Under the guidance of the Ministry of Health, the Supply Chain Management System (SCMS) works in partnership with the Centrale d'Achats des medicaments essentiels du Rwanda (CAMERWA) to ensure the sustainable procurement, supply and distribution of HIV commodities including ARVs, OIs, test kits, laboratory equipment and commodities, male circumcision and injection safety equipment to the people of Rwanda at central, district and FOSA levels. This partnership is based on a Memorandum of Understanding with CAMERWA which was first signed in November 2006 and has recently been renewed through September 30, 2013.

The Memorandum of Understanding enables SCMS to provide health systems strengthening support to CAMERWA for all health commodities including essential medicines in the form of warehouse management strengthening, financial system strengthening, capacity building, skills transfer and performance management. SCMS has provided racking and shelving, layout design, material lifting equipment and warehouse operations training to enable CAMERWA to become a modern and professional warehouse, storage and distribution operation. As part of this process, SCMS is assisting CAMERWA to implement computerized management information systems to support its warehousing and financial management activities.

SCMS will further support CAMERWA with the transition process to the Rwanda Bio Medical Centre which is expected to be completed during COP 2010.

SCMS has been working with CAMERWA to strengthen its procurement systems and processes so that they comply with USG procurement regulations and support CAMERWA in its desire to become a US Government direct grant recipient. This includes the recruitment of a Procurement Adviser based at CAMERWA who is responsible for transferring knowledge in best practice in procurement of all health commodities and in supporting CAMERWA to develop its own procurement plans and framework contracts with prequalified vendors. The goal is to ensure best practices, transparency and value for money in procurement to ensure that quality drugs are supplied to as many patients as possible whilst ensuring cost effectiveness.

SCMS also works closely with the National Reference Laboratory, CAMERWA and other implementing partners to support the procurement of laboratory commodities, reagents and equipment. In addition, SCMS has been providing logistics support to strengthen the laboratory supply chain through development of a commodity data base, harmonized LMIS system and capacity building. In FY 2010, procurement will include laboratory equipment, supplies and reagents for biochemistry, early infant diagnosis (EID), hematology, microbiology, CD4, viral load and biosafety. This consolidated approach to procurement will increase cost savings and improve the efficiency in the current procurement, storage

and distribution of commodities.

A key focus of SCMS support to CAMERWA and the Pharmacy Task Force has been the development and mobilization of the Government of Rwanda's program of Active Distribution of commodities from central level to district pharmacies and health facilities. In COP 09, CAMERWA, PTF and SCMS established an Active Distribution project team to begin roll out of the initiative. A minimum of 15 districts will be part of the Active Distribution scheme by the end of FY 2010. The goal is to roll out active distribution to all 30 districts by the end of 2011.

SCMS is the lead agency building the capacity of the Coordinated Procurement and Distribution System (CPDS) to undertake quantification, forecasting and supply planning in support of the procurement decision making process. In FY 2010, SCMS will continue to support quantification activities within the CPDS, which includes the Ministry of Health (MOH), PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), the Clinton Foundation HIV/AIDS Initiative (CHAI), all USG clinical partners, and UNICEF. By FY 2010, SCMS will also have built capacity with the CPDS to quantify the national laboratory needs which will include Antiretroviral (ART) and non-ART supported sites.

SCMS has been providing support to the MOH in the strengthening of computerized Logistics Management Information System (LMIS) and its integration with other Health Management Information Systems in Rwanda. SCMS is working closely with e-Health department to ensure that the supply chain component of the National e-Health strategic plan is realized with applications and information systems supporting effective and efficient delivery of health commodities in Rwanda. In FY 2010, SCMS will also ensure the sustainability of the computerized LMIS and assure that its implementation leads to improved stock management, reduced drug expiry, and reduced the cost of delivering to the consumers among many other benefits. The LMIS within Ministry of Health along with its computerization will permit proper data collection and analysis for improved decision making within the national supply chain system. SCMS activities are intended to support the Partnership Framework goals by gradually transferring skills and management capacity for supply chain management to CAMERWA, PTF, NRL and other partners. An objective of the Memorandum of Understanding with CAMERWA is to strengthen CAMERWA's procurement, warehousing, and systems administration capacity so that it is able to become a USG direct grant recipient and to take over management of the procurement of PEPFAR funded commodities without the support of SCMS. SCMS technical support is further aimed at assisting CAMERWA's transition to its new status under the Rwanda Bio Medical Centre so that it is empowered to take on the greater responsibilities proposed under the new Bio Medical Centre structure.

FY 2010 will see a reduction in the level of technical assistance being provided to CAMERWA, NRL, PTF and other partners together with an increased emphasis on transfer of skills, mentoring and planning for

exit where appropriate. As part of this approach, SCMS will ensure that ownership of licenses, warranties and maintenance agreements for all laboratory equipment, computerized systems is transferred to the appropriate organization within the Ministry of Health. SCMS support to the Government of Rwanda's Active Distribution initiative will strengthen district level management and supervision of the supply chain and increase their interaction with CAMERWA. The computerized and harmonized LMIS will facilitate more accurate and timely data reporting and validation which will strengthen the quantification process of the CPDS.

Research has shown that 90% of PLWHA are affected by diarrhea, which in turn results in significant morbidity and mortality. Hand washing, sanitation, water disinfection and safe storage have been proven to significantly reduce diarrhea rates. According to the 2005 Rwanda Demographic and Health Survey, only one-third of surveyed households had access to a protected source of drinking water. A significant cause of exposure to diarrheal disease-causing pathogens is inadequate access to safe water. Only 40% of the Rwandan rural population and 60% of the urban population have access to safe water. The objectives of the point of use (POU) activities are to ensure consistent use of POU water treatment products by PLWHA; to increase access to POU water treatment products by PLWHA; and to improve knowledge of POU and its effectiveness, hygiene, and safe water storage.

In FY 2009, 200 service outlets, serving 5,000 PLWHA were provided with HIV-related palliative care. Outlets included health centers and PLWHA--managed income generating cooperatives. Messages were delivered through peer education, IPC and door to door sessions conducted by CHWs and PLWHA association members. A total of 854 people were trained to provide HIV-related palliative care, including 462 public providers (22 district personnel and two providers each from 220 health facilities providing VCT/ART) and 392 PLWHA associations and community volunteers (12 RPO TOT, 80 PLWHA association members and 300 community volunteers).

POU programming through PSI includes distribution of two products, including Sûr'Eau, a locally produced POU liquid solution which recovers the cost of production with every bottle sold, and Pur, a targeted, internationally-produced flocculent disinfectant powder sachet which is particularly effective in treating turbid water and water retrieved from surface sources. Sûr'Eau was launched in FY07 with USAID funding for distribution through community health workers, the community health insurance program, public health facilities, Rwandan Partner Organizations (RPO), and commercial distribution networks. Pur will be launched with international funds in 2010 to target communities with particularly turbid surface water, leveraging existing commercial networks and RPOs, particularly those targeting PLWHA. This activity complements PSI's child survival activities around preventing diarrheal disease in children under five years

In FY 2010 PSI will intensify the POU program targeting PLWHA to increase knowledge of POU, hygiene and safe water storage through health facilities providing VCT and ART, through faith-based RPO targeting PLWHA, and through associations of PLWHA through RRP+, the national network of PLWHA. Activities will include intensified training of trainers, peer education through trained RPO members, community-based distribution as an income generating activity for associations of PLWHA, community events, and mass media communications, which will help avoid stigmatizing the POU products for the general population. Water signage will be expanded for placement at water points in PEPFAR districts, so that safe water messages are targeted at points where communities gather. The activity will expand product availability at health facilities, ensuring access for VCT clients, regardless of HIV status. Additional starter stock will be provided to associations to expand distribution to PLWHA associations trained by partners supported by PSI. PSI will continue to integrate safe water, POU and hygiene messages into existing VCT, care and support materials in collaboration with GOR, USG clinical partners and community partners, to ensure consistent delivery of product and messages to people who present for testing.

PSI supports regular joint supervision visits between the PSI POU and M&E teams and local authorities who oversee technical quality of program implementation by RPOs. RPOs will also receive institutional support through regular financial and institutional mini-audits and ongoing mentoring by the BCSM

capacity building partners of PSI, JHU-CCP and CHF. Training impact will be monitored by improved pre- and post-test QA materials and analysis.

In line with the Partnership Framework objectives, PSI will intensify activities with a particular emphasis on strengthening associations and RPOs targeting PLWHA in cholera-prone districts, and communities sourcing turbid surface water. Intensified sub-granting to local partner organizations, and all associated supportive supervision and capacity building activities, will strengthen the capacity of RPOs to solicit, lead and report on direct funding grants in the future. Community-based distribution of the locally produced product will provide a sustainable income generating opportunity for a locally produced cost recovery product which does not require a donor subsidy. RPOs and associations of PLWHA will be strengthened through training of trainers, institutional assessments and capacity building programs, ongoing mentoring and supportive supervision by the BCSM capacity building team of PSI, JHU-CCP and CHF. This, and all BCSM activities, will contribute to the development of a Rwandan Social Marketing Institution in a sustainable manner.

In FY 2009, SCMS under the terms of its MoU and sub contract, worked closely with CAMERWA for the procurement, storage and distribution of all HIV-related commodities, including ARV drugs. In addition, SCMS provided technical support to CAMERWA with warehouse management, financial management, performance management and other systems strengthening activities, including MIS support via the computerized warehouse management and financial management systems. SCMS provided technical support to CPDS in the areas of quantification, financing, procurement and distribution of ARVs and other commodities. This consolidated approach to procurement increased cost savings and improved efficiencies in procurement and distribution of commodities. SCMS provided TA to the existing committees of the CPDS to conduct national annual forecasts and supply planning of ARVs using Quantimed and Pipeline software packages as the forecasting and supply planning tools, respectively. The use of these tools has enabled the CPDS to prepare quantification reports that inform a supply plan from which PEPFAR commodity procurements are initiated.

In FY 2010 SCMS will continue to support CAMERWA in these activities but will place increased emphasis on skills transfer, capacity building, ownership, and empowerment. The objective is to ensure sustainability and begin transition towards a technical assistance exit strategy. A further objective will be to support CAMERWA in its new role within the Rwanda BioMedical Center.

In FY 2009 CAMERWA, with technical support from SCMS, began implementation and roll out of the Active Distribution initiative. Active Distribution is part of the GOR's decentralization program and involves the planned distribution of health commodities from the central level down to district pharmacies and health facilities. SCMS support included recruitment of an international Active Distribution project manager for one year, with responsibility for developing the implementation methodology, roll out plan and for ensuring that warehouse systems at central and district level are appropriate and ready for Active Distribution. As part of the scope of work for this post, the project manager was required to help CAMERWA recruit a national counterpart project manager and support team. FY 2010 will see the transfer of responsibility of management of Active Distribution to the national counterpart and the roll out of Active Distribution to a minimum of 15 districts by the end of FY 2010.

In FY 2010 SCMS will continue to support the CPDS to accurately quantify the commodities needed to meet short- and long-term program goals using appropriate forecasting methodologies and selected tools. Training, mentoring and sharing best practices will enable GOR counterparts to conducting forecasting and supply planning activities on their own. In FY 2010 SCMS will continue to provide TA to ensure the smooth functioning of the CPDS system. This will include mentoring and coaching support to the MOH CPDS Coordinator plus capacity building to the CPDS quantification committee and on-going support institutionalizing CPDS policies and procedures.

SCMS will continue support to the Ministry of Health by strengthening logistics management information systems, including data collection, validation, storage and reporting at central, district pharmacy and FOSA levels. SCMS will also ensure the sustainability of the computerized LMIS and ensure that its implementation leads to improved stock management, reduced drug expiry, and reduced cost of delivering to the consumers, among many other benefits. The LMIS within Ministry of Health, along with its computerization, will permit proper data collection and analysis for improved decision making within the national supply chain system.

From FY 2007 to FY 2009, PEPFAR transitioned towards a consolidated approach for the procurement of HIV-related commodities through the use of SCMS and NRL as the primary procurement partners. In addition, the GOR expanded the CPDS to include all HIV-related commodities, including OI drugs and diagnostics, test kits and CD4 reagents. SCMS worked closely with CAMERWA for the procurement, storage and distribution of all HIV-related commodities, including laboratory supplies. This consolidated approach to procurement has increased cost savings and improved efficiencies in procurement and

distribution of commodities. In addition, partners worked in close collaboration through joint planning and work plan development, particularly for activities that supported the LMIS and active distribution system.

In FY 2010, SCMS will works closely with CAMERWA for the procurement, storage, and distribution of rapid test kits and supplies (gloves, lancets, filter paper, test tubes and other phlebotomy supplies) for PEPFAR-supported health facilities, to target all voluntary counseling and testing (VCT), provider initiated counseling and testing (PICT) and PMTCT clients. In addition, SCMS procures additional test kits for GFATM sites and is continuing PEPFAR's support to GFATM that began in FY 2005. Test kits will continue to be procured in line with the national testing protocol, which currently includes Determine, First Response, Unigold and Capillus. By FY 2010, Capillus, which currently is the tie-breaker test will no longer be in production and so a new test would have to be chosen to replace it. To support the rollout of the new national testing algorithm, SCMS will procure additional kits for training activities to support the new testing national algorithm. SCMS will coordinate and regularly communicate with USG partners to ensure they have adequate information for the quantification and distribution of test kits, as well as to discuss issues related to test kit procurement and management.

Through the CPDS, SCMS will continue to ensure the quantification of rapid test kits on a bi-annual basis. As part of the plan to build national capacity to quantify laboratory supplies at all levels of the system and ensure smooth functioning of the CPDS system, SCMS will continuing to work closely with the CPDS to ensure appropriate integration of rapid test kits (RTKs) into the system, including development of a supply plan incorporating RTKs, that will be updated on a quarterly basis. As part of the support to the MOH, SCMS will also collaborate with the NRL and other members of the CPDS to ensure appropriate collection and dissemination of logistics data for RTKs generated from the national LMIS. This will help improve decision making at all sites, including those supported by PEPFAR and District Pharmacies, and to ensure appropriate stock management of these commodities.

As the country continues to strengthen its counseling and testing strategy and implementation, SCMS will work with CAMERWA to analyze and report on district pharmacy and health facility stock levels on a regular basis to monitor consumption trends, potential stock-outs, and make any revisions to procurement plans and projections. In FY 2010, a projected number for routine VCT will be 663,363 and for PIT (Provider Initiated testing) will be 571, 260.

Supply Chain Management System (SCMS) partners work in close collaboration through joint planning

and work plan development, particularly for activities that support the computerization of Logistic Management Information System (LMIS) and active distribution system. SCMS works with CAMERWA (Central Purchasing of Essential Drugs, Medical Consumables and Equipment in Rwanda) to procure, store and distribute opportunistic infection (OI) drugs for all PLWHA including children at PEPFAR- supported sites.

In FY 2009, SCMS continued to provide ongoing TA to CAMERWA for quantification, PEPFAR procurement regulations and for appropriate distribution of products to all sites. Product selection conforms to GOR's minimum list of preventive care, OI and other palliative care medications, as well as to WHO QA standards. SCMS supports CAMERWA and the National Reference Laboratory (NRL) in conducting quality assurance of OI medication arriving in country through thin-layer chromatography (TLC) and use of mini-labs. As OI drugs are integrated into the Coordinated Procurement and Distribution System (CPDS), SCMS provides TA and support to the relevant CPDS committees to develop a procurement and distribution plan for OI, to conduct quantification, monitor consumption patterns and stock levels, and to provide regular reports to donors.

In FY 2010, SCMS will continue to work closely with GFATM, MOH, CAMERWA, and districts to ensure the continuous availability and management of drugs and supplies included in the national Standard Treatment Guidelines. SCMS will also work with clinical partners, CAMERWA, and the MOH to review and revise tools to support the storage, distribution, and tracking of health commodities from CAMERWA to the community level.

The overall goal of this activity is to decrease new HIV infections through male circumcision (MC) among Rwanda Defense Forces (RDF) personnel. The program will be presented as part of an expanded approach to reduce HIV infections, and will be promoted in conjunction with other prevention programs, including HIV testing and counseling, treatment for other sexually transmitted infections, promotion of safer-sex practices and condom distribution. MC will not replace other known methods of HIV prevention and will be considered as part of a comprehensive HIV prevention package.

In FY 2010, in collaboration with Drew University and the Centrale D'Achat des Medicaments Essentiels, Consommables et Equipments Medicaux du Rwanda (CAMERWA), SCMS will quantify and procure male circumcision (MC) kits for Rwandan military personnel. Drew University forecasts that an average of 50 males per week in five sites (250 total procedures per week) will be circumcised. It is thus

estimated that 15,000 MC kits per year will be needed. The demand for MC procedures and kits could vary and will be closely monitored. As CPDS increasingly expands to include other commodities, SCMS will support the CPDS to ensure appropriate integration of male circumcision kits into the system, including quantification support, the development of a supply plan, and procurement of male circumcision kits.

For injection safety, behavioral and occupational change measures will have to be under taken to ensure that all injections and needles are used in an optimally safe manner for patients and health care providers. To do so, the appropriate waste bins, sharps containers and safety boxes must be made available to all health care providers. Segregation of waste should also occur to ensure appropriate waste management. Through the provision of these commodities and changes in human behavior, risky practices which might otherwise lead to the transmission of infectious diseases or needle stick injuries will be eliminated. Information on the commodities required to avert any risk needs to be conveyed to users in a timely manner for this intervention to be a success.

In FY 2010, the Partnership for Supply Chain Management (SCMS) will work closely with Centrale D'Achat des Medicaments Essentiels, Consommables et Equipments Medicaux du Rwanda (CAMERWA) and JSI R&T for the procurement, storage, and distribution of injection safety kits and waste management supplies, including approximately 2.5 million auto-disable syringes, 35,714 safety boxes, boots and masks for PEPFAR-supported health facilities. As the CPDS continues to expand to include other commodities, SCMS will continue to work closely with CPDS to ensure appropriate integration of injection safety kits and waste management supplies, including development of a supply plan which integrates injection safety kits and waste management supplies. Regular quantification support for these commodities will also be provided to CPDS. SCMS will also ensure appropriate and timely integration of injection safety kits and waste management supplies information into the national logistics system to ensure appropriate stock management.

In FY 2010, SCMS will continue working closely with the Centrale D'Achat des Medicaments Essentiels, Consommables et Equipments Medicaux du Rwanda (CAMERWA) to support them in conducting coordinated laboratory commodity procurements for the President's Emergency Plan for AIDS Relief

(PEPFAR) supported sites. Procurement will include laboratory equipment, supplies and reagents for biochemistry, early infant diagnosis (EID), hematology, microbiology, CD4, viral load and biosafety. This consolidated approach to procurement will increase cost savings and improve the efficiency in the current procurement, storage and distribution of commodities.

To inform these procurement decisions, SCMS will continue to support quantification activities within the Coordinated Procurement and Distribution System (CPDS), which includes the Ministry of Health (MOH), PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), the Clinton Foundation HIV/AIDS Initiative (CHAI), all USG clinical partners, and UNICEF. By FY 2010, SCMS should have built capacity with the CPDS to quantify the national laboratory needs which will include Antiretroviral (ART) and non-ART supported sites.

Nationally, quantifications for laboratory commodities occur every six months. On a quarterly basis, supply plans revisions will take place as a means of ensuring improved visibility on orders in the pipeline as well as the current stock on hand throughout the laboratory system. Under the current management plan, CAMERWA will begin taking over the leadership of the bi-annual quantification exercises of laboratory equipment, supplies and reagents in a stepwise manner and will be in charge of all quantification activities for all commodities by FY 2010. Overhead surcharges for SCMS procurement services that were previously paid through core funds at the SCMS Project Management Office (PMO) are now being absorbed by the country. These costs along with funds provided for technical assistance for quantification are included in the SCMS budget for FY 2010.

Through CAMERWA, SCMS will procure all of the biochemistry, hematology, and CD4 supplies for an estimated number of 202,469 patients needed in FY 2010. The revised National ART treatment guidelines call for viral load testing in cases of suspected treatment failure. To meet that need, SCMS will also quantify for and procure viral load reagents sufficient to cover the estimated needs of 5,250 PEPFAR supported patients. In addition to this site-level laboratory procurement, SCMS will procure equipment, supplies and reagents for specific central-level activities and functions, including: 1) kits and supplies for 21,000 PCR tests for the national EID program; 2) an estimated 2,500 additional viral load kits and associated supplies for the laboratory component of the national ART program impact evaluation; 3) test kits and supplies for continuing HIV serology and CD4 testing, Quality Assurance (QA) and training systems; 4) PCR supplies and reagents for expansion of PCR capacity to CHUB and as backup for the National Reference Laboratory (NRL); 5) supplies and reagents for opportunistic infections (OI) diagnostics for regional and district-level laboratories as well as supplies for ongoing microbiology.

The proper diagnosis, care and treatment of persons infected with or affected by HIV/AIDS, TB and Malaria requires the strengthening of laboratory health systems. One of the key elements of this effort is

the standardization of test kits, reagents, consumables and equipment needed at each level in the tiered laboratory system within a country. In FY 2010, SCMS will work in close collaboration with the NRL and the laboratory network to standardize equipment and laboratory supplies. Standardization is the process of harmonizing test menus, test techniques, operating procedures, and laboratory equipment for each type of test and for each level in the system. Standardizing the type of platform for laboratory equipment in chemistry, hematology, CD4 and viral load testing across different laboratory levels will offers many benefits to the laboratory system including: cost reduction due to bulk procurement; improved equipment service and maintenance of equipment due to a limited variety of platforms; ease of staff training due to common user interface on the systems; better standardization of reference ranges and test results, and thus improved continuity of care for patients who transfer from health centers to district facilities. Standardization will also help expand sustainable quality testing to improve care and treatment of people infected with and affected by HIV/AIDS, TB, Malaria and other diseases.

Currently, equipment maintenance and service are a critical challenge to the system. The Atelier Central de Maintenance (ACM), which is responsible for providing equipment maintenance in the country, has limited capacity to do so. A bulk of the existing equipment in country also lacks long term service and maintenance contracts from local vendors or respective manufacturers. In the funding provided in FY 2010, SCMS will support the ACM to improve upon the current situation with equipment maintenance and service. In FY 2010, SCMS will have the budget to procure approximately $3.1 million dollars of required equipment. This will represents approximately half the need of the laboratory system. This equipment will be used replace the equipment that is non-functional and support the needs of all PEPFAR implementing partners. In all future procurements of laboratory testing equipment, SCMS will negotiate long term contracts with various vendors and suppliers to ease the burden of service and maintenance responsibility of the ACM.

SCMS will also continue to support the laboratory logistics management System activities which by FY 2010 is expected to be generating consistent and quality logistics data for decision making. Key activities at that time period are expected to focus on supervision and continuous monitoring of the system to help ensure the smooth functioning and improved reporting rates from the logistics management information system (LMIS). The continuous support and strengthening of the logistics system will also help improve the visibility of logistics data from the Health Centers, District Hospitals and Pharmacies for improved decision making for quantification, procurement ordering and distribution.

In FY 2010, SCMS will work in close collaboration with the National Reference Laboratory and the lab network towards World Health Organization (WHO) Accreditation through improved monitoring and support of inventory management and maintenance of equipment to provide uninterrupted service. Accreditation of laboratories offers many benefits, including: strengthening of laboratory management;

working in a safe environment, delivery of a smooth and efficient service; providing prompt, accurate and validated test results in a timely manner to promote client satisfaction; capacity building and improved quality in laboratories internationally.

In FY 2010, funds for ARV medications will continue to support three components:

1. Under the stewardship of the Ministry of Health, SCMS works closely with the Centrale d'Achats des Medicaments Essentiels du Rwanda (CAMERWA), TRAC Plus and the Pharmacy Task Force (PTF) to forecast, procure, warehouse, store, and actively distribute PEPFAR financed ARVs. SCMS has been supporting CAMERWA to strengthen its warehouse management, stock keeping and financial management systems including the installation of computerized management information systems in order to ensure it maintains maximum control over inventory management and distribution of ARVs thus minimizing the risk of stock outs . These drugs are procured through the Coordinated Procurement and Distribution System (CPDS) for 151 PEPFAR-supported ART sites and 62,368 patients. The SCMS Procurement Adviser based at CAMERWA will complete his advisory support during FY 2010. As part of the exit strategy, SCMS will ensure that outstanding skills, knowledge and procurement processes are transferred to CAMERWA procurement staff. A strengthened procurement system making use of framework agreements, value for money and best practice procurement processes and annual procurement planning will ensure that stock outs of ARVs do not occur during FY 2010.

2. SCMS is the lead agency building the capacity of the CPDS. SCMS provides technical support and supervision to the Quantification Committee, the Resource Management Committee and the Implementation Committee to ensure optimal use of funds provided by all donors including PEPFAR. This activity also supports coordination between donors and implementing partners and includes conducting analysis of data on stock inventory and consumption patterns at CAMERWA, Districts and FOSA as well as number of patients per regimes from health facilities. SCMS also continues to participate in quarterly data quality control visits with TRAC Plus and the district pharmacies in support of the coordination of the Laboratory Management Information System (LMIS) between districts and CAMERWA. In addition, SCMS collaborates with the USAID|DELIVER project in the harmonization of family planning, malaria, and other health commodity LMIS applications and the training of the users of these applications. Although there were no reported stock outs of ARVs during FY 2008, emergency orders were placed in three instances to prevent stock outs occurring. The ARVs concerned were Nevirapine, Lamivudine and Tenofovir. These situations arose because of incomplete consumption data

from health facilities and non adherence to agreed national treatment protocols. FY 2009, therefore saw an increased emphasis on strengthening LMIS systems to improve data collection, reporting and validation at all levels in order to prevent the threat of stock outs. This included computerization of the national LMIS and training and roll out in the use of the harmonized forms. This support will continue during FY 2010 with roll out of further supply chain management training to new and existing ART sites. The objective being to minimize and prevent the risk of stock outs and to ensure a harmonized and standardized supply chain at all levels of the supply chain system in Rwanda.

3. SCMS collaborates with PTF/MOH and CAMERWA to strengthen quality assurance (QA) systems. It is critical that all medications reaching patients are safe, effective and meet quality standards. SCMS works with e PTF, CAMERWA and the CPDS to ensure prudent supplier and product selection and certification, and other components of the World Health Organization (WHO) Certification Scheme. SCMS also supports the establishment of Thin-Layer Chromatography (TLC) and mini-laboratories in collaboration with the MOH, University of Butare and the National Reference Laboratory (NRL) to test the quality of ARVs.

New and significantly more expensive treatment regimens, including Tenofovir (TDF), have started being prescribed in Rwanda beginning September 2009 for new patients starting on ARVs as well as patients determined to be failing on currently prescribed ARV regimens. Consequently, additional resources will need to be identified and carefully planned for if the scale-up proceeds not as intended. PEPFAR funds are being utilized to purchase first-line treatment regimens. All pediatric and 2nd line ARV drugs have been donated by CHAI for the past years; however the CHAI second line ARV and pediatric programs are respectively ending in 2009 and in 2010. As many as 4,071 (5% of total ART patients) or more patients predicted to be on 2nd line ARVs by the end of 2011 (with the increased VL testing efforts in identifying patients with treatment failure) could be prescribed new and more expensive second line regimens. The two recommended 2nd line regimens (as per the revised national STG): AZT/3TC/LPV-r and TDF/3TC/LPV-r will cost respectively US $ 606.63 and 621.72 per patient per year. Prescribing the second line regimens to this number of patients could by itself amount to over US $ 2,500,306.42 Close monitoring and coordination with other partners whose financial support helps pay for ARV medications in Rwanda's non-PEPFAR-funded ARV sites, along with ongoing evaluation of the impending regimen changes will be of critical importance for continued ARV treatment success across the country.

In FY 2009, SCMS worked in close collaboration with CAMERWA, NRL, CHUK and CHUB and will

provide technical assistance and funding for the procurement, storage and distribution of all medicines, equipment and laboratory supplies for TB OI's (Cryptococcus infections and other fungal infections) and malignancies related to HIV .

In FY 2010, SCMS will procure anatomical histology equipments with twelve months of warranty and maintenance agreements, Lab consumables and reagents for the pathology to continue diagnosis activities and expand support to the Butare and Kigali University Hospitals. This activity is conducted in collaboration with AIDSRelief, who provides trainings through the Institute of Human Virology, for laboratory technicians and physicians for improved extra pulmonary TB and HIV related malignancies diagnostic .These endeavors will enhance timely diagnosis capabilities for extrapulmonary TB among PLWHA in line with PEPFAR strategy to decrease the burden of TB on PLWHA.

These activities contributes to the Rwanda PEPFAR five-year strategy goal of integrating TB and HIV services by strengthening TB diagnostic capacity at Rwanda's major reference hospitals.

12. Social and Scientific Systems/MEMS

Social and Scientific Systems/Monitoring and Evaluation Management Systems project (SSS/MEMS) will provide monitoring and evaluation (M&E) support to all PEPFAR implementing partners carrying out activities under this budget code, thus strengthening in-country institutional capacities in M&E.

SSS/MEMS has deployed a web-based reporting system for reporting of semi-annual and annual program results' by all PEPFAR implementing partners in Rwanda. This system is updated before each reporting period to reflect changes in PEPFAR indicators and changes required as a result of feedback from users during the previous reporting period. Implementing partners are provided with user training of the system and followed up during each reporting period to ensure data quality. Data quality assessments are carried out in collaboration with GOR counterparts for the PEPFAR indicators, thus building national capacity in this area.

Meetings are held with USG teams, implementing partners and host country counterparts to ensure a shared understanding of GOR and USG reporting requirements and indicators, and to enable the capture of PEPFAR indicators in the GOR databases.

SSS/MEMS will generate burden tables and maps using reported data, to depict USG-supported service coverage for specific indicators. This will enable USG and GOR counterparts to better plan for HIV/AIDS interventions in the country.

M&E capacity building support will be provided to PEPFAR implementing partners to improve their performance monitoring plans, annual work planning processes, reporting and use of data.