Community-Based Drug Rehabilitation and Care in Philippine Local Governments

CBDR in Southeast Asia

Globally, community-based drug treatment and recovery programs are considered a viable and effective strategy to help people who use drugs. Countries such as Australia and the United States have already developed and evaluated community-based drug interventions for targeted populations such as syringe users (e.g., Fox et al., 2017), prisoners with drug use problems (e.g., Grella & Greenwell, 2007), and methamphetamine users (e.g., McKetin et al., 2012).

In contrast, most countries in Southeast Asia (SEA) criminalize people who use drugs and use compulsory detention centers (Kamarulzaman & McBrayer, 2015). However, pressing concerns of human rights violations (e.g., torture, police brutality) have compelled international organizations (e.g., UN, Human Rights Watch) to call for the closing of existing compulsory detention centers in the region (Amon et al., 2013; Human Rights Watch, 2011, 2019). Although some countries have slowly shifted away from a criminal justice to a health and harm reduction framework to drug use (e.g., Cure and Care Centers in Malaysia), some countries (e.g., Cambodia, Philippines) still treat drug use as a criminal offense and a moral failing (Khan et al., 2018; Lai, 2015).

The feasibility of institutionalizing more humane drug policy changes remains a big challenge because of the politically charged environment of most countries in SEA (Vuong et al., 2017). Countries are faced with multiple challenges in implementing CBDR such as difficulties in coordination among parties involved, divergent attitudes between law enforcement and health officials, and conflicting performance targets between different stakeholders (Ma et al., 2016). Furthermore, countries implementing CBDR (e.g., Cambodia, Indonesia, Malaysia, Vietnam) are faced with challenges including the lack of financial resources to implement CBDR, resistance of people who use drugs to access available services, human resources challenges (e.g., unavailability of health workers), prevalence of stigma and discrimination against people who use drugs, and the lack of involvement of different stakeholders in policy processes (Tanguay, Stoicescu, & Cook, 2015). Amidst the overwhelming challenges mentioned above, there is also a wealth of opportunities and lessons gleaned in existing efforts to CBDR in SEA. Tanguay, Stoicescu, and Cook (2015) articulates the need for good governance, transparency, and accountability, as well as the need to “review the roles and responsibilities of various agencies across the public health and public security sectors to balance the workload and ensure positive results” (p. 1).

CBDR in the Philippines

Like many of its neighbors, drug use is a crime in the Philippines. The Philippines’ Dangerous Drug Act (RA 9165) states that possession of 5 g or less of an illegal drug has a minimum sentence of 12 years to life imprisonment and possession of 10 g or more can lead to life imprisonment or death. In 2016, President Rodrigo Duterte declared a war on drugs and at its centerpiece was Oplan Tokhang (Oplan Tokhang is a wordplay of the words toktok and hangyo, Cebuano terms for knocking and appealing). The primary implementers for this drive were the police and community leaders who went door to door in communities, knocking on doors of suspected drug users and asking them to surrender. As of March 2019, the campaign initiative resulted in 1.4 M individuals who voluntarily surrendered (Galvez, 2019). These individuals were not formally charged, but their names were put on a drug watch list and were told that they needed to go to treatment for them to be delisted.

As part of drug demand reduction, the Philippines’ Dangerous Drugs Board (DDB) launched Oplan Sagip (Filipino term for save). It suggested that 90% of PWUDs are low- to mild-risk users and can be treated in communities. It mandated local government units (LGUs) to provide community-based drug treatment and rehabilitation programs for low-risk and mild-risk PWUDs, outpatient rehabilitation for moderate-risk PWUDS, and inpatient rehabilitation for high-risk PWUDS (DDB, 2016). Because the country had no history of CBDR, the CBDR programs being implemented were mostly diversion programs consisting of recreational activities, religious activities, community services, and general counseling. Participants in these diversion programs continued to lapse into drug use and drug-related arrests, and extra-judicial killings continued to rise (Hechanova, 2019). By 2018, drug arrests numbered 149,265, and 4,500 had been killed for drug involvement (Talabong, 2018). The punitive approach and messaging by government leaders that drug users are criminals and pests also exacerbated the stigma toward PWUDs (Hechanova, 2019). On the bright side, some LGUs adopted evidence-informed programs such as the Katatagan, Kalusugan, at Damayan ng Komunidad (translated as Resilience, Health and Care in the Community; KKDK), that utilized cognitive behavioral therapy, motivational interviewing, mindfulness, and family systems theory (Hechanova et al., 2019). There is emerging evidence on this program with studies reporting improvements in the psychological well-being, recovery skills, life skills, and quality of family relationships of participants (Teng-Calleja et al., 2020; Hechanova et al, 2020). However, there is recognition that CBDR initiatives and programs still need more ground work in terms of drug education, access to services, and evaluating processes of drug recovery and care services (Mercano, 2018).

To date, there has been no systematic analysis of what processes or conditions enable and constrain the implementation of CBDR programs. As such, there is a need to generate insights from existing CBDR programs as a precursor to advance evidence-based public mental health practice in local governments. In this study, we attempt to analyze what processes or conditions enable and constrain the implementation of CBDR programs given a context where punitive and prohibitionist national drug policies prevail. The aim of the study was to enhance the growing regional knowledge base on the effectiveness and implementation of CBDR in SEA by offering critical reflections on local government practices in the country.

The study uses the WHO’s Health Systems (2010) framework that describes six components: leadership and governance, health services, workforce, information, technologies, and financing. Leadership and governance refer to strategy, policy, regulations, oversight, and coalitions. Health service refers to the delivery of safe, effective, quality interventions. Health workforce refers to having sufficient numbers of competent, responsive, and productive workers. Health financing refers to having adequate funds. Health information involves the production, analysis and dissemination, and use of timely and reliable data. Using this Health Systems framework, we investigate enablers and barriers embedded in select LGUs across the country. Specifically, we ask the following questions: (1) What were the factors that enabled CBDR in LGUs? (2) What were the barriers in implementing CBDR in Philippine LGUs? (3) What were the outcomes of CBDR at the local government level?

Identification of Cases

Five (5) LGUs implementing respective CBDR programs were included in this study (see Table 1 for details). In order to select LGUs, a panel consisting of representatives from government agencies as well as nongovernment organizations (NGOs) involved in drug recovery was constituted. Nominations were elicited from panel members, and the most commonly cited LGUs were selected. Letters were written to 10 LGUs, and of these, eight agreed to be interviewed. However, only five LGUs had complete representation and sampling of officials, providers, and clients. The five LGUs include Caloocan City, Municipality of Manolo Fortich, Naga City, Quezon City, and Municipality of Talacogon in the Philippines.

Table 1 Community-based drug treatment and recovery programs of the selected LGUs

Local government unit	Community-based drug treatment and recovery program
Caloocan City	Community-Assisted Rehabilitation and Recovery Outpatient Training System (CARROTS)
Municipality of Manolo Fortich, Bukidnon	Community-Based Rehabilitation Network using Katatagan Kontra Droga sa Komunidad (KKDK/ Resilience Against Drugs in the Community)
Naga City	Naga City Oplan Salvar Buhay (Save Lives)
Quezon City	Katatagan Kontra Droga sa Komunidad (KKDK)
Municipality of Talacogon, Agusan del Sur	Talacogon Community-Based Substance Use Recovery and Enlightenment (TCB SURE) Program

Table 1 Community-based drug treatment and recovery programs of the selected LGUs

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Identification and Selection of Participants

Selection of participants was undertaken through referrals made by LGU focal persons. The inclusion criteria were that incumbent LGU officials had a role in CBDR, CBDR providers have been involved in the program for at least six months, and clients who completed the program. The target was to interview eight representatives from each LGU; however, two interviewees declined. The final sample was 38 interviewees that included seven (7) LGU officials and focal persons in charge/administrators of CBDR (e.g., local chief executive, health officer, planning and development officer, antidrug abuse council officers, etc.), 15 CBDR program facilitators, and 16 persons who use drugs (PWUDs) who went through the program. Majority of interviewees (71%) were male and ranged from 25 to 52 years with an average age of 39 years. Recovering PWUDs reported using methamphetamine and shabu from 4 to 23 years (average of 14.5 years). Nine of the PWUDs shared that their first use of drugs was influenced by their friends while two mentioned that they first accessed drugs from relatives who sell this in their communities. Only four of the PWUDs explicitly mentioned having jobs at the time of the interviews.

Instruments

Semistructured interview guides were developed and utilized for this research. For program implementers (LGU officials and CBDR service providers), the interview questions focused on the (1) situation of the community before the implementation of CBDR; (2) drivers of implementation of CBDR program; (3) key objectives, principles, beliefs, and values that guided the program development and implementation; (4) actors and stakeholders involved in CBDR; (5) elements and processes that comprised CBDR; (6) reactions/responses elicited by the program; (7) issues, challenges, and gaps related to program design and implementation and how these were addressed; (8) community situation after the CBDR program implementation; and (9) lessons learned and recommendations from the program, especially in relation to ensuring enhancements and sustainability of the program. In-depth interviews with clients focused on (1) socioeconomic and security conditions in the community before the CBDR program; (2) awareness, knowledge, and attitudes on CBDR; (3) experiences in participating in CBDR, including processes that they have undergone and challenges encountered; (4) changes observed in themselves and in other participants/stakeholders in relation to participation in CBDR; and (5) recommendations for program enhancement and sustainability.

Data Collection Procedures

After acquiring ethics clearance from the researchers’ university, formal communications were sent to program implementers requesting their concurrence to be part of the research and securing permission to conduct data collection activities. Once permission was secured, the research team proceeded to contacting potential respondents to schedule key informant interviews.

Informed consent was obtained prior to the interviews. The interviews were conducted from March to July 2018 in LGU offices, barangays halls, and in some cases, churches using the local languages and recorded through voice recording devices. Key informant interviews ranged from around 30 to more than 60 min. Key ethical principles on confidentiality, anonymity, and do-no-harm were maintained throughout the data collection process.

Data Analysis Procedures

Interview transcripts were analyzed following the thematic analysis procedures of Braun and Clarke (2006). This included familiarization with the data, generation of initial codes, searching and reviewing for potential themes, and defining and naming themes. Members of the research team read the transcripts independently and conducted initial coding based on the WHO framework in separate Excel files. The dimensions of the framework were utilized as higher-order themes. Then, subthemes under each dimension were independently identified across cases by two other members of the research team. Another coding template was created for these cross-case analyses. Comparison of the subthemes generated by the researchers and reviewing of verbatim quotes under each subtheme were conducted by the researchers as part of the intercoding process. The writing of the results section commenced after the researchers agreed on the subthemes and the quotes within it. Quotes presented in the results were translated to English. The sensitivity of the information presented and the agreements with the participants through the informed consent form deters the direct identification of the sources of the quotes. Thus, to demonstrate the breadth of sources for the quotes and to provide some context on where and from whom the quotes came from, each local government unit (LGU) was randomly assigned a code (LGU1, LGU2, …LGU5) and participants were identified by the group that they represent as well as their corresponding number in the data analysis files (e.g., clients/persons who use drugs [PWUD1], local officials/administrators [LOA1], and community-based drug rehabilitation facilitator [CBDRF1]).

Leadership and Governance

Leadership and governance emerged as both enablers and barriers to CBDR. On one hand, program implementers in all of the LGUs expressed that their efforts to address the issue of drug use was in compliance with the President’s directives. An LGU official expressed that they implemented CBDR “in order to align with what the President wanted … a drug-free Philippines” (LGU5, LOA3). According to the interviewee, this mandate from the President led to the formation of Anti-Drug Abuse Councils (ADAC) in LGUs, implementation of various processes based on guidelines of national government agencies, and administration of CBDR programs.

Beyond the national level, an important factor that enabled implementation of CBDR in all five LGUs was the commitment of local chief executives and LGU officials. A CBDR provider noted, “It’s really the mayor…he has the political will to…push this” (LGU5, LOA1). The support of the mayor and the community leaders facilitated the establishment of antidrug abuse councils as well as the creation of policies that support CBDR implementation. According to a CBDR provider, “it is the barangay (barangay is the small unit of local government in the Philippines) leaders who know the people in the community. They can determine who among the participants need to attend CBDR and would need closer monitoring to ensure avoidance of drug use” (LGU2, CBDRF2).

Helpful processes from screening to interventions that identify roles of offices/agencies were also put in place in all of the LGUs. By doing so, the local government was able to form needed partnerships with multiple sectors – church, nongovernment organizations, local police, national government agencies, the business sector, and professional organizations, among others.

Unfortunately, not all LGUs had supportive local leaders. A CBDR provider mentioned that “not all barangays have been that cooperative…(the)reality is, some of the local leaders are actually into drugs” (LGU2, CBDRF2). CBDR providers recounted that they get low turnout as participants are not encouraged to attend the program because of the lack of cooperation from community leaders.

Some leaders felt that threat and fear were needed to motivate people to get treatment. A service provider shared that in their LGU, “clients are told that they should surrender if they would like to live” (LGU2, CBDRF3). While some felt that this was necessary, others report that some PWUDs refused to surrender because they were afraid of the barangay captain and the local police.

There were also those who did not support the punitive approach (e.g. “the President is looking for drug addicts to kill;” LGU4, PWUD1) and reported that unclear guidelines on who should be included in the official listing of drug users in communities served as challenges to CBDR implementation.

Financing and Access to Resources

Aside from leadership, a critical factor in CBDR implementation is budget and resources allotted for the program. The local chief executives and/or CBDR providers mentioned the provision of funding by the LGU as a program enabler. The allocation of budget for CBDR was supported by a local ordinance while donations coming from private organizations augmented the program funds. CBDR providers also noted the importance of getting help from national government agencies. An interviewee mentioned that the “Department of Interior and Local Government and Department of Social Welfare and Development supplies rice that they use to feed the clients during the sessions” (LGU4, CBDRF2). As shared by CBDR providers and clients, the assistance from these agencies allowed the LGU to provide transportation, food, and/or monetary allowances to the clients and their families. Other agencies such as the “Department of Health (DOH) assists by conducting medical examinations” (LGU4, CBDRF2). The DOH, partner universities, and professional associations (e.g. Psychological Association of the Philippines) also provided training materials.

However, some interviewees noted the lack of funds and delayed budget as major barriers. One local government official mentioned that “having limited funds is our greatest challenge because we are second to the poorest municipality here” (LGU4, LOA1). There was also initial hesitation within the LGU to allocate funds to drug use interventions. According to a local government official, “it was hard for people to appreciate it because it costs money and yet you will not spend it on books or buildings” (LGU2, LOA1). These funding-related challenges reflected in the lack of access to resources for the clients such as the limited provision of food, monetary allowance, or medicines. There were also challenges related to the lack of drug-testing kits and training materials that are translated to the local dialects.

Information Systems

CBDR providers noted that information dissemination to raise awareness on drug use through schools and media were helpful in addressing stigma. However, a major barrier in two cities was the inability of leaders and program implementers in the barangays to inform clients about the CBDR activities. According to a local government administrator, “It is the barangay that neglects its responsibility of informing the client of the schedule” (LGU5, LOA2). CBDR providers noted the “lack of prioritization...lack of effort… to encourage participants to join (and) lack of awareness of local leaders regarding addiction” (LGU3, CBDRF2) and “lack of support from local barangays” (LGU3, CBDRF4). A number of clients also reported a lack of information about the program, “there is no information, we were just told to surrender” (LGU1, PWUD2). Another challenge was the dearth of available records and poor information management. A local government administrator shared that LGU records were lost or that current information can now only be accessed through the local police and that “it is only the barangay captain that has the list of clients in their LGU” (LGU5, LOA1).

Workforce

In the Philippines, the drugs of choice are methamphetamine and marijuana for which there are no pharmacological treatments, and interventions are behavioral in nature. Given this, a critical enabler of CBDR is the presence of trained program facilitators. In some LGUs, clients described their facilitators as committed, supportive, accommodating, and respectful. As one client narrated,

However, most LGUs also reported a dearth of drug use or health professionals. The CBDR providers also highlighted the “lack of psychologists” (LGU3, CBDRF1) and “doctors for screening and assessment” (LGU3, CBDRF5). In addition, local chief executives and/or CBDR service providers in all of the LGUs expressed that a major challenge was the lack of trained program facilitators and assessors. A CBDR provider shared,

The lack of personnel appeared to be taking its toll on current workers. As expressed by a CBDR provider, “we are overburdened … all the staff are overworked. I am about to teach the fourth batch (of clients) but I haven’t conducted aftercare to the 1st, 2nd, and 3rd batches” (LGU2, CBDRF1). Some LGUs sought to address the issue of lack of personnel by expanding the number of program implementers. One of the local government administrators shared that before “it is only the midwife who conducts the assessment, but now we can already tap BHWs (Barangay Health Workers) … our workloads can be lessened because we can already tap other health workers” (LGU5, LOA2).

In some LGUs, what worked was having professionals (e.g. psychologists) train other volunteers from churches and the antidrug abuse councils and health workers at the barangay and LGU levels to deliver programs. Another key factor was continuous coaching and mentoring. Some providers mentioned receiving feedback from program managers and regular monthly meetings as useful in improving their skills.

Service Delivery

Despite resource challenges, respondents cited several key enablers that enhanced service delivery of CBDR in respective LGUs. The treatment program focusing on recovery and life skills was seen as an enabling factor. As shared by a client, “I was surprised that it helped me change. What I learned was really effective. When I applied learnings from each module even others saw how I changed” (LGU1, PWUD1).

Majority of LGUs implemented group-based interventions. This was perceived as an enabler by clients who reported that meeting other recovering users was helpful. They said that the group approach facilitated peer bonding and provided them social support. As shared by a client “They opened up about having a reunion … if not for the rehab, we won't be seeing each other” (LGU5, PWUD1).

Beyond treatment, an important part of CBDR is family and community support. A number of LGUs put in place well-integrated and coordinated referral systems of services. As mentioned by a local government official, “Brief intervention is packaged with referral. We look at medical comorbidity during screening … then refer to a doctor for checkup … Everyone enrolled in the program – all our clients automatically go to the district hospital for medical checkup” (LGU4, LOA1). Some participants mentioned receiving free medicines and vitamins or grooming services and joining outreach programs (e.g., clean-up drive) as well as recreational activities like playing sports. Participants perceived the program as targeting holistic recovery of clients which included addressing medical, psychological, social, and economic needs. As shared by a CBDR provider:

Even as there were factors that enabled service delivery, several key barriers were also identified. These included a lack of appropriate programs or materials, scheduling and regularity of implementation, and a lack of assistance of livelihood and wrap-around services.

Some LGUs used lengthy programs aimed for those with severe dependence, and not all LGUs had structured programs or materials. One participant expressed discomfort with some content that was irrelevant, “The topics were mostly about sex, organs, and the like. The topic was supposed to be about rehab and not about sex” (LGU5, PWUD1). A few used a localized evidence-informed program (i.e., KKDK). However, some service providers reported difficulty in understanding the Filipino terms because they had a different dialect.

There were also a number of challenges identified in the implementation process of CBDR. Below are accounts of service providers reflecting issues on efficiency and standardization of service delivery:

Furthermore, participants’ adherence to the program (i.e., attendance and participation) was hampered by conflicts with work schedule. Because a majority of the sessions were being implemented on weekdays, clients who worked lost either the opportunities to earn a living or could not attend the session.

Consistency in service delivery was affected by external circumstances such as inclement weather or conflicting priorities. However, cancellation of sessions affected subsequent attendance. A local government administrator said, “Our clients would inform us that they could attend the next time because they already filed for a leave of absence for this session” (LGU5, LOA2). The same administrator shared that, “What I remember is that it was supposed to resume by February. I don't know what happened as to why it did not push through. And then there was the barangay election last May so it was postponed again.” A service provider echoed the concern on the impact of delays, “That's what is happening now. They undergo the modules and have come so far and then suddenly there is a big lapse of time in terms of the follow-up module until the process is no longer followed” (LGU3, CBDRF1).

Finally, a common gap identified was the lack of reintegration support particularly for those unemployed. A service provider noted that there was minimal involvement of government agencies responsible for providing livelihood and skills training and social welfare support for PWUDs.

Context and Culture

Beyond the dimensions of the Health Systems Framework, the interviews highlighted the salience of context and culture. In particular, the sense of community involving family members, employers, and co-participants was identified as enablers of CBDR. The camaraderie and group support formed throughout the program were cited as protective factors against drug relapse. As shared by a client,

Most interviewees also mentioned that drug use in their community was a major barrier to their recovery. Some clients reported challenges because of peers who were still using drugs as a possible cause of relapse. A CBDR provider expressed that, “no one will surrender because they are afraid of the drug syndicate that is still in the community” (LGU2, CBDRF3).

Aside from peer influence, some interviewees attributed drug use to poverty and access to drugs. As mentioned by an interviewee, “Poverty is one of the reasons why drug use is flourishing. It’s very easy and profitable to sell drugs, … you can get drugs from a lot of sources” (LGU2, CBDRF2).

Misconceptions and a lack of understanding of the nature of relapse also served to demotivate some service providers. One service provider was disheartened that some clients experienced relapse or tested positive while enrolled in the program, “Around 75% in my first batch tested positive in a drug test, and I really took it to heart” (LGU1, CBDRF2).

Another barrier to CBDR was the negative stereotypes of drug users as “having mental defects or mentally ill” (LGU4, PWUD2). This stigma was reported to be a reason why some clients are reluctant to seek help. A service provider shared, “people would say, why would you enroll in a program like that, you’re not crazy” (LGU4, CBDRF2). Another interviewee also added that the belief that “addicts will always be addicts” still persists and discourages help-seeking (LGU4, CBDRF1).

Outcomes

Despite all the challenges in delivering CBDR, majority of the LGUs reported its positive benefits. Some outcomes of CBDR programs that were noted by the participants included improved health and well-being, social/financial protection for the clients, access to services, and service efficiency. There was also an overall decrease in drug use and occurrence of crimes/disruptions in the community.

Limitations and Implications

Overall, the various cases highlight common barriers and enablers of CBDR in the Philippines. One limitation of the study was that it was conducted when the government’s drug war was still being actively implemented. Although privacy and confidentiality of responses were assured and observed, the context may have influenced the candor of respondents. Another limitation of the study was that the cases covered a limited number of LGUs, and research was conducted three years after LGUs began to implement CBDR. Longitudinal data would be useful to see how LGUs and the country evolved. Future studies may wish to see if and how these LGUs have progressed in their delivery of CBDR.

Limitations notwithstanding, there are valuable lessons that can be gleaned from the experiences of LGUs in the Philippines. As the name implies, CBDR requires a holistic and health approach that not just focuses on the drug use but the needs of PWUDs. The case studies suggest many gaps in the dimensions of an effective health system that need to be addressed to ensure the sustainability of CBDR. Despite a plethora of challenges, some LGUs have managed to make CBDR work through effective leadership, partnerships, and by harnessing the participation of the community. It thus appears that the adage “it takes a village to raise a child” also applies to helping PWUDs recover.