The programs for reduction of drug related harms in Macedonia were introduced in 1996 when the Association for Socio-cultural Activities MASK opened the first Needle exchange program, which was maintained the following year by HOPS – Healthy Options Project Skopje. Since then 16 harm reduction programs have been developed, four of which in Skopje and one in 13 other cities. The programs for reduction of drug related harms in Macedonia are complementary, i.e. they offer different services in one place – sterile injection equipment, condoms, services from a medical person, a social worker, fieldwork, HIV and Hepatitis C tests, while in 6 cities we offer free legal aid as well. This characteristic helps distinguish the programs as good practice not only in the region but broader as well. In addition many study visits have been realized in Macedonia where participants from different countries have visited HOPS’s programs in Skopje and acquired knowledge on how to develop a successful program for reduction of drug related harms.
Apart from the City of Skopje, participant in the co-financing of one harm reduction centre (finances 2 employees – a coordinator and a social worker, and covers the rent expenses and the medical waste incineration), all other programs and activities are financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria, whose support is coming to a close in 2016. At present, the continuity of the programs is uncertain due to the lack of financial support once the project supported by the Global Fund ends. Therefore, this year HOPS analyzed the harm reduction programs in order to contribute in finding ways for their financing and sustenance by proposing two models – a minimal model with minimal number of services and minimal finances and an optimal model with optimal number of services and accordingly, with optimal finances.
Methodology used in the Study
The Study required an analysis of the annual budgets, as well as the number of clients and of provided services in 2012, 2013 and the first 9 months of 2014 in all programs for reduction of drug related harms in Macedonia. Those are the programs implemented by the following citizens’ associations: HOPS – Healthy Options Project Skopje, Izbor Strumica in Strumica and Gevgelija, Via Vita Bitola, Zona Kavadarci, Opcija Ohrid, Help Gostivar, CDPPL Tetovo, Puls Kumanovo, Youth Clib Stip, as well as the Red Cross in Macedonia which implements the programs in Kicevo, Prilep and Veles.
The analysis and the two recommended models – a minimal and an optimal model for the harm reduction programs was a subject of discussion at a joint meeting of all organizations that implement these programs.
In addition to the analysis of the budget and activities of the programs for reduction of drug related harms we carried out three discussions with focus groups with the purpose to hear the opinion of users of harm reduction programs and implement their views in the recommendations for the sustenance and further development of these programs.
The efficiency in coexistence with substitution therapy programs
A significant number of records show that harm reduction programs are more efficient when needle exchange programs are joined by substitution therapy programs, i.e. methadone and buprenorphine. Namely, most studies show that the combination of these two programs increases the efficiency in decreasing the HIV and Hepatitis C incidence, i.e. their efficiency is significantly smaller when only one of these two programs is active. (Van Den Berg et all. 2007) This has particular influence on the attempts to reduce the HCV infection.
Hence, the continuity of the programs for reduction of drug related harms in Macedonia is significant for increasing the efficiency of the existing dependence treatment programs in 10 cities throughout the country.
Many studies indicate that the programs for reduction of harm related drugs are financially profitable. Consequently, in 2004 the World Health Organization analyzed several studies researching this matter and concluded that there is sufficient evidence in favour of the financial profitability of needle exchange programs. The profitability rate depends on the type of program, more precisely on the services offered as well as the local characteristics where it is implemented.
According to Lurie & Drucker’s assessment, the number of HIV infections that could have been prevented in the USA, provided there were such programs in the early phases of the HIV epidemics, would have been between 4,394 (15% incidence reduction) and 9,666 (33% incidence reduction). The HIV infection cost the USA health care system between 244 and 538 million dollars respectively.
In Macedonia, the costs per client differ depending on the program and the type of the services provided.
In Skopje, the annual cost per client is 155 Euros. This amount includes free injecting equipment, condoms, free bandages and basic care of wounds caused by long-term or incorrect injection of drugs, health counselling, 20 types of social services, most of which are assistance when applying for personal identification documents in different institutions, counselling on reduction of drug related harms, overdose prevention, referrals to the appropriate social and health institutions, as well as free legal aid. In comparison, only the pharmacotherapy costs, i.e. the Hepatitis C medicament in Macedonia is around 13,000 Euros a year per client. Of course, if we add to this the percentage health institutions spend on treatment, the total amount is much higher.
Views and needs of individuals using the services of harm reduction programs
Discussions with users of harm reduction programs have confirmed the findings based on the experiences of people working/volunteering in these programs. All respondents expressed fear at the mere mentioning of the possibility that the harm reduction centres may be closed or some of the existing services may be terminated. Furthermore, all respondents indicated to a need from additional services, as well as additions to the already existing services. Particularly apparent was their contentment with the benefits from the protection of their health and re-socialization they experienced as a result of the existing programs. Of course, in their opinion the programs are not perfect, however, they were even more thrilled to share their ideas for improving the existing services, granted there are possibilities for that. Still, when asked to make a selection of the existing services based on their needs, the following answers were received.
“All services are important. All services are of priority and are indivisible. We point to certain services only at your insistence. Every service is important depending on the personal needs of the users. Different users use different services. Some take injecting equipment more often, others need medical services or social services, and at times several services are used simultaneously.” All of the respondents share the opinion that the organizations implementing the harm reduction programs should make efforts to maintain the existing services and introduce new, as opposed to the termination of the old services from the programs.
Most users started visiting the harm reduction centres due to the need of sterile injecting equipment, however continued to use other services as well, depending on their personal needs. The centres are of such significance to them that even when not in need of a particular service they visit them to socialize because, as they stated, there they feel comfortable, they feel accepted and heard by others. One person stated that the visits to the harm reduction centre and use of the existing services fills him up with positive energy, thus stressing the importance of these centres.
All respondents stressed that the possible termination of the harm reduction programs or of any of the existing services would have severe consequences on their health as well as the public health because infections as Hepatitis B and C and HIV will be more difficult to control. Therefore, they all pointed to the competent state institutions as the key factor in sustaining the programs for reduction of drug related harms.
Models of the harm reduction programs
All 16 harm reduction programs implemented in 13 cities in Macedonia are realized by professionally trained complementary teams which offer more services in one place – sterile injecting equipment, services from a medical person, social workers, fieldwork HIV and Hepatitis C testing. Legal services, free legal aid, is offered through the programs in Skopje, Strumica, Prilep, Kicevo, Tetovo and Veles.
During 2012, 2013 and the first 9 months of 2014, within these programs there were 170,186 contacts with drug injecting persons, or averagely 3,615 drug users annually. Out of them around 600 (584) are new clients being contacted for the first time that year. Averagely there were 56,728 contacts or around 16 contacts a year per user with these 3,615 users.
The analysis showed that all types of services offered by the programs are important to drug injecting persons and they contribute to the increasing number of contacted users. Of course, most of the drug injecting persons use the service for exchange of injecting equipment. However, in some programs, for instance the one in Tetovo, drug injecting persons tend to use the service of the social worker and a medical person rather than the exchange of injecting equipment.
If Macedonia is to continue encompassing a significant number of drug injecting persons with the harm reduction programs, and thus remain a country with low HIV prevalence, the already implemented programs have to be maintained without reducing the type of services and the activities being offered.
Owing to the need to maintain the existing services and activities offered within the harm reduction programs in Macedonia, the possible reduction of the finances is minimal. It might be possible to reduce the administrative expenses and the personnel not directly included in the organization or the implementation of the Program. However, the number of this type of personnel is very low, and in most organizations the entire personnel participates in the Program’s implementation.
There are three different models of programs in Macedonia: HOPS, which offers the broadest number of services (exchange of sterile injecting equipment, condoms, services from a social worker, medical person, psychiatrist, lawyer) in three drop-in centres and fieldwork with a vehicle, the second model are all other organizations, Bez Izbor from Strumica and Via Vita Bitola, offering standard services – injecting equipment exchange, condoms, services from a social worker and a medical person in one drop-in centre and fieldwork. The third model are Izbor Strumica and Via Vita Bitola, a combination of the first and the second model.
According to the estimations, the minimal model for all 16 existing harm reduction programs in Macedonia is 445,525 Euros, provided the entire personnel are contract engaged, i.e. 514,033 Euros if the entire personnel are employed and not contract engaged.
The optimal model is 502,330 Euros provided the entire personnel are contract engaged, i.e. 566,902 if the entire personnel are employed and not contract engaged.
The minimal model includes all services offered by the existing Program, however the administrative expenses that are not directly related with the Program are reduced, as is the number of personnel, where possible, which is in HOPS, Izbor Strumica and Via Vita Bitola. There are two variants of the minimal model – the first is payments of honorariums and the second – employing all engaged persons.
The optimal model includes all services offered by the existing program, however the administrative expenses that are not directly related with the Program are reduced. The number of personnel is reduced in the same programs as in the minimal model, bearing in mind that the reduction is smaller.
Finally, we can only hope that the people responsible for the Budget of the Republic of Macedonia in 2017, as well as the politicians who vote the Budget, will be humane and responsible to include the programs for reduction of drug related harms within the National Budget, and thus help the numerous families in Macedonia facing drug dependency problems.
The author is currently pursuing his Master’s degree in social politics. He has been working on drug related issues for fourteen years and has developed most of the harm reduction programs in Macedonia. Currently he is working as a manager of CEDR – Center for Education, Documentation and Research within HOPS. He is the author of numerous papers, publications and research. He is also an activist for human rights of marginalized communities and member of several national and international committees, bodies and forums, such as the European Commission’s Forum on Drugs in Brussels. Since 2014 he has been a member of the Board of the Eurasian Harm Reduction Network.