Side Event: Collaboration between government and civil society on health promotion, prevention and treatment of drug use

Organised by Government of Australia and the Civil Society Task Force

David Laffan, Assistant Secretary, Alcohol, Tobacco and Other Drugs Branch, Australian Department of Health

Distinguished delegates, ladies and gentleman, I am honoured to be co-chairing this important event with the Civil Society Task Force on Drugs.  This event in itself is an example of an important topic which the Government of Australia has been placing greater emphasis on at the Commission on Narcotic Drugs over the last few years.

Today we want to highlight the benefit that can be offered to communities and citizens when responses to the world drug problem can be supported by Governments working collaboratively with civil society. In a way, such a dialogue seems natural for the Australian Government, and indeed is an expectation of the Australian community.

Our National Drug Strategy 2017-2026 in founded with the fundamental purpose of providing a national framework to identify national priorities relating to alcohol, tobacco and other drugs, to guide actions by governments in partnership with service providers and the community, and to outline a national commitment to harm minimisation through a balanced adoption of effective demand, supply and harm reduction strategies. The basic aim of our National Drug Strategy is to build safe, healthy and resilient Australian communities through preventing and minimising alcohol, tobacco and other drug-related health, social, cultural and economic harms among individuals, families and communities.

For our Governments to be able to prevent and minimise such a range of harms to individuals, families and communities; we plainly must be willing to work with individuals, families and communities in respectful partnerships. Indeed, “partnerships” is one of the underpinning strategic principals of our National Drug Strategy. And while this type of dialogue is fundamental to the Australian domestic approach to the implementation of drug policy, it is worth recalling that as recently as last week the Commission on Narcotic Drugs underscored the important role of civil society in the consensus based Ministerial Statement on “Strengthening our actions at the national, regional and international levels to accelerate the implementation of our joint commitments to address and counter the world drug problem”.

In addition, the Ministerial Statement underscored the importance of promoting relevant partnerships.  So some of the practical examples we will use today to highlight Australia’s experience of collaboration between government and civil society on health promotion, prevention, and treatment of drug use may in fact be relevant more widely to Governments and civil society in other countries. It is promising to note that the engagement of civil society by members of the Commission and other Member States of the United Nations is improving over time, albeit at times this progress may feel slow and inconsistent. And in recognising the frustrations that members of civil society may feel about the pace of engagement, I am looking forward to hearing challenges that might be identified by civil society participants both on their panel today but also from the floor when we get to the opportunity for questions and comments.

But of course, today is not just an opportunity for civil society to highlight their views on successes and challenges in their meaningful engagement with Governments. It is also an opportunity for Governments to reflect on how we can accelerate our commitments to work constructively with civil society to help our citizens and communities come to terms with the issues that illicit drug use present. Allow me to offer a very specific example from recent drug policy developments in Australia.

In 2014, it became very clear to Governments, communities and individuals in Australia that there was a significant shift occurring in Australian drug markets. Crystal methamphetamine use was becoming more prevalent.  The drug was becoming more pure, cheaper and more readily available.  It was entering drug markets in areas of regional and rural Australia that had previously not seen such potentially harmful drugs. As a consequence of these changes, the harms associated with crystal methamphetamine use became much more apparent.  Presentations associated with methamphetamine use to ambulances and hospitals grew.  There were more call outs for police assistance to manage incidents associated with methamphetamine use.  The burden on treatment service was growing.

In response to this situation, the Commonwealth Government convened a National Ice Taskforce lead by senior law enforcement officials and health practitioners.  This Taskforce convened a detailed series of public consultations in communities all around Australia and took written submissions. The result of all this was that the Taskforce put down a report of possible responses and this was provided to Commonwealth, State and Territory Governments. Together under the banner of the Council of Australian Governments, our National Ice Action Strategy was adopted in 2015.  This Strategy included a significant investment of $2xx.x million Australian dollars to improve access to a number of health promotion and prevention activities, additional treatment services, research, data improvements and information services.

But the thing about this that will no doubt be of most interest to you today is that the implementation of this Strategy and this significant investment was almost entirely done through a robust collaboration between Government and civil society. Non-Government organisations managed and staffed the additional treatment services.  Academia worked with Governments to develop the research agenda and data improvements that supported further policy development.  And National non-Government organisation developed the Local Drug Action Teams that formed the main activities supporting health promotion and prevention activities under the Strategy.

I hope this practical example is useful for people to consider and I am sure that other panellists will have similarly practical examples to share. I thank our civil society representatives here, for the opportunity to share the Australian Government’s experience and thoughts on this topic with CND delegations participants and I look forward to the opportunity for an interactive discussion after. Now, I would like to introduce our co-chair for today from the Civil Society Taskforce on Drugs, Ms Heather Haase, to provide some observations on our theme today.

Heather Hasse, Civil Society Taskforce on Drugs

Close your eyes for a moment, picture what it’d be like here there was no civil society – imagine there were no professional, experts, user group or academics. It’s really difficult isn’t it?

In 2016 – Guterres said ‘CS is a key instrument for the success of today’s UN’. Partnership is a key element in solving global problems. I’ll talk about our version today of the CSTF partnering with member states.

CSTF – joint initiative on VNGOC and NYNGOC, originally formed for UNGASS 2016 – seeks to represent a broad range of speakers from all regions and key affected populations. We launched a civil society consultation last year, and are involved with speaker selections at UN sessions, UNGASS 2016 and CND. 35 members from around the world.

Successes – broadened CS engagement – 9 regions and 10 affected populations. Youth, families, PWUD, cultivators, etc. CS presence in all official sessions. We feel like we’ve learned to work together towards common goal of civil society. Shift in dialogue from punishment to public health, defence and promotion of human rights, partnerships between governments and civil society with wide ranging impact – overdose resolution 55/7 in 2012, IDPC shadow report, UNODC CSO Group on Drug Use and HIV, VNGOC Marketplace. Now many resolutions including civil society voices and key issues.

Remaining challenges – some governments are still warry of civil society participation – see civil society.

Why does this matter?

Chris Killick-Moran; Director, Research and International Drug Policy, Australian Department of Health

Thank you David and I would like to thank the other panellists and participants here today.  I am looking forward to a useful and constructive discussion on what is a very important topic. As has been noted already, the matter of collaboration between Governments and civil society in the development and implementation of policy responses to the world drug problem is very important and one that has been of increasing importance for Australia in the context of the Commission on Narcotic Drugs.

Mr Laffan has already provided one very pertinent and practical example of such collaboration from Australia’s recent domestic policy history and I will draw out a few examples myself. But I thought it might be useful to reflect on some of the recent reforms we have implemented in our engagement with civil society in preparations for the Commission, not to suggest that we have reached the end of such changes but to contemplate where we have further work to explore.

When I first started working on supporting Australia’s delegation to the Commission in 2013, there were good relations between the Government Delegation and civil society and much shared work, particularly on the matter of access to controlled substances for medical purposes. Australia has well-developed systems and mechanisms in place that facilitate consultative approaches in the development of policy and for policy implementation.

Through these consultative mechanisms and the maturity of this model and relationships, Government has been able to develop better policies, including implementation, and evaluation models and frameworks.  These have been welcomed by groups on the ground who are helping individuals. their families and communities to address and implement strategies in harm minimisation, education and integration for drug users. To illustrate this I will take a case study approach to discuss the approach taken by the Australian Government in developing the National Ice Strategy 2015 and the National Drug Strategy 2017-2026.

Australia committed to a post-2015 agenda that focussed global efforts on greater collaboration, sharing of knowledge, and capacity building.  This focus was built into our national framework which aimed at building safe, health and resilient Australian communities through preventing and minimising social and economic harms from drug related health issues. National data reporting and reporting from local communities indicated that an emerging prevalence of illicit drug use was emerging and was having a significant adverse impact on our indigenous and regional and rural communities. At an International level, it was is clear that the global burden of illicit drug use had the potential to hamper economic growth, and was therefore an important issue for the new post-2015 drug strategy. Australia’s  National Drug Strategy 2017-26, ‘A national framework for building safe, health and resilient Australian communities through preventing and minimising alcohol, tobacco and other drug related health, social and economic harms among individuals, families and communities’, built on the work undertaken during the development of the National Ice Action Strategy of 2015. It recognises that traditional approaches to tackling drug problems were no longer sufficient on their own to have an impact.

The purpose of the National Drug Strategy is to promote Australia’s interests by contributing to sustainable reduction in the uptake of drugs, through supporting the third sector capacity and strengthening systems and infrastructure to support that capacity building. We acknowledge that different countries are facing different challenges (ie different systems of government and lack of Civil Society forums) and so there is a need to respect national contexts and approaches. Global agencies and multilaterals such as the CND, INCB, and WHO  have a leadership role in Prevention and Control to counter the world drug problem and  have an important role to play in supporting countries to move from commitment to action and in building and supporting collaborative practices. This may include through providing technical advice, sharing lessons learned from other countries, and coordinating with each other to address priority issues through a multi-sectoral approach. Agencies such as the UNODC, INDB and CND (as a global organisation with a mandate to address the world drug problem) have an important role to play in economic development, including through support for infrastructure, which is linked to improving health outcomes through the WHO sustainable development goals.

Australia’s National Ice Action Strategy marked a shift in how Australia was to work in tackling its drug problems, with a greater focus on innovation and engagement with the non-government, private sector and civil society.  What is often referred to as the third sector, voluntary and community organisations, was recognised as an important resource to draw on, not only in terms of their capacity to deliver programs on the ground, but also in recognition that they had a lot to offer in providing insights into how to better improve program delivery, and feeding this back through being involved in consultation processes and mechanisms to provide advice to government more broadly. To date countries have embraced a cautious and measured approach to the concept of working collaboratively with civil society.  Progress has been equally measured. Working with civil society has the potential to provide a strong foundation for realising a greater rate of change and for sustainable programs and policies. Governments play a key role in providing strategic direction and the frameworks to support research, program implementation and effective reporting and monitoring and evaluation. The quality and depth of this work is immeasurably improved, through the inclusion of stakeholders from across all sectors and levels of government and by those who advocate on behalf of vulnerable groups and those who deliver programs. The Australian Government’s National Ice Action Strategy 2015 and National Drug Strategy 2017-2026, were informed through such a process.

Through an inclusive and consultative approach at the outset, the strategies were informed by reference to the evidence captured through effective reporting and data capture programs, and identification of emerging issues, and what was working on the ground, and what was not possible to be implemented due to lack of resources. The National Drug Strategy 2016-2025 was developed by a cross-jurisdictional Intergovernmental Committee on Drugs.  The strategy set out to provide a nationally agreed approach to prevent, minimise and address the harm caused by alcohol, tobacco and other drug use, both licit and illicit. Acknowledging that governments around Australia were already acting to address ice use, they contributed funding to support the recommendations of the National Ice Action Task Force.  The recommendations supplement the current level of activity that was in place by sub-national (State and territory governments) and the non-government sector. The taskforce report focused on the actions that would complement the level of and investment that was already in place. The National Drug Strategy at the time was drawn on to inform the work of the National Ice Action Strategy, and its three pillars to effectively address the harmful effects of ice use in Australia.  This was applied in a balanced way.  Further the taskforce identified areas where further action was warranted.

Consultations with experts and the community

The Task Force engaged extensively with people around Australia to develop their report. This included speaking to over 100 experts in the research, education, prevention treatment, law enforcement and support for users, families and Indigenous people. The Task Force also visited nine treatment and support services and received around 100 submissions from organisations, clinics, research bodies and academics as part of its public consultations process. The Health Ministers at the time, in concert with other parliamentarians, held community consultations around the country.  This represented significant high level buy in and built momentum and broader awareness of the work of the Taskforce. In addition to the Federal level political involvement, the taskforce also received extensive input and advice from all sub-national (state and territory governments), Commonwealth agencies and the Australian National Advisory Council on Drugs. Our extensive consultative process, although some may think time consuming, have benefitted those who we are, at the end of the day, the individuals, and communities we are trying to assist.

 

Carrie Fowlie, Oceania Representative of the Civil Society Taskforce on Drugs

Thank you co-Chairs and good afternoon Mr Ambassador, ladies and gentlemen.

 

It is an incredible privilege to be here to share two examples of successful collaborations between Australian civil society – including affected communities and notably people who use drugs – and government to improve the health and wellbeing of the Australian community.

 

It is custom in Australia to acknowledge our Indigenous peoples, I pay my respects to any Indigenous peoples here with us today.

 

I would also like to acknowledge the input I have received from civil society to which I am speaking today, including from the national representative organisations:

  • Australian Injecting and Illicit Drug Users League – for people who use or have used drugs
  • Hepatitis Australia – for the hepatitis community sector; and the
  • Australian Alcohol and other Drug Council – for the drug and alcohol sector

 

Partnership is the first strategic principle of Australia’s National Drug Strategy:

  • followed closely by evidence-informed responses
  • this is echoed in Australia’s blood borne virus strategies and provides an essential platform.

 

Two Australian examples of successful civil society and government collaboration & some next steps:

 

Example 1: Collaboration to enable unrestricted community access to subsidised medicines to treat hepatitis C in Australia

  • Viral hepatitis included in Sustainable Development Goal 3.3
  • In response, WHO developed the Global Viral Hepatitis Strategywhich
    • Sets ambitious goals: “elimination of hepatitis C as a major public health threat”
    • 2016: Adopted by all of its Member States & the targets are reflected in Australian domestic policy
    • +70 million people living with hepatitis C globally, only 20% diagnosed, and currently no effective vaccine – the task ahead is enormous
  • Prevalence of hepatitis C among people who use drugs remains extremely high
    • This has been highlighted in the UNODC World Drug Report (2017)
  • CND62 – resolution L4 is focussed on hepatitis C

Australian context

  • Most Australians affected with hepatitis C have histories of injecting drug use
  • Hepatitis C is the major cause of the large burden of liver disease
  • The new direct-acting antiviral medicines:
    • Can cure 95% of people treated
    • Have the capacity to prevent serious liver disease and transmission of hepatitis C
    • Are low cost to the consumer, effective, have few side effects, and have dramatic & rapid benefits.

Australian achievements

Following ongoing dialogue with civil society, the Australian Government has taken a proactive approach to treating hepatitis C including:

  • Investing $1 billion Australian dollars over five years
  • +230,000 Australians living with the disease
  • Direct-acting antiviral hepatitis medicines:
    • Effective for all types of the disease
    • Listed Australia’s national scheme that subsidises medicines
      • Before this listing these medicines were not affordable
    • 2016: subsidised hepatitis C medicines available in Australia
      • Initially between 3-6,000 people were being treated each month.
      • Now people commencing treatment is below 1,000 people per month.
      • Specific action is needed to lift treatment levels to support the 2030 elimination goals and national targets.

Policy co-design

A notable outcome of the collaboration between civil society and government has been the policy design, including that:

  • Australia is implementing a program of unrestricted access to medicines
    • All adults with hepatitis C are eligible including people with ongoing drug and alcohol use and people in custody
    • This promotes non-stigmatizing attitudes to ensure the availability of access to and delivery of health, care and social services for drug users (CND61/11)
  • Involvement of non-specialist general medical practitioners in hepatitis C treatment
    • Builds on Australia’s history of general medical practitioner involvement in HIV and drug treatments such as opioid substitution therapy

Example 2: Collaboration to enable community access to the subsidised medicine naloxone to reverse opioid overdose in Australia

  • Naloxone is listed in the core list of World Health Organisation’s Essential Medicines
  • 2012: Endorsed by the WHO, UNODC and UNAIDS Technical Guide
    • For countries to set targets for universal access to HIV prevention, treatment and care for people who inject drugs.
  • 2014: WHO recommended that people likely to witness an overdose should have access to naloxone.
  • 2018: INCB President “Naloxone is not a controlled substance, we encourage its access to prevent overdose.”
  • Past 20 years: large expansion of programs where naloxone is supplied for people to take home for layperson administration.
    • These programs recommended by the WHO in response to rising opioid-related deaths
  • CND62 – resolutions L5 and L7 have prompted dialogue about the importance of access to naloxone.

Australian context

  • Opioid related deaths have increased in the last 10 years
  • With 6.6 deaths per 100,000 Australians in 2016 (most recent data available)
    • This was the highest number since the peak in 1999
  • In Australia, most (70%) fatal overdoses now involve pharmaceutical opioids.
  • Naloxone is a safe, highly effective rescue medicine for opioid overdose and is available in Australia.

Australian achievements

2012: Take-home naloxone programs were initiated by civil society

  • Many pilot programs involved peer organisations and are operated through services for people who inject drugs.
  • More recently, naloxone has become more embedded in routine health care in a small number of other health services.

Following ongoing dialogue with civil society the Australian Government has taken an active approach to responding to opioid overdose including:

  • 2016: naloxone changed from being available only on prescription to also being for sale over-the-counter in pharmacies.
  • 2018: under the governance of Australian’s National Drug Strategy: Opioid Working Group established
  • 2019: the government committed A$7.2 million dollars over 2 years to pilot a take-home naloxone program in Australia & funding for researchers to identify the key principles and features of a nationally consistent take home naloxone model for Australia.

Moving forward

  • The first statement in the ‘way forward’ section of CND62 Ministerial Declaration states:
    • We commit to safeguard our future and ensure that no one affected by the world drug problem is left behind
    • Addressing the specific needs of vulnerable members of society in response to the world drug problem (CND61/7)
    • … understanding of the specific needs of vulnerable members of society in response to the world drug problem
    • … promote a participatory role for all relevant members of society, in particular those who are vulnerable, in the development and implementation of the national drug policies and programmes
    • …. when developing drug policies and programmes addressing the specific needs of vulnerable members of society, to promote a participatory role, where appropriate, for the scientific community and academia, through the scientific evidence they provide, and for civil society

Moving forward: Australia

The Australian Government:

  • provided additional and new funding for medicines while maintaining a commitment to:
    • comprehensive responses and funding to civil society and government delivered services across the spectrum of health promotion, prevention, treatment and harm reduction including needle and syringe programs, hepatitis c screening, opioid substitution treatment, rehabilitation and overdose education.
  • Also committed to including the community voice in the development of policies
    • demonstrated by the strong involvement of civil society in the content and goals of national strategies.

Important to protect and strengthen going forward

  • Well established in health promotion:
    • a key problem with top down & population wide solutions is that they inevitably create groups of people that are difficult to reach.
  • A consequence: a crucial role for civil society partnership, because civil society can involve the affected communities and NGOs to create a locally based, bottom-up actions that reflects local needs
  • This complements and leverages the top down approach and enables access hard to reach, vulnerable and excluded people.
  • The importance of understanding and responding to access and availability:
    • Where these medicines are & aren’t available, financial & eligibility barriers
    • Australia has impediments to people benefiting from these initiatives
    • Civil society has the capacity to assess and respond to gaps and to produce tailored and custom-made solutions

Summary

  • Achievements result of open, ongoing and structured dialogue and collaboration between civil society and government in Australia
  • Subsidising medicines has been essential
  • Critical next steps:
    • Understand and respond to diverse community needs (and barriers) to ensure access to these medicines
    • Acknowledge and work within this complexity

Collaborative government and civil society policy development, implementation, and evaluation will help ensure our drug and other policies are fit for purpose, more easily implementable and – especially in the two Australian examples provided – are scaled up to reach the communities who need them most & no-one is left behind

Achievements are one result of open, ongoing and structured dialogue and collaboration between civil society and government in Australia.

Questions

Benjamin Philips, NYNGOC: I’d like to thank the Australian government for its leadership and support of this important dialogue. As an Australian citizen, and the manager of the New York NGO Committee on Drugs, and part of the Civil Society Taskforce (CSTF) Secretariat this topic is particularly important to me—and by the turn out here in the room today— to many others too.

I wanted to highlight the importance of civil society being centered in the drug policy process, and I’d like use this opportunity to praise UNODC’s Global HIV Program for its leadership in institutionalizing meaningful civil society participation.

Over the last 7 years the UNODC CSO Group on Drug Use and HIV has brought together 25 global and regional civil society networks specializing in drug use and HIV. An annual meeting and work-plan drives a partnership that has addressed specialist aspects of the HIV response with people who use drugs covering women, stimulants, policing, prisons, drug treatment, the financing of the response, data collection and community mobilization.

In addition, the Strategic Advisory Group (also known as the SAG) brings together member states, the UN and civil society, to review and consider new evidence, and to identify gaps in the strategic information to develop our collective understanding of the evolving HIV epidemic among people who use drugs, and the impact of the global response.

These two key civil society partnership mechanisms between global and regional networks specializing in drug use and HIV, include networks of people who use drugs. These dynamic partnerships allow us to work out how to make sure no one is left behind in global effort to end HIV as a global epidemic.

Question, David McDonald: We have a number of successful partnerships, but some partnerships have not been fruitful and are sometimes counterproductive for either side. Could you comment?

Heather Hasse: Yes, it can be challenging – sometimes partnerships just don’t work. One of our challenges is ideology of agency or government, which can make it difficult to navigate.

David Laffan: All need to acknowledge things from the past and focus on forward journey. Want to recognize ways to benefit people who use drugs in attaining health. In our bilateral with CS yesterday we were very forward thinking – discussed what it will look like over last 3-5 years and into the future.

Steve Allsop, Australian Delegation, Research: Evidence based medicine – need randomized controlled trials – but sometimes they exclude young people, people affected by mental health problems, indigenous people. Research needs to take into account the needs and wants of the people involved in it and who will benefit for it. We need to combine science, practitioners and those who we seek to serve.

Question, Erin Lalor: Australia has done well in working with civil society on prevention, treatment and harm reduction. What implications does this have on international civil society?

David Laffan: Commitment to this

Chris Killick-Moran: When we meet with bilaterals with other countries, they’re not necessarily dialogues they’d like to have in public. We can lead by example and lead the discussions.

David Laffan: Can’t afford to be complacent. Australia encourages all member states to lead by example and interact with their civil society counterparts.

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