USAID/SOUTH AFRICA: INTEGRATED 
PRIMARY HEALTH CARE PROJECT
END OF PROJECT PARTICIPATORY EVALUATION
NOVEMBER 2010
This publication was produced for review by the United States Agency for International Development 
(USAID). It was prepared by William Emmet, Lindsey Carpenter Toomey, and Swati Sadaphal through 
the Global Health Technical Assistance Project.
Cover Photo: William Emmet, Moretele Clinic, Bojanala District, North West Province, October 2010
USAID/SOUTH AFRICA: INTEGRATED 
PRIMARY HEALTH CARE PROJECT 
END OF PROJECT PARTICIPATORY EVALUATION 
DISCLAIMER 
The authors’ views expressed in this publication do not necessarily reflect the views of the 
United States Agency for International Development or the United States Government. 
This document (Report No. 10-01-429) is available in printed and online versions. Online 
documents can be located in the GH Tech website library at resources.ghtechproject.net. 
Documents are also made available through the Development Experience Clearing House 
(dec.usaid.gov). Additional information can be obtained from: 
The Global Health Technical Assistance Project 
1250 Eye St., NW, Suite 1100 
Washington, DC 20005 
Tel: (202) 521-1900
Fax: (202) 521-1901
info@ghtechproject.com 
This document was submitted by The QED Group, LLC, with CAMRIS International and Social 
& Scientific Systems, Inc., to the United States Agency for International Development under 
USAID Contract No. GHS-I-00-05-00005-00.
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION i 
ACKNOWLEDGEMENTS 
The GH Tech IPHC Evaluation Team worked in participation with Malik Jaffer (USAID), Mariah 
Boyd-Boffa (MSH), and Tendani Muthambi of The Integrated Primary Health Care Project 
(IPHC), and thanks the United States Agency for International Development in South Africa for 
commissioning the evaluation of the Integrated Primary Health Care Project and for selecting us 
to undertake this challenging task. The time, patience, goodwill, and depth of knowledge of the 
132 persons interviewed as part of this evaluation made it possible for the team to understand 
the significance of the many and diverse reports and technical interventions associated with 
IPHC’s multiple technical initiatives. The willingness of IPHC staff to provide us with a full array 
of project documentation and to share with us their thoughts on the project’s development and 
their perspectives regarding the IPHC’s initiatives was of significant importance in assisting us to 
understand the complex nature of the challenges associated with meeting IPHC objectives. The 
importance of the contribution of Ms. Anita Sampson, USAID’s COTR for the IPHC to this 
evaluation in terms of framing its technical methodology, cannot be overstated. Finally, the 
evaluation team greatly appreciates the time set aside by the representatives of the National 
Department of Health and of the districts and sub-districts in the five IPHC provinces to meet 
with us and discuss the progress of the IPHC. 
The evaluation team is especially appreciative of the time spent with facility and OVC program 
staff to discuss the effectiveness and sustainability of IPHC initiatives, in seeking to respond to 
the challenge of HIV and AIDS through integration of primary health care services. The six 
members of this evaluation team acknowledge, with thanks and appreciation, the entire staff of 
the IPHC for having assisted us in the many logistical and administrative details associated with 
this evaluation. While many IPHC staff have contributed to this effort, we would like to 
particularly thank Dr. Tracey Naledi, IPHC Chief of Party, and Ms. Tendani Muthambi for their 
invaluable role in securing and scheduling our interviews as well as ensuring that we met with 
the wide range of participants and stakeholders of the IPHC project. Finally, the evaluation team 
expresses its appreciation to the staff of GH Tech, most especially Ms. Taylor Napier, for having 
provided us with administrative support throughout this interesting and challenging assignment. 
ii USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION iii
CONTENTS 
ACRONYMS .......................................................................................................... vii
EXECUTIVE SUMMARY ..................................................................................... ix
I. INTRODUCTION ......................................................................................... 1
II. BACKGROUND ............................................................................................ 3
Overview of PHC in South Africa..................................................................................................3
USAID Strategies and Priorities......................................................................................................3
Description of IPHC Program .........................................................................................................3
IPHC Organizational Structure .......................................................................................................4
IPHC Financial Data .............................................................................................................................4
III. METHODOLOGY ......................................................................................... 7
IV. FINDINGS BY STRATEGIC PERFORMANCE AREA (SPA) ................... 9
SPA 1: Maternal Health and Family Planning.............................................................................9
SPA 2: Child Health ......................................................................................................................... 11
SPA 3: Youth Programs.................................................................................................................. 14
SPA 4: HIV and AIDS ...................................................................................................................... 16
SPA 5: PHC Systems and Services............................................................................................. 20
SPA 6: Orphans and Vulnerable Children............................................................................... 24
V. BEST PRACTICES....................................................................................... 27
VI. STRENGTHS AND WEAKNESSES .......................................................... 29
IPHC Strengths................................................................................................................................... 29
Weaknesses.......................................................................................................................................... 31
VII. CONSTRAINTS........................................................................................... 33
VIII. LESSONS LEARNED .................................................................................. 35
IX. DISCUSSION ............................................................................................... 37
Alignment Between Donor/Contractor/DOH ...................................................................... 37
Human Resources.............................................................................................................................. 37
Management and Leadership Capacity ...................................................................................... 38
A Nationwide Culture of Entitlement and Dependency.................................................... 38
Cultural and Religious Beliefs Present a Significant Barrier to 
Fully-integrated PHC ........................................................................................................................ 38
X. RECOMMENDATIONS .............................................................................. 39
Improve the Use of Data for Decision-making Purposes.................................................. 39
Improve System-wide Accountability......................................................................................... 40
Improve the Uptake And integration of FP/RH into PHC Services............................... 40
Improve the Quality of Senior-level Technical Supervision.............................................. 41
Improve the Effectiveness of Supportive Supervision.......................................................... 41
Address Human Resource for Health Challenges................................................................ 42
iv USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Remove Barriers to the Effectiveness of the PHC Review Process.............................. 43
Enhance the Synergy among all Levels: National to Community.................................... 43
Enhance the Practical Application of the DHER and the DHP........................................ 44
Strengthen Effectiveness and Sustainability of Donor Assisted Initiatives................... 45
ANNEXES 
ANNEX A. SCOPE OF WORK .......................................................................... 47
ANNEX B. IPHC EVALUATION CONTACTS ............................................... 63
ANNEX C. IPHC KEY BACKGROUND DOCUMENTS REVIEWED 
MSH CONTRACTS......................................................................... 71
ANNEX D. IPHC EVALUTION SCHEDULE ................................................... 73
ANNEX E. INTEGRATED PRIMARY HEALTH CARE PROJECT (IPHC) 
END-OF-PROJECT PARTICIPATORY EVALUATION ............. 79
ANNEX F. IPHC: INTERVIEW SUMMARY ..................................................... 83
ANNEX G. MSH/IPHC EXTENSION PROPOSAL ......................................... 85
TABLES 
Table 1. PHC Summary Financial Data (in USD) ........................................ 4
Table 2. IPHC Project Evaluation Interview Respondent Affiliations 
and Totals............................................................................................ 8
Table 3. Progress on USAID/IPHC Indicators for SPA 1. Maternal Health 
and Family Planning ......................................................................... 10
Table 4. Progress on National Department of Health Indicators for SPA 1. 
Maternal Health and Family Planning ........................................... 10
Table 5. IPHC South Africa Evaluation: Assessment of Effectiveness and 
Sustainability of Strategic Performance Area Key Initiatives ..... 11
Table 6. Progress on USAID/IPHC Indicators for SPA 2. Child Health ... 12
Table 7. Progress on National Department of Health DHIS Indicators for 
Spa 2. Child Health ......................................................................... 12
Table 8. IPHC South Africa Evaluation: Assessment of Effectiveness and 
Sustainability of Strategic Performance Area Key Initiatives ..... 14
Table 9. IPHC SPA 3. Youth Program: Progress on Selected Indicators 15
Table 10. IPHC South Africa Evaluation: Assessment of Effectiveness and 
Sustainability of Strategic Performance Area Key Initiatives ..... 16
Table 11. Progress on USAID/IPHC Indicators for SPA 4. HIV/AIDS ........ 17
Table 12. Progress on National Department of Health DHIS Indicators for 
SPA 4. HIV/AIDSs ............................................................................ 18
Table 13. IPHC South Africa Evaluation: Assessment of Effectiveness and 
Sustainability of Strategic Performance Area Key Initiatives ..... 19
Table 14. IPHC South Africa Evaluation: Assessment of Effectiveness and 
Sustainability of Strategic Performance Area Key Initiatives ..... 20
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION v 
Table 15. Progress on USAID/IPHC Indicators for SPA 5. PHC Systems 
and Services ...................................................................................... 22
Table 16. IPHC South Africa Evaluation: Assessment of Effectiveness and 
Sustainability of Strategic Performance Area Key Initiatives ..... 24
Table 17. Progress On USAID/IPHC Indicators for SPA 6. Orphans and 
Other Vulnerable Children ............................................................. 25
Table 18. IPHC South Africa Evaluation: Assessment of Effectiveness and 
Sustainability of Strategic Performance Area Key Initiatives ..... 26
FIGURES 
Figure 1. IPHC Provinces and Districts ............................................................... 3
Figure 2. PSP-E Organization Chart .................................................................... 5
vi USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION vii 
ACRONYMS 
AIDS Acquired immune deficiency syndrome 
ANC Antenatal care 
ARV Antiretroviral 
ART Antiretroviral therapy 
AZT Zidovudine 
CBO Community-based organization 
CD4 Helper T cell 
CHC Community health center 
CHW Community health worker 
C&T Counseling and testing 
DHER District Health Expenditure Review 
DHIS District Health Information System 
DHP District Health Plans 
DHS District Health System 
DOH Department of Health 
DOTS Directly Observed Therapy Short-Course 
EPI Expanded Program on Immunization 
EOP End of project 
FP Family planning 
GH Tech Global Health Technical Assistance Project 
HAST HIV, AIDS, STIs and TB
HBC Home-based care/caregiver 
HCT HIV counseling and testing 
HIV Human immunodeficiency virus 
HRH Human resources for health 
HST Health Systems Trust 
IMCI Integrated management of childhood illnesses 
IPHC Integrated primary health care project 
IR Intermediate results 
IDU Intravenous drug user 
IUD Intrauterine contraceptive device 
KAP Knowledge, attitude, and practice 
KPA Key performance area 
LDP Leadership Development Program 
MCH Maternal and child health 
MCWH Maternal, child, and women’s health
MSH Management Sciences for Health 
NDOH National Department of Health 
MOU Memorandum of understanding 
viii USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
NGO Non-governmental organization 
OVC Orphans and vulnerable children 
PCR Polymerase chain reaction test 
PHC Primary health care 
PMTCT Prevention of mother-to-child transmission 
QA Quality assurance 
RH Reproductive health 
SAG South African Government 
SOP Standard operating procedures 
SPA Strategic performance area 
STI Sexually transmitted infection 
TA Technical assistance 
TASCII Technical Assistance Support Contract II 
TB Tuberculosis 
TOT Training of trainers 
URC University Research Corporation 
USG U.S. Government 
USAID United States Agency for International Development 
YFS Youth-friendly services 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION ix
EXECUTIVE SUMMARY 
The Integrated Primary Health Care Project (IPHC) in South Africa is a collaborative project 
between the South African National Department of Health (NDOH); eight selected districts 
from five provincial Departments of Health from Eastern Cape, KwaZulu-Natal, Limpopo, 
Mpumalanga and North West; and the United States Agency for International Development in 
South Africa (USAID/SA). IPHC began in July 2004 and will end December 30, 2010, with 
Management Sciences for Health (MSH) as the prime contractor. In October and November 
2010, the Global Health Technical Assistance Project (GH Tech) was commissioned to 
undertake an IPHC end-of-project evaluation. Designed by USAID/SA as a participatory 
evaluation, the evaluation team was comprised of three persons from GH Tech Team, one 
person from USAID/SA, and two from MSH. When available, representatives from the NDOH 
joined the evaluation team during site visits to the IPHC-assigned districts. The evaluation 
focused on: 
Review of project results (outputs and outcomes) in relation to the project’s six strategic 
performance areas (SPAs); 
Assessment of the project’s strengths, weaknesses, gaps in service delivery, and any 
constraints to successful implementation; and 
Identification and documentation of best practices, lessons learned, and recommendations 
to inform future activities focusing on sustainability. 
DESCRIPTION OF THE INTEGRATED PRIMARY HEALTH CARE 
PROGRAM 
IPHC builds upon the initiatives and achievements of USAID/SA’s EQUITY Project (1995–2004), 
focusing on supporting the work of the Department of Health and local partners. The project’s
purpose was to improve access to integrated primary health care services, with an emphasis on 
strengthening management systems in planning, financial management, human capacity 
development, and quality assurance (QA); ensuring that the achievements of the EQUITY 
Project are sustained. It is also a priority that long-term improvements continue under local 
management through collaboration with local stakeholders. 
In responding to the project’s purpose, IPHC was designed to provide technical assistance (TA) 
focused on six strategic performance areas (SPA): 
Maternal health and family planning (FP) (SPA1), 
Child health (SPA 2), 
Youth programs (SPA 3), 
HIV and AIDS (SPA 4), 
Primary health care (PHC) systems and services (SPA 5), and 
Orphans and vulnerable children (OVC) (SPA 6). 
Operating in the five of the nine South provinces (Eastern Cape, KwaZulu-Natal, Limpopo, 
Mpumalanga, and North West), the project has provided direct support to nearly 70 health 
facilities as well as to the management teams of eight districts selected in collaboration with the 
NDOH and the targeted provinces.
x USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
EVALUATION METHODOLOGY 
Description of Process 
The evaluation, scheduled during October 10 to November 12, 2010, was conducted using 
participatory approaches and methods and employed a combination of the following qualitative 
techniques: 
Review of relevant documents: In preparation for the evaluation and during the 
evaluation itself, the team reviewed project-related documents supplied by MSH and by 
USAID/SA.
Team planning and review meetings: At the start of the evaluation in South Africa, the 
GH Tech team met to agree upon the evaluative documents and process. In the process of 
the evaluation itself, the team held five team planning meetings that focused on summarizing 
the interim results of the evaluation and on the preparation of the evaluation report. 
Briefing meetings: At the beginning of the evaluation, the team met with relevant staff of 
NDOH, USAID/South Africa, and technical and management staff of MSH to discuss and 
reach agreement on the evaluative process and expected deliverables. Thereafter, the team 
met twice with the same individuals, first to provide them with a preliminary briefing during 
the third week of the evaluation, and then as a final briefing at the end of the evaluation to 
present findings incorporated in the first draft report. 
Interviews and site visits: The six-person team was organized into two teams that 
conducted simultaneous field trips to maximize exposure to field activities. Key informant 
interviews were conducted with senior provincial and district DOH staff, health facility staff, 
local non-governmental organizations (NGOs), and current IPHC staff. All interviews were 
conducted using a standardized interview template that, when practical, was emailed to 
respondents in advance of the interviews. A total of 132 respondents in 31 venues were 
interviewed during the course of the evaluation. At the completion of each day’s interviews, 
members of each of the teams met to summarize their findings, once again using a 
standardized interview summary template. 
Analysis and report writing: The evaluation team used interview and site visit results, 
document reviews, and other relevant sources to obtain a comprehensive and in-depth 
understanding of the IPHC project, in order to support sound analyses, arrive at inferences, 
and make actionable recommendations.
SUMMARY OF FINDINGS ACROSS STRATEGIC PERFORMANCE 
AREAS (SPA) 
The evaluation team assessed that IPHC achieved significant success in building upon the 
programmatic foundation established under the Equity project, and in the effectiveness of its 
introduction of new interventions, tools, and training programs to strengthen facility-level 
management and service delivery within each of the six SPA areas.
However, due to the lack of an exit plan complete with specific deliverable milestones specified 
at the project’s onset, IPHC has generally failed to ensure a measureable level of sustainability 
for interventions introduced during the course of the project.
As an aid to summarizing key findings associated with each SPA, a dashboard was developed by 
the evaluation team to illustrate the effectiveness and sustainability of key IPHC initiatives within 
each SPA. 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION xi
BEST PRACTICES 
―Best Practice‖ is defined as: A clearly defined intervention that is known to provide near optimum 
results every time it is correctly implemented. Accordingly, based on this definition, the following 
IPHC applications, interventions, and tools are best practices within the South African health 
context.
Cross-cutting IPHC Project Best Practices 
IPHC staff have nurtured and enhanced a sense of accountability with reference to the 
provision of technical assistance to all IPHC-supported sites by IPHC staff. 
Tools such as the Primary Health Care (PHC) Review and Supervision Guide have been 
instrumental in promoting effective supervision leading to integrated PHC services. 
IPHC’s approach to training facility staff in data management has led to enhanced 
understanding and proactive use of data for decision-making purposes. 
Specific Best Practices 
The extent to which district and facilities have effectively institutionalized application of the 
PHC review process stands out as one of the principle accomplishments of the Equity 
Project and of IPHC. 
IPHC’s training and promotion of facility mapping of their catchment areas has led to IPHC￾assisted facilities’ ability to more fully identify and respond to the needs of their 
communities. 
IPHC training in the development of clinic health committees has led to increased, effective 
collaboration between the facilities and the communities they serve. 
IPHC’s ability to work within the existing structures of orphans and vulnerable children 
(OVC) programs toward improvements in administrative and data management and 
marketing has enabled these programs to increase their ability to develop themselves as 
viable and sustainable entities. 
IPHC’s work with facilities and communities on the establishment of HIV and AIDS support 
groups has enhanced an environment in which people living with the disease can more 
effectively use services offered by the communities’ facilities.
STRENGTHS AND WEAKNESS 
In assessing IPHC’s strengths and weaknesses, the evaluation team focused on those elements of 
implementation that appeared to contribute or detract from the project’s effectiveness and 
sustainability. 
Accordingly, IPHC’s major strengths were the project’s effectiveness in training; in particular:
Introducing innovative management and supervision processes; 
Enhancing the ability of facility staff to understand and creatively use facility data for 
management purposes; 
Establishing effective collaboration and communication between facilities and the 
communities they serve; 
Nurturing, through its technical assistance management style, a positive and enabling 
environment between IPHC and facility staff. 
xii USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Conversely, IPHC’s major weaknesses were the project’s absence of an exit plan focused on 
sustainability; the abrupt cessation of support for IPHC initiatives; the lack of objective, on-going 
analytical tools and processes to measure the project’s progress toward sustainability; and the 
project’s limited attention to ensuring the relevance of IPHC project indicators with reference 
to monitoring and evaluation. 
CONSTRAINTS 
In assessing constraints associated with IPHC’s implementation, the evaluation team focused on 
those factors associated with IPHC’s implementation that appeared to be beyond the project’s 
ability to control, but nevertheless, that negatively impacted its ability to effectively implement a 
sustainable project. 
External factors or constraints impacting IPHC’s effectiveness and sustainability included South 
Africa’s acute deficit in human resources for health; its limited management, leadership, and 
primary health care (PHC) expertise within NDOH; a culture of dependency on donor 
assistance; and cultural and religious beliefs that limit the willingness of facility staff to provide 
reproductive health services as provided for in government policy. 
LESSONS LEARNED 
Lessons learned in IPHC’s implementation fall into the five thematic areas and can found in the 
sections below. 
Theme 1: Management and Leadership 
Management and leadership skills are essential for the sustainability of primary health care 
programs. 
If facility staff are to be effective, they must have ready access to qualified mentors. 
Skills gained through training dissipate if not regularly practiced. 
To remain current and motivated, facility staff must have access to scheduled in-service 
training. 
Teamwork and communication are key to effective provision of primary health care. 
Theme 2: Data Management 
A national integrated information system is essential to the monitoring and evaluation of the 
nation’s health care system.
For the purposes of effective decision-making, data must be accurate and timely. 
Agreement on core national health indicators assists program managers and health care 
providers to focus and monitor health priorities. 
Excessive amounts of data are a constraint to effective decision-making. 
Theme 3: Integrated PHC Services 
Traditional emphasis on ―silos‖ is an ineffective approach to primary health care delivery. 
Integrated services are the most effective means of providing comprehensive care and 
addressing the likelihood of missed opportunities in regards to access to and provision 
of care. 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION xiii 
Theme 4: Facility/Community Engagement 
Community involvement enhances the ability of communities to work together with facilities 
to respond to health care priorities. 
The development of ―youth friendly‖ services and youth mentors has been an effective 
means of reaching out to youth and encouraging them to utilize facility health services. 
Use of community health workers (CHWs) extends the ability of facility health care staff to 
provide quality and timely health care to the community. 
Cultural and religious beliefs present constraints to facility staff provision of reproductive 
health care as provided for in national health policy. 
Support groups for HIV and AIDS have been effective in responding to the needs of people 
with the disease and provide a model for other disease-specific support groups to emulate. 
Theme 5: Government and Donor Issues 
Collaboration between the government, donor agencies, and implementing contractors in 
the design of projects is essential to the sustainability of donor interventions. 
The design of exit plans for all donor initiatives, complete with measurable and deliverable 
milestones, is key to the sustainability of donor interventions. 
The ―disconnect‖ between the various levels of the DOH in terms of a thorough 
understanding of each level’s needs and priorities is a significant constraint to effective 
management and delivery of health care. 
Health facility employees, especially those working within rural areas, require an 
enhanced employment package to address inequalities and constraints associated with 
living conditions, access to training, and educational opportunities for themselves and 
their families. 
RECOMMENDATIONS 
Documentation associated with each of the following 10 recommendations in the body of this 
report includes the recommendations themselves; the context in which the recommendations 
are offered; and, if applicable, a discussion regarding the technical assistance required to 
implement a specific recommendation. For the purpose of this executive summary, only the 
recommendations are presented. 
Improve the Use of Data for Decision-making Purposes 
Recommendation 
The validity and reliability of the District Health Information System (DHIS) should be 
examined and an action plan to address the identified weaknesses should be implemented.
Improve System-wide Accountability 
Recommendation 
A system-wide organizational development study should be commissioned to assess and 
document current health system organizational strengths and weaknesses, and to develop a 
strategy and action plan to address identified weaknesses. It should be focused on the 
standardized application of national policies and guidelines. 
xiv USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Improve the Integration of Reproductive Health/Family Planning (RH/FP) 
into PHC Services 
Recommendation 
An RH/FP promotion communication strategy should be integrated into PHC services. The 
long-term focused strategy should be responsive to individual behavior change needs, and 
should maximize the potential for change on a broader societal level. 
Improve the Quality of Senior-level Technical Supervision 
Recommendations 
An accredited and accelerated master’s level curriculum with an emphasis on PHC 
management (including statistics and epidemiology), should be developed within South 
Africa’s academic institutions to address the need for professional training for all PHC 
managers at the level of sub-district and above. 
All current PHC managers at the level of sub-district and above (including national level) 
should be scheduled to undertake the accelerated curriculum. 
Successful completion of the master’s level PHC management curriculum should be a pre￾requisite for promotion of DOH employees to supervisory and managerial positions. This 
would apply to supervisors and managers who work outside the PHC setting, as PHC is the 
backbone of South Africa’s health care delivery system.
Improve the Effectiveness of Supportive Supervision 
Recommendations
The DOH should implement a standardized Leadership Development Program (LDP) based 
on the MSH model. 
MSH should design a LDP curriculum to be accredited in South Africa for developing a cadre 
of LDP facilitators in South Africa. Although MSH has recently trained 20 LDP trainers, the 
current MSH training of trainers (TOT) process was not designed for long-term post￾training support (at least 12 months) and for the South African certification of those who 
were trained. 
The DOH should introduce the LDP nationally at the sub-district and facility levels. District 
health management teams, provincial program managers, and national directors should all 
receive orientation to the LDP. 
Following orientation to the PHC review process, national level directors should conduct 
quarterly supportive supervision visits to facilities, and provincial senior managers should 
conduct monthly supportive supervision visits to facilities. 
As a KPA (key performance area) indicator, the sub-district manager should be responsible 
for ensuring that all facility staff are trained in technical protocols, and for implementing 
changes in a timely manner. 
All new health-service delivery staff should participate in a standardized orientation program 
that addresses all aspects of health service delivery at the facility level. 
As a KPA indicator for the facility operations manager, consistent provision of a 
standardized orientation program should be administered to all staff. 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION xv
Address Human Resources for Health Challenges 
Recommendations 
Review and standardize post-specific job descriptions for all levels. Job description review 
should be focused on clarification of responsibilities and on harmonization (e.g., removing 
duplications and overlap) among posts. 
Develop training courses for operations managers to build their capacity to ―work smart‖ 
that is, to work effectively with the limited time and resources available. 
Develop a simple handbook of standard operating procedures (SOP) based on an analysis of 
key tasks, responsibilities, authority and resources for district and sub-district managers as a 
daily reference guide. 
Develop a long-term strategy and action plan to rationalize current DOH staffing patterns at 
all levels. 
Remove Barriers to the Effectiveness of the PHC Review Process 
Recommendation 
A computerized program should be developed for the production of summary ―dashboards‖ 
linked directly to PHC review process data. 
Enhance the Synergy among all Levels: National to Community 
Recommendations 
The NDOH should undertake an exercise to map all PHC programs and focus on the 
development of a strategy to identify and reduce program overlap (harmonization). By 
utilizing gap analysis, the NDOH should also identify and respond to the needs of 
underserved areas. 
As a KPA indicator, central and provincial level staff program managers should be trained in 
PHC and use of the supervisory manual as a guide should be required to undertake 
quarterly (for central staff) and monthly (for provincial staff) supportive supervisory visits to 
health facilities. 
As part of their ―Work Smart‖ training course, facility operations managers should be 
provided with an orientation on the linkage between service delivery and national policy 
on PHC. 
The NDOH should develop and ensure the application of an operations manual for facility￾level catchment area mapping to include the location of villages and OVCs; the availability of 
caregivers, CHWs, and NGOs; and current PHC response priorities such as low 
immunization rates, prevalence and incidence of tuberculosis (TB), HIV, AIDS, diarrheal 
outbreaks, and absence of clean water supply. 
Enhance the Practical Application of the District Health Expenditure Review 
(DHER) and the District Health Plans (DHP) 
Recommendation 
The DHP should be reduced to essential action-oriented interventions complete with 
measurable indicators with a clear linkage to the DHER and available resources. 
xvi USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Strengthen Effectiveness and Sustainability of Donor-assisted Initiatives 
Recommendations 
The NDOH and all provinces included in a project should agree to all initiatives within 
donor-assisted projects as part of the project procurement process. 
All contractors should be required to develop an exit plan with clearly defined milestones 
within the initial three-month project implementation phase. 
All contractors should be required to prepare and present a quarterly review of progress 
against established milestones to the government and to USAID. 
All contractors should be required to prepare an action plan to respond to those areas in 
which identified milestones are behind schedule. 
At the highest level of project implementation, a specific government official should be 
identified and actively engaged as a project implementation counterpart to participate in 
monthly project reviews and in quarterly reviews noted above. 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 1 
I. INTRODUCTION 
The Integrated Primary Health Care (IPHC) project in South Africa is a collaborative project 
between the South African National Department of Health (DOH); eight selected districts from 
five provincial departments of health from Eastern Cape, KwaZulu-Natal, Limpopo, Mpumalanga 
and North West; and the United States Agency for International Development (USAID) in 
South Africa. IPHC began in July 2004 and will end on December 30, 2010, with Management 
Sciences for Health (MSH) as the prime contractor. 
PURPOSE 
The main objectives of the evaluation are to: 
Review of project results (outputs and outcomes) in relation to the project’s strategic 
performance areas (SPAs); 
Assess the project’s strengths, weaknesses, gaps in service delivery, and any constraints to 
successful implementation; and 
Identify and document best practices, lessons learned, and recommendations to inform 
future activities focusing on sustainability. 
AUDIENCE 
The three principal audiences for this evaluation are USAID South Africa, the South African 
National Department of Health (NDOH), and MSH. This evaluation is also intended to provide 
lessons learned and recommendations for future implementing partners working to strengthen 
Primary Health Care (PHC) and HIV and AIDS systems and services in a sustainable manner in 
South Africa. 
SYNOPSIS OF TASK 
In responding to the above evaluation objectives, all three principal audiences requested 
evidence of program impact at district and facility levels, and specific examples of IPHC 
interventions that have been institutionalized. USAID South Africa and NDOH both requested 
information on ways the IPHC project supports the South African Government’s (SAG) re￾engineering and revitalization of PHC services. Additionally, the evaluation’s three audiences 
requested that the evaluation address the following specific issues: 
USAID expressed an interest in lessons learned under the Equity Project and to what extent 
IPHC built on those lessons and profited from them; 
USAID requested information on linkages the IPHC project developed between 
communities and the health system; 
NDOH would like to learn of IPHC interventions related to information systems and the 
use of data that were sustainable; 
MSH requested information on the success of the partnership with the government; and 
MSH requested information on project challenges and how they have been addressed. 
2 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 3 
II. BACKGROUND 
OVERVIEW OF PHC IN SOUTH AFRICA 
Primary health care (PHC) is 
seen as a cornerstone in the 
South African health care system. 
The DOH’s Strategic Plan 2010–
2013 outlines 10 key priority 
areas of which PHC features in 
four areas: (1) overhauling the 
health care system and improving 
its management by refocusing the 
health system on PHC; (2) 
improving the functionality and 
management of the health system 
by decentralizing management 
and training managers in 
leadership, management, and governance; (3) improving human resources planning, 
development, and management with a focus on training of PHC personnel and mid-level health 
workers; and (4) accelerated implementation of the HIV and AIDS strategic plan and the 
increased focus on tuberculosis (TB) and other communicable diseases as part of an approach to 
integrated comprehensive service delivery at a level that is closest to the community. 
USAID STRATEGIES AND PRIORITIES 
To address South Africa’s major health issues, the U.S. Government (USG) partners with SAG 
to ensure that assistance contributes to the SAG’s strategic health plans. This partnership also 
works with non-government, faith-based, private, and grassroots organizations to address the 
impact of HIV/AIDS, TB, maternal and child health (MCH), and family planning and reproductive 
health (FP/RH) for the delivery of quality health care in South Africa. USAID South Africa 
supports activities in all nine provincial regions. The USAID health mission supports the SAG to 
build local capacity, strengthen health systems, establish and foster key partnerships, provide 
health care and treatment, and support innovation in the development of state-of-the-art health 
technologies. 
DESCRIPTION OF IPHC PROGRAM 
The IPHC project under TASCII is funded by USAID and charged with providing technical 
assistance to strengthen the district health system (DHS) in five provinces of South Africa. 
IPHC builds on the successes of the EQUITY Project, focusing on supporting the work of the 
DOH and local partners. The project aims to improve access to, and emphasis on strengthening 
management systems in planning, financial management, human capacity development, and 
quality assurance of the DOH and local partners; ensuring that the achievements of the EQUITY 
Project are sustained. It is also a priority that long-term improvements continue under local 
management through collaboration with local stakeholders. 
Figure 1. IPHC Provinces and Districts 
4 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
The IPHC Project works to improve access to and use of child health, reproductive health, and 
HIV and AIDS services. Operating in five provinces (Figure 1), the project provides direct 
support to nearly 70 health facilities as well as to the management teams of eight districts, 
contributing to effective decentralization and focusing on local capacity, ultimately resulting in 
stronger community-based approaches to health, especially in HIV and AIDS services and 
support. This includes the roll-out of antiretroviral (ARV) drugs, the introduction of new 
approaches to performance-based management in the public sector, the establishment of a 
monthly PHC review system and the creation of district-to-district mentoring and support 
systems to ensure improved data management and quality care. IPHC focuses on supporting the 
TB program, HIV, AIDS, MCH, FP and orphans and vulnerable children (OVC). 
MSH has played the role of lead partner in the IPHC Project with the Health Systems Trust 
(HST) and the University Research Corporation (URC) as collaborating partners up until the 
scheduled end of the project in September 2008. The project was extended until 2010, under 
MSH without the partnership of HST and URC. 
The project works to strengthen and improve health management systems at a district level. A 
supportive supervision system and improved use of data are the two key factors in achieving 
this. Improved data management facilitates good planning processes which are promoted and 
supported. Linkages between health facilities and the communities they serve are encouraged. 
Special attention and support is given to youth mentors, as they play an important role in the 
way that health providers are able to interact with their clients in a clinical setting. The IPHC￾supported facilities offer a comprehensive package of services in a full ―supermarket‖ approach. 
Positive management styles and strong leadership play a central role in good district 
performance. It is necessary to strengthen these management attributes. 
IPHC ORGANIZATIONAL STRUCTURE 
In response to its extension in 2008, to the concomitant reduction in funding and the closure of 
its partnership with URC and HST, the IPHC management structure was reorganized to reflect 
the new funding realities (See Figure 2). 
IPHC FINANCIAL DATA 
Table 1 represents the current financial status of the IPHC through its scheduled closure. 
Based on information supplied by MSH, the project is scheduled to effectively close as of 
December 16, 2010. 
Table 1. IPHC Summary Financial Data (in USD)
Total Contract Amount (USD) 25,902,737
Expended as of 9/30/2010 24,466,422
Accruals as of 11/01/2010 355,040
Balance as of 10/01/2010 1,081,275
Current Burn Rate 302,000
Anticipated Expenditures through 12/31/10 906,000 
Estimated Balance as of 12/31/10 175,275
USAID/SOUTH AFRICA: IPHC PROJECT END OF PROJECT PARTICIPATORY EVALUATION 5 
Figure 2. PSP-E Organization Chart 
COP Dr. Tracey Naledi Director Finance
Carole Evans HIV/AIDS
Vacant Trainer Dr. Almakio Phiri MNCH& Youth
Dr. Nombulelo Skeyile
MNCH 
Coordinator
Nomvuyo 
Shongwe
Engcobo TA
Andile Lesele
TB/HIV 
Vacant M&E
Tendani
Data Capture Vacant Provincial 
Coordinators
EC Nondumiso
EC 
Ntuthu
KZN
Bongi
KZN 
Gugu
Limpopo
Ogrinah
ART TA
Alude Dube
North West
Vacant
Mpumalanga Vacant
Finance
Enid Finance
Lloyd Logistics
Nadia PA Mandisa Receptionist
Keketso IT
Pule
6 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 7 
III. METHODOLOGY 
DESCRIPTION OF PROCESS 
The evaluation was conducted using participatory approaches and methods. The evaluation team 
consisted of three international consultants with expertise in HIV and AIDS care and treatment, 
MCH, health systems management, and community systems of care; one MSH headquarters staff 
member; one representative from USAID/South Africa; and a local MSH Monitoring and 
Evaluation Officer. The use of the word ―facility‖ in this report refers to both the primary health 
care clinic and the community health center. The evaluation was scheduled during October 10 
to November 12, 2010. The evaluation methodology used a combination of the following 
qualitative techniques: 
Review of Relevant Documents 
The evaluation team spent the initial three days (October 10–13) reviewing existing key project 
data and reports (Annex C). MSH internal qualitative assessments of its activities served as 
background to the evaluation. Additional documents were requested from MSH for information 
with reference to the IPHC’s achievement of outputs by SPAs as specified by the MSH 2008 
Extension Proposal. (Annex G).
Team Planning Meeting 
A detailed agenda of visits to various sites as well as evaluation instruments were developed by 
the team before the start of site visits (See Annex D). 
Initial Briefing Meetings 
These meetings with relevant staff of NDOH, USAID/South Africa, and technical and 
management staff of MSH enabled the evaluation team to understand the project activities and 
evaluation expectations, and to finalize the approach and activities for the evaluation. As a result 
of these initial briefings, a final workplan and methodology was developed and approved by 
USAID’s contracting officer technical representative. 
Interviews and Site Visits
The six-person team was organized into two teams that conducted simultaneous field trips to 
maximize exposure to field activities. The teams spent two weeks (October 19 to November 1) 
visiting program sites in eight IPHC supported districts in five provinces—Eastern Cape, 
KwaZulu-Natal, Mpumalanga, Limpopo, and North West. Key informant interviews were 
conducted with senior provincial and district DOH staff, health facility staff, local NGOs, and 
current IPHC staff (See Table 2). 
Each team used a standardized interview and site visit guideline (Annex E) to ensure that the 
teams addressed the same issues. Depending on their availability, two representatives from the 
NDOH joined the teams during the field visits. Each facility visit or district office meeting took 
about two to three hours. Following each day of interviews, key points, issues, and observations 
were summarized using an interview summary form for each interview and site visited. After 
each week of the interviews and site visits, both teams met in Pretoria to compare notes and 
summarize findings. 
8 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Table 2. IPHC Project Evaluation Interview Respondent Affiliations and Totals 
Province Number Province Number
District Representatives Community-based Organizations
Limpopo 8 Limpopo 8
Eastern Cape 6 Eastern Cape 0
North West 17 North West 0
KwaZulu-Natal 13 KwaZulu-Natal 0
Mpumalanga 7 Mpumalanga 0
TOTAL 51 TOTAL 8
Health Services Personnel NDoH & Health Systems Trust
Limpopo 24 Dr. Yogan Pillay, NDoH 1
Eastern Cape 10 Dr. R. Morewane, NDoH 1
North West 9 Mr. Bennett Asia, NDoH 1
KwaZulu-Natal 23 Dr. Tim Wilson, NDoH 1
Mpumalanga 2 Dr. P M Matse, HST 1
TOTAL 68 TOTAL 5
TOTAL RESPONDENTS 132
Analysis and Report Writing 
The evaluation team used interview and site visit results, document reviews, and other relevant 
sources to obtain a comprehensive and in-depth understanding of IPHC project to support 
sound analyses, to arrive at inferences, and to make actionable recommendations. 
Debriefing Meeting 
This meeting was organized with USAID, NDOH, and MSH staff to present the preliminary 
findings and recommendations. The analysis and final draft report writing were completed during 
the last two weeks (November 2–12) of the evaluation. The final draft report was submitted on 
November 12, 2010 to USAID/South Africa for comments. 
CONSTRAINTS AND GAPS 
The respondents and sites were not chosen randomly by the evaluation team. These sites were 
suggested by and agreed upon with the USAID and MSH staff. It is possible that only better￾performing sites were visited. Further, non-IPHC supported provinces or districts were not 
visited for a comparative analysis. Quantitative internal assessment report or data on impact 
indicators was not available to the team before the site visits. This information might have 
helped the evaluation team to contextualize and probe during the qualitative interviews. 
Perspectives of former partners of IPHC (URC and HST) on project activities, progress, and 
achievements were not obtained. 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 9 
IV. FINDINGS BY STRATEGIC PERFORMANCE AREA (SPA) 
SPA 1: MATERNAL HEALTH AND FAMILY PLANNING 
With reference to the MSH Extension Proposal (September 2008—December 2010), the 
IPHC’s interventions in maternal health and family planning focused on one principal objective: 
Improve women’s and maternal health in order to effectively reduce maternal complications 
and deaths. 
Interventions 
In addressing the above objective during the extension period, IPHC was contractually obligated 
by USAID to report on four maternal health and family planning indicators, including the 
following: 
Number of antenatal care (ANC) visits provided by skilled providers from USG-assisted 
facilities, and 
Number of people trained in FP/RH with USG funds. 
In addition, IPHC increased monitoring of the District Health Information System (DHIS) 
population-based indicators during the extension period for maternal health and family planning 
indicators, including: 
ANC coverage; 
ANC coverage < 20 weeks; and 
Women Year Protection Rate. 
Progress on Selected Indicators 
IPHC data (Tables 3 and 4) indicates that the number of ANC visits increased 22%, and the 
number of people trained in FP/RH increased 4% during the last four years of the project. When 
these indicators are compared to set targets, however, achievement against targets is reported 
at 129% for the number of people trained and 307% for the number of ANC visits. For both 
indicators, targets for FY 2009/2010 were set significantly below what was achieved for those 
indicators in FY 2006/2007, particularly in the case of the number of ANC visits. Consistently 
setting targets below program achievements raises questions about the quality of IPHC program 
monitoring by MSH and USAID. Improvements in maternal health and FP indicators are 
supported by DHIS data for ANC coverage: less than 20 weeks (30% coverage increase), and 
women-year protection rate (14% coverage increase). 
10 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Table 3. Progress on USAID/IPHC Indicators for SPA 1. Maternal Health and Family 
Planning
Indicator FY 
2006/2007 
FY 
2009/2010 % Increase
FY 
2009/2010 
Target
% 
achievement 
of target
# of antenatal care (ANC) 
visits provided by skilled 
providers from USG￾assisted facilities
88,000 107,452 22% 35,000 307%
# of people trained in 
RH/FP with USG funds 186 193 4% 150 129%
Table 4. Progress on National Department of Health Indicators for SPA 1. Maternal Health 
and Family Planning
Indicator 2004 2009 % Increase
Indicator 1: ANC Coverage 96% 90% (-6%)
Indicator 2: ANC Coverage < 20 
weeks 26% 34% 30%
Indicator 3: Women-year protection 
rate
23% 26% 14%
Achievements 
Based on reported progress on selected project indicators and DHIS data, positive progress was 
made on maternal health and family planning at IPHC supported sites, and in IPHC-supported 
sub-districts. Additionally, qualitative data collected during interviews with district and facility 
staff highlighted the following findings. 
Facilities reported that IPHC training and support encouraged continuity of care. Before IPHC 
support, it was common for cases to be treated in isolation. Facility staff says that now, if 
patients come for sexually transmitted infections (STIs) treatment or FP services, they also use 
the opportunity to take a pap smear. Pap smear statistics have increased due to this continuity 
of care approach, and also due to giving women more information at clinics and at community 
education campaigns. 
Despite religious and cultural beliefs that do not support family planning in many rural areas, 
there have been positive impacts. Many more women now see the importance of family planning 
and the dangers of not using it. Cultural beliefs also prevent many women from disclosing that 
they are pregnant early enough to receive timely ANC services. Through the use of clinic health 
committees, IPHC training and coaching, and educational campaigns, more ANC bookings are 
being made earlier. This allows HIV testing and, if necessary, treatment of ARV to reduce 
mother to child transmission of HIV. Despite these achievements, facilities report that more 
progress is needed in the areas of disclosing pregnancy and termination of pregnancy. 
Many clinics reported an increase in the number of women and teens referred for family 
planning, and starting a family planning method. This achievement is particularly notable given the 
R250 per child offered by the Department of Social Development to support mothers, which 
has been a perverse incentive for teens and women to have children. Both the IPHC project and 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 11
the South African national ―Love Life‖ initiative have contributed to the increase in uptake of FP
methods. However, more progress is needed, particularly in the area of teen pregnancy. 
Many clinics reported that the use of tools and systems introduced by IPHC to support maternal 
health and FP have improved delivery of these services. They also report that this progress can 
be sustained, since the tools and systems are now embedded in facility operations. 
Effectiveness and Sustainability 
Based on interviews with respondents and on field observations, Table 5 summarizes the 
effectiveness and sustainability with reference to two key indicators associated with IPHC 
maternal health and FP interventions. 
Table 5. IPHC South Africa Evaluation: Assessment of Effectiveness and Sustainability of 
Strategic Performance Area Key Initiatives
SPA 1: Maternal Health and 
Family Planning
Less than
40% 40–80%
Greater than 
80%
(less than40%: Shaded Red 40-80%: Shaded Yellow greater than 80%: Shaded green
Initiative 1: Integrated Services
Effectiveness Five green bars
Sustainability Four yellow bars
Initiative 2: Family Planning
Effectiveness Three yellow bars
Sustainability Two red bars
SPA 2: CHILD HEALTH 
With reference to the MSH Extension Proposal (September 2008—December 2010), the 
IPHC’s interventions in child health focused on one principal objective: 
Improving child survival and reducing infant and child mortality 
Interventions 
In addressing the above objective during the extension period, the IPHC was contractually 
obligated to report on eight child health indicators, including the following: 
Number of people trained in child health care and child nutrition through USG-supported 
programs; 
Number of people trained in maternal/newborn health through USG-supported 
programs; and 
Number of children < 1 year of age fully immunized. 
In addition, IPHC increased monitoring of DHIS population-based indicators during the 
extension period for selected performance areas. DHIS child health indicators included: 
Primary health care utilization rate for < 5 years 
Fully immunized < 1 year rate 
12 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Progress on Selected Indicators 
IPHC data (See Table 6) indicates that progress declined between 41% and 73% on child nutrition 
training, maternal/newborn health training, and immunization for children less than 1 year during 
the last four years of the project. When these indicators are compared to set targets, however, 
achievement against targets is reported between 93% and 154%. These reported declines in 
training and immunization are not corroborated by interviews conducted with district and facility 
staff. Conversely, in the case of immunization for children less than 1 year old, DHIS data (Table 7) 
reports an increase in coverage in IPHC-supported sub-districts from 75% in 2004, to 85% in 
2009. DHIS data also showed an increase in the PHC utilization rate for children under five. 
Setting USAID/IPHC targets well below reasonable program expectations coupled with 
IPHC/DHIS/qualitative interview data inconsistencies raise questions about the quality of IPHC 
program monitoring by MSH and USAID, and about the quality of program data reported. 
Achievements 
Based on IPHC reported progress on selected indicators and on DHIS data, progress on child 
health initiatives declined at IPHC supported sites. However, progress improved overall in the 
sub-districts where IPHC was working. In reviewing IPHC documentation such as semi-annual 
and annual reports, it was not possible to find evidence that would explain the inconsistencies 
between IPHC’s reporting on indicators and that of the DHIS. However, based on the following 
Table 6. Progress on USAID/IPHC Indicators for SPA 2. Child Health 
Indicator FY 
2006/2007
FY 
2009/2010
% 
Increase
FY 
2009/2010 
Target
% 
Achievement 
of Target
Number of people 
trained in child health 
care and child 
nutrition through 
USG-supported 
programs
360 194 (-46%) 125 93%
Number of people 
trained in 
maternal/newborn 
health through USG￾supported programs
213 58 (-73%) 50 154%
Number of children 
<1yrs fully 
immunized
18,677 10,966 (-41%) 10,000 151%
Table 7. Progress on National Department of Health DHIS Indicators for Spa 2. 
Child Health 
Indicator 2004 2009 % Increase
Indicator 2: Primary health care 
utilization rate for < 5 years 3.5% 4.8% 38%
Indicator 3: Fully immunized < 1 
year rate
75% 85% 14%
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 13
findings associated with the evaluation team site visits to the 18 sites included in the evaluation, 
it would appear that significant progress has been achieved on the single child health objective 
specified for SPA 2. 
With training provided by IPHC, community-based caregivers are now able to track children 
lost to follow-up. The use of home visits to check ―Road to Health‖ cards has resulted in fewer 
immunization defaulters and an increased focus on growth monitoring and evaluation and on 
children at risk. 
In selected provinces (e.g. North West and Mpumalanga), IPHC’s 2010 introduction of the 
Leadership Development Program (LDP) appears to have assisted health center staff in 
identifying priorities. These priorities include: the need to conduct catch up immunization, to 
design comprehensive immunization registers, to train nurses in drug supply management, and 
to train nurses and data clerks on data management. 
Integrated management of childhood illnesses (IMCI) focused checklists have been introduced by 
the project and embedded in clinic operations. For example, while Expanded Program on 
Immunization (EPI) protocols existed prior to IPHC interventions, there appears to have been 
limited staff compliance. By contrast, with the introduction of the IMCI checklist, staff 
compliance with these protocols in some facilities visited has approached 100%. Similarly, in 
IPHC assisted facilities, use of the checklist has resulted in malnutrition now being rare in 
patients treated at the clinic and in a significant reduction in life-threatening instances of 
diarrhea. 
Under IPHC guidance, training and supportive supervision are centered on integrated services. 
Facility staff now focus on ensuring that mothers are counseled and, if appropriate, tested for 
HIV/AIDS, TB and STIs, and are also counseled on family planning and immunization compliance. 
As stated by one clinic manager, IPHC’s training and supervision has re-enforced the concept 
that: ―To build a healthy nation, the testing of all mothers will help the next generation be free 
of HIV/AIDS.‖
With training and supportive supervision assistance provided by IPHC, lower categories of 
nurses have been trained and can now weigh and monitor the growth of infants and children 
under five. This simple but effective intervention has freed up higher category nurses for more 
complex clinical work. 
Under IPHC training and supportive supervision in many of the facilities visited community￾based caregivers now ensure that mothers breastfeed within 72 hours and that they maintain 
post-natal monthly visits to their facilities. In the event that there are medical issues, the 
caregivers are trained to refer their clients to the facility and, if an appointment to a clinic is 
missed, the mothers are visited at home to encourage compliance with the scheduled visit.
Effectiveness and Sustainability 
Based on interviews with respondents and on field observations, Table 8 summarizes the 
effectiveness and sustainability with reference to two key indicators associated with child health 
interventions. 
14 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Table 8. IPHC South Africa Evaluation: Assessment of Effectiveness and Sustainability of 
Strategic Performance Area Key Initiatives
SPA 2: Child Health
Less than 
40% 40–80 % Greater 
than 80%
Less than40%: shaded red 40-80%: shaded yellow. Greater than 80%: shaded green.
Initiative 1: Community Tracking of Patients
Effectiveness Six green
bars.
Sustainability Four yellow 
bars.
Initiative 2: IMCI Integration
Effectiveness Five green
bars.
Sustainability Four Yellow 
bars.
SPA 3: YOUTH PROGRAMS 
With reference to the MSH Extension Proposal (September 2008—December 2010), the 
IPHC’s interventions in the youth programs (SPA 3) focused on one principal objective: 
Increasing youth participation in the promotion and provision of youth-friendly services in 
order to reduce reproductive health problems among adolescents. 
Interventions 
In addressing the above objective during the extension period, the IPHC proposed to continue 
or initiate the following interventions: 
Support the implementation of the Adolescent Health Policy at district and facility levels to 
increase uptake of RH services (including HIV and AIDS services); 
Establish and improve linkages between health facilities and youth in the clinic catchment 
areas and capacitate the community youth to support implementation of youth friendly 
services (YFS); 
Create support for a youth presence in health facilities and involve youth in service 
provision with the aim of integrating and sustaining youth mentors through programs of the 
DOH or Department of Social Development; 
Institutionalize the YFS strategy at the district and provincial levels to ensure its 
continuation (including placing these activities in the District Health Plans [DHP]); 
Focus youth mentor activities on achieving the 10 YFS standards; and 
Foster and support acceptance of the youth program as a cross-cutting strategy in health 
facilities and districts by ongoing monitoring, support, and mentoring of youth volunteers in 
health services. 
Progress on Selected Indicators 
Data indicates that the number of youth receiving HIV tests and STI treatment increased in 
facilities and communities served by IPHC-trained YFS staff and youth mentors (See Table 9). 
The number of youths tested for HIV increased 12% (approximately 1,500 additional youth 
reached), and youths receiving STI treatment increased 2% (approximately 200 additional youth 
reached). The number of youth provided with STI information decreased drastically by the end 
of the project. This may be explained by the fact that support for youth programs was 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 15
withdrawn, with the exception of youth mentor stipends, for the two-year extension period. It 
is particularly remarkable that progress in HIV testing and STI treatment was improved, given 
the decrease in program support. This fact points to the success of the training and skills put in 
place before funding for those activities ceased. 
Table 9. IPHC SPA 3. Youth Program: Progress on Selected Indicators 
Indicator FY 2006/2007 FY 2009/2010 
End line % Increase
Number of individuals who 
tested for HIV 13,341 14,895 12%
Number of individuals given STI 
information 263,776 93,772 (-64%)
Number of individuals who 
received STI treatment 12,014 12,213 2%
Achievements 
In most cases, achievements directly associated with the above six interventions were not 
explicitly addressed in the IPHC’s annual and semi-annual reports. However, during site visits to 
facilities and sub-district offices in the five targeted IPHC provinces, significance of IPHC youth 
interventions was noted. 
Based on interviews, IPHC working with facility staff has successfully developed a corps of youth 
mentors whose door-to-door work in communities, schools, clinics, and churches has 
demonstrably resulted in an increased willingness of young people to utilize facility based YFS 
(also enhanced through IPHC training). All facilities visited during the evaluation with YFS, and 
with youth mentors supported by IPHC, reported increases in youth utilization of information, 
counseling, and testing services for HIV/AIDS/STIs, and RH issues. 
Again, based on interviews with health facility staff and with youth mentors themselves, it 
appears that efforts of youth mentors, in coordination with facility-based YFS introduced by the 
IPHC, have resulted in increased numbers of youth taking advantage of clinic-based services. 
This has led to a decrease in teen pregnancy, an increase in youth willing to be tested for 
HIV/AIDS and STIs, and in an increase in the use of contraceptives, including emergency 
contraceptives, among the under-25 population. Thanks to the IPHC-initiated youth mentors’
training and their subsequent interaction with their peers, the environment at IPHC-sponsored 
health clinics has been significantly improved so that youth are now aware of the services 
provided by health facilities and the benefits associated with their utilization. 
Effectiveness and Sustainability 
Based on interviews with respondents and observations in the field, Table 10 summarizes the 
effectiveness and sustainability with reference to two key indicators associated with IPHC youth 
interventions. 
16 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Table 10. IPHC South Africa Evaluation: Assessment of Effectiveness and Sustainability of 
Strategic Performance Area Key Initiatives
SPA 3: Youth Program
Less than 40% 40–80 % Greater than 
80%
Less than40%: shaded red 40-80%: shaded yellow. Greater than 80%: shaded green.
Initiative 1: Youth Mentors
Effectiveness Six green
bars.
Sustainability One red bar.
Initiative 2: Youth-Friendly Services
Effectiveness Six green
bars.
Sustainability Five green
bars.
SPA 4: HIV AND AIDS 
During the extension period (October 2008 to December 2010), IPHC focused on achieving the 
following objectives with the purpose of reducing the impact of HIV and AIDS: 
Strengthen the integration of counseling and testing (C&T) into routine PHC activities; 
Strengthen and expand a comprehensive prevention of mother-to-child transmission 
(PMTCT) program; 
Strengthen ARV treatment service delivery to those who are infected with HIV; and 
Strengthen palliative care in the PHC setting; integrate palliative care for TB and HIV. 
Interventions 
The project aimed to achieve the above objectives by implementing interventions under five HIV 
and AIDS activity sub-categories of SPA 4: (4.1) counseling and testing, (4.2) (PMTCT), (4.3) HIV 
and AIDS treatment, (4.4) palliative care (basic), and (4.5) palliative care (TB/HIV). IPHC was 
contractually obligated to report on thirteen indicators for monitoring these activities, including 
those in Table 11. In addition, IPHC increased monitoring of DHIS population-based indicators 
during the extension period for selected HIV/AIDS indicators (Table 12). 
Progress on Selected Indicators 
Impressive progress has been made on nearly all HIV and AIDS objectives. The only exception in 
the IPHC data (Table 11) is in the area of counseling and testing, and in receiving HIV test 
results. However, this decrease was not supported by DHIS data or by qualitative interviews, 
both of which show significant improvements in this area. Most progress was made in the area 
of integrated HIV/TB testing, with an increase from 6% to 32%. Training for treating TB in HIV￾infected patients increased more than ten-fold, and exceeded the project target set for this 
indicator. 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 17
Table 11. Progress on USAID/IPHC Indicators for SPA 4. HIV/AIDS 
Indicator FY 
2006/2007
FY 
2009/2010 % Increase
FY 
2009/2010 
Target
% Target 
achievement
4.1 Counseling & Testing: 
# of clients who received 
counseling and testing 
and received their test 
results (excl. antenatal)
45,310 40,532 (-11%) 40,000 101%
4.2 PMTCT: # of 
pregnant women 
provided with a complete 
course of antiretroviral 
prophylaxis in a PMTCT 
setting
2,788 3,330 19% 5,000 67%
4.3 Treatment: Indirect # 
of individuals receiving 
antiretroviral therapy at 
the end of the reporting 
period
22,172 31,977 44% 20,000 160%
4.4 Palliative Care 
(Basic): # of individuals 
provided with HIV￾related palliative care 
(including TB/HIV)
2,651 5,153 94% 5,000 106%
4.5 Palliative Care 
(TB/HIV): # of individuals 
trained to provide clinical 
prophylaxis and/or 
treatment for TB to HIV￾infected individuals 
(diagnosed or presumed)
3 319 10,533% 300 106%
18 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Table 12. Progress on National Department of Health DHIS Indicators for SPA 4. 
HIV/AIDSs 
Indicator 2004 2009 % Increase
Indicator 3: HIV testing rate 57% 83% 46%
22%*
Indicator 6: HIV-positive clients screened for TB 6% 32% 462%
Indicator 8: ANC clients tested for HIV 50% 90% 81%
Indicator 11: Nevirapine uptake among HIV-positive 
pregnant women
46% 68% 48%
*For Indicator 3: HIV testing rate, Uthungulu sub-district in Kwazulu Natal reported an increase of 0% to 
82.6%. This was an extreme outlier compared to the other rates reported. It is highly unlikely that HIV 
testing was at 0% in 2004. This drastic reported uptake in testing significantly changes the average district 
HIV testing rate. When Uthungulu’s data is removed, the average percent increase is 22% (less than half 
of 46%). 
Achievements 
The project conducted several training workshops for health professionals and lay counselors 
with a focus on integrating HIV, TB, HIV counseling and testing (HCT), PMTCT, ANC, and FP 
services. Technical assistance was complemented by monthly support visits for mentoring and 
coaching staff on activities including patient chart review, data management, catchment area 
mapping, and use of supervision checklists. Sub-district clinic supervisors disseminated innovative 
tools and systems from IPHC-supported facilities to unsupported facilities. Facility staff reported 
confidence in using these tools and systems, and cited them as playing a key role in integrating 
and improving HIV and AIDS services. For example, facility staff said that the use of tick registers 
have enabled easy tracking of client movement between different health facility units, as well as 
tracking of adherence to ARV treatment. 
IPHC supported the transition to provider-initiated HIV testing in line with the national HCT 
policy. To support HIV testing services, IPHC encouraged the use of rapid HIV test kits, 
significantly reducing the time lapse between testing and issuing of results, resulting in an 
increase in the number of clients receiving their results. The use of clinic health committees to 
clarify HIV and AIDS confidentiality policy has increased community HCT uptake. Youth 
mentors were repeatedly mentioned as a factor in increasing HCT uptake among youth. 
Additionally, as a result of IPHC support, ANC HIV testing increased from 80–90% to 95–100% 
in the majority of facilities. 
With the integration of HIV, TB, HCT, PMTCT, ANC, and FP services, HIV-positive mothers 
are given dual therapy according to new PMTCT guidelines, and pregnant women are referred 
internally for HIV/AIDS, TB, and STI counseling and services. Facilities emphasize early ANC 
booking and HIV testing at the first visit, with some facilities even promoting retests (at least 
twice during pregnancy). Staff recognize that early bookings for ANC allow testing and, if 
necessary, early initiation of ARV treatment to reduce transmission from mother to child. 
Facilities reported an approximately 20% increase in the number of HIV-negative babies tested 
at six weeks. 
In Madibeng sub-district in North West Province, sub-district staff used skills they learned in 
MSH’s Leadership Development Program (LDP) to develop a comprehensive PMTCT register to 
address the problem of PMTCT patient tracking complicated by multiple register use for 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 19
different services. Their improved data review process has led to increased enrollment in the 
PMTCT program following testing— and immediate follow-up with patients with low helper T 
cell (CD4) counts rather than waiting for them to come for the next appointment. Polymerase 
chain reaction test (PCR) rates for infants have increased and CD4 testing has also increased. 
IPHC assisted in accreditation for ARV services and training of staff at most facilities visited. 
Currently, treatment is initiated at hospitals, and patients are down-referred to clinics for 
ongoing management and treatment. IPHC assisted facilities by providing mentoring support to 
integrate anti-retroviral therapy (ART) with other services and to improve down-referral 
systems that decentralize services and lighten patient load at hospitals. 
Collaboration and cross-screening of HIV and TB services has improved the management of 
patients with one or both diseases. IPHC introduced, trained and institutionalized the use of a 
TB screening tool for HIV-positive clients, and cross-screening of all HIV and TB patients is now 
routinely done as a result of IPHC support. Proactive management of TB at the community 
level, through use of home-based care in the provision of directly observed therapy short￾course (DOTS), has helped to reduce the TB defaulter rate. One facility reported a rise in TB 
cure rate from 18% in 2004 to 81% in 2010. Another facility reported a 0% TB defaulter rate in 
the last month. Home-based caregivers also provide palliative care to HIV-positive babies in 
orphanages; care for sick patients; and administer medicines, nutritional supplements and fresh 
vegetables from clinic gardens. 
Effectiveness and Sustainability 
Based on interviews with respondents and on field observations, Tables 13 and 14 summarize 
the team’s assessment of the effectiveness and sustainability with reference to four key 
indicators associated with IPHC HIV and AIDS interventions. 
Table 13. IPHC South Africa Evaluation: Assessment of Effectiveness and Sustainability of 
Strategic Performance Area Key Initiatives
SPA 4: HIV and AIDS
Less than 40% 40–80 % Greater than 
80%
Less than40%: shaded red 40-80%: shaded yellow. Greater than 80%: shaded green.
Initiative 1: Integrated Services
Effectiveness Six green
bars.
Sustainability Four yellow 
bars
Initiative 2: PMTCT
Effectiveness Five green
bars.
Sustainability Four yellow 
bars
20 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Table 14. IPHC South Africa Evaluation: Assessment of Effectiveness and Sustainability of 
Strategic Performance Area Key Initiatives
SPA 4: HIV and AIDS
Less than 40% 40–80 % Greater than 
80%
Less than40%: shaded red 40-80%: shaded yellow. Greater than 80%: shaded green.
Initiative 3: ARV 
Effectiveness Five green
bars.
Sustainability Four yellow 
bars
Initiative 4: TB and HIV
Effectiveness Five green
bars.
Sustainability Four yellow 
bars
SPA 5: PHC SYSTEMS AND SERVICES 
With reference to the MSH Extension Proposal (September 2008–December 2010), the IPHC’s 
interventions to strengthen PHC systems and services (SPA 5) focused on three principal 
objectives: 
Contribute to service quality improvements through selected tools such as the Primary 
Health Care Supervision Manual and structures such as clinic health committees; 
Improve the knowledge and use by service staff and managers of health information of 
acceptable quality for planning, management and monitoring; and 
Support the development of district health plans, operational plans, operational reviews, and 
the conducting of District Health Expenditure Reviews (DHER). 
In addition, the IPHC sought to build on the following products developed previously under the 
MSH Equity Project: 
Clinic Supervision Manual 
The purpose of this manual is to provide a set of flexible, adaptable tools, and guidelines to 
support supervisors in their role of improving the quality of care in the clinics. It is especially 
helpful for focusing managers on the key elements of integrated primary health care as they 
simultaneously integrate new interventions for HIV/AIDS, TB, and malaria. 
District Health Information System (DHIS) 
The DHIS, developed to collect aggregated routine data from all public health facilities in a 
country, is intended to support decentralized decision-making and health service management, 
and allows health care workers to analyze their levels of service provision, predict service 
needs, and assess performance in meeting health-service targets. 
District Health Expenditure Review (DHER) 
A DHER presents a clear picture of funding, distribution, and use of health resources within the 
district. This is an important foundation for planning and helps to restructure district health 
services and manage resources more effectively to meet the needs of communities. A DHER 
focuses on financial data and links this to other resources such as staff, as well as to service and 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 21
population data. These are then analyzed according to performance measures for the various 
costs in the district. 
District Health Plans (DHP) 
From a health-planning viewpoint, it is necessary to describe the relationships with other 
government-funded health services in the plans and reports. Relationships with private health 
providers should also be described, particularly if public/private partnerships are planned or in 
place. District health planning should also serve to integrate the plans of different health 
programs, different management structures, and different disciplines. District health plans and 
reports aim to cover all aspects of health care to ensure that resources are used equitably, 
effectively, and efficiently. 
Primary Health Care (PHC) Review Process 
The PHC Review process is a methodology and means for staff to be involved in monthly joint 
performance monitoring at the facility level and in the promotion and support of periodic PHC 
review meetings at sub-district and district levels. Action plans and lessons learned are shared 
during these review meetings to encourage use of best practices. Use of the Clinic Supervision 
Manual and data management skills are integral to the process. 
Other tools and interventions used include: 
District Monitoring, Economic, Social and Human Resources (MESH) 
The MESH tool was utilized as a checklist to compare district level performance between those 
districts receiving support from IPHC and those with no direct support, in the same provinces. 
Leadership Development Program (LDP) 
The LDP helps organizations develop managers to lead with a vision of a better future. The 
program has three major learning objectives: (1) learn the basic practices of leading and 
managing so that managers are capable of leading their workgroups to face challenges and 
achieve results; (2) create a work climate that supports staff motivation; and (3) create and 
sustain teams that are committed to continuously improving client services. Introduced during 
the project’s last year of operations, the LDP program trained participants from North West 
Province and from Mpumalanga Province. 
Interventions 
In responding to the above objectives during the extension period, indicator tracking was weak, 
and meaningful targets were not set for all indicators. Quality assurance (QA) indicators were 
not tracked at all. The following two indicators were reported: 
DHIS: number of facilities with updated graphed indicators that are displayed; and 
District Health Systems: Number of districts with completed DHPs and DHERs. 
Progress on Selected Indicators 
Tracking the facilities that graph indicators and publicly displaying them appears to have started 
during the last year of the project. Since data is only available for one year, it is not possible to 
calculate a percent increase over time for this indicator. The target set for FY 2009/2010 was 
10, and 68 facilities achieved this indicator. All eight IPHC-supported districts had completed 
DHPs and DHERs by FY 2006/2007. 
22 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Table 15. Progress on USAID/IPHC Indicators for SPA 5. PHC Systems and Services
Indicator FY 
2006/2007
FY 
2009/2010 % Increase
FY 
2009/2010 
Target
% Target 
Achieved
5.2 District Health 
Information System: 
Number of facilities 
with updated graphed 
indicators that are 
displayed
-- 68 -- 10 680%
5.3 District Health 
Systems: # of districts 
with completed DHPs 
and DHERs
8 8 N/A 8 100%
Achievements 
Improved management systems, including data management and supervision tools introduced 
during the EQUITY Project and strengthened during IPHC, formed the foundation from which 
health services were improved. Qualitative data collected during interviews with district and 
facility staff highlighted the following significant systems and services achievements: 
District Health Information System/Data Management 
Training in the DHIS has been conducted for IPHC technical and provincial staff. 
Sub-district and facility staff have gained awareness, through the IPHC project, of the value 
and power of data management and exhibit an increased commitment to the data management 
process. 
There has been improved data management process at district, sub-district and facility levels. 
IPHC has supported district health teams with the establishment of a routine process for DHIS 
data review, analysis, and feedback to facilities and sub-districts regarding the identification of 
trends and gaps in performance. The design and establishment of the data review process is an 
achievement. The next big step is the consistent implementation of this process; staff 
understanding and value of the process at the facility, sub-district and district levels; and 
ultimately, the institutionalization of the routine data review process. 
Joint visits by the IPHC team in collaboration with district and provincial supervisors were 
conducted in districts and facility clusters to support health service program reviews with the 
utilization of DHIS facility data. 
District Health Systems 
The IPHC Project has put systems in place to facilitate a patient-centered approach, increase 
access to services, and increase integration of PHC interventions. This is a significant 
achievement. At the same time, it is recognized that interventions often still exist within vertical 
program structures, and that as the systems facilitating integration are increasingly 
institutionalized, interventions will also become increasingly interconnected in clinic operations, 
resulting in improved integration of PHC delivery. 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 23
PHC Review Process 
Consistent, institutionalized implementation of the PHC review process will take some time to 
achieve, but staff awareness and training in the process is a critical and significant first step. It is 
an achievement of the IPHC Project that facility and sub-district staff are familiar with and 
trained in the use of the IPHC tools (e.g., Clinic Supervision Manual, data management process, 
and PHC review process). Institutionalization of PHC review process tools will require ongoing 
support to staff as they encounter the inevitable challenges that tool utilization will present. 
With continued, accessible technical support, staff skills in tool utilization will mature and 
institutionalization of the tools will, in turn, take place. 
IPHC provided technical support to the district DOH to strengthen the alignment of district and 
provincial annual plans and budgets. Alignment efforts were also directed at the DHP and the 
DHER. 
With regard to the strengthening of the community component of the district health system, 
YFS have had a noteworthy, positive impact on the provision of reproductive health education 
to their youth peers in the community, bringing about increased numbers of youth presenting to 
facilities for care. 
Similarly, the OVC program has in its brief time, increased linkages between the community and 
the facility, community health center (CHC) and district hospital. 
Quality Assurance 
Training in QA techniques and strategies has been provided to staff at the district, sub-district, 
and facility levels. Consistent application of QA techniques is impacted by facility capacity: (e.g., 
human resources, material resources, and infrastructure), highlighting the need for continued 
efforts in these capacity-building areas. 
District management teams (DMTs) have been trained in the processes of supervision and 
monitoring of health services quality. QA capacity at the sub-district and facility levels must be 
further developed and alignment of the facility/sub-district/district levels requires further 
improvement before QA techniques and strategies can be institutionalized. 
Quality assurance capacity has increased as the data management and leadership capacity has 
increased at the sub-district and facility levels. This is an ongoing effort requiring ongoing 
technical support for the near-to-medium term. 
The experiential learning process of the LDP has introduced QA concepts and built capacity to 
utilize QA tools at the facility and sub-district level. 
The quarterly review process of routine DHIS data at the district and sub-district levels has 
been the focus of IPHC technical support, with the goal of achieving improved utilization and 
analysis of routine DHIS data. In turn, analysis of data is to be utilized to review progress with 
annual plans, identify performance gaps, and identify interventions for performance 
improvement. 
Effectiveness and Sustainability 
Based on interviews with respondents and field observations, Table 16 summarizes the 
effectiveness and sustainability with reference to four key indicators associated with PHC 
systems and services interventions. 
24 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Table 16. IPHC South Africa Evaluation: Assessment of Effectiveness and Sustainability of 
Strategic Performance Area Key Initiatives
SPA 5: PHC Systems and Services
Less than 
40% 40–80 % Greater 
than 80%
Less than40%: shaded red 40-80%: shaded yellow.
Greater than 80%: shaded 
green.
Initiative 1: Integrated Services
Effectiveness Five green
bars.
Sustainability Four yellow 
bars.
Initiative 2: PHC Review Process/Quality Assurance
Effectiveness Six green
bars.
Sustainability Three yellow 
bars.
Initiative 3: DHP/DHER
Effectiveness Three yellow 
bars.
Sustainability Two red bars.
Initiative 4: LDP/Management Training
Effectiveness Six green
bars.
Sustainability Three yellow 
bars.
SPA 6: ORPHANS AND VULNERABLE CHILDREN 
With reference to the MSH Extension Proposal (September 2008—December 2010), the 
IPHC’s interventions for the benefit of orphans and vulnerable children (OVC–SPA 6) focused 
on one principal objective: 
Strengthen community-based organizations (CBOs) and networks to enhance the welfare of 
children affected by HIV and AIDS mortality in their families. 
Interventions 
In responding to the above objective during the extension period, IPHC tracked the following 
indicators:
Number of OVCs served—three or more services 
Number of OVCs served—two or less services 
Number of providers/caregivers trained in caring for OVCs 
Progress on Selected Indicators 
Data collected for these indicators indicates significant progress in the number of OVCs 
receiving services during the IPHC project. OVCs receiving three or more services reached 
13,062 in the last year of the project, nearly doubling the 7,156 OVCs receiving services four 
years earlier (See Table 17). Additionally, 6,134 OVCs received at least two services in the last 
year of the project. An area needing improvement appears to be training for OVC service 
providers and caretakers. Less than half of the target set for this indicator was achieved, and the 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 25
number of people trained decreased by nearly 50% over four years. This is likely due in part to 
the decrease in project funding for OVC activities during the two-year project extension period.
Table 17. Progress On USAID/IPHC Indicators for SPA 6. Orphans and Other 
Vulnerable Children
Indicator FY2006/2007 FY2009/2010 % 
Increase
FY2009/2010 
Target
% Target 
Achieved
Number of OVC 
served - 3 or more 
services
7,156 13,062 83% 15,000 87%
Number of OVC 
served - 2 or less 
services
4,930 6,134 24% 5,000 123%
Number of 
providers/caretakers 
trained in caring for 
OVC
477 242 (-49%) 500 48%
Achievements 
Despite the fact that IPHC’s active involvement in the OVC programs ceased (with the 
exception of stipends through March 2010) prior to the extension of the program in October 
2008, IPHC’s interventions are significant. 
Based on interviews with staff attached to OVC program sites visited, it appears that the IPHC 
interventions enhanced the OVC programs’ capacity to develop and manage the database and to 
maintain financial and administrative records. 
In turn, the development of OVC databases and IPHC assistance in the development of 
proposals has enabled OVC programs to successfully solicit government support. Staff from one 
of the OVC sites visited stated: ―Thanks to [IPHC] assistance, we now know who to approach 
and how to do it.‖
The IPHC-sponsored vocational training program appears to have been effective in building the 
income-generating capacity of OVCs to start their own businesses and become financially 
independent as young adults. The computer training, financial management skills, and 
entrepreneurial skills received through the vocational training program provided OVCs with the 
foundation to be financially secure. 
Community members, particularly parents and police, have been pleased with the changes seen 
in their communities as a result of IPHC-supported OVC programs. They volunteer for night 
duty and OVC events, and engage with problem-solving as needs arise. This community 
involvement and support has been encouraging for those delivering OVC services, and has 
strengthened their commitment to creating a better future for OVCs—―tomorrow’s leaders, 
nurses, teachers and pastors.‖
Effectiveness and Sustainability 
Based on interviews with respondents and field observations, Table 18 summarizes the 
effectiveness and sustainability of two key indicators associated with IPHC interventions 
for OVCs. 
26 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Table 18. IPHC South Africa Evaluation: Assessment of Effectiveness and Sustainability of 
Strategic Performance Area Key Initiatives
SPA 6: OVC
Less than 
40% 40–80 % Greater 
than 80%
Less than40%: shaded red 40-80%: shaded yellow.
Greater than 80%: shaded 
green.
Initiative 1: Organizational Development
Effectiveness Six green
bars.
Sustainability Five green
bars.
Initiative 2: Vocational Training Program
Effectiveness Six green
bars.
Sustainability Three 
yellow bars.
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 27
V. BEST PRACTICES 
In its review of IPHC interventions, the evaluation team has defined a ―best practice‖ as: A clearly 
defined intervention that is known to provide near optimum results every time it is correctly 
implemented. Accordingly, the team considers the following IPHC applications, interventions and 
tools to have met the above best practice criteria within the South African health context. 
CROSS-CUTTING IPHC PROJECT BEST PRACTICES 
Supportive Accountability Provided to all IPHC Supported Sites by 
IPHC Staff 
One high-value, transformative, capacity-building approach that IPHC staff provided DOH staff 
throughout the project was consistent, empathetic, positive, technical assistance. Coupled with 
this support was accountability. The linkage of positive support and accountability created an 
environment within which learning could occur, changes could be undertaken, and staff￾empowerment could be nurtured. The linkage of positive support with accountability motivated 
staff to complete initiatives, as they knew they were being held accountable to do so, and their 
work was verbally appreciated by IPHC staff. 
Tools to Guide the Implementation and Supervision of Integrated PHC 
Services 
IPHC provided a full range of tools to support and guide the complex process of PHC service 
integration at the facility level. As staff capacity was developed in the utilization of these tools, 
facility staff experienced the tools’ positive impact upon the provision of an integrated PHC 
package to the patient, and in turn attached increasing value to the use of IPHC tools. 
Data Management 
Throughout the project, IPHC staff provided training and ongoing technical support in data 
capture, reporting, and analysis for use in decision-making. The importance of accurate, timely 
data is now better understood by facility and sub-district staff. This is a significant step forward 
in the strengthening of health services and the provision of targeted health services. 
SPECIFIC BEST PRACTICES 
PHC Review Process 
The PHC review process is the foundation of health systems strengthening and quality 
improvement of PHC services. The PHC review process provides the structure for systematic 
data analysis. This, in turn, strengthens change implementation and monitoring as well as
evaluation of the initiative, and improves the quality of the PHC services received by the patient. 
Mapping of Facility Catchment Area 
Facility staff has been trained and is now creating hand-drawn maps of their catchment areas, 
identifying the citing of resources, ―hot spots‖ of disease, and natural geography (rivers, 
mountains, etc). This visual aid assists planning of health interventions in the communities 
they serve. 
28 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Clinic Health Committees 
The project has clarified clinic health committee members’ roles and responsibilities for both 
the community and the facility staff. This has empowered committee members to become more 
active liaisons between the community and facility, and has strengthened facility health outreach 
initiatives and community understanding of health facility resources. 
Technical Assistance Provided to OVC Programs 
The best-practice component of the project’s support of OVC programs was that support was 
directed at existing programs and structures. This approach strengthens existing networks and 
linkages; a more sustainable development strategy than the traditional supply-driven ―silo‖ 
structure of many development initiatives. The community-facility linkages were strengthened, 
OVC management staff was capacitated, and youth-friendly services, community health workers 
(CHWs), home-based caregivers (HBCs) and youth mentors were supported with training, 
financial and material support. The OVC programs deserve commendation for their effective 
efforts in working toward ―an HIV and AIDS-free generation.‖
Establishment of Support Groups for HIV and AIDS Patients 
This intervention has facilitated information sharing around mutual problems, boosted patient 
morale, and reduced the isolation of HIV and AIDS patients. Community-facility relationship was 
strengthened, with each having a better understanding and appreciation of the other. The 
improved community-facility relationship, in turn, increased community utilization of facility 
services and support of health campaigns in the community. 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 29
VI. STRENGTHS AND WEAKNESSES 
As required under this evaluation’s scope of work, the evaluation team has examined the 
strengths and weaknesses associated with the IPHC’s implementation of the program. 
Accordingly, the following paragraphs represent our assessment of the IPHC’s strengths, broken 
down into six discrete categories, and of the IPHC’s weaknesses, broken down into an 
additional five categories. 
IPHC STRENGTHS 
Strengthening of Management and Supervision 
In all district and sub-district offices, hospitals, community health centers, PHC clinics and 
OVC community organizations visited as part of this evaluation, respondents said IPHC’s 
greatest strength is the provision of management structures and tools to manage health care 
delivery, and the provision of clinical guidelines, checklists and registers to guide and track 
service delivery. As reported by the evaluation’s respondents, standardized application of the 
clinic supervision manual, initially developed under the Equity Project and modified under 
IPHC, has been a major force in assisting health care providers in maintaining a sustained and 
focused approach to the integrated management and provision of HIV, AIDS, TB, PMTCT, 
STIs and IMCI. 
At all facilities visited by the evaluation team, standardized use of registers has now become the 
norm rather than the exception. The IPHC has ensured that proper recording of health services 
delivered within the district is performed in a timely, quality manner. Indeed, a number of staff 
from different facilities cited their learning from IPHC, saying ―…if it was not recorded, it was 
not done.‖ In addition, introduction of the use and application of the PHC Review Process—
from the level of the facility up to and including district and sub-district levels—has resulted in 
PHC being recognized as a vital part of district health service delivery responsibilities. Finally, in 
response to high staff turnover within many of the facilities visited, the IPHC was able to assist 
in getting new staff trained, mentored, and functioning effectively while still managing to assist 
facilities in meeting their technical targets. 
Training 
In addition to its work with staff on institutionalizing the PHC review process, IPHC’s 
introduction of the LDP was cited as a significant IPHC strength. Although regrettably 
introduced during the last year of the project’s implementation, the LDP was cited by course 
participants as having a significant impact in terms of building their confidence and empowering 
them in their ability to manage programs and bring about effective change. In recognizing 
facilities’ needs for capacity-building in HCT, IPHC instituted an on-the-job training program 
focused on ensuring that all facility nurses are able to independently and effectively carry out 
counseling and testing. In addition, IPHC training support on HIV, AIDS, STI, and TB (HAST) has 
led to widespread integration of HAST and FP diagnosis and treatment within those clinics 
supported by IPHC. Finally, IPHC’s training in the management and administration of OVC 
initiatives has resulted in the OVC program’s ability to manage their administration and to 
successfully solicit financial and material support for their programs. As reported by one of the 
OVC program managers, ―Thanks to their [IPHC] assistance we now know who to approach 
and how to do it.‖
30 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Data Management 
In assisting supported facilities with training and implementation associated with the clinic 
supervision manual and with the PHC review process, IPHC devoted a significant amount of 
effort in developing the capacity of facility to understand and work with data associated with 
these two initiatives. Based on the evaluation team’s assessment, it was evident that a significant 
number of facility staff ―own‖ their data, are able to analyze it, and to develop initiatives and 
action plans that are directly associated with the data they have captured and reported. In 
addition, staff at facilities noted that with IPHC assistance, the time devoted to the completion 
of DHP-related data has been reduced from as much as three months for the creation of a DHP 
to less than three days. 
Establishing Linkages with the Community 
One of the hallmarks of the IPHC is its success in developing effective linkages between the 
facilities and the communities they serve. For example, IPHC guidance in the implementation of 
clinic health committees was often cited as leading to a marked improvement in community 
relations and to an increased knowledge-based role for the community in assisting facilities 
respond to health care priorities. Establishment of the committees led to the formation of 
community-supported home-based TB DOTS programs and to more effective integration of 
HIV and AIDS community support groups within the community and with the facilities 
themselves. Through the IPHC project, community health workers were trained to follow-up 
with PMTCT for every child at risk in the community. Traditional healers were trained in the 
promotion of immunizations, oral rehydration, and identification of childhood illnesses requiring 
clinic referrals. Finally, the IPHC’s introduction, training, and support of youth mentors led to a 
marked increase in the willingness of young people to be tested and counseled on HAST, and to 
seek out information related to FP/RH. 
IPHC Specific Impact 
Given that the project was called upon to develop initiatives in a limited number of facilities 
within a limited number of districts, and given that due to confounding variables it is difficult to 
identify the true impact of IPHC interventions, even within their assigned facilities, any 
statement of facility specific impact would be questionable. However, the IPHC did succeed in 
developing individual ―pockets of excellence‖ within the districts to which it was assigned. In 
addition, facility records indicate that following IPHC interventions, facility staff recorded IPHC￾related improvements in selected indicators. For example, following IPHC training, one clinic 
noted an increase in counseling and testing in ANC sessions from 62% to 96%. In another clinic, 
ANC visits increased from 94% to 100%, and PHC visits reached 100% among HIV-positive 
mothers following IPHC’s training interventions. In a third clinic, CD4 counts are now taken 
regularly, enabling staff to identify patients due for ARV and Zidovudine (AZT). Finally, following 
IPHC management and administration training, one of the OVC projects was successful in 
securing a grant of R450,000 from the Embassy of Japan for a new vocational training center. 
Technical Assistance Management Style 
In assessing the process by which IPHC staff provided technical assistance, the evaluation team 
was impressed by respondents’ appreciation for the passion and technical competence of IPHC 
staff as they sought to strengthen clinic staff technical capacity both in management and delivery 
of services. Consistently, clinic staff noted the significance of IPHC staff competence and 
dedication to the achievement of results centered on the value of positive reinforcement and a 
focused and informed approach to problem-solving. Accordingly, the IPHC’s passion for TA
coupled with IPHC’s technical competence was crucial to all success achieved. 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 31
WEAKNESSES 
Questionable Sustainability 
Despite the IPHC’s demonstrated and documented success in introducing effective health 
system strengthening interventions, the evaluation team was concerned about the lack of 
planning and action to strengthen the sustainability of IPHC initiatives prior to the project’s 
scheduled December 2010 termination. While this weakness will be addressed in the report’s 
recommendations, the evaluation team believes that the absence of an exit plan, including 
specification of milestones along the path toward project completion, has severely compromised 
the ability of the DOH to sustain IPHC initiatives. In addition, the absence of an exit plan led to 
an abrupt cessation of support for IPHC initiatives, such as those associated with the youth 
mentor program and the OVC programs. It also led to termination of activities essential to the 
project’s success, especially those focused on quality improvement under URC and on systems 
development under HST. 
Poor Analytical Base 
In its review of project documentation, the evaluation team could find no objective analytical 
base upon which to evaluate the effectiveness or impact of the project’s initiatives. For a project 
focused on health systems strengthening, the evaluation team expected an operations research 
component or independently commissioned qualitative evaluations by which to measure the 
importance, if not the impact, of IPHC interventions. The reports that did exist were generally 
self promotional in nature and lacking in objectivity. Finally, project indicators were generally 
without meaning, as they focused on outputs rather than outcomes and appeared to have low 
achievement expectations in order to guarantee ―success.‖ 
Limited Provincial or District Engagement: 
The evaluation team acknowledges that MSH had limited control over the project’s facility-based 
focus. However, in focusing explicitly on facility interventions, the project’s design was flawed in 
that it neglected the importance of ensuring that district and sub-district program managers 
were fully engaged in the project’s activities and had a vested interest in working toward the 
success and sustainability of IPHC initiatives. 
32 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 33
VII. CONSTRAINTS 
The evaluation team recognizes that issues beyond the IPHC project’s control have constrained 
its progress and the effectiveness and sustainability of its initiatives. The following paragraphs 
identify and discuss the five key constraints that appear to have had the most significant impact 
on its implementation. 
Human Resources 
South Africa struggles with a chronic deficit in human resources for health, and this deficit 
impacts all aspects of integrated primary care delivery in the country. One strategy for 
responding to this constraint is to move from facility-based PHC delivery to community-based 
PHC delivery with facility support. This change in service delivery model holds potential for 
increased access to health care for the community and redistributes available human resource 
capacity for greater impact. Another strategy to address this constraint is to gradually move 
toward a rationalization of the current DOH personnel ―pyramid‖ by reducing the top-heavy 
structure at the top of the pyramid (province and national) in order to provide more (and less 
costly) personnel at the facility level. Increased numbers of trained facility staff are required for 
the delivery of integrated PHC services throughout the country. 
Limited Program Management Expertise 
As a result of its project design, IPHC focused more on operations and management systems at 
the facility level than on strengthening the capacity of DOH leaders at all levels to manage and 
direct improvement of health services and health service delivery systems. As a result, program 
managers at the district and sub-district level have struggled to fully understand the management 
requirements of IPHC initiatives. Provincial and national DOH leaders have not been as engaged 
with the project as needed for institutionalization and sustainability of achievements. However, 
while not part of the project’s design or its workplan, MSH’s recent introduction of the LDP 
appears to have been highly successful in equipping a small but motivated cadre of health 
managers with basic skills in management and leadership. Institutionalization of an accredited 
LDP training program for health service managers may mitigate this constraint of limited 
management and leadership capacity within the DOH. 
Staff Turnover 
If the IPHC’s activities (or any development initiatives) are to be sustained at the facility level, 
chronic staff turnover must be addressed. One strategy to address this constraint is to develop 
an enhanced employment package that provides housing, schooling, and other essential quality of 
life resources for DOH staff, especially in rural communities which struggle to recruit and retain 
skilled facility staff. 
Culture of Dependency 
As expressed by facility staff, the willingness of trained staff to accept responsibility for sustaining 
activities introduced by IPHC is limited—due in part to a donor/recipient culture that 
anticipates that when one donor leaves, another donor will appear. This cultural mindset applies 
equally to managers at all levels of the government. One strategy to address this constraint is to 
insist that all development projects, at their onset, have a SAG-approved exit plan based upon 
the premise that, as projects implement their TA initiatives, government counterparts assigned 
to the project are being proactively mentored and capacitated to assume responsibility at the 
completion of the project. 
34 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Cultural and Religious Constraints 
There is a reluctance of some facility staff to offer certain health care services such as family 
planning or termination of pregnancies, due to conflicts with their cultural and/or religious 
beliefs. One possible approach to alleviating this is to strengthen the quality and frequency of 
supportive supervision to ensure that operations managers and supervisors are trained to 
provide counseling to staff to address cultural and religious constraints, in the hopes of 
achieving greater alignment between personal values and personal health needs. This task is a 
delicate undertaking but one that is required in the interest of ensuring that clients are offered 
and receive a truly integrated package of PHC services as provided for in government policy. 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 35
VIII. LESSONS LEARNED 
Management and leadership are essential skills for successful implementation and 
sustainability of PHC initiatives 
Tools, protocols, guidelines and training itself cannot be implemented effectively and sustained 
without skilled management providing consistent and supportive accountability. Leadership is 
essential to motivate and sustain staff commitment and energy. Ongoing clarification regarding 
how initiatives are tied to achievement of the integrated PHC vision is also essential. 
Ready access to a mentor is important for capacity development and skills transfer. 
People need role models that reflect, in their mindset and behavior, the values that the DOH 
aspires to are a commitment of the individual to the betterment of the community; commitment 
to one’s work within the DOH in order to improve PHC quality and access for all. Mentoring 
and role modeling starts with each manager at the national level and impacts every manager at 
every level below. Individual discipline and accountability matters. 
Regular use of skills is required to retain those skills. Training is an ongoing process. 
Without regular use of skills and ongoing, frequent ―in-servicing‖ and development of skills, 
capacity will dissipate over time and sustainability will be compromised. 
Team work, communication, and feedback are key. 
These three things are key to maintaining good quality systems and services. Vertical or ―silo‖ 
efforts are not effective. Everyone must understand his/her own role and responsibilities and 
those of every team member, in order to value and support the efforts of each member. 
Communication and feedback regarding actions taken, challenges encountered, and strategies 
utilized are all essential if the team is to be successful. Information sharing is empowering to all. 
Alignment and linkages between all levels of the DOH are essential for nationwide 
integrated PHC that is sustainable. 
Without alignment, each level of the DOH is moving in a different direction rather than 
supporting, understanding and valuing each level’s critical role in the building of an integrated 
PHC delivery system. 
Critical importance of accurate, timely data for utilization in informed decision￾making. 
Effective decision-making cannot occur without accurate, timely data. Likewise, monitoring and 
evaluation of actions taken cannot occur, and ultimately improvements in service delivery cannot 
be sustained without accurate, timely data providing feedback to inform staff of progress. 
Information regarding the ―why‖ of problem solving is required to inform decision-making based 
on evidence, to guide ongoing efforts to achieve and sustain quality services. 
An integrated information system for use by all levels of the DOH nationwide 
is essential to all health service provision, including integrated PHC service 
provision. 
Lack of standardized key indicators and DOH training at all levels has produced poor data. 
Therefore, quality data management is constrained and its use in decision-making weakens the 
quality of health care services. 
36 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Community involvement is a key to the successful development, implementation 
and sustainability of integrated PHC service. 
Weak linkages between the facility and the community inhibit the provision of quality PHC 
services. 
Youth respond to their peers. With this understanding, the utilization of youth 
mentors and YFS is an effective strategy. 
Access to PHC services is constrained by the lack of peer outreach to provide health education 
and linkage to the clinic for diagnosis and treatment of HAST. 
Health staff seek quality of life for themselves and their families. 
Accordingly, attention to employment packages that address the housing, education, 
infrastructure, and other needs of health staff and their families strengthens recruitment and 
retention. This is especially true in under-resourced rural areas. 
For integrated PHC to occur, facilities and community health workers must be 
equipped to provide integrated education, diagnostic and treatment services for 
patients. 
The success of cross-screening of HAST and PMTCT and the resultant reduction in ―missed 
opportunities‖ is a dramatic example of the significance of this lesson learned. 
Health initiatives that work with existing organizations and structures, rather than 
creating “silos” of effort, strengthen the communities and patients they serve. 
Cultural and religious beliefs have an impact on the provision, perception and 
sustainability of care. 
Those providing effective PHC interventions must be aware of cultural and religious beliefs and 
work with community leadership to facilitate quality care. 
Support groups are effective structures in the provision of health education, 
problem solving, reduction of stigma, morale-boosting and nurturing of hope and a 
sense of well-being. 
HIV and AIDS support groups are testaments to the effectiveness and value of such groups. 
It is essential that project design and exit plans, with identified funding and human 
resources, be signed off on by the funder, contractor, and DOH before project 
approval. 
Failure to provide for a systematic, planned exit of a donor-supported program is the greatest 
constraint on sustainability and raises doubt as to the value of a donor’s intervention.
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 37
IX. DISCUSSION 
Over the course of the IPHC external evaluation, team members noted ―overarching issues‖ 
that impacted the entire breadth and depth of the IPHC project, and indeed impact health 
development efforts throughout South Africa. These issues are identified below, with the hope 
that progress within the DOH, as well as with future health development projects, will be aided 
by awareness of these larger challenges so that targeted interventions can be developed to 
effectively address them. 
ALIGNMENT BETWEEN DONOR/CONTRACTOR/DOH 
DOH policies and priorities should guide the design of all development projects based on 
demand generated by the DOH, not supply generated by the donor and contractor (e.g., youth 
mentors introduced without DOH ―buy-in‖ to absorb/fund/sustain role). Thorough, specific, exit 
strategies within an agreed-upon timeframe should be a requirement of all project design. The 
donor, contractor and DOH must agree to all aspects of the exit strategy before a project is 
approved. 
Operational research needs to be integrated into all project design to ensure that relevant and 
accurate data is obtained. Well-designed operational research initiatives implemented 
throughout the project will ensure meaningful data analysis of interventions and their impact at 
critical stages and at the project’s final assessment.
Targeted TA should be secured through donors and contractors, with awareness that, although 
the ―building blocks‖ of the last 16 years have indeed created the foundation for integrated PHC 
(e.g., tools, manuals, processes), TA requirements must take on a new dimension focused on 
sustained development of interventions. Targeted TA that develops capacity at all levels of DOH 
to effectively implement, manage, and utilize the interventions of the past 16 years is currently
needed and must be reflected in all future project designs. 
Alignment of technical assistance with specifically-named DOH recipients should be considered 
a priority before the launch of a development initiative or the assignment of technical advisors. 
In addition to strong technical skills, strong negotiation skills and emotional intelligence are all 
essential for effective TA provision. 
HUMAN RESOURCES 
NGO Resources 
In order to rationalize and strategically target development assistance, the NDOH should first 
identify all organizations providing health development assistance in the country. Currently, 
hundreds of NGOs are providing assistance throughout South Africa. 
As part of the rationalization process, the DOH should analyze the resources provided by all 
organizations supporting it and identify and eliminate overlaps. During this process, the DOH 
can identify gaps in resources required to facilitate implementation of its policy and develop a 
strategic plan to be utilized by the DOH, donors, and contractors as a common source for 
identifying where targeted technical assistance can best be applied.
DOH Human Resources 
Inequities exist in human resources allocation throughout all levels of DOH. There is a need to 
harmonize human resources nationwide to achieve effective policy implementation. 
38 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
DOH’s human resources allocation profile is top-heavy. It has a ―V‖ shape, with excessive staff 
at the top of the staff pyramid and insufficient staff and capacity at the sub-district and facility 
level to implement the initiatives intended to realize the health policies crafted by higher levels. 
Job descriptions are often inaccurate and out-of-date. In addition to delineation of tasks, job 
descriptions should clearly state the position’s authority and the resources allocated to the 
position to support the successful conduct of responsibilities. 
MANAGEMENT AND LEADERSHIP CAPACITY 
Targeted TA in management and leadership skills is a significant need in developing DOH staff 
and their capacity to implement and sustain the key ―building blocks‖ of the last 16 years. 
Although district health plans, DHERs, the clinic supervision manual, PHC review process, and 
data management (to name a few) are all clearly delineated, DOH at all levels does not have the 
full complement of management and leadership skills to help staff take these tools and processes 
and implement them effectively, monitor implementation, and sustain impact. 
Guiding and supporting staff to implement, monitor, and sustain the tools and processes 
requires the ability to exercise effective management skills such as team development, 
motivation, delegation, supportive accountability, and constructive criticism grounded in positive 
supervision as opposed to negative fault-finding. 
Positive, skilled managerial role models are needed. Managers at all levels currently struggle with 
a lack of self-discipline and accountability. This is a negative model for others. 
Academic institutions need to develop a standardized, accredited health management curriculum 
and degree program that provides comprehensive management and leadership skills along with 
statistics and epidemiology, and produces professionally trained health managers for the district, 
provincial and national levels. 
The LDP is an effective, ongoing management capacity-building tool for use at the facility and 
sub-district levels that emphasizes the team over the individual and helps individuals move from 
a mindset of dependency to empowerment. Basic management skills are provided in an 
experiential setting to strengthen retention of management capacity. 
A NATIONWIDE CULTURE OF ENTITLEMENT AND DEPENDENCY 
People in different settings noted that some South Africans are losing values and lessons learned 
from the struggle against apartheid. This is especially true for values that included a social 
contract amongst citizens to improve the lives of all. Increasingly the perspective is moving from 
the ―good of all‖ to the betterment of self. Health development depends on a shared vision and 
commitment to ensure quality services for all. Teamwork is essential for success. Respondents 
also noted that follow-on support was expected from donors. 
CULTURAL AND RELIGIOUS BELIEFS PRESENT A SIGNIFICANT 
BARRIER TO FULLY-INTEGRATED PHC 
Family planning is believed to be a crime or, at the very least, is often not supported in 
more conservative areas by the community or by clinic staff. There is a need for targeted, 
collaborative TA between the departments of social development and health to address 
this challenge. 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 39
X. RECOMMENDATIONS 
The IPHC Project and the Equity Project, upon which it builds, have together achieved significant 
progress over the more than 12 years of USAID technical assistance to the SAG. The projects’ 
overarching technical focus been the introduction of initiatives designed to strengthen the 
nation’s PHC system in response to the many challenges associated with HIV and AIDS. The 
recommendations proposed by the IPHC external evaluation team are presented here as 
actionable interventions that the DOH can utilize to build upon the effectiveness and 
sustainability of IPHC interventions. Each recommendation below is placed in context of the 
issue being addressed. Where applicable, each recommendation includes suggestions regarding 
ways in which targeted TA can be applied to facilitate the achievement of a specific 
recommendation. 
IMPROVE THE USE OF DATA FOR DECISION-MAKING PURPOSES 
Recommendations 
District Managers should examine the validity and reliability of DHIS and develop and 
implement an action plan to address identified weaknesses. 
Current registers should be consolidated. 
Development of electronic registers at all levels should be a medium-term (five-year) 
development goal with IT systems developed at the facility level; 
Within the five-year development period, the government should budget for and recruit 
data capturers to provide technical support for all facilities. 
Current health indicators should be rationalized to ensure relevance to management, 
monitoring and evaluation needs. 
Training in the health information systems should be included in the curriculum of all health 
service providers including, but not limited to, that of doctors and nurses. 
Context 
Use of facility-level data was observed through the display of catchment area maps drawn and 
wall-posted graphs and charts for various service-delivery indicators. However, in MSH’s 
quantitative internal assessment report, flaws in data extracted from DHIS system were noted. 
Since record keeping at the facility level is paper-based and transfer of data from the facility to 
the district level DHIS system occurs manually, errors are possible in data transfer. This is due 
to either inadequate data quality checks or lack of coordination between facility and district/sub￾district office. Additionally, at the facility level there are too many registers for a particular 
service, leading to having patient’s information at different locations. This makes collation of data 
difficult, including tracking of patients for follow-up. 
Recommended Technical Assistance 
TA should be directed toward (i) a data-quality audit of the DHIS and data-collection and 
transfer methodology, including an examination and rationalization of current health indicators 
and should be undertaken to inform the actions required to increase validity and reliability of 
data; (ii) the development and implementation, initially for use in a pilot, of a framework for a 
comprehensive electronic patient and facility records management system with unique patient 
identification for improved patient tracking and follow-up; (iii) the development of job 
descriptions for facility-level data capturers; and (iv) a review and upgrading of current entry-
40 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
level curricula for health providers to include training materials focused on the health provider 
role with regards to the maintenance of health information systems.
IMPROVE SYSTEM-WIDE ACCOUNTABILITY 
Recommendation 
A system-wide organizational development study should be commissioned to assess and 
document current health system organizational strengths and weaknesses and develop a strategy 
and action plan to address weaknesses focused on the standardized application of national 
policies and guidelines. 
Context 
Currently, the health care system is dysfunctional in the sense that, from province to province 
and from district to district, implementation of national policy and guidelines and standardized 
application of decentralized management is not universally applied. The result is a nationwide 
lack of a systematic approach that utilizes standardized strategies and tools to effectively address 
the challenge of HIV and AIDS within South Africa. 
Recommended Technical Assistance 
Conduct an organizational development study and develop a concomitant strategy and action 
plan to address identified DOH organizational gaps and weaknesses. 
IMPROVE THE UPTAKE AND INTEGRATION OF FP/RH INTO PHC 
SERVICES 
Recommendation 
An FP/RH promotion communication strategy should be integrated into PHC services. The long￾term focused strategy should be responsive to individual behavior change needs and should 
maximize the potential for change on a broader societal level. Toward that end, family planning 
should be made one of the entry points for HIV prevention.
Context 
The uptake of cervical cancer screening and modern contraceptive methods, particularly the 
intrauterine contraceptive device (IUD), is very low. Cultural and religious norms and beliefs are 
reported as a major hindrance to uptake. It is important to understand both the client and 
health provider related factors that affect acceptance and refusal of FP/RH services. 
Recommended Technical Assistance 
Knowledge, attitude, and practices/usage (KAP) surveys among clients and service providers, 
including the role of religion and culture in the use of FP/RH services, should be carried out to 
understand the myths, misconceptions, and barriers related to the uptake of FP/RH. Using KAP 
survey results, targeted communication messages should be designed to increase the uptake of 
FP/RH services and methods. This survey should also include health system issues, skills, and 
competencies of community health workers as well as an assessment of knowledge regarding 
the linkage between FP and HIV and AIDS. 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 41
IMPROVE THE QUALITY OF SENIOR-LEVEL TECHNICAL SUPERVISION 
Recommendations 
An accredited and accelerated master’s level curriculum, with an emphasis on PHC 
management (including statistics and epidemiology), should be developed within South 
Africa’s academic institutions to address the need for professional training for all PHC 
managers at the level of sub-district and above. 
All current PHC managers at the level of sub-district and above (including the national level) 
should be scheduled to undertake the accelerated curriculum. 
Successful completion of the post-graduate (NQF Level 6) level PHC Management 
curriculum should be a prerequisite for entry of DOH employees to supervisory and 
managerial positions. This would apply to supervisors and managers who work outside the 
PHC setting, as PHC is the backbone of South Africa’s health care delivery system. 
Context 
Staff responsible for supervising and managing the nation’s PHC program frequently lack the 
necessary management and technical qualifications and orientation to effectively supervise PHC 
initiatives being implemented at facility level. 
Recommended Technical Assistance 
TA should be directed toward (i) an assessment of the current level of PHC training among 
existing PHC managers to identify current gaps in training; (ii) a review of the extent to which 
current academic curricula provide PHC training and have the capacity to address gaps 
identified; ( iii) an engagement with selected academic institutions to develop an accredited PHC 
management curriculum to respond to the training needs of PHC managers; and (iv) the 
development of a long-term (five-year) plan to train existing managers and to provide training 
for employees as they are nominated for PHC management positions 
IMPROVE THE EFFECTIVENESS OF SUPPORTIVE SUPERVISION 
Recommendations: 
The DOH implement a standardized LDP based on the MSH model with the LDP being 
adapted to the specific levels and needs of managers. 
MSH designs a LDP curriculum to be accredited in South Africa and utilized to develop a 
cadre of LDP facilitators in South Africa. Although MSH has recently trained 20 LDP 
trainers, the current MSH TOT process was not designed for long-term post-training 
support (at least 12 months) and for the South African certification of those who were 
trained. 
The DOH introduces the LDP nationally at the sub-district and facility levels. District health 
management teams, provincial program managers and national directors should all receive 
orientation to the LDP. 
Following orientation to the PHC review process, national and provincial-level directors and 
managers should conduct quarterly supportive supervision visits to facilities. Directors and 
managers of both levels should utilize PHC review process guidelines during their 
supervisory visits. 
As a KPA indicator, the sub-district manager should be responsible for ensuring that all 
facility staff are trained in and implement changes in technical protocols in a timely manner 
42 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
All new health service delivery staff should participate in a standardized orientation program 
that addresses all aspects of health service delivery at the facility level. New managers 
should receive LDP training within six months of their appointments. 
As a KPA indicator for the facility operations manager, consistent provision of a 
standardized orientation program should be administered to all staff. 
Context 
Supervision by staff from sub-district level and above is frequently negative and heavy-handed in 
its nature, and thus ultimately counter-productive to sustained improvement in staff 
performance. DOH staff at all levels have developed a ―culture of dependency‖ based on their 
reliance on outside TA to provide the effective management and leadership skills so essential to 
sustained quality improvements. Once institutionalized and rolled-out nationally by certified 
trainers, the recommended LDP training should significantly reduce DOH reliance on outside 
TA to provide effective supportive supervision, management, and leadership. In addition, sub￾district managers are not sufficiently engaged currently to ensure that facility staff stay up to 
date on best practices for the provision of integrated PHC, and that newly-assigned facility staff 
are adequately oriented to technical guidelines. 
Recommended Technical Assistance 
Given the specific nature and unique strengths of LDP training, MSH should be engaged to work 
with the SAG to develop a certified LDP training. MSH should be further engaged to ensure that 
a sufficient quantity of LDP trainers is developed to roll out LDP training nationwide. TA should 
assist the DOH in the development of a standard orientation and training package for newly￾appointed facility staff. 
ADDRESS HUMAN RESOURCE FOR HEALTH CHALLENGES 
Recommendations 
Review and standardize post-specific job descriptions for all levels. Job description review 
should be focused on clarification of responsibilities and on harmonization (e.g., removing 
duplications and overlap) among posts. 
Develop training courses for operations managers to build their capacity to ―work smart,‖ 
that is, to work effectively with the limited time and resources available. 
Develop a simple handbook of standard operating procedures based on an analysis of key 
tasks, responsibilities, authority, and resources for district and sub-district managers as a 
daily reference guide. 
Develop a long-term strategy and action plan to rationalize current DOH staffing patterns at 
all levels. 
Standardize organograms for each specific establishment level. 
Develop system-wide job-specific academic and competency requirements for DOH staff. 
Develop human resource incentive packages targeted to rural-area services. 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 43
Context 
Human resources for health (HRH) is a complex issue and the DOH is currently engaged in a 
long-term re-engineering process, partially addressing this challenge. The current top-heavy 
staffing pyramid must be addressed in order to align the allocation of staff according to need at 
each level of the DOH. Re-allocation of staff is also required for improved fiscal responsibility. 
Recommended Technical Assistance 
TA should be directed toward: (i) review and modification of current job descriptions; (ii) 
development and implementation of a ―work smart‖ training curriculum for facility operations 
managers; (iii) performance of a job function review for district and sub-district managers with a 
focus on developing a standard operating procedures handbook for use by these managers; (iv) 
design of developmental competency guide and checklist for use by supported facilities in 
moving toward ―graduation‖ from one competency level to the next; and (v) development of a 
forum for learning for operational managers to extend learning to other sub districts and 
districts, to facilitate leveraged learning and cross-pollination. 
REMOVE BARRIERS TO THE EFFECTIVENESS OF THE PHC REVIEW 
PROCESS 
Recommendation 
A computerized program should be developed for the production of summary ―dashboards‖ 
linked directly to PHC review process data. 
Context 
As currently implemented, the presentation of exhaustive amounts of data during the PHC 
monthly review process makes it difficult for participants to identify areas of concern that 
require action. Linking the initial input of data to the production of summary dashboards will 
enable participants to focus on areas of concern while identifying for special notice those 
facilities that have achieved quality results on established targets. 
Recommended Technical Assistance 
TA should be directed toward: (i) developing and piloting a standardized PHC Review process; 
and (ii) producing computerized PHC review-linked summary dashboards. 
ENHANCE THE SYNERGY AMONG ALL LEVELS: NATIONAL TO 
COMMUNITY 
Recommendations 
The NDOH should undertake an exercise to map all PHC programs in South Africa, 
focused on the development of a strategy to identify and reduce program overlap 
(harmonization) and, by utilizing gap analysis, to identify and respond to the needs of 
underserved areas. 
As a KPA indicator, national and provincial level staff program managers should be trained in 
PHC. Using the supervisory manual as a guide, they should also be required to undertake 
quarterly (for national and provincial staff) and monthly (for district and sub-district staff) 
supportive supervisory visits to health facilities. 
44 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
As part of their ―work smart‖ training course, facility operations managers should be 
provided with an orientation on the linkage between service delivery and national policy on 
PHC. 
The NDOH should review, adapt, and apply the MSH-developed operations manual for 
facility-level catchment area mapping. This should include the location of villages; availability 
of care-givers, CHWs and NGOs; the location of OVCs; and current PHC response 
priorities such as low immunization rates, prevalence and incidence of TB. HIV, AIDS, 
diarrheal outbreaks and the absence of a clean water supply. The adapted manual should be 
included as part of the standardized training and orientation program for all new employees. 
NDOH and PDOH should have a standardized guide for providing support to the district 
level. This sub-recommendation includes a focus on an integrated planning process between 
national and planning level authorities. 
Context 
At all DOH levels there is a pervasive lack of synergy regarding a common understanding and 
commitment to health policies and priorities. Without a common vision supported by a unified 
understanding of the policies to support that vision, initiatives focused on health systems 
strengthening will be severely constrained.
Recommended Technical Assistance 
TA should be directed toward: (i) assisting with harmonization and gap analysis and with the 
development of a strategy and action plan to rationalize gaps; (ii) inclusion of an orientation for 
staff that links policy with service delivery in the ―work smart‖ training program for facility 
operations managers; (iii) development of a standardized ―mapping‖ manual for facility 
operations managers; and (iv) development of an NDOH and PDOH standard guide regarding 
support to district level that includes guidelines for developing annual plans for district-level 
visits aligned with all strategic programs as part of the annual planning process. 
ENHANCE THE PRACTICAL APPLICATION OF THE DHER AND 
THE DHP 
Recommendation 
The DHP should be reduced to essential action-oriented interventions complete with 
measurable indicators with a clear linkage to the DHER and available resources. 
Context 
For planning purposes, there is minimal linkage between the DHER and the DHP. From the 
standpoint of operations applicability, the DHP is not viewed as a useful operational tool, as it 
frequently does not include input from or participation of international development partners.
Recommended Technical Assistance 
TA should be directed toward: (i) an analysis regarding DHER and DHP development and 
utilization and (ii) development of an action plan to improve the utility and application of both 
documents. 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 45
STRENGTHEN EFFECTIVENESS AND SUSTAINABILITY OF DONOR 
ASSISTED INITIATIVES 
Recommendations 
The NDOH and all provinces included in a project should agree to all initiatives within 
donor-assisted projects as part of the project procurement process. 
Development partners and government authorities should conduct needs and gap analyses 
to determine where available resources can be most effectively utilized. 
The practicality of developing memoranda of understanding (MOUs) between international 
development partners and provincial and district-level authorities should be explored, 
supported by all parties, and as developed, reviewed annually by all signatories. 
All contractors should be required to develop an exit plan with clearly defined milestones 
within the initial three-month project implementation phase. 
All projects should be required to develop baseline data for use in periodic and end-of￾project assessments and evaluations. 
All contractors should be required to prepare and present to the government and to 
USAID a quarterly review of progress against established milestones. 
All contractors should be required to prepare an action plan to respond to those areas in 
which identified milestones are behind schedule. 
At the highest level of project implementation, a specific government official should be 
identified and actively engaged as a project implementation counterpart to participate in 
monthly project reviews and in quarterly reviews noted above. 
Context 
During the design phase of the project, little attention was focused on the importance of 
developing an exit plan to ensure that the government agreed to all IPHC initiatives and that 
initiatives would be sustained following the project’s closure. As a result, the great majority of 
IPHC initiatives, while largely effective and well-executed, hold little promise of sustainability. 
46 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 47
ANNEX A. SCOPE OF WORK 
Global Health Technical Assistance Project 
GH Tech 
Contract No. GHS-I-00-05-00005-00
SCOPE OF WORK 
(Revised 9-27-10)
I. TITLE 
Activity: USAID/South Africa: Integrated Primary Health Care Project End of 
Project Evaluation
Contract: Global Health Technical Assistance Project (GH Tech), Task Order No. 01 
II. PERFORMANCE PERIOD 
O/a October 11th, 2010- o/a December 31st, 2010 
III. FUNDING SOURCE 
Mission 
IV. PURPOSE 
The Health Office of USAID/Southern Africa requests technical assistance to implement an end 
of project evaluation of the five-year Integrated Primary Health Care (IPHC) Project. 
V. BACKGROUND 
The Integrated Primary Health Care (IPHC) project in South Africa is a collaborative project 
between the South African National Department of Health (NDoH); five provincial 
Departments of Health (DoH), Eastern Cape, KwaZulu Natal, Limpopo, Mpumalanga, and North 
West; and eight selected districts of these provinces; and the United States Agency for 
International Development (USAID) in South Africa. This task order under the TASC II IQC 
began in July 2004 and currently has an end date of 30 December 2010 with Management 
Sciences for Health (MSH) as the prime contractor. Partners over the life of the project 
included Health Systems Trust (HST) and University Research Corporation (URC). IPHC is 
designed to improve access to and use of child health, reproductive health and HIV/AIDS 
services with an emphasis on improving the management systems at the district level and in 
selected facilities in those districts. The project provides direct support to nearly 70 health 
facilities and to the management teams of the eight districts; to 14 hospitals and three 
community health centers accredited for provision of anti-retroviral (ARV) therapy; and to 
CBOs for support of orphans and other vulnerable children (OVC). A two-year project 
extension, awarded in 2008, continued the focus on the original six strategic performance areas 
of maternal health and family planning, child health, youth program, HIV & AIDS, primary health 
care services and systems, and OVCs; and added the dimensions of consolidation, integration, 
and institutionalization to these initiatives while also encouraging expansion and replication of 
project successes in other districts, facilities, and communities. 
48 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
VI. OVERVIEW OF THE IPHC PROJECT 
MSH undertook an internal assessment of the IPHC project in January 2008. The report of the 
assessment will be provided as an important background document as well as a performance 
baseline for this end-of-project (EOP) evaluation. IPHC has also undertaken an internal 
qualitative evaluation, interviewing provincial, district, sub-district and facility staff. This will also 
be provided to the evaluation team. 
Below is the vision that reflects the main performance areas of the agreement with USAID. The 
IPHC project envisioned that as a result of its efforts, the emergence of functional district health 
systems capable of providing accessible, high-quality HIV & AIDS interventions that are fully 
integrated into primary health care services for the benefit of disadvantaged communities, thus 
offering previously disadvantaged South Africans a better quality of life. 
The technical interventions of the project were designed to contribute to the above goal by 
addressing the following intermediate results (IRs): 
IR 1 Strengthened HIV and AIDS prevention measures 
IR 2 Increased availability of quality STI services 
IR 3 Improved treatment of TB and AIDS 
IR 4 Expanded HIV/AIDS care and support 
IR 5 Expanded systems and services of selected primary health care systems. 
The IPHC Project reports on the following strategic performance areas (SPA): 
SPA1: Improve Maternal Health and Family Planning, with Emphasis on Youth 
SPA2: Improve Child Survival, Health, and Nutrition 
SPA3: Increase Youth Participation in Promotion and Use of Youth-Friendly Services 
SPA4: Reduce the Impact of HIV & AIDS 
– SPA4.1: Counseling and Testing (C&T) 
– SPA4.2: Prevention of Mother-to-Child Transmission 
– SPA4.3: Comprehensive Care, Management, and Treatment 
– SPA4.4: Palliative Care in the OVC Setting; Integration of TB and HIV 
SPA 5: Strengthening Primary Health Care Systems and Services 
– SPA 5.1: Quality Assurance, Clinic Supervision and District Development 
– SPA 5.2: District Health Information System 
– SPA 5.3: District Health Systems 
– SPA6: Strengthen Community Support and Participation for OVC. 
VII. SCOPE OF WORK 
The main purpose of this EOP evaluation will focus on assessing the effectiveness, efficiency, and 
quality of the IPHC project interventions at the facility and district level; identifying what has 
been successfully incorporated into the DOH’s ongoing programs and what challenges remain; 
establishing evidence of project results and impact, and providing lessons and recommendations 
for the planning and management of future projects that focus on health system strengthening. 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 49
The objectives for this evaluation will be to: 
Review project results (outputs and outcomes) in relation to the project’s strategic 
performance areas (SPA) and baseline status or comparison areas/facilities/organizations for 
each SPA (where available) and identify operational constraints encountered; 
Assess the project’s strengths, weaknesses, gaps in service delivery, and any constraints to 
successful implementation; and 
Identify and document best practices, lessons learned, and recommendations to inform 
follow-on activities focusing on sustainability. 
To achieve these objectives, USAID/Southern Africa requires a team of three people to conduct 
a EOP evaluation of the IPHC project. The evaluation will assess the contribution of the IPHC 
project to improving the quality of HIV/AIDS care and support and treatment services at the 
facility and district level and building the capacity of the health system. 
VIII. METHODOLOGY 
The following data collection methods will be used: 
1. Document Review 
– Review key project documents prior to arrival in country; 
2. Team Planning Meeting 
– Orientation and planning meeting to produce a workplan, timeline, interview 
instruments and draft outline of the report. Initial briefing meetings will be held with 
IPHC staff, USAID, and DOH to review finalize the approach and activities for the 
evaluation; 
3. Interviews and Site Visits 
– Key informant interviews to include USAID Mission Health Office staff, National and 
Provincial Department of Health staff and IPHC staff; 
– Visits to provinces and districts to observe the project in action and to collect 
evaluation data (eight selected districts in five provinces will be visited in the Eastern 
Cape, KwaZulu, Natal, Limpopo, Mpumalanga, and North West); 
– At the discretion of the Team Leader, MSH and DOH staff may be asked to excuse 
themselves from certain interviews to allow the team to collect the necessary data; 
– Prepare and present summary findings and recommendations; write and submit final 
evaluation report. 
IX. TEAM COMPOSITION, SKILLS AND LEVEL OF EFFORT 
The Review Team requires a team of three international consultants with expertise in HIV/AIDS 
care and treatment, maternal and child health, health systems management and community 
systems of care. Combined, the team should have expertise in monitoring and evaluating large￾scale programs, reproductive health, and maternal and child health programs and health systems 
strengthening. 
The three team members will be joined by MSH headquarters staff member with expertise in 
HIV and AIDS program management and a local MSH staff member for the local project 
perspective for each of the site visits. Two representatives from the National Department of 
Health and one representative from USAID/South Africa will join the team during field visits to 
provide an in-country perspective. 
50 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
The Team Leader will be an international consultant with extensive experience in HIV/AIDS, 
prevention, care and treatment expertise. The Team Leader will hold conference calls with the 
other two core team members, key representatives from USAID/South Africa Health Office, the 
National Department of Health, and the Management Sciences for Health South Africa staff 
prior to in-country arrival. 
The Team Leader will: 
Finalize the workplan for the assignment; 
Establish assignment roles, responsibilities and tasks for the members of the team; 
Ensure that the logistics arrangements in the field are complete with assistance from the 
local Management Sciences for Health office; 
Facilitate the Team Planning meeting; 
Take the lead on preparing, coordinating team member’s input, submitting, revising, and 
finalizing the assignment report; 
Manage the process of writing the final report; 
Manage team coordination meetings in the field; 
Coordinate the workflow, team tasks and ensure that the team schedule works; and 
Ensure that the team field logistics are arranged. 
The Maternal and Child Health Expert and the Health Systems and/or Community Program 
Expert should each have an advanced degree in health and five years experience in their 
specialties. 
In addition, each team member should have, at minimum, the following skills and experience: 
1. Demonstrated skill in written and oral communication: 
2. Demonstrated knowledge of international HIV/AIDS mitigation approaches, including 
strategies for health systems strengthening and promoting host-country ownership of 
programs; 
3. Ability to work effectively in, and communicate with, a diverse set of professionals; and 
4. Excellent English language skills (both written and verbal). 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 51
Sample LOE Table 
Task Team Leader Team Member-Lindsey 
Toomey 
Team Member￾Swati Sadaphal
Background Document 
Review
3 3 3
International Travel Days 3 3 3
Team Planning Meeting 1 1 1
Meetings and Interviews with 
Key Stakeholders and Field 
Visits
14 14 14
Analysis and Writing Draft 
Report
3 3 3
Debrief 1 1 1
5 5 0
Finalizes Report for 
Submission to USAID
3 1 1
TOTAL 33 days 31 days 26 days
A six-day work week is approved for in-country work. 
X. LOGISTICS 
The evaluation will be conducted over a 32-day period with a start date in-country of on/about 
October 17, 2010. The evaluation team, in collaboration with the staff of Management Sciences 
for Health in South Africa, National Department of Health, and USAID/South Africa will arrange 
all of the meetings, interviews, site visits, in briefing and out briefing in advance. South Africa 
logistical support will be arranged by IPHC/Pretoria office. 
GH Tech will provide all logistical arrangements such as flight reservations, country cable 
clearance, in-country travel, airport pick-up, lodging, and supplies as necessary for the 
evaluation team. 
XI. DELIVERABLES AND PRODUCTS 
1. Pre-trip Briefing: Prior to arrival, the Team Leader and evaluation team will review all 
relevant documentation and schedule a conference call with USAID/Southern Africa, National 
Department of Health, and in-country Management Sciences for Health team members. 
2. Team Planning Meeting and Workplan: After the Team Leader’s arrival in country, a 
workplan will be developed during the team planning meeting and briefings with 
USAID/Southern Africa Health Office, National Department of Health, and in-country 
Management Sciences for Health team members. The workplan should include should include, 
but not be limited to, the following items: 
a. Milestones and deliverables with due dates clearly established 
b. Key interview questions, methods, and tools 
c. Parameters for secondary analyses of existing data 
d. Timeline for key activities, including preparatory activities (e.g., literature review) 
52 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
e. Product due dates 
f. Schedule of in-briefing and formal debriefing presentations 
g. Tentative schedule for informant interviews 
h. Tentative schedule of travel to field sites 
i. Timeline for drafting the assessment report, requesting feedback, and finalizing the 
final report 
3. Debriefing: Prior to departure, the evaluation team will make a presentation to 
USAID/Southern Africa Health Office, National Department of Health, and in-country 
Management Sciences for Health team members. 
4. Draft Report: Prior to departure, the Team Leader will submit a draft evaluation report to 
USAID/Southern Africa Health Office and the National Department of Health— one hard copy 
and one electronic copy on a CD Rom or flash drive. The report (not including attachments) 
will be no longer than 30 pages with an Executive Summary, Introduction, Methodology, 
Findings, Lessons Learned, Conclusions, and Recommendations. 
5. Final Report: After the evaluation Team departs, USAID/South Africa has 14 working days 
to review the draft report and provide one single set of comments. The Team Leader will 
submit the final report to USAID/Southern Africa, Health Office within one week of receiving 
comments from USAID/Southern Africa and the National Department of Health. 
GH Tech will provide the edited and formatted final document approximately 30 days after 
USAID provides final approval of the content. USAID/South Africa requests both an electronic 
version of the final report (Microsoft Word 2003 format) and five hard copies of the report. 
The report will be released as a public document on the USAID Development Experience 
Clearinghouse (DEC) (http://dec.usaid.gov) and the GH Tech project web site 
www.ghtechproject.com). 
XII. RELATIONSHIPS AND RESPONSIBILITIES (USAID AND 
CONSULTANTS) 
GH Tech will conduct and manage the assessment and will undertake the following specific 
responsibilities throughout the assignment: 
Recruit and hire the three-person evaluation team; 
Make logistical arrangements for the consultants, including travel and transportation, 
country travel clearance, lodging, and communications; and 
Respond to all points included in the SOW, including the submission of the final report. 
MSH will provide all compensation and travel costs for their staff and any DOH staff. They 
will also be responsible for logistics, including reserving vehicles and hotel bookings for the 
site visits. 
USAID/South Africa will provide overall technical leadership and direction for the evaluation 
team throughout the assignment and will undertake the following specific roles and 
responsibilities: 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 53
Before In-Country Work: 
Consultant Conflict of Interest. To avoid conflicts of interest or the appearance of a COI, 
review previous employers listed on the CV’s for proposed consultants and provide 
additional information regarding potential COI with the project contractors or NGOs 
evaluated/assessed and information regarding their affiliates. 
Documents. Identify and prioritize background materials for the consultants and provide 
them, preferably in electronic form. 
Local Consultants. Assist with identification of potential local consultants and provide 
contact information. 
Site Visit Preparations. Provide a list of site visit locations, key contacts, and suggested 
length of visit for use in planning in-country travel and accurate estimation of country travel 
line items costs. 
Lodgings and Travel. Provide guidance on recommended secure hotels and methods of in￾country travel (i.e., car rental companies and other means of transportation) and identify a 
person to assist with logistics (i.e., visa, letters of invitation, etc.) if appropriate. 
During In-Country Work: 
Mission Point of Contact. Throughout the in-country work, ensure constant availability of 
the Point of Contact person(s) and provide technical leadership and direction for the team’s 
work. 
Meeting Space. Provide guidance on the team’s selection of a meeting space for interviews 
and/or focus group discussions (i.e., USAID space if available, or other known office/hotel 
meeting space). 
Meeting Arrangements. While local consultants typically will arrange meetings for contacts 
outside the Health Office, support local consultant(s) in coordinating meetings with 
stakeholders. 
Formal and Official Meetings. Arrange key appointments with national and local government 
officials and accompany the team on these introductory interviews (especially important in 
high-level meetings). 
Other Meetings. If appropriate, assist in identifying and helping to set up meetings with local 
professionals relevant to the assignment.
Facilitate Contact with Partners. Introduce the Evaluation Team to implementing partners, 
local government officials, and other stakeholders, and where applicable and appropriate 
prepare and send out an introduction letter for team’s arrival and/or anticipated meetings.
After In-Country Work: 
Timely Reviews. Provide timely review of draft/final reports and approval of the deliverables 
XIII. MISSION AND/OR WASHINGTON CONTACT PEOPLE/PERSON 
Mission Contact for this Assignment: Anita Sampson, Health Office, USAID/Southern 
Africa asampson@usaid.gov +27 12 452 2236 +27834436614 
IPHC Contact in South Africa: Tracey Naledi, Management Sciences for Health, Chief of 
Party, IPHC Project. 
MSH House, Block 6, Phase 4 Boardwalk Office Park; Haymeadow Street; Faerie Glen; Tel: 012 
9913559; Fax: 012 991 2714; Mobile: 0832687310; Email: traceyn@msh.co.za
54 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Final report to be sent to: Anita Sampson, Health Office, USAID/Southern Africa 
asampson@usaid.gov 
XIV. COST ESTIMATE (TO BE PROVIDED BY GH TECH) 
XV. REFERENCES (PROJECT DOCUMENTS) 
Reviewers will be provided with the following background documents in preparation for the 
assignment: 
Key Resource Documents: 
Original (2004) and Extension (2008) Proposals, IPHC/South Africa Project. MSH. 
IPHC Project routine (semi-annual and annual) reports to USAID. 
Youth Services Health Services Review: A Baseline Assessment. Health Systems Trust, 
June 2007. 
The Integrated Primary Health Care (IPHC) Project/South Africa. (Mid-term) Internal 
Assessment. January 2008. 
District Health Barometer; 2007/08. Health Systems Trust. July 2009. 
Workplans 2005–2009 
Field Trip Reports 2005–2009 
IPHC Monitoring and Evaluation Data 2005–2009 
IPHC Four-year report 2005–2009 
IPHC Internal Evaluation Reports (2008 and 2010) 
IPHC communication documents and other internal reports 
XVI. ADMINISTRATIVE AND LOGISTICS FUNCTIONS 
GH Tech will make every effort to support the successful completion of assignments. However, 
GH Tech does not have sufficient staff available to provide full-time administrative/clerical 
services to consultants and teams. Consultants are expected to undertake the following tasks 
independently of GH Tech assistance (unless otherwise stated in the scope of work): maintain 
individual calendars, set appointments, take notes, send emails, make phone calls, do 
photocopying, and other administrative functions necessary to implement the assignment. Team 
leaders are additionally responsible for maintaining the schedule and workplan for the team and 
for making local logistical arrangements (in-country travel, meeting rooms, appointments) when 
overseas, if the USAID mission or CAs are not providing such arrangements. If USAID approves 
and the assignment budget allows it, GH Tech may authorize the team leader to hire a local 
logistics assistant in country. 
GH Tech provides administrative and logistical support in the following specific areas: 
Providing instruction in completing required forms (expense report, invoice, etc.); 
Providing GH Tech office space for DC-based work and assisting in set-up of space (e.g., 
IT/equipment technical support and instructions, office supplies); 
Support for DC-based team planning meetings (facilitation, printing background materials, 
set-up, food, typing of notes if specifically authorized by GH Tech Project Director); 
Arranging travel in the U.S. and from the U.S. to overseas assignment location (country 
clearance, visa, plane tickets, hotel reservations, processing travel advance and expenses). 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 55
Consultants are responsible for arranging in-country travel while overseas and ground 
transportation in the U.S.; 
Facilitating contact with USAID staff; 
Instruction and/or assistance with formatting charts, graphs, and tables and PowerPoint 
slides; and 
Arranging for editing/layout of final report 
All other tasks required to complete the scope of work will be done by the consultant, except 
where the scope of work designates specific tasks for USAID, GH Tech, or another 
organization. Where other specific GH Tech assistance is desired, consultants will make a 
request to the GH Tech Project Director, who may provide staff if the request is deemed 
appropriate and staff is available. 
XVII. CONSULTANT COMMUNICATION WITH GH TECH AND USAID 
The consultant/team leader reports to the GH Tech Project Director or designee and is 
required to keep GH Tech informed of any relevant updates, including deliverables, changes to 
schedule, and constraints/concerns in implementing the assignment. If questions, problems, or 
concerns arise during the course of the assignment, the consultant will discuss those issues with 
the GH Tech Project Director or other GH Tech staff, who will communicate them to USAID 
as appropriate. If USAID requests the consultant to make any changes to the scope of work or 
undertake any activities that are outside of the scope of work, the consultant will ask the GH 
Tech Project Director or designee for authorization. GH Tech staff will ask periodically for 
updates on assignment status or a debriefing at the end of an assignment; the consultant will 
reply promptly and with the level of detail requested. When traveling overseas, the consultant 
will inform the GH Tech assignment manager of their arrival in country, and consultants will 
keep GH Tech informed about their location and travel plans (hotel room number, local travel 
arrangements, etc.). The consultant is required to submit a copy of all deliverables to GH Tech, 
unless informed otherwise by GH Tech. 
XVIII. METHODOLOGY, MILESTONES, AND TIME-LINES 
1. Document Review: Review key project documents prior to arrival in country 
(October 10–13); 
2. Team Planning Meeting: Orientation and planning meeting to produce a workplan, timeline, 
interview instruments, and draft outline of the report (October 17, 2010); 
3. Initial Briefing Meetings: Briefings from IPHC staff, USAID and DOH to review and finalize 
the approach and activities for the evaluation (October 18, 2010); 
4. Interviews and Site Visits (October 19–November 1, 2010): 
5. Key informant interviews to include USAID Mission Health Office staff, National and 
Provincial Department of Health staff and IPHC staff; 
6. Visits to provinces and districts to observe the project in action and to collect evaluation 
data (eight selected districts in five provinces will be visited in the Eastern Cape, KwaZulu 
Natal, Limpopo, Mpumalanga, and North West). 
7. Prepare summary findings and recommendations ( November 2–4)
8. Provide preliminary briefing to USAID, DOH and MSH Staff (November 5) 
9. Prepare Final Draft Report (November 6–11)
10. Present and Deliver Final Draft Report (November 12) 
11. USAID Review of Draft Report (November 12–December 6) with comments to evaluation 
team o/a December 7 
56 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
12. Evaluation team response to USAID Review (December 8–December 14) 
Evaluation Team Composition 
During the interviews and site visits, the evaluation team will be divided into two teams—A and B. 
Team A
William Emmet, GH Tech Team Leader and Team Leader of Team A. (GH Tech) 
Swati Sadaphal (GH Tech) 
Malik Jaffer (USAID) 
Team B
Lindsey Toomey, Team Leader of Team B (GH Tech) 
Mariah Boyd-Boffa (MSH) 
Tendani Muthambi (MSH) 
Key Interview Questions, Methods, and Tools 
The evaluation team will use a respondents' evaluation tool as a guide for discussions with key 
respondents. At the discretion of the Team Leader, MSH and DOH staff may be asked to 
excuse themselves from certain interviews to allow the team to collect the necessary data. 
Following each day of interviews the two teams (A and B), will meet separately to summarize 
key points and issues introduced during the interviews. For this purpose, the team will use an 
interview summary form for each interview and site visited. At the end of each week of site 
visits, the team will meet together to summarize findings associated with their site visits and to 
work on the rough draft of the final report. Team review meetings are scheduled for Saturday, 
October 23rd and Saturday, October 30th. The draft report will be delivered to USAID/SA prior 
to close of business on November 12. 
Parameters for Secondary Analyses of Existing Data 
For the purposes of the evaluation, the evaluation team will review existing data and reports and 
will request MSH for information with reference to the IPHC’s achievement of outputs by 
strategic performance areas (SPA) as specified by the MSH 2008 Extension Proposal. 
Information contained in these reports will be summarized in the report. 
XIX. EVALUATION ISSUES AS PRESENTED AND APPROVED AT THE 
OCTOBER 18TH GH TECH—USAID INITIAL BRIEFING MEETING 
Issue 1: The GH Tech Team would request USAID concurrence that the scope of work’s 
call for an analysis of impact should focus on district-level impact rather than national-level 
impact. 
Issue 2: The GH Tech Team would request confirmation from USAID that the team is not 
expected to examine data relating to those sites not supported by the IPHC. 
Issue 3: The GH Tech Team has worked with MSH to revise the schedule for field visits, 
especially those during Week 2 to Kwazulu Natal and Eastern Cape. The Team would 
request USAID concurrence with the adjusted schedule. 
Issue 4: Documentation from USAID refers to the evaluation as an ―End of Project 
Participatory Evaluation.‖ Team would request USAID’s clarification of the meaning of 
―participatory‖: If the term ―participatory‖ means that all partners in the evaluation team 
(GH Tech, USAID, MSH, DOH) participate in all meetings, then all members of Team A and 
Team B take part and would not be asked to recluse themselves in the event that it was felt 
that respondents might be less than frank in responding to GH Tech questions. Alternatively, 
if USAID would like GH Tech to be in a position to decide on instances where ―closed‖ 
interviews would contribute to more open responses to questions or issues, then the GH 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 57
Tech team would decide on an interview-by-interview basis whether USAID/MSH/DOH 
participants should be asked to recluse themselves if and as appropriate. GH Tech is open 
to either interpretation of the meaning ―participatory‖ and would welcome USAID’s 
clarification on this issue. 
Issue 5: Paragraph VI of the scope of work states that one of the main purposes of the 
evaluation is to focus on ―…recommendations for the planning and management of future 
projects that focus on health system strengthening.‖ Given that it is understood that no 
additional funding is available for a future project, the GH Tech team requests a clarification 
whether USAID is interested in such recommendations. If not, what should be the team’s 
focus in the section on recommendations? 
Issue 6: Paragraph VI of the scope of work includes seven points to be covered in the 
evaluation: 
– Assessment of effectiveness, efficiency, and quality of the IPHC project interventions at 
the facility and district level; 
– Identification of what has been successfully incorporated into the DOH’s ongoing 
programs; 
– What challenges remain; 
– Establishment of evidence of project results; 
– Establishment of evidence of impact; 
– Discussion of lessons learned; and 
– Recommendations for the future with a focus on health-system strengthening. 
The GH Tech Team would appreciate USAID guidance on the weight which the team should 
attach in its report to each of the above points. 
Issue 7: In its preparation of the final report, the GH Tech Team would appreciate USAID’s 
guidance on the mission’s intended use of the final report: Who is the audience and should 
the report’s findings be directed toward a specific audience?
 Issue 8: In preparing its debriefings, the GH Tech Team would request USAID guidance on 
whether the DOH and/or MSH will be included in all debriefings or whether separate 
presentations should be prepared for the three separate audiences. 
Issue 9: In addressing the preparation and delivery of the draft report on November 12th, 
the GH Tech Team would appreciate USAID’s guidance on whether the draft report in its 
entirety should be provided to both MSH and the DOH for their comments and feedback to 
the GH Tech Team. 
Issue 10: With reference to the calendar following the team’s delivery of the draft report 
on November 12th, the GH Tech Team would appreciate USAID’s concurrence with the 
fact that, following USAID’s review and that of MSH and the DOH within 10 business days 
after November 12th, USAID can expect GH Tech’s response to comments no later than 
December 14th. (This last request is due to the Team Leader’s inability to respond to 
comments prior to December 8th.) 
58 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
XX. RESPONDENT’S DISCUSSION GUIDELINES 
Integrated Primary Health Care Project (IPHC) 
End-of-Project Participatory Evaluation 
Discussion Guidelines for Field Visits and Interviews 
The Integrated Primary Health Care (IPHC) project in South Africa is a collaborative project 
between the South African National Department of Health (NDoH); five provincial 
Departments of Health (DoH), Eastern Cape, KwaZulu Natal, Limpopo, Mpumalanga and North 
West, and eight selected districts of these provinces; and the United States Agency for 
International Development (USAID) in South Africa. The project began in July 2004 and 
currently has an end date of 30 December 2010 with Management Sciences for Health (MSH) as 
the prime contractor. Partners over the life of the project included Health Systems Trust (HST) 
and University Research Corporation (URC). IPHC is designed to improve access to and use of 
child health, reproductive health, and HIV/AIDS services with an emphasis on improving the 
management systems at the district level and in selected facilities in those districts. By 2010, the 
project is expected to meet the following objectives: 
1. Improved maternal health and Family planning, with emphasis on youth, 
2. Improved child health and nutrition, 
3. Increased and improved participation of youth in advocacy for reproductive health and 
sexuality and solutions to gender violence, 
4. Reduced transmission and impact of HIV and AIDS, 
5. Strengthened primary health care systems and service delivery, and 
6. Strengthened community support for OVCs. 
In meeting these objectives, The IPHC project reports on the following Strategic Performance 
areas (SPA): 
SPA1: Maternal Health and Family Planning 
SPA2: Child Health 
SPA3: Youth Program 
SPA4: HIV and AIDS 
– SPA4.1: Counseling and Testing (C&T) 
– SPA4.2: Prevention of Mother-to-Child Transmission 
– SPA4.3: HIV and AIDS Treatment (ARV) 
– SPA4.4: Palliative Care (Basic) 
– SPA4.5: Palliative Care (TB and HIV) 
SPA 5: PHC Systems and Services
– SPA 5.1: Quality Assurance 
– SPA 5.2: District Health Information System 
– SPA 5.3 District Health Systems 
SPA 6: Orphans and Vulnerable Children 
Under a contract with USAID/South Africa, the GH Tech Project is undertaking an end-of 
project evaluation whose purpose is to assess the effectiveness, efficiency and quality of the 
IPHC project interventions at the facility and district level; to identify what has been successfully 
incorporated into the DOH’s ongoing programs and what challenges remain; to establish 
evidence of project results and impact; and to provide lessons and recommendations for the 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 59
planning and management of future projects that focus on health system strengthening. In 
responding to the evaluation’s purpose, the evaluation team will focus on the following 
objectives: 
Review project results (outputs and outcomes) in relation to the project’s strategic 
performance areas (SPA) and baseline status or comparison areas/facilities/organizations for 
each SPA (where available) and identify operational constraints encountered; 
Assess the project’s strengths, weaknesses, gaps in service delivery, and any constraints to 
successful implementation; and 
Identify and document best practices, lessons learned, and recommendations to inform 
follow-on activities focusing on sustainability. 
Based on the respondent’s experience and knowledge of the IPHC, in working with 
MSH and its partners, and with reference to IPHC objectives and SPAs, the 
evaluation team’s interviews will focus on the following questions:
1. What is the respondent’s assessment of IPHC progress achieved to date? The respondent 
should be encouraged to consider and comment on IPHC’s contribution to improved 
management systems focused on: 
a. Maternal health and family planning 
b. Child health 
c. Youth program 
d. HIV and AIDS 
– Counseling and Testing (C&T) 
– Prevention of Mother-to-Child Transmission 
– HIV and AIDS Treatment (ARV) 
– Palliative Care (Basic) 
– Palliative Care (TB and HIV) 
e. PHC Systems and Services 
– Quality Assurance 
– District Health Information System 
– District Health Systems 
f. Orphans and Vulnerable Children 
2. What is the respondent’s assessment of IPHC progress achieved to date? The respondent 
should be encouraged to consider and comment on IPHC’s contribution to improved health 
services focused on: 
a. Maternal Health and Family Planning 
b. Child Health 
c. Youth Program 
d. HIV and AIDS 
– Counseling and Testing (C&T) 
– Prevention of Mother-to-Child Transmission 
– HIV and AIDS Treatment (ARV) 
– Palliative Care (Basic) 
– Palliative Care (TB and HIV) 
e. PHC Systems and Services 
60 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
– Quality Assurance
– District Health Information System 
– District Health Systems 
f. Orphan and Vulnerable Children 
3. What is the respondent’s assessment of best practices‖ instituted by the IPHC in addressing 
management systems and health service delivery of the above strategic priority areas. 
What’s new and what’s working?
4. What is the respondent’s assessment of IPHC strengths and weaknesses associated with 
management systems and health service delivery of the above strategic priority areas? If 
something worked well, why did it work well? If something did not work well, why not? 
5. What is the respondent’s assessment of constraints associated with IPHC’s efforts to 
improve management systems and health service delivery of the above strategic priority 
areas? 
– Human Resources 
– Geography 
– Time 
– Funding 
– Community/Facility Interface 
– USAID/MSH/DOH Interface 
– Government Policy 
Facility Policy 
Leadership 
6. Sustainability 
a. What IPHC interventions are not sustainable and why do you think so? 
b. 6.2 What IPHC interventions are sustainable and what actions or interventions would 
the respondent recommend to build upon and improve the sustainability of management 
systems and health service delivery of the above strategic priority areas ? 
7. What is the respondent’s assessment of lessons learned with reference to IPHC’s efforts 
to improve management systems and health service delivery of the above strategic priority 
areas? 
XXI. DAILY INTERVIEW SUMMARY TEMPLATE 
Evaluation Team Interviewer: 
Respondent Name: 
Respondent Title and Affiliation: 
Interview Location: 
Date: 
Respondent Focus: 
SPA1: Maternal Health and Family Planning 
SPA2: Child Health 
SPA3: Youth Program 
SPA4: HIV and AIDS 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 61
– SPA4.1: Counseling and Testing (C&T) 
– SPA4.2: Prevention of Mother-to-Child Transmission 
– SPA4.3: HIV and AIDS Treatment (ARV) 
– SPA4.4: Palliative Care (Basic) 
– SPA4.5: Palliative Care (TB and HIV) 
SPA 5: PHC Systems and Services 
– SPA 5.1: Quality Assurance 
– SPA 5.2: District Health Information System 
– SPA 5.3: District Health Systems 
SPA6: Orphan and Vulnerable Children 
Interview Summary: 
1. Progress of the IPHC Project in Improved Management Systems: 
2. Progress of the IPHC Project in Improved Health Services: 
3. IPHC ―Best Practices‖:
4. IPHC Strengths/Weaknesses: 
5. IPHC Constraints: 
6. Lessons Learned: 
7. Sustainability: 
8. Recommendations: 
9. Comments/ Observations: 
62 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 63
ANNEX B. IPHC EVALUATION CONTACTS 
Name Organization Position Location Date
LIMPOPO: District Representatives
Maponya, R.L. University Research Council
District Coordinator:
Waterberg District Capricorn District 19th October 2010
Mothemi, M. Capricorn District Information Manager Capricorn District 19th October 2010
Mokgoba, T.J. Limpopo Provincial Health 
Transformation and 
Governance Capricorn District 19th October 2010
Lukhele, Z.P. Limpopo Provincial Health CFO Office Capricorn District 19th October 2010
Malumane, N. Capricorn District Capricorn District 19th October 2010
Chuene, S.E. Capricorn District PHC Manager Capricorn District Office 20th October 2010
Phosa, M. Capricorn District MCWHYN Manager Capricorn District Office 20th October 2010
Morewane, M.
Greater Sekhukhune 
District PHC Manager Pretoria East 22nd October 2010
EASTERN CAPE: District Representatives
Kizza, N.M. Chris Hani District District Manager Queenstown 25th October 2010
Sixam, N. Chris Hani District Quality Assurance Manager Queenstown 25th October 2010
Openshaw, M. Chris Hani District Information Manager Queenstown 25th October 2010
Mkabile, N. Chris Hani District HIV/AIDS Programs Queenstown 25th October 2010
Philaphi, N.C. Chris Hani District All Programs Manager Queenstown 25th October 2010
Shibani, N.O. Chris Hani District Planning Officer Queenstown 25th October 2010
NORTHWEST: District Representatives
Moromole, Dineo KS Hospital Complex Acting CEO Bojanala District Office 19th October 2010
Boloyi, D.E. Moretele Sub-District Sub-District Manager Bojanala District Office 19th October 2010
Boikanyo, K.S. Moses Kotane Sub-District Sub-District Manager Bojanala District Office 19th October 2010
64 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Name Organization Position Location Date
Bolokwe, M.E. Bojanala District Office
District Director, District 
Health Services Bojanala District Office 19th October 2010
Matjila, N.N. Bojanala District Office District Coordinator Bojanala District Office 19th October 2010
Tlhowe, Lawrence Rustenburg Sub-District Sub-District Manager Bojanala District Office 19th October 2010
Diratsagae, B.P. Moses Kotane Sub-District Assistant Manager Nursing 
Moses Kotane Sub-District 
Office 20th October 2010
Kgatlhante, A.S.M. Moses Kotane Sub-District Assistant Manager Nursing 
Moses Kotane Sub-District 
Office 20th October 2010
Moabi, S.S. Moses Kotane Sub-District
Assistant Manager Nursing 
(PHC)
Moses Kotane Sub-District 
Office 20th October 2010
Mogupi, T.P. Moses Kotane Sub-District Assistant Manager Nursing 
Moses Kotane Sub-District 
Office 20th October 2010
Moloi, I.M. Madibeng Sub-District Sub-District Manager Madibeng Sub-District Office 21st October 2010
Molefe, M.C.B. Madibeng Sub-District
Ikhutseng Assistant Manager 
Nursing (PHC) Hebron Clinic 21st October 2010
Mogotsi, L.S.F. Madibeng Sub-District
Bapong Assistant Manager 
Nursing (PHC) Hebron Clinic 21st October 2010
Mangezi, M.D. Moretele Sub-District
Assistant Manager Nursing 
(PHC) Moretele Sub-District Office 22nd October 2010
Madia, M.J. Moretele Sub-District
Assistant Manager Nursing 
(PHC) Moretele Sub-District Office 22nd October 2010
Seqwai, K. Moretele Sub-District Acting Clinical Manager Moretele Sub-District Office 22nd October 2010
Sentle, M.P. Moretele Sub-District
Assistant Manager Nursing 
(PHC) Moretele Clinic 22nd October 2010
KWAZULU NATAL: District Representatives
Dube, N. Uthungulu District Office OMN Uthungulu District Office 24th October 2010
Cabeichulu, S.M. Uthungulu District Office OMN PHC Uthungulu District Office 24th October 2010
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 65
Name Organization Position Location Date
Dube, J.Y. Uthungulu District Office
Deputy Director Manager 
Clinical Uthungulu District Office 24th October 2010
Mpupole, Isiphile Uthungulu District Office OMN MCWH Uthungulu District Office 24th October 2010
Ntuli, Bongi Uthungulu District Office PHC Supervisor Uthungulu District Office 25th October 2010
Khumalo, M.H. Sisonke District Office OPM IPC Sisonke District Office 28th October 2010
Mpongoma, S. Sisonke District Office District Information Officer Sisonke District Office 28th October 2010
Langa, Londa
Sisonke District Area 2 
AGM Office
Prinicpal Technical Advisor 
IAP Sisonke District Office 28th October 2010
Nwme, V.V. Sisonke District Office OPM PHC Sisonke District Office 28th October 2010
Msami, T.L. Sisonke District Office STA PMTCT Sisonke District Office 28th October 2010
Mkluze, B.A. Sisonke District Office DDM Sisonke District Office 28th October 2010
Mokgalapa, Yvonne NDOH: DHS Deputy Director Sisonke District 28th October 2010
Makhaye, B.H.S. Sisonke District Office Deputy Manager Sisonke District Office 28th October 2010
MPUMALANGA: District Representatives
Ngaleka, N. Ermelo District Office
Operational Manager: Dun 
Donald Clinic Ermelo District Office 1st November 2010
Mabande, K. Ermelo District Office MNCHW Program Manager Ermelo District Office 1st November 2010
Luthulu, T. Ermelo District Office TB Program Manager Ermelo District Office 1st November 2010
Dhlahla, S. Ermelo District Office
Health Promotion Program 
Manager Ermelo District Office 1st November 2010
Khumalo, T. Ermelo District Office
Health Information Program 
Manager Ermelo District Office 1st November 2010
Makhanya, S. Ermelo District Office NGO Coordination Ermelo District Office 1st November 2010
Dlamini, S. Ermelo District Office Clinic Supervisor Ermelo District Office 1st November 2010
LIMPOPO: Health Services Personnel 
Segorela, K. Moletjie Clinic Clinic Youth Mentor Moletjie Village 19th October 2010
Mokwatlo, M. Moletjie Clinic General Nurse Moletjie Village 19th October 2010
66 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Name Organization Position Location Date
Moabelo, I. Moletjie Clinic Clinical Nurse Practitioner Moletjie Village 19th October 2010
Mabotja, J. Moletjie Clinic Clinical Nurse Practitioner Moletjie Village 19th October 2010
Selepe,W. Moletjie Clinic Clinic Committee Chairperson Moletjie Village 19th October 2010
Setati,P. Moletjie Clinic Cleaner Moletjie Village 19th October 2010
Maubane, M. Moletjie Clinic Lay Counselor Moletjie Village 19th October 2010
Mamabolo, P.J. Moletjie Clinic Registered Nurse Moletjie Village 19th October 2010
Masedi, F.A. Moletjie Clinic Data capturer Moletjie Village 19th October 2010
Magotlane, M.M. Moletjie Clinic Enrolled Nurse Moletjie Village 19th October 2010
Sekgala, R.C. Moletjie Clinic Enrolled Nurse Moletjie Village 19th October 2010
Manoko, M.S. Moletjie Clinic Moletjie Village 19th October 2010
Mofepi, J.J. Moletjie Clinic Moletjie Village 19th October 2010
Motloutsi, S.M Moletjie Clinic Moletjie Village 19th October 2010
Mphahlele, M.J. Lebowakgomo Hospital 
Occupational Health Care
Unit Manager Lebowakgomo 20th October 2010
Teffo, R.G. Lebowakgomo Hospital TB Clinic Manager Lebowakgomo 20th October 2010
Mahlatji, R.D Lebowakgomo Hospital Quality Assurance Manager Lebowakgomo 20th October 2010
Hika, K.M. Lebowakgomo Hospital Lay Counselor Lebowakgomo 20th October 2010
Ramphaka, M. Lebowakgomo Hospital Dietician Lebowakgomo 20th October 2010
Mabena, N.L Lebowakgomo Hospital Lay Counselor Lebowakgomo 20th October 2010
Mailula, M.M. Lebowakgomo Hospital Lay Counselor Lebowakgomo 20th October 2010
Ralithi, L.P. Lebowakgomo Hospital Lay Counselor Lebowakgomo 20th October 2010
Phasha, M.J. Lebowakgomo Hospital ARV Unit Manager Lebowakgomo 20th October 2010
Laka, M. Lebowakgomo Hospital Out Patient Unit Manager Lebowakgomo 20th October 2010
NORTHWEST: Health Services Personnel
Legotlo, L. Tlhabane cluster
Assistant Manager Nursing 
(PHC) Tlhabane CHC 19th October 2010
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 67
Name Organization Position Location Date
Lesejane, N.J. Tlhabane Health Center Operational Manager Tlhabane CHC 19th October 2010
Mataboge, M.J. Tlhabane Health Center Information Officer Tlhabane CHC 19th October 2010
Motlhabi, M.J. Tlhabane Health Center Communication Officer Tlhabane CHC 19th October 2010
Masilo, N.E. Bakubung Clinic Operational Manager Bakubung Clinic 20th October 2010
Letlape, N.H. Hebron Clinic Operational Manager Hebron Clinic 21st October 2010
Phajane, T.A. Oukasie Maternity Operational Manager Hebron Clinic 21st October 2010
Malemane, S.M. Motholung Operational Manager Hebron Clinic 21st October 2010
Tlhake, M.J. Moretele Clinic Operational Manager Moretele Clinic 22nd October 2010
KWAZULU NATAL: Health Services Personnel
Khanyile, Sizakele Chwezi Clinic Operational Manager Chwezi Clinic 25th October 2010
Mgenge, Takhona Inkosinathi OVC Project Data Capturer Inkosinathi OVC Project 26th October 2010
Ndlovu, Nondumiso Inkosinathi OVC Project Finance Officer Inkosinathi OVC Project 26th October 2010
Liman Linda, S.S. Inkosinathi OVC Project Project Manager Inkosinathi OVC Project 26th October 2010
Ndlovu, Reginah Inkosinathi OVC Project Community Caregiver Inkosinathi OVC Project 26th October 2010
Ndlovu, Thoko Inkosinathi OVC Project Community Caregiver Inkosinathi OVC Project 26th October 2010
Peter Inkosinathi OVC Project Facilitator Inkosinathi OVC Project 26th October 2010
Shahdu, Musa Nseleni CHC
Pharmacy Assistant/Former 
Youth Mentor Nseleni CHC 26th October 2010
Mngadi, Khanyisile Nseleni CHC
Pharmacy Assistant/Former 
Youth Mentor Nseleni CHC 26th October 2010
Mhgonezulu, Gugu Nseleni CHC Operational Manager IMCI Nseleni CHC 26th October 2010
Ntuli, Thembi Nseleni CHC Operational Manager ARV Nseleni CHC 26th October 2010
Doke, M.P. Nseleni CHC Youth Friendly Services Chair Nseleni CHC 26th October 2010
Mavundla, B.L. Nseleni CHC Nursing Manager Nseleni CHC 26th October 2010
Mthabela, Mrs. King Dinizulu Clinic Nursing Manager King Dinizulu Clinic 27th October 2010
68 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Name Organization Position Location Date
Magubane, Sister King Dinizulu Clinic Operational Manager King Dinizulu Clinic 27th October 2010
Zondi, T.C. Pholela CHC Clinical Nurse Practitioner Pholela CHC 28th October 2010
Willie, N. Pholela CHC OMN Pholela CHC 28th October 2010
Sikhakhane, T.G.O. Pholela CHC OMN Pholela CHC 28th October 2010
King, B.C. Pholela CHC Acting Facility Manager Pholela CHC 28th October 2010
Maphanga, B.M. Pholela CHC PHC Supervisor Pholela CHC 28th October 2010
Klumalo, Nokuthumla Hlokozi Clinic Clinical Nurse Practitioner Hlokozi Clinic 29th October 2010
Dlamini, Thandekhe Jolivet Clinic Operational Manager Jolivet Clinic 29th October 2010
Jwora, Lethani Jolivet Clinic
Clinic Committee 
Representative Jolivet Clinic 29th October 2010
EASTERN CAPE: Health Services Personnel 
Riwica, N.V. Frontier Regional Hospital ARV Doctor Queenstown 25th October 2010
Chitha, W.W. Frontier Regional Hospital Queenstown 25th October 2010
Phakade, N. Frontier Regional Hospital ARV Coordinator Queenstown 25th October 2010
Tywati, E.S. Frontier Regional Hospital COO Queenstown 25th October 2010
Mbontsi, K. Inxuba Ye Themba LSA Clinic Supervisor
Thornhill Community Health 
Center 26th October 2010
Notshe, N. Inxuba Ye Themba LSA
HIV/AIDS/STI and Prevention 
Manager 
Thornhill Community Health 
Center 26th October 2010
Spenxe, S. Thornhill CHC ARV Coordinator
Thornhill Community Health 
Center 26th October 2010
Tsheko, N.A. Inxuba Ye Themba LSA Operations Manager 
Thornhill Community Health 
Center 26th October 2010
Mntambo, N.C. Inxuba Ye Themba LSA All Programs Manager 
Thornhill Community Health 
Center 26th October 2010
Spelman, K. Thornhill CHC ARV Doctor
Thornhill Community Health 
Center 26th October 2010
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 69
Name Organization Position Location Date
MPUMALANGA: Health Services Personnel
Makhubu, T. Dundonald Clinic Professional Nurse Dundonald Clinic 1st November 2010
Mahla, M. Dundonald Clinic Professional Nurse Dundonald Clinic 1st November 2010
LIMPOPO: Community Based Organizations
Legodi, S. 
Bahlaloga Community 
Home Based Care Manager Moletjie Village 19th October 2010
Boshamane, E.
Bahlaloga Community 
Home Based Care Caregiver Moletjie Village 19th October 2010
Matlala, M. Makotse Women's Club Manager Mokotse Village 21st October 2010
Mphahlele, B. Direlang Project Board Member Lenting Village 21st October 2010
Maphuthi, A. Direlang Project Project Manager Lenting Village 21st October 2010
Tshebesebe L. Direlang Project Financial Officer Lenting Village 21st October 2010
Aphane, J. Direlang Project 
Monitoring and Evaluation and 
Reporting Officer Lenting Village 21st October 2010
Lekgau, C. Direlang Project OVC Coordinator Lenting Village 2st October 2010
National Department of Health & Health Systems Trust
Matse, P.M. Health Systems Trust Project Manager Madibeng Sub-District Office 21st October 2010
Dr. Pillay, Yogan NDoH Deputy Director General NDoH 5th November 2010
DrMorewane, R. NDoH Chief Director NDoH 18th October 2010
Asia, Bennett NDoH Director NDoH 18th October 2010
Dr. Wilson, Tim NDoH Consultant NDoH 31st October 2010
70 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 71
ANNEX C. IPHC KEY BACKGROUND DOCUMENTS REVIEWED
MSH CONTRACTS
Original (2004) Proposal, IPHC/South Africa Project. MSH.
Extension (2008) Proposal, IPHC/South Africa Project. MSH.
Project Management Documents
Contract Performance Matrix.
MSH Performance Monitoring Plan.
Work Plan, 2005.
Work Plan, 2006.
Work Plan, 2007.
Work Plan, 2008.
Work Plan, 2009.
Project Financial Documents
MSH Accruals
MSH Funds by Activity Area
Reports and Analyses
The Integrated Primary Health Care (IPHC) Project/South Africa. Mid-term Internal Assessment. 
January 2008.
IPHC Internal Evaluation Report, 2010.
IPHC Four Year Report, 2005–2009.
IPHC Monitoring and Evaluation Data, 2005–2009.
Youth Services Health Services Review: A Baseline Assessment. Health Systems Trust, June 2007.
District Health Barometer; 2007/08. Health Systems Trust. July 2009.
Internal Assessment of the IPHC Project, 2004-2009. October 2010.
IPHC Project routine (semi-annual and annual) reports to USAID.
PHC Review Manual.
Summary Statistics extracted from Human Resources for Health: A Needs and Gaps Analysis of HRH in 
South Africa, November 2009.
72 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
Trip reports
Field Trip Reports 2005–2009
Communications Documents
Helping Others Help Themselves: A Community-led Response to Healthcare in Mbabakazi. July 2010.
LDP Brochure. MSH, Undated.
NDOH Documents
National Department of Health Strategic Plan, 2010/11–2012/13.
PHC Clinic Supervision Manual, 2009.
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 73
ANNEX D. IPHC EVALUTION SCHEDULE 
DATES TIME ACTIVITY VENUE DRIVING DISTANCE 
Monday, 18th October 
2010
10:00 Meeting with USAID USAID Offices, Groenkloof 
Pretoria
7 km from hotel (VILLAS) 
11:00 Meeting with DOH Representatives 
14:00 MSH Briefing MSH Office Faerie Glen 
Pretoria and VILLAS
16:00 Team Meeting VILLAS
16:30 Team A departs for Limpopo 
Tuesday, 19th 
October 
8:30 Meeting with District Representatives Polokwane - Capricorn 
District Office 
4 km from hotel 
(Masana/Victoria Place/
14:00 Moletjie Clinic Moletjie 60 km from Lonsdale 
toward Polokwane
Wednesday, 20th 
October 
8:00 Lebowakgomo Hospital Lebowakgomo 57 km from Polokwane 
12:00 Unit R Clinic Lebowakgomo Township 5 km from Lebowakgomo 
Hospital
16:00 Travel to Groblersdal Sleep at Guinea Feathers -
0823301916 or Lion's 
Guesthouse (013) 262 2268
119 km 
Thursday, 21st 
October 
9:00 Makotse Women's Club Makotse Village 68km from Polokwane 
13:00 Direlang OVC Project Lenting Village 27km from Makotse Village 
15:30 Travel to Groblersdal Sleep at Loskop Lodge B&B 119 km 
Friday, 22nd October
9:00 Klipsruit Clinic Lessofontein 55km from 
Groblersdal
17:00 Meeting with Greater Sekhukhune 
Representative Pretoria East - Woodlands 
74 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
DATES TIME ACTIVITY VENUE DRIVING DISTANCE 
Saturday, 23rd 
October 09h –13h00 Evaluation Team Meeting: Week Recap VILLAS
Tuesday, 19 October 8:30 Meeting with the Bojanala district 
management team
Bojanala district office 122km from Pretoria. Team 
could also stay overnight in 
Rustenburg
12:00 Visit to Thlabane CHC Thlabane 5.6km 
Wednesday, 20 
October 
8:30 Meeting with the Moses Sikotane sub￾district management team
Moses Sikotane sub district 
office
Villas - Pretoria, 122 from 
Rustenburg
13:00 Visit to Bakubung clinic Bakubung
Thurday, 21st October 9:00 Meeting with the Madibeng sub-district 
manager
PHC Review Meeting 
Madibeng sub district office
16:00
Friday, 22nd October 9:00 Hebron clinic Hebron 45 km from Pretoria 
Visit to Moretele clinic Moretele
Saturday, 23rd 
October
09h –13h00 Evaluation Team Meeting: Week Recap VILLAS
Sunday, 24th October 10:00 Depart Durban for uThungulu District Empangeni 172km from Durban 
15:00
uThungulu District: Meeting with 
district representatives Empangeni 172km from Durban 
Monday, 25th October 9:00 Nponjwana Clinic Nomponjwana Village 
12:00 King Dinizulu 27km from district office 
Tuesday, 26th 
October 
9:00 Nseleni Nseleni 
13:00 Inkosinathi OVC CBO 
Wednesday, 27th 
October 
Drive to Sisonke 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 75
DATES TIME ACTIVITY VENUE DRIVING DISTANCE 
Thurdsday, 28th 
October 
8:30 Sisonke District Meeting Ixopo
13:00 Pholela CHC Pholela Village 108km from Ixopo
Friday, 22nd October 
8:30
Jolivet Clinic Jolivet 53km from Ixopo toward 
Durban 
13:00 Hlokozi 30 km from Jolivet toward 
Durban 
17:40 Fly from Durban to Johannesburg 
Sunday, 24th October 10:00 Travel from Johanesburg to East London 
12:00 Drive from East London to 
Queenstown 200km from East London 
Monday, 25th October 8:30 Chris Hani District Office Queenstown 
13:00 Frontier Hospital Queenstown 5km from district office 
Tuesday, 26th 
October 
9:30 Glen Grey Hospital 50 km from Queenstown 
13:30 Askeanton 15 km from Glen Grey 
Hospital 
Wednesday, 27th 
October 
8:00 Travel from Queenstown and Kokstad Ngcobo 
11:00 All Saints Gateway Ngcobo 358km from Queenstown 
Thursday, 28th 
October 
8:30 Meeting with district representatives Kokstad - Alfred Nzo 
13:00 Madzikane Ka Zulu
Friday, 29th October 9:00 Mt Ayliff Hospital Mt Ayliff 
12:00 Bonukhanyo Youth Organization Mt Ayliff 45km from Mt Frere
14:00 Drive from Kokstad to Durban 
17:40 Fly from Durban to Johannesburg 
76 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
DATES TIME ACTIVITY VENUE DRIVING DISTANCE 
Saturday, 30th 
October
8:30 Meeting with Dr. Tim Wilson Parktown Johannesburg 65 km from Villas 
Saturday, 30th 
October
09h –13h00 Evaluation Team Meeting: Week Recap VILLAS
Sunday, 31st October Report Writing
Monday, 1st 
November 
6:00 Travel to Mpumalanga Ermelo Tendani, Mariah and Swati 
8:30 Gert Sibande District: Meeting with 
district representatives 
Ermelo
14:00 Dun Donald CHC Dun Donald Village 150km from Ermelo 
Monday, 1st 
November 
08:30 – 17:30 Evaluation Team meeting: Briefing Prep 
and Recommendation writing 
VILLAS Bill, Lindsey and Malik 
Tuesday, 2nd 
November 
09:00 –17:00 Evaluation Team meeting: Briefing Prep 
and Recommendation writing 
VILLAS 
Wednesday, 3rd 
November
09:00 –11:30
13:00–18:00 
Evaluation Team Meeting: Week Recap 
and Briefing Prep. Tracey to provide a 
presentation on Re-engineering PHC 
Report Writing
MSH Offices - Faerie Glen 
Pretoria and VILLAS 
Thurday, 4th 
November 
08:30 –16:30 Evaluation Team Meeting :Briefing Prep VILLAS
Friday, 5th November 11:00 —
13:00 13:30 –
16:00
USAID Offices: Debriefing Meeting at 
MSH Offices 
Full Team Recap following USAID 
Meeting
NDOH offices - Civitus 
Building Pretoria
Saturday, 6th 
November
09h –18h00 Report Preparation: Emmet and 
Toomey
VILLAS
Sunday, 7th November 09h –18h00 Report Preparation: Emmet and 
Toomey
VILLAS
Monday, 8th
November
09h –18h00 Report Preparation & Preparation for 
USAID / DOH Review Meeting: -
Emmet and Toomey
VILLAS
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 77
DATES TIME ACTIVITY VENUE DRIVING DISTANCE 
Tuesday, 9th 
November
09:00–18:00 Report Preparation & Preparation for 
USAID / DOH Review Meeting: Emmet 
and Toomey
VILLAS 
Wednesday, 10th 
November 
09h –18h00 Report Preparation: Emmet and 
Toomey
VILLAS
Thursday, 11th 
November 
09h –18h00 Report Preparation: Emmet and 
Toomey
VILLAS
Friday, 12th 
November 
10:00 Final Report Production and Delivery of 
Report to USAID by Close of Business
USAID Offices 7 km from VILLAS 
78 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 79
ANNEX E. INTEGRATED PRIMARY HEALTH CARE PROJECT 
(IPHC) END-OF-PROJECT PARTICIPATORY EVALUATION 
DISCUSSION GUIDELINES FOR FIELD VISITS AND INTERVIEWS 
The Integrated Primary Health Care (IPHC) project in South Africa is a collaborative project 
between the South African National Department of Health (NDoH); five provincial 
Departments of Health (DoH), Eastern Cape, KwaZulu Natal, Limpopo, Mpumalanga and North 
West, and eight selected districts of these provinces; and the United States Agency for 
International Development (USAID) in South Africa. The project began in July 2004 and 
currently has an end date of December 30, 2010 with Management Sciences for Health (MSH) as 
the prime contractor. Partners over the life of the project included Health Systems Trust (HST) 
and University Research Corporation (URC). IPHC is designed to improve access to and use of 
child health, reproductive health, and HIV/AIDS services, with an emphasis on improving the 
management systems at the district level and in selected facilities in those districts. By 2010, the 
project is expected to meet the following objectives: 
1. Improved maternal health and family planning, with emphasis on youth 
2. Improved child health and nutrition 
3. Increased and improved participation of Youth in Advocacy for Reproductive Health and 
Sexuality and solutions Gender Violence 
4. Reduce transmission and impact of HIV and AIDS 
5. Strengthened primary health care systems and service delivery 
6. Strengthened community support for OVCs 
In meeting these objectives, The IPHC project reports on the following strategic performance 
areas (SPA): 
SPA1: Improve maternal health and family planning, with emphasis on youth 
SPA 2: Improve child survival, health, and nutrition 
SPA 3: Increase youth participation in promotion and use of youth-friendly services 
SPA 4: Reduce the impact of HIV & AIDS 
– SPA 4.1: Counseling and testing (C&T) 
– SPA 4.2: Prevention of mother-to-child transmission 
– SPA 4.3: Comprehensive care, management, and treatment 
– SPA 4.4: Palliative care in the OVC setting; integration of TB and HIV 
SPA 5: Strengthening primary health care systems and services
– SPA 5.1Quality assurance, clinic supervision and district development 
– SPA 5.2: District health information system 
– SPA 5.3 District health systems 
SPA 6: Strengthen community support and participation for OVC. 
Under a contract with USAID/South Africa, the GH Tech Project is undertaking an end-of￾project evaluation whose purpose is to assess the effectiveness, efficiency, and quality of the 
IPHC project interventions at the facility and district level; to identify what has been successfully 
incorporated into the DOH’s ongoing programs and what challenges remain; to establish 
evidence of project results and impact; and to provide lessons and recommendations for the 
80 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
planning and management of future projects that focus on health system strengthening. In 
responding to the evaluation’s purpose, the evaluation team will focus on the following 
objectives: 
Review project results (outputs and outcomes) in relation to the project’s strategic 
performance areas (SPA) and baseline status or comparison areas/facilities/organizations for 
each SPA (where available), and identify operational constraints encountered; 
Assess the project’s strengths, weaknesses, gaps in service delivery, and any constraints to 
successful implementation; and 
Identify and document best practices, lessons learned and recommendations to inform 
follow-on activities focusing on sustainability. 
Based on the respondent’s experience and knowledge of the IPHC, in working with 
MSH and its partners, and with reference to IPHC objectives and SPAs, the 
evaluation team’s interviews will focus on the following questions: 
1. What is the respondent’s assessment of IPHC progress achieved to date? The respondent 
should be encouraged to consider and comment on IPHC’s contribution to improved 
management systems focused on: 
1.) Maternal Health and Family Planning 
2.) Child health 
3.) Youth program 
4.) HIV & AIDS with reference to: 
– Counseling and testing (C&T) 
– Prevention of mother-to-child transmission 
– Comprehensive care, management, and treatment 
– Palliative care in the OVC setting; 
– Integration of TB and HIV 
5.) Primary health care systems and services with reference to: 
– Quality assurance, clinic supervision and district development 
– District health information system 
– District health systems (district management teams, district health plans, expenditure 
review) 
6.) Orphans and vulnerable children 
2. What is the respondent’s assessment of IPHC progress achieved to date? The respondent 
should be encouraged to consider and comment on IPHC’s contribution to improved health 
services focused on: 
1.) Maternal Health and Family Planning 
2.) Child health 
3.) Youth program 
4.) HIV & AIDS with reference to: 
– Counseling and testing (C&T) 
– Prevention of mother-to-child transmission 
– Comprehensive care, management, and treatment 
– Palliative care in the OVC setting; 
– Integration of TB and HIV 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 81
5.) Primary health care systems and services with reference to: 
– Quality assurance, clinic supervision and district development 
– District health information system 
– District health systems (district management teams, district health plans, expenditure 
review) 
6.) Orphans and vulnerable children 
3. What is the respondent’s assessment of IPHC progress What is the respondent’s 
assessment of ―best practices‖ instituted by the IPHC in addressing management systems 
and health service delivery of the above strategic priority areas. What’s new and what’s 
working? 
4. What is the respondent’s assessment of IPHC strengths and weaknesses associated with 
management systems and health service delivery of the above strategic priority areas? If 
something worked well, why did it work well? If something did not work well, why not? 
5. What is the respondent’s assessment of constraints associated with IPHC’s efforts to 
improve management systems and health service delivery of the above strategic priority 
areas? 
– Human Resources 
– Geography 
– Time 
– Funding 
– Community/Facility Interface 
– USAID/MSH/DOH Interface 
– Government Policy 
– Facility Policy 
– Leadership 
6. What IPHC interventions are not sustainable and why do you think so? 
7. What IPHC interventions are sustainable and what actions or interventions would the 
respondent recommend to build upon and improve the sustainability of management 
systems and health service delivery of the above strategic priority areas? 
8. What is the respondent’s assessment of lessons learned with reference to IPHC’s efforts to 
improve management systems and health service delivery of the above strategic priority 
areas? 
82 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 83
ANNEX F. IPHC: INTERVIEW SUMMARY 
Evaluation Team Interviewer: 
Respondent Name: 
Respondent Title and Affiliation: 
Interview Location: 
Date: 
Interview Summary: 
1. Progress of the IPHC Project: 
2. IPHC Strengths: 
3. IPHC Weaknesses/Challenges: 
Other Comments and Observations: 
84 USAID/SOUTH AFRICA: IPHC END OF PROJECT PARTICIPATORY EVALUATION 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 1 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
CONTENTS 
Contents .......................................................................................................................................... 1
Acronym List .................................................................................................................................. 2
Executive Summary ........................................................................................................................ 4
I. Background .................................................................................................................................. 6
II. Project Performance to Date ...................................................................................................... 7
A. SPA 1: Maternal Health and Family Planning ....................................................................... 7
B. SPA 2: Child Health ............................................................................................................... 8
C. SPA 3: Youth Program ........................................................................................................... 8
D. SPA 4: HIV & AIDS .............................................................................................................. 8
E. SPA 5: PHC Systems and Services ........................................................................................ 9
F. SPA 6: Orphans and Other Vulnerable Children .................................................................. 10
III. Gaps and Opportunities for Improvement .............................................................................. 10
A. Gaps in Services for HIV & AIDS, STIs, and TB ............................................................... 11
B. Human Resource Constraints ............................................................................................... 11
C. Data Collection, Analysis, and Use ...................................................................................... 11
D. Coordination and Other Challenges ..................................................................................... 11
E. General Cross-Cutting Challenges and Gaps ....................................................................... 12
IV. Project Results Expected for the Extension Period ................................................................ 12
A. Objectives by SPA ............................................................................................................... 13
B. Key Performance Targets ..................................................................................................... 13
V. Overarching Strategies ............................................................................................................. 14
A. A General Principle: Consolidation, Integration, and Institutionalization ........................... 14
B. Provincial/District Support and Oversight ........................................................................... 14
C. Strengthened Links with the National and Provincial Departments of Health .................... 14
D. Project Database Development and Use .............................................................................. 15
E. District Data Management .................................................................................................... 15
F. Service Performance Reviews .............................................................................................. 16
G. Facility Staff and Skills Audits ............................................................................................ 16
H. Identification and Documentation of Best Practices and Models of Success ...................... 16
I. Procedures for Referring and Tracking Patients .................................................................... 17
VI. New Technical Approaches and Activities by SPA ........................................................... 17
SPA 1: Maternal Health and Family Planning .......................................................................... 17
SPA 2: Child Health.................................................................................................................. 18
SPA 3: Youth Program ............................................................................................................. 18
SPA 4: HIV & AIDS................................................................................................................. 18
SPA 5: PHC Systems and Service ............................................................................................ 19
SPA 6: Orphans and Other Vulnerable Children ...................................................................... 20
VII. Project Management .............................................................................................................. 21
VIII. Monitoring and Reporting .................................................................................................... 21
IX. Summary of Resource Requirements ..................................................................................... 23
Annexes......................................................................................................................................... 24
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 2 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
ACRONYM LIST 
AIDS Acquired immune deficiency syndrome 
ANC Antenatal care 
ART Antiretroviral therapy 
ARV Antiretroviral 
CBO Community-based organization 
CLO Community liaison officer 
COP Country operating plan 
CT Counseling and testing 
DAC District AIDS Council 
DHER District health expenditure review 
DHIS District health information system 
DHMT District Health Management Team 
DHP District health planning 
DHS Demographic and Health Survey 
DISCA District STI Quality of Care Assessment 
DMT District Management Team 
DOH Department of Health 
DOTS Directly observed treatment short-course 
FP Family planning 
HAST HIV, AIDS, STI, TB 
HISP Health Information System Project 
HIV Human immunodeficiency virus 
HST Health Systems Trust 
IMCH Integrated maternal and child health 
IMCI Integrated Management of Childhood Illness 
IPHC Integrated Primary Health Care [Project] 
IR Intermediate result 
KZN KwaZulu Natal 
MCH Maternal and child health 
MDR Multidrug resistant 
M&E Monitoring & evaluation 
MESH Management, Economic, Social Cohesion, Community, and Human Resource [Tool] 
MSH Management Sciences for Health 
NDOH National Department of Health 
NGO Nongovernmental organization 
OI Opportunistic infection 
ORT Oral rehydration therapy 
OVC Orphans and other vulnerable children 
PCR Polymerase chain reaction 
PEPFAR President’s Emergency Plan for AIDS Relief 
PHC Primary health care 
PMTCT Prevention of mother-to-child transmission 
RA Responsibility area 
RH Reproductive health 
RTC Regional Training Centre 
SAG South African Government 
SPA Strategic performance area 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 3 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
STI Sexually transmitted infection 
STTA Short-term technical assistance 
TA Technical assistance 
TALI Tool to Assess the Level of Information Utilization 
TB Tuberculosis 
URC University Research Corporation 
USAID United States Agency for International Development 
VCT Voluntary counseling and testing 
YFS Youth-friendly services 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 4 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
Executive Summary 
For over a decade, Management Sciences for Health (MSH) has partnered with the US Agency 
for International Development (USAID), South Africa’s National Department of Health (NDOH) 
and other agencies to strengthen primary health care (PHC) systems and services for the people 
of South Africa. First through the EQUITY Project and, more recently, through the Integrated 
PHC Project (IPHC) which works in eight districts in five provinces, MSH provides technical 
assistance and other support aimed at achieving following vision: 
The IPHC project expects, as a result of its efforts, the emergence of functional district health 
systems capable of providing accessible, high-quality HIV & AIDS interventions that are fully 
integrated into primary health care services for the benefit of disadvantaged communities, thus 
offering previously disadvantaged South Africans a better quality of life. 
In this proposal for the extension to its current IPHC contract, MSH outlines its expectations of 
building upon past experience and lessons learned to bring integrated PHC services to a new 
level of success, and ultimately to sustainability. During the extension period (October 2008 to 
December 2010), IPHC will continue to focus its efforts on achieving objectives in six strategic 
performance areas (SPA) as follows: 
SPA Objectives 
1. Maternal Health 
and Family Planning 
ƒ Improve women's and maternal health 
complications and deaths
in order to effectively reduce maternal 
2. Child Health ƒ Improve child survival and reduce infant and child mortality
3. Youth Program ƒ Increase youth participation in the promotion and provision of youth friendly 
services in order to reduce reproductive health problems among adolescents
4. HIV & AIDS ƒ
ƒ
ƒ
ƒ
…
Strengthen the integration of counseling and testing into routine PHC activities 
Strengthen and expand a comprehensive PMTCT program 
Strengthen ARV treatment service delivery to those who are infected with HIV 
Strengthen palliative care in the PHC setting; integrate palliative care for TB and 
HIV 
all with the purpose of reducing the impact of HIV & AIDS 
5. PHC Services and 
Systems 
ƒ Contribute to service quality improvements through selected tools such as Primary 
Health Care Supervision Manual and structures such as clinic committees 
ƒ Improve the knowledge and use by service staff and managers of health information 
of acceptable quality for planning, management, and monitoring 
ƒ Support the development of district health plans, operational plans, operational 
reviews, and the conducting of DHERs 
…in order to strengthen functional district health systems
6. OVC ƒ Strengthen CBOs and networks 
AIDS mortality in their family
to enhance the welfare of children affected by HIV & 
Proposed activities in these six SPAs will be supported by key overarching and cross-cutting 
strategies focused on a general principle of consolidation, integration, and institutionalization
of all project initiatives. The extension period will allow for consolidation through better field 
coordination, both to encourage integration and as a cost-saving measure. The IPHC team 
proposes institutionalization efforts that will focus on achieving sustainability of the initiatives 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 5 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
introduced through MSH’s technical assistance over the years of its partnership with USAID and 
the NDOH. This proposal describes an approach designed to convert the project’s activities into 
sustainable approaches not only in those districts and facilities that are directly supported by 
IPHC but also ensuring the expansion and replication of these successes in other districts, 
facilities, and communities 
Operationally and managerially, the extension of the IPHC Project will begin with existing staff 
who are under employment contracts currently scheduled to end largely between June and 
September 2008. The proposed approach to consolidation of provincial initiatives will result in 
revised provincial team structures as current employment contracts come to an end. Current 
subcontracts with Health Systems Trust and University Research Corporation will not be 
renewed when they come to an end in September 2008 and resulting staff vacancies will be filled 
as required. The project will continue to work out of its present location in Pretoria with 
provincial teams working virtually from their home bases in project provinces. 
During the extension period, MSH will devote additional attention to documenting and 
communicating IPHC’s results, success stories, and lessons learned. The communication plan 
(Annex 5) is designed to provide the NDOH, at all levels, with necessary information to extend 
IPHC’s approaches, tools, and activities to other provinces, districts, and facilities which are not 
directly partnered with IPHC. 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 6 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Integrated Primary Health Care Project (TASC II) 
I. BACKGROUND 
The Integrated Primary Health Care (IPHC) Project under TASCII is funded by the United States 
Agency for International Development (USAID) and charged with providing technical assistance 
to strengthen the district health system in five provinces of South Africa. IPHC has been 
implemented by a consortium led by Management Sciences for Health (MSH), in partnership 
with Health Systems Trust (HST) and the University Research Corporation (URC). 
IPHC contributes to the achievement of USAID/South Africa’s goal to help the South African 
Government (SAG) reduce the impact of HIV & AIDS and provide better health care for 
historically disadvantaged South Africans. 
The IPHC Project has focused much of its efforts on strengthening the district health systems as 
a vehicle for primary health care (PHC) service delivery. By targeting impact at the facility level, 
IPHC is building a cadre of health care workers who are competent in planning, implementing, 
and evaluating comprehensive, high-quality, integrated PHC in a sustainable manner. 
The IPHC Project has focused capacity building in eight targeted districts in the five provinces; 
these were chosen after a national mapping activity. Selection of the target provinces and 
districts was based on criteria for support provided by the National Department of Health 
(NDOH), and in consultation with USAID and the provinces and districts themselves. These 
provinces and districts, which will remain the focus of support during the extension period, are: 
ƒ Chris Hani and Alfred Nzo districts, in the Eastern Cape Province; 
ƒ Sisonke and Uthungulu districts in KwaZulu Natal (KZN) Province; 
ƒ Capricorn and Sekhukhune districts in Limpopo Province; 
ƒ Gert Sibande District in Mpumalanga Province; 
ƒ Bojanala District in North West Province. 
The technical interventions of the IPHC Project were designed to support USAID/South Africa’s 
health goal of “reduced impact of HIV & AIDS, and improved health care for all South 
Africans” by addressing the following intermediate results (IRs): 
IR 1 Strengthened HIV & AIDS prevention measures 
IR 2 Increased availability of quality STI (sexually transmitted infection) services 
IR 3 Improved treatment of tuberculosis (TB) and AIDS 
IR 4 Expanded HIV & AIDS care and support 
IR 5 Expanded systems and services of selected PHC systems 
In October 2005, USAID issued its new Health Sector Strategic Objective: “Strengthened 
capacity to deliver sustainable and integrated PHC and HIV & AIDS services.” In consultation 
with the South African NDOH, it was agreed that the IPHC Project would focus on the following 
objectives: 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 7 
ƒ Improved maternal health and family planning, with emphasis on youth 
ƒ Improved child survival, health, and nutrition 
ƒ Increased and improved participation of youth in advocacy for reproductive health and 
sexuality and solutions for gender violence 
ƒ Reduced transmission and impact of HIV & AIDS 
ƒ Strengthened PHC systems and service delivery 
ƒ Strengthened community support for orphans and other vulnerable children (OVC) 
II. PROJECT PERFORMANCE TO DATE 
IPHC’s work is organized into six strategic performance areas (SPAs) with related sub￾components in some SPAs. These SPAs are aligned with the project objectives noted above. 
Project interventions are currently undertaken in a number of facilities, districts, and 
communities as indicated in Table 1. 
Table 1. Current Number of Sites Directly Supported, by Strategic Performance Area 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
MCH/ 
FP 
Child 
Health 
Youth 
Programs 
HIV & AIDS PHC 
Services 
and 
OVC 
VCT PMTCT ARVs* Palliative, (CBOs) 
Basic 
Palliative, 
HIV/TB 
Systems 
(districts) 
69 69 58 69 69 12/59 62 62 8 23 
*First number refers to sites initiating ARVs; second number refers to feeder sites. 
A summary of key activities being carried out under each SPA follows and the quantitative 
targets and results for related indicators during the 2006–2007 project year are provided in 
Annex 1. IPHC considers many of these activities to be foundational, and expects to continue 
many as well as build upon them to further advance the project’s impact during the extension 
period. The project will also undertake initiatives during the extension period to address the 
sustainability of these activities. 
 
A. SPA 1: Maternal Health and Family Planning 
IPHC implements many initiatives to improve the integration and quality of reproductive health 
(RH) services, all of which are designed to build the capacity of the District Management Team 
(DMT) to supervise these services. Training of service providers, according to national 
guidelines, aims at improving knowledge and capacity in family planning (FP). Joint supervisory 
visits by project staff and provincial and district program managers are aimed at improving 
technical capacity of managers through in-depth reviews of FP and antenatal care (ANC) using 
the Primary Health Care Supervision Manual. During these visits, emphasis is placed on 
improving the quality of data recording and information reporting in order to improve the 
monitoring and evaluation (M&E) of ANC and FP services. All facilities are supported to ensure 
routine voluntary counseling and testing (VCT) of all ANC clients with provision of test results 
and referral for treatment as required. Also, quality improvement plans are developed at the 
facilities to increase the uptake of VCT among pregnant women. 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 8 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
B. SPA 2: Child Health 
IPHC’s support for child health services is focused on nutrition and growth monitoring, 
immunization, and Integrated Management of Childhood Illness (IMCI) for children under five. 
The project’s technical advisors work with district program managers and clinic supervisors to 
conduct in-depth reviews of child health services in project facilities, using the standard checklist 
from the Supervisor’s Manual. Immunization is supported by giving special attention to the 
availability of equipment and supplies, along with an estimation of the number of newborns in 
the catchment area, monthly target-setting, and monitoring of cohort coverage. A system for 
tracking drop-outs has been introduced, and quality improvement plans have been formulated to 
include facility- and community-level mentoring in integrated maternal and child health (IMCH). 
In pursuit of the NDOH target (60% of facilities covered by trained nurses), facility nurses have 
been trained in IMCI. Additionally, IMCI registers have been introduced to reinforce proper 
IMCI clinical tasks and recording thereof in the facilities; IMCI guidelines were distributed and 
monitored for use; and strategies such as establishment of oral rehydration therapy (ORT) 
corners in the clinics have been pursued. While IPHC has provided hands-on support to selected 
facilities in each target district, the project also supports the planning and implementation of 
subdistrict- and district-level PHC reviews in which progress and problems are monitored and 
actions planned for all facilities in the district.
C. SPA 3: Youth Program 
IPHC has established the Youth Friendly Services (YFS) Program in 58 facilities where facility 
managers and providers are mentored on YFS standards in compliance with the Youth and 
Adolescents Policy. This program began in 2006 and addresses reproductive health and family 
planning, antenatal care, voluntary counseling and testing, sexually transmitted infections, and 
gender-based violence education in addition to clinic testing and treatment services. A baseline 
assessment of the current status of youth access and utilization of health services was 
implemented by HST, a project partner. A youth-centered approach was designed to involve 
young people at all levels of service planning and delivery. Youth groups are identified, 
workshops are conducted, and youth peer mentors have been placed in each facility. Project 
advisors assist to create, strengthen, and maintain linkages and working relationships between 
the youth mentors (96 are currently active) and clinic staff. Youth mentors also participate with 
facility staff in school health visits. 
D. SPA 4: HIV & AIDS 
SPA 4.1: Counseling and Testing. The project supports 69 facilities to increase the uptake in HIV 
counseling and testing, through three kinds of interventions: improving quality of VCT, coaching 
and mentoring of professionals, and increasing youth access to VCT services. The project also 
focused on the integration of HIV & AIDS, TB and STI (HAST) services through introduction of 
the HAST approach and related operational plans. In-depth reviews of TB and STI programs 
were conducted to assess adherence to national guidelines. Compulsory counseling and routine 
offering of testing was reinforced for all STI, TB, FP, and ANC clients. Health care providers are 
mentored in the integration of VCT services along with proper record-keeping and data flow 
during facility visits. STI reviews are conducted using the District STI Quality of Care 
Assessment (DISCA) tool. To encourage VCT uptake, IPHC supports health education talks, 
contacts with local communities, and support groups. 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 9 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
SPA 4.2: PMTCT. The project approach focuses on improving the quality of maternal and child 
health (MCH) services, the capacity and skill of health care providers, and the full integration of 
prevention of mother-to-child transmission (PMTCT) of HIV & AIDS into the full package of 
PHC services. In-depth clinic reviews are the backbone of this quality improvement effort with 
the specific aim of identifying any gaps in service. HIV counseling for groups and individuals is 
provided by lay counselors to increase testing rates of all new ANC visitors. National PMTCT 
protocols provide guidance for administration of nevirapine to babies of HIV-positive mothers 
within 72 hours of birth, and five-day PMTCT training is provided in partnership with HAST 
teams. District and subdistrict meetings and PHC reviews are also used to review progress and 
problems, through the use of routine district health information system (DHIS) data. The 
involvement of district supervisors in the clinic reviews is intended to enhance their monitoring 
and supervision of PMTCT, including support for the use of facility data for self-monitoring. 
SPA 4.3: HIV & AIDS Treatment (ARV). The project provides a consultant physician to support 
the management of antiretroviral (ARV) treatment in 12 hospitals. Other IPHC technical 
advisors support the feeder clinics which refer clients for treatment. Staging of patients, the 
feedback of results, and the management of referrals for treatment are important elements of 
IPHC’s support in this sub-component. The emphasis on assisting project-supported facilities to 
achieve accreditation to provide ARV services is also very important. 
SPA 4.4 & 4.5: Palliative Care. The two palliative care subcomponents focus on basic care and 
support for HIV patients as well as integrated testing and treatment for those affected by both 
HIV and TB. As one important element of providing appropriate palliative care is the proper 
clinical staging of HIV-positive cases using CD4 cell counts, this procedure receives emphasis in 
training and mentoring. Project focuses also include the proper maintenance of clinic-level client 
records (with effective feedback of test results from the testing facilities), and the HAST protocol 
for integration of services and record linkage. Within-clinic referral procedures are emphasized, 
including testing of TB and STI patients and an integrated treatment process. The project 
provides much of this mentoring through direct facility visits, but subdistrict and district reviews 
also offer opportunity for assessment and reinforcement of standard procedures and practices. 
Review of HAST registers are used to discover and then address gaps in performance. 
E. SPA 5: PHC Systems and Services 
SPA 5.1: Quality Assurance. A variety of related interventions have been delivered by the project 
including promotion of clinic quality improvement committees and the increased frequency of 
facility supervision visits, training, and supervision using the Primary Health Care Supervision 
Manual. Project technical advisors and provincial staff are actively involved in joint performance 
monitoring at the facility level and in promotion and support of periodic PHC review meetings at 
subdistrict and district levels. Action plans and lessons learned are shared during these review 
meetings to encourage use of best practices and scaling up. The project has introduced defaulter 
tracing through use of facility tracing registers; coordinated transport schedules to facilitate lab 
specimen collection and transfer; and the provision of national policies, standards, and guidelines 
documents. IPHC technical advisors have encouraged community participation by strengthening 
the role of clinic committees in support of clinic services. 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 10 
SPA 5.2: District Health Information System. The project has supported implementation of the 
new version of the DHIS, including the introduction of new indicator data sets. Workshops were 
held in conjunction with district health expenditure review (DHER) and district health planning 
(DHP) activities to introduce the use of information for decision-making and action; to this end, 
the Tool to Assess the Level of Information Utilization (TALI) was introduced in some districts 
to assess the flow and use of data. Data analysis and review activities were conducted in some 
districts in conjunction with “road show” visits on data use to selected facilities. Facilities have 
been supported to produce and display data graphs and maps. 
SPA 5.3: District Health Systems. The project is working with district health staff to raise 
awareness of the importance of planning and reviewing expenditures within the context of the 
National Planning and Budgeting Cycle and provincial planning, giving special emphasis to 
supporting the annual planning and DHERs. The project has also supported district health staff to 
undertake data audits and analysis, and to write reports. Municipality reviews have been held 
prior to district reviews in some instances and, where they are functional, District Health 
Councils are also brought into the health planning process. 
F. SPA 6: Orphans and Other Vulnerable Children 
The primary strategy for supporting the protection and care of OVC is to strengthen community￾based organizations (CBOs) by providing grants as well as on-site coaching and mentoring, the 
provision of informational materials, and related consultations. IPHC developed and 
disseminated a poster that classifies the various types of activity and support that CBOs may 
choose to organize. Project efforts are also extended to communities to strengthen their support 
to families and children in need. The CBO grants are providing several types of support to OVC 
including the facilitation of NGO collaboration with the Department of Social Development in 
leveraging food parcels, general education, legal assistance, health care, and psychosocial and 
financial support. The recruitment and training of home caregivers is also a growing element of 
this program, as is access to ARV treatment and follow-up. The latter requires good links among 
caregivers, CBOs, and treatment facilities. Target-setting based on estimates of OVC in each 
CBO’s catchment area is being promoted, and CBOs have also been given support to improve 
their record-keeping through the introduction of new intake registers. With a focus on 
sustainability, all CBO grantees are being supported to seek other sources of financial support. 
III. GAPS AND OPPORTUNITIES FOR IMPROVEMENT 
Two sources were drawn on for this section: the self-assessment of continuing challenges by the 
IPHC team (as presented in the project’s 2006–2007 annual report), and the January 2008 
internal project assessment conducted by the MSH/IPHC team. While these gaps and 
opportunities will be the focus of much of the work of the extension period, it is important to 
recognize that some of these challenges are beyond the direct control of the project. It is 
anticipated that, by naming them here, some challenges will be elevated for increased attention 
both by the project and by its partners at district and facility levels during the extension period. 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 11 
A. Gaps in Services for HIV & AIDS, STIs, and TB 
These include challenges related to the need to increase VCT for pregnant women and to 
attracting more men for VCT. Data and information gaps result in delays in initiation and proper 
PMTCT protocols. ARV activities are negatively affected by long and difficult accreditation 
process for referring facilities, turnover in staff qualified to provide ART and low treatment rates 
among children. In STI services, a low proportion of client partners return for testing and 
treatment services and some STI clients are not managed through the syndromic approach. 
Counseling TB clients to obtain HIV tests could be improved. For all these diseases, stigma 
constrains clients from seeking palliative care services. 
B. Human Resource Constraints 
Staff turnover and vacancies impact the work of the IPHC Project because of the need for 
continuity among trained staff to implement services at the facilities and trained counterparts in 
the DHMTs. Equally, if not more importantly, this issue also negatively impacts health service 
delivery throughout South Africa. In particular, attrition has negatively affected delivery of 
IMCI, VCT, and PMTCT services, and has required continuous in-service training by the 
project. Service staff and managers have limited understanding of how to work effectively with 
youth or of the importance of providing YFS. Vacancies for information officers at the district 
and facility levels have had a negative impact on the ability to collect, analyze, and use data 
effectively—both for the project and for improved service delivery. 
C. Data Collection, Analysis, and Use 
 At the facility level, standardization and maintenance of clinic registries lead to difficulties in 
data collection and use. Different versions of the DHIS are used in project districts and this 
challenge is further complicated by the use of an entirely different information system in 
KwaZulu Natal. The lack of a national OVC database and lack of computer equipment among 
CBOs to record data also constrains proper data collection and use in OVC activities. Referral 
systems at service facilities and links with home care workers are weak and require attention. At 
the district level, operational plans are not aligned with provincial budgets or annual performance 
plans and there is also inconsistency in understanding of the system to be used for DHERs. 
Feedback of DHIS data summaries and performance comparisons from districts to facilities is 
very limited and is inadequate in terms of population projections for facility catchment areas. 
Further use of the DHIS by districts and facilities can be reinforced by IPHC and used—with 
minor supplemental data collection for certain PEPFAR indicators—for its reporting to USAID. 
Project staff requires training to use Health Information System Project (HISP) software that is 
tailored for project use. The project strategy for supporting data and service performance reviews 
can be made more efficient, effective, and sustainable by shifting to a team approach and 
working with clusters of facilities rather than individual facilities. 
D. Coordination and Other Challenges 
Lack of coordination among partners at the district level has led to a shift of which facilities 
receive visits for technical support as well as the double-counting of clients served by the 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 12 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
partners. Abolishment of the PHC coordinator post has led to inadequate coordination in 
preparing for and conducting district PHC review meetings. Particular challenges are presented 
in the project’s attempts to strengthen the District Health System. These include the absence of 
or non-functional District Health Councils in some project districts, vacancies in district health 
manager posts, and a general lack of leadership at the district level with inexperienced junior 
staff assigned to important management tasks. 
E. General Cross-Cutting Challenges and Gaps 
ƒ Sustainability. There is a great need to prepare an exit strategy for the project that 
institutionalizes the main performance improvement and integration interventions at all 
levels and includes the youth mentors and OVC special program activities. 
ƒ Scaling up. A means is needed to share interventions and best practices throughout the 
participating districts and provinces as well as with the NDOH. 
ƒ Structural issues and barriers. Limited interactions and poor linkages (e.g., 
disconnections in planning between district and higher levels of government) need to be 
addressed through improved contacts and communications with the national and 
provincial levels. 
ƒ Supervision. While progress has been made, methods of supervision need to be made 
more efficient and shifted to the district and provincial offices. 
ƒ Use of data for everyday management. Considerable improvement is called for in 
completeness, accuracy, use, reporting, and feedback of service data. 
ƒ Alignment issues. A particular challenge exists with regard to alignment of district and 
provincial plans and budgets. 
ƒ Links between facilities and communities. While these are improving—especially with 
the support of home-based or community-based care workers—the existence and 
functioning of clinic committees is variable. 
ƒ Supervisory guidelines and other tools. Significant needs and opportunities exist for 
routinely incorporating data in supervision visits and program performance reviews, 
including use of the District Management, Economic, Social Cohesion, Community and 
Human Resource (MESH) tool to assess district-level performance. 
IV. PROJECT RESULTS EXPECTED FOR THE EXTENSION PERIOD 
The IPHC Project Vision 
The IPHC Project expects, as a result of its efforts, the emergence of functional district health 
systems capable of providing accessible, high-quality HIV & AIDS interventions that are fully 
integrated into primary health care services for the benefit of disadvantaged communities, thus 
offering previously disadvantaged South Africans a better quality of life. 
To ensure the achievement of this vision, the guiding principle during the extension period is that 
all activities carried out under each SPA are undertaken with an increased focus on the 
progressive institutionalization of all tools, methods, and processes within the District Health 
Services. This institutionalization is absolutely essential if the work of the IPHC is to be 
sustained. 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 13 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
A. Objectives by SPA 
For the remainder of the IPHC Project, each IPHC SPA will be aligned with the achievement of 
one or more development objectives as indicated in Table 2. 
Table 2: Objectives by Strategic Performance Area 
SPA Objectives 
1. Maternal Health 
and Family Planning 
ƒ Improve women's and maternal health 
complications and deaths
in order to effectively reduce maternal 
2. Child Health ƒ Improve child survival and reduce infant and child mortality
3. Youth Program ƒ Increase youth participation in the promotion and provision 
to reduce reproductive health problems among adolescents
of YFS in order 
4. HIV & AIDS ƒ
ƒ
ƒ
ƒ
…
Strengthen the integration of counseling and testing into routine PHC activities 
Strengthen and expand a comprehensive PMTCT program 
Strengthen ARV treatment service delivery to those who are infected with HIV 
Strengthen palliative care in the PHC setting; integrate palliative care for TB 
and HIV 
all with the purpose of reducing the impact of HIV & AIDS 
5. PHC Services and 
Systems 
ƒ Contribute to service quality improvements through selected tools such as Primary 
Health Care Supervision Manual and structures such as clinic committees 
ƒ Improve the knowledge and use by service staff and managers of health information 
of acceptable quality for planning, management, and monitoring 
ƒ Support the development of district health plans, operational plans, operational 
reviews, and the conducting of DHERs 
…in order to strengthen functional district health systems
6. OVC ƒ Strengthen CBOs and networks 
AIDS mortality in their family
to enhance the welfare of children affected by HIV & 
The activities and initiatives in these six SPAs will be supported by important overarching and 
cross-cutting strategies focused on the integration, performance improvement, district 
leadership development, documentation, and sustainability of all initiatives. 
B. Key Performance Targets 
The IPHC Project has been given or has defined for itself a total of 120 performance indicators. 
Forty-one of these indicators have been used to set annual performance targets; 32 apply to 
PEPFAR indicators and appear in the Country Operational Plan (COP). The remaining nine 
targets have been set by IPHC. All targets are updated annually; Annex 4 lists the objectives and 
targets with baseline values for each SPA during the extension period. The method of capturing 
and monitoring all indicators against baseline values and targets is described in Section VIII. 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 14 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
V. OVERARCHING STRATEGIES 
The IPHC team has identified the following overarching strategies as its response to identified 
gaps and opportunities. These strategies will be pursued alongside the technical assistance and 
other project activities dedicated to the specific SPAs (covered in Sections II and VI of this 
proposal). The overarching strategies—including the intention to better document and 
communicate what the project is doing and its results—are presented below. 
A. A General Principle: Consolidation, Integration, and Institutionalization 
To the extent possible, all facility and district training, facilitation, and technical support will be 
designed and carried out in a consolidated and integrated manner to address several SPAs at the 
same visit. All field initiatives will also be coordinated to ensure, to the extent possible, full 
provincial and district staff participation. A continuing theme of this approach is to ensure that 
all client needs are attended to in an integrated fashion and across the SPAs when project staff 
members visit facilities. At the same time, training and other facilitation visits to districts, 
subdistricts, and facilities will be planned so that teams of IPHC technical advisors work together 
in a coordinated fashion. Guidelines and procedures for the above activities will be modified to 
enable non-specialist IPHC team members to carry them out when necessary for efficiency. 
B. Provincial/District Support and Oversight 
Job descriptions and functions of project provincial coordinators will be reviewed and revised as 
necessary to ensure that they provide appropriate oversight of these cross-cutting strategies and 
activities. The cross-cutting strategies will be examined for each province and prioritized, based 
on gaps and opportunities identified in each location. Assumed new or additional activities at the 
provincial and/or district levels might include better networking among offices, subdistricts, 
clusters of facilities, facilities, NGOs, and CBOs. These communications links and collaboration 
will be confirmed in writing. Communications will be improved to ensure that provincial and 
national departments of health are fully informed of the project’s activities, best practices, and 
lessons through regular reports and presentations. IPHC district-specific annual plans will be 
worked out in collaboration with the DHMT and included in district operational plans. Also 
supported will be routine district and facility data analysis (DHIS) and problem identification; 
district and facility staffing inventories and skill audits; and monitoring of the preparation of 
district training schedules, plans, and budgets. Provincial coordinators will also ensure the timely 
submission of monthly USAID indicator data to the national IPHC Project office and database 
(from both the DHIS and IPHC data capture); oversee the scheduling; and conduct a results 
analysis of the various program review processes at facility, cluster, and subdistrict levels. 
C. Strengthened Links with the National and Provincial Departments of 
Health 
Recognizing the need for better informing national and provincial health officials about the 
activities, lessons, and best practices of the IPHC Project, project staff will plan and implement 
several activities during the extension period to ensure these individuals and units are kept up to 
date on the progress of the project, priority service performance, and disease trends: 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 15 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
ƒ Participation in regularly scheduled national and provincial meetings, and planning 
opportunities for special project presentations. 
ƒ Shared project reports, including USAID annual reports. 
ƒ Joint design and implementation of special activities with relevant offices and programs. 
ƒ Participation in national calendar events related to the project’s SPAs and provision of 
technical guidance on these events, as required. 
ƒ Identification of, and ongoing communication with key health contact persons in 
important places/roles such as the President’s Office, mayors, District AIDS Councils 
(DACs), community liaison officers (CLOs), and other local bodies and persons. 
Communication will include information about relevant project activities and results. 
ƒ Identification and sharing of models of success among districts and clinics, and among 
partner CBOs. 
D. Project Database Development and Use 
Recognizing the continuing challenge of managing data in IPHC Project sites, and the need to 
collect and report reliable information on a regular basis, the project seeks the support of HISP to 
prepare a modified HISP data platform in the central IPHC office for receiving, analyzing, and 
reporting the data summaries required by USAID. This will necessitate the following: 
ƒ Confirming the data elements and indicators obtainable through the DHIS from district 
databases, and those indicators which must be captured from the facility registers; 
ƒ Devising monthly formats and procedures for project provincial teams to capture and 
compile the data; 
ƒ Setting up and modifying as necessary the HISP data platform for IPHC purposes; 
ƒ Designing the required report formats and content; 
ƒ Training project staff in data cleaning, entry, analysis, and report generation; 
ƒ Undertake the extraction of DHIS data for project facilities to construct a clinic data 
baseline for the project, with support from HST; 
ƒ Develop a training database to track and report the various training activities supported 
by the project to USAID; 
ƒ Participate in the consortium of organizations endeavoring to create a common OVC data 
warehouse. 
E. District Data Management 
During the extension period, the project will work to strengthen the routine use of the DHIS at 
the district level for data analysis and generation of reports (including routine feedback to 
facilities) and, most importantly, the use of the DHIS data and analysis by district health officials 
for level monitoring of disease, service performance and coverage, and resource allocation and 
use in support of annual planning and budgeting, operational planning, and targeted performance 
improvement efforts to subdistricts and facilities. Some specific needs for and examples of 
district level data use include: 
ƒ Confirmation of facility responsibility/catchment areas and estimation of total and target 
group populations within each responsibility area (RA) to better enable facility 
monitoring of service; 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 16 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
ƒ Selected indicator analysis for district and subdistrict monitoring and interpretation to 
enhance PHC reviews; 
ƒ Identification of high risk areas (villages and wards) for disease detection, prevention, 
and management across the district; 
ƒ Identification of high-performing facilities or subdistricts (whose achievements can be 
used for success stories and as examples of sound management) and of low-performing 
facilities or subdistricts (that deserve more attention for uncovering and overcoming 
constraints). Using this information, the project might go on to include mentoring and 
coaching by high-performing facilities and subdistricts for low-performing ones. 
F. Service Performance Reviews 
The project team will devise a modified approach for conducting program performance reviews 
for use at subdistrict or cluster levels. This will require that the existing supervisory checklists 
be modified for guiding joint reviews of clusters of facilities for performance in selected service 
subjects with the incorporation of critical data items and indicators drawn from registers and 
reports that facility representatives bring to the cluster review. Participants in cluster reviews 
will be facilitated by small teams of IPHC technical staff along with district and provincial 
supervisors to confirm their performance with the use of selected indicators, and then to jointly 
discuss how to improve performance in areas of common difficulty. These reviews will 
generally focus on several project SPAs and the related health services which have strong 
natural linkages and interdependencies (e.g., ANC, VCT, FP, and PMTCT) to support their 
integration. Cluster reviews will also reinforce tools and methods for facility analysis and 
display of important trend data, particularly the self-assessment of critical service tasks and 
recording, and monitoring of coverage across the responsibility area to identify pockets of 
underserved communities. Supervisory and performance review visits will continue to be made 
to selected individual facilities that most need such attention, but these are expected to decline 
in favor of the more efficient and effective cluster reviews. 
G. Facility Staff and Skills Audits 
In support of district training for improved planning and budgeting, IPHC will develop and apply 
a procedure for conducting periodic audits of staff in the project districts to determine who is 
currently posted in PHC facilities, and their current skills in terms of post-basic training received. 
Included in this effort will be support for maintaining staff database inventories at district and 
provincial levels, including the skill inventory. This audit effort will link directly to the project’s 
provincial coordinators’ role of supporting the district process of planning annual in-service 
training programs and the application for in-service training seats in the various courses 
scheduled in the Regional Training Centre (RTC). It will also serve to gradually shift the training 
budgets from the IPHC Project to the districts themselves to sustain the training program 
implemented by IPHC. 
H. Identification and Documentation of Best Practices and Models of Success 
The cluster performance review process described above will be the primary means to identify 
well-performing facilities and clusters of facilities across the SPAs addressed by this project. To 
aid this process, the project will define criteria for identifying best practices and a means to 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 17 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
substantiate exceptional facility performance through the use of data and assessment results. 
Case studies will be conducted for these facilities to develop descriptions of the management 
characteristics and practices being employed by these facilities. Assigned focal points within 
IPHC, with the support of provincial coordinators, will continuously seek potential best practices 
and success models and undertake investigations for developing descriptive material. The 
development of such documentation will be part of the overall communication plan for this 
project, described in Annex 5. 
I. Procedures for Referring and Tracking Patients 
A common difficulty in insuring the integration and continuity of care are gaps in the referral and 
feedback communications taking place within facilities, as well as between facilities and higher 
level referral sites and laboratory services. Examples include the linkages required for screening 
and care of OVC, HIV-positive pregnant women, at-risk children, and TB and STI patients. The 
NDOH has initiated a project to improve the referral system in all facilities. The IPHC Project 
will link to this process to strengthen this system within the facilities that we support. The HAST 
approach offers one opportunity to improve these linkages and will be further developed during 
the extension period. In addition, IPHC proposes to undertake a special effort with selected 
district supervisors, facility managers, and CBOs to review current clinical procedures, registers, 
records, and referral slips, and to devise steps to prevent patients from missing necessary testing, 
higher-level diagnosis and treatment, and referral back to the primary facility and community￾based organizations for treatment continuation and follow-up. The ultimate objective of this 
effort is to develop proven procedures for insuring continuous tracking of all infectious disease 
patients and maternal cases to prevent drop-outs from the care process and to confirm the 
outcome of treatment. The improved process will be documented, built into procedures manuals 
and performance review processes and shared with the relevant national health programs. 
VI. New Technical Approaches and Activities by SPA 
As noted in Section II, many current activities have been identified by IPHC for continuation. In 
addition, a number of complementary new activities are proposed for initiation during the 
remainder of the current project year (March–December 2008) and into the extension period. 
These new activities are presented below and elucidated in the project work plan (see Annex 2). 
Some of these activities will be combined with or supported by the overarching strategies 
introduced in Section V. 
SPA 1: Maternal Health and Family Planning 
ƒ Capacitate district coordinators on managing and supporting implementation of the 
Reproductive Health Policies and Guidelines at the facility level. 
ƒ Support the review of RH services at facility and district levels to improve quality of 
care. 
ƒ Strengthen the district perinatal review process with a focus on the inclusion of PHC 
facilities. 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 18 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
SPA 2: Child Health 
ƒ Review and address the availability of nurses trained in IMCI by district and within 
facilities. 
ƒ Provide special support to IMCI supervision through local surveys of performance and 
standards adherence. 
ƒ Support facilitation of the IMCI complementary course to improve the management of 
ARV and treatment of OIs in HIV-positive children under 5 years of age. 
ƒ Ensure integration of PMTCT management in child health program. 
ƒ Capture and analyze child health indicators from the DHIS to identify areas for 
improvement. 
SPA 3: Youth Program 
ƒ Support the implementation of the Adolescent Health Policy at district and facility levels 
to increase uptake of RH services (including HIV & AIDS services). 
ƒ Establish and improve linkages between health facilities and youth in the clinic 
catchment areas and capacitate the community youth to support implementation of YFS. 
ƒ Create support for a youth presence in health facilities and involve youth in service 
provision with the aim of integrating and sustaining youth mentors through programs of 
the DOH or Department of Social Development. 
ƒ Institutionalize the YFS strategy at the district and provincial levels to ensure its 
continuation (including placing these activities in the DHP). 
ƒ Focus youth mentor activities on achieving the 10 YFS standards. 
ƒ Foster and support acceptance of the youth program as a cross-cutting strategy in health 
facilities and districts by ongoing monitoring, support, and mentoring of youth volunteers 
in health services. 
SPA 4: HIV & AIDS 
SPA 4.1: Counseling and Testing 
ƒ Focus on provider-initiated VCT with emphasis on STI, TB, ANC, and high-risk groups. 
ƒ Establish internal referral procedures and registers at facilities to insure testing of these 
risk groups. 
ƒ Promote the use of supervisor checklists and program review protocols (e.g., the DISCA 
Tool) for use by clinic managers supported by the prescribed use of register and report 
data. 
ƒ Focus on STI partner identification, notification, and testing through improved recording 
of tracing, testing, and counseling. 
ƒ Monitor and improve the quality of counseling of high-risk clients. 
SPA 4.2: PMTCT 
ƒ Provide additional training in PMTCT in collaboration with RTCs, district training plans 
and budgets, and the NDOH (HIV Cluster). 
ƒ Improve recording and reporting for PMTCT to ensure the proper management of 
mothers and babies at risk. 
ƒ Support the implementation of the NDOH’s dual therapy policy in the management of 
PMTCT. 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 19 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
ƒ Encourage the “full supermarket” approach to ANC at all facilities to support 
opportunities to promote and provide PMTCT. 
ƒ Improved recording and reporting of CD4 cell count data by monitoring the feedback of 
lab results. 
ƒ Develop improvement strategies with the clinic managers for monitoring feedback and 
recording of lab results. 
ƒ Strengthen the strategies for increasing the uptake of nevirapine and PCR (polymerase 
chain reaction) testing. 
SPA 4.3: HIV & AIDS Treatment (ARV) 
ƒ Form a link with the director of ARV services to keep the NDOH informed of the 
project’s efforts, and to keep abreast of new standards and policies. 
ƒ Develop a quality database showing facility performance to maintain the data required for 
the USAID PEPFAR data warehouse. 
ƒ Take action to insure that ARV quality assurance and training management is are within 
district and provincial DOHs. 
SPA 4.4: Palliative Care (Basic) 
ƒ Provide training in the full range of case situations and disease progression to identify 
HIV-positive clients; this includes record-keeping, data analysis, and facility performance 
self-monitoring and improvement, means. 
ƒ Establish clinic-based HIV support groups and encourage greater promotion, training, 
and use of “treatment buddies.” 
ƒ Focus on better confirmation of HIV status of all health facility clients, identification and 
management of OIs, and insuring the full package of HIV palliative care. 
ƒ Support the facilities to better monitor the recording of cotrimoxazole to HIV-positive 
clients who have initiated ARV treatment. 
SPA 4.5: Palliative Care (TB/HIV)
ƒ Collaborate with the TB TASC team to resolve the indicator discrepancies between 
facility registers and district TB electronic registers. 
ƒ Reinforce the DOTS support system. 
ƒ Support the enhancement of integrated TB/HIV case identification and management 
through performance assessments and improved procedures. 
ƒ Carry out focused training on integrated TB/HIV case management. 
ƒ Improve the management of TB in support of the multidrug resistant (MDR) TB 
program. 
SPA 5: PHC Systems and Service 
SPA 5.1: Quality Assurance 
ƒ Provide training in practical quality assurance techniques. 
ƒ Involve DMTs in service quality monitoring and supervision processes. 
ƒ Support the district and subdistrict quarterly review process enabling better analysis and 
use of routine data (DHIS) for reviewing annual plan progress, identifying and defining 
service performance gaps and problems, and devising performance improvement 
interventions. 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 20 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
ƒ Strengthen the links between health facilities and communities by fostering active 
participation of clinic committees. 
 
SPA 5.2: District Health Information System 
ƒ Support the District Health Office to establish a routine process of DHIS data review, 
analysis, and feedback of performance trends and gaps to the facilities. 
ƒ Plan and carry out joint visits by the IPHC team in collaboration with provincial and 
district supervisors to districts and clusters of facilities to support service program 
reviews using DHIS facility data. 
ƒ Train all IPHC technical and provincial staff in the use of the DHIS. 
SPA 5.3: District Health Systems 
ƒ Enhance and periodically apply the MESH tool for assessing performance of the District 
DOH. 
ƒ Assist the District DOH to improve the alignment between provincial and district annual 
plans and budgets, and district costing of the Annual Performance Plan and Operational 
Plan, along with the Medium-Term Expenditure Framework. 
ƒ Using the above and other methods, strive to institutionalize the use of IPHC tools, such 
as the Primary Health Care Supervision Manual and checklists. 
SPA 6: Orphans and Other Vulnerable Children 
ƒ Address the improvement of OVC case referral for care, including procedures and feed￾back to OVC caregivers, CBOs, and community caregivers. 
ƒ Strengthen the case and service reporting to IPHC for onward reporting to USAID with 
emphasis on shifting this reporting to responsible health and social service officers at 
district and provincial levels. 
ƒ Utilize Child Care Forums at district and ward levels to strengthen CBO linkages with 
local leaders. 
ƒ Further clarify and define CBO catchment/responsibility areas for improving estimation 
of numbers of OVC, setting targets, determining budgets, and allocating grants. 
ƒ Develop a strategy and additional means to enhance CBO independence and phase-out of 
IPHC grants. 
ƒ Identify especially high-performing CBOs and groups of community caregivers in order 
to define models of success; develop and share success stories through the IPHC 
communication plan. 
ƒ Establish links with officials and political leaders, such as the President’s Office, as 
targets of project communications on the community care component. 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 21 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
VII. PROJECT MANAGEMENT 
From March 2008, the IPHC project will reduce the current listed positions and staff but will 
continue to honore URC and HST subcontract positions until the end of these subcontracts on 30 
September 2008 . In the same way current employment contracts for IPHC staff run for several 
more months (terminating between June and late-September 2008); those end dates also will be 
honored (see Annex 3). 
Some changes include: 
ƒ Some current job descriptions will be revised so that the positions can better match 
IPHC’s needs as outlined in this proposal (e.g, human resource manager, grants manager, 
and logistics manager). 
ƒ As current employment contracts end, the provincial teams will be reduced to two staff 
members in total (including the coordinator). Some existing vacancies and vacancies 
created by departing partner staff will need to be filled, but the total number of provincial 
team staff will be reduced. The quality assurance technical advisor position will become a 
less-specialized and more multi-purpose position of program manager. 
ƒ Each Provincial Team will continue to be led by a coordinator who, in keeping with the 
new thrusts of this proposal, will begin to focus more attention on activities at the District 
Health Office level, and on communications and linkages with the Provincial Health 
Department. Such activities include the project’s support to expenditure reviews, annual 
planning and annual budget formulation, along with the strengthening and focusing of 
district and sub-district program review processes. This will reduce—but not eliminate—
the visits by the coordinator to the facilities and cluster program review activities. 
VIII. MONITORING AND REPORTING 
For the extension period, the IPHC Project process for assembling data for monitoring and 
reporting against defined targets and indicators is being modified to rely more on the routine 
DHIS, which will reduce the amount of indicator data to be captured during contacts by project 
advisors at each facility. This approach has several advantages and some challenges. The project 
will be able to rely on data routinely reported to districts through the DHIS, and at the same time 
will devote some facilitation to district-level data analysis and feedback to the facilities. As such, 
it is expected that data entry into the HISP data platforms at district level will be timelier and the 
production of appropriate comparative reports for feedback to the facilities will begin to take 
place. This approach will also help reduce redundancy and inconsistency between the data 
captured by project staff and that reported up through the DHIS. 
While beginning to make greater use of DHIS information for reporting, the IPHC provincial 
teams will still be required to capture PEPFAR data and indicators which are not currently 
reported within the DHIS. This process will be streamlined by building data capture into the 
cluster program review processes. Participating facilities will be required to bring the relevant 
registers and records to these cluster review meetings for use in the program review process. At 
the same time, project technical advisors will be able to extract the required monthly PEPFAR 
indicators. 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 22 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
The project’s provincial teams will be required to transmit the new DHIS client counts along 
with the PEPFAR indicators to the central project office for entry into the modified HISP 
database. The data platform will be set up with HISP staff support to enable IPHC to maintain 
the full set of indicator data across all SPAs and participating districts, and to generate the 
required data summaries for reporting to USAID on a quarterly basis (ARV figures) and semi￾annually and annually for all other indicators. 
ƒ resources 
ƒ The project vision 
ƒ SPA objectives 
ƒ SPA targets and indicators 
ƒ SPA activities: products and milestones 
ƒ Critical 
A broad project monitoring framework has 
been defined to cover all the basic levels of 
project planning and monitoring: 
The conceptual framework encompassing 
these levels of planning and monitoring is 
presented in Annex 4. It is proposed that 
SPA managers populate all columns in this 
framework and update them quarterly. 
Further guidance for the monitoring of performance targets is provided in Annex 3.2 which lists 
all SPAs with their objectives, indicators, related target achievement, the data source, and any 
special data requirements (e.g., gender disaggregation). The annex also provides for the indicator 
targets, 2007–2008 baseline values, and 2008–2009 target values where available. 
The aggregation of indicator and activity data will be undertaken quarterly by SPA managers and 
submitted to the M&E officer, with the exception of the client counts which are provided through 
the DHIS and facility contacts, as described above. 
Reports for USAID will be compiled as scheduled by USAID (quarterly for ARV client data, 
semi-annually and annually for all required indicators). 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 23 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
IX. Summary of Resource Requirements
The complete budget for IPHC activities proposed for the 27-month period (October 2008 to 
December 2010) is provided as a separate document. Cost savings from March 1 2008 until 
September 30, 2008, will result from significant changes in the IPHC approach which include a 
slightly reduced field staff combined with a focus on consolidating and integrating field 
activities. In addition, there will be an increasing focus on institutionalization and sustainability 
of key project interventions as the project moves into its final two years, including assisting with 
the hand over of youth and OVC efforts for funding from other sources. 
MSH will maintain its home office support for technical, finance and administrative activities, 
but at a reduced level of effort. Short-term technical assistance (STTA) proposed will focus on 
follow-up on recommendations from previous interventions and from recent data quality and 
impact assessments. Technical areas addressed through STTA will include strengthening the 
project’s monitoring and evaluation systems. MSH plans to undertake an assessment of its work 
in these selected critical SPAs during the first half of 2009 and will also provide related STTA. 
To ensure a very high quality final contract report, IPHC will have STTA from MSH home 
office communications staff and from an AIDS/PEPFAR specialist to ensure that all PEPFAR 
results are captured and summarized for the life of the project. 
  
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 24 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
ANNEXES 
1. Summary of Quantitative Results, by SPA (Project Year 2006–2007) 
2. Work Plan 
3. Staffing List 
4. Indicator List and M&E Framework 
5. Communication Plan 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 25 
Use or disclosure of data contained on this sheet is subject 
to the restriction on the title page of this proposal.
ANNEX 1. Summary of Quantitative Results by SPAs (Project Year 2006–2007) 
Output Indicators Target Total Achieved 
SPA 1: Maternal Health and Family Planning 
No. total antenatal visits 10,000 88,008 
No. of 1st
 ANC visits 26,064 
Average no. ANC visits per client 4 
No. Pregnant women tested for HIV 19,560 
No. Pregnant women who tested positive 5,353 
SPA 2: Child Health 
No. of children fully immunized 18,677 
No. of children given vitamin A at 6–12 months 19,875 
No. children <12 months who received DPT3 1,500 16,227 
No. nurses trained in IMCI 200 275 
No. CBHWs trained in IMCI home care 85 
No. of children weighed 644,723 
No. children underweight 1,179 
SPA 3: Youth Program 
No. youth given family planning and RH education 49,315 
No. youth receiving HIV testing 8,035 
Increase in youth utilization of RH services 45% 
No. of youths counseled on FP and provided FP methods 800 4,414 
SPA 4: HIV & AIDS 
No. clients receiving counseling and testing and their test 
results 35,000 45,310 
No. of new STI clients 33,542 
No. clients not accessing testing 13,127 
No. and % of STI client partners responding for testing and 
treatment 5,730/21%
No. STI clients syndromically treated 28,492 
No. and % of first ANC visits who were tested for HIV 20,225/ 88.9% 
No. of facility staff supported in data management and data 
use on palliative care 863
No clients receiving palliative care including HIV/TB 35,000 20,034 
No. TB clients tested for TB 5,000 2,462 
No. HIV patients treated for TB 5,000 1,206 
Facilities supported in ARV treatment 12 hospitals 
59 Feeder clinics 
Clients provided with ARV treatment in supported facilities 17,000 22,712 
SPA 5: PHC Services and Systems 
% of facilities having quality improvement teams 100% 92% 
SPA 6: OVC and Community Support Networks 
Number of NGOs receiving small grants 23 up from 6 
Number of OVC served 10,000 12,086 up from 6,208 
Community OVC caregivers trained 400 477 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 26 
26
ANNEX 2. Workplan 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 27 
27
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 28 
28
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 29 
29
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 30 
30
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 31 
31
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 32 
32
ANNEX 3. Staffing List 
CURRENT IPHC STAFF 
February 2008 
NAME TITLE 
MSH Staff 
Agherdine, Nadia LOGISTICS MANAGER 
Brown, Muriel BOOKKEEPER 
Combrink, Gert Cornelius DEPUTY CHIEF OF PARTY 
Dhlamini, Nontuthuzelo PROVINCIAL COORDINATOR, KWAZULU NATAL 
Evans, Carole FINANCIAL MANAGER 
Jaxa, Nozipho ART TECHNICAL ADVISOR, EASTERN CAPE 
Hlabano, Vusi NATIONAL HIV COORDINATOR 
Klaas, Nondumiso Primrose HIV TECHNICAL ADVISOR, EASTERN CAPE 
Mabusela, Mmaphohla Emily YOUTH ADVOCACY TECHNICAL ADVISOR 
Manzini, Khanyisa M&E MANAGER 
Mazaleni, Nomathemba CHIEF OF PARTY 
Mudzunga, Gloria DATA CAPTURER 
Muthambi, Tendani PROGRAM ASSOCIATE 
Ngomane, Sharon DEPUTY DIRECTOR TECHNICAL PROGRAMS 
Pataki, MS ARV TECHNICAL ADVISOR, LIMPOPO 
Pitsi, Moipone HUMAN RESOURCES MANAGER 
Radebe, S GRANTS MANAGER 
Sefularo, Kgomotso HIV TECHNICAL ADVISOR, NORTHWEST 
Setshotlo, Pule INFORMATION TECHNOLOGY OFFICER 
Shamu, Rodwell OVC MANAGER 
Sokhela, GP HIV TECHNICAL ADVISOR, NORTHWEST 
Taole, Khetisa DISTRICT HEALTH PLANNING AND FINANCE TECHNICAL ADVISOR 
Thebela, Theresa Mmalego RECEPTIONIST 
Thela, Samuel PROVINCIAL COORD., MPUMALANGA 
Currently vacant HIV TECHNICAL ADVISOR, NORTHWEST 
Sub Contractors’ Staff
Nonceba, Languza (HST) PROVINCIAL COORDINATOR, EASTERN CAPE 
Ogrinah, Nogoveni (HST) PROVINCIAL COORDINATOR, LIMPOPO 
Currently vacant (HST) PROVINCIAL COORDINATOR, NORTHWEST 
Currently vacant (HST) HEALTH INFORMATION OFFICER 
Currently vacant (HST) CLINIC SUPERVISOR 
Timbela, Damane (URC) QUALITY ASSURANCE TECHNICAL ADVISOR, EASTERN CAPE 
Maponya, Luisa (URC) QUALITY ASSURANCE TECHNICAL ADVISOR, LIMPOPO 
Ndlela, Bongoli (URC) QUALITY ASSURANCE TECHNICAL ADVISOR, KZN 
Lubisa, Judith (URC) QUALITY ASSURANCE TECHNICAL ADVISOR, MPUMALANGA 
Currently vacant (URC) QUALITY ASSURANCE TECHNICAL ADVISOR, NORTHWEST 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Annex 4_Monitoring and Evaluation Framework_Page 33 of 42 
Use or disclosure of data contained on this sheet is subject 
to the restrictions on the title page of this proposal
ANNEX 4 Indicator List and M&E Framework 
Monitoring and Evaluation Framework 
Levels of Planning and Monitoring 
Vision: The IPHC Project expects, as a result of its efforts, the emergence of functional district health systems capable of providing accessible, high quality HIV & 
AIDS interventions that are fully integrated into primary health care services for the benefit of disadvantaged communities, thus offering previously disadvantaged 
South Africans a better quality of life.
SPA Objectives Performance 
Targets 
Activities Critical Products 
(Milestones) 
Critical 
Resources 
1. 
MH & FP 
Improve women's and maternal health 
maternal complications and deaths
in order to effectively reduce 
2. 
Child Health 
To improve child survival and reduce infant and child mortality
3. 
Youth 
Increase youth participation in the promotion and provision of YFS in 
order to reduce reproductive health problems among adolescents
4. 
HIV & AIDS 
Reduce the impact of HIV & AIDS 
4.1 
CT 
Strengthen the integration 
activities
of counseling and testing into routine PHC 
4.2 
PMTCT 
Strengthen and expand a comprehensive PMTCT program
4.3 
ARV 
Strengthen the ARV treatment service delivery to those who are 
infected with HIV
4.4 
PC-Basic Strengthen palliative care in the PHC setting; integrate palliative care 
4.5 for TB and HIV
PC-TB/HIV 
5 
PHC Ser/Sys 
Strengthen functional district health systems
5.1 
Qual Assur 
Contribute to service quality improvement through selected 
structures
tools and 
5.2 
HIS 
Improve the knowledge and use by service staff and managers of health 
information
5.3 
DHS 
Support the development of district health plans, operational plans, 
operational reviews, and the conducting of DHERs
6. 
OVC 
Strengthen CBOs and networks to enhance the welfare of children 
affected by HIV & AIDS mortality in their family
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 34 
Use or disclosure of data contained on this sheet is subject 
to the restrictions on the title page of this proposal
Annex 4.1: Integrated Primary Health Care Project – Extension Period 
SPA Objectives, Indicators, and Targets 
SPA 1: Maternal Health and Family Planning 
Objective: Improve women's and maternal health in order to effectively reduce maternal complications and deaths
Indicator 2007–08 
Baseline 
2008–09 
Target 
2008–09 
Achievement 
Data Source Disaggregated 
by 
# of antenatal care (ANC) visits provided 
assisted facilities. 
by skilled providers from USG- 88,000 15,000 DHIS 
# of USG-assisted services delivery points 
services 
providing FP counseling or 58 65 DC Tool 
# of individuals counseled on FP and provided with FP methods 4,414 4,500 PHC register Gender 
# of people trained in RH/FP with USG funds (health professionals, primary 
health care workers, community health workers, volunteers, non-health 
personnel) 
186 220 Training db Gender
SPA 2: Child Health 
Objective: To improve child survival and reduce infant and child mortality
Indicator 2007–08 
Baseline 
2008–09 
Target 
2008–09 
Achievement 
Data Source Disaggregated 
by 
# of IPHC-assisted facilities offering IMCI services in accordance with the 
national standard treatment guidelines for IMCI services 
68 * DC Tool Province
# of people (health professionals, primary health care workers, community 
health workers, volunteers, non-health personnel) trained in child health care 
and child nutrition through USG-supported programs 
360 * Training db Gender
# of children under 5yrs fully immunized 18,677 * DHIS 
% of children fully immunized under 1yr, for the month 90% PHC register 
# of children given Vitamin A at 6 -11 months 19,875 * DHIS 
# of children under 12 months who received DPT3 in a given year from USG￾supported program 16,227 * DHIS PHC register Gender 
# of children under 5yrs weighed * DHIS 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 35 
Use or disclosure of data contained on this sheet is subject 
to the restrictions on the title page of this proposal
SPA 3: Youth Program 
Objective: Increase youth participation in the promotion and provision on YFS in order to reduce reproductive health problems among adolescents
Indicator 2007–08 
Baseline 
2008–09 
Target 
2008–09 
Achievement 
Data Source Disaggregated 
by 
# of individuals given information VCT information 286,230 * DC Tool Gender 
# of individuals who received pre-test counseling 20,212 * DHIS Gender
# of individuals who tested for HIV 13,341 * DC Tool Gender 
# of individuals given STI information 263,776 * DHIS Gender 
# of individuals who received STI treatment 12,014 * DC Tool Gender
# of STI clients who tested for HIV 4,904 * DHIS Gender 
# of individuals given FP information 230,915 * DC Tool Gender 
# of individuals provided with FP methods (subset of SPA 1) 64,210 * DHIS Gender 
SPA 4: HIV & AIDS 
Component 1: Counseling and Testing 
Objective: Strengthen the integration of counseling and testing into routine PHC activities 
Indicator 2007–08 
Baseline 
2008–09 
Target 
2008–09 
Achievement 
Data Source Disaggregated 
by 
# of service outlets providing counseling and testing according to 
African or international standards 
South 69 80 DC Tool Province
# of clients who received pre-test counseling (excl. antenatal) 20,415 * DHIS 
PHC register 
Gender 
# of clients who received counseling and testing and received their test results 
(excl. antenatal) 
45,310 40,000 DHIS 
PCH register 
Gender 
# of newly identified HIV-infected individuals who were screened for TB 3,664 * DHIS 
PHC register 
Gender 
# of individuals trained in counseling and testing according 
or international standards. 
to South African 349 300 Training db Gender
Indirect # of individuals who received counseling and testing for HIV and 
received their test results 
27,554 85,000 Attendance 
register & DHIS 
Gender 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 36 
Use or disclosure of data contained on this sheet is subject 
to the restrictions on the title page of this proposal
Component 2: PMTCT 
Objective: Strengthen and expand a comprehensive PMTCT program 
Indicator 2007–08 
Baseline 
2008–09 
Target 
2008–09 
Achievement 
Data Source Disaggregated 
by 
# of service outlets providing the minimum package of 
according to South African or international standards 
PMTCT services 69 80 DC Tool Province
# of pregnant women who received HIV 
and received their test results 
counseling and testing for PMTCT 20,225 19,000 DHIS 
# of pregnant women provided with a complete course of antiretroviral 
prophylaxis in a PMTCT setting 
2,788 5,000 DHIS 
# of health workers trained in the provision of PMTCT services according to 
South African or international standards 
220 350 Training db Gender
Indirect number of pregnant women who received HIV counseling 
for PMTCT and received their test results 
and testing 36,789 30,000 Attendance 
register & DHIS 
Indirect number of pregnant women provided with a complete course of 
antiretroviral prophylaxis in a PMTCT setting 
5,203 5,000 Attendance 
register & DHIS 
Component 3: HIV & AIDS Treatment (ARV) 
Objective: Strengthen the ARV treatment service delivery to those who are infected with HIV 
Indicator 2007–08 
Baseline 
2008–09 
Target 
2008–09 
Achievement 
Data Source Disaggregated 
by 
# of service outlets providing ARV therapy 71 15 DC Tool Province 
# of HIV-infected individuals provided 
reporting period 
with ARV treatment at the end of the 4,850 Hospital 
register/DHIS 
Gender 
# of individuals who started ARV therapy during the reporting period 2,600 Hospital 
register/DHIS 
Gender 
# of individuals who ever received ARV therapy 
period (cumulative) 
by the end of the reporting 2,600 Hospital 
register/DHIS 
Gender 
Total # of health workers trained to deliver ART services, according to 
national and/or international standards 
186 400 Hospital 
register/DHIS 
Gender 
Indirect # of individuals receiving antiretroviral therapy at the end of the 
reporting period 
22,172 20,000 Attendance 
register & DHIS 
Gender 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 37 
Use or disclosure of data contained on this sheet is subject 
to the restrictions on the title page of this proposal
Component 4: Palliative Care – Basic 
Objective: Strengthen palliative care in the PHC setting; integrate palliative care for TB and HIV 
Indicator 2007–08 
Baseline 
2008–09 
Target 
2008–09 
Achievement 
Data Source Disaggregated 
by 
# of service outlets providing HIV-related palliative care (including TB/HIV) 62 80 DC Tool Province 
# of 
TB/HIV) 
individuals provided with HIV-related palliative care (including 20,024 25,000 PHC register Gender 
# of individuals receiving post exposure prophylaxis (PEP) [initiated and 
referred at this PHC facility] 
90 250 DHIS Gender
# of family members of HIV-infected individuals who received HIV-related 
palliative care 
2,651 5,000 PHC register 
NGO register 
Gender 
# of HIV-infected individuals provided with the basic care package (incl. 
TB/HIV) 
 10,000 PHC register 
NGO register 
Gender 
# of HIV-infected individuals who received cotrimoxazole prophylaxis 3,715 6,000 DHIS Gender
# of individuals trained to provide HIV-related 
TB/HIV) 
palliative care (including 13 400 Training db Gender
Indirect # of individuals with facility-based, community-based, and/or home￾based HIV-related palliative care including those HIV-infected individuals 
who received treatment for TB 
22,418 25,000 Attendance 
register & DHIS 
Gender 
Component 5: Palliative Care – TB/HIV 
Objective: Strengthen palliative care in the PHC setting; integrate palliative care for TB and HIV 
Indicator 2007–08 
Baseline 
2008–09 
Target 
2008–09 
Achievement 
Data Source Disaggregated 
by 
# of service outlets providing treatment for tuberculosis (TB) to 
individuals (diagnosed or presumed) in a palliative care setting 
HIV-infected 62 80 DC Tool Province
# of HIV-infected clients attending 
receiving treatment for TB disease 
HIV care/treatment services that are 1,296 8,000 PHC register Gender 
# of TB patients tested for HIV 2,463 8,000 DHIS Gender 
# of individuals trained to provide clinical prophylaxis and/or treatment for 
TB to HIV-infected individuals (diagnosed or presumed) 
3 300 Training db Gender
Indirect # of HIV-infected clients attending HIV care/treatment services that 
are receiving treatment for TB disease 
891 10,000 Attendance 
register & DHIS 
Gender 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 38 
SPA 5: PHC Systems and Services 
Component 1 : Quality Assurance 
Objective: Contribute to service quality improvement through selected tools and structures 
Indicator 2007–08 
Baseline 
2008–09 
Target 
200–-09 
Achievement 
Data Source Disaggregated 
by 
# of supervisory visits to the facility 1 
visit/month/
facility 
 DC Tool Facility
# of clinic committee meetings with records/minutes & action plans * 
# of facility staff, supervisors and program coordinators trained using clinic 
supervision tools 
 160 Gender
Component 2 : District Health Information 
Objective: Improve the knowledge and use by service staff and managers of health information of acceptable quality for planning, management, and monitoring 
Indicator 2007–08 
Baseline 
2008–09 
Target 
2008–09 
Achievement 
Data Source Disaggregated 
by 
# of facilities with updated catchment population been posted for all ages? * 
# of facilities with updated graphed indicators that are displayed * 
# of facilities with that have implemented the TALI tool 10 
Component 3: District Health System 
Objective: Support the development of district health plans, operational plans, operational reviews, and the conducting of DHERs 
Indicator 2007-08 
Baseline 
2008-09 
Target 
2008-09 
Achievement 
Data Source Disaggregated 
by 
# of districts with completed DHPs per year 8 
# of districts with completed DHER reports 8 
# of facilities where the MESH assessment tool has been administered * 
SPA 6: OVC and Community Support Network 
Objective: Strengthen Community HBC Organizations and Networks for enhancing the welfare of children affected by HIV mortality in their family
Indicator 2007–08 
Baseline 
2008–09 
Target 
2008–09 
Achievement 
Data Source Disaggregated 
by 
# of OVC served - 3 or more services 7,156 10,000 Grantee register Gender 
Service type 
# of OVC served - 2 or less services 4,930 5,000 Grantee register Gender 
Service type 
# of providers/caretakers trained in caring for OVC 477 500 Grantee register Gender 
Number of OVC served by OVC (indirect) 2,591 * DC Tool Gender 
Use or disclosure of data contained on this sheet is subject 
to the restrictions on the title page of this proposal
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 39 
ANNEX 5 Project Communications Strategy 
Introduction and Situation Analysis 
By offering a two-year cost extension to the IPHC project, the mission and the South African 
National Department of Health (NDOH) have indicated their confidence in the project and 
effectively reiterated their understanding that HIV & AIDS services are only as effective as the 
underlying primary health care system. This extension also reconfirms USAID’s and NDOH’s 
joint commitment to reducing the impact of HIV & AIDS and bettering health care for historically 
disadvantaged South Africans, through the sustainable strengthening and integration of services 
delivered by primary health care facilities and managed by District Health Offices. That being 
said, the wealth of epidemiological and service performance information being generated through 
the facilitation processes at the community, facility, and district level needs to be assembled, 
packaged, and delivered to the higher levels of the health system, especially the Provincial Health 
Departments, the NDOH, and the managers of the national health programs. 
This extension advances a long-term commitment of the US and South African governments 
to the people of South Africa. It has never been more important than now to effectively 
communicate this commitment and its life-saving impacts to the people and governments of 
South Africa and the US. 
We are proposing proactive, creative, and engaging ways to tell these stories, to highlight the 
results and achievements of the unique partnership among the Integrated Primary Health Care 
(IPHC) Project, USAID/South Africa, and the NDOH. The IPHC team, with strategic capacity￾building support from the MSH home office, will use all appropriate means to achieve the 
project’s communications goals. Those goals and objectives are designed to complement the 
technical work and accomplishments of IPHC, USAID/South Africa, and the NDOH. Our plan 
uses proven and consistently implemented communication techniques to ensure the high visibility 
of USAID/South Africa and the NDOH. We will work in partnership with the USAID mission in 
South Africa and in accordance with the norms and standards established by USAID. Upon award, 
we will work closely with stakeholders at the NDOH and USAID/South Africa to continually hone 
tactics and messages; we will also check in with these stakeholders periodically to ensure that the 
plan and the targets remain relevant and effective. Special effort has been and will continue to be 
made to ensure that this plan is realistic and operational; implementation of this plan will be made 
an overarching project activity to which each SPA manager and the project leadership will 
contribute. 
GOAL & OBJECTIVES 
The overall goal of the communications plan is to increase and reinforce awareness—especially 
among our targeted audiences (see below)—of IPHC’s positive impact on individuals and 
communities in the targeted districts. We will do so by capturing and disseminating the project’s 
successes and lessons learned. 
Key communications objectives that support and drive us toward this overarching communications 
goal are: 
ƒ Wide dissemination of accurate and relevant information about the project’s efforts and 
impact; 
Use or disclosure of data contained on this sheet is subject 
to the restrictions on the title page of this proposal 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 40 
ƒ Demonstrations of the project’s effectiveness, namely the positive impact of integrating 
services and strengthening primary health care service delivery (thus evidence of well￾spent US taxpayer money); 
ƒ Creation, cultivation, and maintenance of effective information-sharing with stakeholders 
to demonstrate that integrated health programs are working to mitigate the impact of HIV 
& AIDS and opportunistic infections and to improve health overall. 
TARGET AUDIENCES 
Our primary audience is the Government of South Africa, the NDOH, USAID/South Africa, 
and other in-country USG partners. 
Members of the Government of South Africa will: 
ƒ be better informed of health trends, resource and performance gaps, and effective 
improvement strategies, helping them to make informed funding and policy decisions (e.g., 
government leadership); 
ƒ understand lessons and better practices to enhance better replication and scale-up across 
other provinces and programs (e.g., national-level program clusters); 
ƒ benefit from “positive peer pressure” and be encouraged to take pride in their own 
successes through the publication and dissemination of project impact and results (e.g., 
provincial-, district-, and community-level stakeholders and actors). 
Communications targeting USG partners in South Africa will encourage and enable the sharing of 
interventions, best practices, and lessons learned; communications activities will include technical 
seminars, dissemination workshops, and broad distribution of annual technical reports and relevant 
portions of other reports. 
The secondary audience for this project’s communications is the people of South Africa. As a 
result of IPHC communications activities, they will come to know that the American people and 
the Government of South Africa are committed to reducing the impact of HIV & AIDS and 
providing better health care for historically disadvantaged South Africans. South Africans will also 
understand the importance of strong, integrated primary health care programs in reducing the 
impact of HIV & AIDS in South Africa. 
Furthermore, the people of South Africa will be reminded of the impact and availability of 
essential health care offered by district health services and community-based entities. We will 
reach this audience primarily through proven USAID public affairs tools such as broadly 
disseminated Success Stories that strike an individual-level chord with the South African people. 
The tertiary audience is the American people and decision-makers in Washington, DC,
(including the US Congress). We will communicate effectively to demonstrate the positive impact 
of their tax dollars allocated to foreign assistance. Buy-in from these audiences will help to ensure 
ongoing financial and political support for foreign assistance, specifically for effective, efficient, 
and integrated health programming. Proven USAID public affairs tools like Success Stories 
disseminated through USAID/South Africa, USAID/Washington, and (when appropriate) OGAC 
will be very effective means to reach Americans and American decision-makers. Non-technical 
materials like the “Voices of the Children” mentioned as a project deliverable are also important in 
reaching this audience. 
Use or disclosure of data contained on this sheet is subject 
to the restrictions on the title page of this proposal 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 41 
Use or disclosure of data contained on this sheet is subject 
to the restrictions on the title page of this proposal 
KEY MESSAGES 
Key messages will be a part—overtly or subtly—of all communication activities. Key messages 
might require modification through the course of the cost extension, but those currently 
appropriate for most audiences include the following: 
ƒ The US government and the South African NDOH are committed to reducing the impact of 
HIV & AIDS and improving primary health care services for historically disadvantaged 
South Africans. 
ƒ IPHC and the NDOH—partnering with district- and facility-level public health actors—are 
making a tangible difference in the lives of South Africans by reducing the impact of HIV 
& AIDS by improving primary health care services for historically disadvantaged South 
Africans. 
ƒ A strengthened and integrated primary health care system in South Africa is enabling the 
delivery of effective services to reduce the impact of HIV & AIDS and other related 
diseases. 
ƒ IPHC technical advisors are working with local health professionals, clinic services, and at 
the community level to fight and reduce the impact of HIV & AIDS in their districts. 
ƒ IPHC and the NDOH—partnering with provincial and district public health actors—are 
building a cadre of health workers to ensure sustainable primary health care service 
delivery. 
ƒ IPHC is a USAID project supported by the American people. 
OPERATIONAL COMMUNICATIONS 
This type of communication will cover issues which mainly focus on service delivery, best 
practices, encouraging implementation of government protocols and generally reinforcing proper 
service delivery. This method could be used in attempting to strengthen problematic system 
components, like patient and specimen referral systems. Best practices could be communicated to 
all health professionals within a district, extending also to facilities that are not directly supported 
by the project. Feedback from the DHIS is another area which needs to be communicated more 
constantly to all facilities and health professionals 
Proposed Communication Products and Activities 
The IPHC team will implement this communications plan in concert with technical work; the 
communications calendar/work plan will dovetail with the project’s technical activities, and 
communications deliverables—like those in the rest of the project—will be results-oriented and 
demonstrate evidence-based decision-making.
• Calendars of planned communications events and new initiatives for communities and 
sub-districts, across districts and provinces, and at the national level will help to keep 
communications efforts relevant and complementary to the technical work which is our 
foundation. 
• Ongoing support from the home office will help to build the capacity of local staff to 
conduct effective and strategic communications activities on this project. 
• Case Studies and Success Stories will be regularly produced and widely distributed at 
national, provincial, district, and sub-district levels; to USAID and PEPFAR (as relevant); 
and, whenever possible, to the media and via relevant websites (USAID, MSH, NDOH, 
etc.). These documents will present compelling stories demonstrating the overall impact of 
MSH Extension Proposal, TO 800 under IQC GHS-I-00-03-00030-00 
Page 42 
the project through the experience of an individual or small group of individuals; they also 
will be included in semiannual and annual technical reports. 
• Voices of Children: The OVC Program has outsourced the creation and development of 
the “Voices of Children Report.” 
• Broaden annual report distribution to include sub-districts and facilities as well as sub￾contractors. This will enhance outreach to our tertiary audiences, help facilitate knowledge 
exchange among stakeholders and actors, and help build the project’s technical credibility. 
• Technical Seminars will be sponsored and facilitated by the project. In consultation with 
the NDOH, we will choose relevant themes and topics for workshops/seminars to provide 
avenues for the effective exchange of best practices and lessons learned. Furthermore, these 
sessions can help bolster the perception of the technical leadership of the NDOH, IPHC, 
and USAID. 
• End-of-Project Report. A full description of the project’s work and accomplishments will 
be further enhanced by compelling photography and design, and stories from individuals to 
highlight the important impact of this partnership. 
• Events (seminars, consultations, and planning meetings) with the health departments at 
national, provincial, and district levels. 
Use or disclosure of data contained on this sheet is subject 
to the restrictions on the title page of this proposal 
For more information, please visit:
http://ghtechproject.com
Global Health Technical Assistance Project
1250 Eye St., NW, Suite 1100
Washington, DC 20005
Tel: (202) 521-1900
Fax: (202) 521-1901
www.ghtechproject.com