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 programme in SA region - Current scenario Scaling up OST in SA region Scaling up OST in SA region Supply chain management Supply chain management

OST in South Asia Region Bangladesh – Methadone India – Methadone, Buprenorphine Maldives – Methadone Nepal – Methadone, Buprenorphine COUNTRIES WITH OST Bhutan Pakistan Sri Lanka COUNTRIES WITHOUT OST

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

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

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 guards

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

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

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

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

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

OST clinic located in Government hospital Client load: 100 – 150 Human 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

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

OST clinic located in Government premises Client load: 70 Human 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

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

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

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

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

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

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

Costing – Current costing: range from 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.

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

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

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

Supply chain mechanism Procurement Supply Stock management Replenishment of stocks

Procurement procedures 1.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 2.Determining the quantity – No. of patients X no. of days X average dose per patient per day 3.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)]

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

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

Establishing a supply chain mechanism Vendor Clinic Patient Vendor Central stock Clinic Patient SCENARIO ASCENARIO B

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?

Record maintenance for stock management Central stock register Inventory of the stock to be maintained Signed by the officer supplying the stock to clinic Clinic stock register Inventory of the stock to be maintained Signed by the officer receiving the stock in clinic Daily stock register Information on the daily stock transaction being made Dispensing register Total quantity of methadone dispensed in the clinic in the given day

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

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

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

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

THANK YOU