Harm reduction programs: from fantasy to implementation
20 april 2018
SIMPLY STRATEGIES THAT SAVE LIVES
If you returned to times of the first syringe exchange in Sumy, everything that is happening now would seem like an incredible stuff. Such news as the narcological dispensary buys and distributes a clean injection syringe to its patients. Such news about budget funds for social support of SMT clients. The fact that monthly methadone course costs 18$ and it can be purchased in a municipal pharmacy at the doctor prescription. The fact that the local authorities financially supported the work of a mobile ambulance station for drug users on the distribution of clean syringes and testing for HIV that drives around the city and region districts. Such news as the center for integrated care with an infectiologist, phthisiatrician and gynecologist in the staff is opened on the narcology basis, as well as harm reduction rooms for IDUs. It really was hard to believe it, considering that there was completely different situation before.
HOW IT STARTED
This year will be 17-years anniversary from the moment when the first syringe exchange appeared in Sumy. I remember very well my reaction to the news that on a designated day and time you can go outside to a person who will give clean syringes and alcohol wipes in exchange for used ones.
Perceiving everything related to drugs through my own experience of communicating with law enforcement, in particular several convictions for drug possession, manufacture and five years of forced treatment from drugs, I had had some hesitation before the first visit to syringe exchange. However, getting to know the social worker, later I became a regular visitor, where heard about the harm reduction strategy from drug use at the first time, and then I felt its positive impact on my own life.
SMELL OF METHADONE
2-3 years after the first SEs appearance, news came to us. In the nearest future methadone should have appeared at the Regional AIDS center. That news was well-discussed among Sumy IDUs at syringe exchanges.
Most prospective patients of the methadone program thought that it wouldn’t happen, because it would be impossible to allow drug addicts to celebrate such a feast. It should be noted that it was true that time: methadone didn’t appear in Ukraine in 2003 due to a number of regulatory barriers.
Subsequently, the first programs of the Global Fund in Ukraine were launched, which allowed to implement the harm reduction projects after the International Renaissance Foundation. The quantitative and geographical coverage of drug users by programs were gradually increased, the range of harm reduction services were expanded: testing for HIV and viral hepatitis was begun, mobile ambulance stations were appeared, and the dynamic implementation of substitution therapy in the Sumy region began in 2008. At the same time, there was confidence that it would always be like this.
FIRST TENDRILS OF FEAR
Beginning in 2014, the issue of further fate of harm reduction programs has started to emerge more and more alarmingly, in context of funding reduction from international donors. The prospect of disappearing programs for drug users frightened SMT patients who received vital treatment solely at the expense of the Global Fund. Those days we realized that without attracting resources from local budgets, we couldn’t save the efficient strategies, developed models of medical and social programs, as well as leadership of non-governmental organizations in the issues of combating socially dangerous diseases that were made.
CHANGE OF PRIORITIES
Resources of local budgets for solving any medical and social problems can only be achieved if there is a common unified vision of local authorities, medical, social services and active non-governmental organizations. Our efforts were directed to the formation of local policy in the social field during the latest years.
And our efforts were not wasted. Nowadays medical and social programs for people who use drugs are among the priority issues of public health in the region that need immediate resolution. In addition, local authorities and local non-governmental organizations in Sumy region identified ways to address the problem of spreading socially dangerous diseases among drug users: these are efficient programs and scientifically proven methods of treatment based on best practices in the world.
FROM PRECEDENTS TO SUSTAINABLE PRACTICES
For 2014-2015, we succeeded in implementing the precedent of attracting resources from local budgets for harm reduction program among patients of regional narcological dispensary. We did almost impossible thing: we changed the drug service attitudes to those which aimed not only at the complete refusal from drugs. In the narcology dispensary staff the first social workers were appeared, and the functional duties of the medical staff of the patronage service were supplemented by classical harm reduction services, including the distribution of clean injection equipment.
During the preventive care implementation the narcological dispensary human and material resources were used only of health care institution (the position of a social worker and syringes purchased at the expense of the dispensary). We did it without a single penny from international organizations.
The program services covered 47 dispensary patients among Sumy drug users. Of course, that didn’t solve the problem of harm reduction services transition to budget financing. The importance of the precedent was more political than practical. But after the first success came the other ones.
WHAT GOES AROUND, COMES AROUND
Since 2014, the formation of local policies took place due to development and approval of important regulatory acts and various directives. In particular, there were regional target programs of social field. Due to our initiative and participation the following programs were approved and implemented in Sumy region: Regional program on the implementation of the state drug policy in Sumy region; Regional Social Program on HIV/AIDS Response in 2015-2018; Regional target program for solving priority issues using the social services ordering mechanism in 2017; Regional target program for solving priority issues using the social service ordering mechanism in 2018.
The program activities include the attraction of local budgets for medical and social programs for people who use drugs (syringe delivery, testing, SMT) starting in 2017.
These funds could remain only a declaration of intentions by the authorities, as it often happens. One of the main reasons was that the mechanisms of funding public organizations at the expense of local budgets to provide this kind of social services were still not worked out.
JOY IN STABILITY
Among all unforbidden mechanisms in Ukraine, the best way of ensuring the sustainability of harm reduction services should be considered the procurement of such social services from non-governmental organizations. So we implemented it, having received a social service ordering for support of 230 patients with SMT at the regional narcological dispensary. That was the first case for attracting budget funds for medical services using the social ordering mechanism in Ukraine.
Procurement of social support services for patients with SMT at the regional narcology dispensary should be considered as a significant event in ensuring the sustainability of harm reduction. First of all, local authorities appreciated substitution therapy as an efficient method of treating drug addiction. Secondly, it is equally important to implement the first procurement of social services in Ukraine through the ProZorro Electronic Procurement System. This greatly simplifies the procedures for financing social services, creates conditions for healthy rivalry and promotes the improvement of services quality for target groups.
In 2018, the Sumy Regional Narcological Dispensary through the electronic procurement system ProZorro purchased social services for patients with SMT in the amount of 287,500 UAH. Due to that, almost 500 SMT patients in Sumy region will receive social support services from March to December 2018. This event is a logical continuation of the process of social services denationalization provided in 2016-2017.
The best part is the fact that financing of social support services for SMT patients with the funds of the regional budget took place while the state budget in 2017 for the first time provided the funds for procurement of SMT drugs. Thus, Sumy region became the first region of Ukraine, where the SMT program implementation for all patients is financed by budget funds for 100%, without a single cent of international assistance.
MORE THAN PRAGMATISM
For me, the strategy to reduce harm from drug use is more than a pragmatic approach to the benefits of public health in working with people who use drugs. It is a philosophy and a vital position. It is not only the formation of safe behavior, scientifically based treatment of drug addiction and access to medical and social services for people who use drugs. From the syringe exchange program user to the leader of the most powerful non-governmental organization, I know from my own experience that harm reduction is a community mobilization and a leadership development in advocacy strategies and programs that save health and change lives of many people for the better.
Executive Director of NGO “Club” Chance”