ASSESSMENT OF THE HIV RAPID TEST KITS’ SUPPLY CHAIN

DRAFT 2 March 21 2017

March 21, 2017

This publication was produced for review by the U.S. Agency for International Development. It was prepared by Chemonics International Inc.

This publication was produced for review by the U.S. Agency for International Development. It was prepared by Chemonics International Inc. in partnership with ThinkWell, under USAID Prime Contract No AID-OAA-I-15-00004; Task Order No. AID-OAA-TO-15-00007 Subcontract number: SUB-316 start date 11/23/2016 End date 3/10/2017

Recommended citation: USAID GHSC-PSM Single Award IDIQ. 2016. Assessment of the HIV Rapid Test Kits: Supply Chain in Zambezia and Maputo Provinces. Maputo, Mozambique.

ThinkWell Contact: Caroline Phily Country Director ThinkWell Mozambique [email protected]

Chemonics Contact: Dimitri Peffer Country Director GHSC-PSM Mozambique [email protected]

DISCLAIMER

The authors’ views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the U.S. government.

HIV RAPID TEST KIT ASSESSMENT REPORT | ii CONTENTS

Acronyms ...... iv Executive summary ...... v I Context ...... 1 Background and Context ...... 1 II Methodology ...... 4 III Caveats ...... 5 IV Findings ...... 6 Forecasting & Procurement ...... 6 Distribution ...... 8 Inventory management ...... 10 Utilization ...... 18 Annex 1: Achievement of HIV testing targets ...... 25 Annex 2: Stock flows and consumption of RTKs ...... 26 Central level ...... 26 Provincial level ...... 27 District level ...... 29 Annex 3: RTK allocation from central to provincial level ...... 32 Annex 4: Detailed RTK losses from central level to health facilities ...... 34 Zambezia ...... 34 Maputo Province ...... 35 Annex 5: Contact list ...... 37 Annex 6: Assessment credential ...... 43 Annex 7: References ...... 44

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ACRONYMS ANC Ante-natal Care ART Anti-Retroviral Therapy ATS Testing and Counselling Services CCR Consulta de Criança em Risco CDC Center for Disease Control and Prevention CMAM Central de Medicamentos e Artigos Médicos DPM Provincial Medicine Deposit DPS Provincial Directorate of Health DDM District Medicine Deposit FDC Foundation for Community Development FGH Friends for Global Health HIV Human Immunodeficiency Virus IP Implementing Partner MAC Sistema de Registo de Medicamentos MOH Ministry of Health MSH Management Sciences for Health PAV Programa Alargado de Vacinação PEPFAR U.S. President's Emergency Plan for AIDS Relief PSCM Procurement and Supply Chain Management PSM Procurement and Supply Management RTK Rapid Test Kit SIMAM Medicines and Medical Supplies Information System SISMA Sistema de Informação de Saúde de Moçambique para Monitorização e Avaliação SMI Saude Materna e Infantil T & S Test and Start UATS Unidades de Aconselhamento e Testagem em Saúde USAID The United States Agency for International Development

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EXECUTIVE SUMMARY

The demand for HIV rapid tests in Mozambique has more than doubled over the last five years, driven by expanded access to treatment and the implementation of the National HIV acceleration plan. While complimentary efforts were made to ensure adequate supply of test kits, the country has faced shortages and stock-outs that have hampered the health system’s ability to achieve testing targets. This assessment examines bottlenecks in the supply chain across 4 key drivers of stock: forecasting & procurement; distribution; inventory management; and use. This assessment examines the strengths and weaknesses within each driver, identifies areas of vulnerability, and proposes solutions. A summary of results can be found in table 1. Overall, our assessment found that there is no one driver of stock-outs within the supply chain system for RTKs. We did not find evidence to corroborate rumors or grand theories of large- scale theft conspiracies, profound irrational use / double testing, or gross errors in quantification. Rather, we believe that a range of weaknesses within the supply chain system, exacerbated by exogenous events, converged to create the shortages observed. Our first major finding is that the quantification for RTKs is more than adequate to cover need, at country level and in each province under review. Despite the rapid expansion of testing demand and targets, nearly 3 times more UniGold tests were procured than the number of HIV infected people who have not been identified. Moreover, we found that health facilities are, by and large, adhering to clinical protocols: we did not find any wide-spread evidence of the so- called phenomenon of ‘double testing’. While the test kits were rationally dispensed by providers and procured in adequate numbers nationally, we found that the allocation formula that drives distribution to provinces is not regularly used, leading to inefficient and uneven stock levels that do not correspond to provincial and district needs. Further exacerbating this, we found that there is a generalized lack of capacity (a provincial-level ‘command’ function) to cope with volatility or ‘shocks in the supply chain. Several notable examples of shock that contributed to stock shortages were: 1) the sharp increase in the number of RTKs required to meet new testing targets; 2) production and quality assurance issues arising from the manufacturer of UniGold delayed procurements; and; 3) security issues in Zambezia. Taken together, we find the general rule of ‘one month buffer’ inadequately enforced to deal with the volatility that the supply chain currently faces. Another key driver of stock issues are the losses of kits at each stage of the supply chain below the central level. Our analysis finds that the majority of these losses occur at three key points of the supply chain: 1) provincial warehouse; 2) transportation routes below the provincial level, and 3) health facility. We find that these losses are the consequence of weak control systems. For example, while reconciliation of stock records at the warehouse and transportation levels clearly show discrepancies, there is no enforcement of reporting systems to report or investigate those discrepancies. We believe that the lack of enforcement is a structural issue stemming from inadequate checks and balances, as well as misaligned incentives. Capacity constraints stemming from tedious processes also contribute to loss. For example, at the facility level, pharmacists face capacity constraints to reconcile RTK stock levels on a regular basis, as this would require analysis at up to 10 separate testing points. Similarly,

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external testing programs such as community testing or university testing do not have well organized or enforced RTK consumption reporting systems, leading to losses of stock. These weaknesses open up the door for potential mismanagement and leakage. Overall, many of the issues related to control and reporting stem from difficulties in system- wide monitoring, as full visibility into the system is not possible. For instance, there is a MACS database at the central level, a distinct SIMAM database at the provincial and district level, and these are not integrated into one system. The e-SISMA database, which houses information on service utilization, is not integrated or even reconciled with the SIMAM inventory management system. This lack of systems integration, coupled with various and numerous manual procedures throughout the decentralized system, create a concerning vulnerability.

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Recommendations Based on the findings of this assessment, we recommend intervention in five key areas. The first is re-emphasizing the importance of data visibility throughout the supply chain through an integrated data management system. While this is an ongoing activity that has already been underway for some time, we recommend prioritizing its timely completion. Adding to that, we recommend building automated management dashboards that track key metrics (such as reconciliation levels) to allow for greater and more transparent management. Second, we recommend improving data quality throughout the system by building the capacity of data managers as well as ensuring greater uptime of the IT platform. Turnover of data management staff is high, therefore it is essential to have regular trainings to onboard people to the system, as well as provide refresher trainings for existing staff. Downtime of the platform at the district and provincial warehouse level should be systematically assessed and addressed, as this has been frequently cited as a major barrier to data quality control Third, we recommend to temporally adopt the “push” allocation methodology from the central and provincial level until one month buffer stocks are rebuilt at Provincial and District levels. We recommend for CMAM to reevaluate the current allocation formula methodology and define a need based allocation formula which will ensure easy implementation by wharehouse managers, sufficient control of usage and accurate tracking of testing needs. Our fourth recommendation is focused on strengthening the coordination of distribution activities within provinces. We recommend ensuring that provincial levels are fully mandated, empowered, and capacitated to manage the volatility in the supply chain by establishing ‘provincial command centers’. These command centers can troubleshoot supply issues, support enforcement of policy, respond to ‘shocks’, and coordinate across multiple supply platforms. This unit should have full visibility into the supply chain system once system integration is complete. Further, we recommend ensuring that there be vehicles specifically dedicated to the last mile distribution to the health facilities. Finally, this leads to our fifth recommendation of implementing a range of new measures to strengthen the control systems and the governing environment throughout the supply chain. This entails exploring the feasibility of measures including mandated stock/consumption reconciliation at all levels, risk-based audits, video surveillance for warehouse security, barcoding, and random product tracing. Further, we recommend strengthening the governing environment around the supply chain at all levels to ensure adequate checks and balances are in place within the system. Managers should have safe channels to report losses or concerning reconciliation numbers without fear for their jobs. There is an urgent need to better coordinate with the General Inspection, both at central and provincial level, and ensure that actions are taken to respond to reported losses. To operationalize this incentive, we recommend conducting a thorough assessment of the structural barriers to report and potential conflicts of interest to create a plan to mitigate these factors.

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Figure 1: Key drivers of RTK stock-outs in Zambezia and Maputo Province

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I CONTEXT Background and Context HIV Rapid Tests Kits (RTKs) in Mozambique are procured by external donors and distributed through the public supply chain, overseen by the Central Medical Store (CMAM). When they arrive to the country from the manufacturers, RTKs are stored at the Central Warehouse in Zimpeto. From Zimpeto, RTKs are distributed to the 10 Provincial Warehouses (DPMs) on a monthly basis. Given the short shelf-life of RTKs once they arrive to the country (up to 9 months), they are distributed on a monthly schedule further down the chain to the health facilities (Figure 2), with an intended buffer stock of one month consumption at every level.

RTK inventory at the Central Warehouse is managed in the computer program for warehouse management (MACS), while inventory at all Provincial Warehouses (DPMs) and most District Warehouses (DDMs) is managed through a digital Medicines and Medical Articles Information System (SIMAM). In addition to recording warehouse transactions, SIMAM captures data on orders, distribution and consumption of all medicines and medical articles, including RTKs, down to the health facility level. SIMAM database is distinct at every level, and CMAM has direct access to the data only down to the DPMs. At most health facilities, there are currently only paper registers of orders, distribution and consumption of RTKs, which are aggregated and digitalized only at the respective District Warehouses.

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Figure 2: Mozambique RTKs Supply Chain Diagram

The demand for HIV rapid tests in Mozambique has more than doubled over the last five years, driven by the expanded access to treatment and the implementation of the National Accelerated Response to HIV/AIDS (“Acceleration Plan”). At the end of 2015, there were an estimated 1.6 million people living with HIV in Mozambique. The number of health facilities offering ART went from 255 in 2011, to 937 at the end of 2015, when 738,386 adults were reported to be on ART. In February 2016, Mozambique expanded access to ART treatment to all the HIV infected patients whose

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immune cell (CD4) count is below 500. As a response to PEPFAR 90-90-90 objective1, the MOH initiated in August 2016 a phased roll out of the Test and Start (T&S) approach, with the goal to expand it throughout the country by the end of 2017. These changes have resulted in significant increases in testing targets in the last three years. In April 2016, the targets for year 2016 were increased by 32% compared to what was planned the year before (Figure 3). Given the roll out of the T&S approach, targets are expected to continue to rise over the coming years.

Figure 3: MOH targets for HIV Testing and Counseling (results of the 2016 Quantification)

According to the MOH, 71% of the 2016 national testing targets were achieved by the end of the year2. The target achievement rate was the highest for the provider-led testing (ATS), and the lowest for community testing. National target achievement rate was 54% in Zambezia and 73% in Maputo Province. In comparison, Zambezia surpassed PEPFAR targets for 2016 by 6%, while Maputo Province reached 68% of PEPFAR targets (see Annex 1). Stock-outs of RTKs, particularly UniGold, have been frequently cited as one driver for not achieving the national testing targets in 2016. Anecdotally, PEPFAR implementing partners cited stock-outs of RTKs as one of the major reasons for not achieving targets. Stock-outs were most frequently reported in Zambezia, thus Zambezia was selected as the key province of interest for this assessment. PEPFAR and the Global Fund led advocacy work and held several meetings to improve access to UniGold tests in the country. Several corrective measures were adopted throughout the year. In April 2016, the Quantification Team revised the quantification to increase the amount of UniGold to be procured, and in October 2016, CMAM replaced the formula allocation with a “push” distribution methodology aiming to replenish the buffer stock levels at provincial warehouses. Our analysis of stock level data corroborates anecdotal claims of shortages: we find that there has been a shortage of HIV RTKs at almost all levels during 2016, with the exception of Determine at the central warehouse. CMAM considers that there is a shortage of RTKs if a warehouse stock is below the security level (i.e. one month of consumption) at any given time. Annex 1 provides the overall analysis of stock levels for all sites that we visited for the purposes of this assessment. With the exception of Determine at the central warehouse, none of the warehouses

1 90% of HIV-positive individuals knowing their status, 90% of those receiving antiretroviral therapy, and 90% of those achieving viral suppression 2 MISAU HIV program data as of end of October 2016, estimated on a prorated basis for the whole year.

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managed to maintain a security stock of RTKs in 2016. Of all the districts visited, Inhassunge in Zambezia was impacted the most as it experienced chronic shortages of tests throughout the year. Since October 2016, the situation at the provincial level has reportedly been improving because CMAM significantly increased the quantities distributed since October 2016 and the adoption of a “push” approach for the delivery of RTK quantities, based on monthly provincial targets instead of reported consumption. Thus, the goal of this assessment is to identify the key drivers of stock-outs of RTKs in the supply chain system. The objective of this assignment is to understand the key drivers of stock-outs of Determine and UniGold test kits occurring in 2016, using the Provinces of Zambezia and Maputo Province as an example, and provide recommendations to CMAM and its partners on how to improve access to RTKs in the future.

II METHODOLOGY To identify the drivers of HIV RTK stock-outs in Maputo and Zambezia Provinces, we developed an analytical framework to guide our work that centered around four pillars: Forecasting and Procurement, Distribution, Inventory Management, and Use (Figure 4). This framework was informed by the global supply chain assessment tool developed by Management Sciences for Health (MSH) and adapted to Mozambique to fit the RTK context. Under each of the four pillars, we investigated a set of clearly defined sub-categories to pinpoint the key drivers of stock-outs of Determine and UniGold tests. Figure 4: RTK assessment framework

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We used a mixed methods approach to complete this assessment: analysis of quantitative data from available sources and qualitative data from key stakeholder interviews. We obtained quantitative data on RTKs’ targeting, quantification, procurement, stock management, distribution and consumption from SIMAM, Pipeline, MACS, HIV programs, the PEPFAR database, and Implementing Partners’ databases. In addition, we collected quantitative data (stock cards, delivery slips (guias de remessa) and consumption reports) on site from two provincial warehouses, five district warehouses and 10 health facilities. Guided by our analytical framework, we developed semi-structured questionnaires for key stakeholder interviews at every level. At the central level, we interviewed key stakeholders from CMAM, MOH programs, Implementing Partners, Donors, the Blood Bank, and Laboratory. (For the complete list of interviews, see Annex 5). The qualitative information obtained through the central level interviews informed our approach for collecting the data from the provinces. We conducted a field visits to Maputo and Zambezia Provinces. At the provincial level, we conducted interviews with key stakeholders from the DPS, DPM, and Implementing Partners. In the districts, we interviewed the representatives from DDS, DDM, and the key staff at the health facilities: the director, the pharmacist, and the relevant service providers. In each province, we selected a sample of districts to visit based on pre-determined selection criteria (see Table 1, below). We used the following criteria to select the districts: population size, HIV positivity rate, volume of HIV RTKs received in the previous year, the responsible Implementing Partner, location, and qualitative criteria derived from qualitative interviews. As a result, we visited the districts of Quelimane, Inhassunge and Gurue in Zambezia Province, and Moamba and Manhica in Maputo Province. Table 1: Selection criteria for the districts to be visited in Zambezia and Maputo Province

Volume of HIV Stock-out Province District Partner Location Qualitative criteria tests used positivity incidence Zambezia Quelimane high high (28%) medium iCAP/FGH Urban (close to DPM) the largest district in Zambezia the most stock-outs of UniGold Zambezia Inhassunge low high (19%) high FGH Rural (close to DPM) in 2016 Zambezia Gurue high low (4%) medium iCAP Rural (far from DPM) close to Malawi border Maputo the biggest district & the Manhica high high low Ariel Urban (close to DPM) Province highest consumption of RTKs Maputo Inconsistent consumption data Moamba medium high low Ariel Urban (close to DPM) Province reported In each district, we selected two health facilities based on the same set of criteria. In consultation with the implementing partners and the key informants from the DDS and DDM, we selected health facilities based on their volume of patients, HIV prevalence in ANC, location (rural/urban), and the qualitative criteria such as the capacity of staff to manage RTK stock and report on RTK consumption. III CAVEATS This assessment was intended to be a systems review, not an audit. We did not trace kits, investigate leakages, gather ‘evidence’, or carry out any other investigative tasks. Our scope was to identify systems’ weaknesses and vulnerabilities. The sample chosen for this review was based on convenience, not statistical representativeness. The sites selected for deep analysis were diverse and we attempted to include a good sample of the various clinic types. The sample selection was not large enough, or sampled in such a way, that would lead to generalizable results. Rather, the results are indicative of what areas are likely contributors to stock shortages.

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IV FINDINGS Forecasting & Procurement Quantification Despite perceptions by PEPFAR implementing partners that insufficient quantification is the key driver of stock-outs, we found that the levels of RTKs procured in 2016 were more than adequate to cover testing targets. In 2016, 8 million Determine tests and 1 million UniGold tests were procured (Figures 4 and 5). The quantities of UniGold procured are more than three times as high as the estimated number of people with an unknown positive HIV status (less than 300,000). The quantification assumptions are conservative in that they assume a high level of wastage (29% for UniGold) and re-testing (30% considering the progressive implementation of the Test & Start strategy). Figure 5: Procurement of Determine tests compared to targets and consumption

Figure 6: Procurement of UniGold tests compared to targets and consumption

HIV RAPID TEST KIT ASSESSMENT REPORT | 6 Figure 7: Procurement of Determine and UniGold tests compared to targets and consumption in Zambezia Province

Figure 8: Procurement of Determine and UniGold tests compared to targets and consumption in Maputo Province

Despite not being achieved, national testing targets in 2016 were sufficient for putting the targeted number of new patients on ART treatment. Testing targets are defined using a set of algorithms, based on how many people need to be tested in order to put a certain number of new patients on ART treatment. Their calculation takes into account all national programs that administer HIV tests, including community activities and voluntary male circumcision programs (VMMC). In 2016, Mozambique reached the objective of putting 282,010 new patients on treatment, suggesting a potential overestimation of 2016 testing targets. Therefore, the current target setting methodology should be revised to ensure that testing targets are not overestimated and reflect the high yield focus of the new testing guidelines. Procurement volatility management Existing buffer levels are inadequate to cover the volatility in delivery time of RTKs to Zimpeto warehouse. It takes between six and nine months for procured RTKs to arrive to the Zimpeto warehouse, which made it difficult to meet the increased needs for 2016 in a timely manner. Tests quantified and procured in April 2016 only arrived to Mozambique in September 2016. Therefore, quantities received during the first three quarters of the year were lower than those quantified, and not sufficient to secure adequate buffer stocks at all levels for last year. The existing stock in the country was not enough to cover the increasing consumption needs during those six months. The ideal buffer stock equals to one month of consumption due to the short shelf-life of the RTKs (8 - 12 months upon

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arrival to the country) and numerous level of storage across the country. Increasing stock levels above was tested in the past, but led to significant number of expired tests. Quality issues with the production of UniGold caused delays in several shipments in 2016, which contributed to the shortage of UniGold at the central level. Quantities planed for January and March 2016 both arrived with one month delay. Furthermore, the shipment from October 2016 was delayed from entering the stock due to USAID/ GHSC _QA warnings on potential quality concerns related to production. It took few weeks to control for quality to ensure tests were within acceptable confidence range. Again, the buffer was not adequate to adjust to this destabilizing event. Distribution Transportation Security issues and unpredictable level of stock in DPM in Zambezia were the main constraints for the smooth distribution of RTKs in 2016. The first layer of unpredictability was caused by security issues, which delayed the road transportation of medical supplies from the central level to the province. To combat this issue, CMAM sent RTKs to Zambezia by air from January to April 2016. However, LAM aircrafts did not have the capacity to fit the entire monthly supplies in one shipment, so they sent two airplanes per month, which turned out to be costly and inefficient. Until January 2017 when FGH took over as the lead partner in Zambezia, iCAP financed the distribution of medicines from the provincial to the district warehouses. DPM develops monthly distribution plans, which are executed using three DPS trucks, with a DPS driver and a pharmacist for each. The role of the implementing partner is to finance fuel expenses, maintenance of the trucks and per diems for the DPS drivers and pharmacists. Besides the unpredictability of RTK stock available at the DPM and security issues, the partners and the DPM staff did not point to any other constraints for transportation activities between the DPM and DDM. Lack of access to large enough vehicles at district level constrains timely distribution of RTKs to the health facilities. In Zambezia, iCAP and FGH support the distribution of RTKs at health facility level in their corresponding districts. In iCAP-supported districts, DDMs are responsible for the distribution of medicines, and often rely on iCAP to provide vehicles and fill in the budget gaps for the fuel. FGH vehicles distribute medicines during their routine visits to the health facilities, following the distribution plan developed by the DDM. Given the small size of the DDS and partner vehicles in the districts, health facilities receive their monthly supplies through several installments. In January 2017, FGH contracted a private company with large enough vehicles to transport the entire monthly supply of medicines to the health facilities in Namacurra and Maganja in one installment. In this way, the distribution to all the health facilities in these two districts is completed within 4-5 days each month. Pilot evaluation will take place by May 2017, when FGH will decide whether to roll out the third-party distribution program in their districts or not. Poor planning of transportation leads to delayed ad hoc distribution of RTKs across Maputo Province, which weakens the system’s capacity to plan and mitigate potential shortages. The DPM lacks capacity to organize delivery packages in time for transportation. As a result, private trucks contracted for distribution to DDMs await parked outside the DPM sometimes for days before the deliveries are prepared. Meantime, districts experience shortages of various medicines including RTKs, which Ariel Glaser mitigates by doing emergency distribution using their own vehicles. Given the unpredictability of shipments from the DPM, DDMs cannot adequately plan the distribution to the health facilities. District health authorities are responsible for the distribution to health facilities in Maputo Province. Through sub-agreements, they receive financial and logistical support for transportation from Ariel Glaser. However, districts frequently need to send their vehicles to the DPM to pick up the delayed and missing deliveries, which damper their delivery plans to the health

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facilities. Medicines and RTKs end up being distributed in an ad hoc manner through numerous unpredictable installments throughout the month. Given that there is no security stock at health facilities, due to such an unpredictable and fragmented distribution scheme, some have reported 2-3day stock-out episodes during the last year. Control mechanisms for transportation are strong between the central and provincial warehouses, but are weak further down the supply chain in both provinces. Our assessment found that the control mechanisms are particularly weak between the DPM and DDMs. At this level, we found numerous cases of mismatching entries between what was reported as distributed by the DPM and received at the DDM, implying potential leakages during transport. The only control mechanism in place are the delivery slips (guias de remessa), which are frequently missing at every level in both provinces. The current template for delivery slips does not require transporters’ signature, making it difficult to hold them accountable for the missing stock. When the truck arrives to the delivery point, quantities are supposed to be recounted by a reception commission, but our interviews indicate that this process is often delayed or not implemented at all. FGH has started to call health facilities to check on quantities received every month and support the production of “relatorio de occurencia” if need be. The formal procedures in place for situations in which the stock goes missing are not being followed. If the delivery vehicle arrives with quantities lower than stated on the guia de remessa, the staff responsible for receiving the stock is supposed to submit a relatorio de occurencia to their superiors. Despite frequent discrepancies in stock quantities arriving from one level to the other, our interviews and lack of physical evidence indicate that these formal, written reports are very rarely submitted. Warehouse staff typically resort to resolving the problem by phone, without any written evidence of discrepancies in stock. The reported reasons for not submitting written notifications on missing stock are avoiding the potential conflict, lack of trust that the written notifications will result in action, as well as the conflict of interest. Allocation Methodology The RTKs allocation formula (consumption x 2 – stock on hand) which calculates the quantity of RTKs to be distributed is not adequately applied at any level of the supply chain. Our interviews with all deposit managers from the central to the district levels confirmed that they all knew the official RTK allocation formula (2 x average month of consumption – existing stock), but were not comfortable using it to make requests from the level above or to distribute tests to the level below. Quantities requested by clients are typically higher than two months of reported consumption (see Annex 3), because managers believe that consumption does not reflect their real needs, especially in situations when they are constrained with a very low level of stock on hand. We analyzed Zambezia and Maputo Provinces’ DPM requests to the CMAM central level for 2016 and found than none of the requested and approved quantities corresponded to the formula output (see Annex 3). In reality, warehouse managers use their own judgment to allocate tests, based on current stock levels, the quantities requested by their clients, monthly consumption and the level of influence that the client has. There is no formal justification of allocation decisions, which makes the decision- making process difficult to understand and leaves little space for addressing client dissatisfaction. In many cases, allocation of tests to districts and health facilities is population-based, without consideration of HIV prevalence/positivity, leading to uneven distribution within both provinces. For each district, in addition to the total population, targets should be set based on the HIV prevalence/positivity data. Yet, provinces do not have adequate allocation tools available to calculate the most appropriate ATS targets and corresponding distribution needs. Implementing partners in Zambezia have reported misallocation of tests across districts, with low prevalence districts receiving relatively higher per capita numbers of tests, even during provincial shortage periods

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For example, among FGH-supported districts in Zambezia, Alto Molocue has the biggest population and the lowest positivity (3%) and receives by far the highest volume of Determine tests. At the same time, Inhassunge with the highest positivity (19%) experienced the most severe shortages and stock-outs of RTKs in 2016. Furthermore, in iCAP-supported Gurue district with a 3% positivity rate3, our team observed that SDSMAS defines testing targets for non-priority testing sites, such as vaccination (PAV) and voluntary testing (UATS), thus incentivizing low yield testing practices. Most stock managers we interviewed expressed dissatisfaction with the current distribution practices. Most service providers in our sample claimed that their current test consumption is lower than their real needs, and that they are further constrained by low stock on hand. Some health facility managers and pharmacists request only their monthly consumption, discouraged by their previous experiences of low satisfaction rates. During 2016, they overwhelmingly reported that they never received more than what they consumed the previous month and are thus stuck in a low consumption cycle. District and provincial warehouse managers stated that they do take into account the requested quantities in their allocation criteria, and would cap distribution at the amount requested if deemed reasonable. Nevertheless, we did not find significant correlation between the quantities of tests distributed by DPMs and DDMs and overall reported consumption in 2016. In Zambezia, Implementing Partners and DPS intend to estimate the real consumption needs per health facility and advocate to use these amounts for RTK allocation. At the health facility level, RTK distribution guidelines to testing points4 are not consistent among Implementing Partners and MOH, resulting in accumulation of RTKs stock in some sites. As per CMAM guidelines, pharmacists are trained to distribute RTKs in the health facilities based on the “stock nivelado” approach which is supposed to eliminate the unnecessary accumulation of tests at testing points. With the “stock nivelado” approach, testing points can receive new kits from the pharmacy only when they finish the existing stock. Nonetheless, we have observed that some implementing partners train health professionals at delivery points to request RTKs based on the consumption formula (consumption x 2 – stock on hand). Partners have developed and rolled out a new consumption report template for tracking stock at the pharmacies in Zambezia. The template contains stock entries at the beginning and at the end of the month, which is contrary to the “stock nivelado” approach. Adopting a consumption formula at the health facility level can lead to high quantities of RTKs accumulated at testing points and weak controls mechanisms. There is no standardized prioritization process for allocation of tests in a situation of shortage, leaving room for subjective distribution of RTKs to clients. Warehouse managers receive little guidance on how to rationally distribute tests in the case of a shortage, and clients with stronger voice may get a greater share of tests compared to others. For example, given their strong relationship with the DPM director, Foundation for Community Development (FDC) in Zambezia managed to get tests directly from the DPM. Almost all deposit managers respond to ad hoc requests for tests by various clients, usually communicated via phone calls or messages. Inventory management Inventory control systems Central level

3 PEPFAR data, 2016 4 In public health facilities, there can be a maximum of 8 HIV rapid testing points: 1) UATS (voluntary testing), 2) laboratory, 3) blood bank, and provider-led testing at 4) TB consultations, 5) Maternity, 6) PMTCT, 7) consultas clinicas e triagem, e 8) enfermaria e triagem.

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Central warehouse in Zimpeto is secure and well managed, allowing for minimal leakages of Determine and none of UniGold in 2016. Based on the data from MACS, 234 kits of Determine were unaccounted for in 2016, summing up to 0.23% of the amount that entered the Zimpeto warehouse, including the stock at the beginning of the year. We identified no such leakages of UniGold, meaning that all the stock that entered the warehouse was either distributed or remained in storage at the end of 2016. Control mechanisms for transportation from the central to provincial warehouses are strong and leave little room for leakages. Trucks carrying RTKs from the central to provincial warehouses in Maputo and Zambezia Provinces are sealed, and we found no evidence of leakages at this level. The amount of stock reported as distributed from the central level equaled the amount of stock reported as received at the DPMs. We did not find any anecdotal evidence of leakages at this leg of transportation either.

Box 1: Estimated leakages in Zambezia's supply chain (assessment sample)

In our sample, 18% of Determine and 23% of UniGold were lost by time they arrived from the Zambezia provincial warehouse to health facilities An additional 6% of Determine and 17% of UniGold were unaccounted for after they arrived to the health facilities

Provincial level: Zambezia The largest source of loss in Zambezia occurs at the provincial warehouse due to lack of implementation of stock control and monitoring systems. Based on the data from our assessment sample5, we estimated that approximately 11% of Determine and 8% of UniGold received at the DPM level were lost at the warehouse during 2016 (Figure 9). These losses are evident after reconciling the distribution quantities with stock levels at the beginning and the end of the year, and they are also reflected in the DPM negative inventory adjustments in SIMAM. Negative adjustments to the inventory with no legal explanation should be followed by a formal notification (relatorio de occurencia) submitted to the warehouse manager, followed by an investigation by the Inspector General’s office. In July 2016, significant quantities of RTKs went missing from the DPM just after arrival. Implementing partners supporting the distribution process reported the event to the DPS, who followed up with an in-depth inspection process. The investigation resulted in the change of leadership at DPM level. However, we found no justification for other negative adjustments to inventory, and no evidence of any relatorio de ocurência. The second largest leakage point in our sample in Zambezia is the transportation between the provincial and district warehouses. We found that additional 4% of Determine and 11% of UniGold are lost during transportation between the DPM and the three DDMs (Quelimane, Inhassunge and Gurue) (Figure 9). This means that 4% of Determine and 11% of UniGold reported as distributed by the DPM are not logged as received in any of the DDM databases. In the three DDMs that we visited, roughly a third of monthly guias de remessa with a mismatch between the distribution quantities found at DPM (higher value) and received quantities found at DDM (lower value).

5 Note that this is not a sample representative of the whole province, but rather an illustrative example. Variation across the three districts and six health facilities is high pointing that the situation is not homogenous, thus requiring a broader data analysis in order to draw provincial conclusions

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Overall, an estimated 2% of Determine and 5% of UniGold distributed by the DDM do not reach the health facilities in our sample (Figure 9). These leakages are evident in mismatches between the distribution logged at the district SIMAM database and entries registered at the physical stock cards at health facilities. In addition to the stock cards, we used delivery slips (guias de remessa) to locate the transactions and compare quantities. Dividing one monthly delivery into several installments delivered in an unpredictable manner leaves room for leakages. Splitting an order into several installments makes the missing quantities difficult to trace. For example, in Inhassunge district, the order for RTKs placed in March 2016 was divided in two installments in the first week of April, with the second installment of 11 kits of UniGold and 14 kits of Determine never having been registered as received at the DDM. In some cases, the remaining quantities from the previous month’s order are combined and delivered jointly with a portion of the quantities of the current month’s order, which makes leakages more difficult to track. Stock management practices and control mechanisms at health facilities are weak, thus creating strong exposure to potential leakage. Pharmacists at the health facilities distribute RTKs without evidence of actual need at the testing points. Their rules for distributing the test kits are not clear, as there is no evident monitoring of stock-on-hand at each delivery point. Once the RTKs are distributed to the different delivery points, few pharmacists implement adequate control of stock and utilization practices. Some health facilities with a large volume of testing have attempted to improve stock management by introducing stock cards and daily consumption reporting at every delivery point. In both Zambezia and Maputo Province, there is a need to train the pharmacists to better assess the needs and monitor utilization of RTKs at all testing points. Only 84% of Determine and 72% of UniGold that arrived to the health facilities in our sample were reconciled as consumption. The consumption percentages are even lower if taken as a share of what was intended to arrive to the health facilities before leakages (71% of Determine and 56% for UniGold, Figure 9). Around 5% of the distributed amounts of both tests remain on stock at the pharmacy. Finally, 17% of UniGold and 6% of Determine quantities are unaccounted for at the health facility.

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Figure 9: RTKs supply chain cascade in Zambezia

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Provincial level: Maputo Province

The poor quality of data reported in SIMAM at the DPM and DDM level6 does not allow for the same depth of supply chain analysis for Maputo Province as for Zambezia. In contrast to Zambezia, Maputo Province stakeholders keep a good record of delivery slips, but face serious challenges in reporting inventory and stock flows in SIMAM and on physical stock cards. Therefore, we could not reliably estimate leakages at the warehouses, health facilities and during transportation, but only infer the reasons behind and the implications of poor data reporting practices. There were large negative adjustments of inventory at DPM and DDMs in Maputo Province, mainly to compensate for the poor quality of reporting of distribution. Contrary to the discrepancies we expected to find, the quantities reported as distributed by DPM were lower than the quantities reported as received by DDMs. There is large variation across districts: from 3% in Moamba to 61% in Marracuene. The same was the case for our sample of health facilities that reported larger quantities received than quantities distributed by DDM in their stock cards. We conducted a comparative analysis of the distribution discrepancies in these three districts and the relative share of the negative adjustments in the warehouse that distributed the stock. The results from our sample showed that more than 85% of these adjustments can be attributed to unreported distribution to DDMs and health facilities, while the remainder are unaccounted leakages. Control mechanisms at the health facility pharmacy and testing points are weak in Maputo Anecdotal evidence from both Province. It is difficult to estimate with precision the level Zambezia and Maputo Province of reported consumption and leakages in our sample suggest that buffer for both tests because the quality of data on stock entries is poor. In frequently “disappears” from health addition, two out of four health facilities did not have facilities to be used at service complete stock cards for RTKs. providers’ home-based practices. Due to social stigma and long waiting lines We found no evidence of tests being diverted to at health facilities, nurses and private clinics or private pharmacies in Zambezia technicians frequently use public or Maputo Province. We visited several private clinics system’s supplies to perform services and private pharmacies in both provinces. They either did for their friends, family and neighbors not have rapid tests for HIV, or did not use Determine or at home. UniGold. We found UniGold in one private clinic in Zambezia, but the barcode on the kit did not match the barcodes of kits procured through the national system. Governing environment The system does not have adequate structural incentives or checks and balances in place to enforce the existing control processes. While there are clearly defined processes in place for reporting on inventory discrepancies, stakeholders throughout the supply chain do not have the right incentives to take action upon them. Stock management staff are supposed to submit a relatorio de occurencia on any suspicious stock discrepancies to their superiors, which can cause a conflict of interest. Warehouse directors and CMAM can engage the Inspector General’s Office for further investigation at their discretion. The accountability system is fragile, with limited intervention of the heath general inspection body tofor oversee inventory management and impose penalties. The fact that most disputes around inventory are supposed to be resolved within the supply chain with limited

6 We collected data from DPM and DDMs in Moamba, Manhica and Marracuene

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involvement from a third party such as the general inspection disincentives stakeholders to take action in case control mechanisms break down and stock goes missing. Information system infrastructure There is a MACS database at the central level, a distinct SIMAM database at provincial and district levels, and lack of integration makes it difficult to oversee the entire supply chain at a given point in time. CMAM at the central level has access to SIMAM databases for the central and provincial warehouses. To access the SIMAM data on inflows and outflows of stock at the district level, the team had to physically collect them from every DDM. At the health facilities, stock and consumption are managed through paper-based databases. Comprehensive data analysis can take place only by physically merging these separate databases. This process is too time consuming to be conducted on a regular basis, making it difficult to monitor the entire supply chain at one point in time. The stock management system (MACS) at the central level does not allow an easy access to inventory information at the Zimpeto warehouse. MACS system can generate daily aggregate stock reports, and does not provide segmented information regarding entries to and distribution from the central warehouse. To conduct any data analytics at the central level, one needs to complement MACS data with the physical stock cards at the Zimpeto warehouse. This introduces another layer of complexity for assessing the entire supply chain of any product, including the RTKs. Lack of a real-time monitoring and alert mechanisms for shortages and stock-outs makes it difficult for the central and provincial levels to adequately react in times of need. An adequate real time monitoring/alert system is particularly necessary at the district and health facility level, where RTK stock-outs have an immediate impact on the testing and treatment activities. During 2016, shortages and stock-outs were reported by warehouse managers and implementing partners in an informal manner by calling/messaging their local deposit managers. The processes for reporting shortages (when, how, and to whom) have not been clearly defined. Therefore, evidence on shortages at delivery points remains largely anecdotal. Some implementing partners (FGH in Zambezia) have started to routinely monitor the levels of stock at health facility pharmacies, but this method has not yet been rolled out broadly. The system for reporting on shortages and stock-outs is not well defined at the decentralized level. Throughout 2016, there were numerous anecdotal/email alerts about stock-outs for last year, but there is limited documentation of these. Key informants at the health facility and DDM levels would confirm shortage/stock-out episodes from last year, but most of them did not have documented evidence of it, except showing zero inventory on their stock cards for a particular month. Some implementing partners monitor RTK stock at the health facility level. For example, FGH conducts weekly monitoring of pharmacy stock in their districts in Zambezia; however, they do not take into account the level of stock at different testing points, which makes it difficult to draw conclusions on stock-out occurrences in those health facilities. Stock reconciliation Reported consumption of RTKs has slightly worsened since last year and remains low, particularly for UniGold. In 2016, almost 9 million Determine tests and 1 million UniGold tests were distributed from the Central and Provincial warehouses to the service providers (Figures 10 and 11). However, only 67% of Determine and 45% of UniGold tests that were distributed were reported as consumed (i.e. justified) to CMAM7. Given the implementing partners’ efforts to improve the reporting

7 This percentage is calculated as the total number of tests reported in SIMAM divided by the total number of tests distributed from the Central and to the Provincial warehouses to service providers (source MACS). The distributed quantities are adjusted for stock values at the beginning and at the end of the year at the Central and Provincial level, but not for the levels below (DDMs and health facilities)

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capacity within the system, the justification rate has been steadily improving since 2013, when only a quarter of distributed Determine and a fifth of UniGold were justified as consumed. The situation is consistent across these provinces, with Maputo Province showing the lowest justification rate for both tests in 2016, and Zambezia having the highest justification rate for UniGold8. Figure 10: Determine Distribution from Central and Provincial Warehouses vs. Reported Consumption

Figure 11: UniGold Distribution from Central and Provincial Warehouses vs. Reported Consumption

Health facilities Approximately a third of UniGold tests distributed from the pharmacy to the testing points in health facilities are not reconciled as consumed in the patient register books in both provinces. The share of unreported consumption of UniGold tests is higher in Maputo Province (35%) than in Zambezia (29%). The potential explanations of the reconciliation gaps include undocumented accumulation of stock at testing points, tests that were performed but un-reported, wastage, expired tests, and other leakages.

8 PSM analysis, November 2016

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We found no strong evidence explaining why the reconciliation rate of UniGold tests is lower than that of Determine. The qualitative interviews have illuminated some potential reasons for lower levels of reported UniGold consumption when compared to Determine. First, there is a perception among some service providers that HIV status could be determined by testing only with UniGold. This perception could lead to the malpractice of using only UniGold for those patients with high perceived likelihood of being infected, and not registering it as utilized in case it turns out to be negative. Though we found no explicit evidence of this malpractice we recommend this issue be further investigated, as it can lead to higher demand for UniGold in the black market. Second, lower quantities of UniGold tests are purchased compared to Determine overall (11 UniGold tests are purchased for every 100 Determine tests (11%)), although there is a relatively higher number of UniGold tests per kit (20 UniGold tets per kit vs. 100 Determine tests per kit). Therefore, if 1 kit of UniGold and 1 kit of Determine leak out of the supply chain, the 1 missing kit of UniGold will represent a higher share of the total UniGold tests in the system compared to Determine, thus lower reconciliation rates for UniGold. Finally, all tested patients consumed a Determine test, and only the positive ones consumed a UniGold. When the number of tests is counted in the patient register books, there is a higher chance to miss UniGold entries as they are fewer and dispersed. External HIV testing programs Test consumption data of external HIV programs in Zambezia such as community testing conducted by implementing partners, universities, and private companies are not systematically entered into the district SIMAM database. In Quelimane district in Zambezia, the consumption of tests by clients other than health facilities has remained largely outside of the SIMAM system, despite the partners submitting the data to the DDM. Partners doing community testing submit their consumption data outside the standard reporting cycle, resulting in incomplete information on these activities inserted into the overall consumption numbers for the province given the lack of capacity of the DDM manager to introduce the consumption data into the system. In Maputo Province, there is confusion among CHWs and the health facility regarding where community testing information is supposed to be registered. There is a mixed understanding among partners as to where the community testing information is supposed to be reported: to the health facility pharmacy or to the district warehouse. In Moamba district, community testing data is inserted into the SIMAM system at DDM level, when available. In comparison, in Manhica district, the community partners are supposed to report on community testing to the health facilities. In both locations, we found a significant amount of missing information on community activities pointing to the fragility of the system for reporting consumption. Data quality The SIMAM data on inventory and distribution in Maputo Province is incomplete, at both provincial and district levels. In our sample, we found great discrepancies between different levels of the supply chain. Contrary to what we expected, the quantities reported as distributed by DPM were lower than the quantities reported as received at the DDMs (Annex 4). Similarly, the reported distribution from DDM tends to be lower than the quantities reported as received by health facilities. The reasons for this are periodic technical issues with SIMAM at all levels, which do not allow for data entry, sometimes for weeks/months at a time. Consequently, there have been substantial negative adjustments of inventory in the DPM and DDM stock cards to compensate for unreported distribution of stock. Still, these negative adjustments cannot be fully attributed to belated documentation of distribution as the single cause. Other kinds of leakages are likely to take place, and in order to uncover them, we recommend a more in-depth assessment of the stock flows in Maputo province as our assessment looked at only two of seven districts.

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In Zambezia, the capacity for reporting inventory and distribution information is strong. Zambezia DPM and DDM staff have received effective technical assistance from the implementing partners for adequate reporting of inventory and distributed quantities in SIMAM. The quality of data is high, and the quantities moved across the province largely match from one level to another. Yet, we identified cases of untraceable stock and deliveries: inexplicable negative stock adjustments in warehouses, and quantities leaving the DPM/DDM, and never arriving to the level below. Triangulation of SIMAM consumption data, physical consumption reports, and patient register books showed that the quality of consumption reporting at health facilities in Zambezia is high. We gathered monthly consumption reports for the health facilities in our sample from the corresponding DDMs and pharmacies. In each health facility, we randomly selected the months and testing points and verified the data using patient registers. We found negligible discrepancies, in no particular direction (positive or negative). Based on the qualitative interviews with service providers, pharmacists and implementing partners in Zambezia, we estimate that limited percentage of tests consumed at health facility testing points may not be reported due to negligence or lack of time. In Maputo Province, the system for reporting consumption at health facilities is weaker than in Zambezia. In some health facilities, we found evidence of missing consumption reports for some testing points for some months. In addition, community testing is reported through the health facility consumption reports on some months, and not on others. Incomplete data on consumption in SIMAM has led to an underestimation of justification levels for RTKs in 2016 in Maputo Province. Maputo Province faces significant challenges in reporting consumption of tests in SIMAM. In 2016, consumption data for April and May were entirely missing, while for the other months the completeness of data is questionable. While data on consumption is strong at the health facility, pharmacists and IPs conduct little triangulation with stock levels at testing points. We conducted compared data in the registers with data reports sent through the SIMAM system by health facilities, and found no significant discrepancies. This suggests that service provider reporting is adequate and not a driver of unjustified tests. This information, however, is not triangulated with stock levels, thus missing a strong opportunity to insert an important check in the system. As a caveat, we are unclear as to whether all of the patients are accounted for in the registers, which would require an observational study. The switch from modulo basico to e-SISMA had a negative impact on the quality of information for RTK utilization at the central level, particularly for maternal and neonatal care services. Ante-natal consultations, where all women are routinely tested for HIV, are now reported in e-SISMA on a “cohort” basis. Instead of reporting on the number of tests used, e-SISMA captures the number of women tested, despite many of them being re-tested throughout their pregnancy. The implications of the “cohort” reporting should be taken into account when quantifying the RTK needs. Utilization Adherence to the testing protocols Service providers’ knowledge of and adherence to the general testing protocols appears high9. At every testing point, there were instruction sheets for Determine and UniGold pasted on the wall. All service providers interviewed were aware of the testing protocols: serial testing with Determine followed by UniGold, adequate utilization of buffer, and waiting times. All service providers confirmed having received at least one training and regular supervision for utilization of RTKs for HIV. Testing guidelines are routinely revisited at “ART Café” meetings held once a week for all health facility staff.

9 We used qualitative methods to assess service providers’ adherence to testing protocols

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Moreover, the National Institute of Health conducts paineis de proficiência on a bi-annual basis, whereby they select a national sample of health facilities and measure the quality of HIV rapid testing that they conduct. The latest three paineis de proficiência demonstrated a high level of quality of testing in the country, with the full compliance with the quality guidelines of 84%, 78% and 90%, respectively. There is a delay in the communication of the most recent testing protocol changes, resulting in a delay of their implementation. In Maputo Province, the directors of health facilities and service providers expressed uncertainty regarding some of the latest adjustments to the testing protocols: reporting using the cohort method for maternal and neonatal services (SMI) and high risk children services (CCR), massive testing at the vaccination unit, etc. In Zambezia, the change from massive to targeted testing at the vaccination unit has not been effectively communicated and all health facilities in our sample continue to test all the children that come in for vaccination, as per the old protocol. Therefore, some service providers still adhere to the old protocols due to the delay in receiving adequate update communication. Activities implemented in 2016 to ensure the quality of testing have been widely regarded as effective. HIV testing quality in Mozambique has been highlighted as a programmatic weakness in recent years by several development partners. To improve rapid HIV testing, PEPFAR disseminated the national testing quality improvement guidelines with clearly defined minimum standards, provided refresher trainings, and ensured certification for all service providers performing tests. Implementing partners continued the roll out of supportive supervision in collaboration with central and provincial health authorities. PEPFAR has also been collaborating with the MOH to explore the revision of the national HIV rapid testing algorithm to introduce a confirmatory test prior to initiating treatment to minimize the possibilities of false positives, particularly as the Test & Start approach is rolled out. Although supply chain managers have raised concerns about parallel testing, there was no evidence of it in the field. The justification levels of UniGold utilization are lower than those of Determine, which intuitively points to the risk of parallel testing: using both tests at the same time, and reporting only on Determine in the case the patient is negative. Qualitative interviews with health service providers and implementing partners’ field managers refuted the concern of parallel testing, characterizing it as counter-intuitive: service providers realistically have a greater incentive to steal UniGold kits than to waste them by parallel testing negative patients. In Zambezia, some health facilities are still testing massively, against national guidelines. This is because they did develop the massification strategy for children and the switch to rationalize use has not been sufficiently communicated. Wastage Expired test kits are the most common cause of wastage. Several health facilities reported receiving test kits that were only a couple of months away from the expiration date. In addition, stock- outs of one test can lead to the expiration of the other. For example, Inhassunge district in Zambezia suffered severe stock-outs of UniGold in the first half of 2016. Thus, they could not use the Determine tests either in that period, which reportedly led to the expiration of almost 10% of their annual Determine stock in September. We found evidence of incinerating only a portion of the reportedly expired tests in the district. Despite strong knowledge of the testing protocols among service providers, we observed a high level of documented inconclusive test results in Zambezia (6%), which require repeat testing. A patient’s HIV test result is considered inconclusive if Determine is positive, and UniGold shows a negative result; in that case, both tests should be repeated. Inconclusive test results account for 6% of consumption in Zambezia, with variation from 3% to 14% across districts10. In comparison: in

10 PEPFAR data

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Maputo Province, it accounts for only 1%. Such high reported inconclusive test result rates in Zambezia could either point to the poor quality of tests and/or testing practices, or to serve as a cover up for leakages and should be further investigated. Inadequate buffer management at testing points, particularly for Determine, leads to wastage of tests. As only 1 bottle of buffer is intended for the whole kit of 100 Determine tests, there is significant room for test wastage due to the misuse and loss of buffer. Buffer issues are reportedly less common for UniGold as it comes in kits of 20 tests. For both tests, however, service providers and pharmacists raised concerns about buffer disappearance, which would result in the wastage of the remainder of the kit. Anecdotal evidence suggests that the reasons behind buffer disappearance are personal use at home/private clinics. Wastage of tests due to buffer mismanagement is poorly documented, although qualitative interviews suggest that it is not too common. Repeat testing of the same patients due to the overlap of implementing partners’ activities in communities does not appear to be a big cause of wastage. We did not find evidence of overlap in community testing activities of different partners. Organizations running community testing activities seem to be well coordinated in determining and operating within their geographic locations.

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VI RECOMMENDATIONS Recommendation 1: Prioritize integration and transparency of data throughout the system Central level Prioritize the integration of the various SIMAM databases into an interoperable network to improve monitoring of the whole supply chain. We recognize that this is an ongoing and complex activity, and therefore our recommendation aims to reinforce the importance of this work. An integrated database will enable the monitoring of the entire supply chain from the entry to Zimpeto warehouse to the distribution to the DDM. Getting district information is crucial to an accurate understanding of the situation close to the testing points. In collaboration with key users of supply chain data, CMAM should develop automated monitoring dashboards, customized to the need of different stakeholders. These analytical tools could support supervisors and supply chain managers to get automated warnings in case of RTK shortage for rapid follow up, analyse data quality issues to support feedback to users, and in depth controls of stock adjustment and discrepancies between entries and distribution across levels. The automated dashboard could also look at the evolution of consumption and positivity and automatically identify outliers. When red flags are identified, there should be an internal process for identifying the reasons for discrepancies. Enable MACS to generate electronic stock cards for the central level. Currently, visibility of stock movements from the central warehouse remains difficult, thus providing exposure to leakage. Electronic stock cards will allow for improved visibility of stock and smooth data analytics around potential leakages at the central level. Provincial and district level The level of stocks at all level of supply chain need to be monitored on a weekly basis, to support rapid action in case of shortage and identification of systemic bottlenecks. The consultants recommend for implementing partners to report on RTK stock levels at health facilities, DDM and DPM through a standardized process on a weekly basis, and share information with DPS, DPM and CMAM. As of today, there is no centralized system to visualize at one point in time stock level across the system, especially at district and facility level. Implementing partners have started to track this information, but do not report in a standardized manner. We recommend the rapid evaluation of introduction of RTKs in the NOS list in zambezia for its roll out across the province and country later. Recommendation 2: Improve data quality across the system Central level CMAM should ensure regular maintenance of SIMAM in all provinces. Maputo Province Warehouse in particular requires better support for managing their SIMAM database; due to technical issues, the province could not report the data on consumption for the entire months of April and May, and numerous distribution entries are not properly reported in the system, significantly hindering proper performance monitoring. Prompt action is required to upgrade Maputo DPM systems. The consultants recommend for CMAM to take stock of the current situation of SIMAM infrastructure across the system, and quickly define an action plan to fix the problems identified. CMAM and its partner may also consider allocate a provincial technician dedicated to provide IT support to SIMAM users.

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Provincial level PSM should develop and organize a refresher Training of Trainers (TOT) for all PSM and implementing partners’ advisors on the appropriate use of data management system and processes for data reporting, monitoring and quality control. Our assessment found at that both advisors and warehouse managers to not have a comprehensive, homogenous knowledge of all the processes for proper data reporting and monitoring. Ensuring all advisors are up to date with standards is necessary to make sure coherent information is transmitted to managers and users across the supply chain. We recommend the prompt update of the RTK management guidelines and training material, to be included in the upcoming provincial training that CMAM is conducting in May, as well as the organization of a national workshop with key staff from all implementing partners, including those involved in community testing. District level CMAM should clarify the consumption reporting methodology for external testing programs, and uniformly communicate them to the implementing partners and DDMs. In both provinces, there is a confusion regarding the correct location and timing for reporting RTKs consumed by external programs such as community activities and VMMC. Clearly communicating reporting methodology is crucial for implementing partners and DDM staff to adequately take it into account. Recommendation 3: Develop a robust control system and strengthen the governing environment Central level CMAM should conduct a detailed assessment of vulnerabilities in the control systems at the facility, during transport, and at warehouse levels. This activity first requires an observational study to document current processes and practices. Without conducting a detailed assessment or an observational study, our team identified the following potential interventions to improve control: • Introduce mandatory reconciliation of stock and consumption at every level • Develop an improved security plan for products stored at DPM and DDM, including cameras • Assess the feasibility of introducing random tracers into RTKs packages to be able to follow the destination of tests out of the national health system • Assess the feasibility of enforcing the utilization of product barcodes for the central and provincial warehouse management to enable automatic collection of data and better monitoring • Conduct unannounced risk based audits

Provincial and district level Hold managers accountable for results and introduce a culture of monitoring. CMAM, PSM and IPs should encourage staff across the entire supply chain to document suspicious discrepancies in RTK stocks. Those reports should be directly sent to the General Inspectors’ Office or another independent entity to avoid conflict of interest. Each report should be properly analyzed and actions taken to resolve the issue if need be. If no action is taken in case of leakage, it favors a culture of impunity. CMAM should consider conducting an annual evaluation of relatorio de occurencia usage, to assess the number and type of cases reported, assessed and number of cases followed by necessary actions. Improve transparency and accountability of transporters. Leakages are happening during transport starting from provincial level. We recommend to reduce the number of potential

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transporters, enforce CMAM regulation to provide credential to transportersand better monitor their performance. All transporters should be listed and approved by the health administration, and their signature should be added to the guias de remesas. We also recommend that all distribution trucks to be purchased for the public supply chain have the option to seal the cargo they are transporting. Health facility DDM and its partners should improve the capacity of health facility pharmacists to distribute, manage and control RTK usage, by improving technical assistance at facility level. Our assessment pointed at the fragility of RTK management at health facility level, and highlighted the low capacity of pharmacists to adequately manage RTK. We recommend for partners to focus their effort on facility pharmacist skills improvement. Methods for RTK distribution needs to be clarified and clearly communicated, to avoid conflicting messages across partners. We also recommend to test the implementation of a facility level indicator tracking Determine and Unigold monthly justification, to be monitored by pharmacists. Written explanation for discrepancies should be required. Conduct an observational study to better understand RTK utilization practices at health facilities. This study should include unannounced counting of RTK stock at every delivery point at the beginning and at the end of a defined period in every testing points, and compare RTKs usage with RTK reporting in patient register. This should shed light on potential misuse of RTKs and help better understand the low level of stock reconciliation especially for UniGold. Recommendation 4: Improve allocation methodology to ensure adequate buffer stocks at every level Central, provincial and district level Review current allocation methodology to ensure buffer stocks are rebuilt. Taking into account the difficulties with the current allocation formula, CMAM and its partner should hold a dedicated seminar to decide on the best allocation methodology moving forward. The new allocation formula should improve the situation by: - Ensuring buffer stocks are available at all level - Ensure real needs of users are captured - Make rules and targets transparent for all users - Continue to ensure proper tracking of utilisation of RTKs at facility level

Potential options for allocation methodology include: - “push”methodology, with inclusion of districts level - Pull methodology, with clear definition of consumption level per client in case of shortage - Direct request from health facilities to provincial warehouse, similar to current ARV distribution methodology.

Standardize allocation methodology in case of shortages. Clear prioritization guidelines and tools should be developed for the distribution of RTKs across the country and within provinces in the case of shortages. Ensuring the implementation of a robust allocation methodology will enable the distribution of stock to the clients in the highest need and avoid subjective approach to RTK distribution. Health facility CMAM should take a decision on the approach to be implemented for the distribution of RTKs from the pharmacy to the testing points in health facilities, to ensure better control of stocks. In Zambezia, we encountered differing methodologies for distribution of tests across the

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testing points: some pharmacies implement the stock nivelado approach, while others use the allocation formula (2xconsumption – stock-on-hand). CMAM and his partners should review the pors and cons of the different methodology and adopt the ones that will contribute to a better control of stocks within facilities.

Recommendation 5: Strengthen the coordination of distribution activities at the provincial level Provincial level Create a provincial command center at the DPS level to deal with supply chain issues as they arise. Currently, there is no central unit that has the mandate to immediately resolve supply chain problems. In provinces supported by multiple implementing partners, the core supply chain functions may be supported by different parties, without a central unit to coordinate their efforts. The command unit that we propose should have the mandate and agile management skills to execute and/or coordinate all the core supply chain functions. It is supposed to act as liaison with CMAM to resolve unexpected stock issues or macro shocks to the system. Furthermore, the unit should be able to deal with the issues that arise down the supply chain, such as efficiently reallocating stock in the case of shortages, ensuring adequate lead time for the distribution within the province, finding solutions to the budget shortages to procure essentials such as fuel for distribution, coordinating IPs’ input and needs, and resolving any constrains that may arise with the transportation. District level Ensure that there are vehicles dedicated primarily to last mile distribution of medicines within districts. Relying on one vehicle dedicated to delivering the entire monthly supply of medicines and medical equipment to health facilities will limit the number of installments and thus potential leakages during transportation. Last mile distribution strategies developed by IPs and other stakeholders should be assessed based on their potential to improve planning not only to provide financial support for the existing distribution schemes.

See Annex 5 for short term activities agreed among stakeholders during the dissemination workshop held on March 24th.

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ANNEX 1: ACHIEVEMENT OF HIV TESTING TARGETS

ZAMBEZIA MISAU PEPFAR Total population 4,802,365 Targets 1,134,036 797,766* Achievement- Total Tests 607,187 847,137 Achievement - Positive tests 70,162 62,699 Positivity 12% 6%

DETERMINE UNIGOLD Total test distributed Determine 1,223,900 138,120 % of satisfaction of provincial request 69% 44% % of test justified / distributed to DPM 67% 50%

MAPUTO MISAU PEPFAR Total population 1,709,058 Target 502,044 671,841* Achievement- Total Tests 367,739 453,582 Achievement - Positive tests 42,027 44,072 Positivity (total positive / total test) 11% 10%

DETERMINE UNIGOLD Total test distributed 427,500 65,840 % of satisfaction of provincial request 56% 49% % of test justified / distributed to DPM 77% 61% * PEPFAR targets are excluded sites with limited to no support from PEPFAR implementers. *Fiscal year for PEPFAR targets is 01.10.2015 to 30.09.2016

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ANNEX 2: STOCK FLOWS AND CONSUMPTION OF RTKS Central level

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Provincial level

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District level

*Note that entries for June were missing

*Note that we did not receive the information for Determine tests stock in Moamba district

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ANNEX 3: RTK ALLOCATION FROM CENTRAL TO PROVINCIAL LEVEL

MAPUTO - DETERMINE

Formula Quantidade Quantidade % Data de Data de Data de Tempo de Tempo de MÊS DE PEDIDO de Commentarios Pedida Distruibida satisfacao Pedido Saida Entrada saida transporte alocacao

DEZEMBRO 2015 624 29-Dec-15 Aumento de stock sem justificacao

MARZO 2016 2,000 504 25% 08-Mar-16 29-Mar-16 30-Mar-16 21 1 0

ABRIL 2016 495 675 136% 14-Apr-16 26-Apr-16 03-May-16 12 7 370

MAIO 2016 1,000 540 54% 11-May-16 03-Jun-16 20-Jun-16 23 17 0

AGOSTO 2016 630 630 100% 11-Aug-16 25-Aug-16 26-Aug-16 14 1 104

SETEMBRO 2016 1,080 1,008 93% 06-Sep-16 22-Sep-16 23-Sep-16 16 1 348

OCTUBRO 2016 1,000 198 20% 10-Oct-16 28-Oct-16 08-Nov-16 18 11 0 Stock de NOVEMBRO 2016 500 468 94% 16-Nov-16 29-Nov-16 02-Dec-16 13 3 reposicao Stock de reposicao

Total 4,899 56% 17 6

MAPUTO - UNIGOLD Quantidade Quantidade % Data de Data de Data de Tempo de Tempo de Formula MÊS DE PEDIDO Comentarios Pedida Distruibida satisfacao Pedido Saida Entrada saida transporte de Aprovada sem pedido. O sistema SIMAM não FEBREIRO 2016 336 14-Mar functionava MARZO 2016 1,000 168 17% 08-Mar-16 29-Mar-16 30-Mar 21 1 361.2

ABRIL 2016 336 100 30% 14-Apr-16 26-Apr-16 3-May 12 7 43.3 336 05-May-17

MAIO 2016 600 336 56% 11-May-16 03-Jun-16 20-Jun 23 17 0

AGOSTO 2016 620 336 54% 11-Aug-16 25-Aug-16 26-Aug 14 121.6

AGOSTO 2016 50 16-Aug Pedido de emergencia

SETEMBRO 2016 1,008 336 33% 06-Sep-16 22-Sep-16 23-Sep 16 1 134

OUTUBRO 2016 504 504 100% 10-Oct-16 28-Oct-16 8-Nov 18 11 14.2 NOVEMBRO 2016 672 504 75% 16-Nov-16 29-Nov-16 02-Dec-16 13 3 0 TOTAL 3,342 48% 17 7

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ZAMBEZIA - DETERMINE

Formula Quantidade Quantidade % Data de Data de Data de Tempo de Tempo de MÊS DE PEDIDO de Commentarios Pedida Distruibida satisfacao Pedido Saida Entrada saida transporte alocacao

DECEMBRO 2015 1500 1008 67% 09-Dec-15 17-Dec-15 06-Jan-16 8 20 Diferenca entre o valor em MACS (1008) e entradas (1332) e aprovadas JANEIRO 2016 1485 1332 8.01.2016 12-Feb-16 201 (1502)

FEVREIRO 2016 1,998 1,008 50% 05-Feb-16 10-Mar-16 01-Apr-16 34 22 - Essa quantidad llegou em 2 envios

MARZO 2016 1,042 504 48% 09-Mar-16 30-Mar-16 25-Apr-16 21 26 998 Essa quantidad llegou em 2 envios

AVRIL 2016 1,667 1,305 78% 08-Apr-16 27-Apr-16 11-May-16 19 14 1,048

MAIO 2016 1,424 504 35% 10-May-16 02-Jun-16 16-Jun-16 23 14 1,188 Falto uma caixa de 9 kits no transporte JUNHO 2016 1,602 567 35% 08-Jun-16 20-Jun-16 11-Jul-16 12 21 780 entre nivel central e DPM.

JULHO 2016 1,263 1,210 96% 08-Jul-16 26-Jul-16 05-Aug-16 18 10 1,175

AGOSTO 2016 1,800 909 51% 10-Aug-16 29-Aug-16 12-Sep-16 19 14 202

SETEMBRO 2016 1,215 1,017 84% 09-Sep-16 30-Sep-16 18-Oct-16 21 18 1,184

OTOUBRO 2016 1,350 1,750 130% 10-Oct-16 27-Oct-16 22-Nov-16 17 26 Dos meses foram enviados juntos. NOVEMBRO 2016 540 486 100% 09-Nov-16 30-Nov-16 1,183 Faltaram 54 kits

NOVEMBRO 2016 1,166 594 51% 10-Nov-16 24-Nov-16 12-Dec-16 14 18 1,166 TOTAL 18,052 12,418 69% 19 18

ZAMBEZIA - UNIGOLD Calculo Quantidade Quantidade % Data de Data de Data de Tempo de Tempo de MÊS DE PEDIDO Formula Commentarios Pedida Distruibida satisfacao Pedido Saida Entrada saida transporte Consumo DECEMBRO 1600 336 21% 09-Dec-15 21-Dec-15 06-Jan-16 12 16

JANEIRO 762 504 66% 08-Jan-16 12-Feb-16 197 Essa quantidad llegou em 2 envios

FEBREIRO 978 672 69% 05-Feb-16 10-Mar-16 01-Apr-16 34 22 164 Essa quantidad llegou em 2 envios MARZO 725 336 46% 09-Mar-16 30-Mar-16 25-Apr-16 21 26 276 Essa quantidad llegou em 2 envios quantidad recibida não corresponde as APRIL 1251 774 8% 08-Apr-16 27-Apr-16 11-May-16 19 14 306 quantidades aprovada em SIMAM (102) MAIO 800 336 42% 10-May-16 02-Jun-16 16-Jun-16 23 14 JUNHO 1004 252 25% 08-Jun-16 20-Jun-16 11-Jul-16 12 21 137

JULHO 724 504 70% 08-Jul-16 26-Jul-16 05-Aug-16 18 10 514 AGOSTO 1008 672 67% 10-Aug-16 29-Aug-16 12-Sep-16 19 14 105 SETEMBRO 840 504 60% 09-Sep-16 30-Sep-16 18-Oct-16 21 18 490

OTOUBRO 672 504 75% 10-Oct-16 27-Oct-16 22-Nov-16 17 26 487 NOVEMBRO 672 672 100% 10-Nov-16 24-Nov-16 05-Dec-16 14 11 454 Essa quantidad llegou em 2 envios NOVEMBRO 168 quantidad não requisitada TOTAL 6234 55% 19 17

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ANNEX 4: DETAILED RTK LOSSES FROM CENTRAL LEVEL TO HEALTH FACILITIES Zambezia Provincial level ZAMBEZIA DETERMINE UNIGOLD Zimpeto Saidas 11,924 100% 6906 100% DPM entradas 12,239 103% 6906 100% Missing from Zimpeto saida 324 3% 0 0% Missing from DPM entrada 9 0% 0 0% Ajustes de inventario 1,306 11% 536 8%

District level

DDM Quelimane

DETERMINE UNIGOLD

DPM saida 887 100% 784 100%

DDM entrada 884 100% 706 90%

Missing from DPM saida 0% 50 6% Missing from DDM entrada 3 0% 128 16% Ajustes de inventario 25 3% 1 0%

DDM Inhassunge DETERMINE UNIGOLD DPM saida 265 100% 236 100% DDM entrada 251 95% 225 95% Missing from DPM saida 0% 0% Missing from DDM entrada 14 5% 11 5% Ajustes de inventario 6 2% 0 0%

DDM Gurue DETERMINE UNIGOLD DPM saida 927 100% 233 100% DDM entrada 936 101% 203 87% Missing from DPM saida 72 8% 1 0% Missing from DDM entrada 63 7% 31 13% Ajustes de inventario - 0% 0 0%

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Health facility level US 24 de Julho DETERMINE UNIGOLD DDM saida 101 100% 85 100% US entrada 97 96% 85 100%

17 de setembro DETERMINE UNIGOLD DDM saida 180 100% 130 100% US entrada 175 97% 118 91%

US Inhassunge Sede DETERMINE UNIGOLD DDM saida 69 100% 65 100% US entrada 65 94% 56 86%

US Palane DETERMINE UNIGOLD DDM saida 25 100% 20 100% US entrada 25 100% 19 95%

US Gurue Sede DETERMINE UNIGOLD DDM saida 205 100% 74 100%

US entrada 225 110% 110 149%

Maputo Province Provincial level

MAPUTO DETERMINE UNIGOLD Zimpeto Saidas 4,275 100% 2956 100% DPM entradas 4,275 100% 3956 134% Missing from Zimpeto saida - 0% 50 2% Missing from DPM entrada - 0% 0 0% Ajustes de inventario 763 18% 388 13%

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District level DDM Manhica DETERMINE UNIGOLD DPM saida 525 100% 307 100% DDM entrada 536 102% 324 106% Missing from DPM saida 11 2% 17 6% Missing from DDM entrada 0 0% 0 0% Ajustes de inventario 5 1% -36 -12%

DDM Moamba DETERMINE UNIGOLD DPM saida 230 100% DDM entrada 236 103% Missing from DPM saida 6 3% Missing from DDM entrada 0 0% Ajustes de inventario -7 -3%

DDM Marracuene DETERMINE UNIGOLD DPM saida 439 100% 235 100% DDM entrada 600 137% 379 161% Missing from DPM saida 161 37% 144 61% Missing from DDM entrada 0 0% 0 0% Ajustes de inventario -45 -10% -45 -19% Facility level US Ressano Garcia DETERMINE UNIGOLD DDM saida - 100% 29 100% US entrada - #DIV/0! 44 152%

US Moamba DETERMINE UNIGOLD DDM saida - 100% 63 100% US entrada - #DIV/0! 86 137%

US Palmeiras DETERMINE UNIGOLD DDM saida 27 100% 22 100% US entrada 22 81% 20 91%

US Malavela DETERMINE UNIGOLD DDM saida 18 100% 14 100% US entrada 20 111% 15 107%

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ANNEX 5: SUMMARY OF RECOMMANDATIONS AND WORKPLAN The list of recommendations and activities have been developed in collaboration with all partners during a stakeholder workshop, conducted on March 24th.

Activity Timeframe Responsibility Technical Assistance Recommendation 1: Prioritize integration and transparency of data throughout the system 1.1 Create an interoperable Medium- Term CMAM PSM network of databases

1.2 Develop customized Medium Term CMAM PSM dashboard for all users a- Preparation of RTK Short term CMAM PSM management template per users (NOS) b- Production of quarterly Short term CMAM PSM performance report - Manual c- Production of performance Medium Term CMAM PSM report - Automated

1.3 Integrate Electronic Stock Medium Term CMAM PSM Cards in MACS 1.4 Weekly control of stock Short Term CMAM PSM levels for all levels

a- Evaluation of RTK May 2016 CMAM PSM/ICAP/FGH stock monitoring in NOS b- Preparation of RTK May 2016 CMAM PSM/ICAP/FGH active management – algorithm determining the action in case of shortage/stock out detection (NOS-A)

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c- Develop a action plan May 2016 CMAM PSM/ICAP/FGH based on NOS-A concept proof results to improve stock situation d- Improve reporting and June 2016 on CMAM action methodology wards PSM and expand RTK tracking through NOS- A e- Dashboard to have the Set 2016 on CMAM PSM National weekly active wards stock surveillance system Recommendation 2: Improve data quality across the system

2.1 Ensure appropriate Short Term CMAM PSM maintenance of SIMAM for all users a- Conduct inventory of August 2016 CMAM PSM SIMAM status for all users

b- Develop action plan for August 2016 CMAM PSM SIMAM maintenance

2.2 TOT for all RTK managers Short Term CMAM PSM

a- Update RTK management May 2016 Internal Control, CMAM guidelines including the community testing procedures. b- Conduct CMAM provincial May 2016 Internal Control, CMAM training, including RTK management module c- Conduct RTK management June 2016 CMAM PSM / USAID / workshop for implementing CDC partners d- Roll out the updated July-Dec 2016 CMAM PSM / USAID / management guidelines CDC nationally Implementing partners

Recommendation 3: Develop a robust control system and strengthen the governing environment

3.1 Conduct a vulnerability Medium Term CMAM PSM assessment of control mechanisms

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a- Develop TORs and recruit Short Term CMAM PSM consultant

b- Conduct assessment and Short Term CMAM PSM disseminate results

c- Implement Medium Term CMAM PSM recommendations

3.2 Improve accountability across Medium Term CMAM the system a- Quarter Reconciliation of all Short Term Internal Audit, CMAM the stock adjustments in SIMAM with the proper documentation and justification b- Evaluation of current Short Term Internal Audit, CMAM process and results of usage of relatório de occurencia c- Review processes to submit Short Term Internal Audit, CMAM and address relatório de occurencia d- Involve the General Short Term Internal Audit, CMAM Inspection in the process Adjustments > Support documentation > Justification The third party directly responsible for overseeing inventory management and imposing penalties 3.3 Intensify technical assistance Medium Term CMAM Implementing to district warehouse managers Partners / and facility pharmacists USAID / CDC

3.4 Conduct an observational Short Term CMAM PSM study to better understand RTK utilization practices at health facilities and rational use of the HRDTs Recommendation 4: Improve allocation methodology to ensure adequate buffer stocks at every level 4.1 Review current allocation Short Term CMAM methodology a- Conduct a workshop to April 2016 All partners, including assess pros and cons on Provincial representatives the various options b- Develop guidelines for new May 2016 CMAM allocation methods,

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including guidelines for allocation in case of shortage 4.2 Clarify and communicate Short Term CMAM/PSM/implementing distribution methods within partners health facilities a- Create a working group to Short Term CMAM to lead review the distribution approach (stock nivelado, procurement of additional buffer etc…) b- Develop guidelines and Short Term CMAM disseminate Recommendation 5: Strengthen the coordination of distribution activities at the provincial level 5.1 Create provincial command Medium Term TBD centers a- Assess feasibility of Short Term CMAM including the command center function as part of PELF implementation 5.2 Provide appropriate vehicles Medium Term Global Fund; DPC and CMAM for distribution at all level DPS Zambezia & Maputo a- Buy new vehicles for Short Term CMAM (or DPS?) Global Fund provincial distribution in Zambezia b- Review current situation Short Term FGH en Zambezia c- Review and standardize Short Term CMAM/PEPFAR the provincial distribution plan, integrating the availability of new vehicles. d- Enforce and monitor Medium Term DPS / Provincial Wharehouse FGH, ARIEL, distribution SOPs, PSM ensuring limited emergency delivery of RTKs

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ANNEX 6: CONTACT LIST Institution Name Title Contact Arménio Da Assessor Técnico da Ariel Glaser [email protected] Silva Farmácia Maria Isabel Ariel Glaser Programa de HIV [email protected] Sibia Torres Banco de Head of Banco de Sarah Salimo [email protected] Sangue Sangue CDC Nely Honwana HTC Adviser [email protected] HIV prevention branch CDC Stanley Wei [email protected] chief Custodio Procurement and CHAI [email protected] Mondlane Supply Chain Manager Timothy CHAI [email protected] Bollinger Director of Chemonics Joao Teixeira Forecasting & Supply [email protected] and Distribution Plan Chemonics Juliene Pires HIV/AIDS Manager [email protected] PSM, Regional Advisor Chemonics Isaura Possolo [email protected] Southern Region Chemonics PSM, Logistics advisor Julio Ofumane [email protected] Zambezia in Zambezia CMAM Kamila Magaia Head of procurement [email protected] Lucrécia CMAM Head of M&E [email protected] Venâncio CMAM Jose Filipe [email protected] CMAM Santos Ndlala M&E, supervisao +258843580479 DDM Responsavel da DDM Inhassunge, Joao Dias [email protected] Inhassunge Zambezia DDM Manhica, Marcia Maputo Tecnica de Farmacia +258840537877 Mandlate Province DDM Moamba, Medico Chefe da Maputo Daniel +258846078911 Moamba Province DDM Responsavel da DDM Quelimane, Claudia Popote +258825212929 Quelimane Zambezia DPM Maputo Sonia Chinda Directora da DPM +258823757400 Province DPM Zambezia David Viegas Director da DPM +258840148905 DPS Maputo Chadreque Medico Chefe da [email protected] Province Muliana Provincia FDS? Fátima Mussá [email protected] FGH Maputo Gael Claquin Assessor TB/HIV [email protected]

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FGH Maputo Wilson Silva [email protected] Coordenadora FGH Zambezia Amina Muicha [email protected] Provincial Assessor da farmacia FGH Zambezia Leonardo +258843664300 na DPM Global Fund Sergio Correia PSM Procurement lead [email protected] Pietro Di iCAP [email protected] Mattei iCAP Daitino Sarmili Assessor de Farmácia [email protected] Biby Ali Aconselhamento e iCAP [email protected] Testagem iCAP Manuel Buene Acessor de laboratorio [email protected] Coordenadora iCAP Zambezia Viola Violante [email protected] Provincial Esselina Assessora provincial de iCAP Zambezia [email protected] Machava Farmácia Conselhera de JHPIEGO Judith Aconselhamento e Maputo Testagem JHPIEGO Alicia Maputo Programa de HIV, MISAU Aleny Couto [email protected] Directora MISAU Guita Amane Programa de HIV, ATS [email protected] Programa de HIV, MISAU Roxanne Hoek [email protected] Monitoria e Avaliação Noela Programa de HIV, MISAU [email protected] Chicuecue Prevenção Nathaniel SI Team, USAID USAID [email protected] Lohman Mozambique Leah Senior Health USAID [email protected] Hasselback Commodities Advisor Benedito Logistics Activity USAID [email protected] Chauque Manager Programa de HIV, World Vision Adolfo Eduardo testagem na [email protected] Zambezia Cambule comunidade

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ANNEX 7: ASSESSMENT CREDENTIAL

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ANNEX 8: REFERENCES

1. Central de Medicamentos e Artigos Médicos (CMAM). Strategic Plan for Pharmaceutical Logistics (PELF). December 2012. March 8, 2013. 2. Conselho Nacional de Combate ao SIDA. Resposta Global a SIDA. Relatório de Progresso 2016. Maputo, Moçambique. 3. Direção Nacional de Assistência Medica (DNAM). Guia de Tratamento Antirretroviral e Infeções Oportunistas no Adulto, Adolescente, Gravida e Criança. Moçambique, 2014. 4. Hasselback L, Crawford J, Chaluco T, et al. Rapid Diagnostic Test Supply Chain and Consumption Study in Cabo Delgado, Mozambique: Estimating Stock Shortages and Identifying Drivers of Stock-outs. Malaria Journal 2014, 13:295. 5. Medicines and Medical Supplies Information System (SIMAM): databases at the national, Provincial and District level. 6. Mabunda, Nedio. Qualidade da Testagem do HIV em Moçambique. Instituto Nacional de Saúde. 17 de Março de 2016. Maputo, Moçambique. 7. MISAU e CMAM. Diretriz Nacional de Aconselhamento e Testagem em Saúde (ATS). VI Reunião Nacional Do HIV e SIDA. 16 a 18 de Marco de 2016 (apresentação final). Maputo, Moçambique. 8. MISAU e CMAM. Diretriz para Integração dos Serviços de Prevenção, Cuidados e Tratamento do HIV e SIDA para a População Chave no Sector da Saúde. VI Reunião Nacional Do HIV e SIDA. 16 a 18 de Marco de 2016 (apresentação final). Maputo, Moçambique. 9. Ministério de Saúde (MISAU) e CMAM. Ponto de Situacao de Medicamentos e Testes Rápidos. VI Reunião Nacional Do HIV e SIDA. 16 a 18 de Marco de 2016 (apresentação final). Maputo, Moçambique. 10. MISAU e CMAM. Revelação de Diagnostico para Crianças e Adolescentes Vivendo com HIV. VI Reunião Nacional Do HIV e SIDA. 16 a 18 de Marco de 2016 (apresentação final). Maputo, Moçambique. 11. MISAU e DNAM. Diretriz Nacional para a Implementação do Aconselhamento e Testagem em Saude. 2015 12. MISAU e Instituto Nacional de Estatística (INE). Inquérito de Indicadores de Imunização, Malaria e HIV/SIDA em Moçambique (IMASIDA), Relatório de Indicadores Básicos 2015. Moçambique, Junho 2016.

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13. MISAU, Sub-Grupo de Quantificação do GTM-HIV. Forecasting and Supply Planning (FASP) for HIV Rapid Diagnostic Tests, 2016-2020 Annual Review March/April 2016. 14. Mozambique Stock Management System (MACS) database for Central Level. 15. Office of Inspector General, USAID. Audit of USAID/Mozambique’s Procurement and Distribution of Commodities for the President’s Emergency Plan for AIDS relief. Audit report N. 4-656-09-001-P. Pretoria, South Africa. December 18, 2008. 16. PEPFAR. Mozambique Country Operational Plan (COP) 2016. April 19, 2016. 17. PEPFAR. PEPFAR Technical Considerations for COP/ROP 2016. 18. SCMS, PEPFAR. National Supply Chain Assessment: Measuring Public Health Supply Chain Capability and Performance (Briefer). November 20, 2015. 19. USAID. HIV Test Kits Listed in the USAID Source and Origin Waiver: Procurement Information Document. Edited by Abiola Johnson. Fifth Edition, January 2009. 20. USAID, Deliver Project. Republic of Malawi: HIV Test Kit Supply Chain Assessment and Quantification. MOH, HIV and AIDS Department. April 2008.

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