LESSONS FROM THE FIELD
Human resource development and capacity-building during China's rapid scale-up of methadone maintenance treatment services
Développement des ressources humaines et renforcement des compétences lors du développement rapide et à grande échelle des services de traitement de maintien à la méthadone en Chine
Desarrollo de los recursos humanos y creación de capacidad en relación con el rápido aumento en China de los servicios de tratamiento de mantenimiento con metadona
Jianhua LiI; Changhe WangII; Jennifer M McGooganII; Keming RouII; Marc BulterysIII; Zunyou WuII, *
INational Methadone Maintenance Treatment Training Centre, Yunnan Institute of Drug Abuse, Kunming, China
IINational Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing, 102206, China
IIIThe Global AIDS Programme in China, US Centers for Disease Control and Prevention, Beijing, China
ABSTRACT
PROBLEM: China's National Methadone Maintenance Treatment Programme (MMT) has expanded from eight clinics serving approximately 1000 clients to 738 clinics that have served more than 340 000 clients cumulatively in only 8 years. This has created an enormous demand for trained providers.
APPROACH: Human resource development and capacity building efforts have been conducted in China's National MMT Programme to create a supply of providers trained in administering MMT for opioid dependence.
LOCAL SETTING: From 2004 to 2007, China's National MMT Programme faced several problems: inappropriately low methadone doses, poor compliance, high concurrent drug use and high drop-out rates among clients, and little experience, little training and high turnover rates among providers.
RELEVANT CHANGES: Training programmes for individual providers and their trainers were redeveloped and expanded in 2008. Although programme performance metrics show an increase in patients' annual mean duration in treatment (93 days in 2004 versus 238 days in 2011), the increase in their mean daily methadone dose (from 47.2 mg in 2004 to 58.6 mg in 2011) is modest.
LESSONS LEARNT: Some of the problems that can arise during the development, launch and scale-up of a major national public health effort, such as China's National MMT Programme, cannot be foreseen. Key to the programme's success so far have been the strong commitment on the part of China's government and the optimism and pragmatism of programme managers. Human resources development and capacity-building during scale-up have contributed to improved service quality in MMT treatment clinics and are critical to long-term success.
RÉSUMÉ
PROBLÈME: Le programme national chinois de traitement de maintien à la méthadone est passé de 8 hôpitaux traitant environ 1 000 patients à 738 cliniques qui ont suivi plus de 340 000 patients au total en seulement 8 ans. Cela a généré une énorme demande en prestataires expérimentés.
APPROCHE: Le développement des ressources humaines et des efforts de renforcement des compétences ont été menés par le programme national chinois de traitement de maintien à la méthadone (TMM) afin de proposer des prestataires formés à la gestion du TMM en termes de dépendance aux opiacés.
ENVIRONNEMENT LOCAL: De 2004 à 2007, le programme national chinois de TMM s'est heurté à divers problèmes: doses de méthadone inadéquatement faibles, observance médiocre, importante consommation simultanée de drogues et taux d'abandon élevés chez les patients, faible expérience et taux de renouvellement élevé des prestataires.
CHANGEMENTS SIGNIFICATIFS: Des programmes de formation pour les prestataires et leurs formateurs ont été élaborés et développés en 2008. Bien que des mesures de performance du programme montrent une augmentation de la durée moyenne annuelle du traitement des patients (93 jours en 2004 pour 238 jours en 2011), l'augmentation de leur dose quotidienne moyenne de méthadone est modeste (de 47,2 mg en 2004 à 58,6 mg en 2011).
LEÇONS TIRÉES: Certains problèmes qui peuvent survenir lors du développement, du lancement et de l'application à grande échelle d'un effort national majeur dans le domaine de la santé publique, tel que le programme national chinois du traitement de maintien à la méthadone, ne peuvent être prévus. À ce jour, les clés du succès du programme sont l'engagement marqué de la part du gouvernement chinois ainsi que l'optimisme et le pragmatisme des responsables du programme. Le développement des ressources humaines et le renforcement des compétences lors du développement à grande échelle ont contribué à une amélioration de la qualité du service dans les cliniques de TMM et sont essentiels pour une réussite à long terme.
RESUMEN
SITUACIÓN: El Programa Nacional para el Tratamiento de Mantenimiento con Metadona de China ha pasado de tener ocho clínicas que atendían a aproximadamente 1000 clientes a 738 clínicas con un total acumulado de más de 340 000 clientes atendidos en sólo ocho años, lo que ha creado una demanda enorme de proveedores de servicios cualificados.
ENFOQUE: Los esfuerzos para el desarrollo de los recursos humanos y la creación de capacidad adecuada han llevado al Programa Nacional para el TMM de China a crear un programa para aportar proveedores cualificados capaces de administrar el tratamiento de mantenimiento con metadona (TMM) para la dependencia de opiáceos.
MARCO REGIONAL: Desde el año 2004 hasta el 2007, el Programa Nacional para el TMM chino tuvo que hacer frente a numerosos problemas: dosis inadecuadamente bajas de metadona, cumplimiento deficiente del programa, elevado uso simultáneo de drogas, tasas altas de abandono entre los clientes, falta de experiencia y de formación, así como índices elevados de rotación entre los proveedores de servicios.
CAMBIOS IMPORTANTES: En el año 2008 se volvieron a diseñar y se aumentaron los programas de formación para los proveedores individuales, así como para sus instructores. Aunque las mediciones del rendimiento del programa muestran un aumento de la duración media anual del tratamiento de los pacientes (93 días en 2004 frente a 238 días en 2011), el aumento de la dosis diaria de metadona (de 47,2 mg en 2004 a 58,6 mg en 2011) resulta moderado.
LECCIONES APRENDIDAS: No es posible prever todos los problemas que pueden surgir durante el desarrollo, el lanzamiento y la expansión de un esfuerzo de tal relevancia en materia de salud pública nacional como es el Programa chino para el Tratamiento de Mantenimiento con Metadona. Las claves para el éxito del programa han sido, hasta ahora, el fuerte compromiso por parte del gobierno chino, así como el optimismo y el pragmatismo de los gestores del programa. El desarrollo de los recursos humanos y la creación de capacidad durante su proceso de expansión han contribuido a mejorar la calidad del servicio en las clínicas de TMM y son fundamentales para el éxito a largo plazo.
Introduction
The injection of illicit drugs and the epidemic of human immunodeficiency virus (HIV) infection to which it contributes are still public health challenges in China.1 Methadone maintenance treatment (MMT) has become a critical component of broader harm reduction strategies focused on the harms of dependence on illicit drugs, HIV infection and acquired immunodeficiency syndrome (AIDS), and infection with hepatitis C virus. MMT programmes have been credited internationally with several important effects, which include reductions in illicit drug use and high-risk drug-related behaviour, in the incidence and prevalence of HIV infection and in the incidence of hepatitis C virus infection.25 As a result, China has rapidly scaled up MMT nationwide from eight clinics serving about 1000 clients in 20046 to 738 clinics that had already served over 340 000 clients cumulatively as of the end of 2011. No other country has successfully expanded MMT services in such a short time or to such a degree, and China's National Methadone Maintenance Treatment Programme is now recognized as the largest single opioid agonist maintenance treatment programme in the world.7,8
In addition to the advantages already mentioned, studies have shown MMT programmes to be associated with longer retention in treatment, higher methadone doses and greater availability of ancillary services.9,10 The rapid scale-up of MMT services in China created a huge demand for qualified service providers and placed an unanticipated strain on existing providers in MMT clinics, to the detriment of service quality.1113 Hence, this enormous shortage of human resources soon became one of the most critical problems faced by managers of the MMT programme. It took great perseverance and effort to try to overcome the shortage. The purpose of this article is to review human resource development and capacity-building efforts within China's National Methadone Maintenance Treatment Programme, illustrate changes in programme performance metrics over time, and convey lessons that we hope will provide guidance to other developing countries attempting to implement similar programmes.
During its early years (20042007), China's National Methadone Maintenance Treatment Programme was characterized by very low coverage of the total opioid-dependent population, low average methadone doses (compared with international recommendations), high rates of concurrent drug use among clients, and high client drop-out rates across all sites.68, Although the causes of these problems had not yet been examined, their root cause was thought to be that most public health and MMT clinic staff, as well as clients and their families, knew little about the pathophysiology of opioid dependence or about opioid agonist maintenance treatment. This idea is supported by several international studies.9,10,14,15 Attempts were being made to address these problems through the National Methadone Maintenance Treatment Training Centre (henceforth national training centre), which had been established in 2005 to offer providers in new MMT clinics basic support and clinical and operational training (Table 1). However, this training programme had low coverage, provided no ongoing education and was limited to a few topics.11,12
In mid-2007, the National Training Centre conducted a survey targeting the 320 MMT clinics that were operating as of the end of 2006. The purpose was to discover barriers and facilitators to providing good service over the long term. A total of 854 staff members from 276 clinics participated. According to the survey, the majority of MMT clinic staff members were highly educated (87.0% had at least a college education) and 91.6% held physician or pharmacist positions within the clinics 70.3% as physicians and 21.3% as pharmacists. However, only 63.1% of them (a mean of < 2 providers per clinic) had received training at the national training centre and very few had work experience in rehabilitation for drug dependence or training in psychiatric medicine. Furthermore, most clinics were not fully staffed, as required by MMT programme guidelines, and many had excessive staff turnover. Most of the survey respondents reported feeling underprepared to perform their jobs. More than 80% requested additional training on clinical treatment guidelines, overdose prevention and management, ways to actively involve their clients in treatment, HIV-prevention strategies, and the enforcement of harm reduction measures in MMT service delivery (unpublished findings).
Many of these findings were later corroborated by other surveys of China's MMT programme providers in early 2008.11,12 Respondents cited a lack of professional training and development as a problem that kept them from performing their jobs properly, made them reluctant to prescribe higher methadone doses (despite the implementation of improved dosing guidelines), and prevented them from being able to offer supportive services such as psychosocial counselling, skills training, employment assistance, health screening and referrals or incentive programmes. This contributed to their feelings of inadequacy and disdain from other medical professionals, fear of malpractice liability, concern for their personal safety and burnout.11,12
By the end of 2007, 503 MMT clinics had cumulatively served 97 554 clients, of which 57 947 were still in treatment. However, the programme still had to contend with excessively low methadone doses (mean: 4555 mg daily), low rates of treatment compliance (63% at six months; 48% at one year), and high rates of continued drug dependence on screening (mean: 2740%).8,11 Programme-level metrics derived from the National Methadone Maintenance Treatment Programme's database for the period from 2004 to 2007, summarized in Table 2, support these observations. To solve these persistent problems and move the programme towards professional, high-quality, comprehensive service delivery, clinics needed to be stably staffed with well-trained providers.11,12 Thus, the success of MMT service delivery depended on the rapid establishment of human resources development and capacity-building activities.
Approach
In response, the national training centre modified its capacity-building plans in 2008 after performing a situational analysis and skills and capacity assessment of existing clinics, already described, and of the new National HIV/AIDS Strategy and China's Eleventh Five-Year Plan for Key Science and Technology Research Projects. This resulted in the development and implementation of a new technical training programme for MMT service providers that focused on four main goals:
i) ensuring that every new MMT clinic had at least two staff members trained by the national training centre before opening;
ii) seeing to it that the national training centre delivered psychosocial support training to service providers, as needed, to strengthen their skills and ability to offer quality services;
iii) increasing training coverage and skill building and improving service quality by getting the national training centre to offer training of trainers to core MMT providers in each province. These constituted a small group with the skills and knowledge needed to train new or less experienced staff in the provinces;
iv) getting the national training centre to prepare selected technical experts to conduct week-long field visits to new clinics to provide on-site technical support and performance coaching to service providers.
Training for individual providers at the national and provincial levels was expanded to cover a broader range of topics (Table 1). The national training centre carefully selected 31 providers to train the trainers who would later be responsible for ongoing provider training in the provinces. Three training of trainers' sessions on an expansive list of topics took place between March 2010 and January 2011 (Table 1). Participants who received certification after passing a rigorous examination became part of the technical resource pool and conducted training in their provinces.
Results
Table 2 summarizes the annual national-level performance metrics of the National Methadone Maintenance Treatment Programme from 2004 to 2011. As shown, some metrics improved during this period. For example, increases in staff-to-client ratios, mean number of clients per clinic, and mean duration in treatment (93 days in 2004 versus 238 days in 2011) all indicate improved provider capacity and service quality. However, many opportunities for improvement still exist. For instance, the mean daily methadone dose increased by only 20% (47.2 mg in 2004 versus 58.6 mg in 2011) and is still far below international recommendations. Similarly, little improvements were seen in MMT client retention rate and continued concurrent use of illicit opioids.
Because this study is merely descriptive and observational in nature, we cannot make claims regarding causality. However, improvements coinciding with changes in provider training after 2008 suggest that the human resources development and capacity building activities undertaken within China's National Methadone Maintenance Treatment Programme exerted a positive influence in this respect. Additional research is required to determine causality. The results of surveys of MMT providers that are in the planning stage will make it possible to assess and further improve the new training programme.
Lessons learnt
Several valuable lessons were learnt during the scale-up of China's National Methadone Maintenance Treatment Programme (Box 1). The urgent need for extensive human resources development and capacity building within China's National MMT Programme arose unexpectedly. However, the strong commitment of China's government to ensuring the success of the programme and the optimism and pragmatism of the programme's managers have been key to the results seen so far. Furthermore, programme managers have continued to push forward despite barriers; they have learnt by doing and have solved problems as they arose by making incremental improvements and not losing sight of the goals. The many challenges involved in establishing, maintaining and improving the quality of provider services during the launch and rapid scale-up of a large national MMT programme are not unique to China. Although further research in this area is required and many opportunities for improvement still exist, the lessons presented here can add value to the planning and implementation of similar national MMT programmes around the world, particularly in other Asian countries and in countries of Africa, eastern Europe and the Middle East. 
Acknowledgements
The authors thank MMT programme trainers and Zhijun Li for their collaboration. Jianhua Li and Changhe Wang are joint first author. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the National Centre for AIDS/STD Control and Prevention, the Chinese Center for Disease Control and Prevention, or the United States Centers for Disease Control and Prevention.
Funding: The study was supported by the Chinese National Methadone Maintenance Treatment Programme. Preparation of this paper was supported by the US National Institutes of Health, the Fogarty International Center and the National Institute on Drug Abuse (Grant # 5U2RTW006918-07).
Competing interests: J Li is the director of the National Methadone Maintenance Treatment Training Centre. Z Wu is the director of the Secretariat of the National Methadone Maintenance Programme and the director of the National Centre for AIDS/STD Control and Prevention. Both have been directly involved in the development and scale-up of the National Methadone Maintenance Programme in China.
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(Submitted: 15 June 2012 Revised version received: 19 November 2012 Accepted: 28 November 2012)
* Correspondence to Zunyou Wu (e-mail: wuzunyou@chinaaids.cn).