Towards better measurements and improved system-wide coherence: Policy indicators, development and public health

Side event organised by the International Drug Policy Consortium, the Global Drug Policy Observatory, Switzerland
 
Martin Matter, Switzerland. Available data and indicators are ill suited to assess the impact of drug control. Unexpected, adverse and unintended consequences will not show. If the purpose is to understand how policy affects the drugs phenomenon, then a broad range of intended and unintended consequences should be considered and indicators should be defined in this light. The goal of today is to discuss what the indicators could be.

Dave Bewley-Taylor, Global Drug Policy Observatory. We can all agree that numbers, metrics and indicators, are playing an important role. We must recall that the system has 2 aims: supply of pharmaceuticals for scientific and medical purposes, and avoid non-medical use. The system was based and became developed upon 2 tenants: minimise the scale and eliminate the market through supply measures. The pre-UN period metrics related mostly on import-export statistics. The concern was mainly medical and scientific markets and prevention of leakage in illicit markets. The delineation of a legal trade was the identification of an illicit market, but discussions focused on monitoring the licit market.

After 1961, the focus became on the illicit market. This shift in focus is partly due to the revised bureaucratic structures and a recognition of the problem of a more established illicit market. The system was at the time considered as a model for regulating other illicit markets, such as weapons. There was definitions of hard and soft law and additional conventions. This was the tagline for the event in 1998 and the adoption of the political declaration. But there has been increasing doubts about the system, shared responsibility and balanced approach appeared.

Another decade or so later, we had a similar outcome in 2009 with a deadline in 2019 for eradicating the market. But we adopted 3 pillars for measuring progress. The existing pillars in demand reduction, supply reduction, and international cooperation, limit the way the CND assesses the performance of the system. These metrics are still dominated with seizures and arrests, creating systemic tensions. There is a growing realisation that these indicators are insufficient as we understand more about the nature of drug markets and how they are influenced by domestic measures.

The world drug problem is a weaked problem, which is difficult to solve. This approach fits well with a shifting policy – away from elimination towards market management. Some governments are now looking at this in a more sophisticated way. And here, there are also increasing discussions on the need to shift away from process indicators towards impacts indicators and responses that have an impact on security and the socio-economic development of our communities, increased well being and quality of life. These have great emphasis on health and human rights. At the system level, there is also some movement with the World Drug Report and other mechanisms.

We must also realise that this problem needs to be seen in holistic terms, and link the drug problem with other weaked problems that are interrelated. Complex indicators related to security, development and health, should be used to break the silos of the three pillars. And there is the issue of essential medicines – the three pillars don’t assess this issue adequately.

Alison Crocket, UNAIDS. I won’t speak too much about the issues as these have been widely discussed this week already. The WHO, UNODC, UNDP, many UN bodies have discussed health, and we are well aware about what the heath issues are – burden of HIV, dearth of access to essential medicines and other issues. I want to discuss what the measurements might be. What Dave discussed was an integrated approach. Health is not only about physical health but also about well being and the environment where people live has an impact on their well being. This is something that UNAIDS has been working on for some time, what we call critical enablers.

What could we work towards if we were taking a public health approach? Clearly, the harm reduction approach is critical and central to a health approach towards people who use drugs, and this includes OST, NSP, naloxone, but also a place where they can be without fear of arrest and detention without judicial due process. We also think that the heavy reliance on a criminal procedure to manage drug use has a significant impact on people’s lives and can be counter productive. It has also not achieved a reduction in drug use. It also serves to drive people who use drugs away from the services they need, and puts them away in an environment where they are created as criminals. We should move away from heavy criminalisation of drug users.

The police has an impact on the way people can access services and protect themselves from infections. Sex workers and gay communities who are criminalised also increases their vulnerability. The opposite is true, when a public health approach is adopted, things improve. There are many ways in which the police touches on public health and drug use is another way in which they can act with discretion. The police should not necessarily become social workers but can conduct their duties in an efficient way.

The studies we have have shown that in areas where these changes have taken place, positive outcomes have materialised. A more holistic, integrated approach with the police and law enforcement working with health providers has had very beneficial impacts. HIV, hepatitis C are huge epidemics that can also be tackled more effectively through better drug policies. There is a high return in investment and less waste when we work together. We look forward to taking the opportunity to working more together on this issue.

Mike Trace. IDPC. I would like to share my experience as drug czar in the UK. We decided that we wanted to be very clear with the UK public about what we wanted to do and achieve in drug policy. We said we would run a 10 year strategy, with key achievements and targets. We felt very brave in those days. Looking back on the indicators set out then, I think we could have done better to map our key indicators and we made some mistakes in coherence, but it was a very good attempt at identifying what we were seeking to achieve. Our outcome objectives were 5:

  • reduce scale of drug markets
  • reduce availability of drugs
  • reduce crime associated with use and markets
  • reduce health harms
  • implement more treatment

You can see the incoherence straight away – there are 4 outcome objectives, and one process objective which did not sit easily in the system. What we should have done were – what are the actions, given science then, were best to achieve our objectives. We had prevention, treatment and law enforcement, with a set of activities funded by the government to expand them, to achieve our key objectives.

The third level of our strategy was to measure implementation – what was the penetration of our treatment system. We had around 300 000 to 400 000 people with drug dependence, and only 60 to 70 000 of them in prison. We have made much progress now with about 70% of our target population in treatment. In terms of prevention, we sought to reach people at the right age. We measured this at the extent of implementation. In the field of law enforcement, we used usual indicators with seizures and arrests.

The fourth level of implementation was about whether we had achieved our objectives. And this is where governments are less enthusiastic about going through this process ,10 years into implementation. In general, we have had a very good track record in reducing health harms and drug related crime. In prevention, most of our evaluations came back negatively, they had very little impact but overall the prevalence of drug use had gone down so our overall objectives were being met so we succeeded somehow but not with the programmes we thought would achieve this objective. In terms of law enforcement, we engaged in a lot of policing but this had very little impact on the availability of drugs in the illicit market. The ultimate objective was not met, but then prevalence was down so this is interesting for lessons learned.

In terms of UN indicators, I have been very critical about the indicators we use there. The top indicator is reducing supply and demand and increasing cooperation. These are processes we use to reach the goal of achieving the health and welfare of mankind. We have for decades focused on key indicators and we tend to think of them in very simplistic indicators. We think in how many people use drugs. This is fair, but does not lead to less health and social problems and how interconnected these are. In terms of supply we are asking ourselves if we had more arrests, more seized drugs, more eradicated crops. But we do know that these have no linear connection to how much drugs is being used. We had very little impact on the fundamental outcome – availability.

We do have a challenge. We have become accustomed to some indicators that are incoherent with the rest of the UN system – health and welfare, security, emerging post-2015 development goals. We should seek to achieving system-wide coherence by working together with the rest of the UN system.

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