The Partnership for Supply Chain Management (SCMS) is funded to procure all HIV-related commodities on behalf of the USG and USG partners. SCMS also provides technical assistance to the Central Medical Stores (CMAM) and the MOH in forecasting and supply planning, procurement, warehousing and distribution, and Logistics Management Information System (LMIS) for all essential medicines and laboratory reagents. SCMS works closely with JSI/DELIVER through the President's Malaria Initiative (PMI) and reproductive health/family planning programs to ensure an integrated approach to supply chain management systems building. Forecasting and supply planning of commodities for all HIV-related programs is conducted jointly with CMAM, Clinton HIV/AIDS Initiative (CHAI), and the relevant MOH programs.

SCMS's support to CMAM and the MOH to strengthen the supply chain is directly in line with the goals of the USG and GOM Partnership Framework (PF) to build capacity of CMAM to fully manage its operations by the end of PEPFAR II with reduced technical assistance.

In 2009, SCMS supported CMAM to develop a Pharmaceutical Logistics Master Plan (PLMP), a multi- donor funded, 5 year strategic plan that outlines the vision and requirements for a redesigned supply chain for the health system in Mozambique. With a focus on health systems strengthening, the PLMP emphasizes infrastructure needs; policy, legal and human resource reform requirements for the supply chain; and includes the following key strategies to ensure success: provision of financial and administrative autonomy to CMAM; an active distribution strategy from central to district level; revision in the procurement laws to allow for multi-year contracting; central and district level warehousing needs; LMIS; monitoring and evaluation (M&E) and human resource requirements for the supply chain, including personnel, enhanced salary scales, incentive packages, and pre- and in-service training requirements at all levels.

Recently approved by the MOH, USG has committed to supporting the implementation of the PLMP through the PF in collaboration with other donors. In addition to commodity procurement for all technical areas in FY 2010, SCMS will prioritize roll out of the PLMP, including phase in of active distribution and implementation of an LMIS at district level, in-service training for all levels of the supply chain, strengthening M&E competencies within CMAM, and support to CMAM to manage and execute procurements for Global Fund.

SCMS contributes to the cross-cutting areas of Human Resources for Health and Strategic Information (SI). A significant challenge for the MOH is the severe shortage of qualified and trained personnel in all

areas of the supply chain, including pharmacy staff, particularly at superior level, logisticians and warehouse managers. During FY 2009, SCMS worked with CMAM to develop a revised staffing structure based on requirements for a centrally-managed supply chain, and conducted a skills analysis of existing CMAM staff to identify skill strengths and weaknesses of each staff member based on the proposed staffing structure. SCMS will support new and existing personnel with additional training and mentoring in supply chain management relevant to their designated functions.

Beginning in FY 2010, SCMS will conduct a district warehouse assessment to define district warehouse needs in all districts and implement a pilot of the redesigned logistics system of active distribution from central warehouses directly to the districts. These district warehouse assessments and the pilot will identify key human resource and infrastructure requirements at the district levels. In line with the PLMP and the Human Resources for Health Development (HRHD) plan, SCMS will support CMAM to develop a national integrated logistics training plan for all levels of the supply chain, as well as support the development of a logistic cadre for the MOH in collaboration with JHPIEGO. SCMS will also contribute to SI through the implementation of a functional LMIS for improved resupply and inventory control of health commodities. A focus in FY 2010 for the Laboratory Department at MOH will be the expansion of the laboratory network, including the Laboratory LMIS to manage the laboratory supply chain. SCMS will also contribute to SI through efforts to strengthen coordination and information sharing with all relevant MOH programs and clinical partners around supply chain issues, such as findings from supervision visits and supply plan updates, and joint forecasting and planning, in close collaboration with CMAM and the MOH.

SCMS has significantly reduced costs through joint forecasting and coordinated planning with CMAM and CHAI to avoid duplication of purchases. In addition, with decentralization of procurement functions for laboratory, SCMS has reduced costs through local procurements of laboratory reagents and other supplies. In line with USG's vision outlined in the Partnership Framework, SCMS will work with CMAM to develop a skills transfer and transition plan with identifiable milestones for CMAM, particularly in the area of procurement. These activities will be monitored through joint site visits with CMAM, joint work planning between CMAM and SCMS, monthly reporting to USG, and monthly reporting on activities.

SCMS will receive funds to procure medicines for the prevention and treatment of OIs and STIs, including cotrimoxazole (CTX), for HIV-infected adults, contributing around 40% of the national need for the MOH HIV program.

In addition, USG will increase its contribution to the national CTX need as part of an overall strategy to improve CTX provision and patient care. CTX is an integral component of the basic care package and a highly cost-effective intervention for both ART and pre-ART patients. Data from the national ART evaluation and HIVQUAL have revealed only 30% of ART patients are on CTX, and even lower percentage for pre-ART patients. Strengthening the service delivery, availability and tracking of CTX to ART and non-ART sites is considered a high priority for the GOM and USG, leading to an expected increase in CTX consumption and need.

The remaining needs of CTX and essential OI/STI medicines will be covered through GF Round 9, the GOM, and the Common Fund for the Health Sector (PROSAUDE),

SCMS will also support strengthening the supply chain for CTX, OI, and STI drugs through OHSS funds. CTX, OI and STI drugs are integrated into the national system and distributed through two mechanisms: a push system of essential medicine kits (a one month supply of essential medicines, including CTX, for primary care facilities), and via classica, a pull ordering system based on consumption and needs. Health facilities receiving kits are required to reorder additional stocks as needed through the via classica system. Provision and availability of OI and STI medicines, including CTX, have been challenged by the overall weak supply chain. The roll-out of the Pharmaceutical Logistics Master Plan (PLMP) will significantly strengthen the supply chain for all commodities. SCMS will work with CMAM, provincial advisors, and clinical partners to address logistics challenges around essential medicines, including training ART and non-ART sites in stock management and resupply, and improving national forecasting, planning and distribution for essential OI/STI commodities. SCMS will also provide additional support to

CMAM in procuring essential. medicines using Global Fund resources.

SCMS will procure HIV rapid test kits to support the USG and MOH efforts to expand facility and community based HIV counseling and testing activities and increase testing uptake. The total national need for FY 2010 - 2011 is estimated at around $8 million USD, to support PMTCT, provider initiated testing and counseling (PICT), blood safety, community testing, and CT campaigns. This budget code will be used for HIV testing in non-ANC settings. Additional resources for HIV rapid test kits include GF Round 6 phase 2, GF Round 9, and World Bank funds reprogrammed into UNFPA.

To support the USG and the GOM in their efforts to scale up quality CT services, increased efforts are required to improve the supply chain of HIV test kits. During 2008-2009, Mozambique faced challenges in the supply of HIV rapid test kits due in large part to poor consumption data for forecasting and distribution planning, unreliability of other donor funds and large scale up of testing activities at health facilities and in communities. In addition, weak coordination at central level MOH programs and CMAM for forecasting and distribution planning has led to interruptions in supply due to inappropriate distribution to provinces

Through OHSS funds, SCMS will continue to work with CMAM and the MOH to strengthen the logistics of rapid test kits (RTK) and other commodities. Recent efforts to integrate test kit consumption data into the national pharmacy tools combined with service delivery data will greatly improve the ability of CMAM, MOH CT program, and Laboratory Section to formulate a distribution plan based on need. The roll-out of the PLMP will significantly strengthen the supply chain for all commodities and reduce some of the above challenges. SCMS will also work with CMAM, provincial advisors, Provincial Health Directorates, and clinical partners to address specific logistics challenges around RTKs, including integrating via classica modules into partner and provincial level trainings.

Under this budget code, SCMS will procure commodities to support the scale up of the pediatric HIV program, including HIV rapid test kits, CTX and OI drugs for HIV-infected children and infants. Polymerase chain reaction (PCR) using dried blood spots (DBS) for the early diagnosis of exposed infants is funded under pediatric care and treatment.

Until recently, UNITAID, an international facility for the purchase of drugs against HIV, Malaria and Tuberculosis, through CHAI has donated almost 100% of the needs for pediatric care and support. This support ends after the first quarter in 2011. The total budget for this activity will cover the gaps for the remaining two quarters of the FY 2010 period, until FY 2011 and additional resources can be found to support pediatric services.

Through health system strengthening funds, SCMS will continue to provide technical assistance to the CMAM to strengthen the national supply chain through the roll-out of the PLMP. SCMS will also work with CMAM, partners and provincial advisors to monitor the supply of pediatric-specific commodities and strengthen the supply chain, through joint integrated supervision visits, supporting CMAM to develop a national integrated logistics training plan, and to support the roll-out of the PLMP. SCMS will also continue its support to CMAM in collaboration with CHAI and the HIV program in forecasting pediatric commodities.

The Ministry of Health (MOH) pediatric program estimates 19,000 infants and children to be receiving

treatment by the end of 2010. As infants infected early in-utero or during delivery are often likely to die

before one year without aggressive treatment interventions, it is critical to ensure availability and access

to EID supplies and equipment. SCMS will procure polymerase chain reaction dried blood spot (PCR

DBS) kits in support of the GOM and USG efforts to expand the early infant diagnosis program in

Mozambique. UNITAID through CHAI is ending its support after the first quarter of 2011. The budgeted

amount plus an additional amount from the laboratory budget code, will cover the gaps until additional

resources can be found through Global Fund or a UNITAID extension. SCMS will work with CHAI to

utilize the EID network already established by CHAI.

HIV Surveillance is a key tool for monitoring progress towards reducing HIV infections in Mozambique, the first goal outlined in the PF. During the latest round in 2009, sentinel surveillance was conducted at 36 sites throughout the country and DBS technology - assays to measure recent HIV infection for estimation of HIV incidence - and threshold ARV resistance monitoring to detect transmission of HIV drug resistance were continued. Data from the sentinel surveillance round are used to describe the current burden of disease among pregnant women and to produce estimates of the burden and impact of HIV in

the country and to monitor disease trends over time. Sentinel surveillance data are the cornerstone for allocating resources in the country, though a national sero-survey was conducted in 2009 (results expected next year).

Since 2001, the USG has provided complete financial and technical support for sentinel surveillance activities in Mozambique. In 2009, HIV surveillance moved from the HIV program to the NIH with continuing financial support from the USG. In 2010, funds will be used to procure sample collection equipment and supplies, sample processing equipment and supplies, and test kits necessary to conduct sentinel surveillance and related activities (HIV, syphilis, BED and Avidity tests for recent HIV infection, and threshold drug resistance testing). The surveys typically include about 13,000 pregnant women. For the first time in 2010, procurement of these supplies will be routed through SCMS in order to improve long-term sustainability of surveillance activities

In addition to the continued support of sentinel surveillance in antenatal care settings, the USG will be implementing a BSS, which will be the first survey to comprehensively assess behaviors and HIV prevalence in most at risk populations including truck drivers, sex workers, miners, in Mozambique. SCMS will also procure commodities in support of this activity. This survey is expected to include specimens for HIV testing from about 5,000 participants. Materials may be procured locally, internationally or a combination of both, depending on costs and technical considerations.

SCMS is integral to USG's vision outlined in the PF for health systems strengthening. In coordination with other USG partners and donors, SCMS will strengthen five out of the six blocks of the health system (service delivery, information systems, HRH, procurement systems, leadership) in line with the priorities and goals of the MOH.

In 2009, SCMS supported the development of a PLMP, a multi-donor funded, 5-year strategic plan that outlines the vision and requirements for a re-designed supply chain for Mozambique.

SCMS will support CMAM and the MOH in the implementation and phase in of the PLMP based on lessons learned during the pilot study and district warehouse assessments conducted in early 2010. In FY 2010, SCMS will focus on the following areas: implementation of an LMIS, pre-and in-service training in logistics and supply chain management in conjunction with the Brazil-USG-Mozambique Tripartite Agreement, development of supply chain M&E competencies; strengthening CMAM's procurement

systems; and developing a sustainable laboratory supply chain and network in line with the National Laboratory Strategic Plan.

To resolve short- and medium-term supply chain challenges, SCMS will support provinces, districts, and sites through joint supervision visits with CMAM, and improved coordination with MOH programs and clinical partners, who will have an expanded role in supporting the supply chain.

SCMS will expand its procurement TA to CMAM to include management of GF procurements and procurement and supply management (PSM) plans. A new activity in FY 2010 will include support for two CMAM staff to participate in a three-month procurement training program with I+Solutions in Amsterdam, tailored to meet CMAM's needs, with a particular emphasis on procurement for GF and other donors and development of systems in line with international standards.

This activity will have spillover benefits on the whole health system, including improved drug supplies at health facilities, and strengthened human resource capacity and information systems for laboratory and pharmacy needs, thereby increasing overall quality of health care services.

Nationwide expansion of quality PMTCT services with increased access to more effective PMTCT regimens is a key goal for the GOM and supported by the USG as a critical intervention in the fight against HIV. To support these efforts, SCMS will receive funds to procure PMTCT related commodities, including HIV rapid test kits for pregnant women and their partners, CD4 reagents and CD4 tubes for eligibility screening of HIV-infected pregnant women, ARV drugs for combination ARV prophylaxis for pregnant women and exposed infants, hemoglobin reagents and equipment for anemia screening of HIV- infected pregnant women; and cotrimoxazole (CTX) prophylaxis for pregnant women with CD4 < 350. SCMS will also procure CTX for exposed infants during the last two quarters of the FY 2010 period, as UNITAID, an international facility for the purchase of drugs against HIV, Malaria and Tuberculosis, donations will end after Q1 2011. UNFPA and GF will also procure HIV test kits during 2010-2011.

For effective scale up of PMTCT services, increased efforts are required to improve the supply chain of commodities. During 2008-2009, Mozambique faced interruptions in the supply of HIV rapid test kits due to poor consumption data for forecasting, unpredictability of donor resources, poorly trained health staff, a weak supply chain, and large scale up of testing activities at health facilities and communities. The roll- out of the PLMP, starting in 2010, will significantly strengthen the supply chain for all commodities. With

OHSS funding, SCMS will work with CMAM, provincial advisors, and clinical partners to address PMTCT specific logistics challenges, including: integrating supply chain modules into partner and provincial level trainings for PMTCT sites; integrating test kit consumption data for PMTCT into the national pharmacy tools; and working with CMAM for PMTCT specific commodity forecasting.

There are no targets related to this activity, except that procurement of PMTCT commodities will enable the PMTCT program and implementing partners to reach their proposed targets.

SCMS supports the clinical laboratory network with direct support of equipment, reagents, and commodities for HIV diagnostics and monitoring tests and technical assistance to strengthen the laboratory commodity supply system.

SCMS will procure CD4, hematology and biochemistry equipment and commodities for HIV diagnostics and monitoring tests for nearly 40 laboratories across all 11 provinces. SCMS is implementing a paper- based LIMS in labs receiving USG-funded commodities which will be expanded to all MOH labs as a strategy to improve the flow and validity of information coming from site level. At the central level, SCMS will build capacity to receive, analyze, and utilize these data to inform forecasting, procurement, and distribution decisions. SCMS's supply chain strengthening activities are aligned to both the with the National Laboratory Strategic Plan and the USG PF which calls for USG/GOM collaboration to "Improve commodity procurement and distribution systems at all levels". Supply chain strengthening activities also align to the next generation laboratory indicators by ensuring adequate numbers of labs have capacity to diagnose HIV and monitor therapy and supporting the laboratory accreditation process which requires that labs have an inventory control system for supplies with appropriate documentation and a standardized system for reporting.

Laboratory commodity logistics and inventory management are key elements of good laboratory management. SCMS will collaborate with other lab partners in country to support the curriculum development and facilitation of this subject in the USG supported laboratory management in-service trainings and develop a pre-service module on laboratory commodity logistics to be included in the pre- service laboratory course curriculum.

Currently, USG funded lab commodities are managed in a vertical system outside of the national system. SCMS will build capacity within CMAM to utilize USG funds to manage all lab commodities using the

national system. These activities will be in line with the recently approved PLMP to strengthen the country's logistic system for all medical commodities and lead to a more sustainable system for commodity management that transitions ownership and responsibility to MOH.

The MOH ART program estimates there will be 190,000 ART patients by the end of 2010, of which approximately 19,000 will be children. The forecasted need for FY 2010 is $33 million, an increase in overall pricing based on the new treatment guidelines of the MOH, which includes a transition from a d4T-based first line regimen to a more expensive AZT-based first line regimen.

SCMS will receive funds to procure adult first line ARVs, and a portion of the pediatric and 2nd line ARV needs following the phase out of UNITAID funding. It is a 15% decrease in USG direct support for ARVs. The Clinton Foundation via UNITAID, will donate almost 100% of the national need for pediatric and 2nd line formulations through the first quarter of 2011. The remaining gap will be covered by GF Round 6 phase 2 and Round 9 funds.

The MOH pediatric targets are 10% of all ART patients. Although the country has faced challenges in recent years with scaling up pediatric treatment, expansion of the EID program through DBS PCR diagnosis, and improved referrals for exposed infants and children, have resulted in increased rates of infants and children accessing ART services. In addition, the new pediatric fixed dose combination (FDC) tablets for oral suspension, introduced in Mozambique in February 2009, have greatly improved access for pediatric patients.

Through health system strengthening funds, SCMS will provide technical assistance to CMAM to strengthen the national supply chain through the roll-out of the PLMP. SCMS will continue work with CMAM and the MOH to forecast ARV needs for Global Fund applications as well as to conduct quarterly updates and supply planning. SCMS will work with CMAM, implementing partners, provincial advisors and Provincial Health Directorates to strengthen the use and reporting of the antiretroviral resupply system (MMIA) by ART sites.

SCMS will procure HIV rapid test kits and CTX necessary for the HIV/TB program. The funding was

determined by the forecasted need based on targets of the HIV/TB program.

Although CMAM is the main responsible for procurement and storage of commodities, forecasting and distribution planning is managed by the TB program including at the peripheral levels. Through OHSS funding, SCMS will help to strengthen the supply chain for the TB program, including provide training of program staff in forecasting as well as supply chain management at central and lower levels. SCMS will work with implementing partners and the TB program to integrate supply chain and via classica, an ordering system, modules into provincial and district trainings. As with HBC activities clinical partners will work with sites to improve tracking of CTX provision, including for the TB/HIV program. For HIV test kits, SCMS will also coordinate with the program and clinical partners to integrate the rapid test kit laboratory management information system into the TB/HIV program. SCMS will continue its support to CMAM to conduct joint integrated supervision visits, including for the TB program.