| 4. In which ways is the initiative creative and innovative?
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The conventional therapy is hospital base by using Methadone Detoxification. Most of opium addicts are forced into the treatment to receive total abstinence. This resulted in higher rate of relapse, and the rate of access into treatment and the retention rate are decreased.
For this reason, Harm Reduction applied by establishing Drop-in Center to provide medical services and convenient travelling for the community. Moreover, all sectors in the civil society, there is a process of searching and accessing into the treatment voluntarily. The MMT must be applied in high dose which is enough to prevent craving until the patients receive total abstinence, and other health services are also provided together with occupational support for the families and community participation in caring. As a result, more patients will access into the services that the compliance and the retention rate will be increased. Moreover, the patients will be healthier, and the stigma will be decreased
In many countries, Harm Reduction is implemented by NGO which emphasized MMT and needle exchange. This new innovation has been implemented by the government and community involvement in order to provide continuity and sustainability that focused on standard health services which are covered and provided equally.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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The expansion of the royal project for sustainable problem-solving of the opium cultivation areas had implemented in the first phase (from 2010-2013) by determining strategies which were 1) career development, 2) the strengthening of community and social development and 3) development of the community to solve opium problems.
When the half-plan was evaluated, it was found that the strategy 3 (development of the community to solve opium problem) cannot bring the opium addicts in 7 target communities to access to treatment and rehabilitation and develop quality of life as defined in the strategy due to the lack of a main institution for drug abuse treatment that the patients were not treated appropriately.
The Ministry of Public Health had begun to play a role in determining the framework of solutions, and assigning the Princess Mother National Institute on Drug Abuse Treatment (PMNIDAT) as the main organization to develop treatment program. The PMNIDAT has participated in the project since 2012 that its objective is to provide standard and quality treatment to the opium addicted patients thoroughly, fairly and equally and covered all target groups by applying the concept of harm reduction and process of community participation in the development. In addition, a Drop-in Center was established to provide long-term methadone and healthcare services that emphasized on patients’ convenience to access to the services which resulted in good quality of life. The institution was responsible as a mentor to coach the treatment team to rely on themselves in the implementation. After that, the institution team would be withdrawn and become supervisor to monitor the operation results continuously.
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| 6. How was the strategy implemented and what resources were mobilized?
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The implementation of the master plan consisted of two phases; phase 1 (2012-2013) and phase 2 (2014-2015) that requires strategic planning and management of limited time and resources in order to achieve maximum benefits from the covered operations and driving mechanism to achieve goals.
In the first phase
1. All levels of staff had been developed to perceive and understand the effective treatment for opium addicted patients with harm reduction principles.
2. Adjusting the attitudes and viewpoints of the therapists, law enforcement agencies, community leaders, civil society officers and stakeholders to be positive with the help and treatment of the opium users, that they are chronic patients not criminals.
3. Creating engagement by organizing workshops for health officials, government officials, police, community leaders and village health volunteers that they participated to think, analyze, determine the target and plan the implementation together which focused on building sustainable care for the opium addicts in the community according with each area context.
4. Developing the treatment process of opium addicts in the community in the form of interdisciplinary that the community was involved in all aspects not only the responsibility of public health agencies unilaterally.
5. Managing budget disbursement to be streamlined in operation.
6. Providing suggestion and coaching system that the district health promoting hospital would implement the operation in each area closely and help solving problems creatively and friendly all the time.
7. Organizing seminars for working staff in all areas in order to evaluate and modify the operation together.
In phase 2
1. Establishing “Drop-in” centers in hospitals, sub-district hospitals and sub-district administration organizations. The selected place of establishment was focused on the convenience and saving for travelling to receive health services that the patients will trust and feel comfortable with the services.
2. Focusing on the sustainability and encouraging the opium addiction treatment into normal system of public health service in the area.
3. Strengthening family and community including with stopping opium abuse and creating better quality of life.
4. Developing academic matter as the knowledge base coupled with working in order to receive the form of treatment of the opium addicts in highlands matched with the way of life of hill tribes that resulted in better development of life quality.
The Budget Management
The main budget has been supported by the Department of Medical Services, Ministry of Public Health which was used in the project management, human resource development, the treatment of opium addicts in the community (Drop in) with Harm Reduction concept and research studies.
The National Health Security Office (NHSO) has supported the project with the reimbursement of MMT service charges (35 baht/ person/day) for the hospital.
The local government organizations have supported by bringing the patients to the treatment system and following-up patient care in the community.
The Highland Research and Development Institute (Public Organization) has supported by providing help to the patients in order to have the opportunity to develop agricultural profession that they can access to the market, and they have been employed.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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The project based on community and cooperation consisted of many involved agencies as the stakeholders in designing activities and co-operation in the treatment of opium addicts as follows.
7.1 The Princess Mother National Institute on Drug Abuse Treatment (PMNIDAT) was mainly responsible for project implementation of all areas and driving the policy to provide methadone medication into health services of the community, for example, coordinating with the Food and Drug Administration in order to increase the dispensation of methadone in community hospitals and taking care of the prerogative of methadone maintenance treatment in the concession of the National Health Security Office (NHSO).
7.2. The regional Thanyarak hospitals were responsible for managing, monitoring, supervising, following up the operations in the areas of responsibility to matched with the objectives and reporting the progress to the PMNIDAT (Thanyarak Chaing Mai Hospital was responsible for 5 districts in Chang Mai Province whereas Thanyarak Mae Hongson Hospital was responsible for the areas in Pai District, Mae Hong Son Province).
7.3. Provincial Public Health Offices in Chaing Mai, Mae Hong Son and Tak were responsible for managing and facilitating the operations in the target areas in each province together with staff support.
7.4. Community hospitals/ district health promoting hospitals were responsible for the implementation of treatment services for the opium addicts in the areas and integrated coordinating with the involved organizations to help the opium addicted patients.
7.5. Community Sector such as local government, village chief, headman, community leader and NGO was responsible for communication, searching, forwarding and follow up action.
7.6. Security officers were responsible for providing security.
7.7.The Highland Research and Development Institute (Public Organization) was responsible for supporting and encouraging agriculture profession for the patients.
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| 8. What were the most successful outputs and why was the initiative effective?
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According to the operation results in 4 years, it was found that the spread of HIV and Hepatitis B and C had been reduced among opium addicted people in 7 districts in Highland regions that they received important harm reduction services which wereMethadone maintenance treatment, Voluntary Counseling and HIV Testing including Detection of Tubercle bacillus and Hepatitis B and C.
The achievement of the project:
1) The opium addicts had participated in the treatment service system from 2012-2013 (735 people) ,and there were 816 people in 2014-2015. The project result showed that the patients accepted the treatment and that 92.89% of them still received treatment.
2) There were 14 Drop–in centers of harm reduction that provide methadone medication and 10 service sets of covered health services which help the patients to receive medication and services conveniently and safely. These were the new pattern of services that never been appeared before in the areas.
3) The working network of seven districts consisted of physicians, nurses, public health officers, government administrations officers, security forces, the Office of the Narcotics Control Board, the network of community leaders and civil society.
4) The involved personnel in seven districts have been developed for harm reduction and changed attitudes towards the treatment of opium addicted patients in all areas (140 people per year in 2012-2015; a total of 560 people).
5) The Best Practice was received as the centers of harm reduction from drug abuse in communities. These centers were the place to study visit and exchange knowledge between Thai and overseas drug abuse treatment agencies such as Santivana health promoting hospital in Chaiprakarn District, Ban Ton Lung health promoting hospital in Maetaeng District and Ban Kamwan health promoting hospital in Maeramat District, etc. that they were chosen to present their works in various academic fields.
The project implementation results can make proud of working teams in all areas
That they can help the opium addicts in highlands to reveal themselves and access to the treatment services. Furthermore, the patients also reduced and quitted opium addiction when they were ready. These resulted in better quality of life and peaceful society. The staff also had joyfulness to face with difficult and challenging works that they worked with philanthropic spirit to help fellowmen to be delivered from suffering.
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| 9. What were the main obstacles encountered and how were they overcome?
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In the implementation, there were found problems and solutions described as follows.
1. The remote areas were inhospitable regions and difficult to access. The transportation was inconvenient due to the rainy season that the areas could not be accessible for the operations. Therefore, the process of studying, planning, reviewing and planning was created to access to the areas according to climate conditions and plan to schedule appointments with the patients in advance.
2. The communication was difficult due to various hill tribes and highland areas which was the obstacle in treatment. Thus, the solution is to requesting helps from the tribesmen (officers and patients) who know the languages as interpreter to communicate.
3. The opium was the remuneration for mercenary career, and opium cultivation was for family consumption or sales so opium addiction is highly expanded that it was difficult to implement treatment. Therefore, the building of motivation to access in the treatment was achieved by encouraging family participation and developing family members to become volunteers to help and take care of the patients.
4. The target areas were not ready for the operation to prevent and resolve drug problems, and they are also risk areas for the staff. For this reason, the plan was changed by selecting the areas which were safe to access and ready to develop first.
5. The attitudes and perspectives of the therapist and the relevant person that the opium addicts must quit from the addiction decisively was contradicted to the tribal cultures and tradition. Therefore, the adjustment of the attitudes toward the patients that they suffered from drug addiction brain disease and needed treatment must be created.
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