OST in Public Health SettingExperience of Punjab

Dr. Rana Ranbir Singh

Nodal Officer

OST Center, Tarn Taran

OST in Public Health Setting: Model

Linkage between the government health care facility (providing OST) and the nearest NGO facility (providing IDU TI services)

HOSPITAL with OST

NGO TI

OST in Public Health Setting: Model

OST in Public Health Setting: Model

HOSPITAL with OST

NGO TI

Public Health Setting : Strengths

Large number of Government health care institutions

(psychiatry department in medical colleges &MOH funded DACs)

Availability of referral services –STI, ICTC, ART, DOTS

Ensuring sustainability

NGO TI : Strengths

• Have excellent outreach program

• Are able to

– Reach out to IDUs

– Get information about them

– Make a rapport

– Provide services to them

– Refer them to various services

OST in Public Health Setting - Structure

NACO

Capacity Building Support

OST Sites IDU TI

SACS

DFID/TAST

TSU

STRC

OST in Public Health Setting: Model

• Public Health Facilities provide

Space for establishing the centre

Administrative support for running the center

Nodal Officer – for day-to-day functioning

Medications – available in hospital supply

Support staff - sweeper

Back-up staff – in absence of regular staff

OST in Public Health Setting: Model

OST Centers Infrastructure

Adequate space for all the services Equipment for medical examination and drug dispensing IEC material

Staff 1 Nodal Officer (Head of Psychiatry/Medicine Department) 1 doctor, 2 nurses, 1 counselor, 1 ORW, 1 data manager

Responsibilities Assessment, diagnosis, Treatment initiation and maintenance Dispensing of medication Referral for other services e.g. investigations, consultation, etc. Linking HIV+ve clients to ART, STI & RNTCP Counseling for clients and family members

• IDU TIs

– Referral Linkages• Each OST centre linked with a nearby IDU TI

• Clients referred from TI to OST centre

• OST ORW to remain in regular contact with TI staff

– Responsibilities• Referral of prospective clients

• Outreach for clients who drop-out

• Involving family members/spouses into treatment process

• Supporting clients during maintenance treatment

• IEC activities

OST in Public Health Setting: Model

Selection Criteria:

IDU estimates

HIV prevalence among IDUs

Well equipped district hospital and IDU TI

Location of hospital in vicinity of IDU hot spots

Districts selected for the initiation of OST scheme

Districts IDU Size (HIVPrevalence)

Government Hospitals TI – NGOs

Amritsar 1500 (31.88%)* Guru Nanak Dev MedicalCollege and Hospital

Swami VivekanandMedical Mission

Tarn Taran 1000 (19.85%)* Civil Hospital Swami VivekanandMedical Mission 2

Ludhiana 1500 (19.54)* Civil Hospital Dr. DN Kotnis Health &Education Centre

Jalandhar 1500 (8.61%)* Civil Hospital Aide-et-Action

Gurdaspur 1400 (17.92)* Civil Hospital JK SPYM

*ICTC positivity data 2009-10

Dist. where sites are selected contribute about 50% of estimated IDUs in the state

District selected:

OST Scheme: Implementation Process

1. Stakeholder Consultations

2. Feasibility study

3. Site preparation

4. Staff recruitment and

training

5. BCC & Refresher training

Roll out of OST Scheme

6. Quality Assurance/Mentoring

visits

• Identification and selection of public health facility for OSTimplementation in consultation with NACO

• Release of fund to the OST centre for program implementation

• Regular mentoring and facilitation for the OST centre setup

• Facilitation of staff recruitment and training

• Review of the OST program and feedback to the centers forprogram strengthening as per the need

• Reporting on program performance to NACO

• Timely supply of OST medicine to the OST centre

Role of SACS/TSU

Supply Chain Mechanism

Flipbook : (Sukhpal Ki Kahani) is appreciated by the clients as theyhave been able to relate and identify themselves with thecharacter portrayed in the flipbook.”

Use of flipbook by Regular Clients in the waiting area of OSTcenters to motivate other clients

Pocket diary : used by all the staff. Reported to be informativefor the clients as well as staff of OST & TI NGOs. All importantissues covered.

Passport : Serves as an identity card & gives sense of belongingness

Used as a general health card

Serves for storing immediate/important contact details/ph nos.

Calendar ticked by nurse at the center is useful in getting information whether individual client is visiting the center regularly or not.

Communication Material

Communication Material - Flipbook

OST Pocket Diary

OST Passport – Information Kit

• Quality Assurance visit on Quarterly basis by a team ofSACS, TSU and OST Expert

• Monthly meeting of OST and TI staff to review theprogram performance and chalk out the action plan tostrengthen the program

• Regular reporting in prescribed format by OST centreto SACS

• Monthly submission of CMIS report by SACS to NACO

Monitoring and Reporting

Current Status of Services

131146

159 160176

200

234

0

50

100

150

200

250

January February March April May June July

Total Clients accessing OST services across 5 sites

Current Status of Services

0

10

20

30

40

50

60

70

80

January February March April May June July

Amritsar

Batala

Jalandhar

Ludhiana

Tarn Taran

LESSONS LEARNT

Advantages of OST in Public Health Setting

Sustainability

Availability of other health services/general medicines for OST clients

Appropriate linkages and referrals within hospital and outside

Availability of Psychiatrist/ Medical Officer and optimal

dosage setting

Availability of back-up staff

Emergency services for overdose management

Means of decreasing stigma associated with IDU & HIV

Program related

- Level of Rapport of TI with OST center

- Handholding support by various stakeholders through Advocacy meetings

- Addressing capacity building/training needs

- Communication material such as Passport , Pocket Diary, flipbook

- QA and Mentoring visits to the OST centers

- Recreational activities, provision of food and refreshment etc.

Common Factors

- Non-stigmatic, non-discriminative and respectful

environment at the center

- Flexibility in routine practices at the center

- Involvement of all TI ORWs & TI counselor for follow up

- Recognition of improved health status, Social Status, and mental stability by client motivates adherence

- Involvement of family & social acceptance leads to increased retention

- Provision of Occupational rehabilitation

Recruited: 171 , Retained: 81,

Facilitating Factors

- Ability to establish phone contact with maximum clients

- Involvement of family members of IDU clients

- Excellent coordination between TI and OST center

- Strict schedule for visiting the field once a week by OST

counselor

- Field visits by TI counselor/ORWs for OST followup

- Efforts to establish contact with clients who miss their dose on

the same day over phone & by field visits

OST Center Tarn Taran

- Clients celebrate different festivals/events which develop a feeling of ownership & recognizing the center as another DIC

- Optimal dosage setting (Dose range 4-18 mg, Average Dose 8.9mg)

- Longer dispensing hours suiting client needs

- Advocacy workshops with medical/paramedical/police personnel/electronic & print media/chemist association etc.

- Awareness workshop on Hep B & C

- Timely addressing misconceptions & concerns of community members

- Food/refreshment facility at OST center

- Support at the time of emergency through phone contact with ORW/NO, MO & counselor

- Efforts are made to initiate occupational rehabilitation for OST clients

OST Center Tarn Taran Cont…

• Topic: Sensitization workshop with police personnel & Health Dept. of the hospital

• Venue: OST center

• Participants: SSP, SP’s, DSP’s, SHO’s, ASI's, Civil Surgeon, Asst. Civil Surgeon, DHO, DFPO,DIO

INPUTS

• Continuous liaisoningwith police department, health department for a suitable date.• Workshop organized in the OST center to make the OST center visible to the police personnel

PROCESS • Increased levels of knowledge of police personnel / service providers on IDU issues on vulnerability and Importance of provision of public health services / OST

• A monthly donation of Rs. 15,000/- was committed by police personnel to the OST center, to provide refreshments for OST clients.

OUTCOME

OBJECTIVE : To sensitize the Police Personnel & Health Providers on IDUs

issues & to create greater awareness about the OST Center

Advocacy Meetings

•Topic: Capacity Enhancement Initiative on Hep B & C

•Date: March 31st, 2011 on Hep B & C & to address concerns raised by the clients.

•Venue: OST center

•Participants: IDUs enrolled for the OST, their family members, OST center staff & TI staff like PM, Counselor & ORWs

INPUTS

•A presentation in Local language for better comprehension•Prior information given to OST clients about the Workshop •Workshop organized in hospital premises as OST center was more spacious than DIC•Primary focus was to spread awareness among the clients enrolled on OST and their family members•Make the OST center a comfortable environment for them

PROCESS

• -Awareness spread regarding Hep C and Hep B among participants

• Issues regarding death of clients discussed

•Awareness spread regarding OST among family members of clients

OUTCOME

OBJECTIVE : To Create Awareness in Clients and their families and to

Enhance Capacity of the Service Providers on Hep B & C

Capacity Building

Client’s perspective

• Clients who are on OST report– significant reduction / cessation of illicit opioid use

– Satisfaction with the services, dosages, involvement in dosingdecisions and overall attitude and behaviour of the staff

• Welcome changeAttitude of hospital staff towards IDU

Attitude of IDU towards public health settings

• Expressed needs– Refreshments

– Opportunities for occupational rehabilitation

Thank you