OST IN SOUTH ASIA
Operational issues & supply
chain management
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
• Supply chain management
OST in South Asia Region
COUNTRIES WITH OST
• Bangladesh – Methadone
• India – Methadone, Buprenorphine
• Maldives – Methadone
• Nepal – Methadone, Buprenorphine
COUNTRIES WITHOUT OST
• Bhutan
• Pakistan
• Sri Lanka
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
Government hospital
• OST clinic located in
Government hospital
• Client load: 50 – 200
• Human resource: one
doctor, 2 nurses, one
counsellor, one data
manager
NGO
• 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
Government hospital
• 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
• 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`
Government hospital
• OST clinic located in
Government premises
• Client load: 70
• Human resource: one
doctor, 2 nurses, 3
counsellors
NGOs
• 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
• Scaling up OST in SA region
• 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 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.
Contents of the presentation
• OST programme in SA region - Current
scenario
• 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
Replenishment
of stocks
Supply
Stock
management
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
SCENARIO A
SCENARIO B
Vendor
Vendor
Central stock
Clinic
Clinic
Patient
Patient
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
Clinic stock register
• Inventory of the stock to be
maintained
• Signed by the officer
supplying the stock to clinic
• Inventory of the stock to be
maintained
• Signed by the officer
receiving the stock in clinic
Dispensing register
Daily stock register
• Total quantity of
methadone dispensed in
the clinic in the given day
• Information on the daily
stock transaction being
made
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
Conclusion
• 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
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