Institutional Capacity Assessment Report For Health Regulatory Agency - HEFAMAA 2016

Health Facility Monitoring
and Accreditation Agency
(HEFAMAA):
Organizational and
Technical Capacity
Assessment
[2015 Organizational Capacity Assessment report including
capacity development plan for the agency]
OJUKWU, MARK OJUKWU
ADEBOYE ADEWOYIN
Akaoma Onyemelukwe
SEPTEMBER 2015
This report is funded by UK aid from the UK Government;however, the views expressed
do not necessarilyreflectthe UK Government’s official policies.

Table of Content
Table of Content......................................................................................................................1
List of Tables and Figures ........................................................................................................1
List of Acronyms......................................................................................................................2
Acknowledgements..................................................................................................................3
Executive Summary.................................................................................................................4
1. Introduction ..................................................................................................................6
1.1 Methodology..................................................................................................................6
1.1.1 Organizational Capacity Assessment Domains and Rating................................................7
2. Key Findings..................................................................................................................9
2.1 Overview of HEFAMAA – Mandate, Organizational Structure and Status at time of
Assessment.................................................................................................................9
2.2 HEFAMAA SWOT Analysis...........................................................................................11
2.3 Capacity Assessment Results......................................................................................12
3. Recommendations .....................................................................................................15
Annexes ................................................................................................................................19
Annex 1: Terms of Reference for the Assignment...................................................................19
Annex 2: HEFAMAA Capacity Assessment result, gap analysis and development.....................23
Annex 3: Capacity Development Thrusts................................................................................58
Annex 4: Scenario Mapping Outcome.....................................................................................61
Annex 5: Identification and Prioritization of Capacity Development Assets and Needs .............62
List of Tables and Figures
Table 1: HEFAMAA Capacity Assessment Domain Scores and Weight........................................8
Table 2: Organizational Domain Rating ....................................................................................8
Table 3: HEFAMAA SWOT Analysis .........................................................................................11
Table 4: Summary HEFAMAA Capacity Assessment Weighting and Results .............................12
Table 5: HEFAMAA Capacity Assessment Recommendations ...................................................15
Table 6: Summary Capacity Development Plan ......................................................................58
Figure 1: Organizational Capacity Assessment Process.............................................................6
Figure 2: Regulatory Agency Capacity Assessment Competencies, Domains and Standard
Elements .................................................................................................................................7
Figure 3: Organizational Structure and Status at time of Assessment .......................................9

2
List of Acronyms
HEFAMAA Health Facility Monitoring and Accreditation Agency
HSRL Health Sector Reform Law
HSL Health Scheme Law
HMA Health Management Agency
ICT Information Technology
LASAA Lagos State Advertising Agency
LSMoH Lagos State Ministry of Health
MoH Ministry of Health
NHA National Health Act
NMA Nigerian Medical Association
NHOCAT Organizational Capacity Assessment
PHCB Primary Health Care Board
PCN Pharmaceutical Council of Nigeria
PMVs Patent medicine vendors
SOP Standard Operating Procedures
SWOT Strengths Weaknesses Opportunities Threats
TMB Traditional Medicine Board
TQA Total Quality Assurance
ToR Terms of Reference

3
Acknowledgements
We appreciate the time and contributions of the following people to the development of this
report:
Name Position Organisation
Dr. Modele Osunkiyesi Permanent Secretary Lagos State Ministry of Health
Dr. Mabel Adjekughele Acting Executive Secretary Health Facility Monitoring and
Accreditation Agency (HEFAMAA)
Mrs Sola Hassan HEFAMAA
Dr. Emmanuella Zamba Deputy Director / Head of
Planning/ PATHS2 Focal
Person
Lagos State Ministry of Health
Dr. Ibironke Dada State Team Leader PATHS2, Lagos State
Akaoma Onyemelukwe State Programme/
Technical Specialist HRH
PATHS2, Lagos State (Technical
leadership)

4
Executive Summary
The Lagos State Health Facility Monitoring and Accreditation Agency [HEFAMAA] was created by
Lagos State Health Sector Reform Law 2006. HEFAMAA operates under the supervision of
Lagos State Ministry of Health [MoH] and is led by a six-member Governing Board, under the
leadership of an Executive Secretary. The Agency operates through five [5] departments,
namely [1] Administration & Personnel; [2] Enforcement & Legal Services; [3] Finance &
Internal Audit; [4] Research & Medical Statistics and [5] Inspectorate.
HEFAMAA is tasked with a 13-point mandate. Key amongst these are related to the quality of
service delivery, specifically to; [1] set minimum standards for operations of private and public
health facilities; [2] accredit, inspect, license and register facilities, [3] evaluate facility
performance through monitoring visits and [4] coordinate collection and dissemination of data
on performance indicators.
The institutional/organizational capacity assessment of the agency was conducted in September
2015. The assessment comprised of participatory exercises (Visioning and Scenario Making,
SWOT and Stakeholders’ Analysis), including the use of the Microsoft Excel tool for health
regulatory/accreditation organisations. The capacity assessment tool was adapted from the
National Harmonized Organizational Capacity Assessment Tool - NHOCAT. The HEFAMAA
Capacity Assessment Tool had three sections that [1] scored performance of organizational
capacity across nine domains, [2] identified gaps and [3] generated a capacity development
plan for the agency. It assessed leadership, adaptive, management and operational capacities
including systemic and technical competencies. The systems component considered Human
Resource Management; Budgets and Financial Management; Physical Infrastructure;
Partnerships, Resource Mobilization and Accountability; Knowledge Management, Monitoring and
Evaluation. Technical capacity assessment focused on Leadership and Governance; Experience,
Skills/Technical Management; Coordination; Planning and Supervision/Oversight of Standards.
Total weighting of the nine different domains was 100%. Percentage weights were assigned to
each domain based on relative importance. These varied from 0.7% in Resource Mobilization to
4.7% in Financial Management System.
HEFAMAA had an overall institutional capacity score of 23.4% at the assessment. All domains
were ranged in the categories of Very Poor Capacity to Needing Overhaul. This buttresses the
need for urgent institutional strengthening to support and equip the HEFAMAA team to fulfil its
mandate. For example, the Agency does not yet have a definitive vision, mission and core
values which are the basis for institutional commitment. Strategic management and operational
structures needs to be strengthened. Institutional capacity is weak and the organization
requires increased visibility within the healthcare regulatory landscape in order to establish its
organizational presence.
Organizational systems and structures require overhaul, especially in culture, communication
and human capital management. Management should be strengthened for top-level
engagements within the Ministry of Health. Skilled staff are required to make operational units
functional. Strategic and operational plans are needed to translate its mandate into SMART
goals, objectives and targets. To strengthen HEFAMAA’s institutional capacities, the following
actions were recommended:
1. Management should be led by an Officer on an equivalent rank of Grade Level 17 in the
Civil Service.
2. Develop an organizational strategic plan.
3. Evolve inclusive planning and expanded evidence-based management systems.
4. Review the state healthcare regulatory framework in conformity with current healthcare
regulatory standards and changing health financing landscape following the recent
passage of the Lagos State Health Scheme Law on mandatory health insurance for Lagos
residents.
5. Strengthen linkages and collaborations with other health regulatory bodies in Lagos State.

5
6. Develop strong collaborative intelligence and networking systems for tracking information
on quackery;
7. Strengthen resource mobilization structures.
8. Establish a Corporate Services Unit which would coordinate stakeholder interface and
public relations to improve service delivery and related engagements;
9. Establish a Legal Department to provide guidance for establishment, operations and
litigation matters.
10. Engage in training and human capital investments in leadership, skills acquisition,
strategic thinking and analysis to adapt rapidly to the changing health regulatory
environment.
11. Posting and appropriate deployment of additional technical personnel.
12. Develop and implement a staff appraisal system.
13. Management and administrative structures should be adapted from relevant State civil
service guidelines.
14. Review and/or develop requisite organizational policies and manuals.
15. Develop Organizational Performance, Monitoring and Evaluation systems.
16. Internal mechanisms should be strengthened by defining, documenting and
institutionalizing processes.

6
1. Introduction
The Partnership for Transforming Health Systems Phase II (PATHS2) is working with the Lagos
State Ministry of Health (LSMoH) to strengthen the regulation of health care delivery in the
State. This support will primarily focus on the Health Facility Monitoring and Accreditation
Agency (HEFAMAA). HEFAMAA was established by the 2006 Lagos State Health Sector Reform
Law. The primary objectives of the Agency are to set standards for both public and private
hospitals and other health institutions, improve the quality and efficiency of health care
services to the patients and ensure strict compliance with same (Part 5 [47] HSRL 2006).
The interventions to strengthen regulation of health service delivery through HEFAMAA was
designed to occur in four phases namely 1) rapid assessment of healthcare regulation in
Lagos, 2) organizational capacity assessment of HEFAMAA, 3) development of a capacity
development plan and 4) review of the regulatory framework for the Lagos Health Sector. This
report documents the second and third phase of the strengthening support for healthcare
regulation in Lagos. It outlines the findings of the institutional capacity assessment and
capacity development plan for the Lagos State Health Facility Monitoring and Accreditation
Agency. The objectives of the institutional capacity assessment were:
1. To identify gaps in HEFAMAA’s institutional, organizational and technical capacities for
mandate coordination, facilitation and effectiveness;
2. To develop plans to bridge gaps in institutional, organisational and technical capacities;
3. To formulate strategies for excellent service delivery and relevant skills development.
The capacity assessment process was facilitated by external consultants. Participants at the
two day review meeting comprised of HEFAMAA management and personnel only because the
governing board of the agency was yet to be constituted at the time of the assessment.
1.1 Methodology
The assessment team conducted a desk review of documents such as the 2014 National Health
Act, 2006 Lagos State Health Sector Law, HEFAMAA’s mandate as well as the report of the
Rapid Assessment of the Healthcare Regulatory System in Lagos commissioned by PATHS2.
To guide the development of questions including standard elements in the capacity assessment
tool, the team reviewed the 2006 Health Sector Reform Law (Part 5 Sections 45 -78)
establishing HEFAMAA.
Data was collected over a period of two days and involved four steps (see Figure 1 -
Organizational Capacity Assessment Process).
Figure 1: Organizational Capacity Assessment Process
Step 1: SWOT analysis of the agency looking at its strengths, weaknesses, opportunities and
threats.
Step 2: Organizational capacity assessment across nine organizational domains using the
regulatory agency capacity assessment tool. The team adapted the National Harmonized
Step 1
SWOT Analysis
Step 2
Capacity
Assessment
Step 3
Scenario
Mapping
Step 4
Capacity
Development
Plan

7
Organizational Capacity Assessment Tool – NHOCAT to reflect the unique characteristics of
HEFAMAA as a regulatory agency.
Step 3: Scenario Mapping to explore participants’ current perceptions and vision of an
improved HEFAMAA. Pre-determined parameters were used to define the current
organizational status, participants’ vision of HEFAMAA and to articulate capacity gaps and
needs of the regulatory agency.
Step 4: Capacity development plan developed to address the gaps/needs including
timelines and responsibility centres.
All four steps were participatory thus allowing participants (HEFAMAA staff) to reflect and
answer questions on:
 Where are we now?
 Where do we want to be?
 How do we get there?
 What support do we need and when?
All information gathered were analysed and synthesized to highlight key capacity gaps,
recommendations and participants’ vision for HEFAMAA.
1.1.1 Organizational Capacity Assessment Domains and Rating
The Regulatory Agency Capacity Assessment Tool was used to measure performance against 66
standard elements across nine domains using a participatory approach. The tool assessed
capacity in leadership, adaptive, management and operational areas covering systemic and
technical competencies. Figure 2 shows the relationship between competencies (systemic and
technical), domains and the standard elements.
Figure 2: Regulatory Agency Capacity Assessment Competencies, Domains and
Standard Elements
Each domain was assigned a percentage weight based on its relative importance in HEFAMAA
fulfilling its mandate as a regulatory agency. Domain percentage weights were agreed using a
consultative process with PATHS2 and participants. The weights ranged from 7% for
Procurement and Physical Infrastructure Management to 16% for Planning, Supervision and
Domain4:Partnership, Resource
MobilizationandAccountability
Domain5:HumanResource Management
System
Domain7:Budget and Financial
Management system
Domain8:Procurement, Inventory&
Physical Infrastructure Management
Systems
Domain9:Knowledge Management/
Monitoring andEvaluationSystem
Domain1:Governance & Leadership
Domain2:Experience, Skills andTechnical
Management
Domain3:RegulatoryCoordination
(Networking, Referral andConstituency
Involvement)
Domain6:Planning, Supervisionand
Oversight of Standards
Competencies
RegulatoryAgencyCapacityAssessment
Competencies&Domains
Systemic
Technical
66
Standard
Elements

8
Oversight of Standards. Each domain had five to nine standard elements which contributed to
the overall domain score. Scores were assigned to each standard element based on consensus
and availability of verifiable evidence. Table 1 highlights the nine organizational capacity
domains and percentage weights of each domain.
Table 1: HEFAMAA Capacity Assessment Domain Scores and Weight
Domain Name
Maximum
Domain
Score
Domain
Weight
Domain 1 Governance & Leadership 32 10%
Domain 2
Experience, Skills & Technical
Management
32 11%
Domain 3
Regulatory Coordination (Networking,
Referral and Constituency Involvement)
28 11%
Domain 4 Resource Mobilization & Accountability 20 13%
Domain 5 Human Resource Management Systems 32 10%
Domain 6
Planning, Supervision & Oversight of
Standards
28 16%
Domain 7 Budget & Financial Management System 40 11%
Domain 8
Procurement, Inventory, Physical
Infrastructure Management Systems
24 7%
Domain 9
Knowledge Management /Monitoring and
evaluation system
28 11%
Total 264 100%
The overall score of all nine (9) domains was 100%. Each standard was rated according to
five “capacity performance categories” with scores ranging from 0 to 4: explained below:
0 - very poor capacity; needs overhaul and review
1 - Poor capacity; needs significant support
2 - Acceptable capacity; but in danger of sliding backwards
3 - Good capacity; appears to be sustainable
4 - Excellent capacity; does not require support
The assessment generated relevant information and clarifications were made on standard
elements in the tool. Provision was made for documenting interdependencies or
Aggravation/Extenuating Circumstances that might influence a score. At the end of the
assessment, a dashboard of summary results with colour codes was generated.
Table 2: Organizational Domain Rating
Red
(Critical Concern)
weighted score >0 but <50%
Systemic gaps requiring immediate,
significant, sustained and focused attention
to close.
Yellow (Amber)
(Caution Reaching Critical)
weighted score ≥50% but <75%
Several gaps but cautiously acceptable
performance parameters requiring moderate
level attention to close gaps.
Green
(Stable)
weighted score ≥75% but ≤100%
Relatively stable, no specific or immediate
improvement areas noted.

9
2. Key Findings
2.1 Overview of HEFAMAA – Mandate, Organizational Structure and
Status at time of Assessment
The Private Hospital Registration Authority was transformed into the Lagos State Health
Facility Monitoring and Accreditation Agency in March 2006. HEFAMAA was established by the
2006 Health Sector Reform Law. The primary objectives of the Agency are to set standards
for both public and private hospitals and other health institutions, improve the quality and
efficiency of health care services to the patients and ensure strict compliance with same (Part
5 [47] HSRL 2006).
Figure 3: Organizational Structure and Status at time of Assessment
By Law, the political head of the agency is the Honourable Commissioner for Health however,
this responsibility in the last administration was assigned to the Special Adviser, Public Health.
The operational head of the agency is the Executive Secretary who is full-time and a non-
voting member of the Governing Board. The Governing Board comprises of the Chairman
nominated by the Commissioner for Health, being an experienced medical practitioner with a
minimum of 10 years’ experience of high repute with quality service delivery goals; (b) one
member nominated by the Nigerian Medical Association (NMA); (c) one member nominated by
the National Association of Nigerian Nurses and Midwives, Lagos State Branch; (d) a medical
laboratory scientist nominated by the National Association of Medical Laboratory Scientists of
Nigeria (Lagos State Branch); and (e) a legal practitioner with at least 10 years post call
experience nominated by the Attorney General and Commissioner for Justice.
Part 5 [50] of the Law also empowers HEFAMAA to appoint franchise companies with wide
experience in health care facilities establishment and management including quality assurance
to carry out the monitoring and inspection of public and private health facilities in the State.
However, nine years after its establishment, HEFAMAA is yet to outsource this function to
franchise companies.
Finance
HEFAMAA is entitled to statutory funding from Government and 30% of operational fees from
operations. It is empowered to raise loans, and benefit from donor funds and support.
Government funding had been limited to payment of staff emoluments. According to the Law,
franchisees are entitled to 70% of operational revenue. There are no franchise operators till
date, thus funds earmarked for franchisees are remitted to Government.
Honourable
Commissioner
for Health
Vacant
Enforcement and
Legal Services
Non-existent
Admin/Personnel
Dept.
Shared with
LSMoH
Finance & Internal
Audit
Shared with
LSMoH
Inspectorate
Ad hoc
Research & Medical
Statistics
Non-existent
Chairman
HEFAMAA Board
Vacant
Ex. Secretary
HEFAMAA
Acting
Permanent
Secretary SMOH
Available
Special Adviser
Vacant

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Functions of HEFAMAA (Part 5 [47] HSRL 2006)
1. Set minimum standards for operations of health facilities (both public and private)
2. Issue a format for registration for private facilities to include information on projected
patient flow and monitoring chart for actual performance
3. Accredit, inspect, monitor and license all health facilities
4. Evaluate performance based on set standards by at least a monitoring visit twice a year.
5. Oversee the Drug Quality Assurance Laboratory
6. Disseminate specific performance indicators by way of information to the public from data
made available by the Research and Statistics Department at least quarterly.
7. Ensure actual performance of the indicators
8. Process applications for registration submitted to the Agency from any person.
9. Inspect the premises to be registered under the Law
10. Collate all necessary information on registered health facilities in the State
11. Advise the Commissioner on all matters relating to the registration, inspection and
supervision of private and public hospitals in the state
12. Enforce compliance with the provisions of the Law
13. Ensure the authenticity of credentials of facilities personnel

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2.2 HEFAMAA SWOT Analysis
The strengths, weaknesses, opportunities and threats (SWOT) to HEFAMAA are highlighted in
Table 3 below.
Table 3: HEFAMAA SWOT Analysis
STRENGTHS
1. Access to relevant Government authorities for
regulatory back up and resources.
2. Capacity to generate internal revenue from
registration, license fees and fines.
3. Enabling law vests adequate authority to
execute mandate.
OPPORTUNITIES
1. Favourable Government disposition and
public sensitivity to health care issues.
2. Improved awareness of clients’ rights. This
could enhance community ownership and
regulatory support.
3. Cooperation of major stakeholders on
regulatory and enforcement actions.
4. Improved telecommunications infrastructure
will facilitate quicker turnaround in
regulatory and enforcement actions.
5. Availability of experienced health
professionals under the auspices of the
Lagos State Ministry of Health to serve in
HEFAMAA.
WEAKNESSES
1. Absence of budget monitoring and internal
control policies to streamline fund utilisation
2. Non-existence of some functional units and
technical skills for effective mandate
execution.
3. Lack of critical office space, equipment and
work tools.
4. Inadequate Government funding and
absence of sponsorships from private sector
stakeholders for operations.
5. Lack of functional Local Government Health
Authorities to advocate to community
members and assist with intelligence
gathering on unregistered Health Care
Facilities and malpractices.
6. Inadequacy of appropriate transportation
equipment for use in difficult terrains.
7. Lack of strategic planning systems.
8. Inadequate professional staff.
9. Non-functional website.
10. Inability to exploit geographic information
systems for decision-making.
11. Poor public awareness of Agency’s role in
health care service delivery.
12. Inadequacy of enabling law for regulatory
coverage of contemporary standards in
health care offerings e.g. mobile clinics and
ambulatory service.
THREATS
1. Legal framework of some other agencies
e.g. Traditional Medicine Board and Health
Management Agency creates regulatory
overlaps.
2. Lack of inter-agency engagement between
HEFAMAA and Town Planning Agencies to
monitor compliance with building codes for
health facilities.
3. Lack of inter-agency cooperation on
monitoring and inspection between
HEFAMAA, TMB and PHCB.
4. Bickering among different health
professional groups.
5. Frequent changes and overlap in
Government policies and statutes on
healthcare services.
6. Lack of inter-agency cooperation with Lagos
State Advertisement Agency [LASAA] on
regulation and approval of signages for
health care facilities.
7. Inadequacy of urban planning layouts and
road maps.
8. Competition with other statutory agencies
and parastatals in the Ministry of Health for
professional, financial and material
resources.

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2.3 Capacity Assessment Results
This section of the report contains the summary results of the organizational capacity assessment of HEFAMAA. The detailed capacity assessment tool
with scoring criteria is attached as Annex 2 of this report.
HEFAMAA had a poor performance across all nine domains with an overall score of 23.4%. Performance ranged from the least score of 0.7% in Domain 4
- Resource Mobilization and Accountability to 4.7% in Domain 7 - Budget and Financial Management System. All domains were rated as very poor
capacity needing overhaul or review and coded as colour-red according to the Organizational Domain Rating. Following the baseline assessment,
HEFAMAA should conduct self-assessments on a bi-annual or annual basis to monitor progress and capacity improvements.
Table 4: Summary HEFAMAA Capacity Assessment Weighting and Results
Domain Name
Maximum
Domain
Score
Assessed
Score
Weighted
Score
Domain
Weight
Overall
Score
Findings
Domain 1
Governance &
Leadership
32 9 9.1 10% 2.8%
 Absence of a Governing Board
 Lack of gender balance on the previous Governing
Board [no female representation]
 Absence of vision, mission and core value statements
 Assignment of work is on an ad hoc basis
 No evidence of orientation and identifying board and
management training needs
 Absence of an organogram
 Inchoate communication structures and poor staff
orientation.
Domain 2
Experience, Skills
& Technical
Management
32 4 4.0 11% 1.4%
 Staff knowledge base on health and related regulatory
activity is limited
 Coordination and communication processes for inter and
intra-agency learning are weak
 Institutional engagement in policy formulation and
execution is low.
 HEFAMAA lacks data collection and analysis frameworks
for timely and appropriate policy engagement.
Domain 3
Regulatory
Coordination
(Networking,
Referral and
Constituency
Involvement)
28 9 9.0 11% 3.5%
 HEFAMAA has a good relationship with sister agencies in
health care regulation and control within Lagos state
 However, coordination is not structured and there are
no ToRs [terms of reference] to guide engagements.
 Initiatives are required to exploit latent potential for

13
Domain Name
Maximum
Domain
Score
Assessed
Score
Weighted
Score
Domain
Weight
Overall
Score
Findings
cross learning at National and International fora.
 The agency lacks Technical Quality Assurance
programme/team, constituency engagement and
referral systems.
Domain 4
Resource
Mobilization &
Accountability
20 1 1.0 13% 0.7%
 HEFAMAA has no resource map nor mobilization
strategy. This is compounded by the absence of
statutory capital votes. Government funding had been
limited to recurrent staff emoluments. Alternative
funding is limited to 30% share of operational revenue.
There are no project implementation or financial reports
from operations.
Domain 5
Human Resource
Management
Systems
32 11 11.0 10% 3.4%
 Communication mechanisms exist for information
sharing across organizational units.
 Employee database is updated regularly. However,
human resource policy, procedures and appraisal
systems are not established and those that exist not
effectively utilized.
 Job descriptions are not available and therefore not
utilized to manage staff performance and expectations.
 Skilled technical staff are grossly inadequate.
Domain 6
Planning,
Supervision &
Oversight of
Standards
28 4 4.1 16% 2.3%
 A very poor score for a domain at the heart of
HEFAMAA’s mandate. It reflects the absence of a
documented vision, mission and strategic plans to
define focus and guide operations.
 Operational plans are neither well-utilized nor linked to
medium term sector strategy.
 Stakeholders are not adequately engaged for
institutional effectiveness. Revenue generation is
reported weekly, monthly and annually but reviews are
not done regularly.
 Standards of practice [SOP] are available but seldom
used and limited in scope.

14
Domain Name
Maximum
Domain
Score
Assessed
Score
Weighted
Score
Domain
Weight
Overall
Score
Findings
Domain 7
Budget & Financial
Management
System
40 17 17.2 11% 4.7%
 Absence of budget policies, financial management
manuals and internal audits. External audits are
reportedly conducted by Ministry of Health. Financial
reports were not presented for sighting.
 Budgetary allocations are made by Ministry of Health
without agency input. Operations are funded by the
30% retained on internally generated revenue. Though
an income generating agency, it has no Management
Accountant.
Domain 8
Procurement,
Inventory, Physical
Infrastructure
Management
Systems
24 4 4.0 7% 1.2%
 There are no procurement, stores and supply
management systems.
 Provisions have been made for adequate power supply
and periodic maintenance of vehicles. However, office
accommodation and equipment are inadequate and
fixed asset records are not available.
 For an office regulating health care establishments and
promoting a brand of excellence in the health sector,
the office accommodation is poor, needs to be improved
upon and all personnel in HEFAMAA Head Office
including the Executive Secretary should co-locate.
Domain 9
Knowledge
Management
/Monitoring and
evaluation system
28 8 8.5 11% 3.3%
 The low score indicates that knowledge management,
monitoring and evaluation capacity is weak. Systems
have not been developed for this.
 Service demand evaluation is based on number of
monitoring visits per week but reports are not utilised
for follow-up activity.
 Data management forms are available but not used to
generate feedback on activities.
 Agency lacks a quality assurance and improvement
framework.
Total 264 67 67.9 100% 23.4%

3. Recommendations
Table 5 belowoutlinesthe key recommendations tostrengthenthe capacityof HEFAMAA to
performitsmandate effectively.
Table 5: HEFAMAA Capacity Assessment Recommendations
Domain Recommendation
Domain 1
Governance &
Leadership
 Development of a strategic plan, vision, mission and core value
statements. Same to be communicated to staff and all stakeholders;
 Management team should be led by an Officer on equivalent rank of
Grade Level 17;
 Recruitment and appropriate placement of skilled staff to make
departments (Enforcement and Legal Services, Admin/Personnel
Department, Finance & Internal Audit, Inspectorate, Research &
Medical Statistics) functional;
 Board and Management should reflect gender balance and have clear
definition of roles;
 Facilitate management and governance trainings for Board and
management staff;
 Develop and disseminate operational guidelines, terms of reference,
manuals and processes for statutory roles and responsibilities;
 Develop an organogram to define lines of authority and
accountability; and
 Establish a Legal Unit/Department to provide guidance on
establishment, operational and litigation matters. This should be led
by an officer on equivalent rank of Director [minimum] from the
Ministry of Justice.
Domain 2
Experience,
Skills &
Technical
Management
 Identify technical capacity needs for skills development, acquisition
and effective service delivery (public relations to interface with
clients, regulatory, quality assurance and improvement skills in the
inspectorate unit, knowledge management and M&E skills etc);
 Develop information and communication management systems for
data collection, analysis and dissemination;
 Identify capacity gaps in healthcare regulatory thematic areas for
remedial action;
 Establish basic guidelines and mechanisms for technical
collaborations; and
 Develop a list of potential and existing technical collaborators for
engagement.
Domain 3
Regulatory
Coordination
(Networking,
Referral and
Constituency
Involvement)
 Create technical teams with clear ToR for Supervision and Quality
Assurance;
 Establish a Corporate Services Unit. The unit should coordinate
stakeholder interface in public relations, service delivery and
related engagements;
 Develop referral and networking systems for tracking and updating
information;
 Engage Local Government Health Authorities, constituencies,
community groups and beneficiaries in developing intelligence
cooperation and strong monitoring strategies for the identification
of unregistered Health Care Facilities.
 Undertake learning visits to other National and International
regulatory bodies.

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Domain Recommendation
Domain 4
Resource
Mobilization &
Accountability
 Develop a resource map and mobilization strategies;
 Train staff on resource mobilization, partnership engagement and
management;
 Strengthen upward and downward accountability mechanisms;
 Train relevant staff on financial and activity-based reporting; and
 Incorporate resource mobilization and advocacy in Governing Board
roles and responsibilities.
Domain 5
Human
Resource
Management
Systems
 Request skilled human resource personnel from MoH and other
agencies;
 Develop and implement Human Resource policy and performance
appraisal system. This may be adapted from extant civil service
provisions;
 Develop communication strategy with ICT enhancements on need-
to-know basis;
 Request skilled senior civil servants from MoH as heads of
departments;
 Prepare and disseminate clear job descriptions for each position; and
 Establish staff training scheme and calendar.
Domain 6
Planning,
Supervision &
Oversight of
Standards
 Develop a five year strategic plan;
 Develop and align annual operational plans to overall strategy;
 Develop total quality assurance systems for management and
operational activities; and
 Align operations with national and international standards of practice
in health care system regulation.
Domain 7
Budget &
Financial
Management
System
 Recruit skilled (chartered) accountant(s) and train existing accounts
personnel;
 Develop financial policy, procedure manuals and chart of accounts;
 Establish and implement internal audit mechanisms;
 Develop budgets and multi–year operational plans from strategic
plan;
 Prepare monthly income and expenditure reports, and quarterly
management accounts; and
 Establish budget, financial and project performance review systems.
Domain 8
Procurement,
Inventory,
Physical
Infrastructure
Management
Systems
 Set up a Procurement Unit with skilled staff;
 Procure essential office equipment, furniture and appropriate
operational vehicles;
 Create and updated fixed assets register;
 Establish procurement, stores and supply management systems; and
 Develop and disseminate assets control policy.
Domain 9
Knowledge
Management
/Monitoring and
evaluation
system
 Develop Monitoring/Evaluation and Knowledge Management
systems; recruit skilled staff for implementation;
 Develop Standard Operating Procedures (SOPs) for operations;
 Equip staff with monitoring, supervision and report writing skills; and
 Create Total Quality Assurance (TQA) and management systems.

17
4. Emerging Issues
1. Review the state healthcare regulatory framework in conformity with current healthcare
regulatory standards and changing health financing landscape following the recent passage of
the Lagos State Health Scheme Law on mandatory health insurance for Lagos residents.
2. There are regulatory gaps arising from overlap of roles and responsibilities with other health
agencies (Traditional Medicine Board, proposed Lagos State Health Management Agency).
The law should be reviewed to eliminate overlaps in regulatory oversight with other bodies
e.g. Lagos State Traditional Medicine Board [TMB]. Benchmarks should be identified to
incorporate new products and services in line with prevailing global regulatory standards.
3. The Agency is empowered to appoint franchise operators for health facility monitoring,
inspection and compliance, but none had been identified at the time of the assessment. The
propriety, role and/or conditions for appointment of franchisees should be re -appraised.
4. HEFAMAA is entitled to statutory funding from Government and 30% of operational fees from
operations. It is empowered to raise loans, and benefit from donor funds and support.
Government funding had been limited to payment of staff emoluments. Franchisees are
entitled to 70% of operational revenue. Since there are no franchise operators till date, funds
earmarked for franchisees are remitted to Government. Funding is required to develop and
strengthen the institutional capacity of HEFAMAA.
5. Lack of inter-agency cooperation within the State/Civil Service (e.g. Lagos State Advertising
Agency – LASAA; on advertisement and signages for health services/facilities).
6. Competition with other statutory agencies and parastatals in the Ministry of Health for
professional, financial and material resources.
7. Lack of autonomy. Dependence on MoH for staff deployments and budget allocations. This
limits institutional engagements within the civil service. It dissuades skilled staff from
accepting perceived unfavourable postings and creates bottlenecks in resource flows.
8. Agencies are often treated as extra-departmental off-shoots. HEFAMAA departments are not
fully functional due to inadequacy of office accommodation, technical skills, professional staff
and equipment, and weak internal mechanisms.
5. Lessons Learned
1. As a regulatory body, HEFAMAA needs to institutionalise processes expressly identified by its
enabling law. Without adequate compliance with provisions of its enabling law, the agency
cannot effectively enforce provisions among health facilities.
2. Establishment matters are ensnared by civil service bureaucratic drags. A Legal Department is
required to interpret and streamline institutional structures and processes.
3. Leadership training and capacity development is required for institutional effectiveness and
cross functional engagements.
4. Strategic and operational plans are required to translate mandate into achievable objectives
and targets. These cannot be achieved without appropriate staff placements by skills set.

18
6. Conclusion
Organizational capacity of HEFAMAA was assessed in leadership, adaptive, management and
operational areas covering systemic and technical competences. The systems component
considered Human Resource Management; Budgets and Financial Management; Physical
Infrastructure; Partnership, Resource Mobilization and Accountability; and Knowledge
Management, Monitoring and Evaluation while the technical component focused on competence
in Leadership and Governance; Experience, Skills and Technical Management; Agency
Coordination (Organizing and Constituency Involvement) and Planning, Supervision and
Oversight of Standards.
The cumulative capacity assessment score of 23.4% for HEFAMAA is an indication of weak
systems and management structures. It requires the emergence of sustainable systems,
structures and policies for operational management. Although regulatory bodies often compete
for limited resources, Government should invest and deploy resources (human, financial and
infrastructure) to drive capacity development actions. Going forward, HEFAMAA’s governance and
leadership must be pragmatic, proactive and strategic in the implementation of recommendations
as well as thrusts for capacity development which is outlined in Annex 3 of this report.

19
Annexes
Annex 1: Terms of Reference for the Assignment
Supportinstitutional capacitystrengtheningof the State RegulatoryAgency(HEFAMAA),Traditional
Medicine Board(TMB) PHCBoard and a Private SectorAssociation(AGPMPN)
Budget activity code: 16044 - 6262 Output and Initiative: 2.2.2.1.1 to 2.2.2.1.4
Date of Draft: 18th
November 2014 Consultant(s) Reporting to [person within
programme to manage the task]: Ibironke
Dada
Decision Date: 6th
June 2015 Responsible for Sign-off of SoW/ToRs [person
within programme to sign-off ToRs
SOW Status: Draft / Final copy Person responsible for Quality Assurance (QA)
and technical sign-off [on completion of task by
consultant(s)]:
Purpose of Assignment:
The purpose of this assignment is to strengthen the institutional capacity of the Health Facility
Monitoring and Accreditation Agency (HEFAMAA), PHC Board and a private medical association
(AGPMPN). Institutional capacity assessments will be conducted to provide baseline information on
strengths, gaps and capacity needs. Following the assessment, capacity building plans focused on
key organizational domains such as governance and strategic planning, organizational and human
resources management, resource mobilization and financial management will be developed using a
participatory approach.
Rationale / Justification for Assignment
PATHS2 will explore new opportunities for public and private (PPP) arrangements with the
enactment of the Lagos State Health Agency Law on mandatory health insurance for all Lagosians
in May 2015. Besides the Health Agency, three organizations are critical to the successful
implementation of this new law. These are the Health Facility Monitoring and Accreditation Agency
(HEFAMAA) which accredits and regulates both private and public health facilities, PHC Board
which oversees primary healthcare service delivery and a private medical association (AGPMPN).
Through this law, government will purchase health services from both public and private health
providers.
The key objective of PPP is for government to mobilize and engage the private sector to expand
coverage for the delivery of health care in the state. Our purpose is to strengthen the key
institutions mentioned above to fulfil their mandates, which in turn will lead to health facilities
meeting eligibility criteria as providers for participating in insurance schemes driven by the health
agency law.
The key objective of the health agency law is to establish an institution for the purpose of driving
health care financing schemes that will protect citizens, especially the poor from catastrophic
health expenditure, ie, to improve financial access to health care, especially those with limited
capacity to pay.
PATHS2 will work with these organizations to implement a capacity strengthening program for the
following reasons:
- To gain information on the current organizational and technical capacity of the
organizations
- To establish baseline situation of the capacity and ability of HEFAMAA to regulate the
delivery of health care services in Lagos state.

20
- To identify gaps in the organising, coordination and regulatory functions of both agencies
including AGPMPN
- To strengthen their capacities to foster new and strengthen on-going private public
partnership (PPP) projects
- To work towards the mandate of PHC Under One Roof
This initiative and related activities will contribute to improvement in the regulatory framework in
the health sector (Logframe output level indicator 2.4), which in turn will contribute to
improvement in quality scores (Logframe outcome level indicator 8)
Scope of Assignment
The consultants will facilitate the institutional capacity assessment of key public and private sector
organizations in health. This assessment will cover organizational domains such as governance,
service delivery, financial management, resource mobilization etc. These organizations are the
Health Facility Monitoring and Accreditation Agency (HEFAMAA), Primary Health Care Board
(PHCB) and the private medical association (AGPMPN).
Brief Background
Since 2010, PATHS2 has worked in collaboration with the State Ministry of Health and some of its
agencies to improve the quality of healthcare services in Lagos. During the extension phase which
started in 2014, PATHS2 will work on fostering partnerships between public and private sector
health providers. This is premised on partner organizations having the capacity either as public
agencies to regulate effectively or as private entities to engage government constructively for the
overall good of the population.
The Primary Health Care Board (PHCB) is responsible for coordination, planning, budgeting,
monitoring and evaluation of all the Primary Health Care (PHC) services. This agency is a strategic
partner for the extension phase particularly in light of the PHC Under One Roof initiative and
fulfilling the conditions to access to the Basic Healthcare Provision Fund as articulated in the
National Health Act.
The Health Facility Monitoring and Accreditation Agency (HEFAMAA) have the mandate to regulate
both the public and private sector. It prescribes the minimum standards for both public and private
hospitals and other health institutions so as to improve the quality of he alth care services.
However, this agency has consistently performed poorly. PATHS2 will support HEFAMAA in the
design of a cost- effective monitoring and supervisory system to ensure public and private
providers provide meet the minimum standards required for providing quality services to clients.
The Association of General Private Medical Practitioners of Nigeria (AGPMPN) is a private medical
association with a wide member network. Prior to the enactment of the Health Agency Law on the
state-wide mandatory health insurance program, AGPMPN developed an 18-point agenda for the
association to better position itself and also sought PATHS2’s support for the development of a 5-
year strategic plan.
Specific Tasks:
For this piece of work, three consultants are recommended to provide technical support. Based on
the nature of this assignment, the following specific tasks are required
Lead Consultant
- To collate existing institutional capacity assessment tools and manual
- To facilitate a rapid initial assessment of organizational framework & mandate to inform
design for PHCB, TMB, AGPMPN, HEFAMAA,
- Coordinate the process of adaption of tools and manual to fit each organizational design

21
- Lead harmonization and development of the tools and framework for the institutional
review
- Coordinate and lead the institutional review processes ensuring quality in deployment and
technical reporting
- Participate in all planning meetings
- Debrief each organization & PATHS2 on the outcome
- Lead the production of technical reports for each organization and a harmonised report
with recommendations
2nd
Consultant
- Work on the collation of existing institutional capacity assessment tools and manuals
- Facilitate rapid assessment of organizations framework and mandate for all agencies
- Provide technical capacity for the tools adaptation to fit for both organizations
- Provide technical capacity for harmonization and development of tools and framework for
the institutional review
- Provide technical skills in strategic planning, human resources and financial management
systems of the organization
- Participate and facilitate institutional capacity assessment for all the organizations
- Provide insight on private sector operational issues
- Participate in all planning meetings
- Participate in debriefing of each organization & PATHS2 on the outcome
- Produce consultancy report
- Support the production of technical reports for each organization and a harmonised report
with recommendations
Expected Outputs:
 Capacity assessment tools adapted and harmonized
 Capacity of key Institutions involved in the private sector work assessed.
 Baseline situation of the regulatory framework in Lagos state health sector established
Key Deliverables
1. Report of consultancy
2. Reports/Notes from mandate review
3. Technical report for institutional capacity assessment for each organizations as well as a
harmonized summary including action plan
Profile /Type of Consultants Required: 2 National Consultants are required
The lead consultant will be a senior public health /social development specialist with varied
experience in facilitating institutional capacity assessment for public and private, 2nd consultant
will be a financial management analyst
General qualities required
 Higher relevant academic degrees: Health policy, public health, development studies,
medical sociology, social sciences, or any other relevant discipline required;
 Experience in International development with at least 8 years especially in Health
 Experience in organizational development and management
 Experience in working in supporting strengthening on institutional systems
 Experience in working in supporting strengthening on financial management systems
 Experienced in working with various donors, private sector, partners and public sector
 Excellent research, analytical and writing skills

22
 Excellent skills in team management
 Excellent facilitation skills
 Excellent peoples’ skills.
 Clear understanding and experience in health system strengthening, including
stewardship are mandatory.
 Good understanding of PATHS2 project and its objectives.
 Good understanding of the Nigerian health system.
Reporting & Timing of Consultancy
The assignment is planned to start on the 1st
July 2015. The National Consultants will have a total
of 22 days and 20 days respectively
Duty Station/Location
Within the period of this assignment, the consultants will work with the SPO/HRH Technical
Specialist and report to the State Team Leader in PATHS2 Lagos Office.
Lead Consultant
Activities
No of
days
2nd
Consultant No of
days
To collate existing institutional
capacity assessment tools and
manual
Coordinate the process of adaption of
tools and manual to fit each
organizational design
2 Participate in all planning meetings
Work on the collation of existing
institutional capacity assessment
tools and manuals
Provide technical capacity for the
tools adaptation to fit for both
organizations
2
To facilitate assessment of
organizational framework & mandate
to inform design for PHCB, TMB,
AGPMPN, HEFAMAA
5 To facilitate assessment of
organizational framework & mandate
to inform design for PHCB, TMB,
AGPMPN and HEFAMAA
5
Lead harmonization and development
of the tools and framework for the
institutional review
3 Provide technical capacity for
harmonization and development of
tools and framework for the
institutional review
Provide technical skills in financial
management systems of the
organization
3
Coordinate and lead the institutional
Capacity review processes ensuring
quality in deployment and technical
reporting
- Institutional review for each
organization (2days each x 4
org)
- Development of Reports
Debrief each organization & PATHS2
on the outcome
Lead the production of technical
reports for each organization and a
harmonised report with
recommendations
12 Participate and facilitate institutional
capacity review processes
- Institutional review for each
organization (2days per
organization)
- Development of Reports
Debrief each organization & PATHS2
on the outcome
Support the production of technical
reports for each organization and a
harmonised report with
recommendations
10
TOTAL 22 TOTAL 20

23
Annex 2: HEFAMAA Capacity Assessment result, gap analysis and development
Capacity Score
Assessed standard
0 1 2 3 4
Score
Weight
(0.5 to 1.5)
Evidence
DOMAIN 1: Governance & Leadership 32 10%
1.1 The Agency is
operating under a
known
Law/Mandate
The Agency
mandate or law still
pending withdraft
bill forwarded to
the State House of
Assembly.
Draft AgencyBill
forwardedto the
House andhasbeen
through first
reading.
Draft AgencyBill
available andgone
through first, second
and third readings in
the House.
Draft AgencyBill
passed/signedinto
law but not yet
implemented.
Copyof AgencyLaw is
available andgazetted
(verifybysightingthe
document).
4 0.9 3.6
HEFAMAA law
available as part
of the Lagos State
HealthSector
Reform Law
(2006)
1.2 Multi-sectoral &
Inclusive Board of
the Agency in
place
Membershipof
Board of the Agency
is non-existent.
The Board of the
Agencyis
constituted. 20% of
membership ofthe
Agencyincludes
relevant sectors and
groups.
The Board of the
Agencyconstituted.
50% of membership
of the Agency
includes relevant
sectors andgroups.
The Board of the
Agencyconstituted.
80% of membership
of the Board of the
Agencyincludes
groups.
The Board is
constitutedwith
gender consideration.
Entire membership of
The Agencyincludes
groups
3 1.0 3.0
No female
representation on
the board of
HEFAMAA
1.3 The Agency Board
and Secretariat
roles and
responsibilities
The AgencyBoard
and Secretariat
have NO clear
understanding of
their roles and
responsibilities.
The AgencyBoard
and Secretariat are
orientedonToR
(mandate). The
Agencymission
statement is known
to all.
The AgencyBoard
and Secretariat are
orientedonToR
(mandate). Board
development training
has beenconducted
for Board andstaff.
The Agencymission
statement is known
to all.
The AgencyBoard
and Secretariat are
orientedonToR
(mandate). Board
development
training hasbeen
conducted for
Board andstaff. The
Agencymission
statement is known
to all andthe
Agencyorganogram
is published.
The AgencyBoardand
Secretariat are
orientedonToR
(mandate). Board
development training
conducted for Board
and staff. The Agency
missionstatement is
known to all. The
Agencyorganogram
exists. The Agency
staff jobdescriptions
written andshared.
Management/Board/P
artners meetings hold
regularlyas scheduled,
minutes available and
circulated.
1 1.0 1.0
Mission
statement not
available

24
Capacity Score
Assessed standard
0 1 2 3 4
Score
Weight
(0.5 to 1.5)
Evidence
1.4 Board and
management roles
and
responsibilities
There are noformal
documents that
define current roles
and responsibilities
of Board and
management. The
interpretationis
fluid.
Roles and
responsibilitiesare
not clearlydefined.
Work is assigned on
an ad-hoc basis
accordingto the
perceivedneeds of
the moment.
Roles and
responsibilitiesare in
the processof being
definedbut most
work is stillassigned
on an ad-hoc basis.
Roles and
responsibilitiesare
definedinthe policy
and procedures
manualand they
are beginning to be
usedas the basisfor
assigning work and
rating performance.
Roles and
responsibilitiesare
definedinthe policy
and procedures
manualand are used
as the basisfor
assigning work.
1 1.0 1.0
Work is assigned
on ad-hoc basis
1.5 The Agency's
stakeholders are
well identified and
defined
The Agency's
stakeholders are
not well identified
and defined.
The Agency’s
stakeholders are
identifiedand
defined.
The Agency’s
stakeholders are
identifiedand
defined. The Agency
recognizes the
communityand
other stakeholders as
partners.
Database on
stakeholders
available.
Database on
stakeholders available
(sight database).
Stakeholder analysis
conducted and
updated(sight report).
3 1.0 3.0
Stakeholders’
contact details
available andthey
can be contacted
when needed.
1.6 The Secretariat
have a clear
understanding of
their roles and
responsibilities
Agencyhas no
Operational
Guidelines
(organogram,
schedule of duties)
Agencyhas
documented
Operational
Guidelines
(organogram,
schedule of duties)
but no evidence of
orientation.
Orientationof
Agencystaff on
Operational
Guidelineswith
records to showthat
Agencystaff received
orientation on
Operational
Guidelines.
Records show that
Agencystaff
received orientation
on Operational
Guidelines, with
clear TORs but
duties are not
assignedinline with
TORs.
Records show that
Agencystaff received
orientation on
Operational
Guidelines. There is an
organogram. Roles
and responsibilities
are definedin the TOR
and usedas a basis for
assigning work.
1 1.1 1.1
No evidence of
orientation
available

25
Capacity Score
Assessed standard
0 1 2 3 4
Score
Weight
(0.5 to 1.5)
Evidence
1.7 Authority and
Accountability
There are noformal
documents that
define current lines
of authorityand
accountability. No
organizational
chart.
Organizational chart
to define linesof
authorityand
accountabilityis
being developed.
An approved
organizationalchart
defines lines of
authorityand
accountabilityand is
included in the
Agency’s manualof
policies and
procedures but it is
not followed.
An approved
organizationalchart
defines lines of
authorityand
accountabilityand
is includedin the
Agency’s manualof
policies and
procedures andis
mostlyfollowed.
The approved
organizationalchart
is usedto clarify
linesof authority
and accountability
and evaluate
performance.
An approved
organizationalchart
defines lines of
authorityand
accountabilityand is
included in the
Agency’s manualof
policies and
procedures andis
followed without
contestation.
0 1.0 0.0
No organizational
chart in place
1.8 Training of staff
and Board
members
No training ofstaff
and Agency/Board
members. No
training needs
assessment done.
Training ofstaff and
Board members is
done in response to
invitations andnot
basedonany
identifiedtraining
needs. Records of
training not
maintained.
Board members is
done onown
initiative but not
basedonany
identifiedtraining
needs. Records of
training not
maintained for
individualstaff or
Board members.
Board members is
done based on
result of training
needs assessment.
Records of training
maintained for
individualstaff and
Board members,
but not regularly
updated.
Board members is
done based onresult
of trainingneeds
assessment. Records
of training
maintained, updated
and usedto inform
future training
placements.
0 1.0 0.0
Orientationof
monitors done by
the Executive
Secretarybut no
formal training
done.
SUBTOTAL 9 9.1

26
Capacity Score
Assessed standard
0 1 2 3 4
Score
Weight
(0.5 to 1.5)
Evidence
DOMAIN 2: Experience, Knowledge & Skills Technical 32 11%
2.1 Knowledge and
experience
relevant to
regulatory of
healthcare
services
Staff have nobasic
healthcare
regulatory
knowledge and
experience
relevant to anyof
the healthcare
thematic areas.
At least 25% of
staff have basic
healthcare
regulatory
knowledge and
experience in
relevant
healthcare
thematic areas,
but deployment is
not basedon such
knowledge.
At least 50% of
staff have basic
healthcare
regulatory
knowledge and
experience in
relevant
healthcare
thematic areas and
deployment is
sometimes based
on such
knowledge.
At least 75% of
staff have basic
healthcare
regulatory
knowledge and
experience in
relevant
healthcare
thematic areas,
Programmingand
most of the
deployment are
basedonsuch
knowledge.
Staff have basic
healthcare
regulatory
knowledge and
experience in
relevant healthcare
thematic areas.
Programmingand
all deployments are
basedonsuch
knowledge, whichis
regularlyupdated.
1 1.0 1.0
Deployment to the
agencyis not based
on healthcare
regulatory
knowledge and
experience.
2.2 Organizational
values and
ethical principles
Organizational
values andethical
principles have
not beendefined.
Organizational
values andethical
principles have
been defined but
are not
internalised in the
organization.
Organizational
values andethical
principles have
been defined and
are sometimes
cited bysenior
staff.
Organizational
values andethical
principles are
frequentlycited by
staff at alllevels.
Organizational
values andethical
principles are
widelyknown and
understood and
staff are adheringto
them as a routine.
0 1.0 0.0
No defined
organizational
values andethics
2.3 Knowledge and
skills
improvement
Keystaff and
Board members
do not regularly
update their
knowledge and
skills. No person
has attendedat
least two
conferences or
training sessions
in the past year.
At least 25% of
keystaffand
Board members
regularlyupdate
their knowledge
and skills. More
than one staffand
Board member
have attendedat
least two
conferences or
training sessions
At least 50% of key
staff andBoard
members regularly
update their
knowledge and
skills. Half ofthe
keystaffand
Board members
have attendedat
least two
conferences or
training sessions in
At least 75% of key
staff andBoard
members regularly
update their
knowledge and
skills. Three
quarters of the key
staff andBoard
members have
attended at least
two conferences
or training
All keystaff and
Board members
regularlyupdate
their knowledge
and skills. All key
staff andBoard
members have
attended at least
two conferences or
training sessions in
the past year.
0 1.0 0.0
No staff has gone
for at least two
conferences and
trainings inthe past
year.

27
Capacity Score
Assessed standard
0 1 2 3 4
Score
Weight
(0.5 to 1.5)
Evidence
in the past year. the past year. sessions inthe
past year.
2.4 Basic skills on
healthcare
regulatory of
thematic areas
which the
Agency focuses
on
Keystaff members
have never
received basic
skills needed for
healthcare
regulatoryof the
specific thematic
areas on which
the Agency
focuses on
Basic skill needs
identifiedfor key
staff members
and appropriate
skills transfer
methods
identified, but no
skills
development has
taken place inthe
past year.
Basic skill needs
identifiedfor key
staff members and
appropriate skills
transfer methods
identified;skills
development has
taken place inthe
past year to build
the capacityof at
least one relevant
staff member.
Basic skill needs
identifiedfor key
staff members and
appropriate skills
transfer methods
identified;skills
development has
taken place inthe
past year to build
the capacityof at
least most ofthe
relevant staff
members.
Skills transfer
methods fully
embedded in the
Agencyandusedto
buildthe capacity
on basic healthcare
regulatoryof
thematic areas in
the past year for all
relevant staff
members.
0 1.0 0.0
Onlychecklists
available for use in
the facilities.
2.5 Technical
collaboration
Agencydoes not
have a list of
technical
collaborators and
has not
established a
mechanism for
technical
cooperation/colla
boration.
Coordinating
bodywith a
varietyof
competences
identified, but has
no direct
communication
lineswiththe
Agencyand
stakeholders;
plays little or no
role inAgency’s
or stakeholders’
activities.
Coordinating body
with a varietyof
competences
identified, has
direct
communication
lineswiththe
Agencyand
stakeholders, but
plays noregular
well defined
activitieswith the
Agencyand
stakeholders.
Coordinating body
with a varietyof
competences
identified, has
direct
communication
lineswiththe
Agencyand
stakeholders;plays
regular well
definedactivities
with the Agency
and stakeholders.
Coordinating body
with a varietyof
competences
identified, has
direct
communication
lineswiththe
Agencyand
stakeholders;plays
regular well defined
activitieswith the
Agencyand
stakeholders. The
network hasa
mechanism and
options to get
involvedinpolicy
processes.
0 1.1 0.0
No technical
collaborators
identifiedyet.

28
Capacity Score
Assessed standard
0 1 2 3 4
Score
Weight
(0.5 to 1.5)
Evidence
2.6 Technical
assistance
Agencyhas no
established norms
and guidelines for
technical
assistance to its
stakeholders.
Agencyis inthe
process of
establishing
norms and
guidelinesfor
technical
assistance to its
stakeholders but
has not involved
internal and
external
stakeholders in
defining TA
needs.
Agencyinvolved
internal and
external
stakeholders in
defining TA need
and is inthe
process of
establishing norms
and guidelines for
technical
assistance to its
stakeholders.
Agencyinvolved
internal and
external
stakeholders in
defining TA needs,
has established
norms and
guidelinesfor
technical
assistance to its
stakeholders, but
theyare not easily
available or widely
disseminated
among the Agency
members.
Agencyinvolved
internal and
external
stakeholders in
defining TA needs,
has established
norms and
guidelinesfor
technical assistance
to its stakeholders,
theyare available
and widely
disseminated
among the Agency
members. Includes
fundraising and
resource
mobilization
activities.
0 1.0 0.0
No established
norms and
guidelinesfor
technical
collaborations.
2.7 Policy processes
and dialogue
Agencyis not
involvedinpolicy
process/dialogues.
Mechanism and
options for the
Agencyto get
involvedinpolicy
process/dialogues
are veryweak.
Mechanism and
options exist for
the Agencyto get
involvedinpolicy
process/dialogues
but
communication
betweenthe
Agencyandpolicy
makers is poor.
Mechanism and
options exist for
the Agencyto get
involvedinpolicy
process/dialogues.
There is some
communication
betweenthe
Agencyandpolicy
makers.
Mechanism and
options exist for the
Agencyto get
involvedinpolicy
process/dialogues.
There is a direct
communication
betweenthe
Agencyandpolicy
makers. Agencyis
involvedindrafting
policy.
3 1.0 3.0
Some
communication
exist between the
Agencyandpolicy
makers.

29
Capacity Score
Assessed standard
0 1 2 3 4
Score
Weight
(0.5 to 1.5)
Evidence
2.8 Information and
communication
management
There is no system
in place for data
collectionor for
qualitative and
quantitative data
update and
dissemination.
There is a system
in place for data
collection, but
poor or absent
qualitative and
quantitative data
update;no
dissemination, no
feedback and no
communication
planor systemfor
sharing
information
among Agency
members.
There is a system
in place for data
collection,
qualitative and
quantitative data
update and
dissemination, but
feedback is poor.
There is no
communication
planor systemfor
sharing
information
among Agency
members.
There is a system
in place for data
collection,
qualitative and
quantitative data
update and
dissemination,
feedback is
routine. A
communication
planandan
effective system
for sharing
information
among Agency
members exists.
Data collection,
qualitative and
quantitative data
update system in
place.
Disseminationand
feedback are
routine. A
communication
planandsystemfor
sharing information
among Agency
members exists and
visible operational
processes are
committed to
sharing it widely.
Agencyinfluences
decisionmakingat
the highest level.
0 1.0 0.0
The Local
Government
Monitoring and
Evaluation(M&E)
Officers handles
data fromthe
facilities.
SUBTOTAL 4 4.0

30
Capacity Score
Assessed standard
0 1 2 3 4
Score
Weight
(0.5 to 1.5)
EVIDENCE
DOMAIN 3: Regulatory Coordination (Networking, Referral and Constituency Involvement) 28 11%
3.1 Relationship with
other regulatory
organizations
Agencyhas no
collaboration with
anyother
organization
relevant to
healthcare service
regulations.
Agencyhas
proposalsfor
partnership and
collaboration with
relevant
healthcare service
regulatory
organizations
which are yet to
materialize.
Agencyhas
successful and
productive
relationshipwith
at least one
regulatory
organization
doingsimilar and
relatedwork
relevant to
healthcare service
regulations in the
last three years.
Agencyhas
successful and
productive
relationshipwith
at least two
regulatory
organizations
doingsimilar and
relatedwork
relevant to
healthcare service
regulations in the
last three years.
Agencyhas successful
and productive
relationshipwith
more thantwo
organizations
relevant to healthcare
service delivery
regulations in the last
three years, using
clear and
documented
partnership
guidelinesfor
regulatoryactions.
4 1.0 4.0
Relationshipexists between
the Agencyandmany
regulatoryorganizations
and associations viz;MDCN,
Nursing & Midwifery
Council of Nigeria, NMA
and AGPMPN etc.
3.2 State, National
and international
healthcare service
regulatory fora
The Agencyhas
never participated
in anylocal forum
of organizations
which meet to
deliberate or
interact on
healthcare
regulatoryrelated
issues.
The Agencyhas
identifiedand
collaborates with
local forumof
organizations
involvedin
healthcare service
regulatoryrelated
issues, but has
not participated
in meetings.
The Agencyhas
identifiedand
registered with
local forumof
organizations
involvedin
healthcare service
regulatoryrelated
issues and
participatedinat
least three
meetings in the
past year.
The Agencyhas
identifiedand
registered with
relevant State and
Nationalfora of
healthcare service
regulatory
organizations,
participatedin
most of the
meetings in the
past year and
maintained
records ofsuch
meetings.
The Agency
participates actively
in State, National and
Internationalfora of
healthcare service
regulatory
organizations which
meet to deliberate on
regulatoryissuesand
has records of such
meetings properly
kept andfiledupto
date for the last two
years.
2 1.0 2.0
Meetings ofstakeholders
and grassroots held, with
reports available inthe
Agency.

31
Capacity Score
Assessed standard
0 1 2 3 4
Score
Weight
(0.5 to 1.5)
EVIDENCE
3.3 Relationship with
other healthcare
service regulatory
or supervisory
(supporting)
bodies
The Agencykey
staff members
cannot explain the
Lagos State Health
Development
Plan, Lagos State
HealthReform
Law andother
healthcare service
regulatorybodies
well.
The Agencykey
staff members
can onlyexplain
part of either the
Lagos State
Health
Development
Plan, Lagos State
HealthReform
Law or other
healthcare service
regulatorybodies
in Lagos State.
The Agencykey
staff members
can explainthe
Lagos State
Health
Development
Plan, Lagos State
HealthReform
Law andother
healthcare service
regulatorybodies
in Lagos State.
Most Agencykey
staff members
can explainthe
Lagos State
Health
Development
Plan, Lagos State
HealthReform
Law andother
healthcare service
regulatorybodies
in Lagos State.
All Agencykeystaff
members canexplain
the Lagos State
HealthDevelopment
Plan, Lagos State
HealthReform Law
and other healthcare
service regulatory
bodieswell anduse
this knowledge to
guide their activities
and networking in
Lagos State.
3 1.0 3.0
Most keystaffcandescribe
those laws andreforms
very well.
3.4 The Agency
coordinates the
regulation of
healthcare service
related activities
in the State based
on its mandate
No coordination
platforms with
other healthcare
service regulatory
Agency
established and no
TOR.
Coordination
platforms with
other healthcare
service regulatory
Agency
established. TOR
draftedbut no
forums
established or
meeting.
Coordination
platforms with
other healthcare
service regulatory
Agency
established.
Meeting ad hoc
and not guided by
TOR.
Coordination
platforms with
other healthcare
service regulatory
Agency
established and
meetingguided
byTOR but no
feedback
mechanism in
place for action.
Coordination
platforms with other
healthcare service
regulatoryAgency
established and
meetingregularly
guidedbyTOR.
Coordination
challengesare
identified. Follow-up
and feedback
mechanism with
healthcare service
regulatory
Agencies/Boards and
other partners exists.
0 1.1 0.0
No coordinationplatform
available.

32
Capacity Score
Assessed standard
0 1 2 3 4
Score
Weight
(0.5 to 1.5)
EVIDENCE
3.5 The Agency
participation in
technical quality
assurance and
supervision
The Agencydoes
not participate in
anytechnical
qualityassurance
and supervision
visits conducted
bythe LSMoH,
other healthcare
service regulators
and partners.
The Agencyhas
participatedin
onlyone technical
qualityassurance
and supervision
visit conductedby
the LSMoH, other
healthcare service
regulators and
partners.
The Agency
participates
passivelyin all
technical quality
assurance and
supervision visits
conducted by
LSMoH, other
healthcare service
regulators and
partners.
The Agencyplans
technical quality
assurance and
supervision visits
proposedby
LSMoH, other
healthcare
regulators and
partners.
The Agencyplans and
takes the leadin
technical quality
assurance and
supervision visits
proposedbyLSMoH,
other healthcare
service regulators and
partners.
0 1.1 0.0
No technical quality
assurance platform
available.
3.6 Referral system
and linkages with
other regulatory
organizations
Agencyhas no
referral and
networking
systeminplace.
Agencyhas a
systemfor
referral and
networking but
staff lack
knowledge and
skills for effective
referral.
Agencyhas a
systemfor
referral but staff
lack knowledge
and skills for
effective referral,
networking and
collaboration but
evidence abounds
that skills are
being built.
Agencyhas
functional
referral,
networking and
partnership
systeminplace
and maintains
referral linkages
or networks with
other healthcare
service regulatory
organizations, but
referral,
networking and
collaborating
client tracking
records are not
properlykept.
Agencyhas functional
referral, networkand
partnership systems
in place and
maintains referral
linkagesor network
with other healthcare
service regulatory
organizations;
referral, networking
and collaborating
clients'tracking
records are properly
kept andupto date.
0 1.0 0.0
No referral and networking
systeminplace.

33
Capacity Score
Assessed standard
0 1 2 3 4
Score
Weight
(0.5 to 1.5)
EVIDENCE
3.7 Participation of
constituencies,
beneficiaries and
community groups
Constituencies,
communitygroups
and beneficiaries
are not involvedin
developing
networking and
referral strategies
for the regulatory
Agency.
Constituencies,
community
groups and
beneficiaries are
involvedin
developing the
regulators
networking and
referral strategies
but their needs
are not captured.
Constituencies,
community
groups and
beneficiaries are
involvedand
strategies are
developedbased
on assumptions
about the needs
of beneficiaries
and their
communities.
Strategies are
developedbased
on accurate
informationabout
the needs of
constituencies,
beneficiaries and
their communities
but without active
participationof
such
clients/constituen
cies or
communities.
Strategies are
developedbasedon
accurate information
about the needs of
beneficiaries and
their communities
and with active
participationof such
constituencies, clients
and communities.
0 1.0 0.0
Constituencies and
communitiesdo not
participate in networking
and referral strategies.
SUBTOTAL 9 9.0

34
Capacity Score
Assessed standard
0 1 2 3 4
SCORE
Weight
(0.5 to 1.5)
EVIDENCE
DOMAIN 4: Resource Mobilization & Accountability 20 13%
4.1 Resource map The Agencyhas no
resource mapfor
the State from
which to mobilize
resources.
The Agencyhas
an oldresource
map for the State
(beenupdated
two years or
more). The mapis
not used to
mobilize
resources and
contains onlythe
listing of funding
partners.
The Agencyhas a
resource mapfor
the State but it is
not current
(updated one year
ago). The map is
not used to
mobilize
resources. Map
lists information
onlyon the
amount and
timeline of
available funds.
The Agencyhas an
updateddirectory
on the State
resource mapwith
limited
informationon
amount available,
who to accessand
the timeline for
the funding.
Resource map
available and
updatedwith
detailson available
funding(amount,
timeline,
procedure to
access the fund).
0 1.0 0.0
No resource mapavailable
in the agency.
4.2 Resource
mobilization and
intervention
priorities
Resource
mobilizationis not
derivedfromthe
budget and
operationalplan.
Resource
mobilizationis
derivedfromthe
budget, but not
linked to the
operationalplan.
Resource
mobilization
derivedfromthe
budget, draft
operationalplan
and it is not
aligned to the
intervention
priorities.
Resource
mobilization
derivedfromthe
budget, costed
operationalplan
but not alignedto
the intervention
priorities.
Resource
mobilization
derivedfromthe
budget, costed
operationalplan
and aligned to the
intervention
priorities.
0 1.0 0.0
The agencydoes not
operate onbudgetedfunds.
4.3 Resource
mobilization
expenditure and
accounting
No skills in
resource
mobilizationand
advocacy.
Separate accounts
are not openedfor
different funders.
Skills are available
for resource
mobilizationand
advocacybut no
MoUs are
developedand
signed with
fundingpartners
and no separate
account code for
the different
for resource
mobilizationand
advocacy, MoUs
are developedand
signed with
fundingpartners
but no separate
account code for
the different
funders.
for resource
mobilizationand
advocacy, MoUs
are developedand
signed with
fundingpartners
and different
fundinghas
different
accounting code.
for resource
mobilizationand
advocacy, resource
mobilizationplan
in place, MoUs are
developedand
signed with
fundingpartners
and different
fundinghas
0 1.0 0.0
The agencydoes not have
funders apart from the
government.

35
funders. different
accounting code.
4.4 The Agency
advocacy and
resource
mobilization
strategy
No resource
mobilization
strategyin place.
Resource
mobilization
strategies and
advocacypackage
are developed
from
budget/workplan/
mandate but the
Agencydoes not
engage in
proposal writing
and there is no
interactive forum.
Resource
mobilization
strategies and
advocacypackage
are developed
from
budget/workplan/
mandate, proposal
writingis usedin
resource
mobilizationbut
there is no
Agency/partners’
interactive forum.
Resource
mobilization
strategies and
advocacypackage
are developed
from
budget/workplan/
mandate, proposal
writingis usedin
resource
mobilizationand
there is a platform
for
Agency/partners’
meetingbut no
regular meetings.
Resource
mobilization
strategies and
advocacypackage
are developed
from
budget/workplan/
mandate, proposal
writingis usedin
resource
mobilizationand
there are regular
quarterly
Agency/partners’
forum meetings.
0 1.0 0.0
No resource mobilization
strategyin place.
4.5 Financial and
implementation
report sharing
No
implementation
and financial
report produced.
Implementation
and annual
financial reports
produced but
irregular
circulation.
Quarterly
implementation
and annual
financial reports
produced and
circulatedto
stakeholders.
Quarterly
implementation
and annual
financial reports
produced and
circulatedto
stakeholders.
Regular quarterly
review meeting
heldby
stakeholders.
Quarterly
implementation
and annual
auditedfinancial
reports circulated
to stakeholders.
Regular quarterly
review meetings
heldby
stakeholders.
1 1.0 1.0
No implementationand
financial report produced.
SUBTOTAL 1 1.0

36
Capacity Score
Assessed standard
0 1 2 3 4
SCORE
Weight
(0.5 to 1.5)
Evidence
DOMAIN
5:
Human Resource Management Systems 32 10%
5.1 Human resource
policies and
procedures
Humanresource
policies and
procedures are
absent.
Humanresource
policies and
procedures are in
the processof
development.
Humanresource
policies and
procedures are in
place and
managers are
aware of them
but do not use
them.
Humanresource
policies and
procedures are in
place and
managers use
them
inconsistently.
Humanresource
policies and
procedures are in
place andmanagers
use them consistently
to hire andretain
talentedand
committed staff.
0 1.0 0.0
No humanresource policies
or procedures inplace.
5.2 Communication
mechanisms and
information
sharing
Communication
mechanisms for
sharing
informationacross
organizational
units andamong
staff at different
levels donot exist.
Communication
mechanisms for
sharing
information
across
organizational
units andamong
staff at different
levels are being
developed.
Communication
mechanisms are
in place but are
not used to share
information
across
organizational
units andamong
staff at different
levels.
Communication
mechanisms are
usedto share
information
across
organizational
units andamong
staff at different
levels but they
are ineffective.
Communication
mechanisms are used
consistentlyand
effectivelyto share
informationacross
organizationalunits
and among staffat
different levels.
4 1.0 4.0
Communication
mechanisms are usedto
share information across
organizationalunits andat
all staff levels.
5.3 Job Descriptions No Job
Descriptions exist.
Job Descriptions
are being
developedfor all
positions.
Clear Job
Descriptions exist
for all positions
but are filedand
not used.
Clear Job
Descriptions exist
for all positions,
but theyare used
inconsistentlyand
are not usedto
manage staff
performance
expectations.
Clear JobDescriptions
exist for all positions,
theyare used
consistentlyto
manage staff
performance
expectations andare
regularlyreviewed.
3 1.0 3.0
Job descriptions are not
usedto manage staff
performance expectations.

37
Capacity Score
Assessed standard
0 1 2 3 4
SCORE
Weight
(0.5 to 1.5)
Evidence
DOMAIN
5:
5.4 Performance
evaluation and
staff
development
No performance
appraisalsystem
or procedures for
performance
evaluationand
staff development
exist.
A performance
appraisalsystem
and procedures
for performance
evaluationand
staff development
are being
developed.
A performance
appraisalsystem
is inplace, but
there are no
procedures for
performance
evaluationand
staff
development.
A performance
appraisalsystem
is inplace,
procedures for
performance
evaluationand
staff development
exist but theyare
not used.
A performance
appraisalsystemis in
place, procedures for
performance
evaluationandstaff
development exist
and are in use.
0 1.0 0.0
No performance appraisal
systeminplace.
5.5 Database for
employee
biodata and
career
information
No database for
employee biodata
and career
information exists.
A database for
employee biodata
and career
informationis in
the processof
being set up.
A database for
employee biodata
and career
informationwas
set up but is not
comprehensive as
data is missing. It
is not maintained
and has not been
updatedfor a
year.
A comprehensive
database for
employee biodata
and career
informationwas
set up but is not
maintained and
has not been
updatedfor a
year.
A comprehensive
database for
employee biodata
and career
informationis
maintained and
regularlyupdated.
4 1.0 4.0
Employee database
available andupdated
regularly.
5.6 The Agency
Secretariat
staffing is
according to the
establishing
mandate/law,
Standard and
organogram
The Agency
Secretariat
inadequately
staffed(onlya
Chief Executive
Officer, with no
clearlydefined
Heads of
Department nor
thematic officers).
The Agency
Secretariat
staffedwithat
least Chief
Executive Officer,
two Heads of
Department, two
thematic officers
and support staff.
The Agency
Secretariat
staffedwithChief
Executive Officer,
three Heads of
Departments,
four thematic
officers and
support staff.
The Agency
Secretariat
staffedwithChief
Executive Officer,
four Heads of
Departments,
seventhematic
officers and
support staff.
The Agency
Secretariat
adequatelystaffed
accordingto NSP
Standardand
organogram:
- Chief Executive
Officer
- Heads of
Departments
- Thematic Officers
- Support staff
0 0.9 0.0
The agencyis inadequately
staffed.

38
Capacity Score
Assessed standard
0 1 2 3 4
SCORE
Weight
(0.5 to 1.5)
Evidence
DOMAIN
5:
5.7 New staff
induction and
orientation
New staff is not
inductedand
oriented.
New Staff are
inductedand
orientedbut it is
ad hoc.
New Staff are
inductedand
oriented
accordingto a
documentedstaff
orientation
package.
Staff orientation
package available,
orientation takes
into consideration
gender andright
basedapproach
to management
and
programming,
familiarization
with Values,
Vision, Mission
and Goals
(VVMG).
Staff orientation
package available,
orientation takesinto
consideration gender
and right based
approachto
management and
programming,
familiarizationwith
Values, Vision,
Mission andGoals
(VVMG), knowledge
of Agencylaw and/or
national guidelines on
the establishment of
The Agency.
0 1.0 0.0
New staff not available nor
inducted.
5.8 Personnel policy No Personnel
policyinplace.
Personnel policy
developedand
documentation
available but not
implemented.
Personnel policy
in place, staff
receive
orientation onits
use but do not
have their own
copies.
Personnel policy
in place, staff
have received
orientation and
have copies.
Management
follows the
personnel policy
manualfor
decisionmaking.
Personnel policy
includes job
description,
compensation,
hiring/promotion,
grievances, andwork
hours;Staffreceive
orientation onthe
use of the personnel
policy. All staffhave
copies of the
personnel policy.
Management follows
the personnel policy
manualfor decision
making. Systems have
been establishedfor
performance
0 1.0 0.0
No personnel policy
available for
implementation.

39
Capacity Score
Assessed standard
0 1 2 3 4
SCORE
Weight
(0.5 to 1.5)
Evidence
DOMAIN
5:
appraisal. Tools for
staff performance
appraisalare
available.
Performance
appraisalis inline
with individual job
description and
workplan.
SUBTOTAL 11 11.0

40
Capacity Score
Assessed standard
0 1 2 3 4
SCORE
Weight
(0.5 to 1.5)
Evidence
DOMAIN 6: Planning, Supervision & Oversight of Standards 28 16%
6.1 Vision, mission
and SMART goals
There are no
developedvision,
missionandgoals
of the Agency.
The vision,
missionandgoals
of the Agencyare
developed, not
SMART and not
aligned to
available policies
or strategic plan.
The vision,
missionandgoals
of the Agencyare
developed, not
SMART, alignedto
available policies
but not to
strategic plan.
The vision,
missionandgoals
of the Agencyare
developed,
SMART and
aligned to
available policies
but not to
strategic plan.
The Agencyhas
developedvision,
missionandSMART
goals andthese are
all alignedto
available policies and
strategic plan.
0 1.0 0.0
No vision, missionand
smart goals inplace inthe
Agency.
6.2 Costed strategic
plan
The Agencyhas no
costedstrategic
plan.
Planning process
are not well
articulated,
activitiesare
unplannedand
are often
developedto
meet funder's
requirements.
The strategic
plans are
developedwith
no guidelines, and
not fullyaligned
to the national
healthpolicy,
Lagos State
Health
Development
Plan, Lagos State
HealthReform
Law andnot
costed.
The strategic
plans are
developedinline
with the national
healthpolicy,
Lagos State
Health
Development
Plan, Lagos State
HealthReform
Law and
guidelinesbut
theyare not
costed.
The strategic plans
are developedin line
with the national
healthpolicy, Lagos
State Health
Development Plan,
Lagos State Health
Reform Lawand
other guidelines, such
as the MTEF/MTSS.
Theysupport policy
implementation
aligned to the vision,
missionandgoals of
the Agencyandare
costed.
0 1.0 0.0
No costedstrategic plan
available inthe Agency.

41
Capacity Score
Assessed standard
0 1 2 3 4
SCORE
Weight
(0.5 to 1.5)
Evidence
6.3 Annual
operational
plans
No operational
plans or theyare
not derivedfrom
strategic plans.
Operational plans
are developedbut
neither aligned to
strategic plans
nor has
constituents or
stakeholders’
involvement.
The operational
plans are well
articulatedand
contain the
following basic
components:
• Focus Results
• Objectives
• Activities
• Timelines
The operational
plans are well
articulated,
contain the
following basic
components:
• Focus Results
• Objectives
• Activities
• Timelines
Theyare
developedwith
constituents and
stakeholders.
The operationalplans
are well articulated,
benefits from
previous plans,
routinelyupdated
and adjustedbased
on monitoring
processes. They
contain the following
basic components:
• Focus Results
• Objectives
• Activities
• Timelines
Theyare developed
with constituents and
stakeholders.
1 1.0 1.0
Operational planare not
well utilizedandnot linked
to strategic plans or
stakeholders involvement.
6.4 Funding,
implementation,
tracking and
reporting of
plans
There is no
fundingof
operationalplans,
implementationis
weak or not
existent, tracking
absent andno
reports generated.
There is very
minimal funding
of operational
plans,
implementationis
weak, tracking
absent andno
reports
generated.
There is some
fundingof
operationalplans,
implementationis
proceeding, but
actions are not
tracked or
reported
annually.
There is realistic
fundingof
operationalplans,
implementationis
proceeding, most
actions are
tracked and
reports generated
at least annually.
There is realistic
fundingof
operationalplans,
implementationis
strong, clearlytracked
and reports
generatedquarterly
and annually.
2 1.0 2.0
There are some fundingof
the agencyandreports are
generatedweekly, monthly
and annually.
6.5 Review of plans
and planning
cycle
The Agencyplans
are in place but
not reviewed.
The Agencyplans
are not reviewed
and outcomesnot
usedto inform
the next planning
cycle.
The Agencyplans
are reviewed but
outcomes not
usedto inform
the next planning
cycle.
The Agencyplans
are reviewed and
outcomes usedto
inform the next
planning cycle but
are not
prioritized.
The Agencyplans are
reviewedand
outcomes usedto
inform the next
planning cycle, taken
into the budgeting
process andproperly
prioritized.
0 1.0 0.0
No review ofplaninthe
Agency.

42
Capacity Score
Assessed standard
0 1 2 3 4
SCORE
Weight
(0.5 to 1.5)
Evidence
6.6 Service
standards
internal to The
Agency
The Agency
emphasizes the
number of
regulatory
activities
undertaken,
rather than the
qualityof
healthcare
regulatoryservices
provided to other
organizations.
The Agency
acknowledges the
importance of
high quality
healthcare
regulatory
services provided
to their
constituents. It is
considering
activitiesthat will
helpstaff
regularlyassess
and improve
qualityregulatory
activitiesbut
there is no
documented
quality
improvement and
regulatory
programme.
The Agencyhas
undertaken some
activitiesto
assess and
improve the
qualityof
healthcare
regulatory
services provided
to the
constituents and
other
organizations but
theyare drivenby
external
initiatives. A few
interested
members of staff
have taken
responsibilityfor
conducting
healthcare
regulatory
activities.
The Agencyhas
undertaken
activitiesto assess
and improve the
qualityof
healthcare
regulatory
services provided.
A few interested
members of staff
have taken
responsibilityfor
conducting these
activitiesother
than those driven
bydonors.
There is an
established, on-going
systemfor assessing
and improvingthe
qualityof healthcare
regulatoryservices.
Trainedstaff are
regularlyusingthe
system.
1 1.1 1.1
Standardof practice
available inthe agency.

43
Capacity Score
Assessed standard
0 1 2 3 4
SCORE
Weight
(0.5 to 1.5)
Evidence
6.7 International,
national and
state service
standards and
guidelines
The Agency
emphasizes the
number of State,
National/Internati
onal guidelines
available, rather
than adherence
and use of such
protocols to
facilitate and
monitor delivery
of healthcare
services in the
State.
The Agency
acknowledges
high importance
of State,
National/Internati
onal guidelines
and protocols. It
is considering
activitiesthat will
helpthe Agency
to have access to
such healthcare
regulatory
protocols and
guidelines.
The Agency
undertakes
healthcare
regulatory
activitiesto
promote and
facilitate the
development,
testingand
utilization of
State,
National/Internati
onal
guidelines/protoc
ols andnot
monitor
adherence by
healthcare service
providers only
when activities
are driven by
external related
activities. Some
staff are trained
on new State,
National/Internati
onal standards
and guidelines to
oversee
healthcare
regulatory
services
The Agency
undertakes
healthcare
regulatory
activitiesto
promote and
facilitate the
development,
testingand
utilization of
State,
National/Internati
onal
guidelines/protoc
ols but does not
monitor
adherence by
healthcare service
providers. Some
staff are trained
on new State,
National/Internati
onal standards
and guidelines to
oversee that
healthcare
regulatory
services are
provided.
There is an
established, on-going
systemfor
development, testing
disseminationand
utilization of
protocols (domestic
and international) for
qualityhealthcare
regulatoryservices
delivery. Trained staff
are regularlyusing
acceptedState,
National/Internationa
l standards and
guidelinesto oversee
healthcare regulatory
services that are
provided
0 0.9 0.0
Non-existence in
HEFAMAA.
SUBTOTAL 4 4.1

44
Capacity Score
Assessed standard
0 1 2 3 4
Score
Weight
(0.5 to 1.5)
Evidence
DOMAIN 7: Budget & Financial Management System 40 11%
7.1 Annual
Operational
Plan, Multi-year
Strategic Plans &
Budgets
There is no annual
budget and
operationalplan.
There are annual
budgets which
are able to meet
the donors' needs
in regard to
segregationof
programs and
costs.
There are annual
operationalplans
and budgets
which are able to
meet the donors'
needs inregard to
segregationof
programs and
costs. Annual
budgets are
directlytiedto
the Agency’s
annual
operationalplans
but theyare not
developedjointly
byFinance and
Programs
departments.
There are annual
operationalplans
and budgets
which are able to
meet the donors'
needs inregard to
segregationof
programs and
costs. Annual
budgets are
directlytiedto the
Agency’s annual
operationalplans
and are developed
jointlybyFinance
and Program
departments.
There are annual
operationalplans and
budgets whichare
able to meet the
donors' needs in
regard to segregation
of programs and
costs. Annual
budgets are directly
tied to the Agency’s
annual operational
plans andare
developedjointlyby
Finance and Program
departments. There
is a multi-year budget
developedbySenior
Staff, linkedto
Strategic Plan and
guides annual
budgetingsystem.
0 1.2 0.0
No annual budget and
operationalplanavailable.
The Agencyrelieson its
30% allocationof revenue
generatedas running cost.
7.2 Budget Policies
and Procedures
There are no
established
budgetingpolicies
and procedures
guiding budget
processes.
There are
established
budgetingpolicies
and procedures
guiding budget
processes but
these donot
cover the critical
areas of:
• roles and
responsibilities
There are
established
budgetingpolicies
and procedures
which meet
generally
accepted
accounting
practices and
cover the critical
areas of:
There are
established
policies and
procedures
manualwhich
guides the
budgeting
process, andis
readilyavailable
to all staff
members involved
There are established
policies and
procedures manual
which guidesthe
budgetingprocess,
and is readily
available to allstaff
members involvedin
budgeting. The
policies and
procedures meet
0 1.2 0.0
No budget policies and
procedures available.

45
Capacity Score
Assessed standard
0 1 2 3 4
Score
Weight
(0.5 to 1.5)
Evidence
• review and
approval
processes
• reporting
processes
• variance
detection and
analysis
• roles and
responsibilities
• review and
approval
processes
• reporting
processes
• variance
detection and
analysis
in budgeting. The
policies and
procedures meet
generally
accepted
management
practices and
cover the critical
areas of:
• roles and
responsibilities
• review and
approval
processes
• reporting
processes
• variance
detection and
analysis
•periodic budget
review and
supplementary
provisions where
necessary
Staff members
involvedin
budgetingare
systematically
orientedor
trainedinthe
contents ofthe
policyand
procedures
manual.
generallyaccepted
management
practices andcover
the criticalareasof:
• roles and
responsibilities
• review and
approval processes
• reportingprocesses
• variance detection
and analysis
• periodic budget
review and
supplementary
provisions where
necessary
Staff members
involvedinbudgeting
are systematically
orientedor trainedin
the contents ofthe
manualand they
have the templates
and relatedreport
format theyneedto
track and document
activitiesand
expenses.

46
Capacity Score
Assessed standard
0 1 2 3 4
Score
Weight
(0.5 to 1.5)
Evidence
7.3 Budget approval
and
development
No budget
developedor
approved.
Budgets exist but
are not linked to
existingplans nor
previous
allocationand
expenditure
reports.
Approved
budgets are
basedonexisting
plans.
Approved budgets
are based on
existingplans and
previous year's
expenditure
report.
Approved budgets
are developedwith
inputs from program
managers, based on
existingplans and
previous year's
allocationand
expenditure reports.
0 1.0 0.0
7.4 Annual budget
performance
review
Annual
Performance
Review(APR) of
budget not
conducted
APR is conducted
with 25% of
stakeholders in
the sector
identifiedon the
resource map.
APR of budget is
conducted with
50% of
stakeholders in
the sector
identifiedonthe
resource map.
APR of budget is
conducted with
75% of
stakeholders in
the sector
identifiedonthe
resource map.
APR of budget is
conducted in
collaboration withall
stakeholders inthe
sector identifiedon
the resource map.
0 1.0 0.0
No budget available.
7.5 Financial
management
system and staff
training
No financial
management staff
or theydo not
have the requisite
skills nor software
to manage
financial
informationand
keep records.
Financial
management staff
appointedbut
have inadequate
training andno
software to
manage financial
information,
reports and coded
charts of accounts
to monitor
performance by
project anddonor
requirements.
Financial
management staff
have requisite
training but no
software to
manage financial
information,
reports and no
coded charts of
accounts to
monitor
performance by
project anddonor
requirements.
Financial
management staff
have requisite
training and
software but
software not
meetingthe needs
to manage
financial
informationand
reports. No coded
charts of accounts
to monitor
performance by
project anddonor
requirements.
Financial
management staff
have requisite
training androbust
software to manage
financial information,
reports and coded
charts of accounts to
monitor performance
byproject anddonor
requirements.
0 0.9 0.0
No financial management
systemor staff training
available.

47
Capacity Score
Assessed standard
0 1 2 3 4
Score
Weight
(0.5 to 1.5)
Evidence
7.6 Financial
management
processes for
internal audit
Financial
management
process for
internal audit
transaction,
controls and
reporting of
income and
expenditure not
available.
Financial
management
process for
internal audit
transaction,
controls and
reporting of
income and
expenditure are
not well
documentedand
not readily
available for
implementation.
Financial
management
process for
internal audit
transaction,
controls and
reporting of
income and
expenditure is
well documented
and available but
not used.
Financial
management
process for
internal audit
transaction,
controls and
reporting of
income and
expenditure is
available andin
use bysome
financial and
project
management
staff.
Financial
management process
for internal audit
transaction, controls
and reporting of
income and
expenditure is
available andinuse
byall the Agency
financial andproject
management staff.
4 1.1 4.4
An account management
staff is available fromthe
ministrybut not a core staff
of the Agency.
7.7 Internal monthly
income and
expenditure
reports
Internalmonthly
income and
expenditure
reports are not
developed.
Internalmonthly
income and
expenditure
reports are
developedbut
not in a timely
manner.
Internalmonthly
income and
expenditure
reports are
developedto
support program
and financial
management
decisions but not
accurate andina
timelymanner.
Internalmonthly
income and
expenditure
reports are
accurately
developedto
support program
and financial
management
decisions, but not
in a timely
manner.
Internalmonthly
income and
expenditure reports
are accurately
developedina timely
manner to support
program and
financial
management
decisions.
4 1.0 4.0
Financial is timely.
7.8 External audits External audits are
not conducted.
External audits
are conducted
onlyonce inevery
5 years.
External audits
are conducted
everytwo years
but not byan
approved and
registered firm.
External audits are
conducted byan
approved and
registered firm
once intwo years.
External audits are
conducted byan
approved and
registered audit firm
annually.
4 0.9 3.6
External auditing
conducted regularly.

Institutional Capacity Assessment Report For Health Regulatory Agency - HEFAMAA 2016

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