Implementation Challenges and Opportunities in Decentralized Methadone Service Delivery.

Background: As the burden of opioid use disorder (OUD) increases in low- and middle-income countries, expanding access to medications for opioid use disorder, including methadone maintenance therapy, is essential. Decentralized models of methadone service delivery aim to improve treatment access, reduce costs for clients and burdens on health systems, and deliver more client-centered care. However, questions remain about the feasibility, acceptability, and implementation of decentralized models for methadone delivery, particularly in Africa. We qualitatively examined client and provider perspectives on decentralized methadone service delivery through satellite community health centers in Tanzania. Methods: We conducted a qualitative study with in-depth interviews among 10 providers and four focus groups with 40 participants (clients enrolled in OUD care, outreach workers, and treatment supporters) in Dar es Salaam, Tanzania. Through thematic analysis guided by the Consolidated Framework for Implementation Research (CFIR), we explored the experiences and perceptions of decentralized methadone services, including benefits, barriers, and recommendations. Results: Participants described key advantages of decentralization, such as reduced travel time and costs, improved access for clients with family or work obligations, and less congestion at central specialized opioid treatment clinic. However, they reported challenges across CFIR domains. Under intervention characteristics, clients perceived lower quality of care and less monitoring at satellite community health centers than at specialized opioid treatment clinics. Outer setting factors, such as privacy concerns and stigma, were perceived barriers to decentralized methadone delivery. Compared with specialized clinics, community health centers have fewer wrap-around services, reinforcing perceptions of poor quality of care. Individual characteristics, such as the risk of losing peer support networks and fears of drug testing, further discouraged clients from desiring to be transferred to community health centers. Finally, limited client involvement in planning and unclear communications were viewed as factors contributing to mistrust and resistance among clients to receive their methadone treatment at a community health center. Conclusions: Addressing community stigma, ensuring consistent service quality, supporting and enhancing clients' social connections, and fostering transparent and participatory planning processes will be critical to effectively implement decentralized methadone service delivery.