OST IN SOUTH ASIA Operational issues & supply chain management Dr. Ravindra Rao

1. OST IN SOUTH ASIA Operational issues & supply chain management Dr. RavindraRao

2. Contents of the presentation • OST programme in SA region - Current scenario • Scaling up OST in SA region • Supply chain management

3. Contents of the presentation • OST programme in SA region - Current scenario • Scaling up OST in SA region • Supply chain management

4. OST in South Asia Region

5. 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

9. 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

10. OST clinic 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

11. 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

12. NGO OST clinic • 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

13. GO - NGO OST Government hospital NGO • OST clinic located in Government hospital • Client load: 50 – 200 • Human resource: one doctor, 2 nurses, one counsellor, one data manager • Outreach and follow up services provided by NGOs implementing Harm Reduction TI programmes • Human resource: One outreach worker, one programme manager I N D I A

14. MMT clinic • 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

15. 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

16. Government hospital NGO – SSU • 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

17. Maldives Initiated in the year 2009 Partnership with nodal drug agency with the Ministry of Health OST medicine: Methadone One centre operational in Male`

18. M A L D I V E S Government hospital NGOs • 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

19. Contents of the presentation • OST programme in SA region - Current scenario • Scaling up OST in SA region • Supply chain management

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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.

26. Contents of the presentation • OST programme in SA region - Current scenario • Scaling up OST in SA region • Supply chain management

27. 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

28. 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

29. Supply chain mechanism

30. 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)]

31. 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

32. 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

33. Establishing a supply chain mechanism SCENARIO A SCENARIO B

34. 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?

35. Record maintenance for stock management

36. 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

37. 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

38. 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

39. 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

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