in stock-outs (116-16-PCGOV; 331-12-USG; 331-28-PCGOV; 331-38-USPS; 272-20-PCNGO; 461-14-USG; 542-21-USNGO). Stakeholders in nearly all countries struggled with stock-outs, which constrained the delivery of treatment for HIV (934-17-PCGOV; 461-7-PCNGO; 461-8-PCGOV; 116-12-PCNGO; 587-1-USG; 587-22-USG; 587-18-PCGOV; 331-43-USG), TB (542-21-USNGO), and opportunistic infections (240-25-PCGOV; 587-18-PCGOV; 196-17-PCGOV; 461-17-PCNGO; 116-12-PCNGO; 166-34-PCGOV), and which reduced access to HIV testing (116-12-PCNGO; 934-17-PCGOV; 461-15-USG; 166-5-USG; 166-9-ML/OBL/USACA/USNGO/PCNGO/PCPS; 166-32-USPS; 240-33-USG). Challenges with procurement at the national level, including corruption (542-2-USG; 542-3-USG; 542-11-PCNGO), also threatened effective supply chain management (542-21-USNGO; 331-30-USPS). In some countries, this was attributed to government regulations or processes that caused delays in timely procurement (331-17-USG; 331-28-PCGOV; 542-21-USNGO; 240-3-USG; 240-8-USG; 240-33-USG; 240-21-PCGOV). A weak capacity for financial management was mentioned as a barrier for every step of the supply chain (331-2-USG; 166-6-USG; 166-31-USG; 116-2-USG). Commodity storage (240-24-USG; 331-38-USPS; 116-2-USG), distribution (331-6-CCM; 331-38-USPS; 166-6-USG; 166-31-USG; 542-21-USNGO), and logistics (e.g., tracking inventory) (331-17-USG; 166-11-USG; 166-22-USPS) were also mentioned as challenges. Although national supply chains were often inadequate or overwhelmed, parallel supply chains serving different donors or disease programs were also described as inefficient and as leading to coordination challenges among partners and donors (396-18-USG; 396-21-USG; 396-57-USG; 636-9-USACA; 331-12-USG; 331-38-USPS; 542-21-USNGO).
Across countries, PEPFAR has improved supply chain management capacity for forecasting, procurement, and distribution (240-2-USG; 240-3-USG; 240-5-PCGOV; 240-12-USG; 331-38-USPS; 587-10-USG; 935-9-USG; 935-14-USG; 272-20-PCNGO; 934-5-USG; 934-25-USPS). PEPFAR’s efforts to strengthen partner country supply chains have also had a positive impact on Global Fund programs (240-12-USG; 331-38-USPS; 587-6-CCM). In addition to increasing access to HIV-related commodities (e.g., ARVs and condoms) (272-25-USG; 116-9-PCNGO; 240-2-USG), PEPFAR has also contributed to the increased availability of medicines and commodities for other health issues (166-4-USG). When partner countries have faced stock-outs due to supply chain constraints or delays in disbursements from the Global Fund and other donors, PEPFAR has often provided buffer stocks of medicines and commodities on an emergency basis to prevent the interruption of treatment and to ensure the continuity of care (935-8-PCGOV; 935-17-USG; 587-1-USG; 461-10-PCNGO; 116-9-PCNGO; 240-7-PCGOV; 331-43-USG). PEPFAR partners have been actively involved in convincing ministries of health to use the most effective first-line ARV regimens (196-11-USPS; 272-20-PCNGO).
Conclusion: PEPFAR has improved the capacity of partner country governments to quantify, forecast, procure, store and warehouse,