National M&E Guidelines for HIV Programs

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national monitoring and
evaluation guidelines and
standard operating procedures
(pillar one)

NATIONAL MONITORING AND EVALUATION (M&E) GUIDELINES
AND STANDARD OPERATING PROCEDURES : Pillar 1
August 2011
Development of this National Monitoring and Evaluation (M&E) Guidelines and Standard Operating Procedures: Pillar 1
was supported by the Department of Health and Human Services / Centers for Disease Control and Prevention Division
of Global HIV/AIDS Coorperative Agreement 1U2GPS001805-01. Its contents are solely the responsibility of the authors
and do not necessarily represent the official views of CDC.

5National Monitoring And Evaluation (M&E) Guidelines And Standard Operating Procedures
foreword
The implementation of the Kenya National AIDS Strategic Plan (KNASP II) was guided by the National AIDS
Control Council’s (NACC) goals, visions, and targets. While the KNASP II has been implemented successfully,
various challenges were experienced in this process, especially with regard to HIV information. Various
assessments conducted by stakeholders reveal similar inadequacies in monitoring and evaluation of HIV
activities. Among the key challenges noted have been the lack of guidelines for conducting HIV M&E
activities, existence of parallel data collection and reporting systems which do not seem to interact with
each other, minimal provision of feedback to decentralized levels on data reported which has led to
little use of data in program improvement. Further, the lack of clear guidelines and standard operating
procedures for fundamental M&E activities was a major impediment to the production of quality data that
could be analyzed to produce relevant information for program improvement.
It is with this in mind that the National Monitoring and Evaluation Guidelines and Standard Operating
Procedures:Pillar 1 were developed. Through a highly consultative process that included representatives
from GOK (NACC, NASCOP, HIS, DLTLD, NBTS, NHRL, KMTC, KNH, Moi University), development partners
(CDC, USAID and UNDP) and implementing partners (Afriafya, AIDS Relief, AMPATH, AMREF, BAARA, Danya
International, FHI, Futures Group, HS2020, ICAP,ICF Macro, ITECH, JHPIEGO, LVCT) with a diverse range of
participants including Community Health Workers, Nurses, HRIOs, DHMT and PHMT members, program
and M&E officers and advisers, the National Monitoring and Evaluation Guidelines and Standard Operating
Procedures represent the collective M&E knowledge and information from all sectors that are pertinent
to the current situation in Kenya. Using relevant GOK documents as the basis for the development, this
document provides linkages with other agencies and expounds on the information that is currently within
the domain of the user.
By clearly articulating the M&E roles and responsibilities of each individual, the document reduces
ambiguity and allows all stakeholders to interact harmoniously. Further, SOPs provide step-by-step
information on how to carry out each activity, with additional M&E capacity building conducted
through the National Curriculum for Monitoring and Evaluation of HIV Response in Kenya. Successful
implementation of the national M&E guidelines is expected to provide more accurate, complete and timely
HIV data that will be used at all levels, from the community to the national level, to inform better HIV
program response leading to better outcomes for Kenya.
Dr. S. K. Sharrif, MBS,M.Med, Msc Dr. F. Kimani
Director for Public Health and Sanitation Director for Medical Services
Ministry of Public Health and Sanitation Director of Medical Services

6 National Monitoring And Evaluation (M&E) Guidelines And Standard Operating Procedures 7National Monitoring And Evaluation (M&E) Guidelines And Standard Operating Procedures
preface
The National AIDS and STI Control Program is the arm of the government that has been tasked with
coordinating the Health Sector HIV M&E activities under Pillar 1 of the Kenya National AIDS Strategic Plan III
(KNASP), 2009/10 – 2013/14. This includes providing relevant Health Sector HIV monitoring and evaluation
data in response to the various national and international requirements in an effort to determine the
level of achievement towards mitigating the HIV pandemic. However, despite the fact that the majority of
indicators informing the KNASP are derived from the health sector, there was a huge challenge in ensuring
the timeliness, accuracy and completeness of the data. One of the major impediments cited for this was
the lack of clearly articulated M&E guidelines to operationalize the national KNASP M&E and research
framework.
The rationale for this document, therefore, is to provide clear guidance on the roles and responsibilities of
the various HIV stakeholders that contribute to Pillar 1 structure. Specifically, the document articulates the
M&E roles of key personnel within the following levels:
1. Community Level
2. Facility Level
3. District Level
4. Provincial Level
5. National Level
The M&E guidelines are complemented by the standard operating procedures (SOPs) that give the step-by-
step process for conducting specific M&E activities including:
1. Data Collation
2. Data Validation and Cleaning
3. Supportive Supervision
4. Integrated Supportive Supervision Checklist
5. Presentation and Dissemination
6. Data Storage and Retrieval
With support from all stakeholders, this document should be widely distributed and implemented to
ensure that HIV data management and use are streamlined throughout the country. By incorporating the
M&E principles outlined within the document in our HIV programs, there is no doubt that the information
obtained will be credible and lead to better HIV outcomes for Kenya.
acknowledgment
The development of this document was as a result of team work and a consultative process involving many
stakeholders. We would like to thank the Head of the National AIDS and STD Control Programme, Dr.
Nicholas Muraguri, and Dr. Davies Kimanga, the NASCOP Monitoring & Evaluation and Research Unit, for
their leadership throughout the development of this document especially during the numerous workshops.
We wish to acknowledge the participation of representatives from other government departments
and organizations, especially the National AIDS Control Council (NACC), the Health Information System
(HIS), the Division of Leprosy, Tuberculosis and Lung Disease (DLTLD), National Public Health Reference
Laboratory (NPHLS), Moi University, Kenya Medical Training College (KMTC), and Kenyatta National Hospital
(KNH). Many thanks to all the representatives from the implementing partners who also put in hard work
towards the development of this document including Afriafya, AIDS Relief, AMPATH, AMREF, BAARA,
Danya International, FHI, Futures Group, HS2020, ICAP,ICF Macro, ITECH, JHPIEGO, LVCT, among others. A
comprehensive list of all workshop participants is included in the annex.
Appreciation is extended to the ADAM Consortium for facilitating the development of this National
Monitoring and Evaluation Guidelines and Standard Operating Procedures: Pillar 1 document, which was
made possible through the financial and technical support of CDC.

acronyms
AIDS Acquired Immunodeficiency Virus
CHC Community Health Committee
CHEW Community Health Extension Worker
CHW Community Health Worker
CORP Community-Own Resource Person
DASCO District AIDS and STI Coordinator
DCO District Clinical Officer
DHMB District Health Management Board
DHRIO District Health Records Information Officer
DHMT District Health Management Team
DTLC District Tuberculosis and Leprosy Coordinator
DLTLD Division of Leprosy, Tuberculosis and Lung Disease
DMLT District Medical Laboratory Technologist
GOK Government of Kenya
HIS Health Information System
HIV Human Immunodeficiency Virus
HMT Hospital Management Team
KARSCOM Kenya HIV and AIDS Research and Coordination Mechanism
KEPH Kenya Essential Packages for Health
KNASP Kenya National AIDS Strategic Plan
M&E Monitoring and Evaluation
MCH Maternal and Child Health
MOH Ministries of Health
MOMS Ministry of Medical Services
MOPHS Ministry of Public Health and Sanitation
NACC National AIDS Control Council
NASCOP National AIDS and STI Control Program
NPHLS National Public Health Laboratory Services
PCO Provincial Clinical Officer
PHMT Provincial Health Management Team
PHRIO Provincial Health Records Information Officer
PASCO Provincial AIDS and STI Coordinator
PMLT Provincial Medical Laboratory Technologist
PTLC Provincial Tuberculosis and Leprosy Coordinator
RH Reproductive Health
UNAIDS Joint United Nations Programme on HIV/AIDS
VHC Village Health Committee
table of contents
1. INTRODUCTION 10
2. BACKGROUND: SUPPORTING DOCUMENTS
A. Organizing Framework for a Functional National Monitoring and 12
Evaluation System 12
B. Kenya National AIDS Strategic Plan III (KNASP III) 15
C. KNASP III M&E and Research Framework 16
D. Health Sector Indicator and Standard Operating Procedure Manual 17
E. Taking the Kenya Essential Packages for Health to the
Community: A Strategy for the Delivery of Level One Services 18
F Report on Organizational HIV Monitoring and Evaluation Capacity
Rapid Needs Assessment (RNA) 19
3. MONITORING AND EVALUATION ACTIVITIES AT THE COMMUNITY,
FACILITY, DISTRICT, PROVINCIAL AND NATIONAL LEVELS 20
A. COMMUNITY LEVEL HIV M&E ACTIVITIES 20
B. FACILITY LEVEL HIV M& E ACTIVITIES 22
C. DISTRICT LEVEL HIV M&E ACTIVITIES 25
D. PROVINCIAL LEVEL HIV M&E ACTIVITIES 28
E. NATIONAL LEVEL M&E ACTIVITIES 31
F. ROLE OF STAKEHOLDERS IN HIV M&E 36
1. Non-governmental facilities 36
2. Development and Implementing partners 36
4. TRAINING 37
5. SUSTAINABILITY 37
6. IMPLEMENTATION PLAN 37
7. ANNEXES 38
A. List of Reference Documents 38
B. Standard Operation Procedures 39
C. List of Workshop Participants 71
D. Glossary 73
LIST OF FIGURES
Figure 1: FIGURE SHOWING THE HOW THE 12 COMPONENTS OF A FUNCTIONAL M&E SYSTEM
OPERATE
Figure 2: FIGURE SHOWING KNASP III NATIONAL MANAGEMENT AND ACCOUNTABILITY STRUCTURES
Figure 3: NATIONAL HIV & AIDS DATA FLOW FOR ROUTINE MONITORING SYSTEMS
Figure 4: NATIONAL HIS DATA REPORTING AND FEEDBACK STRUCTURES AND TIMELINES
Figure 5: COMMUNITY STRATEGY LINKAGE STRUCTURE
LIST OF TABLES
Table 1: TABLE SHOWING SUMMARY OF M&E ACTIVITIES AT THE COMMUNITY LEVEL
Table 2: TABLE SHOWING SUMMARY OF M&E ACTIVITIES AT THE FACILITY LEVEL
Table 3: TABLE SHOWING SUMMARY OF M&E ACTIVITIES AT THE DISTRICT LEVEL
Table 4: TABLE SHOWING SUMMARY OF M&E ACTIVITIES AT THE PROVINCIAL LEVEL
Table 5: TABLE SHOWING SUMMARY OF M&E ACTIVITIES AT THE NATIONAL LEVEL

introduction
Monitoring and evaluation (M&E) are fundamental components of any program that aims
to continuously improve and provide better outputs and outcomes. Dependent on the data
management processes to provide quality data that can be used for decision making and program
improvement, M&E are essential tools for program managers. However, for appropriate decisions
to be made, it is important that the data are of the best quality possible and that each of the steps
in the data management process adheres to the highest standards possible. Further, the M&E
roles, responsibilities and activities of each of the persons involved in the process should be
clearly defined to avoid any ambiguity. It is with this purpose in mind that the current document
was developed, to provide an operational guide for conducting monitoring and evaluation of the
HIV program, with specific focus on Pillar 1.
1.1 PURPOSE OF THE DOCUMENT
The purpose of this document is to provide guidance on the monitoring and
evaluation(M&E)roles,responsibilitiesandactivitiesofalltheHIVstakeholders
working with the Ministries of Health (MOH). In addition, the M&E roles,
responsibilities and activities of health workers working at the community
level within the NACC structures are included, in an effort to strengthen the
linkages between the MOH and NACC. This document seeks to articulate the
various M&E activities that are critical for ensuring that high-quality HIV data
are produced and used to make informed program decisions at all levels.
1.2 INTENDED AUDIENCES
This document is intended for use by all persons working within MOPHS and
MOMS, at the community, facility, district, provincial, and national levels on
the national HIV program activities. This includes all stakeholders working
within the HIV arena to support the activities of the Government of Kenya
(GOK), including implementing partners working at the community, facility,
district, provincial, and national levels.
1.3 HOW TO USE THIS DOCUMENT
This document can be used as a quick guide on the various HIV M&E activities
to be conducted at the community, facility, district, provincial/county, and
national levels. It provides information on timelines for conducting the routine
M&E activities as well as clear direction on the roles and responsibilities for
each specific staff. This document provides information on what activity
should be conducted and who is responsible. The Annex contains Standard
Operating Procedures (SOPs) for how to conduct selected activities.
1. HIS Strategic Plan. (2009−2014). Ministry of Medical Services and Ministry of Public Health and Sanitation.
...the current
document was
developed,
to provide an
operational
guide for
conducting
monitoring
and evaluation
of the HIV
program, with
specific focus on
Pillar 1.
1 1.4 WHAT IS MONITORING?
Monitoring is a systematic process covering routine collection, analysis, and
use of information about how well a project or programme is performing. It
involves continuous review of the performance of all the components in the
project to ensure that input deliveries, work schedules, targeted outputs, and
other required actions are proceeding as per the work plans.1
1.5 WHAT IS EVALUATION?
Evaluation is the periodic assessment of a project or program to determine
the achievements against clearly set performance targets. The purpose of
conducting an evaluation is to assess whether the project is making progress
toward achieving its overall goals and objectives, and providing opportunities
for mid-course corrections to project implementation, if necessary.

supporting documents
A. Organizing Framework for a Functional National Monitoring and Evaluation System
Figure 1: How the 12 Components of a Functional M&E System Operate 2
1
2
3
4
5
6 7 8
9
10
11
12
1: Organizational Structures with
HIV M&E
2: Human Capacity for HIV M&E
3: Partnerships to Plan, Coordinate,
and Manage the HIV M&E System
4: National Multi-Sectoral HIV M&E
Plan
5: Annual Costed National HIV M&E
Work Plan
6: Advocacy, Communication, and
Culture for HIV M&E
7: Routine HIV Program Monitoring
8: Surveys and Surveillance
9: National and Sub-National HIV
Databases
10: Supportive Supervision and Data
Auditing
11: HIV Evaluation and Research
12: Data Dissemination and Use
In line with the “Three Ones Principles,” the Organizing Framework for a Functional National
Monitoring and Evaluation System, developed by UNAIDS in 2008, outlines the elements that
constitute a functional HIV M&E system. Figure 1 shows the 12 components and how they interact
with each other.
Component 1: Organizational Structures with HIV M&E
Performance Goal: Establish and maintain a network of organisations
responsible for HIV M&E at the national, sub-national, and service-delivery
levels. Each level needs to have adequate staff with clearly defined roles,
proper leadership, good organisational culture where all are committed to
system performance, and well-coordinated stakeholder participation.
2. MERG. (2008). Twelve organizing components of a functional national HIV M&E system. UNAIDS.
2 Component 2: Human Capacity for HIV M&E
Performance Goal: Ensure adequate skilled human resources at all levels of
the M&E system to complete all tasks defined in the annual costed national
HIV M&E work plan. The issues of adequate and skilled staff have continued
to be a challenge for the health sector in Kenya. The M&E and research
framework proposes that a capacity building plan be developed to ensure that
M&E technical skills, as well as strategic planning aspects, are enhanced.
Component 3: Partnerships to Plan, Coordinate, and Manage the HIV
M&E System
Performance Goal: Establish and maintain partnerships among in-country
and international stakeholders who are involved in planning and managing
the national HIV M&E system. Within the Kenya National AIDS Strategic
Plan (KNASP) structures, technical working groups that incorporate all
stakeholders have been established at all levels.
Component 4: National Multi-Sectoral HIV M&E Plan
PerformanceGoal:DevelopandregularlyupdateanationalM&Eplan,including
identified data needs, national standardized indicators, data collection
procedures and tools, and roles and responsibilities for implementation of a
functional national HIV M&E system. To this end, a national M&E and research
framework in line with the KNASP III was developed.
Component 5: Annual Costed National HIV M&E Work Plan
Performance Goal: Develop an annual costed national M&E work plan,
including the specific and costed HIV M&E activities of all relevant stakeholders
and identified sources of funding. The KNASP III, which provides guidance on
how the country will implement its HIV activities from 2009/10 to 2012/13,
has been costed.
Component 6: Advocacy, Communication, and Culture for HIV M&E
Performance Goal: Ensure knowledge of and commitment to HIV M&E and
the HIV M&E system among policymakers, program managers, program staff,
and other stakeholders. In Kenya, the KNASP III has a communication strategy
that guides the advocacy and communication activities of the KNASP.
Component 7: Routine HIV Program Monitoring
Performance Goal: Produce timely and high-quality routine program
monitoring data. If a functioning health information system (HIS) exists that
routinely collects data on HIV services at health and other facilities, there is no
need to establish another data management system. The current document
provides guidance on the monitoring of routine HIV program data.
Each level
needs to have
adequate
staff with
clearly defined
roles, proper
leadership, good
organisational
culture where all
are committed
to system
performance,
and well-
coordinated
stakeholder
participation.

Component 8: Surveys and Surveillance
Performance Goal: Produce timely and high-quality data from surveys and
surveillance. The national HIV M&E and research framework recognizes
the need for surveys and surveillance, and further states that survey and
surveillance protocol will be captured to ensure that information on key
national indicators are documented.
Component 9: National and Sub-National HIV Databases
Performance Goal: Develop and maintain national and sub-national HIV
databases that enable stakeholders to access relevant data for policy
formulation and programme management and improvement. A national
database is in the process of being developed at the HIS, which will include
HIV data.
Component 10: Supportive Supervision and Data Auditing
Performance Goal: Monitor data quality periodically and address any
obstacles to producing high-quality data (i.e., data that are valid, reliable,
comprehensive, and timely). Regular data quality checks and provision of
feedback are important mechanisms to improve or sustain data quality.
Component 11: HIV Evaluation and Research
Performance Goal: Identify key evaluation and research questions, coordinate
studies to meet the identified needs, and enhance the use of evaluation
and research findings. The Kenya AIDS Research Coordination Mechanism
(KARSCOM) is responsible for coordinating all HIV evaluation and research
activities in Kenya.
Component 12: Data Dissemination and Use
Performance Goal: Disseminate and use data from the M&E system to
guide policy formulation and program planning and improvement. The most
important reason for conducting M&E is to provide the data needed for
guiding policy formulation and program operations.
To achieve the
above outputs,
the KNASP III is
operationalized
through four
pillars.
Figure 2: KNASP III National Management and Accountability Structures3
Cabinet Committee On
HIV Chaired by the Prime
Minister
Pillar 1
Health Sector HIV
Service Delivery
Pillar Implementing
Structures
Pillar Implementing
Structures
Communities, service users, citizens
Civil Society
Organisations.
CBOs, NGOs, FBOs,
Private Sector
Organisations
Pillar Implementing
Structures
Pillar 2
Sectoral Mainstreaming
of HIV
Pillar 3
Community Based HIV
Programmes
Pillar 4
Governance And
Strategic Information
Office of The President
Ministry Of State
Inter- Agency Coordinating
Committee (ICC)
ICC Advisory Committee
NACC board
NACC secretariat
KNASP III Oversight and
Performance Committee
B. Kenya National AIDS Strategic Plan III
The National AIDS Control Council (NACC), in partnership with various stakeholders, developed
the Kenya National AIDS Strategic Plan III (KNASP III) 2009/10 to 2013/14. The vision of the
KNASP III is “An HIV-free society in Kenya” to be achieved through six outcomes namely:
Outcome 1: Risky behavior is reduced among the general, infected, most at risk, and vulnerable
populations.
Outcome 2: Proportion of eligible PLHIV on care and treatment is increased and sustained.
Outcome 3: Health systems deliver a package of health services according to the Strategic Plan.
Outcome 4: HIV is mainstreamed in sector-specific policies and strategies.
Outcome 5: Communities respond to HIV within their local context.
Outcome 6: KNASP III is effectively operationalized.
3. Kenya National AIDS Strategic Plan III (2009/10 – 2012/13). (2009, November). Delivering Universal Access to Services, National AIDS Control Council.
To achieve the above outputs, the KNASP III is operationalized through four pillars. These are the
organizational structures that will be responsible for achieving the outputs and outcomes listed above.

The KNASP III pillars and accountability structures are summarized in Figure 2
on the following page.
The health sector HIV service delivery component, described under Pillar
1, is coordinated by the National AIDS and STI Control Program (NASCOP).
This national M&E guidelines and SOPs document therefore, provides clear
direction on the M&E roles, responsibilities and activities of the health workers
within Pillar 1 as they work within the Kenya National AIDS Strategic Plan.
Figure 3: National HIV and AIDS Data Flow for Routine Monitoring Systems4
C. KNASP III M&E and Research Framework
To ensure that the KNASP III outputs and outcomes are met, the KNASP III M&E and research
framework was developed. This document provides guidance to the key institutions responsible for
collection, management, and reporting of HIV-related data. This includes “managers and others
involved in planning and implementing HIV-related monitoring, evaluation, and research, plus
KNASP III implementers, development partners, and the general public.”
Further, the KNASP III M&E and research framework notes that successful
implementation of the framework requires a detailed operations manual
that will guide the operationalization of the proposed M&E and research
framework. The current document, therefore, provides guidelines that will
operationalize the M&E and research framework for Pillar 1 by outlining the
M&E roles and responsibilities of the various stakeholders working within the
Health Sector HIV Service Delivery.
4. National HIV and AIDS Monitoring, Evaluation and Research Framework (2009/10–2012/13).
Figure 4: National HIS Data Reporting and Feedback Structures and Timelines
D. Health Sector Indicator and Standard Operating Procedure Manual
The Health Sector Indicator and Standard Operating Procedure Manual for Health Workers (May
2008) was developed by the HIS department. The document provides guidance on the data flow
and reporting structures from the facility through the district to the provincial and national levels,
which are summarized in Figure 4 below. According to the manual, facility (HIV) data should be
aggregated onto the standard Ministry of Health (MOH) 711A form and transmitted to the district
level by the 5th of every month. The data are further aggregated onto the MOH 711B at the district
level and transmitted to the national (and provincial) level using File Transfer Protocol (FTP) by
the 15th of the month.
In regard to HIV programs, the Health Sector Indicator and Standard Operating
Procedure Manual provide general information on the various forms for use
in programs, including the integrated reporting tool mentioned above (MOH
711). Further, while descriptions are given on the various data management
SOPs, the current HIV M&E guidelines and SOPs provide more details on some
of the key data management procedures including data validation, report
writing and support supervision, among others.
While the Health sector Indicator and Standard Operating Procedure Manual
provides deadlines for the forward transmission/reporting of data and
mentions that feedback should be provided, there are no deadlines for when
the feedback should be given. Similarly, there is no standard format given for
the provision of feedback. The current document addresses these gaps by
providing deadlines for the provision of feedback as well as clear formats for
the feedback report at each level, which are given below.

The Health
Sector Indicator
and Standard
Operating
Procedure
Manual for
Health Workers
(May 2008)
provides
guidance on
the data flow
and reporting
structures from
the facility
through the
district to the
provincial and
national levels.
NACC
Division Responsible for M&E Research
PILLAR 1
Health Sector Routine
Monitoring Structure
NASCOP
PILLAR 2
Sectoral HIV Mainstreaming
Routine Monitoring Structure
MoSPND
PILLAR 3
Community based HIV
Routine Monitoring
Structure
PILLAR 4
Governance and Strategic
Information Routine
Monitoring Structure
(NACC)
NACC
Regional Offices
NLTP
NBTS
MOH Division
of HMIS
National Line
Ministries
-ACU
-PPMU
Private Sector
Advisory Network
The District
-DASCO
-DHRIO
-DTLC
-DMLT
The DIstrict
-DPMU
-DTC
The District
-DTC
Private Sector
Institutions
Co-ordinator
Civil Society
Organizations
-NGOs
-CBOs
Communities and Individuals
Health Facility
-Public
-Private
-NGO/FBO
National Level-
NASCOP
National Level-HIS
Provincial Level-
PMO (PHRIO)
District Level-
DMOH (DHRIO)
Facility Level-
Facility-in-charge
Due by15th
of the month
Due by 28th
of the month
Due by15th
of the month
Due by15th
of the month
Due by 5th
of the month

E. Taking the Kenya Essential Packages for Health to the Community: A Strategy for the Delivery
of Level One Services
Through this document, the MOH acknowledges that communities are at the heart of the Kenya
Essential Packages for Health (KEPH). According to the document, the community strategy has
four strategic objectives, which are:
1. Providing level 1 services for all cohorts and socioeconomic groups, including the “differently-abled”
taking into account their needs and priorities.
2. Building the capacity of community health extension workers (CHEWs) and community-based resource
persons to provide services at level 1.
3. Strengthening health facility-community linkages through effective decentralization and partnership for
the implementation of level 1 services.
4. Strengthening the community to progressively realize their rights for accessible and quality care and to
seek accountability from facility-based health services.
5. Ministry of Health. (2006). Taking the Kenya Essential Package for Health to the Community, Nairobi.
Figure 5: Community Strategy Linkage Structure 5
An overview of the administrative and management responsibilities of each of
the levels that are within the community strategy is given in Figure 5 below.
The Community Strategy has its own Community Based Health Information
System (CBHIS) through which data are collected and shared at all levels,
from the community to the facility and ultimately to the national level. This
system is expected to link with the HIS system at the facility level, thereby
providing a wealth of information to empower communities towards better
health outcomes.
F. Report on Organizational HIV Monitoring and Evaluation Capacity Rapid Needs Assessment
An Organizational HIV Monitoring and Evaluation Capacity Rapid Needs Assessment (RNA) was
conducted in early 2010 by the ADAM Consortium, in consultation with the GOK. The overall goal
of the organizational RNA was to establish the organizational structure and human capacity for
M&E of the national HIV response at the HIS; NACC; NASCOP; Division of Leprosy, Tuberculosis
and Lung Disease (DLTLD); National Public Health Laboratory Service (NPHLS); and the key
implementing partners.
While the findings of the RNA revealed tremendous improvements at the
national level and in the various subsystems that contribute to the overall
HIV strategic information in Kenya, there were several gaps and challenges
identified. Among the key challenges noted were the lack of guidelines for
conducting HIV M&E activities; the existence of parallel data collection and
reporting systems, which do not seem to interact with each other; minimal
provision feedback to the decentralized levels on the data reported, which has
led to little use of the data in program improvement; and the lack of adequate
capacity for data management and use at the district and facility levels.
The current document was therefore developed to help address some of the
above challenges, with specific focus on providing guidelines that outline the
specific roles and responsibilities of all stakeholders in conducting HIV M&E
activities.
Among the
key challenges
noted were
the lack of
guidelines for
conducting HIV
M&E activities.
JICC
HSCC
DISTRICT/DHSF
HFC HFC HFC HFCHFC
CHC CHC CHC
LEVEL 6
LEVEL 5
LEVEL 4
LEVEL 3,2
LEVEL 1
JICC: Joint Interagency Coordinating Committee HFC: Health Facility Committee
HSCC: Health Sector Coordinating Committee CHC: Community Health Committee
DHSF: District Health Stakeholders Forum

monitoring and evaluation
activities at the community,
facility, district, provincial, and
national levels
3
The following section provides information on the routine HIV M&E
activities to be conducted at the five levels, stating the frequency of the
activity and the office responsible for making sure that the activity is
done.
A .Community-Level HIV M&E Activities
1. Data Collection
Frequency: To be collected daily at each encounter.
Responsible Office: The CHW / CORP are responsible for data collection from
the households at the community level. This involves completing all household
information accurately, as required on the data collection forms, during the
household visit.
2. Data Collation and Summary/Aggregation
Frequency: To be collated on a weekly / monthly basis.
Responsible Office: The CORP / CHW, together with the CHEW, are responsible
for data collation. Data collected from the household should be collated to
provide a summary of the village health issues.
3. Data Validation, Cleaning, and Submission
Frequency: Data validation and cleaning are to be done weekly / monthly,
while data submission is to be done monthly.
Responsible Office: The CHEW is responsible for the data validation, cleaning,
and submission to the next level. Using the information gathered by the CORP /
CHW, the CHEW should be able to review all the data collected and determine
whether it is a true reflection of the village health status. By consulting with
the CORP / CHW on data that are unclear, the CHEW should be able to address
any inconsistencies that are noted or seek guidance from the MOH and other
stakeholders.
4. Data Analysis and Interpretation
Frequency: To be conducted monthly, quarterly, semiannually, and annually.
Data validation
and cleaning
are to be
done weekly /
monthly, while
data submission
is to be done
monthly.
Responsible Office: Basic data analysis and interpretation of village-level
data is conducted by the CHEW, together with the MOH and relevant
stakeholders.
5. Information Dissemination/Presentation and Use
Frequency: To be conducted monthly, quarterly, semiannually, and annually.
Responsible Office: The CORP/CHW, CHEW, DHMB and DHMT members are
responsibleforthedisseminationanduseofdataatthedistrictandcommunity
level.
Frequency: To be conducted quarterly, according to the M&E plan.
Responsible Offices: The members of the DHMT and DHMB are responsible
for conducting support supervision visits to the community level.
M&E Activity Frequency
Team
Composition
Responsibility Resources
Data Collection Daily (at each patient•
encounter)
CHW•
CORPS•
Complete all sections of the•
tools and registers
Ensure accuracy and•
timeliness in data collection
Data collection•
tools
Data Collation and
Summary
Weekly•
Monthly•
Quarterly•
Annually•
CHW•
CORPS•
CHEW•
Collect and complete the•
collation/ summary tools
Community•
summary tool
Data Validation and
Cleaning
Weekly•
Monthly•
Quarterly•
Annually•
CHEW• Routinely validate data• Data validation•
guidelines / SOPs
Data Analysis,
Interpretation, and
Presentation
Weekly•
Monthly•
Quarterly•
Annually•
CHEW•
CHC•
DHMB•
DHMT•
Data mining•
Data manipulation•
Compare data trends•
Interpretation•
Manila papers•
Stationery•
(community chalk
board, etc.)
Support
Supervision
Quarterly• CHEW•
CHC•
DHMB•
DHMT•
Auditing of health systems,•
data quality, processes, and
procedures
Support•
supervision tool
Guidelines•
Information Sharing
and Feedback
Monthly• CHC•
DHMB•
DHMT•
Data review and consumption•
Ensuring data produced is•
consumed within the facility
Early warning indicators•
Manila charts•
Stationery•
ICT tools•
Community black•
board
Table 1: Summary of M&E Activities at the Community Level

B. Facility-Level HIV M&E Activities
1. Data Collection
Frequency: To be conducted daily at each patient encounter.
Responsible Office: All health care workers at the facility level are responsible
for recording the relevant information on the patient cards, charts, registers,
and daily summary tools. This requires that all health care workers understand
all the tools and the elements that they need to collect. Where daily summaries
need to be calculated, the health care workers need to understand the
summaries that are required.
2. Data Collation and Aggregation/Summary
Frequency: To be conducted weekly, monthly, quarterly, and annually.
Responsible Office: In facilities with a Health Records Information Officer
(HRIO), it is the responsibility of the HRIO to summarize all the relevant data
onto the MOH 711A. In the absence of the HRIO, the Facility-in-Charge is
responsible for the collation of data onto the MOH 711A. To be able to do
this, the HRIO should know and understand all the indicators on the MOH 711,
including how they are derived.
3. Data Validation, Cleaning, and Submission
Frequency: To be conducted weekly and monthly.
Responsible Office: Once the data are collated, it is the responsibility of the
HRIO and/or Facility-in-Charge to validate and clean the data and submit the
MOH 711 form to the District Health Records Officer (DHRIO) by the 5th of
every month. This means that the HRIO and/or Facility-in-Charge should know
how to validate and clean the data that they collate onto the summary form.
Frequency: To be done weekly, monthly, quarterly, and annually.
Responsible Office: The HRIO / Facility-in-Charge are responsible for analyzing
the data to provide meaningful interpretation of the information collected. As
such, they should be conversant with data analysis techniques and computer
software programs that are relevant for their use.
The HRIO /
Facility-in-
Charge are
responsible for
analyzing the
data to provide
meaningful
interpretation of
the information
collected.
5. Information Sharing and Feedback
Frequency: To be done monthly.
Responsible Office: The Facility in-Charge / HRIO are responsible for the
dissemination of information gathered from the analyzed facility data. This
can be done during the monthly facility staff meetings where the health care
workers are presented with the hospital data and encouraged to examine /
explain any issues of concern and/or improvement that are noted. In addition,
presentations given that provide visual bar charts and graphs help the staff to
determine the level of progress being made toward reaching the agreed-upon
targets and together determine the interventions required to reach them.
6. Advocacy for Data Use in Decision Making
Frequency: To be done quarterly, annually, and as needed.
Responsible Office: The Facility-in-Charge, department head, and HRIO are
responsible for using the information derived from the program data to
advocate for program improvement.
7. Capacity Building (including OJT/Mentorship)
Frequency: To be done routinely, according to the capacity building plan.
Responsible Office: (1) The Facility-in-Charge is responsible for providing
orientation to health staff upon rotation to a new department. This includes
ensuring that health workers understand the data collection tools to be used,
including the indicators and summary tools. (2) All health care workers who
have attended any training are responsible for providing on-the-job training
(OJT) for the relevant staff at the facility. This will not only reinforce the skills
provided during the training attended, but will also ensure that more staff at
the facility acquire the skills needed to accomplish their tasks. The OJT should
be documented and any challenges encountered noted for follow-up by the
Facility-in-Charge.
Frequency: Data storage to be done routinely; retrieval to be done as
requested.
Responsible Office: Health care workers and HRIO / Facility-in-Charge are
responsible for data storage and retrieval.
All health care
workers who
have attended
any training are
responsible for
providing on-
the-job training
(OJT) for the
relevant staff at
the facility.

C. District-Level HIV M&E Activities
1. Distribution of and Sensitization of Standardized MOH Registers
and Forms (Data Collection Tools)
Frequency: To be done continuously as the need arises (can be done regularly
once the minimum and maximum stock of tools has been determined).
Responsible Office: The DHMT members are responsible for ensuring that all
facilities have adequate tools and keeping an inventory of distributed MOH
tools. Each of the specific program district coordinators, that is, DASCO, DLLC,
DMLT, and DPHN, are responsible for sensitization on their individual program
tools.
2. Data Collation and Aggregation/Summary
Frequency: To be done monthly, quarterly, semiannually, and annually.
Responsible Office: The DHRIO is responsible for collating and summarizing all
the facility-level data received from MOH 711A onto MOH 711B. This should
be compiled on a monthly basis before the 15th of each month.
3. Data Validation, Cleaning, and Reporting
Frequency: To be done monthly and quarterly.
ResponsibleOffice:TheDHMTmembersareresponsibleforindividualprogram
data validation and cleaning while the DHRIO is responsible for uploading and
submission of the validated MOH 711B data to the national level (through the
FTP system).
4. Feedback on Data
Frequency: To be done monthly and quarterly (during the district M&E
meetings).
Responsible Office: The DHMT members are responsible for providing
feedback to each facility on the individual program data submitted to the
district level while the DHRIO is responsible for providing feedback to each
Facility-in-Charge / HRIO on the data received each month on the MOH 711.
Frequency: To be done quarterly, semiannually, and annually.
Responsible Office: The DHMT members are responsible for analyzing MOH
711 district data and interpreting the findings of the data analysis to provide
an overall picture of the district’s performance, for example, progress toward
reaching AOP targets, TB defaulter tracing, TB case finding, and treatment
outcomes.
The DHMT
members are
responsible
for providing
feedback to
each facility on
the individual
program data
submitted to the
district level...
Team
Composition
Tasks Resources
Data Collection Daily (at•
each patient
encounter)
Service provider• Complete all•
sections of the tools and•
registers
Ensure accuracy and•
timeliness in data
collection
Tools•
(Registers, Daily•
summary sheets,
Patient encounter
card, EMR)
Data Collation and
Summary
Weekly•
Monthly•
Quarterly•
Annually•
HRIO•
Facility-in-Charge•
Department head•
Collect and complete the•
collation/ summary tools
Summary tools, e.g.,•
MOH 711
Data Validation and
Cleaning
Daily• Service provider•
HRIO•
Department heads•
Routinely validate and•
clean data
ICT tools•
Guidelines•
Specific quality•
assurance tools
Data Analysis,
Interpretation, and
Presentation
Weekly•
Monthly•
Quarterly•
Annually•
HRIO•
Department head•
Data mining•
Data•
manipulation•
Compare data trends•
Interpretation•
ICT tools•
Manila papers•
Stationery•
Support
Supervision
Quarterly• HMT• Auditing of health systems,•
data quality, processes,
and procedures
Support supervision•
tool
Guidelines•
Data Storage and
Retrieval
Routinely• HRIO• Ordering and replenishing•
stock of tools
Maintenance of equipment•
Bin /Stock cards•
ICT tools•
Filing cabinets•
Files/Folders•
Storage space•
Submission of Reports Monthly•
Quarterly•
Annually•
HRIO•
Ensure timely submission•
of reports
Data summary tools•
Transport facilitation•
Time•
Information Sharing
and Feedback
Monthly• HRIO•
Department head•
Data review and•
consumption
Ensuring data produced is•
consumed at facility
Early warning indicators •
Manila charts•
Stationery•
ICT tools•
Advocacy for Data
Use in Decision
Making
Annually•
When necessary•
HRIO•
Enhance evidence-based•
decision making
Manila charts•
Capacity Building/
OJT/Mentorship
Routinely• HRIO•
Cohort analysis•
Data reconstruction•
Update on tools and•
national guidelines
Mentorship guides/•
Pack
Table 2: Summary of M&E Activities at the Facility Level
NB: Encourage health institutions to hire records staff with minimum health information management
training from recognized medical colleges.

Frequency: To be done quarterly, according to the district M&E work plan.
Responsible Office: Each of these DHMT members is responsible for providing
supportive supervision on individual program indicators and ensuring that the
health care providers are able to record the data appropriately. The DMOH is
the team leader during the supervision visit and is responsible for coordinating
the entire exercise, while the DHRIO guides the data component.
7. Data Quality Audit
Frequency: To be conducted semiannually and annually.
Responsible Office: Each of the DHMT members is responsible for reviewing
program-specific data and developing a data quality improvement plan for
areas that are found to be deficient.
Frequency: To be done monthly, once the monthly summary data are received
from the facility.
Responsible Office: The responsibility of the DHRIO is to ensure that the data
are stored securely, both paper-based and electronic data.
9. M&E Capacity Building (including OJT and mentorship)
Frequency: As the need arises through OJT and according to the district M&E
capacity building plan.
Responsible Office: Each member of the DHMT is responsible for conducting
M&Ecapacitybuildingactivitieswithintheirprogramareas,includingproviding
updates on revised program data collection tools.
Each of the
DHMT members
is responsible
for reviewing
program-
specific data
and developing
a data quality
improvement
plan for areas
that are found
to be deficient.
Team
Composition
Tasks Resources
Distribution /
Sensitization of
Standardized
MOH Registers
and Forms (Data
Collection Tools)
Continuous, as•
need arises based
on workload of the
facility
NOTE: could be•
done regularly if
streamlined
DHMT (DMOH)•
DMSO•
DHRIO•
DPHN•
DASCO•
DNUT•
DLLC•
DMLT•
DHRIO to keep an inventory of•
distributed registers
DHRIO to ensure all facilities•
have adequate standardized
tools
Other members to liaise with•
DHRIO for specific program
tools
Standardized tools•
Inventory of registered facilities•
(updated MFL)
Transport for DHRIO and program-•
specific leads
Data Collation Monthly•
Quarterly•
DHMT• Collate data for all facilities in•
the month
DHRIO: enter data into FTP•
Computer, Summary tools•
Calculator, FTP Template•
Photocopier, backup system•
Team
Composition
Tasks Resources
Data Validation
and Cleaning
Monthly•
Quarterly (TB data)•
DHMT• Routinely validate and clean•
data
Team needs to understand•
what to validate, indicators,
and data elements
Data validation SOPs•
Data Reporting/
Submission
Monthly•
Quarterly•
(TB data)•
Ad hoc •
DHMT• Ensure that facilities submit•
timely, complete, and accurate
reports in time
Acknowledge receipt•
Ensure timely submission of•
report to the next level
Airtime / Courier services•
Data transmission mechanism (e.g.,•
modem uploading FTPs)
Facilities reporting checklist•
Supportive
Supervision
Quarterly•
Ad hoc •
DHMT members,•
based on
purpose of
integrated
supervision visit
Develop support supervision•
plan
Clear understanding of•
program, data, and indicators
Supervision plan•
Feedback plan•
Data Quality Audit Semiannual•
Annual •
HRIO• Ordering and replenishing•
stock of tools
Maintenance of equipment•
Bin /Stock cards•
ICT tools•
Filing cabinets•
Files/Folders•
Storage space•
Data Analysis and
Use
Quarterly• DHRIO•
DASCO•
DMLT•
DLLC•
DPHN•
DRH Coordinator•
Each member to analyze•
program-specific data and
DHRIO to compile district data
Determine key questions to•
guide analysis
Refer to MOH711 Data Analysis•
Plan
Develop presentation template•
Implement quality•
improvement activities based
on the data analysis findings
Computer•
Summary tools•
FTP Template•
Photocopy facility data•
Data analysis guide•
Quality improvement guide / plan•
Current AOP document•
Data Sharing and
Feedback
Monthly• DHRIO / DLLC•
DHRIO / DASCO•
Ensure that feedback is timely•
to the facility and DHMT
Incorporate feedback into the•
program (with the Facility-in-
Charge)
Standardized data-sharing templates•
Data Storage and
Retrieval
Monthly• DHRIO / DLLC • Ensure a systematic and secure•
filing system for hard copies
Ensure backup for electronic•
data
Filing system•
External backup system•
Storage space•
M&E Capacity
Building
Formal training•
− quarterly,
according to the
training plan
OJT / mentorship −•
continuous, based
on identified gaps
DHMT• Ensure that newly deployed•
health care providers are
trained on indicators and tools
OJTs for the M&E staff and•
service provider
Develop a training plan •
Training guide•
M&E curriculum•
Table 3: Summary of M&E Activities at the District Level

D. Provincial-Level HIV M&E Activities
1. Data Collation of District Summaries
Frequency: To be collated monthly and quarterly.
Responsible Office: Each if the PHMT members are responsible for collating
individual program data collected through the MOH 711 to provide a
comprehensive picture of the province.
2. Data Validation
Frequency: To be done monthly, quarterly, and as needed.
Responsible Office: Each of the DHMT members is responsible for validating
their specific program data.
3. Data Analysis and Use
Frequency: To be done monthly, quarterly, and as needed.
Responsible Office: Each of the PHMT members is responsible for analyzing
program-specific data.
Frequency: To be done monthly and continuously as needed.
Responsible Office: The responsibility of the PHRIO is to store data securely
and retrieve data as needed.
Frequency: To be conducted quarterly.
Responsible Office: The PDMS and PDPHS are the team leaders and coordinate
the entire supportive supervision activity. Each of the PHMT members is
responsible for conducting supportive supervision visits and providing support
in each of their program areas.
6. Data Quality Audit
Frequency: To be done semiannually and annually.
Responsible Office: The PHMT is responsible for conducting data quality
audits, according to the HIS DQA protocol.
7. Dissemination and Data Use
Frequency: To be done quarterly, semiannually, and annually.
Responsible Office: The PHMT is responsible for holding data dissemination
forums with all stakeholders.
Each of the
PHMT members
is responsible
for conducting
supportive
supervision visits
and providing
support in each
of their program
areas.
8. M&E Capacity Building
Frequency: To be conducted according to the capacity building plan (AOP).
Responsible Office: The PHMT members are responsible for conducting M&E
capacity building within their specific program areas. This includes conducting
OJT, mentorship, and coaching as needed.
Team
Composition
Tasks Resources
Data Collation of District
Summaries
Surveillance•
data on weekly
basis
Monthly for•
routine data
Quarterly for•
routine data
PHRIO•
PASCO•
PTLC•
PMLT•
PPHN•
Receive district reports•
Follow-up of late, incomplete,•
and defaulter districts
reporting
Compilation by the PHRIO•
Supply of tools•
Tools; MOH 711A•
Registers•
Computers•
Internet connectivity•
Personnel•
Printers, photocopiers•
Stationery•
Data Validation and
Cleaning
Monthly and•
Quarterly for
routine data
As need arises•
PHRIO•
PASCO•
PTLC•
PMLT•
PPHN•
Collect and•
complete the•
collation/ summary tools•
Summary tools, e.g.,•
MOH 711
Data Validation and
Cleaning
Daily• Service•
provider
HRIO•
Facility-in-•
Charge
Department•
heads
Look out for discrepancies,•
timeliness, and quality of data
reported
Liaise with the DHRIO (DASO,•
DLLC, DMLT, DPHN) for
clarification
Data validation SOPs•
Computer•
Stationery•
Data Analysis and Use Quarterly• PHRIO•
PASCO•
PTLC•
PMLT•
PPHN•
Each member to analyze•
program-specific data and
PHRIO to compile all program
data for district
Determine key questions to•
guide analysis
Reference to MOH711•
Develop Data Analysis Plan•
Standardized presentation•
template
Quality improvement based•
on the data analysis
Identify and compare trends•
in the current and previous
reports
Computer•
Summary tools•
Calculator•
FTP Template•
Data analysis guide•
Quality improvement•
guide / plan
Current AOP document•
Table 4: Summary of M&E Activities at the Provincial Level

E. National-Level HIV M&E Activities
1. Ensure Adequate M&E Human Resources
Frequency: Given the urgent need for trained M&E personnel, this should be
addressed immediately and as need arises.
Responsible Office: The M&E Managers, Program Directors, DMS, PDMS within
the Ministries of Health are responsible for ensuring that there is adequate
human resources and capacity for M&E.
2. Harmonize and Standardize M&E Training Materials for Capacity
Building at All Levels
Frequency: To be done immediately and after every 3 years (or as need
arises).
Responsible Office: The M&E officers at NACC and NASCOP are responsible for
ensuring that there is a standardized and harmonized national M&E capacity
building curriculum for HIV.
3. Review the Membership of National TWG (at all levels) to Guide
the M&E Activities
Frequency: To be done after every 2 years.
Responsible Office: The NACC M&E Officers are responsible for reviewing and
maintaining partnerships of all stakeholders in the national M&E TWG. This
includes the membership of Pillar 1 stakeholders that are working directly
with NASCOP to support M&E activities within the HIV health care sector.
4. Develop and Update National M&E Plan and Link it to the National
Strategic Plan
Frequency: KNASP to be developed every 5 years; M&E plan to implement the
activities to be developed and reviewed annually.
Responsible Office: The NACC M&E Officers are responsible for developing the
strategic plan that guides the country’s implementation of HIV activities. This
is developed in consultation with all stakeholders.
5. Ensure Adherence to National Technical Standards of HIV M&E
Frequency: This is a continuous process that is verified through various M&E
activities, including conducting DQA and supportive supervision activities.
Responsible Office: The M&E Manager / M&E Officers at NASCOP are to ensure
that the M&E SOPs are in place, conduct supportive supervision and provide
capacity building activities, and conduct annual performance appraisals.
The M&E
Manager /
M&E Officers at
NASCOP are to
ensure that the
M&E SOPs are
in place...
Team
Composition
Tasks Resources
Capacity Building • As per the AOP
• According to
capacity building
plan
PHMT• Ensure that national•
curriculums are used where
they exist
Identify the participants•
Supervise and coordinate the•
trainings
Mobilize resources•
Follow up on the trainings•
Mentorship•
Stationery•
Facilitators•
Auxiliary staff•
Financial resources•
M&E curriculum•
Capacity building plan•
Support Supervision Quarterly• PHMT• Apply the support supervision•
checklist developed by the
province on the district team
Capacity building during the•
support supervision (OJT)
Provide initial feedback to•
the district team (Supervision
Checklist)
Generate a report on the•
activity
Share the report•
Identify gaps and training•
needs
Submit supervision report to•
the national level
Funds - per diems,•
vehicle maintenance
Stationery•
checklist
SOPs
DQA/DQI (Data Quality
Assurance/ Quality
Improvement)
Semiannual• PHMT•
DHMT•
Sensitize the district teams to•
carry out the assessment
Apply the DQA tool•
Generate DQA report•
Develop QI Plan•
Implement QI Plan•
Facilitators•
Auxiliary staff•
Funds - per diems,•
vehicles, venue hire
DQA protocol•
Dissemination and Data
Use
Semiannual•
Annual•
PHMT•
DHMT•
Prepare information - Hold•
dissemination forums with
the district teams
Hold provincial stakeholder•
forums
Review performance as per•
AOP targets
Prepare reports from the•
dissemination forums
Facilitators•
Standardized templates•
for data review
Data Storage and
Retrieval
Annually•
When•
necessary
PHRIO•
PTLC•
Electronic data backup•
Data filing•
Data storage•
Data retrieval•
Computer•
Filing cabinets•

Frequency: To be conducted quarterly, semiannually, annually, or as needed
according to the individual program requirements.
Responsible Office: The M&E Officers at each of the divisions/programs (HIS,
NASCOP, NPHLS, DLTLD, NBTS) are responsible for analyzing the national
program data.
7. Report Writing and Presentation
Frequency: To be conducted quarterly, semiannually, annually, or as needed
according to the individual program requirements.
Responsible Office: The M&E Officers in each of the divisions at the national
level is responsible for preparing a national report for each program, while
HIS M&E Officers prepare an integrated national report. The officers are also
responsible for sharing the presentation of the report to the division heads.
8. Provide Feedback to the Decentralized Levels
Frequency: To be done quarterly, or as needed according to the individual
program requirements.
Responsible Office: The M&E Officers at each of the divisions are responsible
for providing feedback to the provincial level on the data submitted on a
monthly, quarterly, semiannual, and annual basis.
9. Conduct Supportive Supervision
Frequency: To be done quarterly, according to the national M&E work plan.
Responsible Office: The M&E Officers at NASCOP are responsible for
developing M&E guidelines for supervision, a supervision tool, conducting
supervision visits, providing feedback on the supervision visit, producing and
disseminating reports, and providing mentorship / OJT.
10. Develop and Implement an Annually Costed National HIV M&E
Work Plan
Frequency: To be done annually.
Responsible Office: NASCOP M&E Officers, in collaboration with NACC M&E
Officers, are responsible for developing a costed HIV M&E framework that
encompasses M&E activities at all levels.
11. Coordinate the Advocacy and Communication for HIV M&E
Frequency: To be done according to the advocacy and communication plan/
strategy.
Responsible Office: The NACC is responsible for developing an advocacy
and communication strategy. Once this has been developed, then the
implementation of M&E advocacy and communication plan at all levels.
12. Facilitate Monitoring of Routine HIV Program Data
Frequency: To be done annually.
Responsible Office: The M&E Manager and Officers at NASCOP and HIS are
responsible for ensuring that routine HIV data are monitored for quality. This
includes the review of data collection and reporting tools, ensuring proper
routine transfer procedures, providing feedback at all levels, and producing
an annual HIV program M&E report.
13. Conduct Surveys and Surveillance
Frequency: To be conducted according to the national plan.
Responsible Office: The M&E Officers at NASCOP, in conjunction with the
M&E Officers at NACC, are responsible for developing protocols for all HIV
surveys and surveillance activities, developing and maintaining an inventory
of HIV surveys done, developing a plan for data collection and analysis that
addresses stakeholders’ needs, as well as preparing a report from the surveys
and surveillance
14. Design and Update a Comprehensive HIV Database
Frequency: To be done immediately and updated quarterly.
Responsible Office: The M&E Manager and Officers at NASCOP are responsible
for developing a comprehensive HIV database that establishes linkages
between relevant databases to ensure data consistency and avoid duplication
of efforts.
15. Coordinate and Conduct National HIV Evaluation and
Research
Frequency: Evaluation is to be done according to the HIV M&E work plan;
research to be done as the need arises.
Responsible Office: For Pillar 1, this is coordinated through the Surveillance,
Research and Evaluation Subcommittee of the NASCOP M&E Technical
Working Group (TWG).
16. Information Dissemination and Use
Frequency: To be done according to the national HIV dissemination plan.
Responsible Office: The M&E Officers at NASCOP and NACC are responsible
for developing a dissemination plan, which includes conducting analysis of
data for dissemination, disseminating information, and using data for program
improvement and policy development.
The M&E
Officers at
NASCOP, in
conjunction
with the M&E
Officers at
NACC, are
responsible
for developing
protocols for
all HIV surveys
and surveillance
activities...

M&E Activity Frequency Team Composition Tasks Resources
Ensure Adequate M&E
Human Resources
Immediate and as•
need arises
M&E managers•
Program•
directors
DMS•
PDMS•
Maintain a network of HR for HIV•
M&E (national and decentralized
levels)
Assess M&E staff hiring needs•
and qualifications
•Avail M&E job descriptions to•
all staff
Trained M&E•
personnel
Adequate salaries•
Harmonize and
Standardize M&E
Training Materials for
Capacity Building at
All Levels
Immediate and•
after every 3 years
(or as need arises)
M&E officers•
at NACC and
NASCOP
Conduct an M&E training needs•
assessment
Review existing M&E training•
materials
Standardize M&E training•
materials
Develop and implement M&E•
capacity building plan
Existing training•
materials
Funds•
Technical expertise•
Review the
Membership of
National TWG (at All
Levels)
Every 2 years• • NACC Maintain partnerships•
Hold quarterly TWG meetings•
Ensure follow-up on activities•
agreed upon
Database on•
membership
Effective•
communication
mechanisms
Develop and Update
National M&E Plan in
Line with the KNASP
KNASP – 5 years•
M&E plan – 1 year•
NACC• Provide stewardship•
Ensure stakeholder involvement •
Ensure Adherence to
National Standards of
HIV M&E
Continuous•
process
M&E Manager at•
NASCOP
Ensure M&E SOPs in place•
Provide quarterly support•
supervision, mentorship, audit
Conduct annual performance•
appraisals
Standardize•
all feedback
mechanisms
Clear data flow•
structure
Provide Feedback
to the Decentralized
Levels
Quarterly• All M&E officers•
at NASCOP, HIS,
NACC (at all
levels)
Standardize all feedback•
mechanisms • Clear data
flow structure
Develop checklist for provision•
of feedback
Clear data flow•
structure
Develop checklist•
for provision of
feedback
Develop and
Implement an Annual
Costed National HIV
M&E Work Plan
Annually• M&E officers at•
NASCOP, NACC
in collaboration
with partners
Ensure all HIV M&E activities at•
all levels are costed
Ensure implementation of the•
annual M&E plan
HR•
Finances•
Coordinate the
Advocacy and
Communication for
HIV M&E
According•
to national
advocacy and
communica¬tion
plan / strategy
Director NACC• Develop an advocacy and•
communication strategy
Disseminate and implement•
M&E advocacy and
communication plan
Funds•
M&E Activity Frequency Team Composition Tasks Resources
Facilitate Timely
and High-Quality
Routine HIV Program
Monitoring Data
Annually• NASCOP M&E•
Manager and HIS
Develop and disseminate data•
management strategy
Review data collection and•
reporting tools
Ensure proper routine data•
transfer procedures
Provide feedback to all levels•
Produce annual HIV program•
M&E report
Funds•
Coordinate / Conduct
National HIV Surveys
and Surveillance
As required• NASCOP•
and NACC
(KARSCOM)
Develop protocols for all surveys•
and surveillance
Develop and maintain inventory•
of HIV surveys done
Prepare report from survey and•
surveillance
Logistical support•
Equipment and•
stationery
Design & Update
Comprehensive HIV
Database
Design•
immediately
Update quarterly•
M&E officers &•
IT staff at HIS &
NASCOP
• Establish linkages between relevant
databases
• Ensure database functionality
Computer•
equipment
Dedicated IT and•
M&E staff
Financial support•
Supportive
Supervision
Quarterly• NASCOP M&E•
Program
Manager &
Officers
Develop guidelines and tool•
Develop supervisory tool•
Produce and disseminate•
supervision reports
Provide feedback•
Technical support•
Human resources•
Supportive•
supervision checklist
Coordinate and
Conduct National
HIV Evaluation &
Research
Evaluation –•
according to
national M&E plan
Research – as•
needs arise
NACC and•
NASCOP
Program
Directors,
Program
Managers,
Officers
Develop and drive the research•
agenda
Disseminate and use research•
findings
Human resources•
Guidelines on•
evaluation and
research
Data Dissemination
and Use
According to•
national data
dissemination plan
NASCOP & NACC•
M&E Program
Manager &
Officers
Develop data dissemination•
plan/schedule
Analyze data needs and users•
Provide evidence for data•
use (e.g., in decision making,
planning, resource mobilization)
Develop timetable for national•
reporting
Produce information products•
tailored to different audiences
Use data for program•
improvement and policy
development
Table 5: Summary of M&E Activities at the National Level

F. Role of Stakeholders in HIV M&E
1. Nongovernmental Facilities
All nongovernmental facilities, including those run and supported by Faith-
Based Organizations (FBOs) and Community-Based Organizations (CBOs),
as well as private facilities, are expected to adhere to the same reporting
requirements as the government health facilities. This means that the facilities
are all required to report using the standard MOH711A form to the DHRIO. The
health care workers, as well as the Facility-in-Charges, HRIOs, and department
heads in these facilities, therefore need to receive training on the use of these
tools and to understand their reporting requirements.
2. Development and Implementing Partners
The major role of development and implementing partners is to provide
support to the Ministries of Health in conducting HIV M&E activities. This
includes the provision of financial and technical support in the government-
led M&E activities, with all partners expected to align as much as possible
with the national work plans.
This means that
the facilities
are all required
to report using
the standard
MOH711A form
to the DHRIO.
training
To ensure that the health care providers at every level, as well as all HIV stakeholders, are
equipped to carry out their specified M&E roles and responsibilities, a national M&E curriculum
will be developed. The curriculum will be designed to contain several modules that expound on
the various M&E activities described above, and all health care providers will be trained on their
relevant components or activities.
sustainability
While most of the M&E activities are conducted with support from development partners, it is
important to ensure that the Ministries of Health are able to continue conducting the activities
even in the absence of donor support. Endorsement and use of the guidelines by the Ministries of
Health will help in ensuring that they are entrenched in the government system. One of the ways
to do this is by incorporating the M&E documents, including these guidelines and the training
curriculum, in pre-service training for health care workers. This will ascertain that health care
providers are not only aware of the M&E activities, but also know their roles and responsibilities
in this area.
implementation plan
To ensure that the national M&E guidelines and SOPs are rolled out and used in the country,
several mechanisms will be put in place. Spearheaded by the capacity building subcommittee
within the NASCOP TWG, a dissemination plan will be developed that will guide the
implementation and use of the national M&E guidelines and SOPs. Further, the M&E guidelines
and SOPs are an integral part of the national M&E HIV training curriculum and will thus be
disseminated during the roll-out of the training activities
4
5
6

annexes
A. List of Reference Documents
1. Organizing Framework for a Functional National Monitoring and Evaluation
System, UNAIDS, April 2008
2. Kenya National AIDS Strategic Plan III (2009/10 – 2012/13): Delivering on
Universal Access to Services, National AIDS Control Council, November 2009
3. National HIV and AIDS Monitoring, Evaluation and Research Framework
(2009/10 – 2012/13), National AIDS Control Council, December 2009
4. Taking the Kenya Essential Package for Health to the Community: A Strategy
for the Delivery of Level One Services, Ministry of Health, April 2006
5. Health Sector Indicator and Standard Operating Procedure Manual for
Health Workers, Ministry of Health, May 2008
6. Report on Organizational HIV Monitoring and Evaluation Capacity Rapid
Needs Assessment (RNA), June 2010
B. Standard Operating Procedures
1. Data Collation
2. Data Validation
4. Presentation and Dissemination
6. Reports and Report Writing
C. List of Development Workshop Participants
D. Glossary
7
Standard Operating
Procedures

table of contents
1. Purpose of This Document 41
2. Target Audiences 41
3. Definition 41
4. Procedures for Data Collation 42
A. Frequency of Data Collation 42
B. Person Responsible for the Collation 42
C. Format and Forms for Data 42
D. Receipt and Transmission of Data 43
E. Confirmation of Receipt of Data 44
Data Collation purpose of this document
The purpose of this document is to outline the procedures to be used in collating or aggregating
routine (HIV) data for transmission to the next level, as required within the national health
information reporting system. The collation of non-routine data is not covered in this document.
target audiences
1
2
3
The intended audiences for this document are:
• Community Health Extension Worker (CHEW), Community Unit Leader
• Health Records Information Officer (HRIO), department heads, health Facility-
in-Charge
• District Health Records Information Officer (DHRIO), District AIDS and STI
Coordinator (DASCO), District Tuberculosis and Leprosy Coordinator (DTLC),
District Public Health Nurse (DPHN) , District Medical Laboratory Technologist
(DMLT)
• Provincial Health Records Information Officer (PHRIO), Provincial AIDS and
STI Coordinator (PASCO), Provincial Tuberculosis and Leprosy Coordinator
(PTLC), Provincial Public Health Nurse (PPHN), Provincial Medical Laboratory
Technologist (PMLT)
• National-Level M&E Officers at Health Information System (HIS), National AIDS
and STI Control Program (NASCOP), Division of Leprosy, Tuberculosis and Lung
Disease (DLTLD), National Public Health Laboratory Services
definition
Data aggregation is any process in which information is gathered and expressed in summary
form for purposes such as statistical analysis. A common aggregation purpose is to get more
information about particular groups based on specific variables such as age, gender, or location.
Data collation involves taking the data that have been collected from selected sources and
presenting them in a manageable format.

procedures for data
collation
A. Frequency of Data Collation
Depending on the level at which the data is being collated, the frequency
of data collation may vary depending on the prescribed reporting period.
Generally, data collation is to be done monthly, quarterly, biannually, or
annually.
B. Person Responsible for the Collation
1.1.1 Community Level: The CHEW and Community Unit Leader is
responsible for the data collation.
1.1.2 Facility Level: HRIO and the department/the Facility-in-Charge
heads are responsible for data collation.
1.1.3 District Level: The DHRIO is responsible for collation of all district
health data; the DASCO is responsible for collation of district HIV data; the
DTLC is responsible for collation of district TB and leprosy data; the DPHN
is responsible for all district RH, MCH data; and the DMTL is responsible for
collation of all district laboratory data.
1.1.4 Provincial Level: The PHRIO is responsible for collation of all
provincial health data; the PASCO is responsible for collation of provincial
HIV data; the PTLC is responsible for collation of provincial TB and leprosy
data; the PPHN is responsible for all provincial RH, MCH data; and the PMTL
is responsible for collation of all provincial laboratory data.
1.1.5 National Level: The M&E Officers at HIS are responsible for
collation of national health data (routine); the M&E Officers at NASCOP are
responsible for collation of national HIV data; the M&E Officers at DLTLD
are responsible for collation of national TB (and leprosy) data; and the M&E
Officers at DRH are responsible for collation of national RH, MCH data; the
M&E officers at NPHLS are responsible for collation of national laboratory
data.
C. Format and Forms for Data
1.1.1 Ensure that the correct primary data collection tools from which the
summary data will be compiled are available.
4 1.1.2 Ensure that the correct summary tool is available.
1.1.3 Locate the column from which the data are to be summarized for
each particular indicator on the summary tool.
1.1.4 Be sure to check that the data to be collated are within the
appropriate timelines; for example, for monthly data collation, make sure the
dates for which data are to be collated are for the correct month.
1.1.5 Before the data can be collated, the first step is to ensure that data
validation is done (refer to SOPs on data validation).
1.1.6 Using the provided instructions for each indicator, make the correct
additions from the appropriate column.
1.1.7 Check the additions once more before transferring to the appropriate
section on the summary sheet.
1.1.8 Be sure to retain a copy of the form(s) submitted to the next level.
D. Receipt and Transmission of Data
1.1.1 Community Level: Data are received from the CHW in paper form
by the CHEW and transmitted on paper format to the facility level.
1.1.2 Facility Level: Data are received from the various department or
clinics on paper form (in most cases) and transmitted to the district level on
paper format by the 5th of the following month. However, in facilities where
an electronic data collection system exists, data are collated and transmitted
electronically.
1.1.3 District Level: Data are received on paper and/or electronic formats
from the facility level and transmitted electronically through the FTP system
to HIS by the 15th of the following month.
1.1.4 Provincial Level: The role at the provincial level in data
management is mainly supervisory and not transitory.
1.1.5 National Level: Data are received electronically through the FTP
system from the District level.

E. Confirmation of Receipt of Data
1.1.1 Once the data have been collated and transmitted, acknowledgment
of receipt of transmitted data is required.
1.1.2 For paper-based data submission (community to facility, facility to
district) a paper-based acknowledgment receipt is required. In many cases,
this may be a signature on receipt of the document as proof of having
received it. The written acknowledgment checklist should be provided within
1 day of receiving the summary tool.
1.1.3 For data that are transmitted electronically, the acknowledgment
should also be provided electronically within a day of receiving the data
(consider automated acknowledgment)
table of contents
Data Validation
2. Definition 46
3. Section 1: Facility Level 46
A. Target Audiences 46
B. Procedures 46
C. Treatment of Suspect or Incomplete Data 47
D. Reporting 47
E. Resources 47
4. Section II: District Level 47
A. Responsibility 47
B. Procedure for Validation 47
C. Treatment of Suspect and Missing Data 48
D. Reporting 49
E. Resources 49
5. Section III: Provincial Level 49
A. Responsibility: 49
C. Treatment of Suspect Data 50
D. Resources 51
6. Section IV: National Level 51
A. Responsibility: 51
1. Roles of M&E Officers/Program Officers 51
2. Roles of Database Administrator/Programmer 52
C. Treatment of Suspect Data 53

purpose of this document1
2
3
A. Target Audiences
• Nurse or health care worker
• Heath records officer/data clerk
• Clinical officer/nurse in charge or facility
• Medical Officer of Health
B. Procedures for Validation
The Nurse in charge, Medical Officer, or Records Officer should validate the
data collected in the source documents at the site as described below:
1. Ensure that daily totals are correctly tallied at the bottom of each page of
the register/source documents.
2. All available source documents should be reviewed at least once every
month/before the 5th of every month to ensure they are all complete.
3. Review the dates on the source documents. Do all dates fall within the
reporting period?
The purpose of this document is to describe the procedures for validating data generated at the:
• Facility/site/service delivery level
• District level
• Provincial level
• National level
definition
Data validation is defined as the inspection of all the collected data for completeness and
reasonableness and the elimination of erroneous values. This step transforms raw data into validated
data. The validated data are then processed to produce the summary reports required for analysis.
section I: facility level
4. Every month, ensure at least 20% of the data in the reporting tool (MOH
711) and source documents is validated by:
• Data Screening: Involves the HRIO / nurse in-charge liaising with the
nurse/health care worker to manually review and reconcile suspect
erroneous values in the reporting tools and source documents using
the data collection tools and tally sheets.
• Missing Values: Involves checking for missing and incomplete data in
the source documents and reporting tool before submission to the
district. For missing data, be sure to document what data are missing
and how this will be addressed.
C. Treatment of Suspect Data
1. Clinical officer, nurse in charge, Medical Officer, or Records Officer should
examine the suspect data and liaise with the health worker to replace
erroneous data with the correct data.
2. Ensure that validated values are clear and legible in source documents and
reporting tools.
Important: Maintain raw and validated data collection tools separately.
Differentiate the tools by filing separately.
D. Reporting
1. Theoriginalsignedandcompleteddatareportingtoolsshouldbeforwarded
to the district by the nurse in charge or Medical Officer of Health.
2. A copy of the complete and signed data reporting tools should be filled and
kept on site.
E. Resources
1. Data collection tools (Registers)
2. Data reporting tool (MOH711, Commodity form)
3. Tally sheets
A. Responsibility
• District Health Information Officer
• District Public Health Nurse
• District Leprosy and Tuberculosis Coordinator
• District Laboratory Technician
• District AIDS and STI Coordinator
4 section II: district level

1. Recounting Reported Data: Re-aggregate the number of reports received
from all Service Delivery Points. What is the re-aggregated number? Is this
the total number of reports expected from all sites in the district?
a. Determine how many reports should there have been from all sites.
[A]
b. Determine how many reports there are. [B]
c. Calculate % available reports. [B/A]
d. Determine how many reports were received on time (i.e., received by
the due date). [C]
e. Calculate % on time reports/databases. [C/A]
NOTE: To be able to calculate the % on time reports, there should be a
mechanism for tracking the reports that are submitted by date.
f. Determine how many reports were complete. (i.e., complete means
that the report contained all the required indicator data*). [D]
g. Calculate % complete reports. [D/A]
2. Data Screening: Involves manually month at least 20% of reported data
and liaising with the reporting site to reconcile suspect erroneous values in
the reporting tools.
3. Range Tests: At least 20% of the reported data are compared monthly to
allowable upper and lower limiting values. If values seem erroneous, the
DHRIO will liaise with the site and district health management team to
validate with correct values.
4. Trend Tests: These checks are based on the rate of change in a value over
time. The DHRIO should validate data using trends quarterly. The DHRIO
can liaise with the rest of the district management team to discuss the
trends.
5. Cumulative Data: Check cumulative data with the previous reports to
ensure that it is incremental.
After the reported data are subjected to all the validation checks, the following
should be done with suspect data:
1. DHRIO to write a validation report that lists all data discrepancies, the
reasons for errors, and reasons for missing values.
2. DHRIO to liaise with the sites and the district teams to ensure the correct
data values are updated in the data reporting tools,
3. Feedback should be systematically given to the sites on the quality of their
data,
4. DHRIO should maintain a complete record of all data validation actions for
each data collection tool in a District Data Validation Log (see example of
a data validation log below). This document should contain the following
information for each rejected and substituted data value:
• Site name
• Indicator where error was flagged
• Date when error was flagged
• Action taken Y/N; if no why?
• Nature of action
D. Reporting
1. The original signed and completed data reporting tools should be filled by
the DHRIO in his office.
2. Quality Controls: Ensure that the district database (DHIS? FTP?) has
validation checks and quality controls to flag errors during data Entry (see
Annex: sample data validation spreadsheet/software).
3. Entry of all site data to be done before the 15th of the next month and
forwarded to the national level with a copy to the Province.
E. Resources
1. Data reporting tools (MOH 711, commodity reporting tool)
2. Electronic database
5 section III: provincial level
A. Responsibility
• Provincial Health Records Information Officer
• Provincial AIDS and STI Coordinator
• Provincial Nursing Officer
• Provincial Medical Laboratory Technologist
Site Name Indicator with Discrepancies Date Error was Flagged Action Taken Y/N
If No, Explain
Nature of Action
Liaise with site to1.
validate the errors
identified.
If the site and DHRIO2.
disagree on data value,
the DHMT has final
word on reconciling the
figures.
Table 1: Data Validation Log

1. Recounting Reported Data: Every month, re-aggregates the number
of reports (FTP Spreadsheets, and District Health Information System
databases). Received from all Districts) what is the re-aggregated number?
Is this the total number of reports expected from all districts in the
region?
a. Determine how many reports/databases should there have been from
all districts. [A]
b. Determine how many reports/databases are there. [B]
c. Calculate % available reports/databases. [B/A]
d. Check the dates on the reports/databases received. How many reports
were received on time (i.e., received by the due date)? [C]
e. Calculate % on time of reports/databases. [C/A]
NOTE: To be able to calculate the % of on-time reports, there should be a
f. Determine how many reports were complete (i.e., complete means
2. Calculate % complete reports. [D/A]
3. Range Tests: At least 20% of the reported data are compared monthly to
allowable upper and lower limiting values. If values seem erroneous, the
PHRIO will liaise with site and district health management team to validate
with correct values.
time. The PHRIO should validate data using trends quarterly. The PHRIO can
liaise with the rest of the district management team to discuss the trends.
5. Check cumulative data with the previous reports to ensure that it is
incremental.
After the reported data are subjected to all the validation checks, the PHRIO
should perform the following with suspect data:
1. PHRIO to write a validation report that lists all data discrepancies, the
reasons for errors, and reasons for missing values.
2. PHRIO to liaise with the district teams to ensure the correct data values are
updated in the databases.
3. Feedback should be systematically given to the districts on the quality of
their data.
4. PHRIO should maintain a complete record of all data validation actions for each data collection tool in a
District Data Validation Log (see example of a data validation log below). This document should contain
the following information for each rejected and substituted data value:
• Site name
• Explanation of error
• Source of substituted data value for error
D. Resources
1. Data reporting tools (MOH711, Commodity reporting tools, etc.)
2. Electronic database (FTP, DHIS)
section IV: national level
A. Responsibility
• Monitoring & Evaluation Officers
• Program Officers
• Database Administrators
Roles of M&E Officers/Program Officers:
1. Recounting Reported Data: Every month, re-aggregate the number of reports (FTP Spreadsheets, District
Health Information System databases) received from all districts. What is the re-aggregated number? Is
this the total number of reports expected from all districts in the region?
a. Determine how many reports/databases should there have been from all districts. [A]
b. Determine how many reports/databases are there. [B]
6
District Name District Database with
Discrepancies
Date Error was Flagged Action Taken Y/N
If No, Explain
Nature of Action
Liaise with DHRIO to1.
validate the error?
If the PHRIO and DHRIO2.
disagree on the data
value, the PHMT has
final word on reconciling
the figures.
Table 2: Provincial Data Validation Log

c. Calculate % available reports/databases.[B/A]
d. Check the dates on the reports/databases received. How many reports
were received on time? [C]
e. Calculate % on-time reports/databases. [C/A]
NOTE: To be able to calculate the % on-time reports, there should be a
f. Determine how many reports were complete. (i.e., complete means
g. Calculate % complete reports. [D/A]
time. The PHRIO should validate data using trends quarterly. The PHRIO can
liaise with the rest of the district management team to discuss the trends.
3. Cumulative Data: Check cumulative data with the previous reports to
ensure that it is incremental.
4. Manual Crosscheck: National M&E staff should periodically (at least
semiannually) request a sample. Districts and sites will send them hard-
copy data collection forms, with which they should perform data quality
crosschecks with submitted databases.
5. Onsite Validation: National M&E staff should periodically (at least
semiannually) visit sample Districts to validate the data submitted with
health workers, district, and provincial teams onsite.
Roles of Database Administrator/Programmer:
1. There are quality controls in the national database for when data from
paper-based forms are entered into a computer (e.g., double entry, post-
data entry verification, etc.). For example, the HTC Register provides for
consistency checks, for instance, the entry on the variable “Client tested as”
should be consisted with the entry on the variable “Couple Discordant”.
2. The recording and reporting system avoids double counting people within
and across Service Delivery Points (e.g., a person receiving the same
service twice in a reporting period, a person registered as receiving the
same service in two different locations, etc.).
3. The reporting system/database enables the identification and recording of
a “drop out,” a person “lost to follow-up,” and a person who died.
4. (If applicable) There is a written backup procedure for when data entry or
data processing is computerized.
5. There are backups of all databases received from the districts.
Treatment of Suspect Data:
After the reported data are subjected to all the validation checks, the national
team should perform the following with suspect data:
1. Program Officer/M&E Officer to write a validation report that lists all data
discrepancies, the reasons for errors, and reasons for missing values.
2. Program Officer/M&E Officer to liaise with the district teams to ensure the
correct data values are updated in the databases.
3. Feedback should be systematically given to the districts on the quality of
their data.
4. Program/M&E Officer should maintain a complete record of all data
validation actions for each data collection tool in a District Data Validation
Log (see example of a data validation log below). This document should
contain the following information for each rejected and substituted data
value:
• Site name
• Action taken
• Nature of action
• District AOP targets (annual)
• District AOP achieved (annual)
• Reason why targets were not achieved
District Name District
Database with
Discrepancies
Date Error was
Flagged
Action Taken
Y/N
Nature of Action
Liaise with1.
PHRIO to
validate the
error
If there is2.
disagreement
on data
value, the
PHMT should
deliberate and
agree on the
final decision
District AOP
Targets
( Annually)
District AOP
Achieved
(Annually)
Reason Why
Targets Were
Not Achieved?
Table 3: National Data Validation Log

purpose of this documentSupportive
Supervision The purpose of this document is to outline the procedures to be followed when conducting HIV and
integrated programs M&E supportive supervision visits. Emphasis is placed on supervision of data
management and procedures, including the use of data for program improvement, at all levels where
the supervision takes place.
target audiences
This document is intended for all supervisors who are responsible for conducting support supervision
within their program area and supervisee for proper implementation.
definition
Supportive supervision, also known as facilitative supervision, is a system of management where
supervisors at all levels focus on the needs of the staff they oversee. Supervisors who use the
facilitative approach consider staff as their customers. The most important part of the facilitative
supervisor’s role is to enable staff to manage the quality improvement process, to meet the needs
of their clients, and to implement institutional goals. This approach emphasizes mentoring, joint
problem solving, and two-way communication between the supervisor and those being supervised.
(Facilitative Supervision Handbook, EngenderHealth)
procedures for support supervision
1
2
3
4
A. Frequency
1. At the District Level, the team should cover all the service provision sites
quarterly.
2. At the Provincial Level, it should be conducted biannually.
3. At the National Level, it should be conducted annually.
NOTE: The support supervision activities can also be conducted as the need
arises.
2. Target Audiences 55
3. Definition 55
4. Procedures for Support Supervision 55
A. Frequency 55
B. Team Composition and Functions 56
C. Who Receives Support Supervision 57
D. Tools Require 57
E. Preparation / Planning for Support Supervision 57
F. Provision of Feedback 58
1. On-Site Feedback (Support Supervision Checklist) 58
2. Follow-up Activities and Timelines 58
G. Support Supervision Report 58
H. References: 58

B. Team Composition and Functions
For the supervision visit to be useful, the team that conducts the supportive
supervision visit should consist of persons with technical competence in the
monitoring and evaluation of the program areas for which the supervision
will be conducted. For reviewing of HIV and HIV-related data, the supportive
supervision team should consist of the following, at each level:
National-Level Team Composition:
1. HIS: To provide leadership by ensuring that all team members are present
and clearly understand their individual roles within the team. He/she is
responsible for organizing the logistics of the visit.
2. NASCOP: To review data specific to HIV data issues (tools, reporting,
recording, etc.)
3. DLTLD: To review data specific to TB, TB-HIV, and (leprosy)
4. NPHLS: To review data specific to laboratory activities
5. DRH: To review data specific to RH, MCH
6. Implementing Partner: To assist in reviewing data in the area of technical
support being provided
Provincial-Level Team Composition:
1. PDMS / PDPHS
2. PHRIO
3. PASCO
4. PPHO
5. PTLC
6. PMLT
7. PHRC
8. Implementing partner
District-Level Team Composition:
1. DMOH / DMSO
2. DPHO
3. DHRIO
4. DASCO
5. DTLC
6. DPHN/RH coordinator
7. DMLT
8. Implementing partner
Community-Level Team Composition:
1. CHEW
2. CHC Chair
Facility in-charge4. Implementing partner
who receives support supervision5
6
7
1. Community Level: CHW, CHEW, CORPS
2. Facility Level: Health service providers and the in-charges
3. District Level: DHMT, technical team at the district, and the site service
providers DHMT
4. Provincial Level: PHMT and technical team
tools required
There are standard supervision tools to be used when conducting supportive
supervision visits. The tools should be in hard cover and self-carbonated. A
section on recommendations and summary of findings should be included
in the tools. The document should also provide for the parties, both the
supervisees and supervisors, involved in the support supervision to endorse
the findings. These are:
1. Provincial Supportive Supervision Tool (for national team to supervise the
provincial team)
2. District Supportive Supervision Tool (for Provincial team to supervise the
district team)
3. Facility Supportive Supervision Tool (for the district team to supervise the
facility team)
preparation/planning for support
supervision
1. Ensure that adequate resources are available for provision of resources
(funds, laptops, transport, communication tools, etc.).
2. Ensure that the joint supervisory plan is owned by all specifying the date,
site area, and members to be involved in the activity.
This information should be distributed in advance.

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