A community facilitator from Lapu-Lapu City shows a flip chart explaining a key tool, the General Intervention for Health and Wellbeing Awareness, which enables facilitators to teach substance abuse clients life skills. Photo credit: Jezler Garcesa
When people think about drug treatment, images of incarceration and mandatory inpatient treatment often come to mind. However, the understanding of drug use has changed in the past decade, and today, there is greater recognition that most users are low-to-moderate risk and can be treated without taking them away from their homes or work.
In fact, treatment must be available, accessible, and appropriate, according to the first principle of the “International Standards for the Treatment of Drug Use Disorders” by the World Health Organization and the United Nations Office of Drugs and Crime.
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During the past decade, more countries have shifted toward community-based drug rehabilitation (CBDR). CBDR is a holistic process that incorporates prevention and health promotion, screening and assessment, drug treatment, wraparound family and community services, and aftercare programs closest to where people are.
In the Philippines, CBDR emerged in 2016 on the heels of the aggressive case finding that elicited more than 1.2 million potential clients. The Dangerous Drugs Board declared that a great majority of clients could be treated in their respective local government units (LGUs).
As the country had no history of CBDR, there was a lack of documentation on CBDR’s implementation and impact. To fill this gap, the URC-ledUSAID Expanding Access to Community-Based Drug Rehabilitation Program in the Philippines(USAID RenewHealth)project conducted case studies of 12 LGUs in the Philippines (seven in Metro Manila with five in Regions 4, 7, 8, and 10) to determine the costs, benefits, barriers, and enablers in implementing CBDR.
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Common barriers to CBDR implementation are inadequate resources and limited facilities and equipment. Having dedicated funds for CBDR is important, and the results of the USAID RenewHealth case studies showed that LGUs invest anywhere from 0.04% to 0.53% of their annual budgets for CBDR activities.
The majority of LGUs do not have permanent CBDR staff and rely on volunteers to implement the program. However, some LGUs have hired full-time personnel to deliver or implement CBDR. The findings showed that ratios of CBDR staff members to clients ranged from 1:25 to 1:92, with an average ratio of one staff member to 45 clients.
An additional challenge cited was participant attrition due to conflicting schedules. A number of LGUs have addressed this concern by delivering CBDR programs on weekends or after work. LGUs also reported difficulties in obtaining the participation and cooperation of clients’ families. Key informants highlighted the importance of engaging the family.
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Another barrier cited was community officials’ lack of cooperation. Not every official prioritizes CBDR and some still see drug use as a personal failure or don’t believe in rehabilitating drug offenders.
A key enabler cited by program managers was a strong service delivery network with collaboration between anti-drug abuse personnel, law enforcers, health workers, social workers, the Bureau of Jail Management and Penology, and courts. Other LGUs cited the importance of having civil society and international partners as enablers for CBDR. For example, faith-based organizations and non-government organizations volunteer to help with CBDR programs.
Human resources account for 48% of total CBDR program costs for all LGUs. The next highest expenses were testing kits, equipment, furniture, and supplies (see Figure 1). Other costs were for facility repairs and maintenance, meetings, other medical costs, training for program staff, and prevention programs in schools.
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Even though CBDR requires funding, program managers recognized that its costs were relatively low compared to inpatient treatment. The cost of CBDR for low-risk clients was 12% of the cost of inpatient treatment. The cost of 15 CBDR sessions (for moderate-risk clients) was 16% of the cost of four months of inpatient treatment. And 24 CBDR sessions (for persons deprived of liberty) cost 16% of a six-month inpatient program. In general, the cost of inpatient treatment was 6-8 times the cost of CBDR (see Figure 2).
Beyond savings, both clients and program implementers shared a number of positive outcomes of CBDR. An LGU representative saw the program as providing a one-stop shop to support and address the clients’ needs and help them stop illicit drug use. He said, “Some clients want to stop but do not know how and where to start — the program opens an opportunity for them to act on their drug dependence.”
“I lost my family and was imprisoned, ” Karding said. “When I was released, I thought I could recover on my own. But I found myself still tempted to use. Our barangay suggested I attend, and I tried it. The facilitator was good, and I learned a lot from each of the 15 modules and took lessons to heart. I learned the bad effects of drugs, tips to avoid drug use, my triggers. I eventually was reconciled with my family and found a new job. CBDR was such a big part of my recovery.”
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Service providers shared that their clients not only stopped drug use but also changed for the better. “Our clients now have a better outlook in life, are less irritable, and are less hot-headed, ” one LGU representative said. “Before, they had frequent fights with their wives, but this has since been reduced.”
Although CBDR is still in its infancy in the Philippines, the study emphasizes the importance of investing in and sustaining its implementation. The study has also shown how important it is to take a holistic approach to address the needs of PWUDs. The adage “it takes a village to raise a child” appears to be just as true for drug recovery.
“The general perception of a person who uses drugs is that they are mentally challenged and need to undergo rehabilitation in a facility. But not all of them needs to be ‘checked-in.’ Depending on the severity of drug use, some clients can stay home to their families and earn a living while eliminating drug use. CBDR gives them a chance to live.”— Lito, CBDR program manager, National Capital RegionCarmen married and had a son. Then her husband died in an encounter with police because he was selling drugs. “I woke up one day and asked myself ‘what will happen to my son?’”
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To the capital city, Manila, to live and work. For 10 years, she stayed clean. After ten years, she returned to Cagayan de Oro and remarried. Unfortunately, her second husband was also involved with drugs and ended up in jail.
My life became very complicated when my (second) husband was imprisoned and I started using drugs again. It was worse this time because I was selling drugs too.”
In 2017 when the Philippine Government intensified its campaign against illegal drugs, Carmen was put on a “drug watch list.” The city’s Anti-Drug Abuse Council invited her to attend an orientation at the Oro Citizen’s Wellness and Development Center, a facility that rehabilitates and treats people who use drugs (PWUDs).
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The orientation involved screening by a trained health care worker to assess her level of drug use. She was invited to attend a Community-Based Drug Rehabilitation (CBDR) program.
“I was inattentive and spaced out when I first attended the orientation, ” recalled Carmen. But over the next six months, she attended CBDR sessions and learned how drugs impacted her mind and body and caused her life to be in disarray. More importantly, the program gave her the skills to manage her cravings, understand her triggers, and ultimately, recover from drug use.
“When I stopped using drugs and completed treatment, my physical, mental, and emotional life changed, ” said Carmen. “I cried and told myself that it is never too late to change.”
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In 2018, Carmen completed her CBDR treatment and moved on to an aftercare program to learn vocational skills and start an alternative livelihood. She began earning income by making and selling handicrafts and started on a path to live productively and make healthier choices for herself and her family. She encouraged her husband to complete his own treatment in the same program.
“When I met Carmen, I saw a person who was broken and slowly starting to change, especially when she attended skills training. The potential to earn an income in a respectable way was a changemaker, ” said Rhyselle.
The URC-implemented USAID RenewHealth Project works in 20 cities across the Philippines, including Cagayan de Oro City, to increase access to CBDR services and reduce drug dependency.
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The project trains community facilitators in evidence-based and culturally appropriate CBDR methods. USAID RenewHealth designed and produced a treatment booklet to assist health service providers at the local government level record and monitor the treatment and progress of their clients and determine if they are eligible to complete the CBDR program.
The treatment booklet also helps PWUDs document their drug recovery journey. It serves as a guide to better understand the steps in recovery, including screening, rehabilitation, and treatment, as well as aftercare. Social behavior change messages in the booklet encourage PWUDs to complete their recovery journey.
“A treatment booklet to help monitor the client’s progress and journey is an excellent way to share stories and inspire others about recovery and
