FY21 SIMS 4.1 Above Site Tool - Cleared

S MS
SITE IMPROVEMENT THROUGH

MONITORING SYSTEM (SIMS)
FY21 ABOVE-SITE ASSESSMENT TOOL
Version 4.1, 15 August 2020

Site Improvement through Monitoring System
SIMS is a quality assurance tool used to monitor and

improve program quality at PEPFAR-supported sites that Prioritized
Site
guide and support service and non-service delivery functions. Selection
Goals of SIMS 4.0

 Integrate SIMS into broader framework(s) for analysis, Tailored Site
management and improvement Assessment
 Tailored, nimble, responsive site selection and

implementation based on performance, program needs, Follow-Up after
Remediation
and programmatic gaps
 Actionable to drive improvement or sustain quality
2 Assessment Tools
Organization of SIMS Site Assessment Tool
Set # Set Name
SET 1A General
SET 1B Commodities Management
SET 1C Data Quality
SET 2A Care And Treatment-General Population
SET 2B Care And Treatment For HIV Infected Children
Site Level Tool Above-Site Level Tool SET 3A Key Populations-General
Site assessments are conducted Above-site assessments are
SET 3B Care And Treatment – Key Populations
at both facility and community conducted at PEPFAR-supported
sites (i.e. places where services institutions that are above the SET 4A Preventing Mother to Child Transmission, Antenatal Care,
are provided). Examples include service delivery point (i.e. not Postnatal, and Labor and Delivery
clinics, hospitals, laboratories, where services are provided or SET 4B HIV Exposed Infants
and ‘standalone’ structures. beneficiaries are reached). SET 5 Voluntary Medical Male Circumcision
Examples include health offices SET 6 Adolescent Girls and Young Women and Gender-based Violence
at the national or subnational SET 7 HIV Testing Services
level.
SET 8 Tuberculosis Treatment Service Point
SET 9 Methadone or Buprenorphine Medication Assisted Treatment
2 Types of Assessments SET 10A Laboratory
Comprehensive Assessment is the first assessment SET 10B Blood Safety
at a site or above site location. All relevant
standards (Required and Elective CEEs) should be Organization of SIMS Above-Site Assessment Tool
Set # Set Name
assessed.
SET 1 HIV Planning, Coordination and Management
SET 2 Orphans and Vulnerable Children/Social Services
Follow-Up Assessment determines whether all
SET 3 Guidelines and Policies
CEEs that scored red or yellow during a prior SET 4 Private Sector Engagement and Advocacy
assessment have improved (i.e. red or yellow to SET 5 Human Resources for Health
green). SET 6 Commodities
SET 7 Quality Management
SET 8 Laboratory and Blood Transfusion Support
Core Essential Elements (CEEs) SET 9 Strategic Information, Surveys, Surveillance and Evaluation
SET 10 Protecting Life in Global Health Assistance
Standard: CEEs are built on program quality standards based upon
World Health Organization supported evidence or guidelines and/or Description of Final CEE Scores
documentation of best practices.
COLOR (# score) DESCRIPTION
Assessment Questions: Each CEE is composed of a series of G: Green (3) Meets standard
questions that progressively assess the site against the standard. Y: Yellow (2) Needs improvement
R: Red (1) Needs urgent remediation
Final Score: The final score is red, yellow, green or N/A. CEE scores
Gray (0) Not Applicable selected
are designed to highlight whether a problem exists.
Assessment Date: ____________ Assessment ID: __________
REFERENCE INFORMATION
Set Names and Required vs. Elective Status
Set Name Set # Required Elective

HIV Planning, Coordination, And Management – Set 1 X
Health
Orphans and Vulnerable Children/Social Services Set 2 X
Guidelines and Policies Set 3 X
Private Sector Engagement and Advocacy Set 4 X
Human Resources for Health Set 5 X
Commodities Set 6 X
Quality Management Set 7 X
Laboratory and Blood Transfusion Support Set 8 X
Strategic Information: Surveillance and Surveys Set 9 X
Protecting Life in Global Health Assistance Set 10 X
Description of SIMS Assessment Types and Assessment Tool Composition
Assessment Tool Assessment Type Conducted CEEs to be Assessed

by
Site Comprehensive USG For Required CEEs: All applicable*
For Elective CEEs: All applicable* and
relevant**
Follow-Up USG or IP All CEEs that previously scored red or
yellow.
Above Site Comprehensive USG For Required CEEs: All applicable*
For Elective CEEs: All applicable* and
relevant**
*Applicable means if those services are provided or offered
**Relevant means assessed as needed (at the discretion of the Operating Unit based on
performance, program needs and program gaps)
Explanation of Icons in the SIMS Assessment Tools
Icon Description of Icon Explanation
Eyes Question requires visual inspection of documents,

charts/registers or materials
Pink Square Question requires Chart or register review
FY 21 SIMS Above Site Assessment Tool, Version 4.1 2

Gray Circle Question requires Materials review
Blue Triangle Question requires Document review
Description of Final CEE Scores
COLOR (# score) DESCRIPTION

G: Green (3) Meets standard
Y: Yellow (2) Needs improvement
R: Red (1) Needs urgent remediation
Gray (0) Not Applicable selected
Figure 1: Core Essential Elements (CEE) Structure Used within this Tool
S_01_11_DataRepConHTC_DATA
Assessment CEE ID CEE Abbreviated Name Set Abbreviated
Tool Set ID Name

FY 21 SIMS ABOVE-SITE ASSESSMENT TOOL
Table of Contents
SET 1: HIV PLANNING, COORDINATION, AND MANAGEMENT – HEALTH ..............................................8

CEE #: AS_01_01 Management and Planning – National Strategic Planning-Health sector (National)
[PLAN MGT]............................................................................................................................................... 9
CEE #: AS_01_02 Use of Data from Health Economics and Finance Studies (National/Subnational)
[PLAN MGT]............................................................................................................................................. 10
CEE #: AS_01_03 Management and Planning – Operational Planning (Subnational) [PLAN MGT]........ 11
CEE #: AS_01_04 Supervision – Health Sector (Subnational level) [PLAN MGT] .................................... 12
CEE #: AS_01_05 Routine Data Collection/Review (Subnational level) [PLAN MGT] ............................. 13
CEE #: AS_01_06 Referrals (Subnational level) [PLAN MGT] .................................................................. 14
SET 2: OVC/SOCIAL SERVICES............................................................................................................ 15
CEE #: AS_02_01 Management and Planning – Strategic Planning (Social Services) (National) [SOC
OVC] ........................................................................................................................................................ 16
CEE #: AS_02_02 Social Protection/Child Protection Management Information Systems (Subnational)
[SOC OVC] ............................................................................................................................................... 17
CEE #: AS_02_03 Management and Planning – Operational Planning (Social Services) (Subnational)
[SOC OVC] ............................................................................................................................................... 18
CEE #: AS_02_04 Supervision – Social Services (Subnational) [SOC OVC] .............................................. 19
SET 3: GUIDELINES AND POLICIES ..................................................................................................... 21
CEE #: AS_03_01 National Guidelines for Key Populations (National) [GUIDE] ..................................... 22
CEE #: AS_03_02 Key Populations National Quality Norms (National) [GUIDE] ..................................... 23
CEE #: AS_03_03 Guideline Development (National) [GUIDE] ............................................................... 24
CEE #: AS_03_04 Guideline Distribution (Subnational) [GUIDE] ............................................................ 25
CEE #: AS_03_05 WHO Guidelines for ART Initiation in Different Populations (National) [GUIDE] ....... 26
CEE #: AS_03_06 Data Protection Policies for Collection and Use of Patient Level Data (National)
[GUIDE].................................................................................................................................................... 27
CEE #: AS_03_07 Enabling Policies and Legislation (National) [GUIDE].................................................. 28
CEE #: AS_03_08 Index Testing Services in National HTS Guidelines (National) [Guide] ....................... 29

SET 4: PRIVATE SECTOR ENGAGEMENT AND ADVOCACY ................................................................... 30

CEE #: AS_04_01 Public-Private Partnerships (National/Subnational [PPP-ADVOCACY] ....................... 31
CEE #: AS_04_02 Performance and Service Delivery Transparency (National) [PPP-ADVOCACY] ......... 32
CEE #: AS_04_03 Advocacy (National/Subnational) [PPP-ADVOCACY] .................................................. 33
CEE #: AS_04_04 Health Communication (National/Subnational) [PPP-ADVOCACY] ............................ 34
SET 5: HUMAN RESOURCES FOR HEALTH .......................................................................................... 35
CEE #: AS_05_01 HRH Staffing (National/Subnational) [HRH] ................................................................ 36
CEE #: AS_05_02 In-Service Training (National/Subnational) [HRH] ...................................................... 37
CEE #: AS_05_03 Pre-Service Education (National) [HRH]...................................................................... 39
CEE #: AS_05_04 HRH Regulation (National) [HRH] ............................................................................... 40
CEE #: AS_05_05 Faculty Development (National) [HRH]....................................................................... 41
SET 6: COMMODITIES ....................................................................................................................... 42
CEE #: AS_06_01 Supply Chain: ARVs (National) [COMMODITIES]......................................................... 43
CEE #: AS_06_02 Data Use for ARV Distribution Decision making (National /Subnational)
[COMMODITIES]...................................................................................................................................... 44
CEE #: AS_06_03 Supervision/Monitoring for ARV Supply Chain (National/Subnational)
[COMMODITIES]...................................................................................................................................... 45
CEE #: AS_06_04 Supply Chain: Rapid Test Kits/Diagnostics (National) [COMMODITIES] ..................... 46
CEE #: AS_06_05 Data Use for RTK Distribution Decision making (National/Subnational)
[COMMODITIES]...................................................................................................................................... 47
CEE #: AS_06_06 Supervision/Monitoring for RTK Supply Chain (National/Subnational)
[COMMODITIES]...................................................................................................................................... 48
CEE #: AS_06_07 Supply Chain: Food and Nutrition (National) [COMMODITIES] .................................. 49
CEE #: AS_06_08 Data Use for Food and Nutrition Commodity Distribution Decision making
(National/Subnational) [COMMODITIES] ................................................................................................ 50
CEE #: AS_06_09 Supervision/Monitoring for Food and Nutrition Supply Chain (National/Subnational)
[COMMODITIES]...................................................................................................................................... 51
CEE #: AS_06_10 Medicines Regulatory System - Registration (National) [COMMODITIES] ................. 52
CEE #: AS_06_11 Medicines Regulatory System – Quality Assurance / Quality Control (National)
[COMMODITIES]...................................................................................................................................... 53
CEE #: AS_06_12 Medicines Regulatory System – Pharmacovigilance (National) [COMMODITIES] ...... 54
SET 7: QUALITY MANAGEMENT ........................................................................................................ 55

CEE #: AS_07_01 Quality Management/Quality Improvement (QM/QI) System (National/Subnational)

[QM] ........................................................................................................................................................ 56
CEE #: AS_07_02 Quality Management/Quality Improvement (QM/QI) Consumer Involvement
(National/Subnational) [QM] .................................................................................................................. 57
CEE #: AS_07_03 Quality Assurance: VMMC (National/Subnational) [QM] ........................................... 58
SET 8: LABORATORY AND BLOOD TRANSFUSION SUPPORT ............................................................... 59
CEE #: AS_08_01 HIV Rapid Test Proficiency Testing (PT)/External Quality Assurance (EQA)
(National/Subnational) [LAB] .................................................................................................................. 60
CEE #: AS_08_02 CD4 Proficiency Testing (PT)/External Quality Assurance (EQA)
(National/Subnational) [LAB] ................................................................................................................. 61
CEE #: AS_08_03 HIV Viral Load Proficiency Testing (PT)/External Quality Assurance (EQA)
CEE #: AS_08_04 HIV DNA PCR (EID) Proficiency Testing (PT)/External Quality Assurance (EQA)
CEE #: AS_08_05 Sputum Smear Microscopy Proficiency Testing (PT)/External Quality Assurance (EQA)
CEE #: AS_08_06 Xpert MTB/RIF Proficiency Testing (PT)/External Quality Assurance (EQA)
(National/Subnational) [LAB] ................................................................................................................. 65
CEE #: AS_08_07 Laboratory/Point-of-Care Technology (POCT) Quality Improvement (QI) Program (
[LAB] ........................................................................................................................................................ 66
CEE #: AS_08_08 Specimen Referrals (National/Subnational) [LAB] ...................................................... 67
CEE #: AS_08_09 Quality Assurance of HIV Testing Services (National/Subnational) [LAB] .................. 68
CEE #: AS_08_10 National Blood Transfusion Service Accreditation (National) [LAB] ........................... 69
CEE #: AS_08_11 National Laboratory Strategic Plan (National) [LAB]................................................... 70
CEE #: AS_08_12 HIV Viral Load Capacity (National) [LAB] .................................................................... 71
SET 9: STRATEGIC INFORMATION: SURVEILLANCE, SURVEYS AND EVALUATION ................................. 72
CEE #: AS_09_01 Surveillance and Survey Data Collection According to National Strategy (National) [SI]
................................................................................................................................................................ 73
CEE #: AS_09_02 Surveillance and Survey Data Collection According to an Approved Protocol
(National/Subnational) [SI] ..................................................................................................................... 74
CEE #: AS_09_03 Surveillance and Survey Data Use and Availability (National/Subnational) [SI] ......... 75
SET 10: PROTECTING LIFE IN GLOBAL HEALTH ASSISTANCE (PLGHA) .................................................. 76
Pre-Assessment Checklist ....................................................................................................................... 76
CEE #: AS_10_01 Protecting Life in Global Health Assistance [PLGHA] .................................................. 77

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SET 1: HIV PLANNING, COORDINATION, AND MANAGEMENT – HEALTH

CEE # Abbreviated Title Level
Management and Planning – National National
AS_01_01
Strategic Planning -Health Sector
AS_01_02 Use of Data from Health Economics and National/Subnational
Finance studies
AS_01_03 Management and Planning-Operational Subnational
Planning
AS_01_04 Supervision – Health Sector Subnational
AS_01_05 Data Collection/Review Subnational
AS_01_06 Referrals Subnational

CEE #: AS_01_01 Management and Planning – National Strategic Planning-Health sector

(National) [PLAN MGT]
STANDARD The national authority overseeing the delivery of HIV services has a current, multi-
year HIV strategic plan that was developed in consultation with external stakeholders, based on
data, and costed.
Comment:
Question Response Scoring

Q1 Is there a national, current, multi-year HIV strategic Y N If N=Red
plan for overseeing delivery of HIV services?
Note: The plan is current if it covers the current

calendar year.
If Y, then Q2
Q2 Was the strategic plan both developed and endorsed Y N If N =Yellow
by stakeholders from relevant sectors?
If Y, then Q3
Q3 Was the strategic plan both developed and costed Y N If N=Yellow
using existing HIV output and outcome data? If Y=Green
SCORE

CEE #: AS_01_02 Use of Data from Health Economics and Finance Studies
(National/Subnational) [PLAN MGT]
STANDARD: National and Subnational health economic or finance studies involve key
stakeholders in reviewing underlying data and consuming finalized results.
Comment:

Q1 Have the economic or financial data from these Y N If N=Red
studies been reviewed by technical working
groups or relevant stakeholders?
Note: Examples of stakeholders include: Ministry

of Health officials, program managers, donor
agencies, and multilateral stakeholders.
If Y, then Q2
Q2 Have the findings of these studies been finalized Y N If N=Yellow
and disseminated to stakeholders? If Y=Green
Note: Examples of stakeholders include: Ministry

of Health officials, program managers, donor
agencies, and multilateral stakeholders.
SCORE

CEE #: AS_01_03 Management and Planning – Operational Planning (Subnational) [PLAN

MGT]
STANDARD: Sub-national entities overseeing service delivery sites have annual operational
plans that are costed and data-driven.
Comment:

Q1 Is there current annual operational plan which outlines Y N If N=Red
priorities and actions for delivering services within the
catchment area?
Note: A “current” plan was either created or updated

within the past calendar year.
If Y, then Q2
Q2 For the operational plan in question, are ALL of the # Ticked If 0-4=Yellow
following statements true?
_____ If 5=Green
Tick all that apply:
1) It was developed in collaboration with key
stakeholders who are providing a significant
quantity of services, financing, supplies and
technical assistance.
2) It includes all HIV activities being undertaken by
key stakeholders.
3) It is costed.
4) It reflects the use of existing performance and
health outcome data.
5) It includes a monitoring plan that documents
progress towards completing activities.
Note: Examples of key stakeholders include Civil Society

Organizations (CSOs), Faith-Based Organizations (FBOs),
and government facilities.
SCORE

CEE #: AS_01_04 Supervision – Health Sector (Subnational level) [PLAN MGT]

STANDARD: Sub-National health authorities use standardized tools and processes to
routinely conduct supervisory visits to at least 50% of facilities in their catchment area and
document results of supervisory visits.
Comment:

Q1 Does this sub-national health authority (e.g., District Y N If N=Red
Health Management Team) routinely visit at least 50% of
health facilities within its catchment area to supervise
health care facility staff?
Note: “Routinely” as defined in national guidelines/health

system supervision guidance
If Y, then Q2
Q2 For the supervisory visits, does this sub-national health # Ticked If 0-3=Yellow
authority? Tick all that apply:
1) Use a standardized process and schedule? _____ If 4=Green
2) Use a standardized tool?

3) Provide written feedback to the facility with
action items or recommendations to address
identified gaps and issues (e.g., through supervision
logbooks left at the site)?
4) Maintain documentation of facility visits at the
health authority’s office?
SCORE

CEE #: AS_01_05 Routine Data Collection/Review (Subnational level) [PLAN MGT]

STANDARD: Sub-National health authorities routinely and in a timely way collect, review, and
provide feedback on HIV indicator data from sites within their catchment area.
Instructions: Check the programmatic area(s) included in routinely collected HIV indicator data:
☐ (1) Adult Care & Treatment ☐ (11) Lab

☐ (2) Pediatric Care & Treatment ☐ (12) FP/HIV
☐ (3) PMTCT ☐ (13) Services for Key Populations
☐ (4) VMMC ☐ (14) Gender norms
☐ (5) HTS ☐ (15) Post-violence care
☐ (6) TB/HIV ☐ (16) Supply Chain
☐ (7) Community Care & Support ☐ (17) Blood Safety/Waste Management
☐ (8) Prevention ☐ (18) IDV/MMT
☐ (9) Condoms ☐ (19) QM/QI
☐ (10) Food & Nutrition ☐ (20) Other (specify)_____________
Comment:

Q1 Does this health authority routinely collect HIV program Y N If N =Red
indicator data in a standard format (paper or electronic)
from all sites within its catchment area per national
guidelines?
If Y, then Q2
Q2 Are HIV program indicator summaries consistently reported Y N If N=Red
on a timely basis to the next level of the health system, per
national requirements?
If Y, then Q3
Q3 Is there documentation to show that program indicator Y N If N=Yellow
summaries are reviewed for data quality by health authority If Y=Green
staff routinely throughout the reporting cycle, with
feedback to the sites reporting the data?
SCORE

CEE #: AS_01_06 Referrals (Subnational level) [PLAN MGT]

STANDARD: Sub-National entities overseeing service delivery sites have documented
processes in place to assess referral and linkage systems within their catchment area.
Instructions: Check the programmatic area(s) included in referral and linkage system overseen
by this institution:
☐ (1) Adult Care & Treatment ☐ (9) Condoms

☐ (2) Pediatric Care & Treatment ☐ (10) Food & Nutrition
☐ (3) PMTCT ☐ (11) FP/Safe Motherhood Counseling
☐ (4) VMMC ☐ (12) Services for Key Populations
☐ (5) HTS ☐ (13) Post-violence care
☐ (6) TB/HIV ☐ (14) OVC/social services
☐ (7) Community Care & Support ☐ (15) IDV/MMT
☐ (8) Prevention ☐ (16) Other (specify)______________
Comment:

Q1 Is there a systematic approach to appropriately refer If N=Red
clients to HIV services between community service Y N
providers and health facilities?
If Y, then Q2
Q2 Are there standardized referral forms in use by facility Y N If N=Yellow
and community service providers?
If Y, then Q3
Q3 Does the HIV service referral system track clients Y N If N=Yellow
receiving services and document completed referrals If Y=Green
across service providers?
SCORE

SET 2: OVC/SOCIAL SERVICES

CEE # Abbreviated Title Levels
Management and Planning – strategic planning National
AS_02_01
(Social Services) (National level) [SOC OVC]
Social Protection/Child Protection Management Subnational
AS_02_02 Information Systems (Sub-national level) [SOC
OVC]
Management and Planning – operational Subnational
AS_02_03 planning (Social Services) (Sub-national level)
[SOC OVC]
Supervision – Social Services (Sub-national level) Subnational
AS_02_04
[SOC OVC]

CEE #: AS_02_01 Management and Planning – Strategic Planning (Social Services) (National)
[SOC OVC]
STANDARD: National authority overseeing delivery of social services to children and families
affected by HIV has a current, multi-year strategic plan that was developed in consultation with
external stakeholders, is based on data and is costed.
Comment:

Q1 Is there a national, current, multi-year strategic plan for Y N If N=Red
overseeing delivery of social services to children and
families affected by HIV?
Note: The plan is current if it covers the current calendar

year. The plan may oversee delivery of social services to a
broader population but must include but must include plans
for addressing the health, education, protection, legal and
pyscho-social needs of children and families affected by
HIV, supporting case management, and supporting the
workers delivering these services)
If Y, then Q2
Q2 Was the strategic plan developed involving stakeholders Y N If N=Red
and endorsed by stakeholders from relevant sectors?
If Y, then Q3
Q3 Do All of the following apply to the strategic plan? # Ticked If 0-3=Yellow
Tick all that apply: _____ If 4=Green

1) Developed using existing social service output
and outcome evidence (including relevant health,
education, protection, and legal data)
2) Costed
3) Includes a monitoring plan that documents
progress towards completing the activities
4) Aligned with the national child protection policy
framework, and has provisions for children’s needs
and rights
SCORE

CEE #: AS_02_02 Social Protection/Child Protection Management Information Systems

(Subnational) [SOC OVC]
STANDARD: Authorities use nationally recognized OVC (including social protection/child
protection) information management systems for data collection and analysis processes.
Instructions: Select the programmatic area(s) addressed by the information management system:
☐ (A) Social protection

☐ (B) Child protection
Comment:

Q1 Does this Sub-National Unit (SNU) authority routinely Y N If N=Red
collect and submit data through an existing nationally
recognized information management system?
If Y, then Q2
Q2 Does this SNU authority have routine access to analyzed Y N If N=Yellow
data through the existing nationally recognized If Y=Green
information management system?
SCORE

CEE #: AS_02_03 Management and Planning – Operational Planning (Social Services)

(Subnational) [SOC OVC]
STANDARD: The Sub-National Unit (SNU)-level governmental or non-governmental entity
overseeing service delivery sites has a costed, data-driven annual operational plan that is developed
with, and includes services offered by, governmental and/or non-governmental service delivery
points.
Comment:
Q1 Is there a current operational plan which outlines priorities and Y N If N=Red
actions for delivering social services to children and families
affected by HIV within the catchment area of this Sub-National
Unit?
Note: The plan is “current” if it covers the current calendar year.

The plan may oversee delivery of social services to a broader
population but must include plans for addressing the health,
education, protection, legal and psychosocial needs of children
and families affected by HIV, supporting case management, and
supporting the workers delivering these services. Examples of the
catchment area include: district, province or geographical area
served by a NGO network
If Y, then Q2
Q2 For the operational plan in question, do BOTH apply? # Ticked If 0-
Tick all that apply: 1=Yellow
_____
1) Was it developed in collaboration with key stakeholders
who are providing a significant quantity of services,
financing, supplies and technical assistance?
2) Does the plan include social service activities for children
and families affected by HIV that are being undertaken by
key stakeholders?
Note: Examples of key stakeholders include: Civil Society

Organizations (CSOs), Faith-Based Organizations (FBOs), and
government facilities
If 2, then Q3
Q3 For the operational plan in question, do ALL apply? # Ticked If 0-
1) Costed _____
If 3=Green
2) Developed using existing social service output and
outcome data (including relevant health, education,
protection and legal data)
3) Include a monitoring plan that documents progress
towards completing the activities and outcomes of the plan?
SCORE

CEE #: AS_02_04 Supervision – Social Services (Subnational) [SOC OVC]

STANDARD: Sub-national unit (SNU), regional level or non-governmental social service
authorities routinely conduct supervisory visits to social service organizations in their catchment
area using standardized tools and processes.
Instructions: Check the institution type:
☐ (1) Sub-National Unit (SNU) – Level Governmental ☐ (2) Regional Unit – Level
Governmental
☐ (3) Non-government Level
Comment:
Q1 For the supervisory visits, does this SNU Social Service Office # Ticked If 0-2=Red
use ALL of the following?
Tick all that apply: _____
1) Coordinate routine visits to social service
organizations
2) A standardized process for assessing the quality of
social services
3) A standardized tool
Note: Quality can be assessed through national quality

standards for social service provision or international
standards for residential care institutions). Routinely as
defined by the social service system supervision guidance
Note: The visit may monitor the quality of services to a
broader population but must include children and families
affected by HIV
If all 3, then Q2
Q2 Does the standardized process followed by the SNU Social # Ticked If 0-1=Yellow
Service Office include BOTH?
1) Written feedback to the social service organization
with action items or recommendations to address
identified gaps and issues (e.g., through supervision
logbooks left at the site)
2) Documentation of social service visits that is
maintained at the district office
If 2, then Q3

Q3 In the last quarter, what percent of required supervision If

visits by the SNU Social Service Office were conducted and ≤80%=Yellow
documented? If >80%=
Green
_____%
Numerator: Number of required supervision visits by SNU
Social service Office conducted and documented
Denominator: Number of required supervision visits by SNU
Social Service
SCORE

SET 3: GUIDELINES AND POLICIES

AS_03_01 National Guidelines for Key Populations National
AS_03_02 Key Populations National Quality Norms National
AS_03_03 Guideline Development National
AS_03_04 Guideline Distribution Subnational
AS_03_05 WHO Guidelines for ART Initiation in Different National
Populations
AS_03_06 Data Protection Policies for Collection and Use National
of Patient Level Data
AS_03_07 Enabling Policies and Legislation National
AS_03_08 Index Testing Services in National HTS National
Guidelines

CEE #: AS_03_01 National Guidelines for Key Populations (National) [GUIDE]

STANDARD: National guidelines specific to key populations (sex workers, men who have sex
with men (MSM), Transgender persons and people who inject drugs (PWID), and persons in
closed settings) are updated on a periodic basis to reflect new evidence.
Instructions: Check the Key Populations (KP) identified in national guidelines:
☐ (1) Sex Workers ☐ (2) MSM ☐ (3) Transgender persons ☐ (4)
PWID
☐ (5) Persons in closed settings
Comment:

Q1 Is there HIV national guidelines that address Y N If N=Red
specialized KP programmatic concerns?
If Y, then Q2
Q2 Do the national guidelines include specific Y N If N=Yellow
recommendations for each of the key populations
selected above?
If Y, then Q3
Q3 Has this national guideline been updated within the Y N If N=Yellow
last 5 years? If Y=Green
SCORE

CEE #: AS_03_02 Key Populations National Quality Norms (National) [GUIDE]

STANDARD: National HIV programs set quality norms for the delivery of key population
programs to address factors unique to the vulnerability, risk and service access needs of key
populations.
Comment:

Q1 Do these key population quality norms include ALL the Y# If 0-3 = Red
following standards? Ticked
_____
1) Client confidentiality is required for all services
2) An anti-discrimination policy and code of conduct
for all services
3) People from key populations are not required to
meet specific criteria in order to access services
4) HIV services are provided at no-cost or at a cost
that is affordable
If all 4, then Q2
Q2 Do these key population quality norms include ALL the # Ticked If 0-1=Yellow
following standards?
1) Staff implementing key population services are
required to receive annual training and sensitization
to address key population needs
2) A mechanism to maintain confidential feedback
from clients is in place for services
If both boxes ticked then, then Q3
Q3 Do these key population quality norms include the minimum If 0-5=Yellow
service package per PEPFAR guidance for key populations? # Ticked
Tick all that apply: If ≥6= Green
1) Peer education and community-based outreach ___
2) Sexually Transmitted Infection (STI) prevention,

screening and treatment
3) Condoms
4) Condom-compatible lubricants
5) HIV Testing and Counseling Services (HTS)
6) Antiretroviral Therapy (ART) for all KP living with
HIV
7) Harm reduction for people who inject drugs
(PWID)
8) Reducing stigma and discrimination
SCORE

CEE #: AS_03_03 Guideline Development (National) [GUIDE]

STANDARD: Development of national guidelines is informed by multi-sectoral stakeholders and
documents key aspects of the development process that led to recommended guidelines.
Instructions: From the list below select all technical areas that are the focus of the guideline(s)
being supported by this Implementing Mechanism. Check all that apply:
☐ (A) Adult Care & Treatment ☐ (F) VMMC ☐ (K) HTS

☐ (B) Community Care & Support ☐ (G) PMTCT ☐ (L) Key Populations services
☐ (C) Pediatric Care & Treatment ☐ (H) Condoms ☐ (M) OVC/Social Service
☐ (D) Other Prevention ☐ (I) Food & Nutrition ☐ (N) IDV/MMT
☐ (E) TB/HIV ☐ (J) Post-violence care ☐ (0) Family Planning/Safe
Motherhood
Counseling
☐ (P) Other
_____________________
Use the comment section to record instructional area inconsistencies as they relate to the CEE
responses.
Comment:

Q1 During the development of national guidelines was a group # Ticked If 0=Red
convened and did it consist of the following? If 1-2=Yellow
1) Content experts from specialties involved
2) Representatives of service provider groups
3) Representatives of patients, consumers, or civil
society
Note: Development of national guidelines also includes

adoption or adaptation of international guidelines
If All 3, then Q2
Q2 For guidelines that have reached at least an initial draft # Ticked If 0-1=Yellow
stage, do they include BOTH of the following?
_____ If 2=Green
(1) A summary of the development process
(2) Specific recommendations graded according to the
evidence
SCORE

CEE #: AS_03_04 Guideline Distribution (Subnational) [GUIDE]

STANDARD: Institutions that are responsible for any aspect of guidelines distribution maintain
current copies of national guidelines and distribute them to lower-level facilities in a routine and
timely manner.
Comment:

Q1 Are current copies of all applicable HIV-related Y N If N=Red
guidelines available at this institution?
If Y, then Q2
Q2 For national guidelines received by this institution from Y N If N=Yellow
a higher level this year, were those guidelines If Y = Green
distributed to lower-level sites within 3 months of
receipt?
SCORE

CEE #: AS_03_05 WHO Guidelines for ART Initiation in Different Populations (National)
[GUIDE]
STANDARD: National HIV/AIDS technical practice should follow current WHO guidelines for
initiation of ART for all patient populations, i.e., Test and Start/Treat All.
Instructions: Only assess this CEE at the Ministry of Health or National AIDS Control Program
offices.
Comment:

Q1 Does current national HIV/AIDS technical practice follow
current WHO guidelines for initiation of ART, i.e., Test # Ticked If 0-1= Red
and Start/Treat All for each of the following
populations? Tick all that apply: _____ If 2-3=Yellow
1) Adults (>19 years)
If 4=Green
2) Pregnant and Breastfeeding Mothers
3) Adolescents (10-19 years)
4) Children (<10 years)
SCORE

CEE #: AS_03_06 Data Protection Policies for Collection and Use of Patient Level Data
(National) [GUIDE]
STANDARD: The government has policies in place that support and govern the collection of
patient-level data for health, which include use of data for public health purposes, protection of
privacy of the individual, confidentiality of the data, and use of data in criminal cases.
Instructions: Only assess this CEE at National level MOH
Comment:

Q1 Does the government/Ministry have policies in place
that support and govern the collection and appropriate # Ticked If 0-1= Red
use of patient-level data for health, including HIV/AIDS,
for all of the following? Tick all that apply: _____ If 2-3=Yellow
1) Collection of patient-level data for public health
purposes, including surveillance If 4=Green
2) Collection and use of unique identifiers such as
national ID for health records
3) Privacy and confidentiality of health outcomes
matched with personally identifiable information
4) Use of patient-level data, including protection
against its use in criminal cases
SCORE

CEE #: AS_03_07 Enabling Policies and Legislation (National) [GUIDE]

STANDARD: Policies or legislation exist that govern HIV/AIDS service delivery or health care that
is inclusive of HIV service delivery.
Instructions: Only assess this CEE at National level Ministry of Health.
Comment:

Q1 Are there policies or legislation that govern HIV/AIDS
service delivery or policies and legislation on health care, # Ticked If 0-3 = Red
which is inclusive of HIV service delivery?
_____
1) Polices that permit patients stable on ART to
have reduced ARV pickups (i.e., every 3-6 months)
2) Policies that permit streamlined ART initiation,
such as same day initiation of ART for those who
are ready
3) Polices that permit HIV self-testing
4) Policies that permit pre-exposure prophylaxis
(PrEP)
If 4, then Q2
Q2 Are there policies or legislation that govern HIV/AIDS # Ticked If 0-1 = Yellow
service delivery or policies and legislation on health care,
which is inclusive of HIV service delivery? _____ If 2 = Green

1) A task-shifting policy that allows trained non-
physician clinicians, midwives, and nurses to initiate
and dispense ART
2) A task-shifting policy that allows trained and
supervised community health workers to dispense
ART between regular clinical visits
SCORE

CEE #: AS_03_08 Index Testing Services in National HTS Guidelines (National) [Guide]
STANDARD: National HIV Testing Services (HTS) guidelines include standards on the provision
of Index testing services at the site level. These guidelines include use of a standardized index
testing curriculum to train site level providers.
Instructions: Only assess this CEE at National level Ministry of Health. This CEE can only be
assessed if national index testing guidelines exist.
Index testing, also known as partner notification or contact tracing, is defined as a voluntary
process whereby a trained provider asks an HIV-positive client about their sexual partners, drug
injecting partners, and biological children. If the HIV-positive client agrees to these services, the
trained provider then offers HTS to these partners and/or children.
Internal Notes:
Q1 Do the most recent national HIV Testing Services (HTS) Y N If N = Red

or ART guidelines include standards on the provision of
Index Testing Services (ICT) or voluntary Partner
Notification Services (PNS)?
If Y, then Q2
Q2 Is there a national standardized training curriculum for Y N If N = Red
ICT or PNS that includes the WHO 5 Cs AND how to
assess and address intimate partner violence in the
context of index testing services?
If Y, then Q3
Q3 Are there national tools for documenting the provision Y N If N = Yellow
of index testing services (e.g. an ICT register, patient If Y = Green
forms, space on an ART card, etc.?)
SCORE

SET 4: PRIVATE SECTOR ENGAGEMENT AND ADVOCACY

AS_04_01 Public-Private Partnerships National/Subnational
AS_04_02 Performance and Service Delivery National
Transparency
AS_04_03 Advocacy National/Subnational
AS_04_04 National/Subnational
Health Communication

CEE #: AS_04_01 Public-Private Partnerships (National/Subnational [PPP-ADVOCACY]

STANDARD: Maintenance of public-private partnerships (PPPs) involves regular and
systematic engagement of partners.
Comment:

Q1 In the last 12 months, do ALL of following apply? # Ticked If 0-2=Red

1) Partner meetings were held at least quarterly?
2) Partner meetings included representatives
from members of the partnership?
3) Partner meetings resulted in clearly-defined
action items?
If all 3, then Q2
Q2 Are there protocols in place for managing roles and Y N If N=Yellow
responsibilities between partners? If Y=Green
SCORE

CEE #: AS_04_02 Performance and Service Delivery Transparency (National) [PPP-

ADVOCACY]
STANDARD: The government makes HIV/AIDS program performance and service delivery
data available within 6 months after the date of programming.
Comment:

Q1 Does the government make annual HIV/AIDS program
performance and service delivery data available? A-NUM If #1= Red
Tick only one box: _____# If #2=Yellow

1) More than one year after the date of
programming If #3=Green
2) Within 6-12 months after the date of
programming
3) Within 6 months after the date of programming
SCORE

CEE #: AS_04_03 Advocacy (National/Subnational) [PPP-ADVOCACY]

STANDARD: Entities advocate for issues related to the HIV response, engage key and affected
populations in developing an advocacy plan(s) and provide feedback on implementation
progress.
Comment:

Q1 Has at least one advocacy plan been developed related to Y N If N=Red
an HIV response issue?
If Y, then Q2
Q2 Have those affected by the advocacy issue been involved Y N If N=Red
in developing the advocacy plan?
Note: Examples of those affected by advocacy include:

community representatives, civil society organizations
If Y, then Q3
Q3 Has feedback on the progress of advocacy implementation # Ticked If 0=Red
been provided in the last 12 months to the following _____ If 1-2=Yellow
stakeholders? If 3=Green

1) Civil society representatives
2) Governmental technical officials (e.g., Ministry of
Health)
3) Political authorities (e.g., elected decision makers)
SCORE

CEE #: AS_04_04 Health Communication (National/Subnational) [PPP-ADVOCACY]

STANDARD: Health communication efforts are developed and implemented using best
practice and evidence-based methods.
Comment:

Q1 Where the following activities included in the design # Ticked If 0-2=Red
of health communication materials?
_____
1) Formative research, such as primary or
secondary research, qualitative or
quantitative?
2) Identification and rationalization of audience
3) Pre-testing of messages and tools
If all 3, then Q2
Q2 Were BOTH of the following activities included in the # Ticked If 0-1=Yellow
implementation of advocacy materials for key and If 2=Green
affected populations? _____
Tick all activities that apply:

1) Informed by formative research
2) Mentioned/prioritized in the national HIV
strategy or related documents
SCORE

SET 5: HUMAN RESOURCES FOR HEALTH

AS_05_01 HRH Staffing [HRH] National/Subnational
AS_05_02 In-Service Training [HRH] National/Subnational
AS_05_03 Pre-Service Education [HRH] National
AS_05_04 HRH Regulation [HRH] National
AS_05_05 Faculty Development [HRH] National

CEE #: AS_05_01 HRH Staffing (National/Subnational) [HRH]

STANDARD: The unit responsible for Human Resources (HR) functions makes data-driven
decisions to match staffing to health data at sites over which it has oversight.
Instructions: Check if the HR unit conducts any of the following activities:
☐ (1) Staffing Allocation ☐ (2) Deployment ☐ (3) Transfers ☐ (4) Recruitment ☐ (5)
Retention
If No to All, check NA, and SKIP this CEE: ☐ NA

Comment:

Q1 Does the HR unit have access to health worker data Y N If N=Red
from an on-site manual or electronic HRH database
(i.e., HRIS)?
Q2 In the last 12 months, has the HR unit used the If 0=Red
following to guide allocation, deployment and/or # Ticked If 1=Yellow
transfer decisions for cadres working at sites offering If 2=Green
HIV services? ____
Tick all that apply.
1) Health worker data
2) Other health data (e.g., HMIS, disease burden)
SCORE

CEE #: AS_05_02 In-Service Training (National/Subnational) [HRH]

STANDARD: In-service training provider(s) for health workers utilize curricula aligned with
national norms (e.g., policies, guidelines, regulations, etc.) and PEPFAR policies on non-
discrimination, as well as processes that increase training effectiveness.
Instructions: Check the In-Service Training provider type:
☐ (1) IP Office ☐ (2) District/Regional Training Center ☐ (3) National Training/IST Unit
☐ (4) Other
From the following In-Service Training instructional area(s) please select all those offered or
coordinated by the provider and supported by this Implementing Mechanism. Check all that apply:
☐ (A) Adult Care & Treatment ☐ (H) Community Care & Support ☐ (O) Pediatric Care &
Treatment
☐ (B) PMTCT ☐ (I) VMMC ☐ (P) Prevention
☐(C) Food & Nutrition ☐ (J) HTC ☐ (Q) Post-violence
care
☐ (D) TB/HIV ☐ (K) Gender ☐ (R) Key Populations
☐ (E) Supply Chain ☐ (L) Blood Safety/Waste Management ☐ (S) Leadership &
Management
☐(F) QM/QI ☐ (M) FP/HIV ☐ (T) IDV/MMT
☐ (G) Lab ☐ (N) Other (specify in the comments field)
Use the comment section to record any instructional area inconsistencies as they relate to the
CEE responses.
Comment:

Q1 Do the in-service trainings offered by the training provider(s) # Ticked If 0-3=Red
do the following? Tick all that apply:
1) Use national curricula or are compliant with _____
national policies and guidelines
2) Use standards and regulations set by national
authorities
3) Align with national human resource plans
4) Include information on non-discrimination
Note: Examples of information on non-discrimination include

how to deliver clinically appropriate, sensitive and non-
stigmatizing care.
If all 4, then Q2

Q2 Does the in-service training provider(s) track and submit Y N If N=Yellow

data on in-service training administered to the authority
responsible for oversight of IST data?
Note: Examples of authorities responsible for oversight of

IST data include: national training coordination unit,
professional councils, and regulatory bodies.
If Y, then Q3
Q3 If the CEE is not administered at a national training # Ticked If 0-
coordinating body, ask: 1=Yellow
_____ If ≥2 =
Does the in-service training provider(s) utilize the design Green
and delivery practices listed below? (Tick all that apply from
the list below)
If the CEE is administered at a national training

coordinating body, ask:
Does the institution promote the design and delivery

practices listed below: Tick all that apply:
1) Use team-based learning and/or active

approaches and methodologies
2) Provide guidance for trainee selection
3) Use modes of delivery that reduce site
absenteeism (e.g., on-the-job, distance learning)
4) Conduct participant follow-up / post-training
evaluation
5) Apply follow-up evaluation data to improve
future training
SCORE

CEE #: AS_05_03 Pre-Service Education (National) [HRH]

STANDARD: Pre-service education for clinical and public health workers comprises competency-
based curricula, student practica at high volume HIV sites, and faculty is proficient in current HIV
methods.
Instructions: Select the pre-service education profession type(s) being supported by this
Implementing Mechanism. Check all that apply:
☐ (1) Medical Doctors ☐ (2) Nurses ☐(3) Midwives ☐(4) Clinical officers ☐ (5) Pharmacy ☐
(6) Laboratory ☐ (7) Public health ☐ (8) Paraprofessionals ☐ (9) Other
Use the comment section to record any profession type inconsistencies as they relate to the CEE
responses.
Comment:

Q1 For the pre-service program, do ALL of the following apply? # Ticked If 0-2=Red
1) The curriculum (e.g. degree program) has HIV _____
content that reflects national standards of practice
for cadres offering HIV services
2) The curriculum and course content have been
updated in the last 3 years
3) Faculty received training on the updated
curriculum or course content
If all 3, then Q2
Q2 For the pre-service program, do BOTH of the following apply? # Ticked If 0-
 1) The pre-service curriculum content is competency
_____
If 2=Green
based
 2) Students complete practica at high volume HIV
sites
SCORE

CEE #: AS_05_04 HRH Regulation (National) [HRH]

STANDARD: There is a system to register health workers and a continuing professional
development program in place.
Comment:

Q1 Is there a system to register health care Y N If N=Red
workers within their cadre?
If Y, then Q2
Q2 Is there a national continuous professional Y N If N=Yellow
development (CPD) program? If Y-Green
SCORE

CEE #: AS_05_05 Faculty Development (National) [HRH]

STANDARD: Academic institutions have a system in place to support the development of faculty
to effectively provide learners with the skills and abilities to deliver quality HIV services.
Comment:

Q1 Does this academic institution have processes in place to Y N If N=Red
determine faculty development needs?
Note: Examples of processes in place to determine faculty needs

include: needs assessment, new faculty training survey
If Y, then Q2
Q2 # Ticked If 0-1
Does this academic institution provide faculty with the =Yellow
following? Tick all that apply: _____
1) Orientation and educational training for new staff

2) Ongoing faculty development programs
If 2, then Q3
Q3 Does this academic institution have the following key factors in # Ticked
place to support the continued development of faculty? Tick If 0
all that apply: _____ =Yellow
1) Established health professional education department
(or responsible unit) that coordinates, administers, If >1=
monitors and evaluates the faculty development Green
programs
2) Budgeted internal and/or external resources to
support the continued implementation of the faculty
development plan
3) Provisions to link faculty development programs to
funding, promotion, and reward
SCORE

SET 6: COMMODITIES
AS_06_01 Supply Chain: ARVs National
AS_06_02 Data Use for ARV Distribution National/Subnational
Decision making
AS_06_03 Supervision/Monitoring for ARV National/Subnational
Supply Chain
AS_06_04 Supply Chain: Rapid Test National
Kits/Diagnostics
AS_06_05 Data Use for RTK Distribution National/Subnational
Decision making
AS_06_06 Supervision/Monitoring for RTK National/Subnational
Supply Chain
AS_06_07 Supply Chain: Food and Nutrition National
AS_06_08 Data Use for Food and Nutrition National/Subnational
Commodity Distribution Decision
making
AS_06_09 Supervision/Monitoring for Food National/Subnational
and Nutrition Supply Chain
AS_06_10 Medicines Regulatory System - National
Registration
AS_06_11 Medicines Regulatory System – National
Quality Assurance / Quality Control
AS_06_12 Medicines Regulatory System – National
Pharmacovigilance

CEE #: AS_06_01 Supply Chain: ARVs (National) [COMMODITIES]

STANDARD: National HIV programs routinely oversee the review of ARV supply requirements,
and coordinate procurements and delivery/facility ARV distribution schedules.
Comments:

Q1 Is there a group that is responsible for overseeing Y N If N=Red
forecasting and supply planning for ARVs at a national level
which meets and updates the forecast and supply plan at
least semi-annually?
If Y, then Q2
Q2 Does this group have access to data no more than 3 months Y N If N=Yellow
old for ARV stock on hand at health facilities, distribution
centers, and/or warehouses?
Note: Although not ideal, it is acceptable to have collated

data from districts if the districts have full visibility into stock
on hand.
If Y, then Q3
Q3 For all ARVs procured or donated, does the supply planning # Ticked If 0-7=Yellow
group do ALL of the following at least quarterly? If 8 = Green
_____
1) Review stock on hand and issues data (or where
available, consumption data) from facilities
2) Review stock on hand and issues data from all
appropriate warehouses
3) Update forecasted consumption
4) Estimate future funding needs/gaps for
procurement in the supply plan
5) Review delivery schedules of stakeholders
procuring/donating ARVs to ensure a continuous
supply according to desired stock levels as defined in
the supply chain system design
6) Convene relevant stakeholders and mobilize
resources
7) Coordinate facility distribution functions with
involved stakeholders
8) Monitor and evaluate logistics system performance
using fixed, national metrics (metrics from a national
PMP or another universally available document)
SCORE

CEE #: AS_06_02 Data Use for ARV Distribution Decision making (National /Subnational)
[COMMODITIES]
STANDARD: HIV programs have routine access to supply chain data and have a mechanism in
place to respond to emergency orders, to ensure a continuous supply of ARVs.
Comments:

Q1 Does the central level authority have routine access # Ticked If 0-1= Red
to BOTH of the following supply chain data for each
distribution center? Tick all that apply: _____
1) Timely data on stock on hand for all of the
relevant commodity at every distribution
center during the latest reporting period
2) Timely data on stock for all of the relevant
commodity issued to health facilities during the
last re-supply cycle/ reporting period
Note: Timely is defined as not older than 3 months or
per national standards
If 2, then Q2
Q2 Does the central level authority use supply chain data Y N If N = Yellow
to plan and implement re-positioning or
redistribution of stock between distribution centers
to avoid low stock levels and expiries or in response
to emergency orders?
If Y, then Q3
Q3 Are the logistics data on stock status of the relevant # Ticked If 0-3= Yellow
commodity and issues data routinely shared with the If 4= Green
following audiences that are not primarily concerned _____
with commodity availability, within the broader HIV
program? Tick all that apply:
1) Ministry of Health senior leadership
2) Sub-national level MOH officials
3) National stakeholders
4) Supply Chain Implementing Partners
Note: Examples of logistics data include: stock-outs,
overstocks, expiries, losses.
SCORE

CEE #: AS_06_03 Supervision/Monitoring for ARV Supply Chain (National/Subnational)

[COMMODITIES]
STANDARD: HIV programs routinely conduct supervisory and monitoring visits aimed at
mentoring health workers at facilities to improve the availability of HIV commodities.
Comments:
Question Respons Scoring

e
Q1 Does a health official at the national or subnational level Y N If N=Red
conduct quarterly visits using a standardized process on
which they have been trained to distribution centers within
the country to monitor and supervise activities related to HIV
commodity availability?
Note: Visits do not have to exclusively address HIV commodity

availability but must be capable of addressing HIV-product-
specific issues
If Y, then Q2
Q2 Does the standardized process for monitoring and # Ticked If 0-4= Yellow
supervisory visits prompt officials to mentor staff on ALL of
the following? _____
1) Record keeping
2) Complete, accurate and timely ordering and
reporting
3) Appropriate clean, well-organized with a regularly
updated inventory management system, well-
ventilated storage conditions for commodities (without
commodities on the floor but rather on shelves or
pallets)
4) Adherence to the maximum and minimum stock
levels according to national standards as found in the
national supply chain SOP/national system design to
avoid overstock, stock-outs, losses and expiries
5) Stock status and commodity availability at the site
(which is in part, due to order fill rates and on-time
delivery)
If all 5, then Q3
Q3 Are there formal groups or mechanisms (e.g., committees, Y N If N=Yellow
TWGs) for health officials to gather to discuss HIV product If Y=Green
issues that come up during the monitoring and supervisory
visits with Central Medical Store, Ministry of Health and
other related officials?
SCORE

CEE #: AS_06_04 Supply Chain: Rapid Test Kits/Diagnostics (National) [COMMODITIES]

STANDARD: National HIV programs have a group that routinely meets and reviews data to oversee
commodities forecasting and supply planning.
INSTRUCTIONS: Check the products routinely used by the national program and answer questions
for only those products which are relevant to the national program:
☐ (1) RTKs ☐ (2) CD4 ☐ (3) VL ☐ (4) EID/IVT ☐ (5) TB
Comments:
Q1 Is there a group that meets at least semi-annually and is Y N If N=Red
responsible for overseeing the forecasting and supply planning for
ALL commodities relevant to the national program (as checked
above)?
If Y, then Q2
Q2 Does the group have timely stock data (3 or fewer months old) Y N If N=Yellow
from health facilities, distribution centers and warehouses for ALL
commodities relevant to the national program (as checked above)?
If Y, then Q3
Q3 Quarterly, does the group do ALL of the following? Tick all that # Ticked If 0-7=
apply: Yellow
_____ If 8=Green
1) Review national stock levels
2) Review stock on hand and issues data from all appropriate
warehouses
3) Update forecasted consumption
4) Estimate funding needs/gaps for procurement
5) Review delivery schedules to ensure a continuous supply
according to desired stock levels and avoiding stock-outs
6) Convene relevant stakeholders and mobilize resources
7) Coordinate distribution functions with involved
stakeholders
8) Monitor and evaluate logistics system performance using
fixed, national metrics (metrics from a national PMP or
another universally available document)
SCORE

CEE #: AS_06_05 Data Use for RTK Distribution Decision making (National/Subnational)
[COMMODITIES]
place to respond to emergency orders, to ensure a continuous supply of HIV-related
commodities.
Comments:

e
Q1 Does the central level authority have routine access to BOTH of # Ticked If 0-1 = Red
the following supply chain data for each distribution center? Tick
all that apply: _____
1) Timely data on stock on hand for all of the relevant
commodity at every distribution center during the latest
reporting period
2) Timely data on stock for all of the relevant commodity
issued to health facilities during the last re-supply cycle/
reporting period
Note: Timely is defined as not older than 3 months or national

standards
If 2, then Q2
Q2 Does the central level authority use supply chain data to plan Y N If N =Yellow
and implement re-positioning or redistribution of stock between
distribution centers to avoid low stock levels and expiries or in
response to emergency orders?
If Y, then Q3
Q3 Are all of the logistics data on stock status of the relevant # Ticked If 0-3 =
commodity (e.g., stock-outs, overstocks, expiries, losses) and Yellow
issues data routinely shared with the following audiences that _____
are not primarily concerned with commodity availability, within If 4= Green
the broader HIV program? Tick all that apply:
4) Supply Chain Implementing Partner
Note: Examples of logistics data include: Stock-outs, overstocks,

expiries, losses
SCORE

CEE #: AS_06_06 Supervision/Monitoring for RTK Supply Chain (National/Subnational)

[COMMODITIES]
mentoring health workers at facilities to improve the availability of RTKs.
Comments:

e
Q1 Does a health official conduct quarterly visits using a standardized Y N If N=Red
process on which they have been trained to distribution centers to
monitor and supervise activities related to HIV commodity
availability?
Note: Visits do not have to exclusively address HIV commodity

availability but must be capable of addressing HIV-product-specific
issues
If Y, then Q2
Q2 Does the standardized process for monitoring and supervisory # Ticked If 0-
visits prompt officials to mentor staff on ALL of the following? 4=Yellow
1) Record keeping
2) Complete, accurate and timely ordering and reporting
updated inventory management system, well-ventilated
storage conditions for commodities (without commodities
on the floor but rather on shelves or pallets)
4) Adherence to the maximum and minimum stock levels
according to national standards as found in the national
supply chain SOP/national system design to avoid overstock,
stock-outs, losses and expiries
5) Stock status and commodity availability at the site (which
is in part, due to order fill rates and on-time delivery)
If all 5, then Q3
Q3 Are there formal groups or mechanisms (e.g., committees, TWGs) Y N If
at the national level for health officials to gather to discuss HIV N=Yellow
product issues that come up during the monitoring and If
supervisory visits with Central Medical Store, Ministry of Health Y=Green
and other related officials
SCORE

CEE #: AS_06_07 Supply Chain: Food and Nutrition (National) [COMMODITIES]

STANDARD: Therapeutic and supplementary foods that are procured meet local regulatory
authority and international standards for quality and safety, and are stored properly.
Comments:

Q1 Does evidence exist that therapeutic and Y N If N=Red
supplementary foods provided within the country
for treatment of severe and moderate malnutrition
meet international quality and safety standards?
If Y, then Q2
Q2 Are therapeutic and supplementary foods properly Y N If N=Yellow
stored (lockable, well-ventilated, clean storage site,
free from insects and animals, stored on pallets or
shelves, away from the sun, with an inventory
control system) before they are provided to health
facilities (in regional and central warehouses)?
If Y, then Q3
Q3 Is procurement of therapeutic and supplementary Y N If N=Yellow
foods guided by a forecast and supply plan that is If Y=Green
updated on a quarterly basis with consumption
data?
SCORE

CEE #: AS_06_08 Data Use for Food and Nutrition Commodity Distribution Decision making
(National/Subnational) [COMMODITIES]
place to respond to emergency orders, to ensure a continuous supply of HIV-related Food and
Nutrition commodities.
Comments:

Q1 Does the central level authority have routine access to # Ticked If 0-1=Red
BOTH of the following supply chain data for each
distribution center? Tick all that apply: _____
1) Timely data on stock on hand for all of the relevant
commodity at every distribution center during the
latest reporting period
2) Timely data on stock for all of the relevant
commodity issued to health facilities during the last
re-supply cycle/ reporting period
Note: Timely as defined as not older than 3 months or
national standards
If 2, then Q2
Q2 Does the central authority use supply chain data to plan and Y N If N =Yellow
implement re-positioning or redistribution of stock between
distribution centers to avoid low stock levels and expiries or
in response to emergency orders?
If Y, then Q3
Q3 Are the logistics data on stock status of the relevant # Ticked If 0-3=
commodity (e.g., stock-outs, overstocks, expiries, losses) Yellow
and issues data routinely shared with the following ____ If 4= Green
audiences that are not primarily concerned with commodity
availability, within the broader HIV program? Tick all that
apply:
4) Supply Chain Implementing Partners
Note: Examples of logistics data include: stock-outs,
overstocks, expiries, losses
SCORE

CEE #: AS_06_09 Supervision/Monitoring for Food and Nutrition Supply Chain

(National/Subnational) [COMMODITIES]
mentoring health workers at facilities to improve the availability of Food and Nutrition
commodities.
Comments:

e
Q1 Does a health official conduct quarterly visits using a Y N If N=Red
standardized process on which they have been trained to
distribution centers to monitor and supervise activities related
to HIV commodity availability?
Note: visits do not have to exclusively address HIV commodity
availability but must be capable of addressing HIV-product-
specific issues
If Y, then Q2
Q2 Does the standardized process for monitoring and supervisory # Ticked If 0-
visits prompt officials to mentor staff on ALL of the following? 4=Yellow
1) Record keeping
2) Complete, accurate and timely ordering and reporting
updated inventory management system, well-ventilated
storage conditions for commodities (without
commodities on the floor but rather on shelves or
pallets)
4) Adherence to the maximum and minimum stock
levels according to national standards as found in the
national supply chain SOP/national system design to
avoid overstock, stockouts, losses and expiries
5) Stock status and commodity availability at the site
(which is in part, due to order fill rates and on-time
delivery)
If all 5, then Q3
Q3 Are there formal groups or mechanisms (e.g., committees, Y N If N=Yellow
TWGs) at the national level for health officials to gather to If Y= Green
discuss HIV product issues that come up during the monitoring
and supervisory visits with Central Medical Store, Ministry of
Health and other related officials?
SCORE

CEE #: AS_06_10 Medicines Regulatory System - Registration (National) [COMMODITIES]

STANDARD: A country pharmaceutical product registration system is in place that can effectively
and efficiently register medicines and other health products.
Comment:

Q1 Is there national legislation for pharmaceuticals Y N If N =Red
and medical devices requiring product evaluation,
registration, and fast-tracking for products of
public health importance?
Note: Pharmaceuticals encompass: medicines,

vaccines, biologics.
Note: Specific products of particular public health

importance include ARVs and other essential
medicines and products for the HIV program.
If Y, then Q2
Q2 Does the regulatory authority accept WHO Y N If N=Yellow
prequalification or marketing authorizations from
stringent regulatory authorities (SRAs)?
If Y, then Q3
Q3 Is there at least one product registered for all of Y N If N=Yellow
the medicines recommended in the standard If Y =Green
treatment guidelines for HIV?
Note: Standard treatment guidelines may also be

known as a national treatment policy.
SCORE

CEE #: AS_06_11 Medicines Regulatory System – Quality Assurance / Quality Control

(National) [COMMODITIES]
STANDARD: Countries have a quality assurance system in place to ensure the quality of
medicines according to established pharmacopeia standards and to combat the availability of
substandard and counterfeit medicines in the national treatment policy for HIV or related
opportunistic infections.
Comment:

Q1 Is quality control testing of medicines by qualified Y N If N =Red
government or independent laboratories informed by a
sample collection strategy aligned with the medicines in
the standard treatment guidelines for HIV or related
opportunistic infections?
Note: Standard treatment guidelines may also be known
as a national treatment policy.
If Y, then Q2
Q2 Does the government have its own national drug quality Y N If N=Yellow
control laboratory, or are there existing MOUs or official
agreements with other qualified labs used by the
government for drug quality control testing?
If Y, then Q3
Q3 Did the government identify and confirm any substandard Y N If N=Yellow
or counterfeit medicines through testing that resulted in If Y=Green
regulatory or legal action?
Note: Medicines may be general or HIV-specific.
SCORE

CEE #: AS_06_12 Medicines Regulatory System – Pharmacovigilance (National)

[COMMODITIES]
STANDARD: Medicine safety surveillance (pharmacovigilance) is governed by legislation and a
national pharmacovigilance center or unit that has core structures in place.
Comment:

Q1 Does the country have specific legal provisions for medicines # Ticked If 0-4=Red
safety (pharmacovigilance) in national medicines legislation
or similar legislation? _____
AND
Is there a national pharmacovigilance center or unit with
ALL of the following?

1) Designated staff?
2) Stable basic funding?
3) A clear mandate?
4) Defined structure and roles and responsibilities?
5) An Adverse Drug Reaction (ADR) reporting form?
If all 5, then Q2
Q2 Is there a national database or system for coordination and Y N If N=Yellow
collation of pharmacovigilance data to and from
stakeholders in the country?
Note: Examples include national public health programs,
pharmacies, health care facilities, consumers, market
authorization holders/industry, safety surveillance studies.
If Y, then Q3
Q3 Have any regulatory actions been taken as the result of Y N If N =Yellow
pharmacovigilance information and/or adverse events If Y = Green
reported in the last 12 months?
SCORE

SET 7: QUALITY MANAGEMENT

Quality Management/Quality Improvement National/Subnational
AS_07_01
(QM/QI) System [QM]
Quality Management/Quality Improvement National/Subnational
AS_07_02
(QM/QI) Consumer Involvement [QM]
Quality Assurance: Voluntary Medical Male National/Subnational
AS_07_03
Circumcision (VMMC) [QM]

CEE #: AS_07_01 Quality Management/Quality Improvement (QM/QI) System

(National/Subnational) [QM]
STANDARD: The national HIV program or sub-national unit has a QM/QI system with
dedicated leadership, a budget line item for the QM program, peer learning opportunities, and
a current QM/QI plan.
Instructions: Check the programmatic area(s) included in the QM/QI system:
☐ (1) Adult Care & Treatment ☐ (11) Services for Key Populations
☐ (2) Pediatric Care & Treatment ☐ (12) IDV/MMT
☐ (3) PMTCT ☐ (13) Gender
☐ (4) VMMC ☐ (14) Post-violence care
☐ (5) HTS ☐ (15) OVC/Social Service
☐ (6) TB/HIV ☐ (16) Lab
☐ (7) Community Care & Support ☐ (17) Supply Chain
☐ (8) Prevention ☐ (18) Blood Safety
☐ (9) Food & Nutrition ☐ (19) Other (specify)______________________
☐ (10) FP/HIV
Comment:

Q1 Is there a QM/QI system in place for all supported # Ticked If 0-2=Red
programmatic areas with all of the following:
1) Dedicated leadership _____
2) Budget line item for the QM program

3) Peer learning opportunities available to site QA
participants to gain insights from other sites and
interventions?
If all 3, then Q2
Q2 Is there a current QM/QI plan? Y N If N=Yellow
If Y=Green
Note: The plan may be HIV program-specific or include
HIV program-specific elements in a national health
sector QM/QI plan. “Current” means updated within the
last 2 years.
SCORE

CEE #: AS_07_02 Quality Management/Quality Improvement (QM/QI) Consumer

Involvement (National/Subnational) [QM]
STANDARD: Consumers of health services formally engage in the functioning of the QM/QI
program.
Comment:

Q1 Is there a system in place to solicit feedback from Y N If N=Red
consumers in the QM/QI system?
Note: Patients are consumers.

If Y, then Q2
Q2 Is there a formal, documented process for ongoing Y N If N=Yellow
and systematic participation of consumers in the If Y=Green
QM/QI system?
Note: Participation might be through focus groups,

surveys, or in-depth interviews.
SCORE

CEE #: AS_07_03 Quality Assurance: VMMC (National/Subnational) [QM]

STANDARD: The national VMMC program should have a national or subnational-level quality
assurance (QA) body that regularly reviews VMMC service quality and safety outcomes data.
Comment:

Q1 Does the QA committee or body regularly convene Y N If N=Red
(e.g., quarterly, monthly, weekly)?
Note: As evidenced by reviewing the meeting minutes
on file over the previous 3 months
If Y, then Q2
Q2 Does this committee or body regularly review site, Y N If N=Yellow
regional and/or national VMMC adverse event
outcomes?
Note: As evidenced by reviewing the meeting minutes
on file over the previous 3 months
If Y, then Q3
Q3 Is there written documentation indicating that the Y N If N = Yellow
committee or body reviews and calculates rates of
moderate and severe adverse events at the site, If Y = Green
regional, and/or national levels, and uses this data for
program improvement?
Note: Shown in the meeting minutes or summary
report on file over the previous 3 months
SCORE

SET 8: LABORATORY AND BLOOD TRANSFUSION SUPPORT

CEE # Abbreviated Title Level
HIV Rapid Testing Proficiency Testing National/Subnational

AS_08_01
(PT)/External Quality Assurance (EQA)
AS_08_02 CD4 Proficiency Testing (PT)/External National/Subnational
Quality Assurance (EQA)
AS_08_03 HIV Viral Load Proficiency Testing National/Subnational
AS_08_04 HIV DNA PCR (EID) Proficiency Testing National/Subnational
AS_08_05 Sputum Smear Microscopy Proficiency National/Subnational
Testing (PT)/External Quality Assurance
(EQA)
AS_08_06 Xpert MTF/RIF Proficiency Testing National/Subnational
AS_08_07 Laboratory/Point-of-Care Technology National/Subnational
(POCT) Quality Improvement (QI)
Program
AS_08_08 Specimen Referrals National/Subnational
AS_08_09 Quality Assurance of HIV Testing National/Subnational

Services
AS_08_10 National Blood Transfusion Service National
Accreditation
National
AS_08_11 National Laboratory Strategic Plan
National/Subnational
AS_08_12 HIV Viral Load Capacity

CEE #: AS_08_01 HIV Rapid Test Proficiency Testing (PT)/External Quality Assurance (EQA)
(National/Subnational) [LAB]
STANDARD: The PT/EQA Program provides PT panels or engages in other EQA activities, collects
PT/EQA results from at least 90% of participating laboratories/sites, and provides feedback to all
sites according to the schedule set by the program.
Instructions: Assess this CEE at programs that support HIV Rapid Testing PT/EQA activities.
Comment:

Q1 In the last 12 months, has the PT/EQA Program sent out PT Y N If N=Red
panels or engaged in EQA activities to all enrolled sites
according to the schedule set by the program?
If Y, then Q2
Q2 In the last 12 months, what percentage of enrolled sites If <90%=Yellow
has returned PT/EQA results to the PT/EQA Program within _____%
the schedule set by the program?
Numerator: # of enrolled sites which returned PT/EQA

results
Denominator: # of enrolled sites
If ≥90%, then Q3
Q3 In the last 12 months, has the PT/EQA Program provided # Ticked If 0-1=Yellow
reports, documented feedback, or corrective action on the
results of the PT/EQA? Tick all that apply: _____ If 2= Green
1) To all enrolled sites, including to sites that did
not return results?
2) Within the schedule set by the program?
SCORE

CEE #: AS_08_02 CD4 Proficiency Testing (PT)/External Quality Assurance (EQA)

Assess this CEE at programs that support CD4 PT/EQA activities
Comment:

Q1 In the last 12 months, has the PT/EQA Program sent out Y N If N=Red
PT panels or engaged in EQA activities to all enrolled sites
If Y, then Q2
has returned PT/EQA results to the PT/EQA Program _____%
within the schedule set by the program?
Numerator = # of enrolled sites which returned PT/EQA

results
Denominator = # of enrolled sites
If ≥90%, then Q3
reports, documented feedback, or corrective action on
the results of the PT/EQA? Tick all that apply: _____ If 2= Green
(1) To all enrolled sites, including to sites that did
not return results?
(2) Within the schedule set by the program?
SCORE

CEE #: AS_08_03 HIV Viral Load Proficiency Testing (PT)/External Quality Assurance (EQA)
Instructions: Assess this CEE at programs that support HIV Viral Load PT/EQA activities
Comment:

If Y, then Q2
Q2 In the last 12 months, what percentage of enrolled sites has If
returned PT/EQA results to the PT/EQA Program within the _____% <90%=Yellow
schedule set by the program?
Numerator = ______# of enrolled sites which returned

PT/EQA results
Denominator = ______# of enrolled sites
If ≥90%, then Q3
1) To all enrolled sites, including to sites that did not
return results?
SCORE

CEE #: AS_08_04 HIV DNA PCR (EID) Proficiency Testing (PT)/External Quality Assurance
(EQA) (National/Subnational) [LAB]
STANDARD: The PT/EQA Program provides PT panels or engages in other EQA activities,
collects PT/EQA results from at least 90% of participating laboratories/sites, and provides
feedback to all sites according to the schedule set by the program.
Instructions: Assess this CEE at programs that support HIV DNA PCR (EID) PT/EQA activities
Comment:

e
Q1 In the last 12 months, has the PT/EQA Program sent out Y N If N=Red
PT panels or engaged in EQA activities to all enrolled
sites according to the schedule set by the program?
If Y, then Q2
has returned PT/EQA results to the PT/EQA Program _____%
within the schedule set by the program?

PT/EQA results
Denominator = ______# of enrolled sites
If ≥90%, then Q3
reports, documented feedback, or corrective action on
the results of the PT/EQA? Tick all that apply: _____ If 2= Green
(1) To all enrolled sites, including to sites that
did not return results?
SCORE

CEE #: AS_08_05 Sputum Smear Microscopy Proficiency Testing (PT)/External Quality Assurance
(EQA) (National/Subnational) [LAB]
Instructions: Assess this CEE at programs that support Sputum Smear Microscopy PT/EQA
activities
Comment:

If Y, then Q2
Numerator = _______# of enrolled sites which returned

PT/EQA results
Denominator = _______# of enrolled sites
If ≥90%, then Q3
1) To all enrolled sites, including to sites that did
not return results?
SCORE

CEE #: AS_08_06 Xpert MTB/RIF Proficiency Testing (PT)/External Quality Assurance (EQA)
Instructions: Assess this CEE at programs that support Xpert MTB/RIF PT/EQA activities
Comment:

If Y, then Q2

PT/EQA results
Denominator = _______# of enrolled sites
If ≥90%, then Q3
(1) To all enrolled sites, including to sites that did
not return results?
SCORE

CEE #: AS_08_07 Laboratory/Point-of-Care Technology (POCT) Quality Improvement (QI)

Program ( [LAB]
STANDARD: Implementation of national QI Programs for laboratory and POCT leads to
measurable QI progress in at least 75% of participating laboratories or testing sites.
Comment:

Q1 Has a plan for implementation of the laboratory/POCT QI Y N If N=Red
program been developed?
If Y, then Q2
Q2 What percent of the laboratories/POCT sites participating in If <75% =
the QI Program have achieved measurable QI progress? _____% Yellow
Numerator= ______# of enrolled sites with measurable QI If ≥75% = Green

progress
Denominator = _____# of sites enrolled in QI program
Note: Examples of measurable QI progress include:

accreditation, certification, or other documentation of
achievement towards QI goals
SCORE

CEE #: AS_08_08 Specimen Referrals (National/Subnational) [LAB]

STANDARD: Programs for specimen referral/result reporting have a defined specimen
transportation schedule and standardized procedures for safe operations, ensuring that sites
receive at least 80% of test results.
Comment:

e
Q1 Does the specimen referral/result reporting network have a Y N If N=Red
defined transportation schedule?
If Y, then Q2
Q2 Are there standardized procedures for ALL of the following: # Ticked If 0-2= Red

1) Safe specimen packaging and transport?
2) Specimen tracking
3) Test results delivery
If all 3, then Q3
Q3 What percent of laboratory test results arrive at HIV service If <80% = Yellow
delivery sites within the target turnaround time from
specimen collection to time of result receipt? If ≥80% = Green
____%
Numerator = ____ # of HIV service delivery sites that
receives results with the target turnaround time
Denominator =____ # of HIV service delivery sites that

collect and send specimens for testing referral
SCORE

CEE #: AS_08_09 Quality Assurance of HIV Testing Services (National/Subnational) [LAB]

STANDARD: The HIV Rapid Test Quality Improvement (QI) Program monitors the quality of HIV
rapid testing including the use of standardized laboratory logbooks, verifying the quality of HIV
rapid test kits, and regularly documented site visits to testing sites.
Comment:

Q1 Is there a process by the HIV Rapid Test QI program to Y N If N =Red
ensure that data from the HTS rapid testing logbooks at
the HIV testing sites gets reported and reviewed on a
quarterly basis?
If Y, then Q2
Q2 Is each new batch/lot of HIV rapid test kits verified for Y N If N=Yellow
quality before release to sites?
If Y, then Q3
Q3 Do HIV rapid test program supervisors conduct and Y N If N=Yellow
document site visits at least semi-annually to assess the
quality of HIV testing at the sites y? If Y = Green
SCORE

CEE #: AS_08_10 National Blood Transfusion Service Accreditation (National) [LAB]

STANDARD: Blood transfusion services have a roadmap to achieve accreditation from a regional
or internationally-recognized blood service accrediting body.
Comment:

Q1 Has the National Blood Transfusion Service (NBTS) Y N If N=Red
identified an appropriate blood banking accrediting body?
If Y, then Q2
Q2 Has the NBTS completed a pre-accreditation self- Y N If N=Red
assessment process outlined by the identified accrediting
body?
If Y, then Q3
Q3 Has the NBTS produced an accreditation roadmap based Y N If N=Yellow
on gaps identified through the self-assessment?
Note: The roadmap will be used to direct external technical

assistance activities and frame the use of any bi-lateral
COP funding.
If Y, then Q4
Q4 Is there evidence that NBTS is making progress towards Y N If N=Yellow
remediating issues or gaps identified in the roadmap?
If Y, then Q5
Q5 What percentage of the total number of NBTS blood If <50%=Yellow
centers has achieved accreditation?
If ≥50%= Green
Numerator: Number of NBTS blood centers that achieved ____%
accreditation
Denominator: Number of NBTS blood centers

SCORE

CEE #: AS_08_11 National Laboratory Strategic Plan (National) [LAB]

STANDARD: A National Laboratory Strategic Plan has been developed, approved, costed and
implemented.
Instructions: Assess this CEE at the Ministry(s) and Partners supporting Ministry(s) to develop a
National Laboratory Strategic Plan
Comment:

Q1 Has a National laboratory Strategic plan been developed?
Y N If N=Red
Note: If the national strategic plan is under development,
then select No
If Y, then Q2
Q2 Which of the following most accurately reflect the status of # Ticked If 0-2=Yellow
the National Laboratory Strategic Plan?
______ If 3=Green
1) The National Laboratory Strategic has been
approved
2) The National Laboratory Strategic plan has been
costed
3) The National Laboratory Strategic plan has been
implemented
SCORE

CEE #: AS_08_12 HIV Viral Load Capacity (National) [LAB]

STANDARD: Nationally, there is laboratory capacity to provide HIV viral load testing to meet the
expected needs (per number of PLHIV) and reach sustained epidemic control.
Instructions: Assess this CEE at Ministries and Partners providing support for HIV Viral Load testing
scale-up.
Comment:

Q1 Is there laboratory capacity to provide for HIV viral load
testing that includes all of the following? # Ticked If 0-1= Red
Tick all that apply: _____ If 2-3=Yellow

1) Adequate number of HIV viral load testing
laboratories and efficient laboratories networks to If 4=Green
provide testing to all PLHIV
2) Adequate number of HIV viral load Instruments at
each laboratory to test the expected number of PLHIV
3) Support for Instrument maintenance and supply
chain systems to prevent HIV viral load testing
interruption.
4) Laboratory Information Management Systems for
specimen and result management and provide data on
HIV viral load testing capacity.
SCORE

SET 9: STRATEGIC INFORMATION: SURVEILLANCE, SURVEYS AND

EVALUATION
CEE# Abbreviated Title Levels
AS_09_01 Surveillance and Survey Data Collection National
According to National Strategy
AS_09_02 Surveillance and Survey Data Collection National/Subnational
According to an Approved Protocol
AS_09_03 Surveillance and Survey Data Use and National/Subnational
Availability

CEE #: AS_09_01 Surveillance and Survey Data Collection According to National Strategy
(National) [SI]
STANDARD: The surveillance unit (or designated entity) collects surveillance and survey data
per the national HIV Surveillance and Survey Strategy.
Comment:

Q1 Is there a written national HIV Surveillance and Survey Y N If N=Red
Strategy, based on current epidemiological data from
the in-country HIV epidemic?
If Y, then Q2
Q2 Does the unit collect HIV surveillance and survey data Y N If N=Yellow
among population groups and geographic locales
specified in the national HIV Surveillance and Survey If Y=Green
Strategy?
SCORE

CEE #: AS_09_02 Surveillance and Survey Data Collection According to an Approved

Protocol (National/Subnational) [SI]
STANDARD: The surveillance unit (or designated entity) collects and reviews HIV surveillance
and survey data according to technical standards included in approved protocols.
Comments:

Q1 Were all HIV surveillance and survey protocols approved Y N If N=Red
by an in-country institutional review board prior to the
start of field implementation?
If Y, then Q2
Q2 Within the last year, did the surveillance unit collect all Y N If N=Red
HIV surveillance and/or survey data in accordance with
technical protocols?
If Y, then Q3
Q3 Were data collected for HIV surveillance and surveys Y N If N=Yellow
conducted within the last year reviewed for quality by a
member of the surveillance unit staff? If Y=Green
SCORE

CEE #: AS_09_03 Surveillance and Survey Data Use and Availability (National/Subnational) [SI]
STANDARD: The surveillance unit (or designated entity) ensures that surveillance and survey
reports are made available to stakeholders and the general public, and are used within the
same year for HIV program planning and improvement.
Comments:

Q1 Are HIV surveillance and survey reports highlighting key Y N If N=Red
results made available to stakeholders and the general
public within 12 months of completion of data
collection and field implementation?
If Y, then Q2
Q2 Does the surveillance unit ensure that the most recent Y N If N=Yellow
available HIV surveillance and survey data are used
within the same year for all HIV program planning and If Y=Green
improvement?
SCORE

SET 10: PROTECTING LIFE IN GLOBAL HEALTH ASSISTANCE (PLGHA)

Pre-Assessment Checklist
Instructions:
The following questions are designed to help SIMS Assessors determine whether the PLGHA policy applies
to the Implementing Mechanism being assessed during the Above-Site SIMS visit.
All implementing agencies and partners are expected to conduct agency-specific compliance monitoring
activities at the site-level in addition to monitoring PLGHA policy compliance with this above-site CEE. This
module is part of each PEPFAR implementing agency’s broader processes related to ensuring compliance
with the PLGHA policy.
Which mechanisms are subject to the PLGHA policy?
• PLGHA APPLIES to foreign non-governmental organizations (NGOs) receiving an award or sub-

award of U.S. global health assistance, including PEPFAR funds and commodities. A foreign NGO
is defined as a for-profit (commercial) or not-for-profit non-governmental organization that is not
organized under the laws of the United States.
• U.S. NGOs are NOT subject to the terms of the policy, but U.S. NGOs are required to pass down
the policy’s requirements to foreign sub-recipients of global health assistance.
• The PLGHA policy also does NOT apply to foreign governments or parastatals, or to public
international organizations and other multilateral entities in which sovereign nations participate.
• The policy applies to ALL cooperative agreements, grants, and grants under contract that provide
global health assistance. The policy DOES NOT currently apply to contracts.
NOTE: The course, entitled Protecting Life in Global Health Assistance and Statutory Abortion
Restrictions is available through the GH E-Learning Center and can be accessed using the link below.
https://www.globalhealthlearning.org/course/protecting-life-global-health-assistance-and-statutory
Question Response Use of CEE

1 Is this award with a foreign government Y N If Y = STOP
or a parastatal organization? If N = PROCEED
2 Is this award with a public international Y N If Y = STOP
organization or another multilateral (i.e. If N = PROCEED
WHO, UNAIDS, Global Fund) entity in
which sovereign nations participate?
3 Is this award a contract? Y N If Y = STOP
If N = PROCEED
4 Does this implementing mechanism have Y N If Y = PROCEED
the Protecting Life in Global Health If N = STOP
Assistance Standard Provision in its
award?

CEE #: AS_10_01 Protecting Life in Global Health Assistance [PLGHA]

STANDARD: All partners subject to the PLGHA policy are implementing the policy as required
and have systems in place to ensure compliance with the policy.
Instructions: PLGHA applies to foreign non-governmental organizations (NGOs) receiving an
award or sub-award U.S. global health assistance, which includes PEPFAR funds and
commodities. U.S. NGOs are not subject to the terms of the policy, but U.S. NGOs are required
to pass down the policy’s requirements to foreign sub-recipients of global health assistance. A
foreign NGO is defined as a for-profit (commercial) or not-for-profit non-governmental
organization that is not organized under the laws of the United States.
The PLGHA policy also does not apply to foreign governments or parastatals, or to public
international organizations and other multilateral entities in which sovereign nations
participate. The policy applies to cooperative agreements, grants, and grants under contract
that provide global health assistance. The policy does not currently apply to contracts.
The PLGHA standard provision requires that, prior to furnishing global health assistance to a
foreign NGO sub-recipient (e.g. through a new sub-award that provides global health
assistance, or an amendment of an existing sub-award that provides global health assistance
to add any new U.S. government funding), the recipient must ensure that such sub-award
includes the PLGHA standard provision. Furnishing health assistance does not include the
procurement of goods or services from an organization. The term “applicable” below refers to
sub-awards subject to the policy.
Therefore, these questions should be asked of both U.S. and foreign NGO partners receiving
global health funding through USG assistance mechanisms (i.e. grants and cooperative
agreements).
Is this implementing mechanism currently subject to the Protecting Life in Global Health
Assistance Standard Provision (use checklist on previous page to determine if the mechanism
is subject to the policy)?
If NO, check NA, and SKIP this CEE.
NA ☐
Comment:
Q1 Do you ensure that the PLGHA standard provision is Y N If N = Red

included in applicable global health sub-awards with
foreign NGO sub-recipients to whom you furnish global
health assistance (e.g. when you issue a new health sub-
award to a foreign NGO, or when you provide additional
funds to an existing health sub-award to a foreign NGO)?

If Y, then Q2
Q2 Do you ensure that relevant project staff, including Y N If N = Yellow

applicable sub-partners, are trained on or oriented to the
PLGHA policy requirements (eg: through the eLearning
course or in-person)?
If Y, then Q3
Q3 Does the project have procedures or plans in place for Y N If N = Yellow

conducting compliance monitoring of the PLGHA policy as
applicable, including how to respond to potential If Y = Green
vulnerabilities or violations?
SCORE

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S MS

SITE IMPROVEMENT THROUGH

FY21 ABOVE-SITE ASSESSMENT TOOL

Version 4.1, 15 August 2020

SIMS is a quality assurance tool used to monitor and

Goals of SIMS 4.0

 Tailored, nimble, responsive site selection and

Set Names and Required vs. Elective Status

Set Name Set # Required Elective

Description of SIMS Assessment Types and Assessment Tool Composition

Assessment Tool Assessment Type Conducted CEEs to be Assessed

Explanation of Icons in the SIMS Assessment Tools

Icon Description of Icon Explanation

Eyes Question requires visual inspection of documents,

Pink Square Question requires Chart or register review

FY 21 SIMS Above Site Assessment Tool, Version 4.1 2

Gray Circle Question requires Materials review

Blue Triangle Question requires Document review

Description of Final CEE Scores

COLOR (# score) DESCRIPTION

FY 21 SIMS Above Site Assessment Tool, Version 4.1 3

FY 21 SIMS ABOVE-SITE ASSESSMENT TOOL

SET 1: HIV PLANNING, COORDINATION, AND MANAGEMENT – HEALTH ..............................................8

FY 21 SIMS Above Site Assessment Tool, Version 4.1 4

SET 4: PRIVATE SECTOR ENGAGEMENT AND ADVOCACY ................................................................... 30

FY 21 SIMS Above Site Assessment Tool, Version 4.1 5

CEE #: AS_07_01 Quality Management/Quality Improvement (QM/QI) System (National/Subnational)

FY 21 SIMS Above Site Assessment Tool, Version 4.1 6

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FY 21 SIMS Above Site Assessment Tool, Version 4.1 7

SET 1: HIV PLANNING, COORDINATION, AND MANAGEMENT – HEALTH

FY 21 SIMS Above Site Assessment Tool, Version 4.1 8

CEE #: AS_01_01 Management and Planning – National Strategic Planning-Health sector

Question Response Scoring

Note: The plan is current if it covers the current

FY 21 SIMS Above Site Assessment Tool, Version 4.1 9

Question Response Scoring

Note: Examples of stakeholders include: Ministry

Note: Examples of stakeholders include: Ministry

FY 21 SIMS Above Site Assessment Tool, Version 4.1 10

CEE #: AS_01_03 Management and Planning – Operational Planning (Subnational) [PLAN

Question Response Scoring

Note: A “current” plan was either created or updated

Note: Examples of key stakeholders include Civil Society

FY 21 SIMS Above Site Assessment Tool, Version 4.1 11

CEE #: AS_01_04 Supervision – Health Sector (Subnational level) [PLAN MGT]

Question Response Scoring

Note: “Routinely” as defined in national guidelines/health

2) Use a standardized tool?

FY 21 SIMS Above Site Assessment Tool, Version 4.1 12

CEE #: AS_01_05 Routine Data Collection/Review (Subnational level) [PLAN MGT]

☐ (1) Adult Care & Treatment ☐ (11) Lab

Question Response Scoring

FY 21 SIMS Above Site Assessment Tool, Version 4.1 13

CEE #: AS_01_06 Referrals (Subnational level) [PLAN MGT]

☐ (1) Adult Care & Treatment ☐ (9) Condoms

Question Response Scoring

FY 21 SIMS Above Site Assessment Tool, Version 4.1 14

SET 2: OVC/SOCIAL SERVICES