UNODC Partnership for the Reduction of Injecting

Drug Use, HIV/AIDS and Related Vulnerability in

Myanmar
TDMMRJ63FMM

An Internal Review Report

By
Palani Narayanan
Senior Technical Advisor
December 2008

List of Abbreviation
AHRN
AIDS
ARV
ART
ANTF
ATS
BCC
BI
CAC
CBT
CCDAC
DIC
DTC
DSW
EU
HIRA
HIV
HAARP
FP
IDU
IEC
INGO
NSP
MANA
MMT
MOH
MOHA
MSF
MSM
NAP
OI
PLWHA
PRODOC
QAE
STA
STI
SRH
TB
TC
TOT
TPMC
UNODC
UNAIDS
VCCT
VSWA
YET

Asian Harm Reduction Network

Acquired Immune Deficiency Syndrome
Anti Retroviral
Anti Retroviral Treatment
Anti Narcotics Task Force
Amphetamine Type Substances
Behaviour Change Communication
Burnet Institute
Community Advisory Committee
Cognitive Behaviour Therapy
Central Committee for Drug Abuse Control
Drop In Centre
Drug Treatment Centre
Department of Social Welfare
European Union
Health Information and Research Analyst
Human Immunodeficiency Virus
HIV/AIDS Asia Regional Project
Family Planning
Injecting Drug User
Information, Education, Communication
International Non-Governmental Organization
Needle and Syringe Program
Myanmar Anti Narcotics Association
Methadone Maintenance Treatment
Ministry of Health
Ministry of Home Affairs
Medicine Sans Frontier
Men who have sex with men
National AIDS Program
Opportunistic Infections
People Living with HIV/AIDS
Project Document
Quality Assurance Expert (UNODC J63 Project)
Senior Technical Advisor
Sexually Transmitted Infections
Sexual and Reproductive Health
Tuberculosis
Township Coordinator
Training of Trainers
Township Project Management Committee
United Nations Office on Drugs and Crime
United National Program on AIDS
Voluntary Confidential Counselling and Testing
Volunteer Social Workers Association
Youth Empowerment Team

CONTENT
List of Abbreviations
Introduction
1. Lashio Outreach Program
Observations
Recommendations
2. Myanmar Business Coalition
Observations
Recommendations
3. Marie-Stope International
Observations
Recommendations
4. Community Based Organizations
Youth Empowerment Team
Volunteer Social Workers Association
Oasis
Recommendations for CBO Development

Introduction
This report presents the findings and recommendations of an internal review process
of the J63 project implementation in the city of Lashio. The review was conducted by
Mr.Palani Narayanan, Senior Technical Advisor (STA) to the program, starting
October 2008.
The international consultant (STA) spent a total of 10 working days at Yangon
working with project J63 Staff and in Lashio observing and interviewing project
implementation on the ground. Dr.Sai Kyaw Han (HIV/AIDS Project Standards and
Quality Assurance Expert - QAE), Mr. Zaw Lin Dwe (CBO Capacity Builder), Dr.
Kyaw Lin (Health Information and Research Analyst - HIRA) and Dr. Htay Oung
(Area Supervisor) accompanied the STA.
At the end of the review meeting the STA met with the Project Team members in
Yangon and discussed the findings. It was unanimously agreed that the
implementation of the program in Lashio was lacking in technical competency and
support. There are many areas that need immediate attention and improvement. This
reports analyses each implementing partner and suggest ways of making the
improvements in the short medium term.
Overall the project is lacking in technical capacity to deliver the ambitious scope of
the project design. The Project Design encompasses the following technical areas;
Drugs and drug use heroin, ATS and illicit drugs
HIV/AIDS
Drug Use and HIV Prevention Strategies including
o Outreach
o Drop In Centre
o Needle Exchange Program
o Methadone Maintenance Program through referrals
o Behaviour Change Communication
o IEC development
Care and Support for IDUs living with HIV
o ART and OI through referrals
o Positive Self Help Group
o Home Based Care
o Psychosocial support.
Detox, rehabilitation through referrals
after care
Relapse Prevention
Case Management
Sexually Transmitted Infections (STI)
Sexual and Reproductive Health (SRH)
Family Planning (FP)
Closed Setting
Sex work and IDU

 Road Transport Workers

Monitoring and Evaluation
Community Development including ownership and sustainability
Data collection, documentation and analysis.
The vast technical requirement of the project design unfortunately has not been met
with adequate technical support to the Project Team in Yangon and the implementing
partners in the field. For instance, Case Management is an integral part of the work by
the OPs but no member of the team have ever received a formal training on
conducting Case Management or managing it. Relapse prevention and after care are
being conducted although the implementing partners cannot describe the strategies
that can be used for relapse prevention apart from home visits to drug users to ensure
they are safe and there are no problems with family members.
The STA makes a series of recommendations under each of the topics below.
However there are also some general recommendations for the project. These
recommendations were discussed with the Project Team and UNODC Myanmars
Representative and Assistant Representative.
Over the next 5 months the STA will work with the Project Team to improve the
quality and effectiveness of the J63 Project. The following recommendations are
made;
Step 1: Develop Capacity Building Strategies for the Project Team in Yangon. This
includes familiarising the Project Team members on all technical areas of the J63
Project. This will be in the form of a 6-day training to be conducted in Yangon
between 26 31 January 2009. Project Team members will receive training on
Outreach, Needle Exchange, Case Management, Counselling strategies, After Care
activities, relapse Prevention, Methadone and Stigma and Discrimination.
Step 2: Following on from the training above, the STA and Project Team members
will visit Tachilek for review, identification of issues and exploration of possible
solution. This will be a field level training for the relevant staff.
Step 3: Three main staff members of the project, the QAE, the Area Supervisor and
the CBO Capacity Builder will receive additional focus on developing effective
monitoring and technical assistance guidelines.
Step 4: Once the Project Team is strong and confident, the TC of the Ops will be
brought together with the Project Team to review their program, progress, issues,
challenges and future directions.
Step 5: Following from the coordination meeting between TC, the Project Team is
required to conduct improvements on each of the project sites. This includes ensuring
that the sites are following the structures and guidelines, that the TPMC is working
efficiently, the services are well utilised and that case management is conducted
properly.
Step 6: The CBO Capacity Builder will undertake all necessary action as described in
the recommendations listed at the end of this report.

Step 7: The Project Team will undertake technical capacity and training needs analysis
for Year 3 for both themselves and for the implementing partners and CBOs.
The STA will assist in providing oversight and technical support to each of these
steps.
Findings and Discussion

1. Lashio Outreach Project

1.1 Management of LOP
Lashio is a city with a population of 247,000. Due to its location in or close to the
Golden Triangle and being central in the Mandalay China highway, drug use and
related vulnerability is rather high. There are currently 5 International and local
NGOs that are providing services in this city. They include CARE, MANA,
AHRN, HAARP and the J63 supported LOP (Lashio Outreach Project).
The LOP is a continuation of a project started under FHAM/UNAIDS in 2004.
Since 2007, it has been operating with the support of 3D Fund, the J63 Project.
The LOP is a Drop In Centre with outreach, case management, STI services
(provided by MSI) and primary Health Care facilities. It has a total of 22 staff
including 6 caseworkers, 3 outreach workers and 3 DIC workers.
It is supervised by a Township Project Management Committee which is supposed
to meet every month to discuss the issues related to the implementation of
programs at the LOP. The Medical Superintendent/Consultant Psychiatrist of the
Lashio DTC is the Chairman of this Committee. This TPMC reports to the
Township Steering Committee, which is a Lashio-wide committee that coordinates
the work of all the Harm Reduction NGOs.
As per the design of the Project J63, there is now a Community Advisory
Committee formed, made up of members of the affected community, the families
and community leaders. The Chairman of this CAC is currently the head of
religious group.
Observation 1:
The STA sat through a TPMC meeting during his visit and was disappointed to
observe that most members who attended did not discuss the issues related to the
LOP. Instead the members presented the work of their own organization for other
peoples knowledge. There were two members from MOHA and Social Welfare
Department who were attending for the first time and had very little idea of what
the meeting was about. The LOP Coordinator did not present issues to be
discussed or decisions to be made about LOP. The CAC Chairman did not discuss
issues pertaining to the affected community. The Chair of the TPMC was absent
with apology. The TPMC meeting observed by the STA was not effective.
The structure of the CAC and its role is also questionable. The STA observed one
meeting of the CAC and again was not convinced that it was an effective model

for community involvements. The TC explained that the members of the CAC
changed every month and that it was difficult to maintain the same members at the
CAC.
In discussing the possibilities of inviting the ex-drug user to be on the TPMC, the
TC explained that the ANTF officer who is currently on TPMC does not want to
sit in the same committee as a drug user or ex-drug user.
Recommendation 1:
i.
ii.

iii.

iv.
v.

Develop a Standard Protocol for the TPMC meeting. Train LOP

Coordinator on running the meeting and developing meeting agenda for
discussion.
Reduce the membership of the TPMC and allow the committee to be a
working group. Large membership is appropriate for the TSC, which
meets regularly. The role of the TPMC is not for coordinating the work of
other NGOs with LOP it is to ensure the implementation of LOP is
smooth and problem free.
The CAC should be abolished. There are already too many committees in
Lashio. To ensure the effective involvement of affected community, LOP
should ensure that a drug user is included in the TPMC. LOP should also
conduct a Community Consultation Meeting every quarter to ensure that
the issues and problems of drug users, the sexual partners and families are
heard.
Reducing the size of the TPMC membership and doing away with CAC
will simplify the management/supervision of the LOP and make it more
effective.
There is an urgent need to advocate to ANTF and
CCDAC regarding the need to involve drug users and Comment AS
their family members in decision-making processes of New supervisor of ANTF officer agree to
participation of drug user in TPMC by the
the J63 project. The reluctance of the ANTF officer to Township Coordinators advocating action with
sit in the same committee as a drug user should be a the guidance of Area Supervisor.
challenge to overcome not something that the project
should simply accept. This responsibility should be
held by the Area Supervisor.

1.2. Drop in Centre, Case Management and Outreach

The LOP DIC receives about 15 -25 drop in per day. There are approximately 50
new clients every month and the total number of drop ins is 200 per month.
Clients come mostly for the Primary Health Care facility and to take a rest at the
DIC.
There are currently 6 Case Management Workers and a Case management
Supervisor. The Case Managers have approximately 2 -4 cases each. During
discussion, 5 caseworkers were handing 2 cases the entire day and one caseworker
had 4 cases. According to Case Workers, there was no limit to the time they spent
with their cases. LOP has also been case managing 81 clients since it started 6
months ago. Of the 81 clients, 63 clients are still on the Case Management files.
18 cases have been closed. This is due to imprisonment (9 cases), moved to a

different city (3), moved to work at the mines (2), attending religious school (1)
and 3 cases were lost due to the abrupt resignation of the case worker.
Outreach is currently conducted in Wards 1,7,8 and 12 of
Lashio city. However the coverage of outreach was
surprisingly low. The outreach workers meet about 20 clients
during the morning and another 20 during the afternoon.
Observation 2:
The LOP staff are under utilised. The total number of clients
reached per day is rather small which makes the ratio of staff
to patient rather low. The LOP reaches about 25 users at DIC,
40 users during outreach and 12 users during Case
Management. That is a total of 77 drug users for 22 staff. A
ratio of 1 staff: 3 drug users.

Comment AS
6 Case Worker work for 12 users, they meet and
give service at least 2-3 times/ week for each
client.
4 Outreach Worker handle for 40 users for
outreach work for that day.
2 DIC workers responsible for 25 uses who
come to DIC for their BHC.
Other 10 are Admin(AO1+FC1+Driver1+ SC2)
6, Clinical(Doctor1+Nurses2+counselor1)4
2 case workers are recruited only at Yr 2 by the
advice of STA.

The number of clients reached during outreach is also low.

The Case Management system and training was developed by
the J63 project team without help from any outside experts.
They used the project design document and resources from the
internet to train the staff at LOP. While this is highly
commendable, the system has several flaws that must be
rectified as soon as possible. For example, the Case workers should not be
spending 30 minutes with one clients and then 6 hours with another clients. The
case files should always be in the office and accessible to the Supervisor who
should be able to hand over the case to another caseworker should one of the
resign. Cases should not be lost because the case worker has resigned.
Recommendation 2
1. Conduct TOT on Case management. A new module for Case Management
must be developed, translated and distributed. The Project Team at central
level must be trained on this aspect first before the field staffs are trained. The
STA will conduct this training upon his second visit to Myanmar at end
January/early February. Materials for this training will be collected at the
Kirkton Road Centre in Sydney, Australia.
2. The allocation of human resources at LOP should be reorganised. The LOP
should aim to reach more drug users through outreach. If the number of drug
users is small and most are already being reached, then LOP does not require
this many staff. The Project could in the long term, redistribute the resources
to other agencies such as the CBOs, which are currently under-funded.
3. Also in the medium to longer term the STA and the Project Coordinator must
look into the outreach training manual, outreach implementation in the field
(conduct field visit with outreach workers) and develop a refresher training
course for all outreach workers.
1.3. Needle Exchange Program of LOP

The outreach and needle exchange services of the LOP is an essential part of the
HIV prevention program. NSP is now available in every Ward of Lashio, due to
the effective collaboration among all the NGOs working in this city. The LOP
reports handing out 3300 needles per month during Year 1 of its operation and
6,000 needles in Year 2. The collection rate of used needles is 62% and 82%
respectively. This is a good return rate. However, the rest of the NSP section of
the LOP was difficult to assess because the data presented by the TC was
different from the data kept by Dr.Sai Kyaw Han, the QAE. It seemed like the
injecting drug users were receiving less needles than they should be due to the
shortage of needles at LOP. The reasons for this was the problems the Project
Team in Yangon is facing due to the procurement mechanism of the 3DF UNOPS which has delayed the supply to the field offices.
Observation 3.
The Project Team in Yangon has faced a major challenge in the procurement and
supply of needles and syringes. This has adversely affected the needle and
syringe program in the field. The Project Team has also found creative ways of
securing more needles and syringes for the future, having learnt from the
problems faced in year one.
However, it must be noted that needle and syringes are the most important
commodity in the project and there should not be a shortage of these once the
program has begun. Behaviour change among injecting drug users must be
sustained to have an impact on HIV. Injecting drug users will resort to sharing
needles if needles are not available and accessible.
It was also disappointing to hear that the projects have been giving out 4 needles
a day when there are enough needles and only one needle a day per client when
there is short supply of needles.
Recommendation 3
i.
The Project Coordinator and the Program Specialist should have a
meeting with UNOPS regarding the procurement of these commodities
for the project and highlight the negative consequences of short supply in
the field. Project team should ensure that a larger amount of needles is
ordered for the coming year to prepare for delays in importation etc.
ii.
The Project Team, especially the Area Supervisor, the QAE must be
provided with needle exchange management training. The STA aims to
this in his next visit.
iii.
The QAE together with HIRA must develop better data collection,
analysis and presentation method. Once the data is collected, it should be
actively used and must be interpreted for use by TC in all areas. There
should not be any difference in the data held by the TCs and the QAE and
HIRA.