Human resource development and capacity-building during China’s rapid scale-up of methadone maintenance treatment services
Jianhua Li a, Changhe Wang b, Jennifer M McGoogan b, Keming Rou b, Marc Bulterys c & Zunyou Wu b
a. National Methadone Maintenance Treatment Training Centre, Yunnan Institute of Drug Abuse, Kunming, China.
b. National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing, 102206, China.
c. The Global AIDS Programme in China, US Centers for Disease Control and Prevention, Beijing, China.
Correspondence to Zunyou Wu (e-mail: firstname.lastname@example.org).
(Submitted: 15 June 2012 – Revised version received: 19 November 2012 – Accepted: 28 November 2012.)
Bulletin of the World Health Organization 2013;91:130-135. doi: 10.2471/BLT.12.108951
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.2–5 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.11–13 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 (2004–2007), 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.6–8, 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
Table 1. Comparison of topics covered by the National Methadone Maintenance Treatment Training Centre for the training of methadone maintenance treatment (MMT) providers and their trainers, before and since 2008
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=""> 2>
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: 45–55 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: 27–40%).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.
Table 2. Trends in 15 National Methadone Maintenance Treatment Programme performance metrics before and after human resource development and capacity-building activities, China, 2004–2011
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:
- ensuring that every new MMT clinic had at least two staff members trained by the national training centre before opening;
- 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;
- 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;
- 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.
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.
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.
Box 1. Summary of main lessons learnt
- It is not possible to foresee all the problems that can arise during the development, launch and scale-up of a major national public health effort, such as China’s National Methadone Maintenance Treatment Programme.
- Strong government commitment and an optimistic attitude and pragmatic approach on the part of National Methadone Maintenance Treatment Programme managers have been key to the programme’s success so far.
- Human resources development and capacity-building during programme scale-up directly affects service quality in methadone maintenance treatment clinics and is critical to long-term success.
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.
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).
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.
- Wang N, Wang L, Wu Z, Guo W, Sun X, Poundstone K, et al., National Expert Group on HIV/AIDS Estimation, et al. Estimating the number of people living with HIV/AIDS in China: 2003–09. Int J Epidemiol 2010; 39: ii21-8 doi: 10.1093/ije/dyq209 pmid: 21113033.
- Sullivan LE, Metzger DS, Fudala PJ, Fiellin DA. Decreasing international HIV transmission: the role of expanding access to opioid agonist therapies for injection drug users. Addiction 2005; 100: 150-8 doi: 10.1111/j.1360-0443.2004.00963.x pmid: 15679744.
- Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev 2009CD002209- pmid: 19588333.
- Hagan H, Pouget ER, Des Jarlais DC. A systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs. J Infect Dis 2011; 204: 74-83 doi: 10.1093/infdis/jir196 pmid: 21628661.
- MacArthur GJ, Minozzi S, Martin N, Vickerman P, Deren S, Bruneau J, et al., et al. Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis. BMJ 2012; 345: e5945- doi: http://dx.doi.org10.1136/bmj.e5945.
- Pang L, Hao Y, Mi G, Wang C, Luo W, Rou K, et al., et al. Effectiveness of first eight methadone maintenance treatment clinics in China. AIDS 2007; 21: S103-7 doi: 10.1097/01.aids.0000304704.71917.64 pmid: 18172377.
- Sullivan SG, Wu Z. Rapid scale up of harm reduction in China. Int J Drug Policy 2007; 18: 118-28 doi: 10.1016/j.drugpo.2006.11.014 pmid: 17689354.
- Yin W, Hao Y, Sun X, Gong X, Li F, Li J, et al., et al. Scaling up the national methadone maintenance treatment program in China: achievements and challenges. Int J Epidemiol 2010; 39: ii29-37 doi: 10.1093/ije/dyq210 pmid: 21113034.
- Metzger DS, Zhang Y. Drug treatment as HIV prevention: expanding treatment options. Curr HIV/AIDS Rep 2010; 7: 220-5 doi: 10.1007/s11904-010-0059-z pmid: 20803321.
- Veilleux JC, Colvin PJ, Anderson J, York C, Heinz AJ. A review of opioid dependence treatment: pharmacological and psychosocial interventions to treat opioid addiction. Clin Psychol Rev 2010; 30: 155-66 doi: 10.1016/j.cpr.2009.10.006 pmid: 19926374.
- Lin C, Wu Z, Rou K, Pang L, Cao X, Shoptaw S, et al., et al. Challenges in providing services in methadone maintenance therapy clinics in China: service providers’ perceptions. Int J Drug Policy 2010; 21: 173-8 doi: 10.1016/j.drugpo.2009.09.002 pmid: 19818591.
- Lin C, Wu Z, Rou K, Yin W, Wang C, Shoptaw S, et al., et al. Structural-level factors affecting implementation of the methadone maintenance therapy program in China. J Subst Abuse Treat 2010; 38: 119-27 doi: 10.1016/j.jsat.2009.09.002 pmid: 20015606.
- Lin C, Detels R. A qualitative study exploring the reason for low dosage of methadone prescribed in the MMT clinics in China. Drug Alcohol Depend 2011; 117: 45-9 doi: 10.1016/j.drugalcdep.2011.01.004 pmid: 21310554.
- Soyka M, Kranzler HR, van den Brink W, Krystal J, Möller HJ, Kasper S, WFSBP Task Force on Treatment, Guidelines for Substance Use Disorders. The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of substance use and related disorders. Part 2: Opioid dependence. World J Biol Psychiatry 2011; 12: 160-87 doi: 10.3109/15622975.2011.561872 pmid: 21486104.
- Leavitt SB, Shinderman M, Maxwell S, Eap CB, Paris P. When “enough” is not enough: new perspectives on optimal methadone maintenance dose. Mt Sinai J Med 2000; 67: 404-11 pmid: 11064491.