08.P0107 SCMS-Supplies for Early Infant Diagnosis

2007 accomplishments

Procurement of laboratory supplies, reagents, and equipment is done through MOH's Central Medical

Stores (CMS). Gaps in the system result in delayed receipt of the laboratory equipment, reagents, and

supplies at the end point. In FY2006, the nationwide roll-out of early infant diagnosis began and continued

through FY 2007 with USG support.

2008 Plans

The USG will continue this support to the program by procuring laboratory supplies, reagents, and

equipment for the PMTCT program. Commodities will be procured in accordance with the GOB national

protocols, and USG rules and regulations. About 5,000 infant diagnostic DNA PCR kits will be purchased to

support the implementation of EID nationally as well as equip the second laboratory in Francistown.

These activities will be supported through the in-country SCMS team.

08.P0106 SCMS - Infant Formula Supply Logistics

The Botswana national PMTCT program provides all babies born to HIV-positive mothers with free infant

formula until they are 12 months old. Tins of powdered formula are provided and picked up by mothers at

public health clinics. During FY 2007, 13,000 babies received free formula. The program distributes infant

formula to three warehouses, which in turn distribute formula as it is ordered by districts, which then

distribute to clinics. At the national level, infant formula shortages occurred in 2005 and 2006 and

emergency formula supplies were purchased by PEPFAR. Causes of the shortages include difficulties with

government procurement processes and regional supply shortages. There is no infant formula manufacturer

in Botswana, and formula is usually procured from South Africa via local contractors (though bids from other

manufacturers are accepted). The national PMTCT program has no formal training in supply management,

no contingency plans for purchasing substitute foods for infants and no plan for formula rationing in times of

shortage. Improvements in formula supply chain difficulties are a high priority for the national program.

2007 Accomplishments

An assessment completed by UNICEF and CDC (with SCMS) highlighted the near lack of systems for

forecasting, procurement planning, storage, distribution and general stock management of the product at

the three warehouses and the clinics where it is given out. The new system developed to meet this need

requires maintenance and quality assurance. In April 2007, SCMS began supporting the PMTCT Unit in

procurement planning, process management, and forecasting of infant formula requirements and providing

technical support for designing a more viable and sustainable supply system.

2008 Plans

SCMS will conduct the following activities in FY2008: 1) Design an operational supply and distribution

management system using a robust Logistic Information Management System (LMIS). 2) Assist the PMTCT

Unit in procurement management for bid documents preparation, evaluation criteria and definition of

deliverables for effective supply contract performance management. 3) Train supply officers in inventory

and distribution management, demand management and forecasting, commodity tracking. 4) SCMS

logistics experts will provide continuing on-site mentoring support to entrench tools and standard operating

procedures introduced. All of these will address shortfalls identified in the assessment.

08.C0708: SCMS - Strengthening Lab Capacity

2007 Achievements

Prefabricated laboratories and additional laboratory personnel were provided by another stakeholder to

improve the TB diagnostic capacity in the country. FY2007 funds (including Plus Up funds) were used to

provide laboratory supplies, equipment and improve laboratory space for TB in the primary and district

hospital laboratories, the construction of the second culture and DST laboratory in Francistown and for the

reconstruction of the NTRL isolation room. The support improved quality control and quality assurance

systems in the laboratory network, resulting in enrolment of the reference laboratory for accreditation and

the commencement of the national drug resistance survey in July 2007.

2008 Plans

FY2008 funds to SCMS will serve to procure equipment and laboratory supplies for TB culture and DST at

the NTRL, and to expand these services to the NRH laboratory. FY08 PEPFAR funds will support the

procurement of additional equipment and supplies to the new laboratories, including laboratories under the

MLG. The funds will also help to improve the transport of sputum and results from clinics to the laboratories

and the laboratories to clinics and hospitals.

08.T1002: ARV Drugs: SCMS

The GOB through its MASA program currently provides antiretroviral treatment to 90,478 patients at 32

hospitals and 30 satellite clinics. It is projected that this number will grow to 104,900 patients by September

2008. The number of satellite clinics will increase to 80 by March 2008 and 128 by March 2009.

HIV/AIDS commodities used in prevention, care and treatment are procured and distributed by CMS which

is charged with managing the entire supply chain for the country. CMS receives direct support from

PEPFAR for commodity procurement and this contribution is estimated to be equivalent to about 15% of the

total ARV procurement cost in the country. CMS has also been supported to train and hire staff to support

ART scale-up and to increase procurement of pediatric formulations.

Currently most ARVs used in the country are innovator brands as donations from multinational companies

(Merck) and the rest are procured with government funds. The government receives USG support through

DRU to strengthen systems for generic ARV registration in order to lower cost of ARVs. NDQCL received

support to augment their technology and skills capacity for quality testing of generic ARVs. The Clinton

Foundation has promised to donate pediatric ARVs for FY2007 and FY2008. SCMS proposes to continue

supporting all these organizations in FY2008 to augment capacities needed to build sustainable HIV/AIDS

supply chains in Botswana. SCMS will work as a partner to these organizations within the existing systems

and not develop any parallel systems.

This proposes activity has several components. One component provides technical assistance and support

to CMS to efficiently carry out its responsibility of procurement, quality assurance, storage and distribution

of HIV/AIDS related commodities for all government, mission, mine and non-government organizations in

Botswana. The second component will be on provision of technical assistance to the DRU in its mission to

assure quality of ARVs and related commodities used in care and treatment. The third activity supports the

national MASA program in its role to harmonize and coordinate all partners by ensuring the supply chain is

ready to support and sustain the new treatment guidelines and treatment objectives of the program.

In FY2007, SCMS worked with CMS to strengthen management systems through the development of clear

management quality performance indicators and a continuous monitoring and evaluation plan. Additionally,

support improved the IT infrastructure for commodity tracking at the stores and in the procurement and

distribution pipeline. Two key staff at CMS were trained at the SCMS Regional Distribution Center in South

Africa in good warehousing practices plus exchange visits to regional medical stores for benchmarking

purposes. Ten other staff were trained in procurement planning and forecasting at one of the tailor made

SCMS training programs that also covered use of specific software programs: Quantimed for forecasting

and Pipeline for procurement planning. CMS' in house Quality Assurance Unit received in-house training to

ensure quality of ARVs and related commodities that are provided along the supply chain up to the end

user. Other support provided related to the general operations management at the warehouse based on the

findings and recommendations of the Boehringer-Ingelheim Assessment Report that was adopted by

government. SCMS also supported the STI Unit at the MOH by procuring Acyclovir tablets worth $200,000.

DRU received technical assistance to assess registration systems for generic ARVs and training of in-house

staff in dossier review. Evaluation of application dossiers helped clear the back log in the registration

process.

PEPFAR through SCMS supported CMS and other partners in FY2007 to develop national forecasts for

ARVs needs for the next 24 months and set in place a system for continuous updates of these forecasts as

regular activity. In addition, 10 persons were trained in ARV and related commodities forecasting and

procurement planning. Working through the MASA program SCMS supported the setting up and facilitation

of an ARV Working Group that brings together all partners in the sector - MOH, MOLG, CMS, BOTUSA,

MASA, GFATM, Clinton Foundation, ACHAP, Harvard Program and the others for better harmonization of

forecasting and procurement planning. SCMS continues to assist in providing analyzed supply chain

information on both demand and supply sides that can be relied on to make decisions on resource

mobilization and scale up rates.

2008 plans

SCMS working in collaboration with partners will continue to support planned activities helping to further

enhance systems at the national level. Working with CMS, SCMS will provide support for strengthening the

distribution system for ARVs and related commodities including investigating options for a more effective

distribution structure which CMS can adopt to ensure continuous supply in an efficient manner to all the

ART sites (128 clinics under MLG and 32 hospitals under MOH) spread across the whole country. There will

be more focus on building capacity at the treatment site level for the 32 hospitals offering ART and working

with health clinics under the MLG. This work will involve development of tools for inventory management

and transactions tracking; electronic inventory and dispensing records; training of pharmacy staff in

quantification, product requisition; general inventory management training; commodity transactions tracking

information collection and analysis in order to make the supply system be fully pull based.

CMS currently faces huge challenges in projecting demand for ARVs at sites due to unreliable logistic

information flow and hence supporting hospitals and clinics to build capacity for effective supply chain

management will be the major determinant for ensuring a sustainable supply chain needed for HIV

prevention, care and treatment programs. SCMS will provide technical support to the MOH for the

development of a HIV/AIDS commodities tracking system; implementation of a revamped LMIS; train staff in

collection, analysis and use of information; and provide analyzed information to feed into product

forecasting, procurement planning and distribution management (supply and demand management). SCMS

will support the roll out of whatever technological solution is adopted by the MOH that is also in line with the

general health management information systems of the country. SCMS will continue to work with the DRU

to strengthen systems for quality assurance of ARVs in the country's supply chain. The support will include

short term technical assistance for in-house mentoring of DRU staff; training in post marketing surveillance

of ARVs and adoption of technology solution for maintaining the drug register.

GOB is strengthening its activity related to preventive care for HIV positive women. The newly revised care

Activity Narrative: and treatment guidelines recommends annual PAP smear screening for HIV positive women. A PAP smear

screening clinic is being put up for this purpose. Lack of basic equipment is making implementation difficult.

An amount of $80,000 is earmarked for purchase of PAP smear screening equipment so that the clinic

becomes fully operational.

08.T1116

The Botswana National ART Programme is supported by a multidimensional community mobilization

initiative called MASA. The goal of MASA is to ensure universal access to HIV/AIDS treatment care and

services to the citizens of Botswana who require such. The programme is funded and supported by various

partners which include the government, PEPFAR, African Comprehensive HIV/AIDS Partnership (ACHAP).

The MASA ARV Programme currently has over 90,000 patients on HAART in the public and private sectors

and hopes to reach 110,000 patients on HAART by 2009 and 125,000 patients by 2010. These patients will

be served at both the Ministry of Health (MOH) and Ministry of Local Government (MLG) managed sites.

The MOH has established 32 sites which prescribe and dispense ARVs while the MLG has 60 sites

providing ARV prescription and dispensing services and is rolling out to other sites within the system.

For this rapid expansion to be successful, there is need to have a very strong and robust patient

management cum inventory management system deployed at the facilities where ARVs are dispensed.

Patient clinical and dispensing data are currently being managed with two software systems in the

Botswana ART sites - Meditech developed in South Africa and the MASA system developed in Botswana.

The Meditech system is deployed at 4 pilot facilities but as currently deployed, the system is unable to

provide very useful information on patient regimen ratios and inventory management which are crucial for

forecasting and quantification purposes. In addition, it is not available at district clinics. The MASA system is

deployed in most of the other facilities dispensing ARVs. The system has been very useful to the ART

programme for programmatic purposes. However, like the Meditech system, it is unable to provide useful

information on patient regimen ratios and inventory management for quantification purposes. Both programs

need further customization to improve their effectiveness to enable them generate the specific type of

information required for quantification purposes. The two systems are not interfaced making programmatic

data integration and analysis a problem

The challenges faced by the current data capture system for ARVs in the country include poor quantification

capabilities and inadequate tools for data analysis and reporting. This results in poor information flow to

Central Medical Stores (CMS) and MASA thereby affecting quantification of ART resource needs and

management. The CMS and MASA are concerned about these challenges and improving on these

parameters through the use of user friendly software which can be easily customized to the needs of the

Botswana ART programme will make CMS and MASA more responsive to the needs of a rapidly scaling up

programme. CMS currently faces huge challenges in projecting demand for ARVs at sites due to unreliable

logistic information flow and hence supporting hospitals and clinics to build capacity for effective supply

chain management will be the major determinant for ensuring a sustainable supply chain needed for HIV

prevention, care and treatment programs. SCMS will provide technical support to the MOH for the

development of a HIV/AIDS commodities tracking system. This activity will be for support to the national

MASA program in its initiative of developing a Patient Information Management System (PIMS) by

engagement of design consultants to develop the pharmacy module for the PIMS.

08.T1205: SCMS - Laboratory Procurement

In FY 2007 SCMS supported procurement of key reagents, equipment and supplies for USG supported

programs; assessed, recommended and worked with NHL to re-design a more efficient and effective

laboratory supply chain and logistics management system capable of supporting a sustainable prevention,

care and treatment HIV program in the country including a system for specimen and results handling. An

additional activity in 2007 was to review the system for specimen and results handling between site

laboratories and referral laboratories. Physicians at treatment sites have continuously expressed a need to

streamline the system for specimen and results handling which leads at times to multiple same tests being

requested for the same patient with no results coming back from the referral laboratories. Movement of

specimens and results requires almost similar logistical support as moving reagents and other supplies plus

the commodity tracking information and that is why SCMS was asked to help find a solution to this

challenge.

2008 activities will focus more on operationalizing the system across the country, both at the national level

and the testing sites. This will include:

1) Demand forecasting and procurement planning capacity;

2) Inventory management systems at all levels (national coordination and treatment site) consistent with

Good Inventory Management Practices (GIMP);

3) A robust logistics management information system (LMIS) that provides reliable information to feed into

the forecasting and procurement planning plus decision making processes; that supports the management

of laboratory reagents and supplies, this will include supporting NHL to find the right technological solution

that is compatible with general HMIS of the country and help in its roll out to all the laboratories;

4) development and institutionalization of Standard Operating Procedures for managing supplies and key

reagents used in HIV prevention, care and treatment;

5) Training and mentoring of key personnel in the existing laboratories to augment their skills and

capabilities for effective management of laboratory supplies and reagents;

6) Introducing and institutionalizing continuous monitoring and evaluation plan with clear indicators of

performance to measure and using information derived from this process to make improvements in the

supply chain functioning;

7) SCMS will also continue supporting NHL and BOTUSA with procurement of reagents especially for

conducting surveillance and BAIS III (for an estimated amount of $300,000), medical and laboratory

equipments in the interim as NHL strengthens its capacity to undertake all procurement activities at the

country level. Even as NHL takes on this role, SCMS will provide an opportunity for the country to take

advantage of preferential prices that SCMS has negotiated with several manufacturers leveraging its

economies of scale for multiple country procurement potential.