This Summary Sheet captures the headlines on programme performance, agreed actions and learning over the course of the review period. It should be attached to all subsequent reviews to build a complete picture of actions and learning throughout the life of the programme.
Title: Reducing Maternal and Neonatal Deaths (RMND) in Rural South Africa Through the Revitalisation of Primary Health Care
Programme Value:
£21,054,535
Review Date: October 2014
Programme Code: 200295 Start Date:01/01/2011 End Date: September 2015
Summary of Programme Performance
Year 2012 2013 2014
Programme Score A+ A A+
Medium Medium Medium Risk Rating
Summary of progress and lessons learnt since last review
The RMND programme has continued to make very good progress in support of national strategies for improving reproductive, maternal, child and neonatal health. A particular strength has been its alignment with national strategies and responsiveness to evolving government priorities. The success of this alignment, facilitated by DFID secondments into the National Department of Health (NDoH), is a key lesson learned. The programme has successfully strengthened government health systems particularly through the provision of well-targeted technical assistance and training, though a number of bottlenecks in the wider health system have limited progress in some areas. For example, human resources constraints are particularly evident leading to the understaffing of key teams supported by the programme.
The close working with government systems does mean that much of the work done should be sustainable beyond the lifetime of the programme. However, as the programme enters its final year of operation, strong efforts need to be made to ensure that good work which has been started will be carried on. The programme has had a cost extension to help ensure sustainability and a number of recommendations have been made for how the extension period can be best used.
Summary of recommendations for the next year

RMCH, LSTM and DFID to update the logframe to cover the extension period. A number of indicators are suggested in this annual review. RMCH and LSTM to develop a first draft for discussion by 15 December 2014.

RMCH to perform an analysis of policy and systems barriers to the success of the national strategy focussing on solutions and drawing on examples where bottlenecks have been successfully unblocked.

RMCH to focus on ensuring the sustainability of the work done so far. In particular, focus on the sustainability of District Clinical Specialist Teams (DCSTs).

RMCH to facilitate the transition of the Steercom (the project Steering Committee) into a sustainable multi-stakeholder think tank by helping to identify alternative funding or a host for
Steercom secretariat functions.


RMCH to work with consortium partners and NDoH to organise the lessons learned from output
3 grants to develop a comprehensive strategy on demand and accountability at district level.

LSTM to provide an exit strategy for the sustainability of the Essential Steps in the Management of
Obstetric and neonatal Emergencies (ESMOE) component of the programme.

LSTM to conduct asset checks and submit an asset disposal plan to DFID by 30 Jan 2015.
Please note a full list of acronyms is provided at the end of this report.
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DevTracker Link to Business Case: 202295
DevTracker Link to Log frame: 202295
Outline of the programme
RMND is a four-year technical assistance programme supporting the South African National Department of Health
(NDoH) strategy for Matern al, Newborn, Child and Women’s Health and Nutrition (MNCWH&N). The programme is catalytic and facilitates accelerated implementation of national policies to reduce maternal, newborn and child deaths (MDGs 4 and 5).
The programme has four main components two of which were completed in the early part of the programme and are no longer active. The total budget of the programme is £21,054,535. The components are:
1. The design component of the project was completed in the early stages and is no longer active. The budget for this was £180,218
2. South African National health and Nutrition Examination Survey (SANHANES) was led by Human
Services Research Council (HSRC). This is no longer active as the survey was completed and the results disseminated last year. The findings provided important baseline information for the rest of the project. This component accounted for £2.5 million of the budget.
3. Reproductive Maternal and Child Health (RMCH) work led by Futures Group. This is currently active. It is the largest component of the programme accounting for £14,523,993 of the total budget.
4. Essential Steps in the Management of Obstetric and neonatal Emergencies (ESMOE) training led by
Liverpool School of Tropical Medicine. This is currently active and accounts for £3,055,256 of the total budget.
There are unallocated funds of a total of £795,068 that will be returned to the DFID central budget.
The programme began in June 2012 and was to run until April 2015. A cost extension of both the RMCH and the
ESMOE components of the programme were approved in 2014 enabling DFID to provide significant support to the mid year review of the national MNCWHN strategy, and allowing the programme to run until September 2015 and complete any outstanding activities. The budget figures above reflect the total costs including the extension budgets.
Context
The context remains the same as described in the 2012 Inception Phase and the 2013 DfID Annual Review.
Briefly, changes in the political leadership in South Africa in 2009 created new opportunities to tackle unacceptably high maternal, neonatal and child mortality in South Africa (mortality levels are particularly striking given South
Africa ’s GDP/capita). There has also been a significant shift in policies towards HIV/AIDS treatment since 2009, and for treatment to prevent mother to child transmission from 2004, which is having further significant impact on
HIV related maternal and child mortality. However, HIV is a significant contextual factor for maternal and child mortality in South Africa. The Confidential Enquiry into Maternal Deaths 2008-2010 indicated that 80% of maternal deaths in South Africa had an HIV test and of those deaths, 70% were HIV positive.
Following the approval of the RMND Business Case, South Africa launched the Campaign on Accelerated
Reduction of Maternal Newborn and Child Mortality (CARMMA) in May 2012 and the National Strategy for
Maternal, Newborn, Child and Women’s Health and Nutrition (MNCWHN) 2012-2016. These are key government strategies which the programme is well aligned with. The programme is, therefore, supporting initiatives where there is a strong national commitment. In addition, the African National Congress (ANC) were returned to power following the May 2014 elections and Minister Motsoaledi continues as Minister of Health. The Director General and core team of Deputy Directors General at the NDoH also remain in place. This provides important stability to the RMCH programme and South Africa’s health sector reform process more broadly.
RMCH supports districtlevel implementation of these strategies in 25 of South Africa’s 52 districts. The 25 districts were selected on the basis of having the poorest health outcomes for RMNCH. Further, the ESMOE component of the RMND programme follows a key recommendation of the 5 th report on the Confidential Enquiries into Maternal
Deaths in South Africa to train all health care workers in maternity care. ESMOE training is targeted at 15 districts with the greatest maternal mortality.
Expected results
The expected results of the programme are reduced maternal and child mortality, with an estimated 3000 maternal deaths and 25,000 neonatal deaths prevented and 700,000 disability adjusted life years saved through improved quality of, and access to, reproductive, maternal and child health services for girls and women in underserved districts of South Africa
There are 5 main outputs expected of the RMND programme:
1) Output 1: Districts able to oversee improvement in reproductive maternal and child health services.
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2) Output 2: Strengthened delivery of school health, ward level Primary Healthcare Teams and newborn care services.
3) Output 3: Improved demand and accountability for MNCWH services.
4) Output 4: New knowledge to remove barriers to uptake and access of RMCH services.
5) Output5: Strengthened delivery of obstetric and neonatal emergency services (through ESMOE)
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(1-2 pages)
Annual outcome assessment
The outcome indicators used to assess progress in this programme are based on all 52 districts in
South Africa, although RMND’s work is only done in a sub-set of those districts (25 and 15 districts for RMCH and ESMOE respectively). The graphs below show progress for outcome indicators in
RMCH districts and nationally.
The districts targeted by RMND were some of the worst performing at the start of the programme and in most cases they continue to have poorer outcomes than the national average. There have, however, been promising improvements in some areas including: the ‘couple year protection rate’ (a measure of access to and use of family planning), and antenatal 1 st visits before 20 weeks. The still birth rate in facilities has improved but is still much higher than the national target of 10 per 1000 live births. Postnatal visits at 6 days have not consistently improved in RMCH districts although the national trend does seem to be positive.
Overall there are some encouraging signs of improvement though this is slower than was originally hoped. These results are based on the 2013 – 14 District Health Information System (DHIS) and it may take time for improvements in processes to be translated into improved health outcomes.
Preliminary data collected as part of the evaluation plan of ESMOE in 12 districts shows more promising improvements in some outcome indicators (see output 5 description for more detail).
Figure 1. Outcome indicators for all districts in South Africa.
Source: DHIS, march 2014.
Overall output score and description
Overall output score is: A+
Across all outputs the programme has met or moderately exceeded expectations.
Good progress has been made in supporting of districts to oversee improvement of RMCH services
(Output 1). The support provided by RMND has been highly valued and has helped to strengthen the vital DCSTs. The sustainability of this work is threatened, however, by systemic issues including: problems with appointing staff with appropriate expertise to the DCSTs, lack financial support for the work plans of DCSTs, and weak Ward Based Outreach Teams (WBOTs) in many areas.
Work to strengthen delivery of school health services, ward level primary health care teams, and delivery of newborn care (Output 2) has also made good progress. RMND worked to strengthen capacity in each
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of these areas using a range of approaches including offering technical assistance and health education messaging. Work to improve demand and accountability for RMNCH services (Output 3) has produced a number of useful insights. The challenge now is to ensure that the lessons learned are captured and put into use. The programme has produced new knowledge and improved the availability of data to remove barriers to the uptake and access of RMCH services (Output 4).
Obstetric and neonatal emergency services have been supported through the implementation of ESMOE training in 15 districts (Output 5). This training programme has also received other funding (from the EU) to allow a national roll-out, which can be considered to have been leveraged by DFID’s support. Interim evaluation results suggest that this training may have contributed to significant improvements in health outcomes.
Output
1. Districts able to oversee improvement of reproductive, maternal and child health services
2. Strengthen delivery of school health services, ward level primary health care (PHC) teams, and delivery of newborn care.
Score Weight Risk Rating
A+ 30% High
A+ 35% High
3. Improved demand and accountability for MNCWH services A
4. New knowledge to remove barriers to uptake and access of RMCH services
5. Strengthened delivery of obstetric and neonatal emergency services
A+
A
10%
5%
20%
Medium
Medium
Medium
Key lessons

Alignment with government priorities from design to implementation has produced strong partnership working with the government health system. The benefits of this close alignment have been enhanced by flexibility and responsiveness to contextual changes during the life of the programme. The programme design and implementation, therefore, provide a good model for future programmes.

A key lesson for DFID is that the design of this programme and implementation of another DFID funded programme (SARRAH , Strengthening South Africa’s Revitalised Response to AIDS and
Health) was through a DFID senior health adviser seconded to the NDOH. This role allowed for identification of and alignment with NDOH priorities from the outset.

Another strength of the programme has been its multi-tiered, multi-stakeholder approach.
Interventions at a number of different levels (national, district, community) have been harnessed to improve health outcomes.

The lifespan of the programme (3 years) has been relatively short for this kind of system strengthening work. There is a risk that some of the gains made during the life of the programme will not be sustained beyond the life of the programme. It is vital, therefore, that there is a strong focus on working towards sustainability in the last year of the programme.

DCSTs are crucial to the success of national strategies in this field. Supporting these teams has been an important component of the technical support given by RMND. However, the sustainability of this work is threatened by low levels of staffing in many DCSTs. Also, DCST work plans are not costed with only some activities receiving funding from NDoH and the EU.
Key actions

Update logframe and develop indicators for the extension period.

Perform an analysis of policy and systems barriers to the success of the national strategy

Facilitate the transition of Steercom into a sustainable multi-stakeholder think tank.

Use the lessons learned from output 3 grants to develop a comprehensive strategy on demand and accountability.
Has the logframe been updated since the last review?
Yes, outputs for ESMOE training was previously nested under output 2. This year it has been turned into a separate output (output 5) reflecting its status as a separate stream of funding.
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(1 page per output)
Output Title Districts able to oversee improvement of reproductive, maternal and child health services
Output number per LF 1 Output Score A+
Risk: High
Risk revised since last AR? No
Impact weighting (%):
Impact weighting % revised since last AR?
30%
No
Indicator(s) Milestones
(March 2014)
Progress
(March 2014)
Progress
(Aug 2014)
60% (15 districts) 68% (17 districts) 88% (22 districts) 1.1. % of the 25 priority districts with
DCST dyad teams in place
1.2. Percentage of 25 priority districts that have functional DCST (minimum
DCST Dyads) that have undergone training as part of the national DCST training programme
1.3. Number of Districts assisted with integration of CARMMA and 3 streams of PHC into the DHPs
1.4. Number of Districts assisted with established / strengthened Maternal and Child Health programme review and DCST forums
1.5. Percentage of RMCH supported districts with Mortality and Morbidity reviews
60% (15 districts) 96% (24 districts) 96% (24 districts)
15
15
24
24
60% (15 districts) 96% (24)
25
24
95% (24)
Key Points

As the programme was originally due to finish in March 2015, milestones have been set for March and are not synchronised with the annual review cycle. Throughout the review, therefore, progress has been reported for March 2014 (against the milestone) as well as for August 2014 (the latest available information). Scoring is based on progress by March 2014.

DCSTs are crucial to the success of national strategies in this field. These teams provide technical assistance, training and monitoring functions. Supporting and mentoring these teams has been an important component of the technical support given by RMND. The sustainability of this work is threatened, however, by low levels of staffing and funding for DCSTs.

A fully staffed DCST should have 7 members including a mixture of doctor, nurse and midwifery skills. Due to challenges with recruiting and retaining staff in DCSTs, a twoperson team or ‘dyad’ comprising a doctor and a nurse/midwife has been considered ‘functional’. However, it is generally agreed that two-person teams cannot perform as effectively as fully staffed teams.

Nationally 206/364 (56.6%) DCST members have been appointed while in the 25 RMCH priority districts 106/184 (57.6%) have been appointed. There is also evidence of some attrition in the staffing of these teams though the reasons for this are not clear.

DCSTs do not always have sufficient funds to carry out their work plans. DCST work plans need to be costed in more detail to ensure better insight of how much it costs to function as team and be effective, and to ensure that they receive sufficient funds. Some districts also need clarity on how to access budgeted funds.

RMCH, working with consortium partner Health System Trust (HST), completed a one-year national induction and orientation training programme for newly appointed DCSTs covering seven of South
Africa’s nine provinces by May 2014. The other two provinces made their own arrangements for induction.

One of the 25 priority districts, in Western Cape, has opted out of receiving RMCH training for its
DCST because the province has arranged its own training programme.
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
At national level the programme Steering Committee (Steercom) has proved to be an excellent vehicle not only for steering the RMND programme but also for coordinating the work of key stakeholders in the national MNCWH&N strategy. Continuing this work will be important for the sustainability of the programme’s national-level work.
Summary of responses to issues raised in previous annual reviews (where relevant)
Recommendation : Continue Steercom beyond the life of the project to ensure sustainability.
Response : There is strong support from NDoH to keep this forum operating beyond the life of the RMCH programme, with plans for it to perform a think tank function in support of the national strategy. Revised
Terms of Reference for Steercom were approved at a meeting attended by the review team.
Recommendation : The original ambition of having fully staffed 7-member DCSTs should be maintained.
Response : Expansion of DCSTs to seven member teams is the target agreed by the NDoH and DCST advisors to NDoH. Provinces are being supported with recruitment and retention plans to attract specialists, but this is still a huge challenge.
Recommendation : Steercom should consider potential performance indicators for effective DCSTs rather than relying purely on process indicators.
Response : The Steercom is considering performance indicators to measure effectiveness of DCSTs,
Ward Based Outreach Teams (WBOTs) and school health. RMCH was tasked in the April Steercom to help NDoH select these from District Health Information Systems (DHIS) and discuss in the next
Steercom. RMCH is tracking the key output indicators that are associated with DCST functionality and is working to improve clinical governance for example: ensuring mortality review meetings/forums are held in districts and facilities; and, ensuring that clinical guidelines and protocols are available and followed by front-line clinicians. The Programme is also monitoring performance indicators in the MNCWH&N and
CARMMA Dashboards - a tool developed by the RMCH Technical Unit which is now being used nationally.
Recommendations
In the final year of the programme RMCH should focus efforts on ensuring the sustainability of the work done so far including through DCSTs and Steercom. Specific recommendations are:

RMCH to perform an analysis of policy and systems barriers to the successful implementation of the national strategy including issues related to recruitment and retention of DCST staff, school health, WBOT, and newborn care. This analysis should clearly document the major barriers as well as identifying possible solutions, drawing on examples where bottlenecks have been successfully unblocked for consideration by NDoH and Steercom. Indicators could be added to the RMCH log-frame for the extension period related to this recommendation.

RMCH to support, where appropriate, creative government strategies for achieving fully staffed
DCSTs including engagement with universities and the private sector.

RMCH to facilitate the transition of Steercom into a sustainable multi-stakeholder think tank by helping to identify alternative funding or hosting for Steercom secretariat functions. There should ideally be a phased handover of the Steercom secretariat to a new host starting as soon as possible to ensure continuity. Indicators could be added to the RMCH log-frame for the extension period related to this recommendation.
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Output Title Strengthen delivery of school health services, ward level primary health care (PHC) teams, and delivery of newborn care.
Output number per LF 2 Output Score A+
Risk: High
Risk revised since last AR? No
Impact weighting (%):
Impact weighting % revised since last AR?
35%
Y
Indicator(s) Milestones
(Mar 2014)
50% (200 of the quintile 1 and 2 schools)
Progress
(Mar 2014)
57.8% (231)
Progress
(Aug 2014)
96% (384) 2A.1
. Percentage of public schools implementing strategies to promote demand for school health services in the 25 priority district
2A.2
. Number of learners who received health education messages in line with the
Integrated School Health Policy
(ISHP) service package
2B.1
. % of 25 districts with ward based teams led by a PHC nurse and have been orientated on aspects of MNCWH Continuum of Care
19,880
60% (15)
25,468
92% (23)
34,517
100% (25)
2B.2
. % of 25 districts with CHWs trained and implementing the house-to-house health promotion on Family Planning and other key
MNCWH components
2C.1
. Percentage of the 25 priority districts implementing newborn care improvement plan
60% (15)
60% (15)
36% (9)
92% (23)
100% (25)
96% (25)
Key Points

RMCH provides a technical assistance and capacity building package to strengthen the provincial and district co-ordination of the
(ISHP). Coverage has improved significantly since the approval of the School Health Approach by the Director General of the Department of Basic Education in September 2013.

In spite of some significant progress in improving coordination between government departments there is still resistance from DBE to providing sexual and reproductive health services (as opposed to sex education) in schools. Agreement in principle to allow schools to opt in to providing such services has been reached.

RMCH has worked successfully with consortium partner Save the Children UK to improve coverage of school health services. They have supported the establishment of Integrated School health
Programme (ISHP) task teams, including health and education department representatives, in 24 districts. These teams are responsible for implementing school health services. Coverage may be at risk beyond the end of the programme when RMCH support is withdrawn, particularly in older
(adolescent) learners.

Ward Based Outreach Teams (WBOTs) are teams of community health workers led by nurses. By
August this year RMND had successfully trained all WBOTs in programme districts, effectively meeting the milestones for March 2015.

Risks to the sustainability of this work include: under-staffing of WBOTS; national variation in the incentivisation of WBOT staff (in some areas they are not paid at all while in others a range of incentives are provided); an on-going need to measure the quality of the work done by WBOTs and have an effective system of performance management. Establishing these teams has been slow and they are still a relatively weak part of the health care system.
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
Newborn care is an area which has historically fallen in the gap between maternal and paediatric care. RMND leads the national newborn care improvement plan by providing technical assistance at national and district levels. Interviews with key stakeholders found that this support has been highly valued by recipients.

There is a risk to the sustainability of the newborn care work after the end of the programme, though alternative sources of funding are being sought by NDoH to allow the work to continue. Also NDoH will soon have a Director with clear responsibility for newborn care which should give on-going policy support to this area of work.
Summary of responses to issues raised in previous annual reviews (where relevant)
Recommendation : Work towards improved coordination between NDoH and DBE.
Response : The School Health Team is working with DBE to input into the school health curriculum and the team has further developed training guidelines to assists schools with health education for adolescents in line with the ISHP programme.
Recommendation : Measure the impact of WBOT work in terms of outcomes such as post natal care uptake and family planning uptake.
Response : Establishing WBOTs has been slow and obtaining reliable information about their status from districts is not easy. So far, outcomes have not been used to monitor the impact of RMND support though RMND plans to work with the primary healthcare unit in NDoH to develop a tool to analyse the impact of the WBOTs.
Recommendations

Task teams have been established as part of a strategy to implement the Integrated School
Health Programme nationally. These teams are jointly staffed by NDoH and DBE. At present responsibility for leading and coordinating these teams is unclear. This creates a risk to the sustainability of the school health work. RMND to work with relevant government departments to clarify responsibility for leadership of these teams.

RMND to work with NDoH and DBE to galvanise support for an opt-out approach (instead of optin) to providing sexual and reproductive health services in schools.

In the final year of the programme the focus of school health and WBOT work should move from achieving coverage to measuring quality and impact. Measures of quality, performance and impact should be developed with NDoH and put into use before the end of the programme.
These measures are not primarily to assess the performance of the RMND programme but to aid the future development of the national strategy. Indicators could be added to the RMND logframe for the extension period related to this recommendation.

Important work done by the programme on empowering districts to manage newborns should be reinforced by the newly established NDOH unit on newborn care as a key strategy for building confidence at district hospitals and reducing the need for costly and risky referrals.
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Output Title Improved demand and accountability for MNCWH services
Output number per LF 3 Output Score
Risk: Medium
Risk revised since last AR? No
Impact weighting (%):
Impact weighting % revised since last AR?
A
10%
No
Indicator(s) Milestones
(Mar 2014)
Progress
(Mar 2014)
Progress
(Aug 2014)
Number of functional multi-stakeholder mechanisms supported by the Civil
Society Organisations in the 25 districts through the RMCH grants mechanism
Number of innovative initiatives that have been documented and shared in the form of mixed method tools across the 25 RMCH districts to improve demand
Number of grants provided to civil society organisations to improve
Demand & Accountability of MNCWH services in the RMCH sector
15 multistakeholder mechanisms supported
4 mixed method tools (models, tools, policy briefs
& case studies) developed
10
22
0
10
28
9
10
Key Points

Demand-side issues are critical to achieving most of the health outcomes targeted by this project.
For example, the number of post-natal visits at 6-days is sensitive to demand from mothers and is one outcome which has not showed consistent improvement with rates increasing in 2012/13
but falling back somewhat in the following year (2013/14) in RMND districts See Figure 1 for
details.

RMND work in this area was designed to support District Management Teams through grants made to Civil Society Organisations to work with communities to increase access, utilisation and community ownership of MNCWH services. Ten grants were made through a consortium-partner
Social Development Direct (SDD).

A primary focus of this work was on teenage pregnancy and demand for contraception. One of the main findings was that the attitudes of health workers are a major barrier for teenagers seeking family planning services.

One of the major insights of this work has been the need to integrate demand and supply-side work. Work to increase the accountability of health services can result in health workers feeling targeted in an adversarial manner. Working to improve understanding on both sides may be a more productive and solution orientated approach.

The programme has also given vital support to the development and launch of MomConnect, a flagship government mHealth programme sending messaging services to pregnant women and mothers of young children. This is an important national demand-side initiative.

Although a number of useful lessons have been learned through this work, there is a risk that the work done to support district strategies on demand and accountability will not be sustained beyond the end of the project.
Summary of responses to issues raised in previous annual reviews (where relevant)
Recommendation : explore collaboration with other DFID-funded programmes and mHealth projects.
Response : The programme has supported MomConnect (see above).
Recommendations

RMND to work with SDD and NDoH to organise the lessons learned from output 3 grants and to develop a comprehensive strategy on demand and accountability at district level – positive examples such as the partnerships developed in Zithulele district hospital and elsewhere could be scaled up and replicated more widely. A plan to disseminate the lessons-learned as widely as
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possible should also be developed. An indicator could be added to the RMND log-frame for the extension period related to this recommendation.

The accountability component could be greatly strengthened if district hospitals were empowered to respond to local demand more rapidly. Procurement bottlenecks impede this and the NDOH could work with national treasury to increase the capital expenditure threshold at district level.

RMND and NDOH to disseminate information to CSO partners on the processes for accessing
NDOH budget for civil society.
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Output Title New knowledge to remove barriers to uptake and access of RMCH services
Output number per LF 4 Output Score A+
Risk: Medium
Risk revised since last AR? N
Impact weighting (%):
Impact weighting % revised since last AR?
5%
N
Indicator(s) Milestones
(Mar 2014)
Progress
(Mar 2014)
The number of district RMCH baselines completed
15 District based reports and profiles on the status of implementation of MNCWH,
CARMMA and 3 streams of
PHC
4 Quarterly technical reports capturing lessons learnt
Achieved in 2012/2013
Quarterly technical reports analysing progress in 25 districts against national averages capturing Lessons learned from
RMCH
Mid-term Evaluation of the National
Maternal, Newborn, Child and Women's
Health & Nutrition Strategy 2012-2016
TOR consolidated, Steering
Committee formed, Draft
Methodology, workplan and budget developed for MTR
4 Quarterly technical reports capturing lessons learnt have been submitted and approved by DfID and NDoH.
TOR consolidated;
Steering Committee formed; Methodology; workplan and budget developed for MTR. The desktop review and field work for MTR completed.
Key Points

Data, information and knowledge are needed for the success of relevant national strategies.

Many of the outputs expected in this area where met ahead of target.

The work RMND has done to support the mid-term evaluation of the national MNCWHN strategy has been particularly valuable. Preliminary findings of the review were presented at the Steercom meeting attended by the review team. The results were promising though it was unclear what action would be taken as a result of the findings.

In addition to the work specified in the log frame indicators, RMND has done a lot of useful work on making key information and knowledge available. This includes development of: the DCST handbook; the DCST recruitment status booklet; several dashboard booklets on national, provincial and district national strategy data; and infographics fact sheets on newborn care and the 16 MDG Countdown interventions identified as priorities by NDoH.

There is a risk that the end of the RMND programme will leave a gap in knowledge management in the national system.

Administrative barriers to regular access to District Health Information System is another risk which may prevent the tools which have been developed from being used as effectively as they might be.
Summary of responses to issues raised in previous annual reviews (where relevant)
Recommendation: RMND should seek evidence on whether and how baseline assessment data are being used to inform planning.
Response : RMND programme has developed the District-Based Reporting Tool (DRT) which contains a section on bottleneck analysis, some of which includes findings from the RMND baselines assessment.
This tool is primarily used to inform DMTs on how to plan and implement interventions based on the gaps and prioritisation process. The DRT has been adopted by three provinces (KZN, NW and LP) and there is evidence that MNCWH provincial coordinators are using this for better planning and monitoring of the MNCWH programme at district level. The tool also allows the DMT to review district profiles, district performance dashboard indicators and status of implementation of key MNCWH interventions.
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Recommendation : Lessons that are being learnt from implementation of the RMCH technical package of interventions should be systematically documented.
Response : Case studies and lessons learnt documenting good practices are being captured every quarter. A good practice book is currently being compiled as recommended. DCST work plans and action items are used to assess if the key lessons learnt from the RMCH programme are incorporated into the district quality improvement plans.
Recommendations

In the final year of its operation RMND should focus on ensuring that the tools which have been developed are put into regular use at district and provincial levels. An indicator could be added to the RMND log-frame for the extension period related to this recommendation.

RMND should include barriers to accessing District Health Information Systems data in its wider analysis of policy and political barriers to success (recommended above).

RMND to suggest other relevant logframe indicators for this output for the next year since the current indicators have largely been met already.
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Output Title Strengthened delivery of obstetric and neonatal emergency services
Output number per LF 5 Output Score A 1
Risk: Medium
Risk revised since last AR? Y
Impact weighting (%):
Impact weighting % revised since last AR?
20%
Y
Indicator(s)
5.1. Percentage of 12 priority districts that have received training as part of ESMOE expansion.
5.2. Number of in service care workers trained in firedrills (EOST) (Nested ESMOE logframe indicator)
Milestones 2014
Not set 1
NA
Progress (Oct 2014)
10
1521 trained at baseline
Key Points

Essential Skills in Managing Obstetric Emergencies (ESMOE) is a training programme which trains teams of health workers (including doctors, nurses and midwives) to handle obstetric emergencies. This is a highly regarded programme which DFID UK has funded in a number of other countries through the Making it Happen programme.

DFID SA funding is supporting the application of this training in 15 districts in South Africa. The contract for this work is held by the Liverpool School of Tropical Medicine (LSTM) with the
University of Pretoria acting as the local implementing partner. In 3 of the 15 districts the
University of Pretoria works with local medical schools, which implement the training on the ground. The programme has been well received and integrated with the national MNCH strategy and there are now plans to implement it nation-wide.

There are two models for impl ementing ESMOE. The first, ‘saturation training’, involves a 2 or 3 day course including didactic teaching and practical exercises. This training is designed to be followed up by regular ‘fire drills’ (practice exercises) carried out in facilities. This is the model of training being implemented with DFID SA funding. Saturation training is completed when 80% of staff in a district have been trained.

A second model of ESMOE training known as EOST (Emergency Obstetric Skills Training) has been implemented in South Africa using EU funding. This is a shorter, less expensive model which focusses on implementing fire drills in facilities. The effectiveness of these two models is being compared by the University of Pretoria using a step-wedge study design. The results of this study will inform future government policy on implementing ESMOE nationally.

Interim analysis of the results of saturated training in 12 districts shows some very encouraging
(though preliminary) results including: 94.3% of candidates having improved their skills and
81.03% having improved their knowledge after training; statistically significant reductions after the training compared to before in number of early neo-natal death rate (from 25.4 to 16.5 per 1000 live birth, and peri-natal mortality rate (from 52.3 to 41.6 per 1000 live births). If these results are confirmed, ESMOE training is likely to have contributed to the improvements along with other interventions such as the strengthening of DCSTs.

The programme of saturation training is on track to be completed in all 15 districts by March 2015 though clarification is needed that this has been achieved in the three districts where training is implemented by medical schools (see below).

In previous years, indicators for this training were nested under output 2 in the logframe. In line with recommendations made in last year’s annual review this is now treated as a separate output with 20% weighting.

Two issues have arisen with the reporting of this work which need to be resolved. The first was clarification that DFID SA funding has been used to support training in 15 districts, not 12 as the logframe currently indicates. The confusion arose because training in three districts is
1
Note that this is a new output in the logframe and milestones for 2014 were not set in advance of the annual review. The output score is based on good progress having been made towards the 2015 milestone of training being completed in all districts.
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implemented through medical schools which report to the University of Pretoria, rather than directly to LSTM. It is currently unclear whether full 80% coverage of saturation training has been achieved in the 3 districts covered by medical schools. The second issue is that LSTM has been reporting results against two logframes, the DFID SA logframe and a much larger logframe which is used by DFID UK for its funding of ESMOE training as part of the Making it Happen programme.
Summary of responses to issues raised in previous annual reviews (where relevant)
Recommendation : The ESMOE component of RMND should be treated as a separate output under the log-frame.
Response : The logframe has been amended accordingly.
Recommendation : Opportunities for collaboration between ESMOE and the other streams of RMND work should be more explicitly identified.
Response : Coordination across all the streams of the RMND programme has improved somewhat since last year with representatives from each consortium sitting on the board of the other. However, explicit opportunities for operational collaboration across all streams have not been identified.
Recommendations

LSTM (with University of Pretoria) and DFID SA to reach an agreement clarifying the reporting requirements for the 3 districts where training is implemented by medical schools. It is recommended that reporting should be to the same standard and in the same format as for the
12 districts where training is implemented by the University of Pretoria.

In addition the existing output indictor, Percentage of the 12 priority districts that have received training as part of ESMOE expansion , should be revised to include all 15 districts and the milestone for 2015 should be updated from 12 to 15.

LSTM and DFID SA to agree on additional logframe indicators for next year, including the extension period. It is not recommended that LSTM continue to report against the full DFID UK log-frame. Instead, a limited number of additional indicators (2 – 3) should be added to Output 5 of the RMND logframe and reporting should be against these for the 15 districts in which DFID
SA is funding ESMOE training. Indicators to be agreed by the end of November 2014. Suggested new indicators are: o Analysis and write up of step-wedge study comparing saturation training with EOST model to be completed and disseminated, including publication on DFID’s R4D platform. o Completion of refresher training courses in the 15 districts.

The results of the step-wedge study should be used to inform national decision-making about the future implementation of ESMOE as part of the national strategy.

LSTM to provide an exit strategy for the sustainability of ESMOE training in South Africa by the end of December 2014, in coordination with the national ESMOE board.

A key issue in South Africa has been to integrate emergency obstetric skills into the basic training curriculum for nurses, doctors and midwives. RMND partners, outside of this programme, can support the NDOH and ESMOE board to advocate for these changes and provide technical support where required.
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Key cost drivers and performance
This programme aims to reduce maternal and neonatal deaths ‘ by improving the quality of, and access to, reproductive and maternal and child health services by girls and women in underserved districts in
South Africa.’ The catalytic nature of the programme makes direct attribution of decreases in maternal and child mortality difficult.
DFID describes VfM of programmes as ‘ maximising the impact of each pound spent to improve poor people’s lives .’ VfM is measured by looking into the economy, efficiency and effectiveness of the programme
Economy (inputs)
 The main cost drivers for this mainly technical assistance programme are personnel costs, grants and equipment costs. Approximately 70% of the budget managed by Futures Group and 25% of the budget managed by LSTM is spent on personnel costs. 14% of the Futures Group budget is spent on grants and 45% of LSTM’s 2014/15 budget will be spent on equipment e.g. birth registers and


 mannequins.
To date Futures Group has saved approximately 4.97% per contractor by making an effort to use local contractors as much as possible as opposed to international contractors who tend to be more expensive.
Both partners attempt to reduce costs by using tools like Skype to minimise communication and travel costs.
Procurement policies have been effectively implemented by Future’s Group including: the use of prescribed contractual authorisation levels, full tenders and preferred supplier list. All purchases over
GBP£500 undergoing a competitive procurement process.
Efficiency (outputs)
 The NDoH noted that Futures Group is responsive to their needs particularly in scaling up the programme to work in 25 districts as opposed to the original 15 planned. This has been done within the planned resources.
 LSTM has managed to deliver the outputs agreed in their original proposal with less resources than originally planned.
 Programme forecasts and invoicing are usually relatively well matched. See below for details:
Forecasts vs actual spend
LSTM
Apr-14 May-14
Forecast £439,032.00
Actual spend
£440,317.00
Variance £1,285.00
Variance (%) -0.29%
Jun-14 Jul-14 Aug-14
£86,631.00
£74,265.00
£12,366.00
14.27%
Sep-14
Futures Group
Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14
Forecast £568,797.00 £497,868.00 £494,294.00 £475,444.00 £501,009.75 £494,068.75
Actual spend £511,113.84 £509,345.58 £479,836.59 £524,418.66 £511,634.27 £502,859.78
Variance £57,683.16 £11,477.58 £14,457.41 £48,974.66 -£10,624.52 -£8,791.03
Variance (%) 10% -2% 3% -10% -2% -2%
Effectiveness (impact)
The funding that has been provided through the RMND programme has been catalytic. Below is a key example of this:

RMCH has assisted the recruitment process of DCSTs nationally and worked with officials to obtain additional funding from the EU and other donors to employ DCST staff in disadvantage districts. The
EU invested R1,200,000 (£67,830) in 2013 and R37,000,000 (£ 2,091,430) in DCST recruitment and
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
R9,000,000 (£508,725) on DCST accelerated plans (2014). Thus, RMND effectively leveraged significant investment from the EU to support this work nationally.
Similarly, following DFID ’s decision to fund ESMOE training, additional funding from the EU was obtained to increase coverage of the training programme nationally.
VfM performance compared to the original VfM proposition in the business case.
VfM are measures not clearly stated in the business case though it suggests using DALYs (Disability-
Adjusted Life Years). The economic evaluation in the business case estimated that 700,000 DALYs could be saved through improved quality of, and access to, reproductive, maternal and child health services by girls and women in underserved districts of South Africa
Recommendation: All streams of RMND to work together to assess the feasibility of measuring cost per
DALY for this programme using the assumptions made in the economic evaluation in the business case.
Assessment of whether the programme continues to represent value for money
Yes, the programme continues to represent VfM. It has been successful in achieving what was originally expected within the planned resources.
Quality of financial management
Futures Group (Output 1 – 4)
Futures Group has demonstrated sound financial management by ensuring that the programme since inception three years ago has operated within approved budget. Monthly budget forecasts (expenditures against actuals) are reviewed and reported to DFID quarterly. The accounting system has been well structured to allow cost tracking using a budget tracking system which also gives better insight and understanding of the main cost drivers.
Methods used to monitor financial performance include internal audits (the Partners Programme Review) and external audits, evaluations of grantees by external parties and due diligence checks on partners.
LSTM (Output 5)
LSTM grant management processes and procedures are regularly audited as part of the institution’s risk management policy, ensuring full compliance with funding body terms and conditions at all times. LSTM has well-established processes for operating in overseas institutions and has developed key controls to ensure that risk of fraud and corruption is minimised. Contractual agreements are established with any institution which is involved in, or delivers, any of its activities. Contractual agreements describe financial controls that the partner institution is expected to have in place to administer project funds, with the added control for LSTM to retain funding until financial reports, detailing expenditure are received.
Date of last narrative financial report
Date of last audited annual statement
LSTM: 31/10/2014; Futures 1/04/2014
LSTM: August 2014. Futures: December 2014
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Overall risk rating:
This programmes risk rating is medium.
Overview of programme risk
The risks highlighted in the most recent risk assessments by Futures Group and LSTM as high in probability and high in impact remain the same as in the last Annual Review:

Difficulty in clearly demonstrating the impact of DFID investment due to the catalytic nature of the programme and its contribution to long term results.
Mitigation: DFID is funding, with other development partners, the mid-term review of the MNCWH strategy commissioned by NDOH. The results of the MTR will produce proxy indicators for the outputs that can collectively be attributed to NDoH and development partners (including RMND).

The sustainability and effectiveness of the ESMOE training may be hindered by staff not being available for ESMOE training and high turnover of trained staff
Mitigation: 'Task shifting' has empowered nurses and midwives, among whom there is less turnover, to take immediate actions to save lives.

Limited RMND resources, scope and district coverage to fully attribute MCH outcome changes to
DFID support in the 25 priority districts.
Mitigation: The recent exercise by NDOH measuring estimated Lives saved when implementing specific high impact interventions aligns well with the strategic interventions that RMND has implemented. These will assist with estimated attribution of DFID support to outcome changes in
South Africa.
Risks that have been identified during the Annual Review include:

Risks to sustainability of the work done after the end of the programme in 2015. Mitigation measures have been highlighted throughout the review. The most serious risks to sustainability result from policy and political bottlenecks including human resource constraints. An analysis of these by RMND has been recommended.
Outstanding actions from risk assessment
A risk register (log) identifying the key risks, owners, probability and impact and mitigation actions has been introduced and implemented from July, 2014 by both LSTM and Futures Group. This is a live document which will be updated when new risks that warrant the attention of DFID and NDoH are identified.
Recommendation:

LSTM and Futures Group to discuss risks with each other and look into ways they can collaborate on mitigation.
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Delivery against planned timeframe
The programme is largely on track and outputs moderately exceed expectations. The programme end date was originally March 2015 but has been extended to September 2015. This cost extension was given to ensure the sustainability of the programme.
Performance of partnership (s)
Key partnerships are with the NDoH and the wider health and donor communities.
NDoH
The partnership between the NDoH and DFID was well established prior to the programme’s design.
This has meant that RMND is closely aligned to NDoH policy and has enjoyed a high level political buyin. The programme has continued to work very closely with NDoH officials ensuring that their work remains relevant and responsive to NDoH’s needs. Interviews with NDoH officials found that the support provided by the programme has been highly valued.
Steering Committee/ESMOE Advisory Board
The RMCH steering committee (Steercom) meets quarterly, bringing together key stakeholders. It is chaired by the NDoH and the following organisation are represented: DFID, USAID, UNICEF, PATH,
University of Pretoria, UNFPA, Futures Group and other stakeholders. This has been a key opportunity for donors and implementing partners to align to working on maternal and child health.
The ESMOE Advisory Board is chaired by Professor Jack Moodley of the University of KwaZulu Natal and the following stakeholders are represented on the Board: DFID, NDoH, University of Pretoria,
Futures Group and various organisations working on the ground at district level. Again this helps the programme to be well coordinated with the wider health and donor community.
Asset monitoring and control
DFID conducted a spot check at the Futures Group office of selected assets and time sheets in mid-
August. The spot check found that Futures Group tracking of assets was largely well done. DFID reiterated the fact that all stolen or lost assets need to be immediately reported to DFID even when the assets are insured as well as the fact that all assets bought by DFID funds remain the property of DFID.
Futures Group provided evidence of good practice by maintaining asset registers for their consortium partners and grantees, by conducting spot checks, quarterly submission of asset registers by partners, and procuring the services of independent audit firms. The most recent audit is still in the process being finalised and the results of the audit will be shared with DFID.
Assets have been procured by LSTM mainly for ESMOE training. These assets include laptops, projectors and mannequins. The current asset register has some gaps including clarifying if any assets have been lost or stolen, date of procurement, state of assets (e.g. broken), date on which asset register was completed and prices of the assets. In addition there is the issue that many of these assets have effectively been transferred to government health facilities and now appear on their asset registers. This transfer is not in line with DFID ’s policies as assets are only supposed to be transferred or disposed of at the end of the programme after approval from the DFID Head of Office.
Recommendation: LSTM to conduct asset checks to ascertain the gaps highlighted above and submit an exit plan and asset disposal plan to DFID for approval. The asset disposal plan should also address all the assets that have been transferred to government facilities. These documents should be submitted to DFIDSA by 30 November 2014.
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Update on partnership principles (if relevant)
1. A commitment to reducing poverty and achieving the Millennium Development Goals (MDGs)
Summary: South Africa’s progress on the Human Development Index is static. Progress against MDG targets in health and education is positive and progress against HIV related indicators impressive given the scale of the problem. Inequality, slower than expected economic growth, equitable access to public services are major challenges, but remain central to government planning and development strategies.
A commitment to respecting human rights and other international obligations
Summary: Domestic respect for international human rights instruments is delivered through South
Africa’s constitution - widely recognised as one of the most progressive in the world, with robust independent accountability mechanisms and the inclusion of both civil and political rights and economic and social rights. The Constitutional Court and independent bodies like the office of the Public Protector have been able to enforce the provisions of the Constitution. Despite the positive framework, there are significant areas of concern in relation to human rights in practice.
3. A commitment to strengthening financial management and accountability, and reducing the risk of funds being misused through weak administration or corruption
Summary: There have been many reported and prosecuted incidents of official corruption. South Africa was ranked 72 out of 177 in Transparency International’s 2013 Corruption Perceptions Index. Official corruption remains high on the political agenda; South Africa is seen as a global leader in terms of budget transparency, with the budget process being widely regarded as an example of global best practice. The EU and South Africa carried out a PEFAR assessment in 2014 and South Africa was again given an ‘A’ rating for its overall public financial management capability.
4. A commitment to strengthening domestic accountability
Summary:
South Africa is a founding member of the ‘Open Government Partnership’ and its successful bid to become co-chair and then lead chair for the OGP demonstrates a commitment to increasing government accountability and transparency both in South Africa, in the region and globally. This partnership aims to bring together government and civil society to find innovative means to improve accountability despite the clear tensions between the two in recent years.
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Evidence and evaluation
There is no change in the evidence that would have implications for the programme. The theory of change and programme design do not need to be amended. The programme itself is generating some new evidence including around demand and accountability and the effectiveness of ESMOE training.
A number of pieces of evaluation work have been done:

Interim analysis has been carried out on the health outcomes associated with ESMOE training in districts with promising provisional results (reported above) though these signs of improvement cannot be attributed entirely to ESMOE; the other work of the RMND programme and other factors undoubtedly contribute too.

RMND engaged the services of an external consulting firm to assess outputs achieved by CSO grantees implementing demand and accountability interventions as per the Output 3 CSO
Engagement Plan and Demand and Accountability objectives. Results are expected by mid-
November 2014.
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
RMND engaged the services of an external consultant for an internal exercise to improve financial management policies and procedures. There have been noticeable improvements in
RMND financial management since last year.
Monitoring progress throughout the review period
The annual review process was conducted in October 2014 by DFID officials including Tim Elwell-
Sutton (Health Adviser, DFID UK), Joel Harding (Governance Adviser, DFID SA), Martina Dhliwayo
(Programme Manager, DFID SA). Interviews were held with key informants including NDoH officials,
Futures Group and their consortium partners (HST, SCUK, SDD) and University of Pretoria trainers.
Field visits to observe ESMOE training in Port Elizabeth and district-level work in OR Thambo district were carried out. These gave reviewers an opportunity to receive feedback directly from health workers and those working in the community and schools.
Monitoring between annual reviews is done through :
1. Monthly reporting for Outputs 1 - 4 and quarterly reporting for Output 5.
2. Monthly meetings with the NDOH, Futures Group and DFID
3. Quarterly steering committee for Outputs 1 - 4 c and quarterly advisory board meetings for
Output 5.
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Acronyms
CARMMA
CFP
CRH
CHWs
CSO
DBE
DCST
DDG
DFID
DHIS
DHP
DMT
EANC
EC
ESMOE
M&E
NC
NDoH
NMM
NW
PHC
RMCH
RMND
FS
GP
HBB
HCWs
HE
HPS
HST
ISHP
KZN
LP
MCH
MP
MNCWH&N
RSM
SARC KZN
SBST
SCI
SDD
SCUK
SGB
WC
WBOTs
Campaign on Accelerated Reduction of Maternal
Newborn and Child Mortality
Contraceptive and Fertility Planning Policy
Centre for Rural Health
Community Health Workers
Civil Society Organisation
Department of Basic Education
District Clinical Specialist Teams
Deputy Director General
Department For International Development
(United Kingdom)
District Health Information System
District Health Plan
District Management Team
Early Antenatal Care
Eastern Cape
Essential Steps in the Management of Obstetric and neonatal Emergencies
Free State
Gauteng Province
Helping Babies Breathe
Health Care Workers
Health Education
Health Promoting Schools
Health Systems Trust
Integrated School Health Programme/ Policy
KwaZulu Natal
Limpopo Province
Maternal and Child Health
Mpumalanga
Maternal, Neonatal, Child and Women’s Health and Nutrition
Monitoring and Evaluation
Northern Cape
National Department of Health
Ngaka Modiri Molema
North West
Primary Health Care / Primary Health Care Clinic
Reducing Maternal and Child Mortality through
Strengthening Primary Health Care in South Africa
Reducing Maternal and Neonatal Deaths
Programme
Ruth Segomotsi Mompati
South Africa Red Cross, Kwa-Zulu Natal
School Based Support Teams
Soul City Institute
Social Development Direct
Save the Children UK
School Governing Bodies
Western Cape
Ward-based Outreach Teams
22

The Annual Review is part of a continuous process of review and improvement throughout the programme cycle. At each formal review, the performance and ongoing relevance of the programme are assessed with decisions taken by the spending team as to whether the programme should continue, be reset or stopped.
The Annual Review includes specific, time-bound recommendations for action, consistent with the key findings.
These actions – which in the case of poor performance will include improvement measures – are elaborated in further detail in delivery plans. Teams should refer to the Smart Rules quality standards for annual reviews.
The Annual Review assesses and rates outputs using the following rating scale. ARIES and the separate programme scoring calculation sheet will calculate the overall output score taking account of the weightings and individual outputs scores
Description Scale
Outputs substantially exceeded expectation
Outputs moderately exceeded expectation
Outputs met expectation
Outputs moderately did not meet expectation
Outputs substantially did not meet expectation
A++
A+
A
B
C
Teams should refer to the considerations below as a guide to completing the annual review template.
Complete the summary sheet with highlights of progress, lessons learnt and action on previous recommendations
Briefly o utline the programme, expected results and contribution to the overall Operational Plan and DFID’s international development objectives (including corporate results targets). Where the context supporting the intervention has changed from that outlined in the original programme documents explain what this will mean for
UK support
Annual Outcome Assessment
Brief assessment of whether we expect to achieve the outcome by the end of the programme
Overall Output Score and Description
Progress against the milestones and results achieved that were expected as at the time of this review.
Key lessons
Any key lessons you and your partners have learned from this programme
Have assumptions changed since design? Would you do differently if re-designing this programme?
How will you and your partners share the lessons learned more widely in your team, across DFID and externally
Key actions
Any further information on actions (not covered in Summary Sheet) including timelines for completion and team member responsible
Has the logframe been updated since the last review?
What/if any are the key changes and what does this mean for the programme?
Output
Set out the Output, Output Score
Score
Smart Guide i

Enter a rating using the rating scale A++ to C.
Impact Weighting (%)
Enter the %age number which cannot be less than 10%.
The figure here should match the Impact Weight currently shown on the logframe (and which will need to be entered on ARIES as part of loading the Annual Review for approval).
Revised since last Annual Review (Y/N).
Risk Rating
Risk Rating: Low/Medium/High
Enter Low, Medium or High
The Risk Rating here should match the Risk currently shown on the logframe (and which will need to be entered on
ARIES as part of loading the Annual Review for approval).
Where the Risk for this Output been revised since the last review (or since inception, if this is the first review) or if the review identifies that it needs revision explain why, referring to section B Risk Assessmen
Key points
Summary of response to iprogrammessues raised in previous annual reviews (where relevant)
Recommendations
Repeat above for each Output.
Key cost drivers and performance
Consider the specific costs and cost drivers identified in the Business Case
Have there been changes from those identified in previous reviews or at programme approval. If so, why?
VfM performance compared to the original VfM proposition in the business case ? Performance against vfm measures and any trigger points that were identified to track through the programme
Assessment of whether the programme continues to represent value for money?
Overall view on whether the programme is good value for money. If not, why, and what actions need to be taken?
Quality of Financial Management
Consider our best estimate of future costs against the current approved budget and forecasting profile
Have narrative and financial reporting requirements been adhered to. Include details of last report
Have auditing requirements been met. Include details of last report
Output Risk Rating: L/M/H
Enter Low, Medium or High, taken from the overall Output risk score calculated in ARIES
Overview of Programme Risk
What are the changes to the overall risk environment/ context and why?
Review the key risks that affect the successful delivery of the expected results.
Are there any different or new mitigating actions that will be required to address these risks and whether the existing mitigating actions are directly addressing the identifiable risks?
Any additional checks and controls are required to ensure that UK funds are not lost, for example to fraud or corruption.
Outstanding actions from risk assessment
Describe outstanding actions from Due Diligence/ Fiduciary Risk Assessment/ Programme risk matrix
Describe follow up actions from departmental anti-corruption strategies to which Business Case assumptions and risk tolerances stand
Delivery against planned timeframe . Y/N
Compare actual progress against the approved timescales in the Business Case. If timescales are off track provide an explanation including what this means for the cost of the programme and any remedial action.
Performance of partnership
How well are formal partnerships/ contracts working
Are we learning and applying lessons from partner experience
How could DFID be a more effective partner
Smart Guide ii

Asset monitoring and control
Level of confidence in the management of programme assets, including information any monitoring or spot checks
Update on Partnership Principles and specific conditions.
For programmes for where it has been decided (when the programme was approved or at the last Annual Review) to use the PPs for management and monitoring, provide details on: a. Were there any concerns about the four Partnership Principles over the past year, including on human rights? b. If yes, what were they? c. Did you notify the government of our concerns? d. If Yes, what was the government response? Did it take remedial actions? If yes, explain how. e. If No, was disbursement suspended during the review period? Date suspended (dd/mm/yyyy) f. What were the consequences?
For all programmes, you should make a judgement on what role, if any, the Partnership Principles should play in the management and monitoring of the programme going forward. This applies even if when the BC was approved for this programme the PPs were not intended to play a role. Your decision may depend on the extent to which the delivery mechanism used by the programme works with the partner government and uses their systems.
Evidence and evaluation
Changes in evidence and implications for the programme
Where an evaluation is planned what progress has been made
How is the Theory of Change and the assumptions used in the programme design working out in practice in this programme? Are modifications to the programme design required?
Is there any new evidence available which challenges the programme design or rationale? How does the evidence from the implementation of this programme contribute to the wider evidence base? How is evidence disaggregated by sex and age, and by other variables?
Where an evaluation is planned set out what progress has been made.
Monitoring process throughout the review period.
Direct feedback you have had from stakeholders, including beneficiaries
Monitoring activities throughout review period (field visits, reviews, engagement etc)
The Annual Review process
Smart Guide iii