Czech-Slovak Commonalities in Developing Harm Reduction
The Federation of the Czech and Slovak Republicsceased to exist in 1993. Until then, both countries had shared a 75-year-long history since 1918, interruptedby the SecondWorld War, when the Czech Republic became the German Protectorate of Bohemia and Moravia and Slovakia was a nominally independent state. There were some similarities before 1993 (e.g. joint legislation, the same strategies, etc.) and some differences (e.g. industry, people living in cities, etc.).
In the Czech Republic and Slovakia, harm reduction programmes developed against the background of the complex nationwide processes and events that marked the transformation period of the 1990s. These are likely to have significantly influenced and shaped the opportunities for the incorporation of such services into the system of the drug policy, as well as into the more general health and social policies pursued on the national level, and the limitations of such incorporation. In the light of the development of both countries’ respective drug scenes, drug services networks, and monitoring systems, the following characteristics stand out:
a) HR services emerged and developed in a relatively favourable epidemiological situation as far as HIV/AIDS and viral hepatitis are concerned.
Both countries have shown a relatively positive epidemiological situation in terms of HIV/AIDS and hepatitis among both the general population and PWID.[1] This had a crucial impact on the shaping of the content, form, and intensity of the public discussion on the drug policy and the funding of drug services, which are a delicate topic, particularly as regards harm reduction. The political dimension, i.e. the urgency with which both countriesresponded to the epidemiological situation and trends, was of major importance. While both countries have faced largely the same favourable epidemiological situation in terms of e.g. HIV or HCV incidence, harm reduction programming has received different political andfinancial support in both countries.
Table 1: Overview of development in selected indicators in the Czech Republic (2005-2018)
Indicator
|
2005
|
2006
|
2007
|
2008
|
2009
|
2010
|
2011
|
2012
|
2013
|
2014
|
2015
|
2016
|
2017
|
2018
|
Total number of newly identified HIV cases in the Czech Republic
|
90
|
91
|
121
|
148
|
156
|
180
|
153
|
212
|
235
|
232
|
266
|
286
|
254
|
208
|
- including the number of cases who may have contracted the infection through injecting drug use*
|
5
|
5
|
17
|
12
|
7
|
7
|
12
|
10
|
10
|
15
|
11
|
11
|
8
|
11
|
Needle and syringe programmes (NSPs) – number of programmes in the Czech Republic
|
88
|
93
|
107
|
98
|
95
|
96
|
99
|
103
|
110
|
105
|
104
|
104
|
108
|
107
|
Number of needles and syringes distributed in the Czech Republic (in thousands)
|
3272
|
3869
|
4457
|
4644
|
4859
|
4943
|
5293
|
5356
|
6175
|
6594
|
6403
|
6469
|
6402
|
6932
|
* Including the mixed category of PWID/MSM, where both risk factors are present.
Source: [37, 35]
Table 2: Overview of development in selected indicators in the Slovak Republic(2005-2018)
Indicator
|
2005
|
2006
|
2007
|
2008
|
2009
|
2010
|
2011
|
2012
|
2013
|
2014
|
2015
|
2016
|
2017
|
2018
|
Total number of newly identified HIV cases in the Slovak Republic
|
21
|
27
|
39
|
49
|
45
|
25
|
46
|
43
|
80
|
83
|
79
|
82
|
66
|
82
|
- including the number of cases who may have contracted the infection through injecting drug use
|
0
|
1
|
1
|
3
|
1
|
1
|
0
|
1
|
1
|
1
|
3
|
1
|
0
|
1
|
Needle and syringe programmes (NSPs) – number of programmes in the Slovak Republic *
|
10
|
13
|
14
|
9
|
n.a.
|
7
|
9
|
9
|
8
|
8
|
8
|
8
|
8
|
n.a.
|
Number of needles and syringes distributed in Slovakia (in thousands)
|
362
|
384
|
421
|
254
|
318
|
317
|
352
|
350**
|
321
|
275
|
347
|
358
|
396
|
n.a.
|
* The first exchange programme in Slovakia was launched in 1994[26].
** Estimate from the annual reports of HRorganisations
Sources: [38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54]
b) Harm reduction interventions introduced in both countries showed a minor or declining emphasis on public health concerns, while a growing emphasis was placed on the social context and dimension of the services provided.
It is noteworthy that despite the relatively favourable epidemiological situation, in both countries HR services began to develop successfully, and the Czech Republic even built a relatively dense, accessible, and efficient network of services providing sufficient coverage of its entire territory. For the characteristics of harm reduction programmes in both countries, it is important to note that they are mainly provided by non-governmental organisations. The position of NGOs in this region is challenging; they often operate in a vague and inconsistent policy environment and play only a marginal role in governance processes [55, 56]. However, the development of this network was made possible mainly thanks to the emergence and growth of specific drug services. The involvement of the existing network of public health agencies (public health institutes and services) was negligible. In fact, the system of public health services stood aside from the process and has provided no structural support to people who use drugs up to this day. On the other hand, harm reduction services featured a strong social dimension and relationship with the social welfare network from the beginning, and these are being further enhanced even now. There may be various reasons for this:
c) HR services were represented by no specific group of professionals, and the absence of involvement on the part of health professionals was particularly significant.
Accordingly, the health sector has not provided much support for harm reduction services. Thus, they are often viewed as social or social rehabilitation services rather than public health services. This applies despite the fact that, in the Czech Republic, HR services are defined by the healthcare-related Act No. 65/2017 Coll., on the protection of health from the harmful effects of drugs(Section 27, which also provides a basic definition of professional care in terms of dependency), and in Slovakia they are referred to in the Bulletin of the Ministry of Health [57], which defines outreach work.
d) The pressure posed by a rapid and hard-to-control increase in infectious diseases associated with injecting drug use was absent in these countries (see above).
e) The systems of funding have been based on multiple sources. In the Czech Republic, for example, the subsidy system administered by the former National Drug Commission, presently the Government Council for Drug Policy Coordination (GCDPC) – Government Office, existed in parallel to the subsidy schemes of the Ministry of Labour and Social Affairs (MoLSA) and of the Ministry of Health (MoH). In Slovakia, additionally, long-term financial support was provided by Nadácieotvorenejspoločnosti – Open Society Foundation (OSF), which played a significant role in the context of the funding of HR services in that country (see below).
f) In both countries, the systems of social care developed in line with their respective strategies. These processes involved the integration of harm reduction programmes into the systems of social services, specifically social prevention services, primarily in the form of outreach programmes and drop-in centres, two out of a total of 32 types of social services defined in the Czech Republic by Act. No. 108/2006 Coll. on social services. As a result, the system of the provision of social services was newly provided with a strong legal framework, which also serves as the basis for funding. While the portfolio of social affairs has provided standard coverage for what is denominated and categorised as a social service, the health departments in both countries have traditionally, and for a long time, adopted very reserved and recently almost negative standpoints on the integration of harm reduction programmes into health policies, as well as on the provision of financial support for such programmes; they are simply viewed as not health/medical enough and inconsistent with the notion of “healthcare”. Despite their obvious public health dimension, harm reduction programmes thus continue to be increasingly dependent on non-health resources, which make their integration into the system of health services even more difficult.
g) The association of illicit drugs with pre-1989 political dissent [29]may have led to a deep-rooted and enduring idea of drugs being related to the disruption of society and posing an immediate danger to it. Although transformed, this notion still seems to echo in the present. This leads to the stigmatisation of PWUD and drug services, primarily harmreduction services, which can be demonstrated by a number of community and political measures against drug services (see Table 2)
h) The discussion about the effectiveness and development of harm reduction programmes often bears signs of populism, lacks relevant arguments, and abounds in simplifying judgments that are in sharp contrast with the state of the art of research and the results of studies concerned with this area. Even members of the professional community are frequently heard to make statements to the media that contradict the evidence-based approach. To a great extent, this may result from a lack of awareness and understanding on the part of certain professional groups (including psychiatrists and clinical psychologists, in particular) and, to some degree, from the persistent residue of what was called the “narcological system of service management” that was typical of the countries of the former Soviet bloc. Ideological arguments and legislative systems framing drug use and drug possession as a crime complicate the implementation of a full range of harmreduction interventions, including heroin-assisted programmes, drug consumption facilities, or harmreduction interventions in prisons.
i) Another significant factor is the insufficient pressure exerted by civil society. These countries show an obvious lack of the voices of people who use drugs and their parents and partners, drug services,and communities in policy making and in mass media reporting.
Czech-Slovak Differences in Developing Harm Reduction
The first HR services for people who inject drugs were established in the Czech Republic in the early 1990s. The programmes that came into existence at that time were later used as models for the emerging network. The concept of the provision of such services was adopted from abroad (see, for example, the design of the first Drug Policy Strategy [58]) and was also closely linked to efforts seeking to monitor the development of the situation[2]and to have the opportunity to subject it to further research activities. Thanks to the structural support provided on the national level, which culminated between 1997 and 2001, the Czech Republic managed to build what, in the European context, may be considered a dense network of relatively easily accessible and efficient harm reduction programmes [35]. For example, the numbers of needles and syringes exchanged have been rising in recent years (see Table 1) and complex issues, such as collaborating with pharmacies and reinforcing the network of HR programmes by their involvement in the programmes, have been opened.[3] Additional innovative interventions, including the distribution of gelatine capsules intended primarily for people who use pervitin as an oral alternative to riskier injecting practices, have also been developed [60, 61].
The situation in Slovakia was somewhat different. Unlike in the Czech Republic, the resources available to the Slovak counterpart of an interdepartmental funding scheme, called the Anti-drug Fund, have never been used to provide structural support for HR services and thus create conditions for their development. On the contrary, the attempt to open discussion on a quest for a structural solution (integrating the public health perspective) by developing uniform quality standards for low-threshold services [62]was rejected by the health sector at the very beginning for reasons which are difficult to understand [63]. While compromised by numerous major shortcomings, this initiative, the highlights of which were supported by the Bulletin of the Ministry of Health [57]published five years earlier, was promising in terms of the further development, strengthening, and stabilisation of the health component of HR services within the Slovak healthcare system. It should be noted that the key argument used to support the negative position was the senseless (although symbolic and essential with a view to the subject matter of this paper) requirement that the HR programmes should restrict their activities to the domain of social interventions only[4] and give up the ambition of conducting public health interventions. On the other hand, financial support from the OSF in the years 1998-2005 made it possible to establish a small network of services in the largest Slovak cities which continued to be maintained and developed until this source of funding was disengaged. Unfortunately, HR services have not been securely integrated into the financial framework of social and health services in the Slovak Republic.
Both the pieces of legislation pertaining to the Ministry of Labour and Social Affairs and the Ministry of Health, respectively, are equally confusing as concerns the definition of HR programmes in the Czech Republic. Apparently, the law providing for the portfolio of the Ministry of Labour and Social Affairs disregards the entire health component or any references thereto, in spite of the fact that the authors of the stipulations have declared their efforts to specify the activities pursued by the programmes as a whole. In this respect, the Health Ministry-related legislation is even more vague and incomplete and as a result of the legislative changes since 2017, specific harm reduction services are not anchored in the health sector. Harm reduction is mentioned as part of professional care, without any further description (see Table 2).
The key to the understanding of the core of the problem may be looked for in the years 2009 and 2010, when the consequences of the global financial crisis also became fully manifested in the Czech and Slovak Republics. The lack of financial resources exacerbated the hitherto little-discussed disagreement about the process of the integration of harm reduction services into the system of healthcare. These services, in fact, were the first in line to fall victim to the situation in the Czech Republic by losing almost the whole of their previous financial support from the health portfolio. Simply speaking, these two years, for the first time, displayed the consequences of the above-described processes in concrete terms. While the Ministry of Labour and Social Affairs maintained a rising tendency in the funding of social services, including those for people who use drugs, until 2009, the Ministry of Health recorded long-term cuts in funding which led to a decrease in financial support for HR programmes. In addition, the year 2010 experienced a drop in resources provided from all the sources of funding available (see Table 3).
Table 3: Developments in funding from the national budgets in the Czech Republic (2005-2018, in thousands of EUR).
Source
|
2005
|
2006
|
2007
|
2008
|
2009
|
2010
|
2011
|
2012
|
2013
|
2014
|
2015
|
2016
|
2017
|
2018
|
ADF/ Subvention from Government office in total (CR)
|
3547
|
3838
|
3762
|
4008
|
3686
|
3381
|
3695
|
3599
|
3690
|
3385
|
3482
|
4659
|
5428
|
7362
|
- harm reduction
|
n.a.
|
n.a.
|
1765
|
1952
|
1840
|
1744
|
1950
|
1911
|
1887
|
1804
|
1789
|
2194
|
2267
|
3064
|
MoH in total (? in CR)
|
1124
|
635
|
801
|
757
|
569
|
849
|
861
|
746
|
570
|
857
|
918
|
777
|
1368
|
1681
|
- harm reduction
|
n.a.
|
n.a.
|
105
|
159
|
163
|
64
|
79
|
150
|
195
|
156
|
293
|
367
|
503
|
739
|
MoLSA (? in CR)
|
1546
|
1753
|
2054
|
3186
|
3282
|
3628
|
3129
|
3355
|
3713
|
5195
|
5889
|
6857
|
7870
|
11371
|
- harm reduction
|
n.a.
|
n.a.
|
1193
|
1808
|
1839
|
2013
|
1697
|
1809
|
2046
|
2342
|
2623
|
3241
|
3481
|
4524
|
HR TOTAL in CR
|
n.a.
|
n.a.
|
3063
|
3919
|
3842
|
3821
|
3726
|
3870
|
4128
|
4302
|
4705
|
5801
|
6252
|
8327
|
Note: Developments in the funding of drug services in total and HR services specifically provided from the respective national budgets. Analysis of financial support provided from the respective budgets of the Government Council for Drug Policy Coordination (Government office), Ministry of Health (MoH), and Ministry of Labour and Social Affairs (MoLSA).
Average exchange rates in the respective years were used for the re-calculation of expenses from CZK to EUR.
Table 4: Developments in funding from the national budgets in the Slovak Republic (2005-2018, in thousands of EUR).
Source
|
2005
|
2006
|
2007
|
2008
|
2009
|
2010
|
2011
|
2012
|
2013
|
2014
|
2015
|
2016
|
2017
|
2018
|
ADF/ Subvention from Government office in total (SR)*
|
1656
|
1928
|
1314
|
407
|
1461
|
639
|
500
|
484
|
–
|
–
|
–
|
–
|
–
|
–
|
- harm reduction
|
88
|
349
|
66
|
81
|
54
|
120
|
62
|
55
|
–
|
–
|
–
|
–
|
–
|
–
|
MoH in total (? in SR)
|
1124
|
635
|
801
|
757
|
569
|
849
|
861
|
n.a.
|
515
|
515
|
515
|
510
|
538
|
520
|
- harm reduction
|
n.a.
|
n.a.
|
105
|
159
|
163
|
64
|
79
|
n.a.
|
33
|
30
|
50
|
41
|
53
|
40
|
MoLSA (? in SR)
|
1546
|
1753
|
2054
|
3186
|
3282
|
3628
|
3129
|
3087
|
2791
|
2709
|
2910
|
2910
|
n.a.
|
3025
|
- harm reduction
|
n.a.
|
n.a.
|
1193
|
1808
|
1839
|
2013
|
1697
|
57
|
33
|
32
|
17
|
36
|
29
|
30
|
OSF (N/A in SR) HR**
|
54
|
21
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
HR TOTAL in SR
|
142
|
370
|
1364
|
2048
|
2056
|
2197
|
1838
|
112
|
66
|
62
|
67
|
77
|
82
|
70
|
Note: Developments in the funding of drug services in total and HR services specifically provided from the respective national budgets. Analysis of financial support provided from the respective budgets of the Anti-Drug Fund (ADF), Open Society Foundation (OSF), Ministry of Health (MoH), and Ministry of Labour and Social Affairs (MoLSA).
*till May 2009 ADF; 2009-2012 Subvention from Government Office; from 2013 MoH
** In 2001 and 2002, for example, support amounted to approximately EUR 144 and EUR 121 thousand, respectively. In the following years, funding was reduced, and in the years 2005 and 2006 both the programmes and the support were brought to an end.
[1]The national estimates suggest that there were approximately 41.7thousand ‘problem drug users’ (central estimates) in the Czech Republic in 2017 and 18.8 thousand in Slovakia in 2006 [35, 36].
[2]Note, for example, the initiation of the first study in the Czech Republic to use the Rapid Assessment and Response (WHO) methodology conducted in 1995 [59].
[3] As part of the IGA NR9447 project, a proposal for more intensive cooperation with pharmacies on harm reduction interventions was drafted; it is estimated that pharmacies sold 1.5 million syringes to PWID in 2009 [27, 28].
[4] This is in contradiction of the integrative approach to such services as recommended by the key EU documents cited in the introductory section above.