issues amp supply chain management Dr Ravindra Rao Contents of the presentation OST programme in SA region Current scenario Scaling up OST in SA region Supply chain management Contents of the presentation ID: 731697
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Slide1
OST IN SOUTH ASIA
Operational issues & supply chain managementDr. Ravindra RaoSlide2
Contents of the presentationOST programme in SA region - Current scenarioScaling up OST in SA region
Supply chain managementSlide3
Contents of the presentationOST programme in SA region - Current scenario
Scaling up OST in SA region
Supply chain managementSlide4
OST in South Asia RegionSlide5
Existing OST models in SA regionDifferent modalities of implementationSetting (
Hospital / NGO / Hospital – NGO)Medications used (Methadone / Buprenorphine
)Activities/areas of OST implementationLinking clients to OST centre (outreach services)Assessment and dispensing (Clinic services)Psychosocial servicesSlide6Slide7Slide8Slide9
Bangladesh OST ProgrammeInitiated in July 2010 in partnership with Ministry of Home through icddr,b
Methadone as OST medicine
One centre in DhakaClient load ~ 150Slide10
B
A
NGLADESH
OST clinic
Government hospital based clinic at the Drug treatment centre run by the
Deptt
of Narcotics Control,
MoH
Outreach, psychosocial and clinic services provided within one single setting
Human resource: one medical doctor, 2 nurses, one
counsellor
, 8 outreach workers, one co-
ordinator
, 2 guardsSlide11
India OST programme OST integrated in National AIDS Control Programme – Phase III
Three models operationalBuprenorphine
NGO based: 52 sites Government –NGO collaboration: 15 sitesMethadoneGovernment hospital based: 5 sites piloted by UNODCSlide12
NGO OST clinic
Run through NGOs implementing Harm reduction intervention
programmesClinic in the Drop-in-Centre located in the vicinity of the IDU hotspotsClient load: 50 – 200Human resource: Doctor, 2 nurses, one counsellor, 2 outreach workers
I
N
D
I
ASlide13
GO - NGO OST
OST clinic located in Government hospitalClient load: 50 – 200
Human resource: one doctor, 2 nurses, one counsellor, one data manager INDIA
NGO
Government hospital
Outreach and follow up services provided by NGOs implementing Harm Reduction TI
programmes
Human resource: One outreach worker, one
programme
managerSlide14
MMT clinic
Run through Government De-addiction
Centres, run by Ministry of HealthReferral of clients by NGOs working in the city/townClient load: 50 – 100Human resource: one Doctor (part time), 2 nurses, one counsellor
I
N
D
I
ASlide15
Nepal OST ProgrammeRe-initiated in the year 2007, as an emergency response
Pilots in partnership with Ministry of HomeOST medicine: Methadone, ? Buprenorphine
Currently operational through 3 unitsSlide16
OST clinic located in Government hospitalClient load: 100 – 150Human resource: one doctor, 3 nurses, one counsellor, one data manager, 3 Guards
NGO – SSU
Government hospital
Outreach, follow up and
counselling
services provided by Social Support Unit (SSU) managed by NGOs
Human resource: 5 – 7 staff
N
E
P
A
LSlide17
MaldivesInitiated in the year 2009Partnership with nodal drug agency with the Ministry of Health
OST medicine: Methadone
One centre operational in Male`Slide18
OST clinic located in Government premisesClient load: 70Human resource: one doctor, 2 nurses, 3 counsellors
NGOs
Government hospital
Outreach, follow up and part-
counselling
services provided by 3 NGOs
Human resource: 3 – 5 staff
M
A
L
D
I
V
E
SSlide19
Contents of the presentationOST
programme in SA region - Current scenario
Scaling up OST in SA regionSupply chain managementSlide20
Scale-up: ConsiderationsSetting the targetUniversal access to HIV prevention services40% of IDUs to be covered with OST (Target setting guidelines, UNODC, UNAIDS, WHO, 2008)
However…. Current coverage is < 3% in any country of SA regionDifferent countries are in different stages of IDU-HIV epidemic
Coverage is largely limited to IDUs, and not to opioid dependent drug usersSlide21
Following the epidemicEstimate IDU from major districts/provincesShortlist provinces with significant IDU estimatesIdentify provinces without OST services
Categorize provinces based on IDU estimates (high, medium and low priority) Prioritize provinces with moderate-high IDU-HIV prevalenceSlide22
Choosing OST centresSelect models, medications based on in-country & regional experienceShortlist potential centres
Conduct feasibility assessmentsAccessibility to the clientsInfrastructure
Safety measures for stock-keepingSlide23
Training and capacity buildingSensitisation meetings for policy makers (one day)Trainings Induction trainings for core staff (5 days)Exposure visits/study tours
Refresher trainings (3 days)Develop in-country capacities – capacity building institutions
Staff selectionDefining roles & responsibilitiesSlide24
Establish Quality assurance mechanismDevelop tools for standardisation of operation (Standard operating procedures, operational guidelines)Regular monitoring and evaluation of the programme
Success determined by registration and retention of clients into the programme
Factors influencing qualityDose of medicationDuration of treatmentStaff attitudeSatisfaction of clientsSlide25
CostingCurrent costing: range from 30000 USD – 180,000 USD
Start up cost
Sensitisation meetingTraining programmesFeasibility assessmentRefurbishment of centresImplementation costHuman resourceMedical doctorTwo nursesOne counsellor Two outreach staffOne data managerAccountantOther support staffRunning cost - travel, communication
Procurement cost
Medication
Buprenorphine: 37,000 USD
Methadone: 8,000 USD
Others:
Dispensers, water, etc.Slide26
Contents of the presentationOST
programme in SA region - Current scenario
Scaling up OST in SA regionSupply chain managementSlide27
International regulatory frameworkDifferent mechanism for narcotics /
psychotropicsMethadone
Covered under the 1961 conventionPrior quota and annual consumption reporting requiredBuprenorphineCovered under the 1971 conventionAnnual quota not required to be allocatedAnnual reporting for Buprenorphine (optional)Essential medicine list – WHO Methadone and buprenorphine in the listSlide28
Laws / policies of countriesDrawn in accordance to the conventionsMost of the countries support the use of narcotics / psychotropics for medicine and scientific purpose
India: use of opioids for OST (de-addiction) mentioned under NDPS act Nepal: harm reduction and OST endorsed in the National Drug policySlide29
Supply chain mechanismSlide30
Procurement procedures
Determining the medicine required Methadone: syrup in 5 or 10 mg/ml strengthsBuprenorphine tablets: 8 mg, 2 mg, 0.4 mg, 0.2 mg
Determining the quantityNo. of patients X no. of days X average dose per patient per dayRequest for QUOTARequired only for MethadoneNodal Ministry requests INCB for a quota for Methadone [Department of Narcotics Control (Bangladesh), Ministry of Home Affairs (Nepal), Central Bureau of Narcotics (India)]Slide31
Procuring agencyEach country has a nodal agency for procurement of goods and suppliesMaldives State Trading OrganizationNepal
‘Sajha’ trust
Negotiate rates with procuring agency (management cost)Invitation for bidsInvite International Competitive bidsSlide32
Bidding agencyMust have a WHO-GMP certificate or equivalent certificateFor export, supplier would need “Certificate of Pharmaceutical Product”(COPP) as recommended by WHO
Manufacturers / DistributorsEvidence of its technical, financial and production capability
Finalise vendorTechnical and financial qualificationNegotiate RatesSlide33
Establishing a supply chain mechanism
SCENARIO A
SCENARIO BSlide34
Stock management
Licenses from relevant authorities for storage and transport
Central stocksStorage area of central stockResponsible officer for central stockSafe keeping: secure systemFlow of stocks from central to OST clinicChain of custodyClinic stocksStorage areaSecure systemStaff-in-charge?Slide35
Record maintenance for stock managementSlide36
Securing sustained supply: considerations
Clear understanding of the various Ministries/departments dealing with quota, licensing and procurement
Ensure clear commitment from the ministries – licensing, narcotics control / homeEnsure procurement is made well in-advancePrepare a standard supply chain protocol / guidelineSlide37
Securing sustained supply: considerations
Stock replenishment
Stock projectionRotate stocks with eye on expiry datesEstablish a strong supply chain mechanismIdentify officers responsible in-charge of the stock at every pointMaintain records strictlyCheck at regular intervalsSlide38
ConclusionOpioid dependence is a chronic medical condition and requires long term therapyDifferent modalities followed in different countries for operationalising MMT
Goal and objective of OST in each countryTreatment of opioid dependence Prevention of HIV among opioid users, especially injecting drug users
Urgent need to scale up OST in South Asia region Slide39
Advocacy for inclusion of narcotics / psychotropics
in the national essential medicine listRemoval of import duties
Use of computer based software for stock management (copy right issues, monopoly of pvt sector !)Robust supply chain an important part of scale up plan for OSTConclusionSlide40
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