Botswana experienced supply chain challenges which necessitated the invitation of the Partnership in Supply Chain Management Project (SCMS) to provide technical assistance beginning in 2007.

The objective of SCMS is to improve the supply chain management of HIV/AIDS medicines and related commodities through strategic planning and provision of short term technical assistance to the Ministry of Health (MOH) to build capacity, provide/design standardized tools, and train MOH staff to institutionalize new practices and management systems. SCMS has also developed monitoring and evaluation tools and a Performance Management Plan (PMP) and trained MOH staff to use the tools to ensure sustainability of system improvements. By including development of supply chain management curricula at local training institutions, SMCS strengthened in-country training structures which will ensure a continuation of the introduced improvements beyond the life of SCMS project.

This approach is in line with the Partnership Framework signed between the Government of Botswana (GOB) and the USG in December 2010, taking into account the second phase of PEPFAR, which encourages USG support to shift from providing emergency support to focusing on developing sustainable systems for Botswanas HIV/AIDS response.

The burden of TB infection in Botswana, particularly co-infection with HIV, has created the need to introduce more robust diagnostic technologies to enable early TB diagnosis and treatment. There is also a need to expand TB diagnostic capacity in the country. To support the MOH in FY 2011, SCMS procured Mycobacterium Indicator Tube (MGIT) and PCR equipment and the required reagents for TB diagnosis. With the introduction of these technologies, TB diagnosis has been reduced from eight weeks using the conventional Lowenstein Jensen (LJ) culture method to six weeks by MGIT and one week by PCR. The National TB Reference Laboratory (NTRL) has been implementing a quality management system and the laboratory is now in the process of being accredited. One of the requirements for accreditation is that all equipment should be calibrated on a regular basis. SCMS has been outsourcing equipment calibration for NTRL since the Biomedical Engineering Services at MOH does not have the capacity to do the work. In FY 2012, SCMS will continue to support the NTRL with procurement of reagents and supplies for the new technologies. SCMS will also continue to outsource maintenance and calibration services for NTRL, while providing technical assistance to Biomedical Engineering Services to develop systems and build staff capacity to sustain these initiatives.

At the inception of the SCMS project in 2007, the knowledge base of laboratory personnel on supply chain management of health commodities was very limited. Laboratory logistics systems, both the inventory control system (ICS) and the logistics management information system (LMIS), were not established. Supply chain decision making was not evidence-based since there was no logistics information flow between the central level and users. These deficiencies culminated in stock outs from inadequate forecasts and/or high expiries due to overstocking. Interruption in testing was common which sometimes hampered timely antiretroviral treatment initiation and/or monitoring. SCMS, in partnership with the MOH, has been strengthening systems for laboratory commodities. As a first step, SCMS provided capacity building trainings in basic principles of logistics management systems, quantification, and supply planning. Automated tools for quantification and supply planning, namely the Laboratory Quantification Tool and the Pipeline Tool, were introduced. SCMS leveraged knowledge gained through these trainings by working with the MOH to design a laboratory logistics system. In FY 2011, the system was rolled out to 42 laboratories through a training-of-trainers model. Notable achievements realized included 89 lab personnel with competency in lab logistics system; implementation of the system at 67% (28/42) of trained facilities, which are now following best practices in warehouse management; 67% LMIS reporting rate compared to none at baseline. Other achievements include transfer of the management of lab commodities supply chains from the National Health Laboratory to CMS. Trainings have been provided to Biomedical Engineering Services staff to build their capacity in lab equipment maintenance including calibration, as this is critical in laboratory accreditation and in decreasing equipment downtime. In FY 2012, system strengthening efforts will focus more on achieving a high level of country ownership and sustainability, as well as strengthening partnerships with other implementing partners towards achieving the ultimate goals--continuous availability of health commodities, reduced expiries, and improved customer satisfaction. Rollout of the lab logistics system will continue. Systems for lab commodities managed outside laboratories, e.g., rapid diagnostic kits and test tubes, will be integrated within the medicine logistics system. SCMS will continue to work with the Biomedical Engineering Services to strengthen systems for laboratory equipment maintenance. Technical assistance will be provided for automation and integration of ICS and LMIS within the Laboratory Information System and with the electronic medical record system where possible. The lab commodities security forum will be strengthened to incorporate lab logistics monitoring and supervision functions within the laboratory services management structures; and post-market surveillance for lab reagents, particularly rapid diagnostic kits, will be established. To sustain these activities, a supply chain management curriculum that includes training in lab logistics systems will be provided to medical technology students at the Institute of Health Sciences and UB. Waste management systems for laboratories will be developed and documented.

These activities address a range of supply chain management problems which still affect the supply and distribution of medicines and other health commodities to facility level. Firstly, the ongoing management support to Central Medical Stores (CMS) will continue throughout FY 2012. This support will include the completion of several strategic projects which were initiated in 2009. In response to a request from the MOH, SCMS has been providing a team of senior managers to CMS since 2009 to help solve long-standing management problems. The MOH requested SCMS support to push CMS towards operational excellence and to be seen as a benchmark organization in sub-Saharan Africa.

FY 2012 funds will be used for capacity building and mentoring of locally-appointed CMS managers who will manage CMS when the SCMS managers depart. This is the most important activity in ensuring that the work completed by SCMS is fully sustainable. Funds also will be used to complete the development of the Logistics Management Unit (LMU). The LMU is responsible for collecting, analyzing and disseminating logistics data from end user facilities. The remit of the LMU is gradually expanding to accommodate new commodity groups; by the end of the FY 2012, the LMU will be processing data for ARVs, lab supplies, TB drugs and a range of essential medicines. These data are vitally important for accurate procurement planning and ensuring that distribution to end users is in line with actual needs

There will be consolidation and continuation of the new procurement strategy introduced by the SCMS team, which includes framework contracts that have proved highly successful in increasing medicine availability and rationalizing stockholdings. The ongoing management support will consolidate these gains and extend the use of the contracts to new commodity groups. Funds will be used to complete the ISO accreditation process, and embed the quality management culture. CMS will be ready for its first assessment by the Botswana Bureau of Standards by the end of 2011. Following that assessment, remedial work may be required to address any shortcomings identified by the assessors. Once CMS gains ISO accreditation, the focus will shift to ensuring that the quality management culture is firmly embedded within the organization.

In addition to the continuation of the successful management support at CMS, these funds will also be used to support the implementation of the new Medicines LMIS across Botswana. This new system addresses a wide range of shortcomings in the way that hospitals and clinics manage inventory, collect data and calculate order quantities. The LMIS is being rolled-out in conjunction with the MOH and UNFPA, beginning with a training-of-trainers program. In this regard, the FY 2012 funds will be used to train health workers down to the health facility level, and substantial TA will assist the MOH to monitor and evaluate the results as the system is put in place.

The GOB made a commitment to achieving the goal of Zero New Infections by 2016 and has identified Voluntary Male Medical Circumcision (VMMC) as an additional low-cost prevention strategy to prevent further HIV transmission in the country. The MOH is currently making efforts to scale-up VMMC service delivery throughout the country, with its main objective being to provide VMMC services to 80% of HIV negative men aged between 0-49 years within a five-year program, requiring the provision of a total of nearly 385,000 circumcisions.

In order to achieve this ambitious goal, the VMMC program will be scaling up at a much faster pace. PEPFAR is committed to providing support aimed at making VMMC safe and as such is providing funds for the procurement of supplies and equipment. This requires an efficient procurement system to purchase 60,000 VMMC kits, 60,000 HIV test kits and supplies, 18 Diathermy machines, medical equipment for four additional (nine total) sites, and two clinics-in-a-box; and a well-functioning supply chain management system to deliver VMMC kits and equipment to key locations throughout the country in a timely fashion to meet the anticipated demand without any interruptions. The storage and distribution of these kits and machines will be in line with the established government mechanisms through Central Medical Stores. With funds from FY 2012, SCMS will provide technical assistance to strengthen the VMMC kits supply chain management to all GOB agencies including the MOH and the Botswana Defense Force. SCMS will also assist the National VMMC Technical Working Group with reliable systems for forecasting, procurement, supply planning, distribution, consumption reporting, monitoring and evaluation. Monitoring and evaluation tools will be developed and MOH counterparts trained to institutionalize and ensure country ownership and sustainability.

The Botswana National Strategic Framework II 2010 2016, calls for an increased focus on prevention activities that are directly linked to the Vision 2016 goal of no new infections. The HIV/AIDS epidemic in Botswana is driven largely through sexual transmission and the availability and correct use of condoms play a critical role in the response to the Botswana epidemic. In addition, condoms are an important tool in family planning and STI prevention programs.

Botswana has been experiencing condom management challenges including limited coordination and information-sharing between key actors for decision-making. Weaknesses in forecasting and procurement are based on inadequate information and erratic distribution with data only available for the number of condoms issued from the central level. Data on indicators of availability, consumption and accessibility at service delivery points do not exist.

SCMS will use FY 2012 funds to strengthen the condom logistics management system (inventory management and LMIS), which will improve logistics data recording and reporting throughout the supply chain. This will help the MOH to forecast condom requirements and prevent condom stock-outs at all levels and will help ensure that only condoms of acceptable quality are available at all levels of the condom supply chain. SCMS will achieve this by including condoms in the LMIS and training health workers to use the system including the monitoring and evaluation tools. SCMS will collaborate with the MOH and UNFPA to finalize the condom strategy, which encompasses capacity building within the MOH to sustain condom management initiatives. SCMS will also work with the National Drug Quality Control Laboratory to strengthen the quality analysis of condoms procured for national use. This work will cover both male and female condoms in support of new gender initiatives being developed by the MOH and PEPFAR partners.

Previously, early infant diagnosis (EID) commodities were distributed from the national health laboratory, while the distribution of the rest of the PMTCT supplies was handled by Central Medical Stores (CMS). In FY 2011, SCMS successfully facilitated transfer the distribution mechanisms for EID commodities to CMS to improve efficiency and customer service.

SCMS continued to procure EID collection kits in FY 2011, as well as provide technical assistance in forecasting and supply planning of these commodities. In FY 2012, SCMS will continue to procure EID commodities. However, for sustainability and country ownership, at the end of FY 2011 the MOH is expected toprovide funds for these commodities through the CMS budget.

Logistics management activities such as capacity building in management of health commodities and logistics management information systems (LMIS) reporting for all PMTCT supplies, including EID commodities is integrated within the Medicines LMIS, which is currently being rolled out countrywide.

In 2007, SCMS in partnership with the MOH, identified supply chain challenges to include weak procurement, supply planning, and inventory management and distribution processes at Central Medical Stores (CMS) and health facilities leading to overstocking, expiries, and stockouts of health commodities. The Drug Regulatory Unit (DRU) had a backlog of applications for market authorization due to understaffing, weak processes, and an outdated information management system. The National Drug Quality Control Laboratory (NDQCL) did not have enough physicochemical and microbiological capacity to be able to perform priority drug tests to support drug regulation and procurement activities. SCMS has built the capacity of the DRU and NDQCL in drug registration, records information management systems, and pharmaceutical analysis. By training DRU staff on specialized regulatory topics and SIAMED, developing a robust records management system, introducing application evaluation retreats, and building the capacity of the Drugs Advisory Board, the backlog in applications for market authorization was cleared. The DRU is able to review all applications as soon as they are submitted, thus providing timely support for CMS drug procurement. SCMS partnered with the U.S. FDA to train NDQCL staff in physicochemical analysis and antimicrobial limit testing and established collaborative linkages with the University of Botswana (UB) and North West University in South Africa. SCMS has provided a team of technical experts to transform CMS management and technical assistance for the development of a procurement training program at the Public Procurement and Asset Disposal Board (PPADB).

In FY 2012, SCMS will establish structures to institutionalize the supply chain management system at the MOH, CMS and health facilities. They will establish a commodity security coordinating forum at the MOH, a Logistics Management Unit (LMU) at CMS, and a Laboratory Management Information System that will extend to the District Health Management Team level. Monitoring and evaluation systems and tools at PPADB and DMU will be strengthened to sustain the improvement efforts. Systems for continuous human capacity development will be strengthened to ensure long term availability of human resources that are needed to operate and maintain an efficient supply chain management system. This includes training of trainers and the roll out of logistics management systems by MOH staff, procurement training by PPADB trainers, introduction of logistics training at health staff training institutions including the UB, and collaboration between the North West University and UB for training of drug analysts. Private sector pharmacists will be trained by the MOH to evaluate drug applications for the DRU to counteract the effects of staff attrition. SCMS will also use budgeted funds for software and IT development support and procurement to establish logistics systems to facilitate submission of reports to the LMU for aggregation and analysis for decision making.