Harm Reduction Rise and Fall. The Lessons Learned from the Greek Experience, Challenges and Recommendations

Background

Greece traditionally was tailored towards abstinence- based models, and in comparison, with other EU countries was slower on adopting harm reduction on the national drug policy. Greece belongs to the EU countries with the lowest coverage of needle and syringe provision as well as OST [2, 3], disproportionate lower when considering the drug misuse problem from the general population and the early on start of the disorder.

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For many years the insufficient provision of Opioid Substitution Treatment (OST) in Greece was unable to correspond with the demand for services. As indicative in August 2010, more than 5.300 people were on the waiting list for OST; whereas the average waiting time in Athens was more approximately seven years. This combined with lack of programs to supply clean needles and low uptake of antiretroviral therapy for IDUs were predominant factors for the HIV outbreak [4, 5]. The negative societal attitudes and prejudice against harm reduction and lack of political commitment have influenced the development of harm reduction programming. The societal prejudices and opposition from local residents led on 2011 to the closure of four OST units in the centre of Athens resulting in the loss of 1.400 treatment slots, in a red zone area, an area with the highest concentration of IDU’s in Greece.

Part of the resistance and fragmentation of harm reduction development can be attributed to certain relevant stakeholders with different agenda and competitive interests, and strong influential voice in all levels of the political spectrum. Following a more moralistic approach, they were advocating against harm reduction programs and cultivating for years a mistrustful environment. Despite the efforts to raise awareness that the drug policy is not a bipolar, and that abstinence-based models and harm reduction are not competitive approaches but rather compatible and complementary, the drug policy dialog in Greece remained fragmented and polarized relying on outdated rehabilitation concepts and ideological preconceptions. This arbitrary dichotomization and combative climate provided a limited space for investigating policy alternatives and reaching consensus on this controversial policy, hindering in this way, the development of harm reduction legislation and implementation.

Choice of Methods

This project aimed to fill a major knowledge gap and increase the capacity of civil society organizations to track national spending and to assess funding shortfalls. The methodology for this review suggests the study design, the data sources and strategies that were used to answer these questions and the analytical tools to analyse the data. Pragmatic rationality implies the choice of the most appropriate approach to data collection and analysis depending upon the research questions [6]. In order to provide additional insight from the HRI quantitative findings, an explanatory sequential design was adopted. This two-phase mixed methods design was utilized in order to build upon the initial HRI quantitative results by using qualitative data from the interviews and the focus group discussions [7, 8].

The follow-up explanations model focuses on a more detailed examination of the results. Since the quantitative analysis in the study was based on HRI protocols and compared data from other countries as well, the researcher was interested to analyze country specific findings, thus the need of additional exploration was required. The second qualitative phase was utilized to collect text data through individual semi-structured interviews, in order to elucidate and supplement the quantitative findings and provide additional insight of the Greek harm reduction contextual reality that may “reveal the story” behind the quantitative associations. Therefore, the grounds for the utilization of qualitative approach in this study refer to: a) Understanding quantitatively the harm reduction landscape in Greece, b) Complementing and questioning the results of the quantitative data, and c) Informing the design of the quantitative research. Thus, the role of the qualitative method in this study was to elucidate and provide additional insight of the precipitating factors of the HIV epidemic in Greece through the subjective interpretation and experience of the key stakeholders at the time of the crisis.

Overall, the practical utility of mixed methods appears to be appropriate in understanding and responding to the public health challenges related to drug policy initiatives. One of the basic advantages of this method refers to reduction of inappropriate certainty and strengthening triangulation and interpretability, corresponding in this way to growing complexity of social and health care issues that demand creative investigation [9].

Research Questions

The study seeks to answer the following overarching evaluation questions: 1) What is the level and source(s) of current financial investments in harm reduction programming within the country? And which interventions are supported by this investment? 2) What are the main funding gaps and challenges? And to what extent does funding go towards priority interventions; 3) Which government departments/ministries currently holds budgets that includes funding for harm reduction programming? And what is the decision-making process on resource allocations for harm reduction at the national and local level? 4) How the information revealed could be used for resourcing advocacy purposes?

Data Sources and Data Collection Instruments

The Data Collection was Based from the Following Sources: Desk based review and documented material.

The review involved relevant documentation from governmental and non-governmental institutions on harm reduction expenditures, investments and programs. In addition, other documentation through literature searches in both the academic and grey literature. For this purpose, a search strategy has been developed.

Stakeholder consultations including the experience and the views of those affected by the policies and involved in their implementation is a valuable tool for transparent and informed policy-making. This was performed in several targeted consultations with diverse stakeholders and service users in order to collect data on the current situation of the financial investments in harm reduction programming and the interventions that are supported with this investment. All relevant stakeholders had the opportunity to express their opinion, have sufficient time for their responses and they were provided with adequate feedback regarding the consultation process, its aims and goals.

Consultation Strategy

Step 1: Objectives of the Consultations based on the stage of the project circle, the objectives of the consultations with the stakeholders were:

• Gather evidence and factual information data and knowledge that will help to estimate the financial investments in harm reduction programming and the interventions that are supported with this investment as well as the potential effects on the performance of the existing harm reduction policy
• Collect views, opinions and gather new ideas of the relevant stakeholders in order to identify funding gaps and challenges, possible policy impact of punitive and repressive policies; explore new ideas and alternatives for harm reduction sustainability.
• Assess existing resource allocations schemes, ideas and analysis; Investigate decision making on resource allocations for harm reduction from diverse stakeholders; cross check and validate existing information or analysis; and explore different harm reduction priority issues on related investments. The Step 2 of this explanatory sequential design was the Stakeholder mapping in order to involve the identification of the target group that will be consulted. The selection criteria for the identification of stakeholders’ categories involve a) those affected by harm reduction policies b) those who formulate and implement harm reduction policies and c) those that have knowledge and expertise and are active in the harm reduction field.

Interviews

The researcher conducted several semi-structural interviews based on topic guide with the relevant stakeholders. Data obtained from the semi-structured interviews with the relevant stakeholders provided a thorough understanding on the harm reduction investment, their capacities, resources, needs and gaps. The predefined questions of the interview protocol were based mainly on the investment tracking tool, but also included thematic areas from the online survey both provided by HRI. The interviews were conducted in the stakeholder premises and lasted approximately two hours. In each interview, the questions were adjusted according to the stakeholder’s expertise. As an example, for OKANA (Organization against Drugs) which is responsible for the substitution treatment in Greece, the questions were targeted on OST, while in the interview with KEELPNO (Hellenic Centre for Disease Control and Prevention), the questions were targeted on ART, etc. Active involvement of the beneficiaries & target groups enabled better understanding of their problems, highlight potential methods of addressing them and set the grounds for the participatory planning process. The structural interviews involved thematic areas that cover: Demographics such as the total number of people received OST; the number of people who inject drugs living with HIV on ART nationwide; national spending on OST, NSP, ART; Programmed spending with breakdowns for OST, NSP, ART; Coverage nationwide OST, NSP, ART and contribution of international funding; Funding allocation and decision making; Funding challenges and gaps; and sustainability of harm reduction.

Focus Group Discussion (FGD)

At the second stage, Focus Group Discussions (FGD) were conducted to gather information on harm reduction, identify potential problems, funding gaps and challenges, as well as explored the distribution of harm reduction funds. The researcher as a facilitator of the group used the topic guide to organise a discussion among participants. The topic guide included a set of structured questions to steer the discussions. A note taker recorded the participants’ comments. The FGD took place at the Greek National Drug Coordination office and lasted approximately two hours. The FGD consisted of 8 staff members from the identified organizations. Participants were notified of the topic in advance and explained how the information will be used. The participation of these individuals was voluntary, based on their consent. The topic guide of the FGD assessed areas related to: Source, allocation and distribution of harm reduction funds; Advocacy for harm reduction investment; Funding gaps and trends; and future funding landscape for harm reduction programmers. The FGD complemented and supplemented the information obtained from the surveys, providing critical information for triangulating survey and interview data from the participating sites. At the second stage, the findings from both stages were validated. This was achieved by creating a ‘map’ of funding gaps ‘hotspots’ and challenges that were prioritized. The list of the interviewees along with their contribution can be found in Table 1. Beyond one organization all invited relevant stakeholders and policy makers responded positively and contributed to both the interviews and the focus group discussions.

Data Collection Tools

Three data collection tools were used for the study. The first was the Investment Tracking Tool provided by HRI and allowed to capture the investment into harm reduction, the sources of funding and how these funds have been spent (e.g. interventions, geographical area and particular groups reached). The second was the Harm Reduction Works! Also provided by HRI and consists on an online survey that also assisted capturing the source, allocation and distribution of harm reduction funds, funding gaps and trends as well as future funding landscape for harm reduction programs. The first two provided mostly quantitative data and main findings can be found on the HRI report Harm reduction investment in the European Union, Current spending, challenges and successes, 2017.

Data Analysis

Data analysis was conducted in collaboration with HRI researchers from both quantitative and qualitative data and can be found in the above mention report. In addition, content analysis was utilized in order to review the qualitative data and identify themes which emerge from the written data and the information provided on the interviews and the FGD. These themes were analysed in order to answer the main questions of the study and showcase the good practices as well as the harm reduction funding crisis. The application of mixed methods involves knowledge-building based on pragmatic principles, affirming that truth is “what works” [7].

Lessons Learned and Future Steps

Recommendations Based on Study Findings: The socio economic conditions in Greece and the pressure from donors, required cost-effective responses, in order to improve quality and raise standards of care with the use of limited available resources. An integrative community- based harm reduction approach would provide several advantages. An inter-sectoral approach beyond its cost effectiveness, the common use of existing infrastructures and local resources, would improve also the quality of services within existing programs as it provides a more comprehensive package of care and it is designed to correspond to the diverse needs by matching individuals to the appropriate levels of care.

Maximized efficiency in the use of limited resources and facilitate the integration of harm reduction into existing community services. Fostering harm reduction accessibility making services more accessible and offers services in a neutral site and Open Access Services-OAS (e.g. mobile units; street agencies). This will increase service efficiency and reduce costs, since it will offer more comprehensive array of service responses aligned with true service user needs. Acknowledging individuals exhibit different problems in terms of severity, intensity and frequency that require different levels of care, this system will be designed to correspond to this diversity by matching individuals to the appropriate levels of care.

Secured response specificity through Drug Referral Schemes (DRS) and a placement system model. Providing structured, multi-disciplinary, and task-oriented enable users to be placed on the most appropriate service to meet their needs. Beyond the cost effectiveness, integrated care pathways improve effectiveness and the quality of care, since individuals may have multiple problems that require effective coordination among services or may have continuous care needs requiring referral to a different level of service over time.

The socioeconomic crisis and the HIV outbreak as catalysts of change generated reforms and facilitated the acceptance and implementation of harm reduction, which until then it was a highly controversial, stigmatized and purposefully neglected. However, there is a long way and many obstacles to overcome in order to reach the desirable levels of political consensus for an evidence based resource allocation in the drug policy arena. Beyond the relevant policy makers (un)readiness, it is the right the time and the appropriate contextual conditions for the implementation of contemporary evidence based and impact oriented drug policies in Greece. The lifesaving preventative interventions and their positive impact to the community contributed on reducing the longstanding resistance and prejudices toward harm reduction and on gaining widespread recognition and support. The most validating and restorative for the harm reduction field, is the fact that those who for years were opposing and propagating against harm reduction in Greece, during the outbreak and the fragile contextual environment, were active participants investing a significant amount of their resources on harm reduction outreach interventions. This is an important lesson learnt for policy makers, relevant stakeholders, potential donors and the community.

From Punitive and Repressive Justice System towards Health-Based Community Policing and Therapeutic Jurisprudence

This shift in attitudes about harm reduction and a compassionate, human rights approach is emerging at a time when law enforcement and policy makers had orchestrated an unprecedented repressive and over- punitive approach towards the vulnerable sector. Constant violation of human rights and systematic use of violence, over-repressive and punitive interventions including sweep operations with arbitrary massive arrests, forced medical examinations, detention camps and preventing access to harm reduction services was the ‘new Greek law enforcement model’. The effects of such over-repressive policies and the punitive, discriminatory attitude of the Greek authorities towards to most vulnerable sector, split society, foster a culture of discrimination and threaten the achieved progress made so far on respect of human rights and the rule of law. Several scientific communities, NGOs and international agencies such as the UNAIDS and the Human Rights Watch have expressed strong reactions, condemning the interventions made by the Greek authorities.

In Greece, despite the new Law on drugs that introduces effective alternative measures and other crime prevention policies, its implementation is lacking, in practice there is a significant proportion of pretrial detention and mandatory minimum sentences for drug users with non-violent minor offences. Another interesting and compelling finding of this study is current inhuman and degrading conditions of the Greek penitentiary institutions. The disproportional incarceration of drug users, as well as lack of imprisonment alternatives for drug depended individuals causes significant overload for the criminal justice system and undermine the notion of proportionality and fairness of the law. This is reflected by the fact that Greece has one of the highest levels of incarceration for minor non- violent drug related offence, with 1/3 of the prisoners is serving terms for drug offenses. Also, Greece has the fourth most overcrowded prisons in Europe, with 121 inmates for every 100 available places compared to a European average of 94 per 100. The lack of access and availability of health care and harm reduction services in prisons raise serious ethical and moral concerns.

Furthermore, the study findings also indicated that there are significant legislative barriers such as lengthy bureaucratic procedures and the unwillingness and reluctance of the prison administration to adopt and implement harm reduction interventions in prisons. These findings are in line with the alarming report of the European Committee (EC, 2015), indicating that the situation in the Greek prisons has become critical and that urgent action is required for their recovery, starting with tackling the excessive overcrowding, the excessive use of power, corruption and malpractices from all prison personnel from top down and the widespread deficiencies regarding access to health care and health-care policy regarding drug misuse. The threat for expansion of another HIV outbreak potentially within prisons is considerable and the need for harm reduction measures very apparent. Under this prism, it is imperative to develop efficient policy evaluation framework to assess the potential adverse effects and associated costs of drug control policies. This could provide the basis for mobilizing the efforts to encourage policy reform and the implementation of contemporary approaches in the penal system based on the principles of restorative justice and therapeutic jurisprudence. Economic downturn in Greece created an evolving stance and an opportunity to act towards innovative initiatives and contemporary, organized and impact-oriented drug policies.

There is a pressing need to further expand and empower this inter-sect oral collaboration by involving all relevant sectors of the society, especially the law enforcement. Harm reduction advocates and relevant stakeholders should use this ‘harm reduction momentum’ to convert the spontaneous crisis intervention that temporary arise in Greece as a response to the HIV outbreak to a sustainable best practice harm reduction model. A strategic framework that through inter-sectoral coordination mechanisms, evidence-based and community-based assets make efficacious use of multiple partnerships to meet identified needs within a framework that promotes sustainable and place-specific harm reduction interventions [19]. Secondly, police involvement in harm reduction activities will not only terminate the series of unintended related harms i.e. Hindering harm reduction services; poorly violation of users rights; harassment, extortion, torture and ill treatment, judicial corporal punishment for drug offenders, arbitrary detention, and denial of basic health services, but it will also provide a cost effective model that utilizes the available community resources wisely and efficiently. This model will complement public health and harm reduction goals and will be an additional positive component on addressing the health and social needs of vulnerable populations. The development of good practice guidelines for police will facilitate the transitional phase from punitive adversarial law enforcement towards harm reduction-based approaches to law enforcement.

Overall, it is evident that legislative gaps concerning harm reduction in Greece generates major problems in practice (closure of supervised consumption rooms, police confronting users and street workers hindering service delivery). Moreover, implementation of punitive adversarial laws in a form of legal action towards practitioners (prosecuting, harassing frontline workers) for providing harm reduction preventive services, may lead to “defensive practices” and further alienate this already overburdened section of professionals in the drug prevention field. The punitive stance adopted by the Greek authorities with the swiping operations, destroying injecting equipment, police arrests and confiscation; preventing drug users access to health; and penal- centered practices i.e. criminalization of HIV lead to further degradation of NHS, devaluate harm reduction street work, and influence professional liability in the addiction field [20]. Taking into consideration the significant staff turn-over, lack of carrier paths and absence of reinforcement for new practitioners to engage in harm reduction in Greece, this approach could seriously damage the provision and quality of the services, distancing new practitioners due to risk of unclear professional liability.

It must be highly prioritized to implement community based policing and foster police role as a health promotion agents with participation in preventive harm reduction programs i.e. overdose reversal, street work with psychoeducation and targeted referrals. This will also facilitate the resource relocation process from law enforcement repressive operations towards prevention and other social welfare initiatives [21].