1. Identifying & Mitigating Risks Charlotte Kristiansson October-November 2013

2. Risk Assessment approach considers four Risk Types based on grant management objectives and decision-making drivers Four key objectives Achieving grant performance and impact, while ensuring sustainability High quality health services, products and equipment in funded programs for beneficiaries incl. access and equity for key risk populations and vulnerable groups Effective governance, oversight and grant management by all stakeholders Efficient and correct use and proper accounting of Global Fund investments and resources Four key types of risks 1. Programmatic & Performance Risks 2. Fiduciary & Financial Risks 3. Health Services & Products Risks 4. Governance, Oversight & Management Risks Decision-making often driven by trade-offs between these objectives and risks

3. Output: QUART – risk reporting tool

4. Risks interlinked and drive other risks: Quality of Health Services main driver of risk and itself driven by other areas

5. Implementation Mapping & Risk Analysis Map Implementers Down to Beneficiaries Key Actors External to Implementation Arrangement Fund, Asset, Info Flow Roles & Responsibilities Unknowns Prioritize Key Fiduciary & Programmatic Entities/Processes Assess Risk How Well Are Key Entities Fulfilling their Roles? How Reliable is Our Basis for Knowing This? MOH UND P MIS PNL P CMS Reg Dist. Reg Clinic (88) % 30%30% % 20%20% % 10%10% % 10%10% % 40%40% % 20%20% % 50%50% % 10%10% Procure HPs (100%) Mass Media (20%) Trainings (20%) Supervision (15%) HR (40%) Store HPs (100%) Store & Distribute HPs (100%) Store & Distribute HPs (40%) M&E (30%) Supervise health service (15%) Administer Drugs (75%) Track Patients (20%) Record Pis (5%) MOH UNDP MIS PNLP CMS Regional MoH (4) District MoH (10) Regional CMS (3) Clinics (88) % 30 % % 20 % % 10 % % % 40 % % 20 % % 50 % % 10 %

6. How are implementation maps useful? Get to know your grant NFM – grant making Useful tool during grant negotiations Daily program management: Tailoring LFA work More meaningful discussions with PRs and LFAs Mission planning Risk management

7. Step 1 – Gather information PR National Institute of Pathology National Health Institute USAID SR ASSISTANCE CMSSR HELP SR - PNLS UNDP National Reference Lab Regional Lab Network Tertiary Hospitals

8. Step 2 –Organize the information PR National Health Institute SR ASSISTANCE CMS SR HELP SR - PNLS UNDP National Reference Lab Tertiary Hospitals Obj. 2 MARPs Obj. 1 ART

9. Step 3 – identify how entities are linked PR – (CSO) National Health Institute SR ASSISTANCE CMS SR HELP SR - PNLS UNDP Tertiary Hospitals Obj. 2 MARPs Obj. 1 ART Reporting line Fund flow Asset flow

10. NGO SRs (how many?) GF MoH PNLP (PR) UNDP MIS CMS Regional CMS (3) Regional MoH (how many?) ? Clinics (how many?) ? Basic Benefit of Mapping a Grant: Clarity on Process, Responsibility, Fund Flow Initial Map: Lots of Unknowns

11. MoH M&E Forecasting Procure HPs Administer Drugs Track Patients Record PI Data M&E Supervise Health Service Mass Media Training Supervision Coordination Store & Distribute HPs M&E Supervise Health Service Store & Distribute HPs Member of CCM Coordination NGO 1 (SR) GF PNLP (PR) UNDP MIS CMS Regional CMS (3) Regional MoH (4) District MoH (10) Clinics (88) NGO 2 (SR) 50%/ 30% 50%/ 45% 42%/ 38% 38%/ 20% 35%/ ? 8%/ 10% 15% / 1% 15%/ ? 10%/ ? ? 2%/ 0% ? Final Map: We know who is getting how much of our money to do what with it to reach the beneficiaries.

12. Added Benefits of Map Can provide different “views” –Context –Unique Process –Oversight –Prioritization –Risk Links to other/more detailed information

13. Contextual View: Map grants together; and with national program and other donors/TA M&E Forecastin g Procure HPs Administer Drugs Track Patients Record PI Data M&E Supervise Health Service Mass Media Training Supervision Coordination Store & Distribute HPs M&E Supervise Health Service Store & Distribute HPs Member of CCM Coordination NGO 1 (SR) GF MoH PNLP (PR) UNDP MIS CMS Regional CMS (3) Regional MoH (4) District MoH (10) Clinics (88) NGO 2 (SR) Grant 1 Grant 2 PEPFAR

14. Procure HPs Administer Drugs Track Patients Record PI Data Store & Distribute HPs M&E Supervise Health Service Store & Distribute HPs NGO 1 (SR) GF MoH PNLP (PR) UNDP MIS CMS Regional CMS (3) Regional MoH (4) District MoH (10) Clinics (88) NGO 2 (SR) Process View: Isolate a Process, like PSM

15. M&E Forecasting Procure HPs Administer Drugs Track Patients Record PI Data M&E Supervise Health Service Mass Media Training Supervision Coordination Store & Distribute HPs M&E Supervise Health Service Store & Distribute HPs Member of CCM Coordination NGO 1 (SR) GF MoH PNLP (PR) UNDP MIS CMS Regional CMS (3) Regional MoH (4) District MoH (10) Clinics (88) NGO 2 (SR) 50%/ 30% 50%/ 45% 42%/ 38% 38%/ 20% 35% / ? 15% / 1% 15% / 4% 10%/ 8% 4%/ ? 2%/ 0% 32%/ ? Prioritization View: Fiduciary and Programmatic 8%/ 10%

16. Trainin g Member of CCM Coordination NGO 1 (SR) GF MoH PNLP (PR) UNDP MIS CMS Regional CMS (3) District MoH (10) Clinics (88) NGO 2 (SR) Conflict of Interest View: Wife of CCM Chair runs SR 2, and is mother of Director of SR 1. PR Deputy is brother of repeat vendor for Radio BCC.

17. M&E Forecasting Procure HPs Administer Drugs Track Patients Record PI Data M&E Supervise Health Service Mass Media Training Supervision Coordination Store & Distribute HPs M&E Supervise Health Service Store & Distribute HPs Member of CCM Coordination NGO 1 (SR) GF MoH PNLP (PR) UNDP MIS CMS Regional CMS (3) Regional MoH (4) District MoH (10) Clinics (88) NGO 2 (SR) 50%/ 30% 50%/ 45% 42%/ 38% 38%/ 20% 35% / ? 8%/ 10% 15%/ 1% 15%/ 4% 10%/ 8% 4%/ ? 2%/ 0% 32% / ? The Risk View: Known and Unknown Risks

19. 19 PR CSO Big HR budget at CS PR & 2500 CHWs/volunteers (ghost workers, double payments, handling cash etc.) Many SRs (23) (Management of funds? Criteria for transfers, cash payments etc., FMS, minimal standards + programmatic risks, overlap, geographical distribution etc.) Many SSRs (95? Or same appearing in several SDAs?) (Management of funds? Criteria for transfers, cash payments, double payments etc.) Many SRs “shared with USAID” (overlap, double funding, double reporting) 75% of SRs procure themselves (procurement capacity, financial efficiency, value-for-money) CS PR has Board consisting of members organizations being GF program SRs (Governance issues, CoI) Big BCC budget (financial efficiency, appropriate geographical distribution etc.)

20. 20 PR MoH CMS procure all Health products & Equipment & allocated budget high (procurement capacity, financial efficiency, value-for-money) High training budget & SSRs carrying out training (per diem cash transfer, double counting, value-for-money etc.) SRs show low absorption (programmatic risks, management issues?) High Infrastructure & Equipment budget (constructions/rehabilitation? Procurement of vehicles? Risk areas) Substantial budget for BCC mass media & 100% absorption though absorption is low in other SDAs (risk of lack of financial efficiency, appropriate geographical distribution, value-for-money) Complex PR set-up with “artificial SRs” & different units acting PMU, PR finance, SR finance (management issues?)

21. 21 Both PRs Dual track grant with two PRs implementing several SDAs together but no apparent coordination (management issues, programmatic risks, financial efficiency etc.) Community level data from CHWs, volunteers etc. only reported to CSOs, not entered into National HIS (programmatic risks, value-for- money, difficult to track output and contribution of investment).