The Right Service,
With the Right Product,
At the Right Place,
At The Right Time.
A Detailed Evaluation of the National Harm Reduction PSM in Mauritius
Prepared for
National AIDS Secretariat
By AIDS Projects Management Group (APMG)
May 2011
Abbreviations ...................................................................................................................... 2
PSM Discussion ................................................................................................................... 4
APPENDIXES ......................................................................................................................... 33
Appendix 1 : Details of paraphernalia found at all levels ................................................. 33
Appendix 2 : Dead-space syringes – communication with scientist W. Zule ................... 39
Appendix 3 : Some of the paraphernalia available with some comments from
international experience ................................................................................................... 40
Appendix 4 : Pictures of the Principal Warehouse ........................................................... 41
Appendix 5 : Pictures illustrating steps in the Methadone dispensing process ............... 43
Appendix 9: Pictures illustrating Methadone warehousing ............................................. 44
Appendix 10: List of tables ................................................................................................ 45
1
ABBREVIATIONS
AIDS
ART
BBSS
CCM
CSD
CSO
CSW
CUT
DIC
MFPWA
GIPA
GFATM
HBV
HC
HCV
HIV
ORW
M+E
MARP
MFPWA
MMT
MoHQL
MST
MST HC
MSM
NATReSA
NEP
NGO
NHRTF
NMTC
PLWHA
PR
PSM
PWID
SDI
SR
Acquired Immune Deficiency Syndrome
AntiRetroviral Therapy
Biological and Behavioral Surveillance Survey
Country Coordinating Mechanism
Central Supplies Division (warehouse)
Civil Society Organization
Commercial Sex Workers
Collectif Urgence Toxida
Drop In Centre
Mauritian Family Planning and Welfare Association
Greater Involvement of People Living with HIV/AIDS
The Global Fund to Fight AIDS, Tuberculosis and Malaria
Hepatitis B Virus
Health Centre
Hepatitis C Virus
Human Immunodeficiency Virus
OutReach Worker
Monitoring and Evaluation
Most At Risk Populations
Mauritian Family Planning and Welfare Association
Methadone Maintenance Therapy
Ministry of Health and Quality of Life
Methadone Substitution Therapy
Methadone Substitution Therapy Health Centre
Men having sex with men
National Agency for the Treatment and Rehabilitation of
Substance Abusers
Needle Exhange Programs
Non-Governmental Organization
National Harm Reduction Task Force
National Methadone Therapy Centre
People Living with HIV/AIDS
Principal Recipient
Procurement and Supply Management
People Who Inject Drugs
Seriously Disruptive Incident
Sub-Recipient
2
STI
TB
UIC
UNGASS
UNODC
VCT
WHO
Sexually Transmitted Infections
Tuberculosis
Unique Identifying Code
United Nations General Assembly Special Session
United Nations Office of Drug Crime
Voluntary Counselling and Testing
World Health Organisation
3
PSM Discussion
This PSM discussion is segmented in four parts : 1/ paraphernalia, 2/ opportunity to
increase the range of paraphernalia, 3/ paraphernalia selection, procurement, and
tendering procedure, 4/ paraphernalia distribution from service delivery points to the
Central Supplies Division (CSD) and the Principal Warehouse, 5/ case of Methadone, 6/
effective coordination and monitoring of PSM.
Paraphernalia and client’s satisfaction
APMG consultants visited and collected paraphernalia at the field level, in pharmacies,
at the intermediary stocks, in the CSD, at the Principal Warehouse, and inquired in the
tenders at the Procurement Office level. List, pictures, and details (and reference for
sake of simplicity) of paraphernalia found across the supply chain are exhibited in
Appendix 1. The summary is as follow :
4
Tableau 1 : Summary of the different existing products in the current supply chain and reference
Being distributed in the field
Harm Reduction service delivery points
Pharmacies
Needle 22G
(black)
Ref : NEP - 22G 1 ¼
Hypodermic needle disposable, 22G 1
¼ , luer lock, sterile, individually
packed
Needle 23G
(blue)
Needle 27G
(grey)
Intermediary
Warehouse
Upstream stocks
Central Supplies Division and
Principal Warehouse
Same as NEP - 22G 1 ¼
Hypodermic needle disposable,
22G 1 ¼ , luer lock, sterile,
individually packed
Procurement department
Yes, tendered in 2010 for
calendar year 2011
Confirmation brand
Tender in 2011 for 2012
cancelled
Yes, tendered in 2011 for
calendar year 2012
No brand ? manufacturer :
Changzhou Lianjie Imp &
Exp Co ltd, China
Int WH - 23G 1’
Hypodermic needle disposable,
23G 1, luer lock, sterile,
individually packed
Ref : NEP - 27G ¼
Hypodermic needle disposable, 27G ¼,
luer lock, sterile, individually packed
Ref : NEP - 27G ½ Neoject’
Hypodermic needle disposable, 27G ½ ,
luer lock, sterile, individually packed
Ref : Int WH - 27G ½ Hypodermic
needle disposable, 27G ½, luer
lock, sterile, individually packed
Same as Int WH - 27G ½
Hypodermic needle disposable,
27G ½, luer lock, sterile,
individually packed
Ref : NEP - 27G ½ China
Hypodermic needle disposable, 27G ¼,
luer lock, sterile, individually packed
Yes, tendered in 2010 for
calendar year 2011
brand ?
Yes, tendered in 2011 for
calendar year 2012
brand ?
Syringe 1cc
Ref : Pharma – 1cc orange cap
with needle plastic blistered
Disposable, sterile, individually
packed, 1cc Insulin syringes
with needle ‘’orange capped’
Ref : Ctr WH – 1cc insulin syringe
orange cap
Disposable, sterile, individually
packed, 1cc Insulin syringes with
needle G29‘’orange capped’’
Price: Rs 1.1
5
Being distributed in the field
Harm Reduction service delivery points
Pharmacies
Intermediary
Warehouse
Ref : Int WH - 1cc syringes plastic
blistered
Disposable, sterile, individually
packed, 1cc Insulin syringes
without needle
Medium dead space
Ref : NEP 1cc paper blistered
Disposable, sterile, individually packed,
1cc Insulin syringes without needle
Medium dead space
Syringe 3cc
Upstream stocks
Central Supplies Division and
Principal Warehouse
Ref : Ctr WH – 1cc insulin syringe
26G ½
Disposable, sterile, individually
packed, 1cc Insulin syringes with
needle ‘’orange capped’’
?? Same as - Int WH - 1cc syringes
plastic blistered
Procurement department
Yes, tendered in 2010 for
calendar year 2011
brand ?
?? Same as - NEP 1cc syringes
paper blistered
Yes, tendered in 2010 for
calendar year 2011
brand ?
?? Same as - 3cc syringes plastic
blistered
Yes, tendered in 2010 for
calendar year 2011
brand ?
?? Same as - 3cc syringes paper
blistered
Yes, tendered in 2010 for
calendar year 2011
brand ?
Pharma – 3cc with 23G 1 ¼
plastic blistered
Disposable, sterile, individually
packed, 3cc Insulin syringes
with needle 23G 1 ¼
High dead space
Ref : Int WH - 3cc syringes plastic
blistered
Disposable, sterile, individually
packed, 3cc syringes without
needle
High dead space
No brand ?, manufacturer :
Jiangsu Yile Medical Article Co
Ltd, China
NEP 3cc paper blistered
Disposable, sterile, individually packed,
3cc syringes without needle
High dead space
6
APMG consultants cannot comment on which needles are preferred by PWIDs in
Mauritius. This should be carefully studied in focus groups and should be linked with the
drug of use, individual anatomy, site of injection, etc. Provision of needles 27G
(superficial intravenous injection in large and fine veins) and 22G (deep vein intravenous
injection, intramuscular injection for anabolic steroids) associated with a 1cc and 3cc
syringes makes sense to cover basic needs. It will be interesting to verify if PWIDs really
prefer insulin syringe in two pieces or in one piece. PWIDs that APMG consultants met
clearly praised the ‘’orange capped’’ one, previously distributed and only available at
pharmacies for a fee.
There several key themes associated with PMS in Mauritius. The following represent key
themes categorised by their associated recommendations:
1) Transparent Needle and Syringe Selection Process
Periodically establish diverse focus groups to understand the practice of injection, and
inform selection of needles and syringes (gauge, length of needle, syringe in 1 piece vs.
2 pieces, etc.). The written documentation of satisfaction/dissatisfaction should support
decision making for product selection. It then becomes the official rationale why one
product more expensive could better suit customer needs than a cheaper version.
2) Insulin 1cc ‘’orange capped’’
Confirm via focus group that it is the preferred 1cc. Since this product is already
available at the CSD (ref : Ctr WH–1cc insulin syringe ‘’orange cap’’), it could be quickly
tested in the field with a provision of hundred samples to ten diverse PWIDs in two
representative sites and document anonymous feedback in writing. After it is certain
that this brand/product is satisfactory, any other 1cc syringes of any type should
physically removed out the supply chain with proper information and education.
3) High to medium dead space syringes
1cc and 3cc syringes distributed by Harm Reduction services are medium/high dead
space and are more likely to keep blood while shared (even after rinsing) 1, thus with a
higher chance to transmit blood borne disease. Pharmacies provide high dead space 3cc
syringes too.
With proper information and education to PWIDs, it is recommended the transition
from high/medium dead space syringes into low dead space ones. If the
recommendation on 1cc insulin below is implemented, only the 3cc syringe remains to
be transitioned. Pharmacies should also be informed and educated to the concept of
high/medium dead space syringes and risks at both national/field levels: the National
Council of Pharmacists and pharmacies located in the surroundings of PWIDs.
1
See Annexe 2 : Dead-space syringes, discussion with scientist William Zule
William Zule, Elizabeth Costenbader, Curtis Coomes : Dead Space Syringes and HIV Risk
among Injecting Drug Users
4) Variety of products with different packaging/labeling/needle length
These products must be harmonized, unified after meticulous focus group testing.
Inappropriate stocks at all levels should be replaced by the accepted ones. This decision
might lead to a financial write-off for the harm reduction budget but it will add stability
to the paraphernalia offering, PWIDs will be less likely disoriented, and trust and
satisfaction will be gained back. When stability in product specification has been found,
the Procurement department should take into account the specification of current
products (label, color, packaging, needle length) for future tenders. APMG consultants
recommend that any decision to change specifications from an already accepted
product should be prohibited. Exception could be made if there is no other solution
could be found. PWIDs’ satisfaction, loyalty, and high coverage is at this price. The focus
group documentation then becomes the official rationale of the reason why product
specifications cannot be changed.
5) Reporting mechanism for satisfaction and quality
Satisfaction and quality reporting currently exists in Mauritius but is informal:
satisfaction comments provided by PWIDs are reported to the National Harm Reduction
coordinator via quarterly paper-based contact/distribution reports or sometimes orally
from service providers. Our discussion with PWIDs showed that most of the time, direct
complains from PWIDs are not even told to and documented by service providers. Issues
with quality of paraphernalia are reported to the National Harm Reduction coordinator
by email or by phone, again informally. The National Harm Reduction coordinator brings
then these non-formal complaints to the Procurement department and rarely at the
Product Selection committee. This means that the quality complaints never inform
procurement decision and product selection, nor PWIDs’ voice about satisfaction being
heard at this level.
A formal channel for bottom-up reporting satisfaction and quality issue should be
established including a procedure stating : 1/ who will receive the complaints (National
Harm Reduction coordinator), 2/ how the complaint will be conveyed to the NHRC (by
email), 3/ how a complaint should be written (facts : what happened, where, when,
reported by who, what organization, who is the client, what paraphernalia with what
specifications, what brand, what lot #, what expiration date ; and very important should
include pictures), 4/ what will be the role of this person (a/ receive and log the
complaints, b/ ensure good investigation and forward complaints to Procurement
department, c/ spread the information (what paraphernalia, what brand, what lot #,
what expiration date) to other service delivery points if needed and query that similar
complaints are not happening, and if there are, take the necessary decisions to ensure
spread of information, safety and eventually remove stocks of defective products, d/
follow-up with Procurement Department and suppliers on further decisions/actions
needed, e/ bring forward satisfaction/quality complains to Selection committee so that
it will be taken into consideration in future awarding decision). Later in this report, we
will recommend the creation of a paraphernalia sub-committee. Satisfaction and quality
should be reported on a regular basis to the committee.
8
6) Quality Assurance and WHO paraphernalia standards
GFATM requires that PRs’ procured products meet standards of WHO’s Guide For The
Quality Assurance of Single Use Injection Equipment2. APMG consultants believe only
needle meeting these requirements is NEP-27G ½ of the brand Neoject. Needle/syringe
paraphernalia does not meet always these standards as it relates to : 1/international
product standards, 2/ conformity with quality system standards, 3/ labelling standards
(2.2.3 Packaging and labelling of products – current products do not always identify
a/brand, b/manufacturer’s info, c/product’s specifications (gauge AND needle’s length)
c/lot number and expiration date. APMG consultants also noted that alcohol swabs
don’t have expiration dates nor a recognizable brand
Current and future injecting paraphernalia procured by SRs and MoH must meet WHO
standards set out in the Guide For The Quality Assurance of Single-Use Injection
Equipment3. APMG consultants recommend to translated this guide into specifications
that should be inserted in the tenders for Harm Reduction paraphernalia. APMG
consultants propose to 1/ remove as soon as possible the current products and stocks
not meeting these WHO requirements, 2/ stop tenders made in 2011 for the calendar
year of 2012, 3/ harmonize the different products currently in the supply chain between
the Procurement department and the field. The national Harm Reduction Response will
gain a great recognition by a/ end-users (increased satisfaction thanks to less quality
issues, less confusion with product identification, b/ by service delivery points (less
burden thanks to better satisfaction and less quality complaints to report, less changes
in product specification and identification, less education to provide when new products
are introduced, less products and stock to handle), c/by warehouses (less products to
stock and handle) that should lead to more customers accessing Harm Reduction
services and higher coverage (number of needles/day/PWID).
Opportunity to increase the range of paraphernalia
Safe injection
A large number of PWIDs reported to APMG consultants that they use tap/bottled water
as injection water, rum bottle caps with a twisted wire around as cooker, white vinegar
as acidifier to dissolve brown-sugar type of drug, cigarette filter as filter, any flat object
to crash pills of Suboxone. No information was found about the tourniquet. We
assumed that condoms or any other tie could be used as tourniquet. These common
practices in absence of adequate paraphernalia do not promote single usage, sterile preinjection manipulation, safe injection, and after-injection cares limiting blood-borne
disease sharing, skin and vein injuries, and fostering self cares.
Safe tattooing
2
www.who.int/injection_safety/toolbox/docs/en/InjEquQualityGuiden.pdf
3
http://www.who.int/entity/immunization_safety/publications/safe_injections/PQS_Prequalification_injection_devices_manufacturers_guide.pdf
9
APMG consultants met a large number of PWIDs, SWs, MSMs, and other MARPs with
old and recent tattoo. They reported that tattoo parlours could be professional and less
professional. Products used in the non-professional tattoo parlours were sewing
needles, with or without disinfectant. Since tattooing involves a large amount of
bleeding and thus risk of blood-borne disease transmission and infection, APMG
consultants believe that this tattooing practice could potentially participate to the
HIV/HCV epidemic in Mauritius. Adding tattooing paraphernalia could open a new
channel to access new untapped at-risk population, provide new services, and increase
clients’ contacts, satisfaction, and care.
7) Paraphernalia availability, quantification, costing, and guidance in elaboration of
GFATM phase II
Focus groups of PWIDs, SWs, MSMs, and other MARPs first should be organised to
document the usage of bottle cap, white vinegar, cigarette filter, tap water, and tie in
the injection process and segmented by drug of choice, and sewing needle in the
tattooing process. The second step will consist of getting feedback on available
paraphernalia. Third step: how to procure this paraphernalia for this sample testing ? 1/
ask manufacturers to provide free samples with the hope that they will be better known
and thus might be selected in future tenders, quantity nevertheless is often limited, 2/
use the Direct Procurement (under 100,000 MRU) under the Procurement Regulations
of Mauritius, 3/ get a donation from private or international donor. Fourth step should
include sample test in the field within clients that have never participate to focus group
nor heard about these new paraphernalia. This step should include education and
proper documentation of satisfaction + potential increase of clients’ visits or new
comers (the effect ‘’new product’’ has been well documented in The impact of citrate
introduction at UK syringe exchange programmes: a retrospective cohort study in
Cheshire and Merseyside, UK4). Both documents will support a/ satisfactory product to
be tendered and probably awarded, b/potential impact in program coverage and
success, and c/ future quantification of paraphernalia needed. Some of the
paraphernalia available with some comments from international experience can be
found in appendix 3.
Quantification, costing, and guidance in the elaboration of GFATM phase II
This high level quantification should be confirmed/modified with results from focus
group and field sample testing in Year 1 of phase II, and with any noticeable change in
hypothesis and injecting behaviour. New prices and new products should also be added.
Best practice of 1 needle + 1 vial + 1 cooker + 1 filter (+ 1 acidifier for brown sugar) per
injection is difficult to reach, the maximum hypothesis take into account successful
scenario in other countries.
4 The impact of citrate introduction at UK syringe exchange programmes: a retrospective cohort study in Cheshire and
Merseyside, UK
Caryl M Beynon, Jim McVeigh, Martin Chandler, Michelle Wareing and Mark A Bellis
http://www.springerlink.com/content/98t735788263w118/
10
Tableau 2: Quantification and costing of new paraphernalia for GFATM phase II
Paraphernalia
Hypothesis : Needles
Hypothesis: Syringes
without needle
Hypothesis : PWID
reached
Year 1
Info pending
Info pending
Year 2
Info pending
Info pending
Year 3
Info pending
Info pending
Year 4
Info pending
Info pending
Info pending
Info pending
Info pending
Info pending
Cooker
for 100,000 MRU
Acidifier
for 100,000 MRU
Filter
for 100,000 MRU
Vial of Water for
Injection
Tourniquet
for 100,000 MRU
Depends on brown sugar
usage
Max : ⅓ needles or ¼
vials
Min : ¼ needles
Depends on brown sugar
usage
Max : ½ needles
Min : ¼ needles
Max : ½ needles
Mini : ¼ needles
Max : 10% needles
Min : 3 x ½ PWID reached
Depends on brown sugar
usage
Max : ½ needles or ½
vials
Min : ¼ needles
Depends on brown sugar
usage
Max : ¾ needles
Min : ¼ needles
Max : ¾ needles
Min : ¼ needles
Info pending
Depends on brown sugar
usage
Max : ½ needles or ½
vials
Min : ¼ needles
Depends on brown sugar
usage
Max : ¾ needles
Min : ¼ needles
Max : ¾ needles
Min : ¼ needles
Info pending
Tattooing needle
TOTAL
for 100,000 MRU
600,000 MRU
Info pending
?
Info pending
Info pending
?
Info pending
for 100,000 MRU
? Info pending
Info pending
8) M+E of larger-range paraphernalia provision
When Mauritius provides a larger range of paraphernalia, M+E should incorporate a
regular thorough analysis of how these paraphernalia are paired. It will improve 1/
future quantification, forecasting, and precise ordering, and enable the procurement of
better products, 2/ the quality of field work. For instance, a specific team from a specific
sub-recipient distributing harm reduction supplies can constantly show 1 vial for 2
needles for 0 swabs. This might indicate that this team forgets to bring swabs, and does
not inform PWID that every injection should be done with a new vial of water for
injection. This type of indicators should be presented regularly and in details at the
Harm Reduction committee according to a pre-agreed template and format. This
information should also be shared at the national level and at the SR level, and should
inform both field and national decision-making for action and change in strategy (see
chapter on M+E).
Paraphernalia selection, procurement, and tendering procedure
Current successful process with a less successful impact
As stated in the PSM Plan Round 8 Phase I, MoHQL Procurement Unit is in charge of the
procurement process and lead the product selection. MoHQL Procurement Unit is
located on the 10th floor of the MoH, the team is competent, well structured, and
guided by policies, procedures, roles, and responsibilities (see the organisational
mapping in the PSM Plan Round 8 Phase I) set by the Procurement Policy Office. All
health products for hospital and other health facilities in Mauritius are channelled
through this Procurement Unit and efficiently tendered in a very structured annual plan.
11
This process can be named ''hospital-type of procurement'', which involves a top-down
procurement and product selection with no voice from patients that are mostly imposed
medicines and health supplies. The harm reduction philosophy is reverse and
has/does/will not function well if paraphernalia/services are imposed to PWIDs, SWs,
MSMs, and other MARPs, they will not use it. The procurement of paraphernalia should
follow a ''harm-reduction-type of procurement'' which uses a bottom-up procurement
approach and product selection with a focus on clients’ needs and desires. This
specificity of the field of harm reduction is widely documented with scientific
publications and should not require elaborate demonstration.
MoHQL Procurement Unit and PRs diligently follow the PSM Plan Round 8 Phase I but
this ''hospital-type of procurement'' will have less success in a harm reduction
environment. We believe that the Plan should have recognized it and set up a specific
selection process for harm reduction paraphernalia. It should also be noted that the
Plan 1/ does not mention harm reduction paraphernalia other than condoms, 2/ harm
reduction paraphernalia is not included in the role and responsibility for Product
Selection in table 1, and 3/ in the Quality Assurance Procurement and Product Quality
Control (whose responsibility falls under the MoHQL Pharmacy board). The Plan mainly
focuses on medicine. APMG consultants do not understand why the entity responsible
for condoms Product Selection is only the Procurement Unit and does not include (such
as for ARVs) AIDS Unit, NDCCI, Pharmacy Department, and Central Supply Department.
APMG consultants believe that this ''hospital-type of procurement'' and limited Quality
Assurance control has an important negative impact on clients’ satisfaction, their
loyalty, their product adherence, their trust in harm reduction services. This is reflected
in the unsatisfactory coverage and numerous clients’ complaints.
Alternatives and recommendations on paraphernalia selecting and tendering
To be successful, the harm reduction selection, procurement, and tendering process
should 1/ ensure clients’ need satisfaction with a direct and full involvement of PWIDs,
SWs, MSMs, and other MARPs in the paraphernalia selection process, 2/ promote longterm constancy in product specifications and brands. The financial implication might be
that a more expensive product win the bid.
12
Alternative processes for paraphernalia selection
PWIDs, SWs, MSMs, and other MARPs should be the final voice in the paraphernalia
selection. This should be achieved by a/respecting Mauritius policies set by the
Procurement Policy Office, or b/ getting a special exemption to deviate from current
Procurement Polices. With our understanding of the Mauritius policies and preliminary
discussions with the Procurement department, the alternatives could be listed as such :
13
Tableau 3 : Alternative processes for paraphernalia selection
Scenario #1 (*): we assume that a special exemption will be needed from the Procurement Policy Office to alter the national Procurement Policy for harm reduction paraphernalia.
Scenario #2 (**): we assume that alteration of the national Procurement Policy is not needed/not possible, alternatives could/should be implemented without exemption/within the national
Procurement Policy.
Selection/Bid evaluation
committee –current
setting/baseline
Alternative #1
(indirect representation of MARPs
with field test)
Procurement Unit
Selection/Bid evaluation
committee -recommended
2/ Representatives of PRs and SRs,
3/ AIDS Unit,
4/ Procurement Unit,
5/ Pharmacy Department,
6/ Central Supply Department,
Final say should come from
2/ Representatives of PRs and SRs (for
satisfaction’s needs),
3/ AIDS Unit (health
recommendations),
4/ Pharmacy Department (for Quality
Assurance)
Decision making process MARPs satisfaction is #1
criteria
0/ Procurement Unit will get samples
from suppliers
1/Samples are provided to PRs and
SRs 2 weeks prior Selection
Committee meeting
2/ Field test amongst PWIDs, SWs,
MSMs and other MARPs and
documentation by PRs & SRs
3/ Documentation supports selection
committee decision
Document from sample field testing
Legal document supporting
selection decision
No exemption**
Alternative #2 - Best
(direct representation of MARPs with
field test)
Procurement Unit
1/ Representatives of PWIDs, SWs,
MSMs and other MARPs,
2/ Representatives of PRs and SRs,
3/ AIDS Unit,
4/ Procurement Unit,
5/ Pharmacy Department,
6/ Central Supply Department,
1/ Representatives of PWIDs, SWs,
MSMs and other MARPs (for
satisfaction’s needs),
2/ Representatives of PRs and SRs (for
satisfaction’s needs),
3/ AIDS Unit (health
recommendations),
4/ Pharmacy Department (for Quality
Assurance)
0/ Procurement Unit will get samples
from suppliers
1/Samples are provided to PRs and
SRs X weeks (more than 2) prior
Selection Committee meeting
2/ Field test amongst PWIDs, SWs,
MSMs and other MARPs and
documentation by PRs & SRs
3/ Documentation supports selection
committee decision
Document from sample field testing
Alternative #3
(direct representation of MARPs
without field test)
Procurement Unit
1/ Representatives of PWIDs, SWs,
MSMs and other MARPs,
2/ Representatives of PRs and SRs,
3/ AIDS Unit,
4/ Procurement Unit,
5/ Pharmacy Department,
6/ Central Supply Department,
1/ Representatives of PWIDs, SWs,
MSMs and other MARPs (for
satisfaction’s needs),
2/ Representatives of PRs and SRs (for
satisfaction’s needs),
3/ AIDS Unit (health
recommendations),
4/ Pharmacy Department (for Quality
Assurance)
During the Selection Committee
meeting
Special exemption*
Alternative # 4
(direct representation of MARPs
with field test)
Procurement Unit
1/ Representatives of PWIDs, SWs,
MSMs and other MARPs,
2/ Representatives of PRs and SRs,
3/ AIDS Unit,
4/ Procurement Unit,
5/ Pharmacy Department,
6/ Central Supply Department,
1/ Representatives of PWIDs, SWs,
MSMs and other MARPs (for
satisfaction’s needs),
2/ Representatives of PRs and SRs (for
satisfaction’s needs),
3/ AIDS Unit (health
recommendations),
4/ Pharmacy Department (for Quality
Assurance)
0/ Procurement Unit will get samples
from suppliers
1/Samples are provided to PRs and
SRs 2 weeks prior Selection
Committee meeting
2/ Field test amongst PWIDs, SWs,
MSMs and other MARPs and
documentation by PRs & SRs
3/ Documentation supports selection
committee decision
Weakness
Strength
Alternative #1
(indirect representation of MARPs
with field test)
Take more time
PRs & SRs must respect Procurement
deadline
Need a strict procedure including
method of sample testing
Award might not be the cheapest
product
Control needed by PRs & SRs whether
award decision aligned with field tests
Investigate and truly meet clients’
satisfaction
Ensure success of harm reduction
response
No exemption**
Alternative #2 - Best
(direct representation of MARPs with
field test)
Take more time
PRs & SRs must respect Procurement
deadline
Need a strict procedure including
method of sample testing
Award might not be the cheapest
product
Investigate and truly meet clients’
satisfaction
Ensure best success of harm reduction
response
Alternative #3
(direct representation of MARPs
without field test)
Little time to decide
Not certain that awarded product is
the most satisfactory one
Award might not be the cheapest
product
Fast
Easy for Procurement Unit
Special exemption*
Alternative # 4
(direct representation of MARPs
with field test)
Take more time
PRs & SRs must respect Procurement
deadline
Need a strict procedure including
method of sample testing
Award might not be the cheapest
product
Control needed by PRs & SRs whether
award decision aligned with field tests
Investigate and truly meet clients’
satisfaction
Ensure success of harm reduction
response
15
9) Product selection
APMG recommends alternative # 2 or a similar/hybrid version including direct
representation of PWIDs, SWs, MSMs, and other MARPs and field sample testing.
The Pharmacy Department should continue to be responsible for pharmaceutical
products and also be responsible for Quality Assurance of harm reduction
paraphernalia.
PSM Plan Round 8 Phase I or future version should be entirely updated with a/ harm
reduction paraphernalia, b/ any changes in the Product selection process, c/
responsibility of the Pharmacy Department for Quality Assurance of harm reduction
paraphernalia.
Alternatives for product constancy and tendering
The lack of consistency in product specifications, packaging, and brand is a great factor
in disorienting MARPs in keeping a safe (injecting, sex, etc.) practice. MARPs are very
attached to satisfaction and do not like to deviate from established routine.
New/different products every year are not recommended. This should be reflected in
the ''harm-reduction-type of procurement'', especially in the tendering schedule. It is
APMG consultants’ understanding that MoHQL Procurement Unit is required to tender
every year under Mauritius policies set by the Procurement Policy Office, the rationale
being the ability to attain the best price (GFATM’s value for money).
Tableau 4 : Alternative processes for paraphernalia tendering
Scenario #1 (*): we assume that a special exemption will be needed from the Procurement Policy Office to alter the national
Procurement Policy for harm reduction paraphernalia.
Scenario #2 (**): we assume that alteration of the national Procurement Policy is not needed/not possible, alternatives could/should
be implemented without exemption/within the national Procurement Policy.
Tender policy –
current
setting/baseline
**No exemption
Alternative #1
Alternative #2
(tender for multiple years)
(tender for 1 year + new
award only if better
product)
Tender for 1 year of usage
Tender for 1 year of usage
Tender policy –
recommended
Tender for multiple years
of usage (2 to 3 years + 1
optional year)
Strength
Stronger to negotiate lower
price
Short term constancy
Reduce burden on
Procurement Unit
Only short term constancy
Risk of not benefiting of
new/better/cheapest
products
Weakness
Special exemption*
Alternative # 4
All the above or hybrid
versions
Tender for 1 year of usage
Tender for 1 year of usage
New tender and new
award should bring better
MARPs’ satisfaction that
current product
Best long term constancy
Opportunity to get
new/better products
Best long term constancy
Opportunity to get
new/better products
Not stronger to negotiate
lower price
Same burden on
Procurement Unit as
baseline
Not stronger to negotiate
lower price
Same burden on
Procurement Unit as
baseline
Need solid documentation
of MARPs satisfaction
Mitigation
Need solid documentation
of MARPs satisfaction
Clause in the contract for
new/better product as
exiting reason
10) Paraphernalia tendering
APMG consultants’ current knowledge of Tendering Policy is not sufficient to
recommend any alternative that would best fit within the national Procurement Policy.
It is also unclear to APMG consultants why tenders of same type of paraphernalia have
been disaggregated: why both syringes cannot be included in the same tender, same for
both needles since they are more than likely to be manufactured by the same
manufacturer. To our limited knowledge of the national Procurement Policy, it could be
possible. Constancy will certainly be gained (both needles and both syringes will be of
the same brand). It is known in the supply chain field that the larger the amount of
business brought to a supplier, the larger the economy of scale and the discount passed
on to the customers, bringing potential savings.
Paraphernalia distribution from service delivery points to Central warehouses
Current model
In a nutshell, service delivery points have to drive to the intermediary stock within the
National Harm Reduction Coordinator to pick up their request, then drives back to the
local stocking location and replenish their stocks. The van from the CSD delivers to the
intermediary stock so that the National Harm Reduction Coordinator replenishes his
own intermediary stock. The table below maps the flow of paperwork, information, and
product :
17
Tableau 5 : Flow of paperwork, information, and product from service delivery points to Central warehouses
Service delivery points
Harm Reduction unit, NEP Liaison Office
(HRU–NEP LO) &
Intermediary Stock
Central Supplies Division
Principal Warehouse
0/ visual signal : stock need to be replenish
1/ populates Indent Form
2/ transmits to NHRC by email/fax/phone
call
3/ receives Indent Form
4/ checks availability
5/ sets up pick-up time with service delivery
points
6/ drives to NRC & intermediary stock
7/ signs Indent Form to acknowledge
reception
8/ drives back to PDC
9/ Restocks stocking location
10/ files Indent Form
National Harm Reduction Coordinator
(NHRC) &
Intermediary stock
a/ signal : stock need to be replenish
b/ populates Combined Indent, Issue Note &
Receipt Voucher in 4 copies
c/ transmits to Central Supplies Division
Central Supplies Division
Principal Warehouse
d/ signs 4 copies of Combined Indent, Issue
Note & Receipt Voucher
e/ enters into Management Information
Systems
f/ keeps 1 copy for own filing
g/ Issues a Delivery Note and signs it,
transmits to Principal warehouse
h/ signs Combined Indent, Issue Note & Receipt
Voucher, keeps 2 copies, 1 for own filing, 1 for finance
department
i/ populates Delivery Note and signs it
j/ picks up stocks and load in lorry
k/ drives to HRU–NEP LO
l/ presents Combined Indent, Issue Note & Receipt
Voucher
Service delivery points
Harm Reduction unit, NEP Liaison Office
(HRU–NEP LO) &
Intermediary Stock
m/ signs Delivery Note to acknowledge
reception
n/ Restock stocking location
o/ keeps 1 copy of Combined Indent, Issue
Note & Receipt Voucher and 1 copy of
Delivery Note for own filing
National Harm Reduction Coordinator
(NHRC) &
Intermediary Stock
Central Supplies Division
Central Supplies Division
Principal Warehouse
Principal Warehouse
I/ signal : stock need to be replenish
II/ contacts manufacturer and requests stock
III/ etc.
19
Mauritius being not a very large island, local stocks can be reached and replenished on a
timely fashion (several hours), and APMG consultants did not hear of local stock-out
that could have impacted harm reduction services. The intermediary stock managed by
the National Harm Reduction coordinator receives deliveries from the CSD warehouse
and Principal Warehouse. The intermediary warehouse plays a larger role since the
entire/yearly stock of alcohol swabs is move from the Principal Warehouse to the
intermediary warehouse and the Principal Warehouse does not carry this item (swabs
are small and annual usage is not big). This system seems to satisfy both service delivery
points and NHRC although this is not of the mandate of the NHRC to manage and
periodically receive stocks at the Principal Warehouse. APMG consultants consider that
the time of service delivery points staff and the NHRC should be best allocated to other
tasks than supply chain ones, given that the Principal Warehouse has a monthly delivery
schedule to more than 100 health sites across the island plus a rush/urgent delivery
mechanism. The NHRC still should monitor the information of supply distribution, this is
a really important piece of information that should be managed and analysed by the
NHRC staff.
11) Intermediary stock and role of NHRC
APMG consultants believe that a/ the Intermediary stock is not necessary, adds to the
burden of the NHRC and should be reverted to the Principal Warehouse under specific
condition, and that b/ the Principal Warehouse should delivers directly to service
delivery points.
The intermediary stock should be transferred back to the Principal Warehouse and this
unnecessary task be not of the NHRC mandate any more. The NHRC should still be
responsible for authorizing the Indent Form and monitoring the data. This important
source of data should be used for evaluation purpose, and should be presented at the
periodic harm reduction committee. It would be best if service delivery points could fill a
web-based reorder form that will automatically populate an excel database. The NHRC
will then be able to a/ authorize deliveries in a very quick fashion, b/ monitor indicator
from a database that does not need manual input from his staff, reducing his burden.
The description of the Roles and Responsibilities of the NHRC should be updated if these
recommendations are implemented.
12) Direct deliveries from the Principal Warehouse to service delivery points.
To reduce the burden and burnout of harm reduction service providers, and take
advantage of the supply chain capabilities, APMG consultants recommend that service
delivery points be included in the monthly delivery schedule of the Principal Warehouse.
A precise procedure (the tables in chapter could be partially used and fleshed out) must
be written in agreement between service delivery points and the Principal Warehouse,
specifically detailing 1/ cut-off time (at the Principal Warehouse), and 2/ delivery
day/time (at service delivery points), 3/ limited variability in delivery scheduled time.
This procedure should then be communicated within all service delivery points. Any
change should be communicated in advance by the Principal Warehouse delivery service
and well planned to prevent any disturbance of service. The new/simplified process
mapping will be as such:
Tableau 6 : mapping of the new direct delivery process from the Principal Warehouse to service delivery
points.
Service delivery points
National Harm Reduction
Coordinator (NHRC)
Central Supplies Division
Principal Warehouse
0/ visual signal : stock
need to be replenish
1/ populates web base
Reorder Form before cutoff time, sends it by
clicking
2/ receives e-reorder form
3/ controls and approves
4/ forwards to Central
Supplies Division before cut
off time
5/ monitors monthly
database
6/ fills and signs 4 copies of
Combined Indent, Issue Note &
Receipt Voucher
7/ enters into Management
Information Systems
8/ keeps 1 copy
9/ Issues a Delivery Note and
signs it, transfers to Principal
Warehouse
10/ signs Combined Indent, Issue
Note & Receipt Voucher, keeps 2
copies, 1 for own filing, 1 for
finance department
11/ populates Delivery Note and
signs it
12/ picks up stocks and load van
13/ delivers service delivery points
14/ presents signed Combined
Indent, Issue Note & Receipt
Voucher
15/ signs Delivery Note to
acknowledge reception
16/ restocks stocking
location
17/ files Delivery Note and
Combined Indent, Issue
Note & Receipt Voucher,
Paraphernalia warehousing and alternatives
Health product warehousing is being phased into a more modern facility. A large
modern Central Warehousing is scheduled to be built in la Tour Koenig within three
years. In the meantime, the CSD keeps some consumable stocks and all the medicines
and hosts the administrative office. A second temporary warehouse also exists at the
Tobacco Board site. The Principal Warehouse receives and distributes most of the
consumables. These 3 sites are in the same district but not accessible without a car.
APMG consultants found paraphernalia stocks at both the CSD and the Principal
21
Warehouse. The majority of the stock is located at the Principal Warehouse, the
inventory stored there is very large since the annual usage was procured for every single
item. Stocking areas were designated and referenced. ‘’Global fund’’ and ‘’AIDS unit’’
signs posted on harm reduction stock were noticeable but needed consistency across
other piles. On our visit on a rainy day, the need of reroofing for the inventory to be out
of water. Pictures are in Appendix 4.
13) Current warehousing
APMG consultants think that both the Principal Warehousing and CSD will have problem
to pass WHO standards for warehousing health products! Non compliance with
warehousing standards could potentially lead to substantive product wastage and
distribution of compromised products. Given 1/the current state of health product
warehousing, 2/limited product offering (8 in total : 5 for safer injection, 3 for safer sex),
and 3/ a longer term solution is sought for the MoH’s central warehousing facility but
without any certainty and precise deadline, APMG consultants consider that the best
short-term, reactive, and relevant option is outside the current MoH warehousing
system. This is happening de facto since the National Harm Reduction Coordinating Unit
manages the entire annual stock of alcohol swabs and holds small inventory of the other
paraphernalia – an Intermediary Stock. These alternatives will probably require an
official permission from the MoH. In the following table, we listed the most reasonable
alternatives with high level considerations:
Tableau 7: Alternatives for warehousing
Baseline
Alternative #1
Alternative #2
If granted permission
Warehousing performed by
Principal Warehouse
and Central Supplies
Division
Strength
Weakness
Will not pass WHO
warehousing standards
Privileged space in the current
warehousing
Outside MoH& temporary
Principal Warehouse and Central
Supplies Division
Private sector
Inexpensive
Easy to implement
Long term solution
Efficiency highly probable
Meet WHO standards
End contract when new
Central Warehouse is built.
More expensive
Will not fully meet WHO standard
APMG consultants recommend to contract with a warehousing third party that meets
WHO warehousing standards stated under Guidelines for warehousing health
commodities5. The Council of Pharmacists could be of help to list private reputable
companies in Mauritius.
5
http://www.who.int/rhem/programme_management/guidwarehealcomm/en/
22
Case of Methadone
Top-down flow of Methadone
Methadone is imported via a controlled substance licence delivered by the MoH and the
National Customs Office. Other importations are not authorized. This annual
Methadone shipment is immediately inventoried at the CSD in Plaine Lauzun, stocked
and locked in two segregated and secure rooms. The CSD’s van weekly delivers
pharmacy sections of all dispensing centers with their need for five days, the boxes of
six litres of Methadone are stored in the pharmacies. One day prior to the client’s visit,
pharmacists fill numbered reusable plastic bottles with an automated Methadone
dosing machine. They are then topped with orange-flavoured powdered-Tang combined
with tap water until an approximate line traced on the plastic bottle. In the afternoon,
they will be delivered to the dispensing sites if not on the same location, stored in pilled
racks at room temperature, until consumption on the next morning. After consumption,
empty numbered reusable plastic bottles are washed in a sink with dish soap, dried and
stored to be refilled in the afternoon. One pharmacist, one dispensing technician, and
one washer work at the dispensing sites from 6AM to 9AM. Both pharmacist and
dispensing technician have contact with customer, one reading client’s number and
name, the second picking the file and have it signed, the other picking the
corresponding plastic bottle in the rack and handing it over to the client through the
window. Little attention is given to how the client drinks the bottle. The plastic bottle is
given back, little is said, and the paper log is filed again (see MST section).
Tableau 8: Detailed process of Methadone procurement and delivery in Mauritius
MST Pharmacies
Central Supply
Division
National Customs
Office
Procurement
Office
• 2 /Procurement Office
tenders, receives bids,
and awards contract
Ministry of
Health
• 1/MoH provides
Procurement Office
with specifications
and quantities for
next year.
• 3/ Together with MoH,
Customs Office authorizes
shipment
• 4/ Cutoms Office gives
clearance to shipment
• 5/Receives shipment,
controles quantity &
specifications,
acknowledges receipt
• 6/Stocks pallets in seperate,
secure rooms
• 7/Records stock in IT
system
• 9/Acknowledges requests,
fills and prepares Combined
Indent, Issue Note & Receipt
Voucher + Delivery Note
• 10/ Loads appropriate
quantity in van for weekly
deliveries
• 11/Drives and delivers to
Pharmacy section of
dispensing sites
• 8/ Requests quantity to
Central Supply Division
• 12/Receives methadone,
controls quantity &
specifications,
acknowledges reception
when signing Combined
Indent, Issue Note &
Receipt Voucher + Delivery
Note
• 12/Files paperwork
• 13/ Stockes Methadone in
stocking area
23
Pharmacy at
MST
In the afternoon,
14/ calibrates dispensing machine with first methadone bottle
15/ Picks numbered plastic bottles and fills with automated
dispensing machine reading corresponding client files
16/ Replaces plastic bottles in order in racks
17/ Fills up (until the mark) with Tang orange juice previously mixed
with tap water and previousely stored in fridge and screws cap
18/ Piles racks according to destinations (dispensing center attached
to pharmacy or other trubutary dispensing sites)
MST Dispensing
Center
In the afternoon,
19/ picks up racks and stores them on the
shelves/table around dispensing window
In the morning,
20/ opens at 6am
21/ Identifies client’s name and locates number
22/ Picks corresponding paper file and
corresponding plastic bottle
23/ Gets client signature and hands over
corresponding plastic bottle
24/ Watches from the window client drinking
Methadone
25/ Receives back empty bottle, replaces it in
order in rack
26/ Closes at 9AM/12PM for one site
27/ Checks remaining full bottles /no-show and
follow-up
28/ Puts used plastic bottles and used cap in sink,
washes with ordinary dish soap and cleaning
snake, puts away in boxes/racks to dry
29/ Sorts again in racks for refill in pharmacy
section in the afternoon
• This process takes approx 5 hours per day
This process is illustrated in Annexe 5.
13) Methadone dispensing layout, schedule, and process
APMG consultants visited most of the Methadone dispensing site. The one of
Pamplemousse is located in the surrounding of the hospital, the dispensing site then
takes advantage of the hospital pharmacy section and its hospital staff. APMG
consultants noted that the dispensing site is adjacent to a police station. The staff also
mentioned that police presence is needed to police clients queuing for too long that
become agitated. This symptom indicates that although Methadone dispensing has
been successful, it could be more user-friendly and not require police presence.
Agitation and verbal violence might come from impatience in queuing for too long or in
a crowded area.
To prevent violence, impatience, crowded queuing, APMG consultants recommend the
reconfiguration of pickup layout as a loop-type and the opening for longer hours. These
points are discussed in the MST section.
APMG consultants additionally recommend using more efficiently automated dispensing
machine capabilities. Only when coupled with the loop-type layout and extended hours
(both recommended above), Methadone can be dispensed/dosed on-demand. This
means that when the new client informs the staff with his name and number, the
dispensing technician enters immediately this info into the automated dispensing
machine and doses the Methadone in a disposable paper cap, adds the cold orange
solution and hands it to the client while the pharmacist has the paperwork signed.
Benefits for the client will be : 1/ a cold/more engaging medicine, 2/ a more humane
container new and clean every time, 3/ less variation in taste, etc. Benefits for the staff :
1/ no pre-preparation, 2/ no washing, 3/ no need to sort and resort by dosage, to
arrange in racks (except for tributary dispensing sites). APMG consultants encourage
24
sourcing a cheap paper cup with clear but subtle mark in the inside of the cup with a
food grade ink that will not interact with Methadone/orange juice chemicals, Lab
analysis will be best. APMG consultants recommend that two registered nurses take the
role of the pharmacist and the dispensing technician if that role could be undertaken by
nurse. The washer can be allocated to other tasks (see MST section).
Tableau 9 : Mapping of the simplified recommended process
Previous process
Pharmacy section at Methadone dispensing
Methadone dispensing center
center
(1 pharmacist, 1 dispensing technician, 1
washer)
1/ In the afternoon, calibrates dispensing
machine with first Methadone bottle
2/ Picks numbered plastic bottles and fills with
automated dispensing machine reading
corresponding client files
3/ Replaces plastic bottles in order in racks
4/ Fills up (until the mark) with Tang orange
juice previously mixed with tap water and
stored in fridge and screws cap
5/ Piles racks according to destinations
(dispensing center attached to pharmacy or
other tributary dispensing sites)
6/ In the afternoon, picks up racks
7/ Stores on the shelves/table around
dispensing window
8/ In the morning, opens at 6am
9/ Listens to client’s name and number
10/ Picks corresponding paper file and
corresponding plastic bottle
11/ Gets client signature and hands over
corresponding plastic bottle
12/ Watches from the window client
drinking Methadone
13/ Receives back empty bottle, replaces it
in order in rack
14/ Closes at 9AM/12PM
15/ After 9am/12PM, checks remaining full
bottles/no shows and follow-up
16/ Puts used plastic bottles and used cap
in sink, washes with ordinary dish soap and
cleaning snake, puts away in boxes/racks
to dry
17/ Sorts again in racks for refill in
pharmacy section in the afternoon
Recommended process
Methadone dispensing center
(2 registered nurses)
1/ In the morning, opens at 6am
2/ Calibrates dispensing machine
with first Methadone bottle
3/ Listens to client’s name and
number
4/ Enters info into the software of
the automated dispensing
machine, fills a paper cup, adds
cold orange juice
5/ Gets client signature on
paperwork,
6/ Hands over paper cup
7/ Watches from the window
client drinking Methadone
8/ Closes at 9am/6pm
9/ After closure, checks no-shows
and remaining full bottles, followup
Methadone warehousing
APMG consultants visited the only storing location of Methadone at the CSD in Plaine
Lauzon. The annual stock has been shipped in one time. This means that the CSD holds a
large number of pallets at the beginning of the year. This expensive inventory is locked
in two separate, segregated, and well secure rooms, managed by a pharmacist.
Temperature and brightness are monitored with air conditioning machine and window
25
blinds. To meet WHO warehousing standards, these locations will need some
renovations and cleaning as seen in the pictures in Annexe 9.
14) Methadone warehousing
The details of WHO warehousing standards are listed in the WHO Guidelines for
Warehousing Health Commodities6. APMG consultants observed that the most urgent
requirements to be met are: 1/roofing consolidation, 2/humidity management, and
3/storage space cleaning.
Methadone dispensing and clients’ expectation and satisfaction
APMG consultants visited numerous dispensing sites. Often clients expressed concern
about variation in taste, texture, dosage, and sometimes color of the dispensed liquid
from day to day, fantasying about the efficiency/dosage of the Methadone. Although it
is known to the staff (but not to the clients) that the Methadone brand has changed in
2008 moving from a red concentrated liquid to transparent color, changes in taste,
texture, concentration can come from very diverse causes, let alone misperception from
clients. Methadone being a medicine, all variations 1/ raise a legitimate concern
amongst clients, 2/ encourage mistrust and suspicion, 3/ promote competition for larger
dosage amongst clients, 4/ create the feeling that they are not treated as real patient, 5/
foster fantasy and myth , 6/ give the impression that the Methadone dose will be hold
the client, 7/ and eventually may discourage adherence. This can become a real threat
to the success of the national Methadone program.
Tableau 10 : Root causes of variability in Methadone dosing and taste
Change in taste
Cause
Root cause
Methadone
Different dosage
Orange additive
Different dosage
Different temperature
Bottle
Other taste added
Machine not well calibrated for the day operation
Machine not well adjusted
Machine not well cleaned
Wrong client
Orange juice expired
Orange concentrate not well dosed
Orange concentrate not well mixed
Water not well dosed
Tap water tainted
Different length of fridge storage
Not well rinsed
Not well cleaned
Not well dried
Stored in a tainted rack
Did not reach/passed the mark
Filling
15) Methadone dose dispensing and variability in flavour and dosage
6
http://www.who.int/rhem/programme_management/guidwarehealcomm/en/
26
APMG consultants recommend taking seriously these concerns from clients. 1/ Ondemand Methadone dispensing will exclude impact from the bottle container, its
cleaning, rinsing, drying, stocking and provide a more user-friendly cup. 2/ A clear
procedure should also be written including systemic and meticulous double control by
the other staff member present during the operations. 3/ Clients should be encouraged
to declare changes in taste to staff, so that staff could inquire. 4/ An option will be to
purchase liquid orange additive that will not require water mixing. This will add stability
and drastically limit variation but be bulky to handle. 5/ It will them become possible to
refrigerate the orange juice, this will promote clearly satisfaction amongst clients. 6/ It is
to the knowledge of APMG consultants that the tender for automated dispensing
machines did not include maintenance contract. Since dispensing machines are
precision machine, they should be controlled and readjusted periodically. A wrongly
adjusted machines, dispensing reduced doses could lead a large number of clients not to
be hold by the Methadone, and thus be encouraged to use drug again and potentially
drop-off MST.
Tableau 11 : Root causes and mitigation of variability in Methadone dosing and taste:
Change in taste
Cause
Root cause
Mitigation
Methadone
Different dosage
Double control of calibration by the other staff
Periodical maintenance by service company
Double control of the file by the other staff
Orange
additive
Different dosage
Machine not well calibrated for the day
operation
Machine not well adjusted
Machine not well cleaned
Wrong client
Orange juice expired
Orange concentrate not well dosed
Orange concentrate not well mixed
Water not well dosed
Tap water tainted
Length in fridge
Not well rinsed
Not well cleaned
Not well dried
Stored in a tainted rack
Did not reach/passed the mark
Different
temperature
Bottle
Filling
Other taste added
Double control of expiration date by the other
staff
Double control of orange dosing by the other
staff
Solved by on-demand dosing (recommended
above)
More precise mark on paper cup
Double control of mark by the other staff
Evaluation of diversion risk by process flow step and usage quantification
APMG consultants were asked to evaluate the risk of diversion. During site visits and
stakeholder interviews, dispensing center staff and clients mentioned diversion at the
dose unit and either at the 1L bottle unit. This diversion should constitute a real concern
since it is a symptom that 1/ demand is not fully satisfied, 2/ although Methadone is
publicly free of charge, money is made out of it, 3/ there is a black market of a
controlled drug.
Tableau 12: diversion risk by flow step and appropriate control
27
Methadone flow steps
Entity
Risk
Control
responsible
Importation for the country
MoHQL
Parallel importation
Imported quantity = procured quantity
Imported quantity ≤ quantity dispensed
(+/- stock effect)
Quantity cleared = imported quantity
Clearance at the Customs
Customs
Delivery to the Central
Supplies Division
Central Supplies Division
lorry
Central Supplies Division
Diversion at
reception
Diversion at
reception
Stocking at the Central
Supplies Division
Central Supplies Division
Diversion from stock
Quantity currently inventoried = imported
quantity – previous orders/ from
Dispensing Centers
Delivery to Dispensing
Centers
Central Supplies Division
lorry
Diversion at
distribution
Quantity ordered = quantity received
Stocking at Dispensing
Centers
Dispensing Centers
Diversion from stock
Quantity received = total quantity
dispensed
(+/- local stock effect)
Dispensing to clients
Dispensing Centers
Diversion at
dispensing
Absorption to clients
Dispensing Centers
Diversion at
absorption
Quantity received = total quantity
dispensed
(+/- local stock effect)
Dispensing Centers staff carefully watch
absorption by client
Quantity delivered = imported quantity
Quantity inventoried = imported quantity
16) Diversion risk and monitoring
1/ APMG consultants strongly advise continuing the evaluation above and continue to
perform periodic control using the templates included. A detailed procedure should be
written and agreed upon. Although the last step (absorption of the Methadone by
clients) has no paper trail, and depends on the Dispensing Center staff to watch the
client, the entire up-stream steps have a paper trail. This should be carefully evaluated
and controlled. 2/ The loop-type layout of dispensing center should help to monitor
more efficiently whether the client really absorbs the Methadone. This step should be
clearly indicated in the Procedure. 3/ The up-stream step (quantity dispensed to clients)
is now digitalised via automated dispensing machines and can be extracted on excel and
converted into annual/quarterly data that could be matched with the
imported/procured/inventoried/distributed quantity.
This role should be undertaken by the M+E department of the Harm Reduction Task
Force and performed periodically. 4/ It could be interesting to inquire as undercover
person and ask for availability of a 1L bottle. Should such an inquiry be started, the CSD
should track and log the barcode of every bottle issued to Dispensing Centers in case the
diverted bottle comes from this stock. 5/ More fundamentally, diversion of Methadone
indicates that it exists barriers to access a free medicine that the public health
encourages. This is the issue that should be studied.
28
Quantification of diversion
APMG consultants gathered information about Methadone usage at all steps and
evaluate how they compare. A large number of required information is still pending.
Thus it is difficult to conclude and make recommendations.
Tableau 13 : quantification of Methadone usage by step
Methadone flow steps
Control
Importation for the country
Imported quantity = procured quantity
Imported quantity ≤ quantity
dispensed
(+/- stock effect)
Quantity cleared = imported quantity
Pending info
9,600 bottles 1L
Pending info
Pending info
Nil
Awaiting
8,000 in 3
months
Pending info
Delivery to the Central
Supplies Division
Quantity delivered = imported quantity
Quantity inventoried = imported
quantity
Pending info
4,369 bottles 1L
Pending info
Stocking at the Central
Supplies Division
Quantity currently inventoried =
imported quantity – previous orders/
from Dispensing Centers
Pending info
Pending info
Pending info
Delivery to Dispensing
Centers
Quantity ordered = quantity received
5,013 bottles of
1L
9,202 bottles of
1L
Stocking at Dispensing
Centers
Quantity received = total quantity
dispensed
(+/- local stock effect)
Pending info
Pending info
Pending info
Dispensing to clients
Quantity received = total quantity
dispensed
(+/- local stock effect)
Dispensing Centers staff carefully
watch absorption by client
Pending info
Pending info
Pending info
Not available
Not available
Not available
Clearance at the Customs
Absorption by clients
Calendar year
2009
Calendar year
2010
2011- Q1
17) Effective coordination and monitoring of PSM for paraphernalia and Methadone
APMG consultants feel that although the current PSM of Harm Reduction paraphernalia
has reached a successful stage after a couple of years, the coordination of all the steps
of the PSM that have a tendency to naturally work in silo could be somewhat 1/
coordinated more effectively, 2/ information be shared up-stream and down-stream, 3/
ensured that the full PSM chain is monitored, and 4/ adequate/rapid decision making is
done. To effectively mainstream, scale-up, and increase in quality services, and reach
significant health outcomes, the harm reduction response will need a committee to
coordinate PSM. APMG consultants recommend that the National Harm Reduction Task
Force have a PSM Sub-Committee informed by its own M+E team. The members will
include Procurement Office, CSD, National Harm Reduction coordinator, representatives
of PRs and SRs. Some of the roles and responsibilities of this PSM Sub-Committee should
be the followings:
29
Tableau 14 : roles and responsibilities of the PSM Sub-Committee
Themes
Reported by
Situation of scheduled Procurement
New paraphernalia
Procurement office
Procurement office
Relation with manufacturers
Procurement office
Situation at Central Warehouses
Situation of deliveries
Paraphernalia satisfaction and quality
Central Supplies Division
Paraphernalia Year-To-Date usage
Paraphernalia annual usage
National Harm Reduction coordinator
Representatives of PRs and SRs
National Harm Reduction coordinator
Main recipients : for decision
Non listed stakeholders : for information
National Harm Reduction Coordinator
Central Supplies Division
National Harm Reduction Coordinator
Representative of PRs and SRs
Central Supplies Division
National Harm Reduction Coordinator
National Harm Reduction Coordinator
Representative of PRs and SRs
Procurement office
Central Supplies Division
Procurement office
Central Supplies Division
APMG consultants believe that the harm reduction response will gain in 1/ quality
service, 2/ better information flow between various stakeholders, 3/ reactivity and
resilience, 4/ increased clients’ coverage and satisfaction, and eventually 5/ better
health outcomes.
Data collection of paraphernalia provision & Methadone dispensing
From the field level, bottom-up to PR level
Data collection is one the great assets of the harm reduction response in Mauritius.
Both PRs have established a stable and detailed log mechanism that records every
contact made by SRs (with sometimes date, site, gender, client code, age, number, and
type of syringes and needles, swabs, incertive and receptive condoms, number of
needles and syringes collected, HIV test and new contacts). One PR has it on soft copy
by client contact (lowest granularity), the other PR has approximately the same on hard
copy by PRs visit (first level of consolidation). These sets of data are both consolidated
independently by each PRs for internal purposes. They then feed local and GFATM
reporting requirements and eventually inform CCM’s dashboards for both PRs.
During their stay in Mauritius, APMG consultants were told that an agreement about a
unique identifier between both PRs had been found. This prepares a great evidencebase mechanism for informed, efficient, resilient, and rapid decision making, if this
goldmine is well exploited. Unfortunately, neither these datasets are connected with
Methadone dispensing one which was previously on a paper format (logged in clients’
individual files). It is now extractable from the automated dispensing machine software
and should be easily dump into excel for thorough analysis and reporting.
Again, NEP and Methadone dataset is the foundation to reshape the harm reduction
response and strategy in Mauritius according to following parameters: geography, age
(youth, older), type of drug consumption (heavy, small), genre (male or female) , sex
work (yes or no), contact/usage with MST (no, yes, relapsed), paraphernalia habits, used
paraphernalia returned, etc. AMG consultants strongly suggest taking very seriously this
goldmine and allocate M+E resources to analyse and provide support to evidence-based
decision making.
30
APMG consultants found that data utilisation, indicator analysis should not be
considered only for administrative reporting. For good decision supporting and making,
this M+E task should be mainstreamed and be brought to a higher level to support an
efficient harm reduction response at the national level and intermediary levels, until the
field.
Output at the CCM level
APMG consultants were told that CCM is presented with two dashboards with
conflicting
information,
population/services
overlapping
is
unclear,
nominators/denominators are not comparable, in sum, CCM usage of dashboard is
somewhat limited for decision making and national coordination of harm reduction
response.
PSM Specific Recommendation Summary















Study and document paraphernalia usage via focus group, involve clients in
paraphernalia selection.
Phase-out high/medium dead space syringes from distribution channels (direct and
parallel such as pharmacies), educate stakeholders and clients.
Harmonized, unified products along the stocking steps, ensure limited changes in
product brand and specification in the long run.
Establish efficient reporting mechanism for satisfaction and quality that will inform
the Harm Reduction Task Force, and the Procurement Office for future bid award.
Ensure that current and future paraphernalia meet WHO requirements for
manufacturing, product and labelling standards.
Use GFATM phase II to re-quantify paraphernalia and introduce new paraphernalia.
Reinforce M+E of paraphernalia pairing to inform the National Harm Reduction Task
Force, PRs, and SRs.
Reverse procurement process from ''hospital-type of procurement'' to ''harmreduction-type'' and establish structure, procedure at the Procurement Office level.
Modify tendering process to provide product constancy in the long term, aggregate
tenders for certain type of products, and ensure quality control
Move intermediary stock at NHRU to Principal Warehouse, improve and digitalize
order information and use this dataset for efficient M+E.
Organize direct delivery from the Principal Warehouse to SRs.
Find a solution for paraphernalia products to be stored in a warehouse meeting
WHO standards.
Change layout and hours of service of Methadone dispensing (see MST section).
Dispense on-demand Methadone, phase out reusable plastic bottle (see MST
section).
Make sure Methadone warehousing meet WHO pharmaceutical warehousing
standards.
31




Study Methadone dosage variability, contract periodic maintenance of automated
dispensing machine.
Study, quantify, and monitor periodically Methadone diversion risks.
Effectively coordinate and monitor PSM with digital data, reporting and evaluation
of paraphernalia, Methadone, and other services with unique client identifier,
develop and mainstream data analysis and reporting to National Harm Reduction
Coordinator and future National Harm Reduction Task Force (see M+E section).
Create a unique M+E team of statisticians supporting decision making of National
Harm Reduction Coordinator, future National Harm Reduction Task Force, and
national harm reduction response (see M+E section).
32
APPENDIXES
Appendix 1 : Details of paraphernalia found at all levels
a. At the field level
At the field level, APMG consultants visited several sites where paraphernalia was
distributed and services provided. First, the ground of site was searched for recently
discarded paraphernalia, these products were pictured and then compared with the
ones being distributed, clients were asked to comment in case of inconsistency.
Secondly, clients were asked to give their opinion on paraphernalia currently distributed
by NEP service providers in terms of product satisfaction, quality and availability. At this
level, four different needles (22g and 27g) were found, and two types of syringes (1mL
and 3mL), one alcohol swab and two types of condoms (one receptive/female and one
insertive/male). See the following table listing found paraphernalia and including most
frequent comments from customers (on the left side, a reference has been given to help
the navigation) :
Brand : Neoject
Manufacturer : Neomedic, UK
Specifications : on the blister : grey 27G ½
(written)
Comments : great satisfaction, great
quality, difficult to find now
Brand : Disposable Hypodermic Needle (?)
Manufacturer : Changzhou LIanjie, Imp &
Exp, China
Specifications : on the blister : grey 27G ½
(length not written)
Comments : currently provided by service
providers, correspond to the need, needle
has sometimes holes, needle bends easily.
NEP-22G 1 ¼
Brand : Disposable Hypodermic Needle (?)
Manufacturer : Changzhou LIanjie, China
Specifications : on the blister : black 22G 1
¼ (length not written)
Comments : currently provided by service
providers, correspond to the needs
Brand : Disposable Hypodermic Needle (?)
Manufacturer : ?
Specifications : on the box : grey 27G ¼
(gauge & length not written)
Comments : currently provided by service
providers, correspond to the needs
NEP-27G ¼’
Specification & brand
Clients’ comments
NEP-27G ½
Neoject
Back side with label
Brand & specification
NEP-27G ½ China
Blistered front side
Color of the tip & length of
needle
Ref #
Table 1A : paraphernalia found at the field level
33
Brand : Disposable Syringe (?)
Manufacturer : ?
Specifications : 3mL without needle
Comments : ok, come sometimes with
mold
NEP-1cc paper
blisetered
NEP-3cc paper blisetered
Brand : Insulin syringe (?)
Manufacturer : ?
Specifications : 1mL without needle
Comments : ok, come sometimes with
mold
Brand : Alcohol Prep Pad (?)
Manufacturer : ?
Specifications :
Comments : ok
Brand : ?
Manufacturer : ?
Specifications : double butterfly
Comments : breaks easily, only one size,
only this brand, would prefer the one with
delaying effect
No picture
Brand : Female Condom
Manufacturer : FC Company
b. Parallel channel (pharmacies)
APMG consultants also visited parallel distribution channels such as pharmacies. PWIDs
visit these parallel distribution channels when harm reduction services are not available,
or paraphernalia provided are not satisfactory in specification or in quality and PWIDs
prefer/have the means to pay. Only one pharmacy has been visited, the owner
confirmed that more that one PWID visit the pharmacy per day to purchase
paraphernalia, sometimes paraphernalia is given for free. See the following table listing
found paraphernalia and including most frequent comments from customers :
34
Specification & brand
Clients’ comments
Brand : Disposable Syringe (?)
Manufacturer : ?
Specifications : 3cc/3mL with blue needle
23G 1 ¼ (length not written)
Comments : ok
Brand : Sensecure,
Manufacturer : MorningSide, UK
Specifications : 1cc/1mL ‘’orange cap’’
with needle
Comments : praised as the best one, often
found newly discarded on the ground
Pharma–3cc with
23G 1 ¼ plastic
blistered
Back side with label
Brand & specification
Pharma–1cc orange cap
with needle plastic
blistered
Blistered front side
Color of the tip & length of
needle
Ref :
Table 1B : paraphernalia found at pharmacies
Brand : lubricant Play, condom Performa
Manufacturer : Durex
Specifications : delaying effect
Comments : praised by PWIDs and SWs as
the best one
c. At the intermediary warehouse
APMG consultants visited the intermediary stock located at the Harm Reduction Unit
which is considered as the intermediary warehouse. See the following table listing
paraphernalia found :
Table 1C: paraphernalia found at the intermediary stock
Specification & brand
Clients’ comments
Brand : Disposable Hypodermic Needle (?)
Manufacturer : ??
Specifications : grey 27G ½ (gauge &
length not written)
Comments : currently distributed by
service providers, correspond to the
needs
Brand : Disposable Hypodermic Needle (?)
Manufacturer : Changzhou LIanjie, China
Specifications : on the blister : blue 23G 1
(length not written)
Comments : currently not provided by
service providers in the field
Int WH-27G ½
Back side with label
Brand & specification
Int WH-23G 1
Blistered front side
Color of the tip & length of
needle
35
No picture
Brand : syringe (?)
Manufacturer : ?
Specifications : 3cc/3mL without needle
Comments :
Int WH-1cc syringes
plastic blistered
Int WH-3cc syringes
plastic blistered
Brand : Disposable Syringe (?)
Manufacturer : ??
Specifications : 1cc/1mL without needle
Comments : currently not provided by
service providers in the field
Brand : Alcohol Prep Pad (?)
Manufacturer : Qingdao Medicado Imp &
Exp Co ltd, China
Specifications :
Comments : same as ones distributed by
service providers
Brand : ?
Manufacturer : ?
Specifications : double butterfly
Comments : breaks easily, only one size,
only this brand, would prefer the one with
delaying effect
Same as ones distributed by service
providers
d. At the CSD and Principal Warehouse
APMG consultants then visited both warehouses located at the CSD, and at the
Principal Warehouse for commodities. See the following table listing paraphernalia
found :
Back side with label
Brand & specification
Specification & brand
Clients’ comments
Brand : Disposable Hypodermic
Needle (?)
Manufacturer : Changzhou
LIanjie, China
Specifications : on the box : 22g
with length of 1 1/4
Comments : ?? identical to the
ones provided by service
providers in the field
Same as NEP-22G 1 ¼
Blistered front side
Color of the tip & length of
needle
Ref :
Table 1D : paraphernalia found at the Central Supplies Division and Principal Warehouse
36
Specification & brand
Clients’ comments
Brand : Disposable Hypodermic
Needle (?)
Manufacturer : Changzhou
LIanjie, China
Specifications : on the box : 22g
with length of 1 ¼
Comments : not sure if this
product is distributed in the field
and satisfy PWIDs, not labelled as
used for Harm Reduction services
Brand : Needle
Manufacturer : Tenso, China
Specifications :27g needle of
length of ½
Comments : not sure if this
product is distributed in the field
and satisfy PWIDs, not labelled as
used for Harm Reduction services
Ctr WH–1cc insulin syringe orange cap
Ctr WH–1cc insulin
syringe 26G ½
Ref :
Back side with label
Brand & specification
Brand : Disposable Syringe (?)
Manufacturer : ??
Specifications : 1cc/1mL without
needle
Comments : labelled as used for
Harm Reduction services
Brand : Disposable Syringe (?)
Manufacturer : ??
Specifications : 3cc/3mL without
needle
Comments : labelled as used for
Harm Reduction services
Ctr WH–1cc insulin
syringe 26G ½
Blistered front side
Color of the tip & length of
needle
Same as NEP-22G 1 ¼
Brand : Disposable Insulin Syringe
(?)
Manufacturer : Tenso, China
Specifications : 1cc/1mL with 26g
needle of length of ½
Comments : not sure if satisfy
PWIDs
Same as Int WH-27G ½
Brand : Insulin Syringe (?)
Manufacturer : Changzhou
Shuangma Medical devices,
China
Specifications : 1cc/1mL
‘’orange’’ with 29G needle
Comments : currently not
provided by service providers on
the field, correspond to the
needs
37
e. At the level of Procurement department
At the level of Procurement department, we found the following results of the last and
current tenders :
Table 1E: paraphernalia at the past/current bid level, Procurement Office
Needles
Tendered in 2010
for calendar year 2011
for MofH
with GFATM budget
Disposable, sterile, individually
packed, insulin needles of 22g
length
300,000 units, brand ? &
manufacturer ?:
Price : Rs 0.28
Hypodermic needle disposable,
22g 1¼ , luer lock, sterile,
individually packed
150,000 units, brand ? &
manufacturer ?::
Product B0326301,
tender : DO 5/2010,
Tendered in 2011
for calendar year 2012
in process of being re-tendered
Hypodermic needle disposable,
22g 1 ½’’, luer lock, sterile,
individually packed
624,000 units
Disposable, sterile, individually
packed, needle of 23g 1’’, color
blue, single use, non toxic and
pyrogen free
624,000 units, no brand ?,
manufacturer : Changzhou Lianjie
Imp & Exp Co ltd, China
Disposable, sterile, individually
packed, insulin needles of 27g
length ?
300,000 units, brand ? &
manufacturer ?:
Price = Rs 0.4
Syringes
Disposable, sterile, individually
packed, insulin syringes without
needle, 1mL
300,000 units, brand ? &
manufacturer ?:
Price = Rs 2.1
Disposable, sterile, individually
packed, syringes without needle,
3mL
300,000 units, brand ? &
manufacturer ?:
Price = Rs 0.61
Swabs
Alcohol swab, 2.75 x 3.25 cm
400,000 units, brand ? &
manufacturer ?:
Hypodermic needle disposable,
27g ½, luer lock, sterile,
individually packed
200,000 units, brand ? &
manufacturer ?:
Product : B0326304/BO0326312
Tender : DO 5/2010
Disposable, sterile, individually
packed, insulin syringes without
needle, 1mL
150,000 units, brand ? &
manufacturer ?:
Product B0300709 ??
tender : DO 54 Jul 09-Dec 09
Disposable, sterile, individually
packed, syringes without needle,
3mL
400,000 units, brand ? &
manufacturer ?:
Product B0301300 ???
tender : DO 54 Jul 09-Dec 09
Disposable, sterile, individually
packed, needle of 27g ½
624,000 units, brand ? &
manufacturer ?:
Disposable, sterile, individually
packed, insulin syringes without
needle, 1mL
624,000 units, brand ? &
manufacturer ?:
Disposable, sterile, individually
packed, syringes without needle,
3mL
624,000 units, brand ? &
manufacturer ?:
Alcohol swabs/pads, saturated
pad with 70% Isopropyl Alcohol for
disinfection use, packed in
batched of 10 units
10,000 units of 10, brand ? &
manufacturer ?:
38
Appendix 2 : Dead-space syringes – communication with scientist W. Zule
Subject: RE: Syringe from Mauritius
Date: Thu, 19 May 2011 16:25:49 -0400
From: zule@rti.org
To: feytiat@hotmail.com
Hi Pierre,
Syringes that have a plunger, which extends into the tip of the syringes (i.e. the top syringe in your
picture) eliminate the dead space in the tip of the syringe. However, there is still dead space in the plastic
hub of the needle. We measured the dead space in a couple different needle and syringe combinations.
Dead space in high dead space syringes ranged from about 55 micro-liters to 150 micro-liters and
averaged about 90 micro-liters. Dead space in syringes like the ones in the pictures you sent ranged from
38 micro-liters to 48 micro-liters. Dead space in low dead space syringes ranged from 1 micro-liter to 8
micro-liters and it averaged around 2 micro-liters. So the syringes with the extended tip are probably
slighter better than regular high dead space syringes, but they still retain a lot more blood than low dead
space syringes retain. Although I haven’t performed additional experiments, I would guess that after
injection and rinsing those syringes would probably retain 300 or 400 times more blood than a low dead
space syringe would retain. However, they probably less than half as much blood as a high dead space
syringe would retain.
I hope that helps. Let me know if you have other questions.
Best,
Bill
-------------------------------------------------------------------------------From: feytiat@hotmail.com
To: zule@rti.org
Subject: Syringe from Mauritius
Date: Thu, 19 May 2011 20:09:14 +0000
Hello Bill,
I just came back from an assignment in Mauritius and shared the information about your work around
high dead space syringes.
I took a picture of a new type of syringe and wanted to pick your brain whether you consider it as a low
dead space, thus safer. See the picture enclosed, top syringe.
To me, this is a medium dead space, thus still needed to be phased out.
Thank you and best regards
Pierre de Vasson, MSc, MBA
Vasson Consulting - Support for AIDS and Health Programs with APMG
828 West 7th avenue,
Vancouver, BC V5Z1C1, Canada
Cell phone : +1 604 561 9333
Pacific Standard Time
E-mail : feytiat@hotmail.com, skype : feytiat
39
Appendix 3 : Some of the paraphernalia available with some comments
from international experience
Paraphernalia
Cooker
Strength
Sterile blistered or not
Come naked or with dry
gauze or/and filter
Aluminum – almost one
time use
Color coded for no sharing
Sterile blistered or not
Come naked
Aluminum – almost one
time use
Weakness
Expensive
Not very stable
Very
expensive
Very stable
Made of steel – not single
use
VitC or Citric
http://www.daniels.co.uk/
VitC or Citric
www.t-injecta.com
VitC or Citric
http://www.exchangesupplies.org/
SteriCitrik
www.apothicom.org
Low
Sterile blistered
Low
Sterile blistered
Dosage might be too
much: 100mg for Citric
sachet, 300mg for VitC
sachet
Low
Sterile blistered
Low
Sterile blistered
SteriFilt, membrane on plastic top
www.apothicom.org
Cotton pellet
www.apothicom.org
Very
expensive
Low
Sterile blistered
Very
expensive
Sterile blistered
Best product, filter at 0,45
micron
Tourniquet
Wheel filter (diameter 25 or
15mm)
http://phenomenex.com
As a pharmaceutical product, need
a registration in Mauritius
Must be single dose, between 2
/3mL for 1/3 cc syringes
Available in hospitals
Tattooing needle
Regular brand
Low
Acidifier
Filter
Vial of Water for
Injection
Brand and contacts
SteriCup, holds 2,5mL
www.apothicom.org
Price
Medium
DaniCup, holds 2,5mL
http://www.daniels.co.uk/
Medium
Exchange
http://www.harmreduction.co.uk
Inexpensive
Not color coded
Mention of filtering at 0,45
micron is disputed
Not sterile
Not a best practice, if
injected could lead to
cotton fever and abscess
Very
expensive
Low
Should be latex free
40
Appendix 4 : Pictures of the Principal Warehouse
View of the Princial Warehouse
Harm reduction stock
Palettes of 1cc boxes and stocking area reference State of the floor on a rainy day
41
Traces of leaks from the roof on the boxes
Box piling
42
Appendix 5 : Pictures illustrating steps in the Methadone dispensing
process
43
Appendix 9: Pictures illustrating Methadone warehousing
44
Appendix 10: List of tables
Tableau 1 : Summary of the different existing products in the current supply chain and
reference ............................................................................................................................. 5
Tableau 2: Quantification and costing of new paraphernalia for GFATM phase II .......... 11
Tableau 3 : Alternative processes for paraphernalia selection ........................................ 14
Tableau 4 : Alternative processes for paraphernalia tendering ....................................... 16
Tableau 5 : Flow of paperwork, information, and product from service delivery points to
Central warehouses .......................................................................................................... 18
Tableau 6 : mapping of the new direct delivery process from the Principal Warehouse to
service delivery points. ..................................................................................................... 21
Tableau 7: Alternatives for warehousing .......................................................................... 22
Tableau 8: Detailed process of Methadone procurement and delivery in Mauritius ...... 23
Tableau 9 : Mapping of the simplified recommended process ........................................ 25
Tableau 10 : Root causes of variability in Methadone dosing and taste .......................... 26
Tableau 11 : Root causes and mitigation of variability in Methadone dosing and taste: 27
Tableau 12: diversion risk by flow step and appropriate control ..................................... 27
Tableau 13 : quantification of Methadone usage by step ................................................ 29
Tableau 14 : roles and responsibilities of the PSM Sub-Committee ................................ 30
Appendix 4 : Details of paraphernalia found at all levels
a. At the field level
At the field level, APMG consultants visited several sites where paraphernalia was
distributed and services provided. First, the ground of site was searched for recently
discarded paraphernalia, these products were pictured and then compared with the
ones being distributed, clients were asked to comment in case of inconsistency.
Secondly, clients were asked to give their opinion on paraphernalia currently distributed
by NEP service providers in terms of product satisfaction, quality and availability. At this
level, 4 different needles (22g and 27g) were found, and 2 types of syringes (1mL and
3mL), 1 alcohol swab and 2 types of condoms (1 receptive/female and 1 insertive/male).
See the following table listing found paraphernalia and including most frequent
comments from customers (on the left side, a reference has been given to help the
navigation) :
Table 1A : paraphernalia found at the field level
45
Brand : Neoject
Manufacturer :Neomedic, UK
Specifications : on the blister : grey 27G
½’’ (written)
Comments : great satisfaction, great
quality, difficult to find now
Brand : Disposable Hypodermic Needle (?)
Manufacturer : Changzhou LIanjie, Imp
&Exp, China
Specifications : on the blister : grey 27G ½
(length not written)
Comments : currently provided by service
providers, correspond to the need, needle
has sometimes holes, needle bends easily.
Brand : Insulin syringe (?)
Manufacturer : ?
Specifications : 1mL without needle
Comments : ok, come sometimes with
mold
Brand : Disposable Syringe (?)
Manufacturer : ?
Specifications : 3mL without needle
Comments : ok, come sometimes with
mold
Ref #
NEP-22G 1 ¼
NEP-27G ¼’
NEP-27G
½Neoject
Brand : Disposable Hypodermic Needle (?)
Manufacturer : Changzhou LIanjie, China
Specifications : on the blister : black 22G 1
¼ (length not written)
Comments : currently provided by service
providers, correspond to the needs
Brand : Disposable Hypodermic Needle (?)
Manufacturer : ?
Specifications : on the box : grey 27G ¼
(gauge & length not written)
Comments : currently provided by service
providers, correspond to the needs
NEP-27G ½ China
Specification & brand
Clients’ comments
NEP-1cc paper blisetered
Back side with label
Brand & specification
NEP-3cc paper blisetered
Blistered front side
Color of the tip & length of
needle
46
Brand : Alcohol Prep Pad (?)
Manufacturer : ?
Specifications :
Comments : ok
Brand : ?
Manufacturer : ?
Specifications : double butterfly
Comments : breaks easily, only one size,
only this brand, would prefer the one with
delaying effect
No picture
Brand : Female Condom
Manufacturer :FC Company
b. Parallel channel (pharmacies)
APMG consultants also visited parallel distribution channels such as pharmacies. PWIDs
visit these parallel distribution channels when harm reduction services are not available,
or paraphernalia provided are not satisfactory in specification or in quality and PWIDs
prefer/have the means to pay. Only one pharmacy has been visited, the owner
confirmed that more that one PWID visit the pharmacy per day to purchase
paraphernalia, sometimes paraphernalia is given for free. See the following table listing
found paraphernalia and including most frequent comments from customers :
Table 1B : paraphernalia found at pharmacies
Ref :
Specification & brand
Clients’ comments
Brand : Disposable Syringe (?)
Manufacturer : ?
Specifications : 3cc/3mL with blue needle
23G 1 ¼ (length not written)
Comments : ok
Brand : Sensecure,
Manufacturer : MorningSide, UK
Specifications : 1cc/1mL ‘’orange cap’’
with needle
Comments : praised as the best one, often
found newly discarded on the ground
Pharma–3cc with
23G 1 ¼ plastic
blistered
Back side with label
Brand & specification
Pharma–1cc orange cap
with needle plastic
blistered
Blistered front side
Color of the tip & length of
needle
47
Brand : lubricant Play, condom Performa
Manufacturer : Durex
Specifications : delaying effect
Comments : praised by PWIDs and SWs as
the best one
c. At the intermediary warehouse
APMG consultants visited the intermediary stock located at the Harm Reduction Unit
which is considered as the intermediary warehouse. See the following table listing
paraphernalia found :
No picture
Brand : syringe (?)
Manufacturer :?
Specifications : 3cc/3mL without
needle
Comments :
Int WH-23G 1
Specification & brand
Clients’ comments
Brand : Disposable Hypodermic
Needle (?)
Manufacturer : ??
Specifications :grey 27G ½ (gauge &
length not written)
Comments : currently distributed by
service providers, correspond to the
needs
Brand : Disposable Hypodermic
Needle (?)
Manufacturer : Changzhou LIanjie,
China
Specifications : on the blister : blue
23G 1 (length not written)
Comments : currently not provided by
service providers in the field
Brand : Disposable Syringe (?)
Manufacturer : ??
Specifications : 1cc/1mL without
needle
Comments : currently not provided by
service providers in the field
Int WH-1cc syringes plastic
blistered
Back side with label
Brand & specification
Int WH-3cc syringes plastic
blistered
Blistered front side
Color of the tip & length of needle
Int WH-27G ½
Table 1C: paraphernalia found at the intermediary stock
48
Brand :Alcohol Prep Pad (?)
Manufacturer : Qingdao Medicado
Imp &Exp Co ltd, China
Specifications :
Comments : same as ones distributed
by service providers
Brand : ?
Manufacturer : ?
Specifications : double butterfly
Comments : breaks easily, only one
size, only this brand, would prefer the
one with delaying effect
Same as ones distributed by service
providers
d. At the Central Supplies Division and Principal Warehouse
APMG consultants then visited both warehouses located at the Central Supplies
Division, and at the Principal Warehouse for commodities. See the following table listing
paraphernalia found :
Table 1D : paraphernalia found at the Central Supplies Division and Principal Warehouse
Ref :
Specification & brand
Clients’ comments
Brand : Disposable Hypodermic
Needle (?)
Manufacturer : Changzhou
LIanjie, China
Specifications : on the box : 22g
with length of 1 1/4
Comments : ?? identical to the
ones provided by service
providers in the field
Brand : Insulin Syringe (?)
Manufacturer : Changzhou
Shuangma Medical devices,
China
Specifications : 1cc/1mL
‘’orange’’ with 29G needle
Comments : currently not
provided by service providers on
the field, correspond to the
needs
Same as NEP-22G 1 ¼
Back side with label
Brand & specification
Ctr WH–1cc insulinsyringe orange cap
Blistered front side
Color of the tip & length of
needle
49
Specification & brand
Clients’ comments
Brand : Disposable Hypodermic
Needle (?)
Manufacturer : Changzhou
LIanjie, China
Specifications : on the box : 22g
with length of 1 ¼
Comments : not sure if this
product is distributed in the field
and satisfy PWIDs, not labelled as
used for Harm Reduction services
Brand : Needle
Manufacturer : Tenso, China
Specifications :27g needle of
length of ½
Comments : not sure if this
product is distributed in the field
and satisfy PWIDs, not labelled as
used for Harm Reduction services
Ctr WH–1cc
insulinsyringe 26G ½
Ref :
Back side with label
Brand & specification
Same as NEP-22G 1 ¼
Blistered front side
Color of the tip & length of
needle
Same as Int WH-27G ½
Brand : Disposable Insulin Syringe
(?)
Manufacturer : Tenso, China
Specifications : 1cc/1mL with 26g
needle of length of ½
Comments : not sure if satisfy
PWIDs
Brand : Disposable Syringe (?)
Manufacturer : ??
Specifications : 3cc/3mL without
needle
Comments : labelled as used for
Harm Reduction services
Ctr WH–1cc
insulinsyringe 26G ½
Brand : Disposable Syringe (?)
Manufacturer : ??
Specifications : 1cc/1mL without
needle
Comments : labelled as used for
Harm Reduction services
e. At the level of Procurement department
At the level of Procurement department, we found the following results of the last and
current tenders :
Table 1E: paraphernalia at the past/current bid level, Procurement Office
for MofH
Tendered in 2010
for calendar year 2011
with GFATM budget
Tendered in 2011
for calendar year 2012
in process of being re-tendered
50
Needles
Disposable, sterile, individually
packed, insulin needles of 22g
length
300,000 units, brand &
manufacturer:
Price : Rs 0.28
Hypodermic needle disposable,
22g 1¼, luer lock, sterile,
individually packed
150,000 units,brand&
manufacturer::
Product B0326301,
tender : DO 5/2010,
Hypodermic needle disposable,
22g 1 ½’’, luer lock, sterile,
individually packed
624,000 units
Disposable, sterile, individually
packed, needle of 23g 1’’, color
blue, single use, non toxic and
pyrogen free
624,000 units, no brand,
manufacturer : Changzhou Lianjie
Imp &Exp Co ltd, China
Disposable, sterile, individually
packed, insulin needles of 27g
length
300,000 units,brand&
manufacturer::
Price = Rs 0.4
Syringes
Disposable, sterile, individually
packed, insulin syringes without
needle, 1mL
300,000 units,brand&
manufacturer:
Price = Rs 2.1
Disposable, sterile, individually
packed, syringes without needle,
3mL
300,000 units,brand&
manufacturer:
Price = Rs 0.61
Swabs
Hypodermic needle disposable,
27g ½, luer lock, sterile,
individually packed
200,000 units,brand&
manufacturer::
Product : B0326304/BO0326312
Tender : DO 5/2010
Disposable, sterile, individually
packed, insulin syringes without
needle, 1mL
150,000 units,brand&
manufacturer::
Product B0300709 ??
tender : DO 54 Jul 09-Dec 09
Disposable, sterile, individually
packed, syringes without needle,
3mL
400,000 units,brand&
manufacturer::
Product B0301300 ???
tender : DO 54 Jul 09-Dec 09
Alcohol swab, 2.75 x 3.25 cm
400,000 units,brand&
manufacturer::
Disposable, sterile, individually
packed, needle of 27g ½
624,000 units,brand : &
manufacturer:
Disposable, sterile, individually
packed, insulin syringes without
needle, 1mL
624,000 units,brand&
manufacturer::
Disposable, sterile, individually
packed, syringes without needle,
3mL
624,000 units,brand&
manufacturer::
Alcohol swabs/pads, saturated
pad with 70% Isopropyl Alcohol for
disinfection use, packed in
batched of 10 units
10,000 units of 10,brand &
manufacturer::
Appendix 5: Pictures of the Principal Warehouse
View of the Princial Warehouse
Harm reduction stock
51
Palettes of 1cc boxes and stocking area reference State of the floor on a rainy day
Traces of leaks from the roof on the boxes
Box piling
52
53
Appendix 6 : Dead-space syringes – communication with Investigator W.
Zule
Subject: RE: Syringe from Mauritius
Date: Thu, 19 May 2011 16:25:49 -0400
From: zule@rti.org
To: feytiat@hotmail.com
Hi Pierre,
Syringes that have a plunger, which extends into the tip of the syringes (i.e. the top syringe in your
picture) eliminate the dead space in the tip of the syringe.However, there is still dead space in the plastic
hub of the needle.We measured the dead space in a couple different needle and syringe
combinations.Dead space in high dead space syringes ranged from about 55 micro-liters to 150 microliters and averaged about 90 micro-liters.Dead space in syringes like the ones in the pictures you sent
ranged from 38 micro-liters to 48 micro-liters.Dead space in low dead space syringes ranged from 1 microliter to 8 micro-liters and it averaged around 2 micro-liters.So the syringes with the extended tip are
probably slighter better than regular high dead space syringes, but they still retain a lot more blood than
low dead space syringes retain.Although I haven’t performed additional experiments, I would guess that
after injection and rinsing those syringes would probably retain 300 or 400 times more blood than a low
dead space syringe would retain.However, they probably less than half as much blood as a high dead
space syringe would retain.
I hope that helps.Let me know if you have other questions.
Best,
Bill
-------------------------------------------------------------------------------From: feytiat@hotmail.com
To: zule@rti.org
Subject: Syringe from Mauritius
Date: Thu, 19 May 2011 20:09:14 +0000
Hello Bill,
I just came back from an assignment in Mauritius and shared the information about your work around
high dead space syringes.
I took a picture of a new type of syringe and wanted to pick your brain whether you consider it as a low
dead space, thus safer. See the picture enclosed, top syringe.
To me, this is a medium dead space, thus still needed to be phased out.
Thank you and best regards
Pierre de Vasson, MSc, MBA
Vasson Consulting - Support for AIDS and Health Programs with APMG
828 West 7th avenue,
Vancouver, BC V5Z1C1, Canada
Cell phone : +1 604 561 9333
Pacific Standard Time
54
E-mail : feytiat@hotmail.com, skype : feytiat
55
Appendix 7 :Some of the paraphernalia available with some comments
from international experience
Paraphernalia Brand and contacts
Cooker
SteriCup, holds 2,5mL
www.apothicom.org
Acidifier
Filter
Price
Medium
DaniCup, holds 2,5mL
http://www.daniels.co.uk/
Medium
Exchange
http://www.harmreduction.co.uk
Very
expensive
VitC or Citric
http://www.daniels.co.uk/
VitC or Citric
www.t-injecta.com
VitC or Citric
http://www.exchangesupplies.org/
SteriCitrik
www.apothicom.org
SteriFilt, membrane on plastic top
www.apothicom.org
Low
Cotton pellet
www.apothicom.org
Low
Strength
Sterile
blistered or
not
Come naked
or with dry
gauze or/and
filter
Aluminum –
almost one
time use
Color coded
for no sharing
Sterile
blistered or
not
Come naked
Aluminum –
almost one
time use
Very stable
Sterile
blistered
Low
Sterile
blistered
Low
Sterile
blistered
Low
Sterile
blistered
Very
Sterile
expensive blistered
Inexpensive
Weakness
Expensive
Not very
stable
Not color
coded
Made of
steel – not
single use
Dosage
might be too
much:
100mg for
Citric sachet,
300mg for
VitC sachet
Mention of
filtering at
0,45 micron
is disputed
Not sterile
Not a best
56
practice, if
injected
could lead to
cotton fever
and abscess
Wheel filter (diameter 25 or
15mm)
http://phenomenex.com
Vial of Water
for Injection
Tourniquet
Tattooing
needle
As a pharmaceutical product, need
a registration in Mauritius
Must be single dose, between 2
/3mL for 1/3 cc syringes
Available in hospitals
Regular brand
Very
Sterile
expensive blistered
Best product,
filter at 0,45
micron
Very
expensive
Low
Should be
latex free
Low
57
Appendix 8 :Pictures illustrating steps in the Methadone dispensing process
58
Appendix 9: pictures illustrating Methadone warehousing
59
60