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Clinical Assessment for Systems Strengthening (ClASS)

The ClASS Framework is based upon the following key principles:

Successful Transition: HRSA has successfully used the ClASS framework to support the transition of 13 HRSA/PEPFAR programs to local partners in nine countries, including Harvard’s Nigeria program, which was the largest at approximately $40 million at its peak.

Strategic Coordination: ClASS is an expert-based assessment that is complementary to other monitoring assessments used at the country level. It is not intended to substitute or duplicate the first line of assessment used by Ministries of Health, the United States government, or implementing partners.

Adapted for Relevance: The ClASS methodology is designed to provide requisite, culturally sensitive, and non-punitive monitoring and support. In recognition of the uniqueness of every setting, ClASS provides a comprehensive framework that can be adapted by using consultative and qualitative methods to assess and strengthen local capacity, ownership, and leadership at all levels of health care.

TA and Activity Planning: TA provided through the ClASS process is driven by assessment findings and evidence-based practices. The TA process begins in conjunction with the on-site assessment phase and all TA recommendations are informed by financial, administrative and technical considerations for effective implementation. Improvements are prioritized based on USG and country requirements and the realities on the ground.

Strong Foundations: The ClASS framework draws on 20 years of experience from HRSA’s domestic HIV/AIDS program. The Primary Care Assessment Tool (PCAT), which has been used to monitor domestic HIV/AIDS programs funded by HRSA under the Ryan White CARE Act, was adapted and further enhanced through an extensive review of over 30 tools used by PEPFAR implementing partners. Domestically, HRSA has been integrating TA into HIV planning to ensure effective use of resources since 1998.




George Tidwell, Branch Chief

Global Health Systems Branch

Division of Training & Capacity Development

Health Resources and Services Administration (HRSA)

Tel: 301-443-4688


Chuck Kuehn, Senior Program Manager

International Training & Education Center for Health (I-TECH)

Tel: 206-543-9706

CLASS training

The Health Resources and Services Administration (HRSA), with support from the International Training and Education Center for Health (I-TECH), developed the ClASS framework in 2008 to promote long-term sustainability and country governance of high quality HIV/AIDS programming. Since then, ClASS has built the capacity of 99 organizations, including governmental and civil society organizations, to manage programs in 17 PEPFAR countries in sub-Saharan Africa, the Caribbean, and Eastern Europe. From its initial development, the ClASS framework involved input from a variety of global health partners including HRSA, the Centers for Disease Control and Prevention (CDC), Ministries of Health, and civil society organizations.

The ClASS Framework

Flip chart

The ClASS framework is designed to foster country-owned, sustainable, and high quality HIV and other health care and treatment programs that promote equity and accountability. Based on an iterative process of customized assessment and technical assistance (TA), ClASS builds the capacity of local organizations and institutions to provide high quality programs to underserved and key populations.

ClASS assessments are participatory, appreciative, and transparent. They provide a strategic advantage to the organization being reviewed by generating practical organizational strengthening action plans and evidence-based TA. Program monitoring and subsequent reassessments identify capabilities attained and further capacities to be built. The framework is based on five key principles (see sidebar) and identifies opportunities for strengthening the health delivery system through a comprehensive approach that aims to:

  • Maximize resources and avoid duplication
  • Promote good governance and leadership
  • Promote efficiency, effectiveness and sustainable outcomes
  • Ensure financial stability
  • Ensure programmatic compliance

The ClASS Toolkit


ClASS tools follow a modular format which offers the flexibility of creating a custom assessment that is relevant to each organization. Current modules assess administrative, financial, leadership and management, counseling & testing, clinical/technical, and program capacity at all levels. Each module is divided into three sections: Core Competencies, Open-ended Questions, and Performance Criteria/Verification Information. The modules serve as both a guide and a gauge for assessing grantee or partner TA needs.

Adapting the ClASS Framework for a Variety of Needs

The ClASS methodology allows for focused, in-depth analysis and assistance. ClASS provides local partners with the capacity and support that they need to develop responses appropriate for their communities with the goal of more sustainable national health services. To date, HRSA and in-country CDC teams have applied ClASS tools in a variety of operational areas including HIV care and treatment, counseling and testing, leadership and management, fiscal accountability, administration, health service delivery, and medical and nursing education. Since 2009, the ClASS modules have been used in:

Pre-Award Assessments

  • Assessing organizational capacity to provide and maintain quality service delivery
  • Assessing potential grantee capacity in program management, financial management, clinical program management, counseling & testing and leadership and management

Post-Award Assessments

  • Baseline assessments of grantee/sub-grantee grants management capacity 
  • Identifying capacity building needs
  • Transition readiness technical assistance
  • Support assurance of quality of care


  • Administrative and fiscal systems capacity
  • Leadership and management capacity
  • Clinical service delivery, in-service training, teaching facility identification
  • Subcontractor and Partner Selection
  • Organizational capacity assessment
  • TA for capacity enhancement/systems strengthening
  • Preparation for transition to local ownership

Subcontractor and Partner Selection

  • Organizational capacity assessment
  • TA for capacity enhancement/systems strengthening
  • Preparation for transition to local ownership
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