Type of Review: Annual Review
Project Title: Accès aux Soins de Santé Primaires (ASSP)
Date started: 1 April 2013
Date review undertaken: July 2013
Instructions to help complete this template:
Before commencing the annual review you should have to hand:
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the Business Case or earlier project documentation.
the Logframe
the detailed guidance (How to Note)- Reviewing and Scoring Projects
the most recent annual review (where appropriate) and other related monitoring reports
key data from ARIES, including the risk rating
the separate project scoring calculation sheet (pending access to ARIES)
You should assess and rate the individual outputs using the following rating scale and
description. ARIES and the separate project scoring calculation sheet will calculate the overall
output score taking account of the weightings and individual outputs scores:
Description
Outputs substantially exceeded expectation
Outputs moderately exceeded expectation
Outputs met expectation
Outputs moderately did not meet expectation
Outputs substantially did not meet expectation
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Scale
A++
A+
A
B
C
Introduction and Context
What support is the UK providing?
The UK is providing £184.9 GBP million over five years to strengthen basic health service
provision in the Democratic Republic of Congo (DRC) in order to improve reproductive,
maternal, neonatal and child health (£179.7m), and to strengthen the capacity of the central
Ministry of Health to support service delivery (£5.2m). The programme will build on DFID’s
proven track record of improving access to health care and delivering health results in the
DRC as a result of its previous Access to Healthcare programme, which ended in March 2013.
The programme will support 56 health zones (out of 515) in five of the eleven provinces in
DRC, providing at least six million people with access to essential primary and secondary
healthcare services. The design phase began in October 2012 with implementation running for
five years from April 2013 to March 2018.
DFID’s support focusses on engagement at three levels:
1. Engagement with non-state service providers to strengthen public sector health services
DFID will continue to strengthen public sector provision of health services by working through
non-governmental organisations, civil society and faith based networks to implement this
programme, whilst strengthening government health management teams. Funding will allow
for subsidisation of user fees, especially for vulnerable groups such as pregnant women and
children under five.
2. Engagement with communities and individuals
The programme will have an emphasis on strengthening empowerment and accountability at a
number of different levels, ensuring that citizens have a greater voice and that both service
providers and the government are more accountable for delivering quality basic health
services.
3. Engagement with the state
Improving basic service delivery is a key entry point to strengthening the social contract in
DRC. DFID will focus on strengthening the role of the Ministry of Health to act as an effective
steward, provide an enabling environment for service delivery from a range of providers, set
policy and manage health information.
The total budget for the programme consists of two high-level components:
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The bulk of the budget (£179.7 million) is for support for service delivery and health
systems strengthening at health zone and provincial levels. This has been
supplemented by a contribution of SEK 34 million from Sweden (SIDA), bringing the
total to value of this component to £182.9 million. Implementation of this component is
being carried out by a consortium led by IMA World Health.
-
£5.2 million is for a sub-project called Renforcement des Capacités Institutionelles
(RCI), to provide capacity building and technical assistance to the Ministry of Health at
central level. This will focus on key stewardship/policy functions with a strong emphasis
on strengthening public financial management, for example in budget planning and
execution and strengthening information systems.
Whilst this new programme builds upon DFID’s previous Access to Healthcare programme, it
also differs from it in a number of key ways:
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 Greater focus on strengthening empowerment and accountability, to contribute to a
more responsive government and potentially a stronger social contract.
 Greater emphasis on working through Faith Based Networks to support service
delivery.
 More support to strengthen the Ministry of Health, by strengthening links between
the provincial level, health zones and health centres, providing technical assistance
in key areas such as public financial management, and strengthening the use of
information for oversight eg through the national health information system (SNIS).
 Increased geographical coverage: the programme will support 56 health zones,
compared to 20 in the previous programme Access to Healthcare. This is partly
achieved through increasing our investment, but also by adopting a more costeffective approach which offers better value for money.
 Shift to a “managed programme” approach: rather than directly working through
individual NGOs, we will provide our support through a consortium of organisations
led by IMA World Health. This will facilitate a more coherent approach across the
programme and provide a mechanism for closer quality assurance and cost
monitoring.
 Better use of evidence: operational research / impact evaluation features prominently
in the programme, allowing it to learn and adapt during implementation, and to
contribute to policy engagement.
What are the expected results?
This programme will aim to provide life-saving essential primary health care to at least 6 million
people over 5 years, with an emphasis on reproductive, maternal and child health. The
programme will support 56 health zones (out of 515) in five of the eleven provinces in DRC.
In addition to delivering health outcomes and health facilities/zones with better capacity, the
programme will also support the government to be a more effective steward/provide an enabling
environment and seek a stronger social contract through empowering citizens to hold both the
government and non-state providers of health care (such as faith based organisations) to
account.
Impact: Improved reproductive, maternal, neo-natal and child health (RMNCH) in the
Democratic Republic of Congo.
Outcome: Increased coverage with essential reproductive, maternal and child health services
in DFID-supported health zones target areas.
Key results:
This programme will deliver the following key results in target areas by the end of 2014/15:

Reduce U5 mortality by 50% in target areas:
o Vaccinate 64,600 one year olds against measles each year.
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
Improve reproductive and maternal health:
o Provide contraception - 155,000 CYPs (couple years protection) cumulatively by
2014/15 and 355,000 CYPs by the end of the five year programme.
o Ensure that 75,000 births per year are attended by skilled health personnel.
o Make sure 100% of health facilities in target areas offer appropriate emergency
obstetric care.
o Provide 75,000 pregnant women with Intermittent Presumptive Treatment (IPT) for
malaria during ante-natal visits.

Provide 600,000 people with access to clean water and sanitation.
The programme will also deliver additional benefits such as improved nutrition, enhanced
empowerment and accountability, and institutional capacity building.
What is the context in which UK support is provided?
The DRC is the poorest country in the world according to the 2011 Human Development
Index. Three in five of its 65 million people live on less than $1.25 (£0.80) per day. The DRC
has some of the worst health indicators in Sub Saharan Africa. With one fifth of children born
not reaching their first birthday, the DRC has the second highest level of child mortality. It also
has the fourth highest level of maternal deaths, accounting for almost one in ten of all maternal
deaths in Africa.
Access to health services is extremely limited. It is estimated that less than a quarter of
citizens have access to healthcare across the country. Some of this lack of access is related
to the barrier of cost since user fees are the norm.
DRC remains affected by conflict and fragility which continues to impact on the health system.
This is a complex environment to work in with many challenges. But better access to basic
health services and strengthened empowerment and accountability can have a positive impact
on both recovery from conflict recovery and preventing further conflict.
Government financing to health care is extremely limited and as a result the Ministry of Health
takes very limited responsibility for the provision of salaries and other resources required for
public service provision. Per person per annum, the government contributes $2, donors $4
and households $6. There is a strong link between subsidising care of vulnerable groups and
delivering improved health outcomes. DFID will continue to ensure that user fees are not a
barrier to care and will have a strong focus on operational research and evaluation so that
findings can feed into policy discussions with the government and other donors.
DFID has invested heavily in capacity building of government facilities/health zone
management teams through international NGOs. However the government is unlikely to be
able to take over running these facilities in the medium term, particularly while salaries and
drugs remain unfunded. Faith based networks are likely to remain key to sustainable service
delivery, supporting half of public sector delivery and co-managing health zones. Continued
support through these networks is required to improve access to healthcare and public sector
provision as a whole. DRC has potentially strong human resources in health and a strong
public health approach so there is great potential to deliver good health results.
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In general, donor support remains fragmented in DRC and DFID will work more closely with
other donors to ensure coherence of support nationally. DFID’s comprehensive approach has
strong support from the Ministry of Health and is in line with DRC policy, and there is good
evidence that it is more cost effective in terms of averting Disability Adjusted Life Years.
If DFID were not to continue support to healthcare it is expected that the results achieved by
DFID over the past three years would be reversed, ultimately dropping back to the much lower
levels of access to health services in the health zones concerned. This would contribute to
compromising DRC’s progress towards Millennium Development Goals 4, 5 and 6.
Unfortunately, the Government of DRC is not yet in a position to ensure that gains made under
donor-funded interventions can be sustained.
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Section A: Detailed Output Scoring
Although the business case for this programme was approved in July 2012, implementation
started in April 2013, in order to allow for the procurement process and a design phase to take
place. As a result, at the time of this first annual review only three months of implementation
have occurred, and baseline surveys have yet to be completed. For this reason, insufficient time
has elapsed and no data are yet available to allow the progress of the programme to be
meaningfully assessed against the logframe indicators.
However, such an assessment will be possible at the next annual review: by then the baseline
surveys will be complete, and data will have been collected against a full year of
implementation.
Output 1: Enhanced health service delivery and quality in DFID-supported health zones
Unable to assess at this stage (baseline)
Output 2: Increased empowerment and accountability in health service planning and
delivery in DFID-supported health zones
Unable to assess at this stage (baseline)
Output 3: Improved access to health services in DFID-supported health zones
Unable to assess at this stage (baseline)
Output 4: Increased and sustainable access to safe drinking water, improved sanitation,
hygiene education and better environmental health in rural and peri-urban communities
Unable to assess at this stage (baseline)
Output 5: Enhanced government capacity for key functions (RCI programme)
Unable to assess at this stage (baseline)
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Section B: Results and Value for Money
1. Progress and results
1.1 Has the logframe been updated since last review?
IMA have proposed changes to the logframe, and the milestones now need to be completed and
updated in view of the larger number of health zones than originally anticipated, and the outcomes of
the design phase. This should be done through a joint working session between DFID and IMA in the
coming weeks, and given the scale and complexity of the programme should ideally be supported by
the DFID drawdown function for logframe reviews.
1.2 Overall Output Score and Description:
Unable to assess at this stage (baseline). The overall progress of the programme is on-track, and for
this reason an interim output score of A is applied.
1.3 Direct feedback from beneficiaries
During the design phase, the design team met and consulted with a wide range of political authorities,
health management teams and civil society representatives. In total, three Governors, four provincial
Ministers for Health, four provincial Medecins Inspecteurs, five Medecins Chefs de Districts, 58 health
zone management teams, 20 religious leaders and 11 civil society organisations were consulted.
Feedback from the central Ministry of Health on the progress and approach of the programme has
consistently been positive. MoH have been closely engaged in the design and early implementation of
the programme. It is anticipated that the Ministerial Decree to formally establish the steering group for
the programme (with joint membership from GoDRC, donors and IMA) will soon be signed.
Limited direct feedback on the programme is currently available from political authorities at the
provincial level, or from provincial and health zone management teams. During the field visit to
Maniema and Province Orientale, there was evidence that provincial and health zone authorities and
management teams do not yet have a sufficient understanding of the programme, the manner of its
implementation (and how this differs to that of the previous programme), and their role in this.
No direct feedback from service users is yet available for this first annual review. For future annual
reviews, it is anticipated that this will become available through the operational research / impact
evaluation and community empowerment and accountability components of the programme, as well as
less formally through direct interaction with service users and the wider community during field visits.
1.4 Summary of overall progress
Overall progress achieved by ASSP since approval of the business case is as follows:
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A procurement process has been carried out in order to identify the lead implementation partner
for the programme, according to OJEU procedures. This resulted in the selection of IMA World
Health as the lead implementation partner, in consortium with technical partners who will provide
specific expertise for key aspects of the programme such as reproductive health and operational
research / impact evaluation. Further detail of the procurement process is provided in the section
on value for money.
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The programme has undergone a design phase, in collaboration between the programme
consortium (IMA World Health and its partners), DFID and the Ministry of Health. This involved
identification of the health zones to be supported, visits to four of the provinces involved in order
consult with stakeholders and assess needs, and preparation of plans for implementation.
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The institutional arrangements for the programme are now largely in place:
o IMA World Health have selected the implementation partners that will provide direct support
to health service delivery at the level of individual health zones, and have put into place sub-
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contract with these organisations (World Vision in Equateur, SANRU in Kasai Occidental,
Caritas Congo in Province Orientale and Maniema, and IRC in South Kivu).
o Programme staff have been selected by IMA and its consortium partners, and all but a few
posts (eg a WASH lead, a gender lead and a healthcare management information systems
specialist) have been filled.
o The programme steering committee (with membership form DFID, IMA and MoH) has not yet
been established, but the MoH is currently preparing an Arrête Ministeriel for this purpose, and
in the meantime there have been regular joint meetings between the parties to monitor and
guide the design and early implementation of the programme.
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A systematic situational analysis of the health zones and facilities that will be covered by the
programme has been carried out. This offers a valuable repository of information for detailed
planning, and for documenting the achievements of the programme.
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Medical supplies, vehicles and equipment are being procured, and this has been a key activity
during the early stages of the programme.
o To date, IMA have been managing procurement directly, through international suppliers. This is
considered a largely interim measure in order to maintain continuity of supplies in existing
health zones and across the programme as a whole, whilst the capacity of national drug
procurement agencies and depots (under the FEDECAME system) is strengthened. Over time,
IMA plan to progressively transition from international procurement to procurement through
national agencies and depots. With this in mind, IMA have conducted an assessment of the
capacity of these facilities in each of the programme areas.
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Health facilities in need of construction or rehabilitation have been systematically identified.
Construction has not yet commenced, but there is evidence that planning for this has progressed
well.
o At present, IMA plan to build 350 health centres and to rehabilitate a further 323 (120 health
centres have been identified as not being in need of rehabilitation).
o IMA have proposed modifications to the government-approved plans for health centres, and are
preparing architectural plans of these for confirmation.
-
Good progress has been made in strengthening data systems for health service management,
and there are strong signs that this has been taking place in close collaboration with MoH:
o DHIS2 has been adopted by the Ministry of Health (pending final sign-off by the Minister) as the
software platform for healthcare management information systems (HMIS) and fifteen
individuals from the Ministry of Health have been trained in its use.
o Planned next steps include supporting the configuration of DHIS2 to meet the specific HMIS
needs of DRC, provision of IT equipment to health zones, training of health zone management
teams and healthcare workers, and piloting of the system in health zones and provinces
supported by ASSP.
Renforcement des Capacités Institutionnelles (RCI)
The RCI project was approved alongside ASSP, but is being managed separately. The project seeks to
improve core functions of the Ministry of Health such as stewardship/leadership, facilitating an enabling
environment for service delivery (from a range of providers), policy setting, implementation/ quality
control and information management.
The total budget for RCI is £5.21 million over the period 2012/13 and 2017/18. £1.3 million has been
allocated to support the Demographic Health Survey (see below), and further interventions to
strengthen Ministry of Health capacity are currently being identified.
Demographic Health Survey (DHS)
The Demographic Health Survey entered implementation at the beginning of 2013, after delays during
the planning process. DFID is providing its contribution to the DHS through a Memorandum of
Understanding with UNICEF. The Minister of Plan chairs the steering committee on a quarterly basis
and this meeting is attended by other donors and ICF Macro, the technical partner for implementation
of the DHS. A technical committee also meets once a fortnight to discuss operational issues.
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The pilot survey has been undertaken and fully evaluated. The findings of the evaluation will be used to
refine the methodology and survey tools. Currently, field workers are being trained in using the tests for
biomarkers. The survey will formally commence in August 2013 and is due to be completed by end
June 2014. This coincides with the termination of World Bank and USAID funding and will allow for
reporting against the 2015 Millenium Development Goals.
1.5 Key challenges
Community empowerment and accountability
During the design phase, the plans that were developed for the community empowerment and
accountability component of the programme were not felt by IMA and DFID to be sufficiently strong to
proceed with in their current form. For this reason, IMA elected to not to continue with its consortium
partner for this element, but instead to develop their own proposals for community empowerment and
accountability. This was agreed to, on the understanding that the default option would be to install a
new technical lead for this crucial area of the programme, if IMA’s own proposals are not themselves
felt to be sufficiently robust. These proposals have recently been received and are being considered.
Procurement and distribution
Although procurement of medical supplies and equipment have taken place fairly smoothly since the
start of the programme, there have been difficulties, particularly in relation to distribution of drugs to
existing health zones:
- There have been stock-outs of Artemisinin-based Combination Therapies (ACTs, for treating
malaria) in Maniema. IMA have reported that this was due to insufficient production to meet
demand from ASSP and other programmes, and anticipated that supplies would once again
become available within a week (and would be flown into Maniema to minimise further delay).
- Also in Maniema, whilst other drug supplies have been arriving in that province, there have been
delays in distributing these on to health facilities, resulting in stock-outs. The reasons for this are
not clear, but it seems that imperfect communication between IMA and its implementing partner in
Maniema (Caritas Congo) may have played a part. Current information is that stock-outs have also
occurred in Kasai Occidental.
1.6 Annual Outcome Assessment
The outcome for this programme is “Increased coverage with essential reproductive, maternal and
child health services in DFID-supported health zones”. It is too early to assess the programme in
relation to the achievement of its outcome.
2. Costs and timescale
2.1 Is the project on-track against financial forecasts:
Yes. To date, approximately 4.5% of the budget has been spent, in the course of the design phase
(October 2012 to March 2013) and the first quarter of implementation (April-June 2013). This first
quarter represents 5% of the total duration of implementation. On this basis, the programme is on-track
to remain within budget over its lifespan, particularly as a number of costs (supplies and equipment,
salary supplements) are relatively front-loaded into the earlier part of the programme.
2.2 Key cost drivers
The table below presents spending of the programme to date, including on the design phase (ie from
October 2012 until present). So far, £8.1 million has been spent out of a total budget of £182.9 million.
The major cost drivers have been procurement of supplies (drugs, mosquito nets, equipment),
vehicles, solar panels, staff costs and management fees.
A disproportionate amount of spending has taken place on supplies, vehicles and solar equipment,
which is explained by the front-loading of procurement of these items as full implementation is
prepared for. Conversely, little has been spent on construction or on Village Assaini (water and
sanitation), as these activities have not yet commenced.
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Expenditure to date
Percentage of
expenditure
Medicines, supplies and equipment
£4,048,818
49.7%
Personnel costs
£962,611
11.8%
Management costs
£685,140
8.4%
Solar panels
£571,058
7.0%
Salary supplements for health staff
£364,030
4.5%
Transport
£169,077
2.1%
Storage and office space
£158,464
1.9%
Construction & Rehabilitation
£11,078
0.1%
Communications
£2,198
0.0%
Water and sanitation
£0
0.0%
Other
£1,180,959
14.5%
TOTAL
£8,153,433
Note: ‘Other’ covers a range of items such as vehicles, training, developing promotional materials and radio
messages, management of epidemics and emergency situations and Data Quality Audits.
2.3 Is the project on-track against original timescale:
The initial expectation was that early implementation of ASSP would commence during the final part of
Access to Healthcare, in order to create a period of parallel implementation that would facilitate
transition between the two programmes. In the end, ASSP did not become operational until shortly
before Access to Healthcare came to an end on 31 March. This was due to delays in key aspects of
the design process, which took longer than expected and had knock-on effects on one other: for
example, final selection of health zones was not completed until November; this in turn led to delays in
the process for selecting implementing partners, which itself then took longer than anticipated. There
have also been delays in finalising plans for certain sub-components of the programme, namely
community empowerment and accountability and WASH.
Despite these delays, the overall progress of the programme remains on track in relation to the
timescale. Implementing partners were selected and in place (albeit under interim sub-contracts) in
time for transition at the beginning of April, drugs and other supplies have been procured and have
been arriving in-country, and scale-up into new health zones in Kasai Occidental and Equateur –
planned to take place in July – is now ready to proceed.
3. Evidence and Evaluation
3.1 Assess any changes in evidence and implications for the project
No changes in evidence have emerged that have implications for the programme at this stage. The
operational research and impact evaluation component of the programme will generate evidence from
the programme itself. This will allow minor or major adjustments to be made as required during
implementation, as well as informing wider policy discussions. Key areas where this will take place are
in relation to user fees and access to health services, and the extent to which government reforms and
payment of healthcare worker salaries will be sufficient to allow the programme to achieve maximum
impact.
3.2 Where an evaluation is planned what progress has been made?
A substantial operational research and impact evaluation component is planned for the programme,
and this is being led by Tulane University / University of Kinshasa. To date, a protocol has been
developed for data collection at baseline, midpoint and endpoint, which will enable to overarching
impact of the programme to be determined. This includes plans to compare progress in ASSP health
zones with that in unsupported health zones, to permit a degree of attribution of change to the
programme. Additional operational research protocols are being developed, including for studies to
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examine the relationship between user fees and other determinants of health service utilisation, and
the impact of community empowerment and accountability upon service delivery and quality.
4. Risk
4.1 Output Risk Rating:
High
4.2 Assessment of the risk level
At this early stage of implementation, the overall risk level for this programme is deemed to be high, for
the following reasons:
-
The large scale and complexity of the programme: ASSP is being implemented by a consortium
of no fewer than nine members, and consists of multiple domains (such as strengthening
national drug procurement and supply systems, developing data systems for healthcare and
human resource management, and community empowerment and accountability). Managing
and coordinating these multiple organisations and areas of activity will almost certainly be
challenging.
-
The delivery model for this programme: Avoiding or phasing out the payment of salary
supplements (primes) to frontline healthcare workers whilst simultaneously adopting a much
reduced NGO presence than was the case in Access to Healthcare gives rise to greater
fiduciary risk, as staff have both a greater incentive and a greater opportunity to commit fraud.
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The nature of the intervention: The current programme design is based upon a number of
assumptions (such as willingness and ability to pay for services). Given that not all of these
assumptions will necessarily hold, it is crucial that the programme recognises and tests them,
and is prepared to adapt as needed (this includes being able to respond to adverse or
favourable changes in context, for example if the Government opted to adopt a policy of gratuité
in the health sector).
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The operating environment: Most of the areas where the programme will be implemented offer
minimal physical and institutional infrastructure to support service delivery or the activities of the
programme partners. By way of illustration, it takes two days to reach Punia health zone by
road.
Whilst these risks are considerable, each is accompanied by potential benefits:
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The diverse nature of the consortium brings with it considerable capacity and a broad range of
expertise and experience, and the ambitious scope and scale of the programme have the
potential to achieve maximum impact through comprehensive support to the health system at
scale.
-
The delivery model reduces the risk of substituting the role of government, and leaves space for
provincial and health zone management teams to assume greater responsibility for service
delivery.
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The intervention has the potential to provide cost-effective support to service delivery, and to
achieve an incremental shift towards more sustainable financing of the health system.
-
With the challenging operating environment comes a high level of unmet need, and potential for
positive impact.
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4.3 Risk of funds not being used as intended
The complexity of the programme, the presence of multiple downstream partners, the phasing out of
salary supplements for frontline healthcare workers and the large investment in mobile assets
(vehicles, drugs, equipment and construction materials) create added risk of misuse of funds in this
programme. IMA are a credible partner in managing this risk, and have experience of doing so in
similar programmes in DRC. A Due Diligence Assessment of IMA has been performed and this has
identified a number of opportunities to optimise the management of fiduciary and other forms of risk in
ASSP.
4.4 Climate and Environment Risk
During the annual review IMA presented innovative plans for minimising adverse environmental effects
of construction, including the use of stabilised blocks as a cheaper, more durable and less damaging
alternative to fired bricks. Low-consumption low-smoke industrial and domestic stoves are to be trialled
for the sterilisation of equipment at hospital and health centres respectively. IMA have begun to
procure solar equipment for health facilities, and plan to install a solar-powered fridge for every two
aires de santé in the programme.
The climate and environment assessment for the business case anticipated that the programme would
present a low level of risk and a medium level of opportunity, and at present there is no evidence that
this assessment should change.
4.5 Other cross-cutting issues
Conflict and resilience
IMA have established from their situational analysis that 69% of health zones covered by the
programme have a ‘very calm’ security situation, and 22% have a ‘moderately calm’ security situation.
No health zones were identified as being insecure, although in 9% of health zones the security
situation was not determined. The programme would benefit from a clear strategy for understanding
and responding to the specific risks and causes of conflict in individual health zones and for achieving
health system resilience in emergency situations.
Gender
A gender review was carried out as part of the annual review by participants in the workshop, using the
standard DFID DRC methodology. This has ascertained that the programme currently has an amber
rating for gender.
Criterion
Does the programme
design include
comprehensive analysis of
the situation of women and
girls?
Observations
Amber: The programme design includes a
degree of analysis of the situation of women and
girls, but this cannot be considered to be
comprehensive. It was anticipated that this would
be included in the baseline situational analyses
performed in each of the health zones, but it is
not clear that this has been done. There is as yet
no specific gender strategy for the programme.
Recommendations
A gender strategy should be
developed, and be based upon
comprehensive analysis of the situation
of women and girls in the health zones
to be supported.
Does the logframe include
results and indicators
relating to W&G, and those
that include transformative
change?
Amber: The logframe includes indicators that
relate specifically to women and girls, and
disaggregation of indicators by age is planned.
However, the current logframe does not fully
capture transformative change for women and
girls (although utilisation rates disaggregated by
gender will do so to an extent).
As the community E+A component is
further developed, at least one
indicator that captures the
transformative impact of this for women
and girls should be considered for
inclusion in the logframe.
Does the Theory of
Change explicitly refer to
W&G throughout?
Amber: The proposed revised TOC presented by
IMA refers explicitly to women and girls, but does
not demonstrate how outcomes for women and
girls are expected to be achieved, and what
change will occur as a result.
A specific theory of change for gender
should be developed as part of the
gender strategy for the programme.
Does programme have
elements that seek to
address discriminatory
socio-cultural norms?
Amber: Implementation plans demonstrate some
awareness of discriminatory socio-cultural
norms, but this is not yet sufficiently systematic,
nor is it clear yet to what extent and how these
The gender strategy should include an
analysis of such norms in the health
zones that will be supported, and
present realistic plans for challenging
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will be challenged through the programme.
these through the programme.
Does programme contain
specific measures on
adolescent girls?
Green: The programme contains specific
measures for providing services to adolescents,
including sexual and reproductive health
services.
Plans for meeting the needs of
adolescents now need to be
operationalized, and should as much
as possible be included in the
community empowerment and
accountability component. The
programme should reflect on the extent
to which provision of SRH services to
adolescents is constrained by the legal
framework, and discuss with DFID
where there may be opportunities to
seek change.
Does the programme have
appropriate and adequate
plans and resources for
gender technical support?
Green (provided this is implemented): During the
annual review, IMA and Pathfinder confirmed
that a gender lead will be recruited in the coming
weeks, and that this individual will be responsible
for overseeing development and implementation
of a gender strategy for the programme.
A clear job description should be
developed, in order to obtain the
appropriate scope and level of gender
expertise.
Do implementing partners
demonstrate a strong
commitment to gender
issues, have adequate
gender capacity and a clear
gender action plan?
Amber: The evidence for this is currently
incomplete. A gender lead and a gender action
plan are not yet in place, but commitments to
these have been provided by the consortium.
The level of commitment to gender
issues will need to be further assessed
at the next and subsequent annual
reviews.
Are the programme-specific
commitments in the Action
Plan for Adolescent Girls
under implementation?
Overall
Amber: These commitments have been partly
addressed.
The commitments need to be
addressed in the gender strategy for
ASSP.
Amber
5. Value for Money
5.1 Performance on VfM measures
It is not yet possible to substantially assess performance in relation to specific VfM measures, beyond
the extent to which this was done during the commercial evaluation during the procurement process
through which IMA was selected as the consortium lead. Unit costs for activities and outcomes will
become available for benchmarking during implementation.
5.2 Commercial Improvement and Value for Money
There was a strong response to the call for tenders for the contract under which this programme is
being implemented. Cost-effective delivery of health supplies and equipment will be a major factor in
the success of this programme. IMA originated as a supplier of equipment and their winning bid
showed an excellent understanding of procurement issues as well as a strong vision for the
programme as a whole.
A set of Key Performance Indicators will be used to test performance, and these will be assessed at
the next annual review. 10% of the management/technical assistance budget line allocation is
contingent on satisfactory attainment these key performance indicators.
5.3 Role of project partners
There are currently nine direct project partners in the consortium that is implementing ASSP:
- IMA World Health (consortium lead)
- Technical leads: Pathfinder (reproductive health), Tulane University / University of Kinshasa
(operational research and impact evaluation), HISP (healthcare management information
systems) and Intrahealth (human resource information systems). A replacement technical lead
for community empowerment and accountability now needs to be identified.
- Implementing partners: SANRU (Kasai Occidental), World Vision (Equateur), IRC (South Kivu)
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and Caritas Congo (Maniema and Province Orientale).
DFID’s interface with the programme is primarily through IMA. As consortium lead, the role of IMA is to
manage delivery by downstream partners, set the overarching operational framework for the
programme, and to manage essential activities such as procurement and infrastructure development.
Technical leads are responsible for providing the programme with specific expertise in key areas, and
for supporting the implementing partners to deliver in each of those areas. The implementing partners
in turn are responsible for directly providing support to service delivery at health zone level.
This arrangement has the potential to provide a coherent but flexible approach to service delivery
across a large number of health zones, supported by specialist expertise. However, its success will rely
upon good coordination and communication between the consortium members, with clear allocation of
roles and responsibilities. These relationships are just now beginning to be tested as the programme
moves into implementation, and IMA must continue to ensure that they function well throughout. This is
a key operational aspect of ASSP that should be regularly scrutinised, including at subsequent annual
reviews.
5.4 Does the project still represent Value for Money:
Yes. The value for money assumptions set out in the business case still hold. The extent to which they
continue to do so will become more apparent over the course of implementation, and will be further
examined at subsequent annual reviews.
5.5 If not, what action will you take?
Not applicable.
6. Conditionality
6.1 Update on specific conditions
Not applicable.
7. Conclusions and actions
Overall, ASSP has performed adequately so far, and has met expectations. Although there have been
some problems, the transition from Access to Healthcare to ASSP has taken place reasonably
smoothly, and the foundations of the new programme are now in place. Significant early progress has
been seen in key areas such as procurement, infrastructure and healthcare management information
systems.
This performance is reflected in an interim score of A (met expectation), pending availability of
baseline and milestone data at the next annual review. However, this is a very early stage of the
programme, and the coming challenges are considerable: with this comes a high level of risk.
The following recommendations for the programme emerge from this annual review:
1. Continued progress is needed by the programme to proactively identify risks and assumptions,
and to address these. More effective use needs to be made of theories of change to systematically
identify those risks and assumptions. Once these risks and assumptions have been identified,
strategies for managing the risks and testing the assumptions need to be further developed,
including through operational research and contingency planning.
2. The diversity of the consortium charged with delivering the programme represents a major asset,
but also brings with it risks. IMA need to give ongoing high priority to good coordination and
effective communication between consortium members, supported by clear definition of roles.
3. Related to this, clear communication of the programme to stakeholders – including to service
providers, healthcare workers and communities - is essential if those stakeholders are to develop a
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sense of ownership of and commitment to it. Over the coming months, IMA should give high priority
to articulating the programme and its approach to stakeholders, both directly and indirectly through
its implementing partners. At the same time, DFID DRC should seek to maintain as high a level of
interaction with provincial authorities as possible, in order to strengthen awareness of the
programme at that level and generate commitment to it.
4. Management of drugs and supplies present a further specific area of risk to the programme, as is
often the case with programmes such as this. IMA should develop and present an action plan for
managing this risk (particularly in Maniema where drug management is thought to particular need
of strengthening) in order to avoid stock-outs and minimise fiduciary risk.
5. Community empowerment and accountability is a crucial component of the programme, and
finalisation of the plans for this should be considered a high priority. DFID will provide IMA with
feedback on its proposals for community empowerment and accountability, and will work with IMA
to identify an alternative technical lead if necessary.
6. The logframe needs to be reviewed and updated, ideally with support from drawdown service.
7. A gender strategy should be developed for the programme, as well as a strategy addressing
issues of conflict and resilience.
8. Review Process
The annual review process consisted of a field visit to Maniema and Province Orientale, followed by a
workshop hosted by IMA World Health (with participation by the consortium partners, DFID DRC
health, social development and evaluation advisers, and the Ministry of Health).
In view of the scale and complexity of ASSP, for the next annual review DFID DRC should consider
forming a team of relevant advisers (with additional external capacity if required) in order to carry out a
detailed assessment of each component of the programme.
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