OST IN SOUTH ASIA Operational issues & supply
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OST IN SOUTH ASIA Operational issues 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 OST
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01
OST IN SOUTH ASIA
Operational issues & supply chain management
Dr. Ravindra Rao<br>
Operational issues & supply chain management
Dr. Ravindra Rao<br>
02
Contents of the presentation OST programme in SA region - Current scenario
Scaling up OST in SA region
Supply chain management<br>
Scaling up OST in SA region
Supply chain management<br>
03
Contents of the presentation OST programme in SA region - Current scenario
Scaling up OST in SA region
Supply chain management<br>
Scaling up OST in SA region
Supply chain management<br>
04
OST in South Asia Region<br>
05
Existing OST models in SA region Different modalities of implementation
Setting (Hospital / NGO / Hospital – NGO)
Medications used (Methadone / Buprenorphine)
Activities/areas of OST implementation
Linking clients to OST centre (outreach services)
Assessment and dispensing (Clinic services)
Psychosocial services<br>
Setting (Hospital / NGO / Hospital – NGO)
Medications used (Methadone / Buprenorphine)
Activities/areas of OST implementation
Linking clients to OST centre (outreach services)
Assessment and dispensing (Clinic services)
Psychosocial services<br>
06
Bangladesh OST Programme Initiated in July 2010 in partnership with Ministry of Home through icddr,b
Methadone as OST medicine
One centre in Dhaka
Client load ~ 150<br>
Methadone as OST medicine
One centre in Dhaka
Client load ~ 150<br>
07
B
A
N
G
L
A
D
E
S
H 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 guards<br>
A
N
G
L
A
D
E
S
H 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 guards<br>
08
India OST programme OST integrated in National AIDS Control Programme – Phase III
Three models operational
Buprenorphine
NGO based: 52 sites
Government –NGO collaboration: 15 sites
Methadone
Government hospital based: 5 sites piloted by UNODC<br>
Three models operational
Buprenorphine
NGO based: 52 sites
Government –NGO collaboration: 15 sites
Methadone
Government hospital based: 5 sites piloted by UNODC<br>
09
Run through NGOs implementing Harm reduction intervention programmes
Clinic in the Drop-in-Centre located in the vicinity of the IDU hotspots
Client load: 50 – 200
Human resource: Doctor, 2 nurses, one counsellor, 2 outreach workers I
N
D
I
A<br>
Clinic in the Drop-in-Centre located in the vicinity of the IDU hotspots
Client load: 50 – 200
Human resource: Doctor, 2 nurses, one counsellor, 2 outreach workers I
N
D
I
A<br>
10
GO - NGO OST OST clinic located in Government hospital
Client load: 50 – 200
Human resource: one doctor, 2 nurses, one counsellor, one data manager I
N
D
I
A Outreach and follow up services provided by NGOs implementing Harm Reduction TI programmes
Human resource: One outreach worker, one programme manager<br>
Client load: 50 – 200
Human resource: one doctor, 2 nurses, one counsellor, one data manager I
N
D
I
A Outreach and follow up services provided by NGOs implementing Harm Reduction TI programmes
Human resource: One outreach worker, one programme manager<br>
11
Run through Government De-addiction Centres, run by Ministry of Health
Referral of clients by NGOs working in the city/town
Client load: 50 – 100
Human resource: one Doctor (part time), 2 nurses, one counsellor I
N
D
I
A<br>
Referral of clients by NGOs working in the city/town
Client load: 50 – 100
Human resource: one Doctor (part time), 2 nurses, one counsellor I
N
D
I
A<br>
12
Nepal OST Programme Re-initiated in the year 2007, as an emergency response
Pilots in partnership with Ministry of Home
OST medicine: Methadone, ? Buprenorphine
Currently operational through 3 units<br>
Pilots in partnership with Ministry of Home
OST medicine: Methadone, ? Buprenorphine
Currently operational through 3 units<br>
13
OST clinic located in Government hospital
Client load: 100 – 150
Human resource: one doctor, 3 nurses, one counsellor, one data manager, 3 Guards Outreach, follow up and counselling services provided by Social Support Unit (SSU) managed by NGOs
Human resource: 5 – 7 staff N
E
P
A
L<br>
Client load: 100 – 150
Human resource: one doctor, 3 nurses, one counsellor, one data manager, 3 Guards Outreach, follow up and counselling services provided by Social Support Unit (SSU) managed by NGOs
Human resource: 5 – 7 staff N
E
P
A
L<br>
14
Maldives Initiated in the year 2009
Partnership with nodal drug agency with the Ministry of Health
OST medicine: Methadone
One centre operational in Male`<br>
Partnership with nodal drug agency with the Ministry of Health
OST medicine: Methadone
One centre operational in Male`<br>
15
OST clinic located in Government premises
Client load: 70
Human resource: one doctor, 2 nurses, 3 counsellors Outreach, follow up and part-counselling services provided by 3 NGOs
Human resource: 3 – 5 staff M
A
L
D
I
V
E
S<br>
Client load: 70
Human resource: one doctor, 2 nurses, 3 counsellors Outreach, follow up and part-counselling services provided by 3 NGOs
Human resource: 3 – 5 staff M
A
L
D
I
V
E
S<br>
16
Contents of the presentation OST programme in SA region - Current scenario
Scaling up OST in SA region
Supply chain management<br>
Scaling up OST in SA region
Supply chain management<br>
17
Scale-up: Considerations Setting the target
Universal access to HIV prevention services
40% of IDUs to be covered with OST
(Target setting guidelines, UNODC, UNAIDS, WHO, 2008)
However….
Current coverage is < 3% in any country of SA region
Different countries are in different stages of IDU-HIV epidemic
Coverage is largely limited to IDUs, and not to opioid dependent drug users<br>
Universal access to HIV prevention services
40% of IDUs to be covered with OST
(Target setting guidelines, UNODC, UNAIDS, WHO, 2008)
However….
Current coverage is < 3% in any country of SA region
Different countries are in different stages of IDU-HIV epidemic
Coverage is largely limited to IDUs, and not to opioid dependent drug users<br>
18
Following the epidemic
Estimate IDU from major districts/provinces
Shortlist provinces with significant IDU estimates
Identify provinces without OST services
Categorize provinces based on IDU estimates (high, medium and low priority)
Prioritize provinces with moderate-high IDU-HIV prevalence<br>
Estimate IDU from major districts/provinces
Shortlist provinces with significant IDU estimates
Identify provinces without OST services
Categorize provinces based on IDU estimates (high, medium and low priority)
Prioritize provinces with moderate-high IDU-HIV prevalence<br>
19
Choosing OST centres
Select models, medications based on in-country & regional experience
Shortlist potential centres
Conduct feasibility assessments
Accessibility to the clients
Infrastructure
Safety measures for stock-keeping<br>
Select models, medications based on in-country & regional experience
Shortlist potential centres
Conduct feasibility assessments
Accessibility to the clients
Infrastructure
Safety measures for stock-keeping<br>
20
Training and capacity building
Sensitisation 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 selection
Defining roles & responsibilities<br>
Sensitisation 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 selection
Defining roles & responsibilities<br>
21
Establish Quality assurance mechanism
Develop 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 quality
Dose of medication
Duration of treatment
Staff attitude
Satisfaction of clients<br>
Develop 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 quality
Dose of medication
Duration of treatment
Staff attitude
Satisfaction of clients<br>
22
Costing
Current costing: range from 30000 USD – 180,000 USD Start up cost
Sensitisation meeting
Training programmes
Feasibility assessment
Refurbishment of centres Implementation cost
Human resource
Medical doctor
Two nurses
One counsellor
Two outreach staff
One data manager
Accountant
Other support staff
Running cost - travel, communication Procurement cost
Medication
Buprenorphine: 37,000 USD
Methadone: 8,000 USD
Others:
Dispensers, water, etc.<br>
Current costing: range from 30000 USD – 180,000 USD Start up cost
Sensitisation meeting
Training programmes
Feasibility assessment
Refurbishment of centres Implementation cost
Human resource
Medical doctor
Two nurses
One counsellor
Two outreach staff
One data manager
Accountant
Other support staff
Running cost - travel, communication Procurement cost
Medication
Buprenorphine: 37,000 USD
Methadone: 8,000 USD
Others:
Dispensers, water, etc.<br>
23
Contents of the presentation OST programme in SA region - Current scenario
Scaling up OST in SA region
Supply chain management<br>
Scaling up OST in SA region
Supply chain management<br>
24
International regulatory framework Different mechanism for narcotics / psychotropics
Methadone
Covered under the 1961 convention
Prior quota and annual consumption reporting required
Buprenorphine
Covered under the 1971 convention
Annual quota not required to be allocated
Annual reporting for Buprenorphine (optional)
Essential medicine list – WHO
Methadone and buprenorphine in the list<br>
Methadone
Covered under the 1961 convention
Prior quota and annual consumption reporting required
Buprenorphine
Covered under the 1971 convention
Annual quota not required to be allocated
Annual reporting for Buprenorphine (optional)
Essential medicine list – WHO
Methadone and buprenorphine in the list<br>
25
Laws / policies of countries Drawn in accordance to the conventions
Most 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 policy<br>
Most 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 policy<br>
26
Supply chain mechanism<br>
27
Procurement procedures Determining the medicine required
Methadone: syrup in 5 or 10 mg/ml strengths
Buprenorphine tablets: 8 mg, 2 mg, 0.4 mg, 0.2 mg
Determining the quantity
No. of patients X no. of days X average dose per patient per day
Request for QUOTA
Required only for Methadone
Nodal Ministry requests INCB for a quota for Methadone [Department of Narcotics Control (Bangladesh), Ministry of Home Affairs (Nepal), Central Bureau of Narcotics (India)]<br>
Methadone: syrup in 5 or 10 mg/ml strengths
Buprenorphine tablets: 8 mg, 2 mg, 0.4 mg, 0.2 mg
Determining the quantity
No. of patients X no. of days X average dose per patient per day
Request for QUOTA
Required only for Methadone
Nodal Ministry requests INCB for a quota for Methadone [Department of Narcotics Control (Bangladesh), Ministry of Home Affairs (Nepal), Central Bureau of Narcotics (India)]<br>
28
Procuring agency
Each country has a nodal agency for procurement of goods and supplies
Maldives State Trading Organization
Nepal ‘Sajha’ trust
Negotiate rates with procuring agency (management cost)
Invitation for bids
Invite International Competitive bids<br>
Each country has a nodal agency for procurement of goods and supplies
Maldives State Trading Organization
Nepal ‘Sajha’ trust
Negotiate rates with procuring agency (management cost)
Invitation for bids
Invite International Competitive bids<br>
29
Bidding agency
Must have a WHO-GMP certificate or equivalent certificate
For export, supplier would need “Certificate of Pharmaceutical Product”(COPP) as recommended by WHO
Manufacturers / Distributors
Evidence of its technical, financial and production capability
Finalise vendor
Technical and financial qualification
Negotiate Rates<br>
Must have a WHO-GMP certificate or equivalent certificate
For export, supplier would need “Certificate of Pharmaceutical Product”(COPP) as recommended by WHO
Manufacturers / Distributors
Evidence of its technical, financial and production capability
Finalise vendor
Technical and financial qualification
Negotiate Rates<br>
30
Establishing a supply chain mechanism SCENARIO A SCENARIO B<br>
31
Stock management Licenses from relevant authorities for storage and transport
Central stocks
Storage area of central stock
Responsible officer for central stock
Safe keeping: secure system
Flow of stocks from central to OST clinic
Chain of custody
Clinic stocks
Storage area
Secure system
Staff-in-charge?<br>
Central stocks
Storage area of central stock
Responsible officer for central stock
Safe keeping: secure system
Flow of stocks from central to OST clinic
Chain of custody
Clinic stocks
Storage area
Secure system
Staff-in-charge?<br>
32
Record maintenance for stock management<br>
33
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 / home
Ensure procurement is made well in-advance
Prepare a standard supply chain protocol / guideline<br>
Ensure clear commitment from the ministries – licensing, narcotics control / home
Ensure procurement is made well in-advance
Prepare a standard supply chain protocol / guideline<br>
34
Securing sustained supply: considerations Stock replenishment
Stock projection
Rotate stocks with eye on expiry dates
Establish a strong supply chain mechanism
Identify officers responsible in-charge of the stock at every point
Maintain records strictly
Check at regular intervals<br>
Stock projection
Rotate stocks with eye on expiry dates
Establish a strong supply chain mechanism
Identify officers responsible in-charge of the stock at every point
Maintain records strictly
Check at regular intervals<br>
35
Conclusion Opioid dependence is a chronic medical condition and requires long term therapy
Different modalities followed in different countries for operationalising MMT
Goal and objective of OST in each country
Treatment of opioid dependence
Prevention of HIV among opioid users, especially injecting drug users
Urgent need to scale up OST in South Asia region<br>
Different modalities followed in different countries for operationalising MMT
Goal and objective of OST in each country
Treatment of opioid dependence
Prevention of HIV among opioid users, especially injecting drug users
Urgent need to scale up OST in South Asia region<br>
36
Advocacy for inclusion of narcotics / psychotropics in the national essential medicine list
Removal 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 OST Conclusion<br>
Removal 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 OST Conclusion<br>
37
THANK YOU<br>