BACKGROUND: In 2000 the NDOH requested USAID support in addressing two critical weaknesses in the South African Government's (SAG) HIV prevention program relating to condom procurement and distribution: the poor quality of condoms that were distributed in South Africa and the frequent and prolonged shortages and stock-outs in the provinces - both problems which resulted in negative media towards, and an erosion of public confidence in, the SAG HIV prevention program. SCMS, in close collaboration with national and provincial counterparts, will build upon JSI's successful development and implementation of a package of technical solutions to these two critical shortcomings. First, JSI-supported systems have eliminated poor quality issues by ensuring compliance testing to World Health Organization specifications and standards of all production batches regardless of local or overseas manufacture, thus guaranteeing that only high quality public sector condoms are distributed in South Africa. Second, the JSI-developed Logistics Management Information System (LMIS) has enabled the NDOH to eliminate shortages and stock-outs in the provinces by establishing and servicing 172 primary distribution sites across all provinces. These two achievements were crucial in empowering the SAG to sustain its HIV prevention focus in its response to HIV and AIDS epidemic and maintain its long-term goal of ensuring that people who are currently HIV-negative, remain negative. Making condoms available to sexually active populations and thereby positively influencing male norms and behaviors (key legislative issue) is an essential component of the SAG's ABC campaign. PEPFAR funds will be concentrated on ensuring the NDOH's technical know-how needed to efficiently operate the supply chain and sustain the focus on most at-risk populations.

ACTIVITIES AND EXPECTED RESULTS: SCMS will also build upon JSI's capacity building with the NDOH to facilitate the eventual withdrawal of USG support. LCS will continue to provide technical assistance in the procurement, quality assurance, warehousing, distribution and tracking of approximately 30 million condoms per month to sexually active youth, adults and family planning clients, with a particular focus on non-traditional outlets for high risk, marginalized populations. LCS will intensify efforts within the NDOH to establish appropriate government posts for quality assurance and logistics management, and provide formal and informal, on the job training. LCS will provide additional focused assistance to the provinces and districts to ensure all levels of the logistics management system are able to fully operate and sustain the program once USG/LCS support ceases in September 2008. It is recognized that it is critical from the USG and SAG perspectives that this successful program is sustained into the future.

LCS will contribute substantially towards the vision in the USG Strategic Plan for South Africa by building human capacity within the NDOH and provincial DOHs in procurement, quality assurance, supplier contract management, warehousing and distribution, while maintaining a zero stock-out rate for the primary distribution sites. This activity will also assist significantly in achieving the 2-7-10 goals for averting 7 million new HIV infections.

This $100K will enable SCMS to expand the number of sites serviced by 52 (i.e. a total of 132 sites). These expansion sites will comprise non-traditional outlets aimed at making condoms more readily available at the community level through a Pubic Private Partnership (PPP) between the South African Business Coalition for HIV and AIDS (SABCOHA), the National Department of Health, and Prestige/Supercare Cleaning industry leaders

Targets

Target Target Value Not Applicable Indirect number of community outreach HIV/AIDS prevention
programs that are not focused on abstinence and/or being faithful Indirect number of mass media HIV/AIDS prevention programs that
are not focused on abstinence and/or being faithful Indirect number of individuals reached with community outreach
HIV/AIDS prevention programs that are not focused on abstinence and/or being faithful Indirect estimated number of individuals reached with mass media
HIV/AIDS prevention programs that are not focused on abstinence and/or being faithful Indirect number of individuals trained to provide HIV/AIDS
prevention programs that are not focused on abstinence and/or being faithful Indirect number of targeted condom service outlets
Number of targeted condom service outlets 232  Number of individuals reached through community outreach that
promotes HIV/AIDS prevention through other behavior change beyond abstinence and/or being faithful Number of individuals trained to promote HIV/AIDS prevention
through other behavior change beyond abstinence and/or being faithful

Table 3.3.05:

INTEGRATED ACTIVITY FLAG:

In addition to ARV Drugs, the Partnership for Supply Chain Management implements related activities described in ARV Services (#8107). It is also linked to potentially all USG South Africa PEPFAR partners interested in procuring commodities or technical assistance from the PFSCM.

SUMMARY:

The Partnership for Supply Chain Management (PFSCM) project is tasked with supporting PEPFAR by strengthening secure, reliable, cost-effective and sustainable supply chains that procure and deliver high quality antiretroviral drugs (ARVs) and related commodities to meet the care and treatment needs of people living with HIV (PLHIV). Several PEPFAR treatment partners in South Africa have expressed interest in taking advantage of PFSCM services. The major emphasis area is commodity procurement, and minor areas include logistics, local organization capacity development, training, and quality assurance.

BACKGROUND:

In September 2005, the PFSCM was awarded an agreement by USAID to support PEPFAR in terms of strengthening supply chains for ARVs and related commodities, with an initial focus on fourteen African countries, including South Africa. The PFSCM was established in response to widespread recognition that a continuous pipeline of high quality, low-cost ARVs and related commodities is critical to successful ARV patient management at the individual level, and to reaching the PEPFAR goals at the macro level. The overall mission of the project is to strengthen or establish secure, reliable, cost-effective and sustainable supply chains to meet the needs of people living with HIV. In collaboration with in-country and international partners, the PFSCM's mandate is to deploy innovative solutions to enhance supply chain capacity, ensure accurate supply chain information is gathered, shared and used, and provide quality, best-value healthcare products. The PFSCM project team comprises a current total of 17 non-profit organizations, commercial private sector companies, academic institutions and faith-based organizations. Three of these key organizations are based in South Africa: the Fuel Group, where the PFSCM has established a regional distribution center to service Southern Africa and beyond, North West University which houses the only WHO-accredited quality assurance laboratory in sub-Saharan Africa, and Affordable Medicines for Africa (AMFA) which has provided medicines to faith-based organizations throughout Africa for many years.

ACTIVITIES AND EXPECTED RESULTS:

The PFSCM, led by John Snow, Inc. (JSI) and with Management Sciences for Health's Rational Pharmaceutical Management (RPM Plus) project, will work with PEPFAR treatment and palliative care partners to improve the cost-effectiveness of their supply chains for ARVs and related commodities, including drugs for opportunistic infections and palliative care, drugs for sexually transmitted infections (STIs), drugs and supplies for home-based care, drugs for TB, rapid HIV test kits, laboratory equipment and supplies, and other medical supplies. Treatment and other partners may include, but will not be limited to: Catholic Relief Services (CRS), Hope Worldwide, BroadReach Healthcare, the Anglican Church of Southern Africa HIV/AIDS Office, the Hospice and Palliative Care Association of South Africa and the South African National Defence Force (SANDF). Activities will focus on technical assistance and human and organizational capacity building in supply chain management and related areas. PFSCM is prepared to assist the National Department of Health (NDOH) and provincial health departments should it be requested.

Activity 1: Drugs and Related Commodity Procurement

The PFSCM will procure drugs and related commodities for PEPFAR-supported care and treatment partners at competitive costs and will make these commodities available via the South Africa-based Regional Distribution Center on an ongoing basis. The PFSCM will negotiate directly with manufacturers, leveraging global SCMS procurement forecasting to further drive down pricing over time. The PFSCM will also provide quality assurance for all commodities procured through the regional distribution center.

Activity 2: Technical Assistance

Technical assistance will focus on the following areas: quantification and forecasting, procurement, quality assurance, freight forwarding and inventory management, distribution (including pharmacy services for individual patient treatment packs), logistics management information systems, and assistance to manufacturers and suppliers. Technical assistance will be provided by local partners as well as international PFSCM staff.

Activity 3: Human and Organizational Capacity Development

The PFSCM will provide training as requested in technical areas of supply chain management for both PEPFAR treatment partners and provincial and NDOH counterparts. The PFSCM will take advantage of the in-house capacity of the Fuel Group's state-of-the-art Regional Distribution Center facilities and supply chain expertise, and the North West University's quality assurance laboratories and expert training staff to provide hands-on training and experience in freight forwarding and inventory management and quality assurance. Training will also be provided by international PFSCM staff.

Activity 4: Pain and Symptom Control

Anecdotal evidence suggests that PLHIV in PEPFAR-supported care and treatment programs experience pain and symptoms related to HIV disease, opportunistic infections and/or side effects of ARV therapy which are not adequately addressed by health providers. Increasingly ART clients are switched to second line ARV treatment regimens due to medication side effects or other symptoms, raising questions as to whether symptoms could be more effectively managed first, without resorting to sudden changes in treatment regimens. It is proposed that the PFSCM would assist USG PEPFAR Task Force and its partners to review the occurrence of common symptoms and pain experienced by PLHIV, current strategies to manage symptoms and pain, including indications for switching PLHIV to second line treatment regimens. Particular emphasis will be placed on appropriate management of neuropathic pain with ART by PEPFAR partners. The PFSCM will also explore the existence of common medications for symptom and pain management on the South Africa Essential Drug Lists and their availability and cost in PEPFAR-supported facility and community-based care and treatment sites and in select NDOH sites. Information will be utilized by USG PEPFAR Task Team, PEPFAR partners and the NDOH to better inform and improve program management of pain and symptoms which would ultimately improve the quality of life and well-being of PLHIV in South Africa.

Plus up funds will enable PEPFAR to assist Western Cape Department of Health (WCPDOH) with procurement of ARV commodities. WCPDOH requested financial assistance from PEPFAR to cover the shortfall of ARV drugs in the province. The ARV drugs will cover 800 children and 8000 adults. The funding budgeted herein is not sufficient to cover the full cost of the drug order and thus additional funding for commodities, and associated Technical Assistance for treatment and lab services, will be provided through the COP 08 mechanism.

The PFSCM will contribute significantly towards meeting the PEPFAR goals by assisting treatment and palliative care partners to establish and sustain secure, reliable, and cost-effective supply chains of high quality products to meet the needs of HIV-infected care and support and ARV treatment patients. It is expected that overall quality of care will improve from this intervention, meeting the PEPFAR 2-7-10 goals.

INTEGRATED ACTIVITY FLAG:

This ARV Services activity is linked to the Partnership for Supply Chain Management (PFSCM) activity described in ARV Drugs (#7935). It is also linked to the ARV Services activities of both the Foundation for Professional Development (#7593) and Catholic Relief Services (#7487), and potentially all USG South Africa PEPFAR partners interested in procuring commodities or technical assistance from the PFSCM.

SUMMARY:

John Snow, Inc. (JSI), through the PFSCM, is using PEPFAR funds to strengthen ARV patient information and reporting capabilities utilizing STAT (Secure Technology Advancing Treatment), a system based on biometric fingerprinting to ensure data verification and smartcards as a mobile, patient-retained medical record. JSI has developed the STAT system as a cost-effective system that is both scaleable and sustainable. The major area of emphasis is local organizational capacity building, with minor emphasis on development of network/linkages/referral systems, quality assurance and supportive supervision, training and human resources. The primary target populations are people living with HIV (PLHIV) and public and NGO healthcare providers. In addition to smartcards, the PFSCM, led by JSI and with Management Sciences for Health's Rational Pharmaceutical Management (RPM Plus) project, will provide technical assistance in a wide range of supply chain issues, including quantification, quality assurance, inventory management, distribution and tracking. Of the total $3 million in funding for this activity, $2 million will be for the smartcards and $1 million for supply chain management technical assistance.

BACKGROUND:

The lack of verified program reporting data/performance indicators and use of cumbersome and often incomplete paper-based patient medical records continue to present major challenges in scaling up antiretroviral treatment (ART) programs. Under the DELIVER project, JSI developed a public-private partnership with a local biometrics and smartcard leader to design and field test a prototype patient information and reporting system, named STAT, based on combination biometrics and smartcard technology. The system was successfully demonstrated in a static clinic environment and also in an offline, remote, rural setting for both ART and care and support services. In order to address emerging issues during the pilot phase around proprietary software, licensing fees, and data transmission costs, which made large-scale implementation impractical, JSI developed new partnerships in FY 2006 to continue the development of the STAT system in an open source environment, eliminate licensing fees, and design a data transmission mechanism that was both scaleable and sustainable. The new version of the system was implemented in both NGO and government ART clinics.

In FY 2007, JSI and the PFSCM will substantially expand the number of patients utilizing the STAT system, with a focus on public sector sites at the provincial level. This latter focus is important as the National Department of Health (NDOH) has included biometrics and smartcards in its long-term strategic plan for developing an electronic patient medical record for South Africa. JSI and the PFSCM will continue to build on their collaborative relationships with the SAG, and will also explore potential deployment of the STAT system in private sector environments. If, however, the NDOH or provincial Departments of Health do not demonstrate interest or commitment in using this technology, this may be the final year of funding for this initiative.

Of particular concern in expanding ART services is the reality that large accredited ART sites are becoming overburdened with patient follow-up and are struggling with the human capacity to add new patients. Under these circumstances, the development of effective down referral systems where patients can receive follow-up care and drug re-supply closer to their local communities is critical. The STAT system offers several crucial components to a successful down referral model: from a clinical and quality of care perspective it enables doctors who have stabilized ART patients to track patients over time, quickly assess them, and make clinical treatment adjustments when patients are referred back to the initiating ART treatment site in case of treatment failures; from a patient perspective it enables patients to easily access ARV services at multiple service delivery sites; and from a program performance perspective, it enables program managers

and funding agencies to access verified (i.e. high quality) PEPFAR indicators at any time, providing virtually real time reporting and strategic information capabilities.

ACTIVITIES AND EXPECTED RESULTS:

Specific activities will include STAT system training for ARV service providers, implementation and maintenance of the STAT system at sites, and the development of sustainable financial support mechanisms to ensure STAT remains after PEPFAR funding has been utilized to introduce the system and provide the initial implementation. The focus of activities will include technical assistance and human capacity development.

Activity One: Expand STAT Patient Information and Reporting System

JSI and the PFSCM will substantially expand implementation of the STAT system with selected PEPFAR treatment partners and provincial departments of health. There will be a particular focus on utilizing the STAT system as a means of implementing an effective patient medical record and program reporting system for ARV down referral models. JSI and the PFSCM will build on FY 2006 collaboration with the Reproductive Health and HIV Research Unit (RHRU) in Durban, the Foundation for Professional Development (FPD), and Catholic Relief Services (CRS) and will more than double the number of sites and patients utilizing the system in FY 2007.

Activity Two: Human Capacity Development

Training on the patient information system for ARV service providers and data capturers will be conducted for all those participating in the expansion program. Follow-up supervision and technical assistance will be provided and evaluated. It is expected that overall quality of care will be improved by the system's ability to track patient information including ARV initiation, drug regimen changes, and treatment outcomes.

Activity Three: Technical Assistance

Technical assistance will focus on the following areas: quantification and forecasting, procurement, quality assurance, freight forwarding and inventory management, distribution (including pharmacy services for individual patient treatment packs), logistics management information systems, and assistance to manufacturers and suppliers. Technical assistance will be provided by local partners as well as international PFSCM staff.

JSI and the PFSCM will contribute significantly towards meeting the vision of the NDOH in developing an electronic patient-retained record and will also contribute significantly towards meeting the vision of the USG PEPFAR Task Force Five-Year Strategy for South Africa by providing a state-of-the-art system to facilitate the virtual real time collection, analysis and reporting of the required PEPFAR M&E indicators for ART for thousands of patients. This will contribute to the PEPFAR goals of 2 million people on treatment.