Update of baseline assessment of policies, resources and services for people who inject drugs: key findings and recommendations

Chris Hagarty, Jimmy Dorabjee, Gary Lewis,

Fritz Lherisson, Fabio Mesquita & Anne Bergenstrom

Presented by Peter Higgs

The Burnet Institute

Context

• 2006: UN RTF commissioned the Centre for Harm Reduction (CHR), Burnet Institute, to undertake a baseline assessment of current programs and services for drug users in 12 countries in South and South East Asia.

• An analytical framework tool was developed (by CHR with review and input from UN RTF) to monitor and evaluate scale-up activity in 3 main areas;

– National Program Support

– Barriers to scaling-up

– Service coverage and program implementation

• A desk review and input from the 12 selected countries contributed a baseline assessment, which informed identified gaps and recommendations for the UN RTF work plan, and efforts to scale-up of harm reduction services in the region.

2009 Update

• 2009: Centre for International Health (CIH), Burnet Institute, commissioned to update the baseline assessment of current programs and services for drug users in 15 priority countries in South and South East Asia:

– South East Asia: Cambodia, China (People’s Republic of), Indonesia, Lao PDR, Myanmar, Malaysia, Philippines*, Thailand, Viet Nam.

– South Asia: Afghanistan*, Bangladesh, India, Maldives*, Nepal, Pakistan.

* new countries not included in 2006 Baseline Assessment

2009 Update – Process (Output 1)

Revision of the Analytical Framework tool (the matrix).

• Recognition that 2006 matrix did not reflect recent priority shifts in harm reduction program development, implementation, monitoring and evaluation

(eg: WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users).

• Analytical framework tool revised by CIH (June 2009) in collaboration with the working Group consisting of members of the UN RTF established to review and endorse matrix (August 2009).

• Revised matrix reflects the core services which make up a comprehensive package of harm reduction services.

2009 Update – Process (Output 1)

• National Program Support: Political Commitment, Civil Society

Engagement, Donor Commitment, Multi-sectoral Involvement, Involvement of IDUs in the Response, Costed National Harm Reduction Strategy, Legal and Policy Environment, Surveillance Systems

• Monitoring and Evaluation (M&E) Systems:

• Program Implementation: NSP, OST, T&C, ART, Prevention and

treatment of STIs, Condom programs, Targeted IEC, Primary Health Care (opportunistic infections), viral hepatitis, tuberculosis, Peer Education

• Services in Prisons and Compulsory Drug Treatment Centres (CDTCs):

• Barriers to Scale Up: Political Commitment, Civil Society

Engagement, Legal and Policy Environment, Law Enforcement, Comprehensive Services, Resources, Involvement of IDUs in the Response,

Availability of Commodities, Scaling-Up Plans, Capacity Building, Monitoring and Evaluation

2009 Update – Process (Output 2)

Review and updating of country-specific data matrices.

• Utilising the large body of regional and country specific technical literature, resources and reports released in recent years.

• Focused on service availability and conditions which could act as enablers or barriers to the delivery of comprehensive harm reduction services.

• Official letter from UN RTF co-chairs (Gary Lewis, UNODC and JVR Prasada Rao, UNAIDS) sent to country focal points to request their assistance in reviewing and contributing to country-specific data (June 2009).

• Draft matrices reviewed and updated by UN RTF country focal points (September 2009 - January, 2010).

2009 Update – Process (Output 2)

• Completion of data collection and finalisation of country-specific data matrices (January, 2010).

• These feature;

– 113 identified, country-specific gaps in the legal and political environment that affect delivery of comprehensive harm reduction services, and

– 102 country-specific recommendations to address the identified barriers to the scale-up of harm reduction services.

2009 Update – Process (Output 3)

Summary report and comparative analysis of policies, resources and services from 2006 to 2010

• Report identifies common gaps across the 15 priority countries.

• Compares identified gaps across the 12 priority countries included in 2006 baseline assessment.

• Contributes common recommendations across the 15 priority countries.

Limitations of this update activity

• The activity was time-limited – only 3 months according to TOR. Data collection only 6 weeks!

• However in practice, it took 7 months (at no extra cost).

• Input to the matrices contingent on capacity and time availability of country focal points and in-country teams to respond.

• Release and dissemination of report may prompt further input from country-level stakeholders to more accurately report service coverage in their countries.

• Matrices collect country-specific data only. Regional initiatives have demonstrated potential in influencing policy, programs and services.

Key Findings

Gaps

Comparisons

Recommendations

Comprehensive harm reduction services

Gaps:

• No country delivers all 9 core interventions which make-up the comprehensive package of harm reduction services.

• In ~35% countries, IDU-targeted ART and T&C services not available or not reported.

• In ~50%, OST and/or NSP not available or not reported.

• No country identified IDU-specific viral hepatitis and tuberculosis services.

Recommendation:

• Technical capacity building, resourcing and legal and policy reform … are necessary to enable scale-up of comprehensive services, both in the general community, and in closed settings.

Political commitment to harm reduction Gaps:

• 8 countries: harm reduction interventions which target IDUs.

– Some unable to commit appropriate resourcing.

– Commitment at the national/central level not reflected at the implementation/service level.

• 4 countries: have documented commitment;

– in practice not necessarily comprehensive services.

– May not be voluntary.

• 3 countries: only limited commitment.

Comparison, 2006-2010:

• Greater, documented commitment; challenge remains to translate commitment to service provision.

Recommendation:

• Donors, United Nations and technical agencies and civil society have a strong role to play in contributing to sustainability and effectiveness of IDU-targeted harm reduction programs.

Multi-sectoral and civil society involvement in the response

Gaps:

• 9 countries: limited, effective civil society engagement.

• Response driven by law enforcement in some countries.

• Poor multi-sectoral coordination between central level and service level.

• Civil society orgs leading human rights-based approach to HIV prevention amongst PWIDs.

Comparison, 2006-2010:

• Greater multi-sectoral and civil society involvement

• Initiation of multi-sectoral and civil society involvement

• Meaningful civil society involvement in planning and decision making still a gap.

Multi-sectoral and civil society involvement in response

Recommendations:

• Ensuring multi-sectoral and civil society involvement.

• Multi-sectoral involvement of government agencies essential to ensuring the harm reduction response is both comprehensive and incorporates a human rights-based approach.

• Civil society involvement (including PWID groups) in policy/strategy development and program planning essential to ensure programs meet identified needs.

• Prohibitive laws and policies which inhibit civil society involvement should be reviewed and replaced with enabling processes.

Involvement of PWID in the response

Gaps:

• Only ~60% identified PWID involvement in delivery of services.

• 12 countries: PWID not involved in the development of policies and strategies, or planning, monitoring and evaluation of harm reduction programs.

Comparison, 2006-2010:

• Greater involvement of PWID in policy, strategy, program development in South East Asia.

• In most countries, PWID involvement is still limited to service delivery.

Recommendation:

• Donors, United Nations and technical agencies must play a strong role in advocating for the inclusion of PWID in national planning and coordination processes.

Legal and policy environment

Gaps:

• National HIV and AIDS strategies and programs support harm reduction activities, despite laws which prohibit or inhibit NSPs, OST or targeted education.

• 12 countries: laws prohibit at least 1 of the 9 core interventions.

• Supportive legal reform in ~35% of countries; often not accompanied by capacity building of law enforcement.

Comparison, 2006-2010:

• Documented, policy environment has improved.

• Legal reforms in place, or committed to.

Legal and policy environment

Recommendations:

• Advocacy and technical support from donors, United Nations and technical agencies, civil society and national Bar Associations should be directed to amending (or clarifying) laws which prohibit harm reduction approaches, stigmatise those who access or deliver services, or inhibit human rights.

• Involvement of the judiciary as a multi-sectoral partner in national and sub-national HIV and AIDS policy/strategy development.

Capacity and resourcing

Gaps:

• Resourcing insubstantial to achieve necessary scale-up.

• Particularly so for M&E.

• Limited technical capacity for policy development, program planning, service delivery, M&E.

– Considered the most important barrier to scale-up.

Comparison, 2006-2010:

• Donor initiatives, especially TGF, DfID, AusAID, USAID … contributing increased resources for scale-up.

• Donor support remains an issue.

Recommendations:

• Technical agencies to prioritise capacity development for data collection, reporting and analysis.

• Donors to prioritise the resourcing of same.

Surveillance and M&E

Gaps:

• Surveillance fails to disaggregate for PWID poor denominators.

• PWID surveillance often passive; misses non-attendees.

• Behavioural surveillance often in service areas leads to bias.

• M&E capacity of service providers low.

Comparison, 2006-2010:

• Minimal improvement since 2006.

Recommendations:

• Technical agencies to commit to building capacity for data collection, reporting and analysis.

• Donors to prioritise the resourcing of same.

Prisons & Compulsory Centres for Drug Users

Gaps:

• Only 5 countries provide harm reduction in prison settings.

• Limited information regarding services in CCDUs.

Comparison, 2006-2010:

• Progress in

– Indonesia, Malaysia, Cambodia, Viet Nam and India.

Future follow-up surveys

Additional Recommendations:

• A mechanism to capture regional, civil society and drug user led initiatives to be considered in future follow-up of this activity.

• Follow-up of the activity should be conducted within 3 years

– Reflecting the increased momentum of the harm reduction response in Asia.

– Reflecting the capacity of in-country teams to devote time to this activity.

Acknowledgements

• Thank you to all regional and country-level personnel who contributed to the update:

Dr Tasnim Azim, Ezazul Islam Chowdhury, Dr Adeeba Kamarulzaman, Tariq

Zafar, Ton Smits, Baralee Meesukh, Pascal Tanguay, Carmen Chan, Harsheth

Virk, Dr M. Suresh Kumar, Karyn Kaplan, Dr Mukta Sharma, Dr Salil Panakadan, Rokhsana Reza, Dr Mozammel Hoque, Graham Shaw, Phauly Tea, Tony Lisle, Peter Lunding, Dr Nwe Nwe Aye, Dr Bernhard Schwartlander,

Giovanni Nicotera, Markus Buhler, Olivier Lermet, Alankar Malviya, Bobby Rawal Basnet, Dr. Ma. Elena G. Filio-Borromeo, Oussama Tawil, Dr Muhammad Saleem, Nadeem Rehman, Zimmbodilion Mosende, Teresita

Marie Bagasao, Dr Madeline Salva, David Bridger, Dr Vladanka Andreeva, Asia Dong Phuong Nguyen, Jason Eligh, Dr. David Jacka, Cho Kah Sin, Dr Bob Verbruggen, Rachel Odede, Kunal Kishore, Cristina Albertin, Suruchi Pant,

Gray Sattler

• Special thanks:

Dr Anne Bergenstrom and Jimmy Dorabjee

Acknowledgements

• Thank you to SIDA for supporting the work of the UN RTF, and the completion of the 2009 update.

Report available

• Burnet Institute website www.burnet.edu.au

• UNODC website

www.unodc.org/eastasiaandpacific/