being closed. Haiti has been regularly affected by natural disasters and is frequently obliged to concentrate efforts and resources in relief and emergency interventions. Haiti is susceptible to hurricanes and floods which are common and seriously affect agriculture, infrastructures and health conditions of the population. On 12 January 2010, a massive earthquake of 7.0 magnitude struck Haiti. According to the Haitian Government, approximately 222,570 people died and 300,572 were injured. Critical infrastructures, including those for health, were severely damaged or destroyed and it is estimated that about 190,000 houses collapsed or were badly damaged across all affected areas. The earthquake left an estimated 2.3 million people displaced. After the earthquake, a cholera outbreak hit the country in October 2010, which was the most severe in the last century and was made more complex by the humanitarian situation post-earthquake. As of February 2011, according to OCHA, the overall trend of the cholera epidemic was towards a plateau or a slow decrease in cases. However, cases continue to be regularly reported, especially in remote areas where health services are very poor. In the month of October 2012 a new cholera alert was reported with an increased number of cases. Considering the incubation period the recent outbreak cannot be entirely attributed to the consequences of the storm “Hurricane Sandy.” More cases are likely to be detected in the coming weeks. Hurricane Sandy further affected a large number of Haitians. The strong rains and flooding which occurred in the last week of October 2012 damaged infrastructure and forced many to evacuate their homes. PAHO/WHO reported 3,295 destroyed houses, 10,183 damaged ones and 18,000 families affected. 54 confirmed deaths were reported, 20 missing persons, and several thousand evacuated with a threat for potential famine for around one million people, further complicated by the destruction of agricultural resources.

2.2 CURRENT IMPLEMENTATION PERIOD PERFORMANCE Progress Towards Impact / Outcome Proposal Goal : Reduce the morbidity and mortality due to malaria In Haiti Year 1 Impact and Outcome Indicator

Baseline Baseline Year Value

Target

Year 2 Result

Confirmed malaria cases per 1,000 persons 2011

1.45/1000

1.45/1000

Parasite prevalence in malaria transmission areas with microscopic detection of parasitemia

2011

0.9%

% of households with at least two LLINs

2009

3.7%

7.1%

% of children U5 sleeping under an ITN the previous night

2009

12.5%

16.1%

% of pregnant women (and other target groups) sleeping under an ITN the previous night

2009

13.4%

11.8%

Target

Result

TBD Q4/2012

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% of patients presenting to a health worker with confirmed malaria who received antimalarial treatment according to national treatment policy

2012

TBD/HMIS

35% (Q8)

Comments: Based on trends in reported cases, hospitalizations and deaths, WHO estimates suggest a pattern of fluctuating malaria cases and death rates over 2000 to 2010. These estimates are difficult to interpret given the ongoing scale-up of parasitological microscopy diagnosis and the limitations of the surveillance systems of Haiti. A decline since 2006 in malaria-attributed deaths is suggestive of some program impact, but the World Malaria Report (WMR) 2011 considers that there is insufficient data to assess impact. The number of confirmed cases at sentinel sites for 2011 indicates that the Annual Parasite Index is 1.45/1000 population and WHO reported 84,153 microscopy confirmed cases in 2010. Although it seems that diagnostic and treatment services’ coverage are expanding, the World Malaria Report 2011 considers that there is insufficient data to assess impact. The WHO trend estimates indicate that Haiti may not reach the MDR targets by 2015. A prevalence household survey undertaken in 2011 shows a prevalence of 0.9% among sampled general population that the CCM compares to a 2007 result of 4.9%. However, these numbers are not directly comparable data as the methodologies to sample the slides were different: in 2007 the PNCM national malaria prevalence survey systematically tested all fever cases presenting in randomly selected health clinics across several districts during a fixed time period, whereas the 2011 survey samples were taken in randomly selected households. The 2007 survey might suggest a higher positivity rate as the slides were taken among people already requesting health care and might not represent the situation for the whole population. The main findings of the household survey conducted by PSI in 2011 revealed that 7.1% of households have at least two LLINs compared to 3,7% in the baseline survey, 16.1% of children under five years are sleeping under a LLIN compared to 12.5% in 2009, 11.8% of pregnant women are sleeping under a LLIN compared to 13.4% in 2009. Given the delayed distribution of LLINs in Phase 1 (started in May 2012), its impact will not be possible to measure until the Phase 2 period. The Health Management Information System lacks consistency, timeliness and completeness in the reporting received from the 10 Health Directorates covering the country, which suggests that data reported to WHO shows a skewed vision of malaria in Haiti. A Global Fund Secretariat assessment indicates that only 40% of the required malaria routine reports are timely received. The routine health system and the malaria surveillance system show incomplete data, and therefore, to monitor progress in the fight against malaria and measure impact, four sentinel sites have been put in place with the support of the Global Fund. A multi-stakeholder program review is expected to take place in 2013, and recommendations would be ready by the end of the year.

PROGRAM IMPACT RATING

Progress Towards Goals

8

Financial Performance and Programmatic Achievements Financial Performance at Program Level:

PR Type

No. of SSFs / Grants

Cumulative Signed Budget to cut-off date (Grant Agreement)

Cumulative Adjusted Budget to cut-off date (EFR)

Disbursed to cut-off Expenditures to cutdate (Finance) off date (EFR)

NGO

1

$27,570,161

$27,570,161

$20,214,516

$17,509,624

Grand Total

1

$27,570,161

$27,570,161

$20,214,516

$17,509,624

Disbursed vs Adjusted Budget at cut-off date

71%

Expenditure vs Adjusted Budget at cut-off date

64%

Current Implementation period % time elapsed

65%

Programmatic Achievements versus Finance Performance: Disclaimer: Please note that in many cases the expenditure categories in the EFR do not align with the SDAs in the Performance Framework that results in inconsistent data presented in the table below. This discrepancy will be resolved shortly.

Macro Category

Prevention

Total Expenditure Amount to cut-off date (EFR)

Expenditure vs Budget at cut-off Programmatic date Achievement

Prevention: Behavioural Change Communication $972,844 Community Outreach

$377,595

39%

Prevention: Insecticide-treated nets (ITNs)

$19,568,658

$13,699,714 70

109%

Prevention: Vector control (other than ITNs)

$2,167,299

$234,381

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50%

$4,190,579

$2,003,066

48%

$213,171

$62,623

29%

0%

Supportive Environment: Monitoring drug resistance

$51,609

$1,783

3%

80%

Treatment: Prompt, effective antimalarial treatment

$1,477,117

$459,929

31%

65%

$28,641,277

$16,839,091 59%

71%

Service Delivery Area

Total Adjusted Budget Amount to cut-off date (EFR)

120%

Prevention: Behavioural Change Communication Mass Media Program Management and Administration Supportive Environment: Coordination and partnership development (national, community, Supportive Environment public-private)

TB Treatment Grand Total

Average Performance on Top 10

90%

Average Performance All Indicators

70%

OVERALL PROGRAM RATING

B1

Please comment on the linkages between the grants in the program under review and the correlation or deviation between programmatic achievements and expenditures. The Ministère de la Santé Publique et de la Population (MSPP) created the Plan Stratégique National de Lutte Contre la Malaria (PNCM) in consortium with other relevant actors including other ministries, as well as local and international NGOs and with the support of WHO and CDC. The overall goal of the PNCM is to 1) to reduce mortality and morbidity due to malaria; and, 2) to contribute to the elimination of malaria on Hispaniola. Despite a late start of Phase 1 (SR budgets were approved between October and November 2011), the

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grant performance improved substantially from the first semester of the second year, until the cut-off date of 30 June 2012. Additional improvement is expected by the end of Phase 1. The last quarterly progress report (September 2012) demonstrated a programmatic rating of A2. On a programmatic level, the major accomplishment is the LLINs distribution campaign. Approximately two million LLINs were distributed in a very short period of time, significantly increasing net availability and their use among the general population. Despite very difficult circumstances for distribution (security threats, logistics and transportation, limited availability of national police, limited support from departments, rain falls, etc.) the LLIN indicator surpassed the 30 June target to 110%. The BCC SDA indicator 1.1 also surpassed the 30 June target (236%). The Global Fund Secretariat approved the revised indicator that takes into account the Interpersonal communication sessions only and excludes the mass media given the complexity of estimating the audience reached. There was also significant progress on other programmatic indicators, particularly, vector management activities (50%) and functional sentinel sites to monitor drug resistance (80%) which, while still below 100% achievement, are underway compared to the zero percent of performance in March 2012. The Vector control SDA activities 3.1 were hampered by the lack of equipment/ larvicides. The distribution of larvicides was delayed by the custom clearing process. Efforts are being made to accelerate the clearing of the remaining larvicides and the procurement of the necessary equipment. Meanwhile, PNCM has launched the inventory of larvae gites and conducted fumigation using existing equipment and malathion in five geographic departments. The bi-national coordination with the Dominican Republic has moved slowly but significant foundational work took place before the cut-off date for the CCM Request. Meetings are held between the authorities in charge of malaria control in the two countries and agreements involving three counties located on the border were signed in September 2012 to develop joint malaria control efforts in borders. During Phase 2, the coordination to implement joint malaria control interventions will be reinforced through more countybased agreements instead of bi-lateral. The indicator has been reformulated accordingly. Progress towards goals is shown by interim results from a household survey conducted in November 2011 that revealed a parasite prevalence of .4% (using RDTs) and .9% (978 samples confirmed by PCR). Malaria transmission is shown to be lower than initially thought. Indicators on ownership and use of LLINs showed slight improvements between the household surveys conducted in 2009 and in 2011. As the LLIN campaign ended in Phase 1, improvement is expected in 2013. Progress in financial performance is aligned with the programmatic progress ratings. Cumulative cash outflow is up to 71%, compared to some 52% three months ago. Further acceleration of spending particularly by SRs has been reported in the last six months of Phase 1. Due to the late start of SR activities in Phase 1, the initial results could be achieved only starting from AprilJune 2012, and this has delayed the expected performance at Month 18 (June 2012). Most results related to phase 1 have been achieved in the second half of 2012. During Phase 2 the achievements will be consolidated by procuring and distributing two million RDTs, in order to reinforce diagnostics, and with 1.5 million doses of chloroquine and 1.5 million doses of primaquine, will be supporting the corresponding scale up of case management activities. Furthermore, measures will be taken to strengthen the surveillance system to allow for the collection of accurate epidemiological data. In addition to these very targeted and proven efficient strategies, support activities (such as BCC and M&E) will be implemented as a way of complementing case management, vector control and surveillance activities. From the managerial point of view, several weaknesses were detected during Phase 1 in the general management and the oversight of health products by the PR, which are not entirely addressed in the proposed Phase 2 PSM Plan. Storage conditions and inventory management at PSI’s central warehouse were found to be inadequate, as well as storage conditions at peripheral sites. The PR did not have an information system in place to effectively register and monitor the flow of health products along the supply chain. This affected all products, from pharmaceuticals to LLINs. The PR reports a difficulty to ensure wide access to free antimalarial drugs funded with this grant due to an incentive from health facilities to dispense privately sourced ones, for which they benefit from a profit

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margin. Some measures have been taken, such as promotion of the free medicines. However, this is not regarded as sufficient. The possible magnitude of this deviation of patients has not been estimated.

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2.3 NEXT IMPLEMENTATION PERIOD REQUEST Has the CCM Request met the Focus of Proposal requirements per the threshold based on the income classification for the country?

Yes

Please describe how the CCM Request is focused on underserved and most-at-risk populations and/ or high-impact interventions. Haiti is classified as a Low Income Country and the focus on specific populations is not required. However, during Phase 2, the same programmatic orientation of Phase 1 will be followed with some adjustments to the program activities suggested by lessons learned during Phase 1 and reflecting epidemiological realities. From the WHO Malaria Report 2011, 100% of the population is living in malaria prone areas, with 47% of the population living in low transmission areas and 53% in high transmission zones. Greater emphasis will be placed on: 1) Systematic diagnosis and treatment of every case according to National Malaria Treatment policy, 2) Strengthening of surveillance system, and 3) Targeted vector control activities. Phase 2 implementation efforts will contribute to the national scale up of diagnosis and treatment activities in line with new National Malaria Case Management policy and to the strengthening of the health system through the establishment of a robust surveillance system. The adjustments are the following: a) A scale up of diagnosis and treatment to ensure 100% of diagnosis and treatment and shift from current emphasis from symptomatic treatment; b) Strengthening of the existing health surveillance system to provide timely and accurate epidemiological data; c) Designing of targeted vector control activities to respond to specific needs (including analysis of Phase 1 LLIN distribution, fumigation, larvae destruction); d) Implementing BCC using mostly interpersonal communication on small groups; and e) Coordinating and partnership development in the island of Hispaniola reinforcing agreements at county level. The proposed adjustments are in line with the National Strategy, as stated above, which prioritize the systematic diagnosis and treatment of every case. The adjustments are also in line with the lessons learned from Phase 1 as overtreatment of malaria may happen because of unconfirmed diagnostic and weakness of the surveillance system. The weaknesses of the health system in Haiti are multiple and the government resources are mostly dedicated to salaries and only in small part to operation and investments. The CCM has proposed the use of specific resources to finance a general initiative of the health system. Part of the requested resources would support a portion of the training costs of the denominated polyvalent community health workers and environmental health workers. These trained people are supposed to benefit the impact indicators for the grant as well as building sustainability for malaria control and other health programs. However, the direct relation with the expected impact in the program has not been established and this is considered a limited value for money investment. Any future mass campaign of LLINs will be based on micro stratification of malaria risk. As this is not yet done, coupled with the timing of 2015 and the surrounding questions of LLIN efficacy, the Global Fund Secretariat will not request funding to replace the two million LLINs distributed in 2012. Any spatially targeted vector control in the future will be funded under the New Funding Model (NFM).

Has the CCM Request considered issues of human rights and gender equality?

Yes

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In Haiti there is a lack of universal access to basic social services: education, water and sanitation, and health. Life expectancy is 62 years (76 in the region), under-5 mortality is 165 deaths per 1,000 children (18 4 in the rest of the region) and maternal mortality ratio is 350 per 100,000 live births (regional is 63). Many health centers receive numbers of patients that exceed their capacity. Hospitals and health centers are overcrowded, and often lack necessary materials to attend to the patients as necessary. Following the devastating earthquake of 2010, more than 40% of the Haitian people did not have access to health services. In addition, many health centers in Haiti lack qualified personnel to detect and treat malaria which is a disease that remains an economic burden for thousands of families. Due to this lack of knowledge on malaria, many health centers have a regular practice of giving anti-malarial medicines to all patients presenting fever symptoms. There has been a change in treatment protocols in Haiti, according to which a confirmation of cases is now required prior to treatment and the CCM Request goes in this direction. The CCM General Assembly is composed of representatives of women, youth, faith groups, unions, people affected by the diseases and Lesbian, Gay, Bisexual and Transgender associations who actively participated in the discussion on aid effectiveness together with the governmental sector and the bilateral and multilateral constituencies. They all jointly support the CCM Request. Phase 2 is meant to offer free malaria treatment for the entire population promoting universal access to health facilities involved in the fight against malaria. This approach is in line with the National Strategy that aims at providing free malaria treatment to all those in need. Despite the fact that there is no legal or social impediment to free access to health services, at the moment the private/philanthropic sector controls 350-400 health facilities that cover 60% of the population. To reach the affected population, health authorities will need to use advanced strategies and the integration of the sub-medical traditional sector and private sector within the program. The proposal aims at reaching this result with the introduction of rapid tests as a means of diagnosis. To ensure equity of access in all geographic areas of Haiti, the CCM aims at involving health facilities run by the private and NGO sector. Please describe the activities proposed for the next implementation period. Phase 2 will contribute to the national scale up of diagnosis and treatment activities in line with National Malaria Case Management policy (Normes de Prise en charge) and to the strengthening of the health system through the establishment of a robust surveillance system. The limited capacity of government resources is mainly oriented to the covering of health staff at central and department level. Through the lessons learned during Phase 1 the CCM Request recommends to maintain the investment effort to support the same programmatic implementation during Phase 1 while placing greater emphasis on: 1) systematic diagnosis and treatment of every case according to National Malaria Treatment policy; 2) strengthening the surveillance system; and 3) targeted vector control activities. By the end of Phase 2, the Program is expected to reach approximately two million tests using RDTs at a national level. The corresponding investment in malaria drugs should be optimized and more focused. An improved BCC environment should support population knowledge around malaria. There is also expected to be a closer collaboration with the Dominican Republic, with specific department initiatives to be developed. The WHO is supporting these initiatives for other diseases. To address the lack of a National approved M&E plan, the following strengthening activities will be conducted: revision and finalization of the existing national monitoring and evaluation plan, revision of reporting tools to allow the provision of accurate health information on time (HMIS), and staff training. With the recommended modifications to M&E strategies and lessons learned, an improvement is expected in data collection and consolidation of health information in the national information system.

4

Haiti: Health Profile, World Health Organizations, 2010

13

At the same time, some operational research will be intensified. A number of studies have been suggested for Phase 2 but a revision of these elements should be done in order to confirm what data will be collected and how these will be used. Some studies would be co-financed by partners (WHO and CDC). Based on an optimization of the relevant expected results in Phase 2, the Program is intended to support these studies considered as value for money investment. The specific objectives associated to the relevant strategy which will be followed during Phase 2 include: Objective 1: Increase awareness of malaria and treatment-seeking behaviors among the population Strategy: Implement a comprehensive BCC strategy using interpersonal communications to create awareness and motivate populations to seek treatment for any fever (with no other obvious cause) will be implemented. Objective 2: Reduce malaria transmission by implementing targeted vector control strategies based on epidemiological requirements. Strategy: Implement a targeted vector control strategy that focuses primarily on higher transmission areas to effectively interrupt and eventually halt the transmission of malaria where needed. A comprehensive package of activities informed by the entomological and epidemiological requirements (including analysis of LLINs use, fumigation, larvae destruction) will limit human-vector contact, with the aim of interrupting the transmission of malaria. Objective 3: Improve coordination and partnership development Strategy: Improve Coordination and Partnership development efforts to obtain high-level government commitment, mobilize the domestic and international funding required for a successful elimination plan. The CCM request continues the capacity development component in Phase 2 as building the capacities of local counterparts will improve the quality of implementation and thus of malaria service-delivery in Haiti. Objective 4: Establish a robust surveillance system to allow for accurate collection of epidemiological and entomological data on time. Strategy: Strengthen the existing health surveillance system by integrating onto MESI (Monitoring, Evaluation and Surveillance Interface) a sentinel surveillance system of 86 sites and at the same time reinforcing the national surveillance system. This will help provide timely and accurate epidemiological data, detect and prevent epidemics and will provide accurate levels of transmission allowing the program to develop targeted vector control activities. The CCM Request reinforces capacity building in this domain and also should be addressing the main weaknesses detected in Phase 1. Objective 5: Improve and intensify malaria case management by systematically diagnosing and treating every case as per national guidelines Strategy: Scale up of diagnosis and treatment to ensure 100% of diagnosis and treatment, thus acting as a key element in the reduction of the parasite reservoir. Objective 6: Strengthen Monitoring and Evaluation systems to allow for the accurate collection of epidemiological and entomological data on time. Strategy: Revise the existing monitoring and evaluation system to respond to weaknesses identified during Phase 1 and to fit the needs of an elimination program by developing tools and procedures that will allow the collection and analysis of critical epidemiological data. For all the objectives, there is an important role for SRs who count for almost half of the original proposed budget. However, several initiatives have been considered to provide limited value for money or are not presenting a proven effectiveness in their implementation. Some of the operational plans, the M&E strategies, as well as the SRs’ associated budgets will be revised in order to obtain the expected value for money from each particular intervention, thereby guaranteeing an increased impact and optimal use of resources. The PR will have to complete the reinforcement of the main weaknesses detected in phase 1 and a positive step has been the appointment, from April 2012, of a new director in Haiti who is providing a new dynamic for improvement of the management of the PR.

14

Budget allocation for the next implementation period by cost category:

HTI Malaria Global Fund Recommended Budget Planning and Administration 5.1%

Monitoring and Evaluation 12.2%

Overheads 10.2%

Communication Materials 5.4% Infrastructure and Other Equipment 0.7% Procurement and Supply Management Costs 2.9%

Medicines and Pharmaceutical Products 2.0% Health Products and Health Equipment 7.2%

Human Resources 44.6% Training 6.5%

Technical Assistance 3.3%

Budget allocation for the next implementation period by SDA: Supportive Environment: Program management and Administration 39%

Years 3-5

Information, education and communication (IEC) and behavior change communication (BCC) 10%

Prevention - Targeted Vector Control 1% Supportive environment: Coordination and partnership development 8% Supportive Environment: Monitoring and Evaluation 15%

Treatment - Prompt, Effective Malaria Diagnosis and Treatment 22%

Robust Survelliance System 5%

Are the activities to be funded in the next implementation period appropriate given the specific country and disease context?

Yes

15

Through the lessons learned during Phase 1, the CCM Request recommends to maintain the investment effort to support the same programmatic orientation during Phase 1 while placing greater emphasis on: 1) systematic diagnosis and treatment of every case according to National Malaria Treatment policy (which is being enhanced with the introduction of RDTs and improved quality of diagnostics / treatment); 2) strengthening the surveillance system, including an improvement of M&E and national data collection processes; and 3) targeted vector control activities. By the end of Phase 2, the Program is expected to reach approximately two million tests using RDTs at a national level. The corresponding investment in malaria drugs should be optimized and more focused, including an improved BCC environment that should support population knowledge around malaria. The Global Fund Secretariat recognized the need for reinforcing and prioritizing case management and the low results in the OSDV have required a reinforcement of the organization with implementers and their relationships with the PR and the MoH.

Are the proposed changes, if any, considered material?

No

The manner in which the LLINs were initially programmed in year 3, 4, and 5 is unclear. The 200,000 LLINs could be used to expand the geographic scope of the blanket vector control approach (and thus could be sent out now) but the PR reported that the universal campaign has already been completed. However, the proposed strategy is not considered clear and the expected impact limited in terms of the technical use of the LLINs in Phase 2. The procurement of 200,000 LLINs is therefore not recommended. In addition the campaign is being completed in the second semester of 2012 – early 2013. Any need to replace LLINs should not be planned before 2015. A survey on the effectiveness of the use of LLINs and other studies are in process and national authorities, as well as technical partners and the Global Fund, will use the outcome to identify which are the more appropriate prevention strategies in the future for Haiti. Finally the funds available for Phase 2 would not be enough to cover an additional replacement campaign (US$ 14 million in Phase 1). Any other initiative for replacement of LLINs is out of the scope of this grant and should be eventually evaluated and considered as appropriate. During discussions with specialists at CDC, WHO and others in Haiti and advisors at the Secretariat, the importance of case management in the transmission setting has been emphasized and the CCM Request ensures sufficient support for capacity building of health personnel around PSM as it is considered a major challenge to success. M&E systems require a review in their organization to guarantee that the main weaknesses are addressed.

3. RECOMMENDATION BY PRINCIPAL RECIPIENT 3.1 PRINCIPAL RECIPIENT 15 Grant Number

HTI-811-G07-M

Principal Recipient

Population Services International

Grant Start date

01/02/2011

Grant End date

31/03/2013

a. COUNTRY TEAM PERFORMANCE RATING

5

B2

This section needs to be repeated for each PR in the portfolio.

16

Country Team rationale for the Recommended Performance Rating The performance trend of the program went from C in the first two quarters (Feb-Jun and Jul-Sep 2011) to B2 in the third quarter (Oct-Dec 2011) and B1 in the last two quarters until the cut-off date (Jan-Mar and Apr-Jun 2012). The main reason behind the slow increase in performance and the consequent lower rating for Phase 1 was the initial delay in the implementation of the grant following the selection of a PR under the ASP terms (PSI). The grant was signed in February 2011 andthe first disbursement was transferred to PSI and reached Haiti in May 2011. Implementation was also challenged by multiple administrative situations that impeded the immediate contracting of goods, services and SRs until the end of 2011. SR activities started reporting only in March 2012. Despite a late start of Phase 1 (SR budgets were approved between October and November 2011), the grant performance improved substantially from the first semester of the second year, until the cut-off date of 30 June 2012. However, this improvement was insufficient to reach a better performance rating. Within this limited period of time and in spite of the significant efforts made by multiple actors, the performance rating reached by the cut-off date was B1. However, the multiple lessons learned are now included in the management process and results have been improving steadily. Financial execution in the period Q7 reached US$ 2 million and the performance has been reported as A2. The final quarter of Phase 1 will be reaching an A rating closing the first two years of implementation. The cumulative renewals rating is at a B1 level with 90% achievement for the three Top Ten indicators: 1.3 Number of people reached by community outreach activities, 2.1 LLINs distributed to target population (both performing at an A rating level) and 4.1 Number of fever cases receiving anti-malaria treatment (B rating). All three indicators have been reviewed in the OSDV but verification factors could not be established for 2 indicators, 1.3 and 2.1. This questions the data quality of two performing indicators. Data could not be verified at the primary level in several service delivery points and data reflects only the aggregation level reports. There are other issues reported in the OSDV related to data quality as incompleteness of forms, non-harmonization of reporting tools, lack of evidence of supervision, inconsistencies among reports and primary documents. As far as LLINs distribution, a monitoring plan was approved by the Global Fund Secretariat and several documents are cited in the OSDV evidence but some of these registers could not be accessed showing poor data management practice. The Global Fund Secretariat found insufficient evidence of follow up by the PR to ensure LLINs are properly handled at community level. In addition, delays in operationalizing the sentinel sites had an impact in the measurement of impact and outcome indicators and should be taken into account for the performance of the grant. Given the above context, the Global Fund Secretariat considers that due to data quality uncertainties and overall grant programmatic performance for the first 18 months, the grant should be rated as B2.

b. COUNTRY TEAM RECOMMENDATION CATEGORY

Go

Country Team rationale for the Recommendation Category Considering the following: 1. The program started implementation with delays and within the effective time for Phase 1, many activities only started early 2012, limiting the achievement of programmatic results at month 18. There is an effective potential for improvement as the last stage of Phase 1 is presenting good performance. 2. There are signs for progress towards goals. The implementation of program activities has shown an important improvement during the last year of execution in Phase 1 (from C in first semester to A2 expected by month 24). 3. The CCM Request is addressing the main identified needs in terms of case management and improving diagnostic and treatment services for malaria, not entirely covered in Phase 1. The CDC has stressed the importance of case management in this transmission setting and wanted to ensure enough support was going to HCSS around PSM as they see this as a major threat to success.

17

4. The CCM Request is aligned to the National Malaria Strategy. 5. There have been important improvements in the management of the program. Lessons learned as well as the identified risks are being addressed to enhance PR and national entities to improve capacity in M&E, Procurement and Financial systems. The QUART analysis included several actions to enhance the capacity of implementers and reduce identified risks in M&E (data collection and monitoring), procurement (PR procurement processes to be enhanced), financial (better reporting capacity for the PR, PSI). The initial delays presented in Phase 1 will not be present in Phase 2. 6. Annual audit PSI (2011) is unqualified and weaknesses have been addressed. 7. However, some planned activities for Phase 2 require a degree of revision to be in line with the major recommendations proposed by the Global Fund Secretariat and partners: -

-

There are weaknesses in the current organization that supports M&E systems. The scope of work for M&E should be revised to guarantee an optimal use of resources between government, PR and SRs with the focus to improving national M&E data collection systems. The justification to finance the evaluation of malaria and antimalarial services and other proposed studies. It is necessary a clearer justification as to why a number of studies are required and what the immediate benefits will be in terms of addressing the identified problems. The corresponding section needs to be revised to show what data will be collected and how these will be used. Interventions by Sub recipients require a revision to guarantee the optimal use of resources and focus on the priority areas (case management, HCSS, diagnostics, vector control, M&E).

Therefore, the Global Fund Secretariat recommends a Go for Phase 2, linked to the fulfillment of Secretariat Conditions as follows: 1. An evaluation at the end of year 3 that assesses the effectiveness of the implementing resources and their capacity to ensure the scale up in case management interventions in year 4 and year 5. 2. A budget revision for key SRs based on the rationalization and reorganization of the M&E, training and studies-related activities focusing in the key identified intervention areas. 3. The provision of a revised PR M&E strategy to focus on improving the coordination of implementers and the strengthening of the national M&E system. 4. Updated PSM Plan, 5. Analysis of HR with PR and SRs justifying proposed interventions guaranteeing no duplication in some geographic areas. Other managerial actions are being proposed to ensure the improvement in managerial capacity of the PR and key sub recipients. The fulfillment of these Secretariat conditions will guarantee an optimal use of the allocated resources in Phase 2 within a favorable Haitian context.

c. RECOMMENDED INCREMENTAL AMOUNT

US$ 7,152,429

Please explain key differences between CCM and Country Team Recommended Incremental Amount. The Global Fund Secretariat has reviewed the CCM request taking into account the epidemiological context, country capacity and Phase 1 programmatic and financial performance. The CCM request of US$ 19,995,135 represents 172% of the original TRP-approved budget for Phase 2 (US$ 11,597,980) and is suggested to be partially funded by a significant under spending from Phase 1. The cumulative spent rate of 64% has been taken into account as well, and the in-depth review of individual activities in the budget in terms of their value added in achieving program objectives and outcomes. The Global Fund Secretariat initiated an in-depth review of all SR budgets to identify if there is any overlap between geographical and programmatic coverage. As a result the Global Fund Secretariat is suggesting a number of adjustments that target the achievement ofbetter efficiency to the Program, reduce budget padding and improve the use and complementarity of the Global Fund resources. None of the adjustments proposed have an adverse impact on the capability of the program to achieve its objectives. The Global Fund Secretariat is recommending the following adjustments to the original request for the total amount of US$ 5,379,830: Salary supplements for PNCM

Human Resources

$

(925,393)

18

Health Products and Health Equipment

$

(847,952)

Human Resources Health Products and Health Equipment Health Products and Health Equipment Medicines and Pharmaceutical Products Procurement and Supply Management Costs

$

(530,133)

$

(750,276)

$

(2,558)

$

(8,055)

$

(198,061)

$ $ $ $

(782,702) (225,000) 418,821 (51,087)

Unit cost for M&E computers and Intercom General Evaluation travel

Training Training Human Resources Technical Assistance Infrastructure and Other Equipment Monitoring and Evaluation

$ $

(38,000) (93,240)

Error on budgeting RDT training and BCC workshop PESADEV removal PESADEV removal PESADEV removal PESADEV removal

Training Communication Materials Human Resources Monitoring and Evaluation Overheads

$ $ $ $ $

33,226 (54,375) (87,453) (52,251) (18,000)

PESADEV removal

Planning and Administration

$

(16,100)

LLINs distribution supervision costs

Monitoring and Evaluation

$

(381,435)

Reduction to from three to one Health Facility Survey, and reduction of trial research and choloquine resistance monitoring

Monitoring and Evaluation

$

(425,673)

Adjustment of PSI overhead based on adjustments and OPN on iNGO indirect costs

Overheads

$

(344,134)

Unsubstantiated distribution of 200,000 LLINs Alignment of PSI HR costs to Year 2 revised budget Decrease in RDT unit cost to align with PQR Adjustment on inflation for HPE Adjustment on inflation for PhP Adjustment on PSM costs to reflect reductions in procurement Trainings for community health workers not VFM External training for PNCM staff Error on budgeting M&E officers TA on surveillance system

The final Phase 2 budget recommended for funding by the Global Fund Secretariat is US$ 14,575,304, which still represents 126% of the original TRP-approved budget. The final incremental amount of US$ 7,152,429 is 68.5% of the adjusted TRP-approved amount, and US$ 993,901 above the investment range recommended for B2 rated grants. However, the Global Fund Secretariat believes that the budget is reasonable and puts forward the following considerations that should be taken into account in justification of the funding decision above the investment range: 





The original proposal included Sogebank as a PR with the administrative costs of approximately US$ 1,600,000 over three years. After Sogebank stepped down as a PR, PSI resumed PR-ship, which had an adverse effect on PR human resource costs (US$ 3,000,000 over three years as adjusted by the Global Fund Secretariat) and overheads. M&E in the original proposal was significantly under-budgeted (US$ 491,000 over three years). After adjustments for cost efficiencies the Global Fund Secretariat believes that the Phase 2 M&E budget of US$ 1,779,000 is essential in improving national and program M&E systems to improve surveillance and on site data as recommended in the M&E assessments and as evidenced in the weak results of the latest OSDV. Salary supplements requested in the CCM Request are not recommended in the incremental amount. The budgeted amount to cover salary supplements was never disbursed during Phase 1 because of the lack of a national policy. The Renewals Panel does not endorse the inclusion of

19

salary supplements in Phase 2 as they represent a distortion of the governmental salary system. Therefore, the Global Fund Secretariat considers that the incremental amount of US$ 7,152,429 represents value for money despite being outside of the indicative range.

Grant Performance rating

B2

Adjusted TRP clarified amount for next implementation period

US$ 10,438,182

Indicative investment range % of adjusted TRP clarified amount =

High

Low

US$ 6,158,527

US$ 3,131,455

20

DETAILED REVIEW BY PRINCIPAL RECIPIENT6

4.

4.1 PRINCIPAL RECIPIENT 1 Grant Number

HTI-811-G07-M

Principal Recipient

Population Services International

Grant Start date

01/02/2011

Grant End date

31/03/2013

STEP 1: Programmatic Achievements Overall Performance Rating to cut-off date: PR : Population Services International, Haiti

Feb 1 2011 - Jun 30 2011 Jul 1 2011 - Sep 30 2011 Oct 1 2011 - Dec 31 2011 Jan 1 2012 - Mar 31 2012 Apr 1 2012 - Jun 30 2012 C

C

B2

B1

B1

Cumulative Indicator Rating at cut-off date: Service Delivery Area Prevention: Behavioral Change Communication Mass Media Prevention: Behavioral Change Communication Community Outreach

Indicator Number

Is Top 10 Is Training

Indicator

1.1

Proportion of men and women who believe that malaria is dangerous for pregnant women

1.2

Proportion of men and women who believe that malaria is dangerous for children under 5

Rated Target

Rated Result

Percentage

120%

1.3

Yes

Number of people reached by community outreach activities

50000

112998

2.1 Prevention: Insecticide-treated nets (ITNs) 2.2

Yes

Number of LLINs distributed to target population

1800000

1968150 109%

Number of OR studies on the efficacy of LLINs implemented and reports distributed

Prevention: Vector control (other than 3.1 ITNs)

Number of Departments with integrated vector management (IVM) measures implemented 10 and IVM agents submitting monthly reports

5

50%

Number of suspected cases receiving antimalarial treatment

138750

58209

42%

4.2

Percentage of all suspected malaria cases that received a parasitological test

N: D: P: 60 %

N: D: P: 53.3 %

89%

Supportive Environment: Monitoring drug resistance

5.1

Functional sentinel sites for monitoring antimalarial drug resistance

5

4

80%

Supportive Environment: Coordination and

6.1

Number of administrative communes located on the border with binational agreements for the prevention and control of malaria

4

0

0%

4.1 Treatment: Prompt, effective antimalarial treatment

6

Yes

This section needs to be repeated for each PR in the portfolio.

21

partnership development (national, community, publicprivate)

implemented (from 4 provinces)

Training Indicator Rating

N/A

Average Performance on Top 10

90%

Top 10 Indicator Rating

A2

Average Performance All Indicators

70%

All indicators Rating

B1

Number of TOP TEN Indicators with B2 or C Rating

1

Renewals Indicator Rating

B1

How has the grant performed in the current implementation period? The performance trend of the program went from C in the first two quarters (Feb-Jun and Jul-Sep 2011) to B2 in the third quarter (Oct-Dec 2011) and B1 in the last two quarters until the cut-off date (Jan-Mar and Apr-Jun 2012). Expected performance for the last semester of Phase 1 is A. The cumulative renewals rating is at B1 level with 90% achievement for the three Top Ten indicators: 1.3 Number of people reached by community outreach activities (120%): the indicator has been revised to take into account interpersonal communication only, excluding mass-media and special events. 112,998 persons were reached vs a target of 50,000. 2.1 LLINs distributed to target population (109%): the mass distribution campaign can be considered the most relevant result of the period. 1,968,150 LLINs have been distributed to the population in six departments (out of 10) through 630 sites. This activity required the full deployment of the staff of the PR and was threatened by security problems during the implementation. Special SWAT Police force was involved to allow the distribution because the violence in some cities. This is the more relevant success in Phase 1. The number of LLINs distributed surpassed the number financed by Global Fund grants in the entire Latin American and the Caribbean region. 4.1 Number of suspected cases receiving anti-malaria treatment (42%): 57,377 confirmed and not confirmed cases received malaria treatment until the cut-off date. Data have been reported by nine out of ten departments starting only from P5 (Jan-Mar 2012). The performance trend is expected to improve in the last semester of Phase 1. Top Ten: 4.2 Percentage of all suspected cases that received a parasitological test (89%): 30,720 suspected malaria cases received a parasitological test. Nine out of ten departments reported data for P6. The main gaps concern 4.1 as described above. Due to lack of data, the indicator could be measured only starting from P5. Vector control activities (3.1) were hampered by lack of larvicides due to a long customs process. Bi-lateral coordination (6.1) was slow and is now implemented / measured at level of counties with significant improvement. Both indicators improved results in the last semester of Phase 1. Disbursed funds (US$ 16,839,093) are equal to 59% of phase 1 budget (US$ 28,641,276) at cutoff date. If we include the last disbursement of October 2012 (US$ 916,635), the cumulative disbursed amount is 62%, in line with a cumulative performance rating of B1. One of the main reasons provided by the CCM for the variance between budget and expenditures is the delay in starting implementing the program activities. The grant started officially in February 2011, but the first disbursement to SRs, for a total of US$ 510,098 took place in November 2011. At cut-off date, the overall burning rate was 59 %. However, it was much higher for health products and equipment (77 %), medicine and pharmaceutical products (75%); and communication materials (68%); amounts spent by the PR (66%). The burning rate for Monitoring and evaluation was only 11% due to delayed activities by the sub-recipients, delayed health facility survey and delayed LLINs efficiency survey. The salary supplement budget has not been spent, pending a national policy to be endorsed by the CCM. Savings were possible for more than US$ 2 million for reduced unit cost of LLINs and reduced procurement and supply management costs.

22

In addition to the low cumulative results, some of the figures reported by the PR were invalidated or adjusted by the Global Fund Secretariat due to issues with data quality and reporting. M&E systems both at PR and SRs levels show weaknesses, with the PR unable to collect data at site level for several indicators. Most of these sites are government ones, under the responsibility of MoH. The M&E improvement at government level is a priority and the final updated version of the National M&E Plan for malaria is expected early 2013. During Phase 1 the Global Fund Secretariat worked closely with the PR to review the indicator definitions and methods of reporting to ensure that the PR is adequately reporting results. All these weaknesses affected the already delayed implementation and financial performance at month 18.

Revised Indicator Rating

B2

STEP 2: Quality of Data and Services 8 November 2012

Date of most recent OSDV:

Indicator Text

Number of people reached by community outreach activities Number of LLINs distributed to target population Number of suspected cases receiving antimalarial treatment

Overall Verification Factor

28.5% 0% 34.5%

Data Quality Rating

Major data quality issues Major data quality issues Major data quality issues

Summarize the findings from the most recent OSDV, DQA, RSQA or any other external data quality or quality of services assessments. Include a summary of the M&E systems issues and recommendations arising from these assessments. The OSDV report identified several issues: 

 

Data on the implementation of Information, Education and Communication activities was not reported disaggregated by SDP; and therefore the verification at the sites could not be verified. The data was not gathered directly by the SDP but by the SRs working with them, which could increase the possibility of double counting. No evidence of the distribution of LLIN was found at the primary level facilities. The PR directly conducted the distribution and took all reports. Not all SDPs reported data on people put on treatment to the health directorates.

Overall M&E system issues indicate that there are inadequate M&E system and tools; that verification of data reported at SDPs needs improvement through systematic follow-up of not reporting and feedback provision to all SDPs. The PR acknowledges the weaknesses of the M&E system being i) lack of appropriate coordination among the Planning and Evaluation unit of the Ministry of Health and the National Malaria Program, ii) inappropriate data collection and reporting tools that are inconsistently used, iii) delays in the data management and flow, and iv) insufficient data quality control due to lack of staff and resources. For overcoming these weaknesses the CCM suggests strengthening a PR owned parallel system until the in-country capacities are built by June 2013. The Country Team considers this approach not “value for money” and will recommend that the use of the approved M&E budget is conditioned to a refocus to strengthening the in-country capacities and to more strategic studies and surveys. The CCM also suggests reinforcing M&E resource officers to be positioned at 10 Directorates. In order to guarantee the sustainability of this approach and their contribution to the reinforcement of the national M&E systems and data collection, a better definition and organization of the R&R of M&E resources is required in order to focus on key areas.

23

Identified Issues

LFA Recommendations

Data Quality Issues Inadequate M&E system:  Inadequate tools  No verification of SDPs  No tracking or follow-up of SDPs not reporting  No feedback provided to SDPs  SDPs cannot replicate results reported during recount

   

Start conducting verification exercises at the SDP level to understand how the data is collected and reported; Review the tools used at the SDP level in conjunction with its M&E specialists; Institute procedures to conduct regular tracking, follow-up and feedback to the SDPs and the subrecipients; and Provide training and capacity building to the SDPs.

Source documents frequently not found at the SDP level

The PR should ensure that primary records are kept at the SDP and not transferred to the sub-recipient.

No verification conducted by Departmental Directorate at the SDP level or from PNCM at the Departmental Directorate level. No documents found at any of the sites involved in LLINs distribution which creates accountability issues (as SDP cannot validate the information reported by PSI)

The PR should put into place a plan to strengthen the M&E capacity of the PNCM.

More than one report of bednets distribution with conflicting information signed by the same person on the same date for the same site which creates accountability issues on the validity of the signed report.

The PR needs to ensure for future bednets distribution that minutes of the events are recorded at the sites and copies left at the site higher; the PR also should undertake quality assurance of submitted reports.

No consumption data of pharmaceuticals and other health products systematically collected, hampering proper monitoring and quantification efforts.

The staff at PSI responsible for management of supply chain processes need to be trained in Global Fund PHPM guidelines and standards, checklists and appropriate recording and reporting formats need to be developed for all the supply chain activities. The trained PSI staff should supervise and document the supply chain management across different points.

The PR needs to ensure for future bednets distribution that minutes of the events are recorded at the sites and copies left at the site.

Quality of service Issues Some of the sites reported never having received any anti-malaria drugs and consequently revert to purchasing drugs from private agencies and selling them back to their clients

The PR should work closely with PNCM to ensure the distribution of free drugs.

There is a perverse incentive for health facilities to keep on dispensing antimalarial medicines obtained through private channels since they benefit from profit margins in selling to end user. Thus, resistance has been observed to move towards the free medicines procured with Global Fund support.

Awareness generation in the community regarding availability of free anti malarials from MSPP and labeling the PR’s supply with ‘Global Fund Supply – Not for sale’ labels. Staff should be trained to distinguish when to sell drugs and when to distribute them for free. MoH to take necessary measures to avoid duplicate supply lines of the same drugs.

The tool used for community mobilization is sometimes simply an attendance sheet of site clients. Oftentimes, the theme discussed is not reported, the

The PR needs to develop appropriate tools that are relevant to the indicator being reported

24

instructor name is not listed, the date does not appear; and the lists are not found at the sites No appropriate data collection tools to track the number of cases treated; even at sites supported by their own sub-recipients

Tools development was an expected deliverable of Phase-I implementation. The PR should (i) ensure that its sub-recipients use an appropriate standard tool to track this indicator; (ii) work with the PNCM to develop and implement appropriate data collection tools.

STEP 3: Grant Management and Compliance Grant management assessment

Rating

In the first year of implementation, the Program has obtained "C" ratings and a performance improved programmatically with “B1” and "A2" ratings in the last 2 progress updates. Some of the results reported by the PR have been consistently invalidated or adjusted due to the issues with data quality and reporting. For several indicators, the PR was unable to report results in line with the indicator definition. To address the issue the CT worked with the PR to review the indicator definitions, relying less on the HMIS system which has major data quality deficiencies and using the TrAC+ survey (2011), situation analysis and sentinel sites’ preliminary results (final by the end of 2012). Improvements have been noted in 2012 as reported in the last two progress reports that were overall rated ‘B1’, but the M&E weaknesses still excluded agreeing with a programmatic ‘A’ rating.

Monitoring and evaluation

M&E systems both at PR and SR levels are still weak, with the PR unable to extract data at site levels for several indicators. Reporting on data about Major diagnosis and treatment results is incomplete. Most of these sites are under the responsibility of the MoH at central or decentralized level. Several studies and plans are expected in 2013 to contribute to define correctly baselines and targets, according to the epidemiological situation (National M&E Plan for malaria, Sentinel site survey, Health facility survey,). Nevertheless the priority for the PR and CCM should be to put into place a plan to strengthen the M&E capacity of the PNCM. The PR should work closely with the PNCM to develop and implement appropriate and simple data collection tools to be used in all sites to track indicators. Provide training and capacity building to the personnel at site level to use the tools and strengthen the coordination capacity from sites to the departmental level up to the centralized level. Regular follow-up with SRs and sites were services are delivered should be in place to monitor the use of tools.

In the first year of Program implementation, PR governance and oversight was relatively weak, with major delays in hiring PR staff, negotiating SR agreements, and launching program activities. In addition, the PR had very little control over SRs and struggled with ensuring the SRs' compliance with Global Fund reporting and implementation requirements. However, as of 2012, with a new Executive Director of PSI Haiti, the PR has shown evidence of much stronger governance and oversight. The Program management Program Management Unit at the PR is composed of well-qualified Minor professionals, most of them are local Haitian specialists. In 2012, more effective mechanisms have been developed in managing SRs, following up on arising challenges and resolving them, and improving compliance of SRs with the Global Fund programmatic and financial requirements. In Phase ,1 there were nine SRs spread through all 10 departments in Haiti, and conducting activities in more than 250 health centers, which made the work of the PR on verification and supervision quite challenging. In

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addition, the most important SR for this Program is the National Malaria Program, and their programmatic and financial performance has been very poor since the beginning of the Program. According to the PR, the motivation of the government staff is low due to the lack of decision on the payment of salary supplements. This low motivation negatively affects program performance. While UNDP (PR of the HIV and TB grants in Haiti) succeeded in overcoming the challenge of working with the government staff to ensure adequate implementation of activities, PSI still struggles with this. Salary supplements requested in the CCM request are not being recommended by the Renewals Panel nor included in the incremental amount to avoid a distortion of the governmental salary system and because a national policy has never been finalized. An additional drawback to the effective PR governance and oversight is the fact that many of the key processes in grant implementation are managed from the PSI HQ level (such as preparation and submission of the programmatic and financial reports, procurement), which takes away from the PR's authority and "ties the hands" of the local PSI office in Haiti on a number of important issues. Following discussion between the Global Fund Secretariat and PSI, some of these aspects improved as shown by the improved rating but some difficulties during verification processes still exist. It should be noted, however, that the local PSI office in Haiti successfully engages in collaborative efforts with the CCM and bilateral and multilateral partners in Haiti on the issues of Program strategy and direction, resolution of bottlenecks, finding effective solutions to arising issues, and jointly developing interventions for Phase 2. A strong collaboration has been established with CDC, WHO and National Malaria Program. At the beginning of the Program in February 2011, the PR had major delays in submission of PU/DRs and EFRs, notably due to the poor quality of the initially submitted documents and the need for additional clarifications. As the PU/DRs are being prepared in Washington rather than by the local Haiti team, PSI team in Haiti was unable to provide the necessary explanations quickly, and the process of disbursement reviews has been often delayed. Training sessions were conducted and in 2012 the quality of the submitted documents has significantly improved, even though additional information is generally still required following the submission of PR products.

Financial management and systems

It has also been challenging for the PR to comply with the timely fulfillment of the conditions precedent and special conditions. However, as of today, only one special condition remains outstanding, and that condition is within the authority of the CCM, and not the PR. Some irregularities have been observed relating to the procurement process to award the contract for the transportation of LLINs. An investigation was conducted by PSI-HQ Global Internal Audit (GIA) to address the problem. The investigation unearthed an existing lack of capacity in the procurement system within the local office for the selection of the qualified firm to ensure the transportation of the LLINs. The Global Fund Secretariat also assessed the same lack of capacity and observed that procedures of the PSI procurement manual were not followed fully with a first payment made and the distribution started before the contract was signed. The amount of the contract was US$ 203,509 out of which US$ 26,353 was paid before the firm was dismissed. These irregularities caused delays and additional cost for the PR (legal fees not covered by the grant and now under PSI responsibility). PSI is currently re-hiring staff to manage the procurement process and stock management. To ensure a robust revised process, the Global Fund Secretariat will be closely monitoring implementation during Phase 2.

Minor

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During Phase 1, the PR complied with the approved PSM plan. Important deficiencies were found in storage capacity and inventory management both in PSI’s central warehouse and at a peripheral level. Problems in the distribution system were also reported. Due to the lack of an appropriate logistics information system, the PR is currently not able to monitor flow of health products at peripheral level, and stock outs of some antimalarials have been reported. There is an incentive for health facilities to continue dispensing antimalarial medicines obtained through private channels since they benefit from profit margins in selling to the end user. Thus, resistance has been observed to move towards the free medicines procured with Global Fund support. It is unclear whether this deviation has been taken into account in the quantification of needs.

Pharmaceutical and Health Products Management

There was no documented evidence of joint regular coordination and monitoring among the PSI Central Warehouse, the Department Warehouses (under MSPP) and the Health Centers (under the SRs and MSPP) as stated in the PSM Plan. Minor LLINs distribution was monitored. The distribution teams faced several security problems at community level in the most dangerous areas. However, with the support from the police and mobilizing all its staff and resources, the PR managed to complete the distribution. However, concerns have been raised about poor follow up on LLINs use by the PR. As for Phase 2, the approach proposed by the PR to use LLINs as a strategy for epidemics response is not considered appropriate.The quantification of health products for Phase 2 needs to be revised and the PSM plan adjusted accordingly. In principle, the large scale introduction of RDTs is considered appropriate. However, the amounts to be procured in years 2 and 3 of Phase 2 will be revised yearly with evidence from the current RDT consumption survey initiated by CDC. Total value reported in the PQR is US$ 11,763,737.50. Percentage of PSM Plan Reported 78%. The reference price ratio is 0.97, and 99 % has been verified by the Global Fund Secretariat. The first audit of the Program was delayed due to extensive discussion between the Global Fund Secretariat and PSI Headquarters prior to approving the audit ToRs. The PR audit was finalized in September 2012 and rated as ‘unqualified’.

The Additional Safeguard Policy (ASP) of the Global Fund was invoked in April 2010 after the dramatic consequences of the earthquake further weakened the governance and institutional capacity in Haiti. Indeed, the Additional Safeguards earthquake exacerbated concerns that had been previously identified by the Global Fund, including weak governance and national capacity, as well as poor civil society participation in decision-making. One of the first measures taken by the Global Fund Secretariat in consultation with country stakeholders under the ASP, and following the resignation of Fondation Sogebank, was to select UNDP as PR for the existing HIV grants and the Round 9 TB program, and PSI for the Round 8 Malaria program. The ASP will be revoked when the efforts to lay the foundation for Haiti’s long-term recovery have produced the desirable results.

RECOMMENDED PERFORMANCE RATING

B2

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STEP 4: Progress towards Impact /Outcome IMPACT RATING

Progress Towards Proposal Goals

STEP 5: Operational Risk Management Please note what tool was used to support the assessment of operational risks and required actions Qualitative Risk Assessment Tool (QUART) Lite. Based on the following context: - Country classification as high risk. - Situation with former PR Sogebank and closing grants (malaria included) in process. - Natural disasters affecting the country jeopardize any sustainable infrastructure; damage from the 2010 earthquake still not overhauled. Other recent problems include the cholera epidemics, Hurricane Sandy and the increase in insecurity. - Minimum stable health infrastructure in the country and weaknesses in the national health sector. - General state of poverty as per national indicators. - According to Transparency International, the index of perception of corruption puts the country 177th among 180 states. Mitigation measures include: • From the reorganization, it was decided an increase in the Secretariat allocated resources to the country. This will permit an expansion in the collaboration with National Authorities, bilateral and multilateral partners, implementers and overall a closer contact with beneficiary and affected populations in the country. • In the past months, the improvement of the country situation and a better trend in the implementation of the three grants have permitted a substantial improvement in the programmatic results even if there are still important challenges and risks to overcome. • In comparison to the situation 18 months ago, important advances have been reached in: o Governance: role of the CCM, Minister of health, and other authorities o Grant management: PRs, SRs, stakeholders and o Coordination efforts with partners. From initial identified risks, from 2011 important improvement was reached and the results that reflect the mitigation in risk in 2012 are: – Normalization and stabilization of the situation with major stakeholders in Haiti after major challenges and loss of trust following the findings of the OIG report and resignation of the former PR Fondation Sogebank – Progressive catch-up and increased performance of Global Fund grants from the end of 2011. – In-depth due diligence review of budgets and financial management capacities of both PRs and all SRs – Expanded collaboration with partners that expanded to grant management issues, such as joint evaluations and development of capacity-building activities as well as active participation in proposal preparation and implementation. – Major CCM reform leading to the adoption of the conflict of interest policy, creation of the CCM oversight committee, election of the First Lady of Haiti as the CCM Chair and election/ designation of new CCM members by the sectors. With this positive trend, the Secretariat has decided to support these efforts with the following measures: - As mentioned, additional Secretariat staff is allocated to support Haiti. - Expected reduction in the frequency of reporting as associated risk is under control from the beginning of the Additional Safeguard Policy. Challenges being addressed as per Quart Analysis: - Support the capacity building actions for National Institutions. For malaria, reinforcement in M&E capabilities for gathering and reporting health data is considered a priority. - Assure an adequate level of resources and coordination for case management. - Continue the coordination and information exchange with all stakeholders in country. - Assure appropriate actions to improve national reporting capacity and PR managerial capacities.

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LITE Operational Risk Heat Map: LOW RISK 1 Programmatic & Performance Risks

2 Financial & Fiduciary Risks

3 Health Services & Products Risks

1.1 Limited Program Relevance

2.1 Low Absorption or Over-commitment

3.1 Treatment Disruptions

1.2 Inadequate M&E and Poor Data Quality

2.2 Poor Financial Efficiency

3.2 Substandard Quality of Health Products

1.3 Not Achieving Grant Output Targets

2.3 Fraud, Corruption or Theft of Funds

3.3 Poor Quality of Health Services

1.4 Not Achieving Program Outcome & Impact Targets

2.4 Theft or Diversion of Non-Financial Assets

3.4 Poor Access and Promotion of Equity & Human Rights

1.5 Poor Aid Effectiveness and Sustainability

2.5 Market and Macroeconomic Losses

4 Governance, Oversight & Management Risks 4.1 Inadequate CCM Governance & Oversight 4.2 Inadequate PR Governance & Oversight 4.3 Inadequate PR Reporting & Compliance 4.4 Inadequate Secretariat and LFA Management & Oversight

2.6 Poor Financial Reporting

Legend Very High High Medium Low Unable to rate If the grant was reviewed by the Operational Risk Committee, please include a summary of the recommendations here.

Not applicable for LITE QUART report.

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Risk mitigating measures Main Areas

Programmatic and Performance Risks

Compliance Issue/Risk

Prevention or Mitigating measure type (Board Condition, Secretariat Condition, MA, other)

Description of mitigating measure

Timeframe (prior to signature, at signature, first disbursement, second disbursement, disbursement linked to specific action or category, date, on-going) 31 June 2013

National Malaria Strategy beyond 2014

Management Action

The Principal Recipient, in coordination with national authorities, should present the M&E national strategy including the actions to address the weaknesses in national data collection and reporting identified in Phase 1 review.

M&E Strategy and operational Plan not addressing weaknesses in data quality

Secretariat Condition

Prior to signature

Insufficient data exists on overall malaria program

Condition Precedent

The Principal Recipient should present a coordinated M&E operational Plan that updates Roles and Responsibilities of main implementers, addresses the M&E gaps in systems and procedures, identified in collaboration with major stakeholders such as the PNCM, WHO and CDC. The document should include a budgeted national capacity-building plan and supervision visits plan The Principal Recipient shall submit to the Global Fund the final report of the malaria program review before the use of funds for year 4 of the program. The Principal Recipient acknowledges that, if applicable, the Performance Framework will be reviewed based on its final results.

Lump sums for studies and surveys and insufficient justification on use of data

Condition Precedent

The Principal Recipient shall submit to the Global Fund the Terms of Reference (ToRs), including study protocol, for conducting an independent and impartial Operational Research (OR) studies on:

Disbursement of funding for M&E studies and surveys (30 June 2013)

15 November 2013

a. therapeutic efficacy surveillance of their first line antimalarial drugs according to

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the standard WHO protocol b. health facility survey c. study assessing malaria outcome indicators

Financial and Fiduciary Risks

Health Services and Health Products Quality Risks (including Equity and Human Rights)

Incomplete verification by LFA because of limited financial information available

Managerial Action

Mechanism to verify cash balance and transfer of funds from PSI HQ to local office

Before the submission of the first PU/DR report under Phase 2.

Not sufficient evidence available at initiation of Phase 2 on the quantities of RDTs required for the entire implementation period

Secretariat Condition

The Principal Recipient should provide a revised quantification of Rapid Diagnostic Tests for years 4 & 5 based on the evidence and data collected during the first year.

Prior to procurement of Rapid Diagnostic Tests for years 4 & 5

Need to review the PSM Plan to take into considerations the issues raised (quantification of medicines, revision of number of microscopes)

Secretariat Condition

The Principal Recipient should provide a revised Pharmaceutical and Supply Management plan with revised quantification of pharmaceuticals and health products.

Prior to grant signature

Inadequate storage conditions and inventory management at PSI’s central warehouse and peripheral warehouses and inadequate logistics information system to monitor flow of health products along the supply chain

Secretariat Condition

The Principal Recipient should submit an action plan with timelines and milestones to improve storage and distribution arrangements and inventory management

Within three months of grant signing

Governance, Oversight and Management Risks

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RECOMMENDED PERFORMANCE CATEGORY

Go

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STEP 6: Programmatic achievements and financial performance Financial situation at cut-off date Please insert the tables from Excel file, Financial Template-PR.

Disbursements Signed Budget for current implementation period less: disbursed to cut-off date Undisbursed amount at cut-off date

US$ 31,107242 US$ 20,214,516 US$ 11,802,183

Cash at cut-off date PR

SRs

Disbursed to PR to cut-off date

20,214,516

N/A

Less: Disbursed from PR to SRs

-1,883,226

1,883,226

Less: Expenditure incurred to cut-off date

-1,641,6961

-1,092,663

Add: Interest received

31,295

20,214,516 17,509,624 31,295

Add: Other income - please specify Equals: Cash at cut-off date

Total

1,945,624

790,563

2,736,187

Please explain the reasons for undisbursed funds and/or available cash (activities not performed, savings realized, etc.) The main reason behind the low financial performance and the consequent lower rating for Phase 1 was the initial delays in the implementation after the selection of a PR under the ASP terms (PSI). The grant was signed in February 2011 but the first disbursement to PSI reached Haiti in May 2011. The implementation was challenged by multiple administrative situations (procurement delays and later customs constraints) that impeded the immediate contracting and pay of goods (LLINs accounting for approximately US$ 12 million) and services. Important savings of more than US$ 2 million were reached in the procurement of LLITNs and many activities were delayed or unable to be fully executed in Phase 1. In addition, and because of the restrictive conditions for contracting SRs, contracts were completed only at the end of 2011. SR activities received financing only at the end of 2011 and SRs started reporting only in March 2012. Despite a late start of Phase 1 (SR budgets were approved between October and November 2011), the grant performance improved substantially from the first semester of the second year, until the cut-off date of 30 June 2012. However, this improvement was insufficient to reach a better performance rating. Within this limited period of time and in spite of the significant efforts made by multiple actors, the performance rating reached by the cut-off date was B1. However, the multiple lessons learned are now included in the management process and results have been improving steadily. Financial execution in the period Q7 reached US$ 2 million and the performance has been reported as A2. It is expected that the A-performance will be maintained by the closing of phase 1.

Have all liabilities at cut-off date been taken into account in the post-cut-off date Yes budget? If not, please ensure unaccounted liabilities are budgeted in the remaining current implementation period.

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Programmatic achievements and financial performance Percentage of funds budgeted at PR level

82%

Percentage of funds budgeted at SR/SSR level

18%

Macro Category

Prevention

Total Expenditure Amount to cut-off date (EFR)

Expenditure vs Budget at cut-off Programmatic date Achievement

Prevention: Behavioral Change Communication $972,844 - Community Outreach

$377,595

39%

120%

Prevention: Insecticide-treated nets (ITNs)

$19,568,658

$13,699,714 70%

109%

Prevention: Vector control (other than ITNs)

$2,167,299

$234,381

11%

50%

Program Management and Administration

$4,190,579

$2,003,066

48%

Supportive Environment: Coordination and partnership development (national, community, public-private)

$213,171

$62,623

29%

0%

Supportive Environment: Monitoring drug resistance

$51,609

$1,783

3%

80%

Treatment: Prompt, effective antimalarial treatment

$1,477,117

$459,929

31%

66%

$28,641,277

$16,839,091 59%

Service Delivery Area

Total Adjusted Budget Amount to cut-off date (EFR)

Prevention: Behavioral Change Communication - Mass Media

Supportive Environment

Treatment Grand Total.

Please provide a summary of the expenditures vs. budget analysis using EFR including for deviations between programmatic performance and expenditure rate, based on EFR. The biggest driver for financial performance is the procurement and distribution of LLINs, due to lower unit costs achieved and delays on final payments to suppliers and distribution workers. Program Managements costs are the second biggest driver due to a slow start and extremely delayed signature of SR agreements. Activities with SRs only started at the end of 2011. Figures reported in June 2012 were showed a lower execution than expected for 18 months.

STEP 7: Financial Recommendation Please insert tables from Excel file, Financial Template-PR.

Resources available to finance program for next implementation period Year X

Year Y

Year Z

TRP clarified amount allocated to PR

4325958

3704143

3567879

Any Board mandated adjustments

432,596

370,414

356,788

Adjustment +/(-) for (borrowing) and/or staggered commitments not yet committed Adjusted TRP clarified amount CCM reallocations +/(-) (implementation arrangements)

Total 11,597,980 1,159,798 -

3,893,362

3,333,729

3,211,091

10,438,182

-

-

-

-

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Adjusted TRP clarified amount after CCM reallocations

3,893,362

3,333,729

3,211,091

+ Undisbursed amount at cut-off date

10,438,182 9001926

+ Cash at cut-off date

2,736,187

=Total Resources available (after cutoff date for the next Phase/Implementation Period)

22,176,295

Summary Budget Recommendation and Incremental Amount

Total Budget requested by the CCM (after cut-off date for the next implementation period)

Year W after cut-off date

Year X

Year Y

Year Z

Total

4,315,238

6,673,938

6,780,228

6,500,969

24,270,373

Adjustment to budget if Counterpart Financing requirement is not met

-

Adjustments to CCM Funding Request by Secretariat +/(-) Total Budget Recommended by the Secretariat Undisbursed amount at cut-off date Cash at cut-off date RECOMMENDED INCREMENTAL AMOUNT % of Adjusted TRP clarified amount (cannot exceed 100% of Adjusted TRP clarified amount)

4,315,238

2,090,323

1,663,291

1,626,216

5,379,830

4,583,615

5,116,937

4,874,753

18,890,543 9,001,926 2,736,187 7,152,429 69%

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