The Harm Reduction Study Visit Evaluation Report Kuala Lumpur, Malaysia 9th-15th January 2011

Prepared by

scope centre of learning and research

for Project Sponsor

South Asia’s HIV epidemic is severe, but further spread is preventable. The future size of South Asia’s epidemic will depend on an effective two-pronged approach. First, and most critical, the epidemic’s growth will depend on the scope and effectiveness of HIV prevention programs for male and female sex workers (SWs) and their clients, for injecting drug users (IDUs) and their sexual partners, and for men who have sex with men (MSM) and their sexual partners. Second, it will depend on the effectiveness of efforts to address the underlying socioeconomic determinants of the epidemic and to reduce stigma and discrimination toward people engaging in high-risk behaviors, who are often the marginalized in society, as well as toward people living with HIV/AIDS.... Capable and committed individuals and groups are needed to facilitate program implementation at all administrative levels.... Governments and their program implementing partners need to invest in building and using a comprehensive information base to identify the priority constituents and locations for focused prevention programs. In addition, improving the scale, coverage, quality, and integrity of program implementation requires substantial capacity building. Multi-sectoral responses can address both the immediate practices and the underlying socioeconomic factors that contribute to transmission. Largescale, targeted prevention programs with saturation coverage based on these principles can greatly decrease the size of South Asia’s HIV epidemic, prevent the establishment of an epidemic in the general population, markedly reduce expenditures for disease control, and mitigate socioeconomic impact, hence providing a high return on investment.

Excerpt from AIDS in South Asia Understanding and Responding, World Bank Report http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/SOUTHASIAEXT/0,,contentMDK: 21019386~pagePK:146736~piPK:146830~theSitePK:223547,00.html

Contents Executive Summary

1

Country Backgrounds

3

The Maldives

3

Bangladesh

4

Harm Reduction in Malaysia

5

The Study Visit

9

Program Highlights

12

Delegates’ Comments

23

Pre and Post-Visit Survey

25

Impact Assessment

25

Outcomes Measured Against Objectives

30

Evaluation By The Delegates

31

Conclusions

34

Recommendations

35

Appendices

37

Appendix 1: Participants List

37

Appendix 2: Study Visit and Roundtable Program

38

Appendix 3: Pre-Study Visit Survey Form Sample

40

Appendix 4: Post-Study Visit Survey and Evaluation Form Sample

41

Appendix 5: About Scope Group

42

2

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Executive Summary Injecting drug use has become a major driver of HIV transmission in Asia. Consequently, the need for governments to develop effective policies and appropriate responses to reduce the spread of HIV/AIDS in Asia is as urgent as ever as the concentrated HIV epidemic in this population could spill into other atrisk populations. However, introducing new programs and transforming the policy makers’ and population’s understanding of the drug use and HIV issue takes brave leaders who themselves are convinced that these programs can work in their own countries, not just in foreign lands that bear no cultural, religious nor economic resemblance to theirs.

Differing cultural values and religious sentiment combined with lack of knowledge and understanding can become a barrier to such social innovation. However, the success stories from Muslim countries such as Iran and Malaysia show that cross-sector partnerships with religious leaders and organizations can increase the support for, and success of, national harm reduction programs even in settings as diverse as mosques and prisons.

Study visits to countries that have documented success stories form an important and integral part of any advocacy work within the field of harm reduction. Such visits provide opportunities for country leaders and opinion-makers to witness for themselves success stories of other countries and partake in meaningful dialogue with the relevant individuals that have been instrumental in implementing the programs. As the old adage goes: “Seeing is Believing” and the program in Malaysia is testament to this. Malaysia is an example of a country that has demonstrated how political leadership commitment, combined with smart partnerships across sectors can create an enabling environment for harm reduction supported by evidence-based principles.

Working in partnership with the World Bank under the South to South Learning program, the Scope Centre of Learning and Research (SCOLAR) facilitated a Harm Reduction Study Visit for high level officials from the Maldives and Bangladesh to key harm reduction program sites in Kuala Lumpur, Malaysia from 9th to 15th January 2011.

The 13-person strong delegation comprised key parliamentarians, government officials and civil society leaders representing various sectors from the Maldives and Bangladesh. Accompanying the delegation were representatives from the South Asia Regional office of the World Bank, the United Nations Office on Drugs and Crime, Bangladesh and the United Nations Development Program in the Maldives (please see Appendix 1 for participants’ details).

Harm Reduction Study Visit to Malaysia: Evaluation Report

1

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

The 7-day visit to various sites implementing the harm reduction program included the following:  1. 1Malaysia Cure and Care Clinic - once a compulsory rehabilitation centre manned by security guards which had now been transformed to a voluntary, open-concept, medical-oriented clinic with in and outpatient facilities and the provision of harm reduction services 2. University Malaya Centre of Addiction Science where medical and spiritual treatment of addiction goes hand in hand in the setting of a mosque 3. Kajang Prison to visit a Methadone Clinic run inside the correctional setting where patients are invited to join the program voluntarily 4. Ministry Of Health Hospital Kuala Lumpur Methadone Clinic to learn from their experience of piloting the harm reduction project in Malaysia and witness how technology and automation has assisted in scale up of the program to reach more patients whilst ensuring patient safety and data accountability 

The study visit program design also incorporated opportunities for informal discussions through facilitated meetings with the Islamic Development Council (JAKIM) and during the Roundtable event. The Roundtable on Enabling Environments provided an opportunity for open dialogue among the government and civil society representatives of the three countries. In creating “champions for change”, it is important to know how to manage change and hence, one of the roundtable sessions addressed this issue directly.

The study visit to Malaysia successfully exposed the delegates to effective national harm reduction services, and provided them with the opportunity to meet with key officials from the Malaysian government and patients undergoing treatment to discuss how to create an enabling environment, specifically addressing health, legal and social issues including  stigmatization and criminalization of drug use. It also provided the delegates with the opportunity to understand both theoretical and practical aspects of the Malaysian harm reduction program. The site visits, expert presentations and roundtable discussions provided the delegates with a broad spectrum of inputs and experiencesharing with their counterparts in Malaysia. The study visit also built new relationships and ideas for future capacity building and advocacy programs.

Overall, the study visit was a great success as the comments and feedback obtained from the evaluation surveys showed a positive impact on the delegates’ understanding and perception towards harm reduction and the importance of their own role in creating enabling environments in their respective countries. Additionally, the visit reinforced and supported the Malaysian government’s own decisions in scaling up the harm reduction program to meet the national coverage targets for HIV prevention by way of international recognition of their efforts.

Harm Reduction Study Visit to Malaysia: Evaluation Report

2

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Country Backgrounds The Maldives The Maldives is a country with a unique situation in the South Asia region in that it has one of the worst drug use epidemics in the world but one of the lowest HIV prevalences. A country with a population of 300,000 and predominantly Muslim, the government has made national efforts to control the drug epidemic by implementing tough laws on drugs. The majority of the prison population is incarcerated for drug-related offenses and possession of over 1g of any drug can land a person in prison for 12 to 25 years. Data on HIV/AIDS from the Maldives is limited but what has been reported does show low HIV prevalence rates in the country. There are relatively small numbers of injecting drug users and sex workers at the moment but recent observational accounts suggest that injecting drug use may be growing in the Maldives as is the commercial sex industry. The initial drug of experimentation and the main drug of abuse in the Maldives is heroin and an estimated 30% of youth in the country uses heroin or other substances. An independent report commissioned in 2010 found that heroin is predominantly smoked but rising numbers of users are injecting it. The challenge for the Maldives is to ensure it remains a low HIV prevalence country despite increasing high risk behaviors among the at-risk populations. Harm reduction measures in the Maldives offer a great opportunity to avert an HIV epidemic and keep HIV prevalence rates low.

Drug abuse and stigmatisation prevention campaign posters from the Maldives supported by UNICEF Harm Reduction Study Visit to Malaysia: Evaluation Report

3

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Bangladesh Bangladesh has completed eight rounds of its HIV surveillance and the data has shown that the current HIV epidemic occurs mainly within injecting drug users and in the major cities in the country, especially Dhaka. There is also evidence of a limited but growing HIV epidemic amongst men who have sex with men. To date, the spread of HIV by female sex workers and their clients is still low, which affords a window of opportunity for the government to avert an epidemic in that group. The most commonly injected drug in Bangladesh is buprenorphine, with heroin mainly consumed through smoking. Needle and syringe exchange programs had started in 1996 with the launch of the National HIV/AIDS policy which supported behavioral change interventions to prevent the spread of HIV. These included the provision of clean needles and condoms to injecting drug users. The methadone maintenance pilot, a project supported by the UNODC was recently launched in July 2010 with an aim to enroll 300 patients. The enrollment of patients to the program has been slow with the latest figures as of December 2010 standing at 136 patients. Nevertheless, early results from the pilot has been positive and another centre is scheduled to be opened in the near future. The results of the pilot will determine the decision for continuation of the program and plans for scale-up. The evolution of the harm reduction program in Bangladesh thus provides an opportunity for the government to learn from the experiences in Malaysia especially as both countries have a predominantly Muslim population and they share the same pattern of the HIV epidemic being driven by injecting drug users.

An estimated 60% of the population live below the poverty line in Bangladesh Harm Reduction Study Visit to Malaysia: Evaluation Report

Injecting drug users on the streets in Bangladesh 4

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Harm Reduction in Malaysia

Malaysia is a multicultural, multiethnic and multi-religious country with a population of 28 million people. There are an estimated 170,000 injecting drug users in the country. Heroin is the main drug of use whilst methamphetamine use is growing at a steady rate annually. The cumulative number of HIV cases in the country was 87,170 as of December 2009. The HIV epidemic in Malaysia is concentrated mainly in injecting drug users and to a growing extent, their partners, men who have sex with men and female sex workers. It was the failure of achieving Millennium Goal No. 6 of reducing HIV/AIDS that led the government to respond with the introduction of harm reduction as an HIV prevention measure. The Harm Reduction Program was first introduced in Malaysia in 2005 as a pilot project and was endorsed in 2006 by the Cabinet following positive results in the first six months of the pilot.

The national Harm Reduction Program consists of the Methadone Maintenance Therapy (MMT) program, the National Drug Substitution Therapy Program (using Suboxone and Buprenorphine and managed by General Practitioners) and The Needle and Syringe Exchange Program and condom distribution (managed by the NGO, the Malaysian AIDS Council and its partner organizations under the supervision of the Ministry of Health).

A busy intersection in Bukit Bintang, Kuala Lumpur, an area that has a high population of sex workers and people who use drugs Harm Reduction Study Visit to Malaysia: Evaluation Report

5

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Strong leadership support has carved the way for a multisectoral collaboration through the National Task Force for Harm Reduction set up in 2005 and led by the Ministry of Health. It counts the Police, the National Anti Drugs Agency, the Islamic Development Council, Prisons Department and the Malaysian AIDS Council amongst its committee members.

Even though Malaysia started late in their bio-behavioral surveillance of the patterns and practices related to the HIV epidemic, the data collected from a 2009 survey has shown that the HIV prevention programs in the country have already shown returns on the investment and has supported further scale-up plans to 2015. Collectively, the programs have now reached approximately 35,000 injecting drug users and the latest National Strategic Plan for HIV/AIDS aims to scale up to reach 136,000 injecting drug users by 2015 (80% of the injecting drug use population). This is a very ambitious target but the government has taken up this challenge by recruiting

Methadone maintenance program in Ar-Rahman Mosque - a University Malaya Centre of Addiction Sciences research project

all relevant sectors including civil society as partners in implementation.

As the drug dependence treatment program in Malaysia continues to evolve and more sectors and stakeholders join to support harm reduction, the government is able to expand their reach and coverage of the program to the most diverse of settings, most recently to a mosque. The majority of the Malaysian population is Muslim and the involvement of the religious organizations and leaders has played a pivotal role in gaining support for the harm reduction program in the country. The program in Malaysia has not been without its challenges, especially as the legal environment plays an important role on the access to services. Some of the lessons learnt in Malaysia has enabled the government to tailor their response further and create an enabling legal environment. For example, one of the early challenges Malaysia faced was with the arrest of patients who turned up to clinics for their methadone, on grounds of other offenses which had not been served. This has significantly reduced A typical Needle and Syringe Package distributed by the Malaysian AIDS Council. Condoms are handed out only upon request

through smart collaborations with the Police and National Anti Drugs Agency. Such ‘smart partnerships’ has enabled swift actions to address challenges faced in implementation both at the national, state and district levels.

Harm Reduction Study Visit to Malaysia: Evaluation Report

6

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Malaysia's efforts in harm reduction and drug dependence treatment grows from strength to strength and continues to be noticed internationally. It has sealed the country as one of the best practice examples of how such programs should be managed. This is especially so in their approach to how programs can be implemented without the need to amend laws which can be a time-consuming, complicated process and in their management of sensitive religious issues surrounding the A group counselling session for methadone patients in the setting of a GP practice

buy-in and implementation of new programs.

Most importantly, Malaysia has recognized the importance of the involvement of a wide range of stakeholders in their national program even at the initial design and concept stage. Support from the highest offices in the country was sought very early on and strict data collection and management as well as monitoring and evaluation has been implemented to support policy making and generate future funding for the program.

Malaysia’s openness to share their experiences and discuss the challenges faced with other governments is truly inspiring and commendable and it was on these grounds that the World Bank selected Malaysia as the destination for the Harm Reduction Study Visit.

“The harm reduction policy in Malaysia has shown very positive results as recovering drug users are able to become productive citizens by maintaining jobs and taking responsibility for their spouses and children. They are being accepted in the community as a functioning member of society, and this is very important as it has helped to reduce the stigmatization of this group that has been going on for far too long” Dr S Khalid, Technical Consultant for the Harm Reduction Study Visit Scope Centre of Learning and Research (SCOLAR) 

Harm Reduction Study Visit to Malaysia: Evaluation Report

7

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Harm Reduction Study Visit to Malaysia: Evaluation Report

8

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

The Study Visit The Scope Centre of Learning And Research (SCOLAR) in partnership with the World Bank, was tasked with the responsibility to design, manage and coordinate the Study Visit to Malaysia in order to ensure high quality of services and a sustainable and objectives-driven knowledge transfer process. It was the objective of the World Bank to effectively build the capacity and expand the exposure of the high level policy makers and political leaders from the Maldives and Bangladesh towards creating a pool of champions and advocates for improved harm reduction policies and an enabling legal environment in their respective countries. The study visit to Kuala Lumpur, Malaysia took place from 9th to 15th January 2011 and provided the delegates from the governments of the Maldives and Bangladesh with the opportunity to gain first hand experience of the successful harm reduction program in Malaysia.

Participants A multi-sectoral group of 15 representatives from government and civil society from the Maldives and Bangladesh were invited to participate in the Study Visit but two could not attend at the last moment. The delegates represent a group of key decision-makers and high-level officials from various ministries and organizations in the governments of the Maldives and Bangladesh. The full participants list is available in Appendix 1.

The Harm Reduction Study Visit delegates outside the Malaysian AIDS Council offices. Clockwise (back row): Christoffer Erichsen, CEO of Scope Group; Ahmed Adil, Maldives Minister of State for Home Affairs; Anwarul Haque, Judge High Court Division, Ministry of Law, Justice and Parliamentary Affairs, Bangladesh; Mariam Claeson, Coordinator, World Bank South Asia region and Md. Mozammel Hoque, UNODC Bangladesh. Clockwise (front row): Izzadeen Adunaan, Ministry of Islamic Affairs Maldives; Iftekhar Uddin-Khan, Deputy Secretary Public Health, Ministry of Health and Family Welfare Bangladesh; Aminath Zeeniya, Director General DDPRS Maldives; Dzulkifli Ab Rahman , Associate Consultant SCOLAR; Ivana Lohar, UNDP Maldives; Abdul Muhsin Hameed, Parliamentarian, Maldives; Arup Ratan Choudhury, President, Association for the Prevention of Drug Abuse, Bangladesh; Meher Afroze Chumki, Parliamentarian, Bangladesh; Khandker Mohammad Ali, Director General, Department of Narcotics Control and Md. Ashraful Islam Khan, Inspector General of Prisons

Harm Reduction Study Visit to Malaysia: Evaluation Report

9

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

The Study Visit Objectives 1. To meet the individuals and organizations that are involved in the harm reduction and substance misuse management programs in Malaysia in order to share experiences and best practices with one another 2. To obtain a deeper understanding of the principles and importance of effective harm reduction and substance misuse management and the latest evidence and best practices internationally 3. To experience the cultural and religious context and how partnerships with religious leaders can support provision of care and support for those in need and strengthen advocacy for harm reduction programs 4. To understand and identify essential principles in the planning and management of a national harm reduction program 5. To identify key components for a structured capacity and capability building plan for the harm reduction and substance misuse management programs in The Maldives and Bangladesh 6. To identify and discuss possible applications of new knowledge gained in Malaysia on a policy, strategic, advocacy, technical and operational level in The Maldives and Bangladesh 7. To share experiences and summarize lessons learnt from the site visits and review possibilities for future collaboration between the participating governments and relevant organizations in the region

To achieve these objectives, the study visit included the following sites so as to expose the participants to a variety of settings in which harm reduction programs can be implemented: 1. Malaysian AIDS Council Headquarters and IKHLAS NGO, an NSEP and Drop-In Centre site in the community 2. Tampin Community Clinic, a Ministry of Health clinic that employs a holistic approach to rehabilitation and treatment of patients in the community 3. 1Malaysia Cure and Care Clinic - once a compulsory rehabilitation centre manned by security guards which had now been transformed to a voluntary, open-concept, medical-oriented clinic with in and outpatient facilities and the provision of harm reduction services 4. University Malaya Centre of Addiction Sciences where medical and spiritual treatment of addiction goes hand in hand in the setting of the Ar-Rahman mosque 5. Kajang Prison to visit a Methadone Clinic run inside the correctional setting where patients are invited to join the program voluntarily 6. Ministry Of Health Hospital Kuala Lumpur Methadone Clinic to learn from their experience of piloting the harm reduction project in Malaysia and witness how technology and automation has assisted in scale up of the program to reach more patients whilst ensuring patient safety and data accountability  Harm Reduction Study Visit to Malaysia: Evaluation Report

10

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

In addition to the site visits, Scope facilitated a Roundtable on Enabling Environments for Harm Reduction which provided the delegates with an opportunity for open dialogue with their counterparts in Malaysia and the relevant stakeholders in the country. Presentation handout materials, and a reference CD of over 100 “evidence” documents and guidelines published by international authorities was distributed to all participants as a concise reference library for the delegates to share with their colleagues in their respective organizations. Additionally, photographs were provided in a separate compilation as a memento item for the delegates.

The Roundtable event was held at the beautiful Putrajaya International Convention Centre

au {9 p

@ odd

nc

es {q p

qse

=a+

pelb

rue6

rn

as

\ po UureHg i,iiil uo*cn Luorle'ap !ilffit *org . ; e d ; ':*::: ur"n ",-, epvv w iu"r ";:'J= e;su{ppguv sa^rpfp "qa, =1.il """,:=

Q fi,., * @f s r .t o

r le s

d r 6 ,r r U o rue6 6r

dnS

Presentation handouts and reading materials were provided to all attendees at the Roundtable event including a CD compilation of over 100 relevant Harm Reduction publications and articles Harm Reduction Study Visit to Malaysia: Evaluation Report

11

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Program Highlights Day 1: 1Malaysia Cure & Care Clinic, National Anti Drugs Agency Once a compulsory rehabilitation centre manned by security guards, the Cure & Care Clinic has now been transformed to a voluntary, open-concept, medical-oriented clinic with in and outpatient facilities and the provision of harm reduction services such as methadone dispensing. Psychiatrists and HIV specialists run consultation clinics and patients are provided a menu of services offered for them to

The Director of the clinic, Mdm. Maizurah showing delegates around the treatment area and methadone clinic

choose from. The clinic is a revolutionary concept in Malaysia compared to the “tough and rugged” approach it once employed. The paradigm shift in the National Anti Drugs Agency stems from the findings and recommendations of Project SMART, a specialized project commissioned in 2008 and concluding in 2010 which assisted the agency in reviewing their strategies, identifying gaps in services and resources, whilst linking them to evidence-based practices and international benchmarks. In addition to the project, the National Key Result Area for Crime Reduction became the catalyst for rapid transformation of the agency’s services in order to address the rising crime committed by drug dependants. Key Takeaway: Change is possible and the public-health approach to drug dependence treatment does work

Harm Reduction Study Visit to Malaysia: Evaluation Report

12

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Day 1: Hospital Kuala Lumpur (HKL) Methadone Clinic, Ministry of Health One of the highlights of the week was the visit to Hospital Kuala Lumpur’s Methadone Clinic. Dr. Norliza Chemi and Dr. Salina Aziz hosted the delegates and talked them through the history of the Harm Reduction program in Malaysia as HKL was one of the pioneering sites for the methadone maintenance program (MMT) . The discussions focused on the role that can be played by government hospitals in the MMT component of the Harm Reduction strategy. The delegates were shown a practical example of distribution of methadone to opiate dependent patients on a daily basis and how strict stock and record management takes place, based on the detailed SOPs and documentation needed to manage the program. The clinic serves 320 patients daily from 7.30am to 4.00pm including weekends and holidays. The delegates also witnessed how through the use of an Automated Methadone Dispensing System, technology was leveraged to ensure accountability and data management and how it assisted in scaling up the program. There was ample opportunity for the delegates to have informal discussions with the doctors, pharmacists and patients on the day. Key Takeaways: 1. Methadone is a cheap and cost effective measure for opiate dependency treatment and can also prevent the spread of HIV/AIDS and reduce crime 2. The MMT program in Malaysia has shown how patients can be productive healthy citizens and functioning family members once their disease is managed effectively 3. Technology can be leveraged in program scale-up, management of data and accountability processes and standardisation of procedures. It serves as a very useful and cost-effective measure when resources are scarce

The delegates standing in front of a mural drawn by a patient on the methadone programme at the Hospital Kuala Lumpur Methadone Clinic Harm Reduction Study Visit to Malaysia: Evaluation Report

At the dispensing room 13

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Day 2: University Malaya Centre for Addiction Sciences (UMCAS) Dr. Rusdi Rashid, Program Coordinator of UMCAS hosted the delegation. The SEDAR program where medical meets spiritual therapy was presented. This program, conducted in the Ar-Rahman mosque is supported by the Imam of the mosque, Islamic Development Council (JAKIM) and the Ministry of Health. The SEDAR program (Spiritual Enhancement and Drug Addiction Rehabilitation) is a program that combines methadone dispensing with religious advice, prayers and counseling for patients. One of the challenges of scaling up the MMT program is finding appropriate venues and the mosque provides a neutral venue where the patients can find spiritual guidance and consolation. The religious leaders had been trained to understand about addiction before support was gained and they were involved in the design of the program from the very start. Plans are to expand the program to other mosques and also other religious groups if funding is made available following reporting of the results of the current study. The visit also provided an opportunity for the delegates to speak to one of the patients on the MMT program who explained how the program had helped him stay drug-free and avoid crime and lead a normal life working as a driver.

Dr. Rusdi invited the delegates to submit articles for publication in the UMCAS online journal. SCOLAR and UMCAS will be keeping the delegates up-to-date on training courses available within the field. Key Takeaways: 1. New innovative approaches to harm reduction services need not exclude religious groups and settings. 2. Buy-in from all parties concerned is absolutely essential to create ownership of the program and prevent resistance to implementation

Harm Reduction Study Visit to Malaysia: Evaluation Report

14

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Day 2: Malaysian AIDS Council (MAC) The Malaysian AIDS Council (MAC) is an umbrella organization for several HIV/AIDS NGOs and manages and channels funds received from the government in addition to managing the National Syringe Exchange Program (NSEP). MAC has successfully recruited spokespersons that are famous celebrities or respected individuals to contribute to the advocacy for harm reduction, as well as prevention of stigmatization towards HIV. Their current President, Datuk Zaman Khan, is a retired senior police officer and ex-Commissioner General of Prisons. He has played a crucial role in harm reduction advocacy and capacity building within the enforcement agencies in Malaysia as well as the religious organizations. MAC has managed to develop a professional NGO in terms of their good governance and accountability processes as well as the professionalism of the materials produced by the organization through their partnership with the media industry and several leading local designers. They have also invited the prime minister’s wife, Datin Seri Rosmah Mansor as their patron as she is very dedicated to the cause for women and children’s issues. This move has ensured endorsement and support of their programs and assisted in raising funds.

The delegates were hosted at the MAC headquarters by Datuk Zaman and were later taken to visit IKHLAS, an NSEP site located in Chow Kit, an area in Kuala Lumpur that has one of the highest prevalences of drug users and sex workers. Key Takeaways: 1. NGOs can play a crucial supporting role in a national harm reduction program 2. Accountability and good governance as well as minimum standards are important and necessary in the management of NGOs and the programs they run

Datuk Zaman Khan, President of MAC addressing the delegates

The delegates during a light moment

Harm Reduction Study Visit to Malaysia: Evaluation Report

At the IKHLAS NSEP Site 15

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Day 3: Tampin Community Health Clinic

Tampin Community Health Clinic is located in Tampin, a district approximately 100km south of Kuala Lumpur and bordering Melaka city. It is a public clinic under the Ministry of Health and is a model clinic for harm reduction in Malaysia. Nowhere else in the country has shown such a successful collaboration across relevant sectors - from the public to private as well as the community. The clinic provides methadone and NSEP programs as well as job placement, counseling, community services and welfare for their patients. The delegates were welcomed by the doctors in the clinic, the District Office representatives, the communities, Police, National Anti Drugs Agency, state religious department, agricultural department and also the media. Dr. Claeson was interviewed and the article appeared in the local Malay newspapers and television. The delegates were later taken to visit the homes and work places of patients who had successfully returned to life in the community. The visit allowed the delegates to understand the cultural context in which the harm reduction program is part of in Malaysia. Key Takeaways: 1. Cross-sector collaboration can work if all parties are invited early on in the designing and planning process so that they feel ownership of the programs and its beneficiaries 2. Community acceptance and involvement in rehabilitation can help support and reinforce patients’ recovery processes 3. Service providers need to provide a continuum of care in the community so that all needs of the patients are met, not just the medical perspective 4. Politicians, local community leaders as well as the media can play a crucial role in advocacy work within harm reduction

Harm Reduction Study Visit to Malaysia: Evaluation Report

16

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Day 4: Roundtable on Enabling Environments for Harm Reduction in Putrajaya International Convention Centre The Roundtable on Enabling Environments was held in the beautiful grand surroundings of Putrajaya International Convention Centre (PICC). Invitations were sent to all relevant organizations from various sectors in Malaysia. Despite some last minute cancellations from the VIPs due to unforeseen circumstances, the turnout was fantastic (84%) and tremendous support was shown from the Malaysian hosts who were very busy people but made this event a priority by spending a full day there. The fact that the VIPs could not attend at the last moment due to urgent appointments actually created a more open platform for discussions as the local attendees were more relaxed to share their views and opinions. This event also provided the opportunity for open discussions and dialogues at the working level between the delegates and the Malaysian stakeholders which in itself, does not normally occur in Malaysia.

Representatives from the Maldives and Bangladesh presented very interesting presentations on their country situation which was received with interest by the Malaysian participants. All in all, the day was enjoyed by all participants as it was a unique experience even for the local participants who seldom get a chance to attend such events where informal discussions and open dialogue can take place. Many of the local participants came to the Scope team afterwards to commend the World Bank for providing such an opportunity for Malaysia and felt honored that their country was chosen as a venue for the study visit.

Harm Reduction Study Visit to Malaysia: Evaluation Report

17

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Representatives from the Malaysian Ministry of Health, Attorney General’s Chambers and Police as Panelists

A representative from the NGO IKHLAS asking questions

Key Takeaways: 1. Such platforms can provide many opportunities for the relevant stakeholders to engage in meaningful dialogue with one another in order to understand the challenges and barriers faced, what works and what does not as well as allow the involvement of international agencies in the process 2. The Roundtable showed that the harm reduction program in Malaysia is still an evolving process and will continue to be so with the challenges and barriers faced. What was most important was that the Malaysian government recognized these challenges and made special efforts to address it whilst being open to discuss how improvements could be made and allow independent evaluation and monitoring of their programs. This is one of the biggest lessons to be learnt for other governments who are newly implementing their harm reduction programs.

Harm Reduction Study Visit to Malaysia: Evaluation Report

18

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Day 5: Kajang Prison The final day of the site visit was to Kajang Prison, located in the neighboring state of Selangor. Kajang Prison was one of the pioneers of methadone dispensing in prisons in Malaysia. The program is supported by the Ministry of Health and a concurrent research program run by a collaboration between Yale University and University of Malaya also takes place there. The prisons in Malaysia have generally been very supportive of the methadone maintenance program and treatment of drug dependency but so far, support has not been gained for prison needle and syringe exchange programs. The delegates were greeted and hosted by the Prison Director, Mr. Al-Naseef and his team. They were shown the grounds inside and visited the methadone dispensing clinic as well as the school for youth rehabilitation.

Key Takeaways: 1. Harm reduction programs in prisons can work if managed effectively so that continuity of care is maintained when the patients leave prison to return to the community. In this regard, close collaboration across sectors is important and follow-up plans should be made prior to the patient’s departure 2. Prisons can play a crucial role in the compliance to treatment of medical conditions as it allows daily care and follow-up of patients as well as ensuring compliance to medication. Directlyobserved therapy (DOTS) for methadone and antiretrovirals as well as TB medicines has shown positive results so far in the Malaysian setting

Harm Reduction Study Visit to Malaysia: Evaluation Report

19

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Leisure Program The delegates were taken for a sightseeing tour of Kuala Lumpur city on the day of their arrival and every day of the week there was a small leisure visit incorporated. Some of the highlights were the Welcome Dinner which showcased a Malaysian cultural dance show, the trip up the KL Tower where the delegates were able to see a 360o view of Kuala Lumpur city, a visit to the Museum of Islamic Art and also to Melaka, to see the historical city and sample local Straits’ Chinese food.

At the Kuala Lumpur Tower

Sampling hawker stall food Harm Reduction Study Visit to Malaysia: Evaluation Report

At the Islamic Art Museum 20

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Dr Claeson outside the Stadthyus, Melaka

The Maldivians relaxing by the Melaka River

A Famosa Church ruins, Melaka - a remnant from the Portuguese colonialists

Typical Melaka Straits Chinese architecture

Harm Reduction Study Visit to Malaysia: Evaluation Report

Melaka River in the evening

21

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Harm Reduction Study Visit to Malaysia: Evaluation Report

22

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Delegates’ Comments "What is most impressive with the Malaysian response to HIV is the focus on tackling the main driver of the concentrated epidemicinjecting drug use. We are here to learn from the Malaysian methadone maintenance program which is an international best practice, and from the ongoing paradigm shift from viewing drug use as a criminal act to drug use as a chronic health problem requiring long term treatment, care and support" Mariam Claeson, Program Coordinator for the World Bank South Asia Region "The visit was very useful, very informative. We have learnt a lot. During the visits, we had discussed about starting methadone programs in our prisons. I’m very much convinced this it is the right time for us to start, with the help of Mariam (World Bank). Overall, I’m very happy with the discussions with different parties as it gives us a very important opportunity to explore what we have to do next....... Policy makers and legislators can help the vulnerable families who suffer from the drug problem. We shall focus on treating addiction as a chronic illness with medication rather than criminalizing them, just like we treat the chronic illness diabetes" Ahmed Adil , Maldives Minister of State for Home Affairs whose portfolio includes the Police and Penitentiaries in the Maldives

“Clearly this is an excellent study tour and the knowledge gained does not go to waste as we will go back to Bangladesh and try to do our best to achieve our goals. We saw already how Malaysia achieved to overcome many challenges (in their Harm Reduction program) and in Bangladesh, we are only starting with the pilot project. It will be a challenge for us but if we work altogether hand in hand, we can..” Meher Afroze Chumki, Member of Parliament, Bangladesh who is also the President of the Parliamentary Standing Committee on Women and Children Affairs Harm Reduction Study Visit to Malaysia: Evaluation Report

23

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Harm Reduction Study Visit to Malaysia: Evaluation Report

24

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Pre and Post-Visit Survey Scope Centre of Learning And Research designed and distributed an anonymous survey to the delegates on the day of arrival and again on the day before departure to assess the perception of the delegates towards harm reduction.

Impact Assessment The response rate of the pre-visit survey was 84% and the post-visit survey 77%. This was attributed to the fact that the post-visit survey was handed out the evening before departure to the airport and the respondents possibly did not wish to partake in any activities on their last night in Kuala Lumpur. Some respondents submitted their post-visit survey to SCOLAR upon return to their home countries. The pre-visit survey on the other hand, was handed out and collected in the same sitting. A set of twelve (12) identical statements and questions were asked in the pre and post-visit surveys and the responses to the questions are reported in the charts below:

9#:";4+<"=5>7?@,-"A,/2?0"B,->,-53"4->"2-?+54353" *C5"735",D"2//5.4/">+7.3"" (!" '!"

A+5EF232*"

&!"

A,3*EF232*"

!"%!" $!"

Prior to the visit, there were equal numbers of delegates who disagreed and agreed with this statement (45%) and following the visit, 80% disagreed, with close to 60% strongly disagreeing and 20% disagreeing.

#!" !"

)*+,-./0" 1234.+55"

1234.+55"

657*+4/"

8.+55"

)*+,-./0" 8.+55"

8$9":3*;"<4=6>?+,"@*+-*3;;42"3*4"1,>+,212)4,)" A1)B"*4.1-1+62"CD2.3;1>"+*"+)B4*E"F3.642"3,="G*1,>1G.42"" '!" &!"

!"

%!"

@*4HI121)"

$!"

@+2)HI121)"

Close to 70% of the delegates either strongly disagreed or disagreed that harm reduction programs were inconsistent with religious values and principles after the visit compared to 45.5% prior to it.

#!" !" ()*+,-./" 0123-*44"

0123-*44"

546)*3."

7-*44"

()*+,-./" 7-*44"

Harm Reduction Study Visit to Malaysia: Evaluation Report

25

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

8%9"":";44.")<3)"=/"4>12?,-"@,+A.4B-4"3C+6)"D:EF" 26C2)3,G4"3C624"3,B"<3*="*4B6G?+,"12"26HG14,)" '!" &!" %!"

!"

I*4JE121)"

$!"

I+2)JE121)"

#!"

Whilst only 50% agreed to this statement prior to the visit, 60% agreed or strongly agreed to the statement after the visit. This could be explained by the fact that a lot of the knowledge in this field is quite technical and some of the delegates come from administrative or non-medical backgrounds hence they do not feel that their existing knowledge is sufficient.

!" ()*+,-./" 0123-*44" 0123-*44"

546)*3."

7-*44"

()*+,-./" 7-*44"

<&=">":0?8.6-70?"-@8"088?"A/."@7.B".8?:CD/0" E./1.7BB86"50".86E/068"-/"-@8"6E.87?"/A"F>GH;>4," +!" *!" )!" (!" '!"

!" &!"

I.8JG565-"

%!"

I/6-JG565-"

$!" #!" !" ,-./0123" 45671.88"

45671.88"

98:-.72"

;1.88"

,-./0123" ;1.88"

60% of the delegates agreed whilst 10% disagreed that they understood the need for harm reduction programs in response to the spread of HIV/ AIDS prioir to the visit and an overwhelming 90% strongly agreed and 10% agreed with the statement after it. This shows that the site visits gave the delegates a better understanding of the need for such programs.

8'9"0*6-"(6:2;)6;+,"<=4*3>/"12"3,"1?>+*)3,)" 3,@",4A4223*/">*+-*3??4"B+*")=4">*4C4,;+,"+B" DEFG7E0(" '!" &!"

!"

%!"

H*4IF121)"

$!"

Interestingly, the results for this statement showed almost similar results pre- and post-visit in that the majority of the delegates either agreed or strongly agreed with it.

H+2)IF121)"

#!" !" ()*+,-./" 0123-*44" 546)*3." 0123-*44"

7-*44"

()*+,-./" 7-*44"

Harm Reduction Study Visit to Malaysia: Evaluation Report

26

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

;(<"3-90"+9=5>,9>./"?@7-6A2"45"4BA.-,6/,"4/",@7" ,-76,B7/,".C".A46,7"6DD4E>./" *!" )!" (!" '!"

!" &!"

F-7GH454,"

%!"

F.5,GH454,"

$!"

The graph shows that the visit played an impact on the perception of delegates towards OST in opiate addiction with 70% of delegates strongly agreeing to this statement compared to 70% who were neutral prior to the visit

#!" !" +,-./012" 34560-77" 879,-61" 34560-77"

:0-77"

+,-./012" :0-77"

:);"<=6"766>06"5.>"*1,3./6"?@A=5./6" B,-/,5CC6"34"5."3CD-,+5.+"5.>".6A6445,1" ,64D-.46"+-"D,6E6.+"+=6"4D,65>"-F"GHIJ9H2*" )!" (!" '!"

!"&!"

B,6KI343+"

%!"

The responses to this statement did not show any significant difference between pre and post visit surveys

B-4+KI343+"

$!" #!" !" *+,-./01" 2345/,66" 768+,50" 2345/,66"

9/,66"

*+,-./01" 9/,66"

":;<"=+"34"3>?-,+5.+"+-"3.@-0@6"?6-?06"AB-"846" C,8/4"5.C"?6-?06"AB-"03@6"A3+B"D=EF9=2*"3."+B6" C6@60-?>6.+"-G"?-03H364",605+6C"+-"+B646"344864" )!" (!" '!"

!"

&!"

I,6JE343+"

%!"

In response to this statement, 100% of delegates agreed or strongly agreed after the visit compared with 80% prior to the visit

I-4+JE343+"

$!" #!" !" *+,-./01" 2345/,66" 768+,50" 2345/,66"

9/,66"

*+,-./01" 9/,66"

Harm Reduction Study Visit to Malaysia: Evaluation Report

27

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

:;<"2,8/"846,4"4=-80>"?6"+,65+6>"5.>"/3@6."+=6" 45A6",3/=+4"54"B5C6.+4" )!" (!" '!"

!"

&!"

D,6EF343+"

%!"

D-4+EF343+"

$!" #!"

Interestingly, 100% of respondents agreed or strongly agreed prior to the visit but post-visit, there was one respondent who was neutral to the statement whether drug users should be treated and given the same rights as patients

!" *+,-./01" 2345/,66" 768+,50" 2345/,66"

9/,66"

*+,-./01" 9/,66"

8'!9"012)*1:6;+,"+<"=+,>+?2")+"@1-@"*12A"-*+6B2" 12"3,"4C4=;D4"?4)@+>")+"B*4D4,)")@4"2B*43>"+<" EFGH7F0(" '!!" &!"

!"

%!"

I*4JG121)"

$!"

There were more delegates (80%) who strongly agreed with this statement pre compared to post-visit (65%)

I+2)JG121)"

#!" !" ()*+,-./" 0123-*44" 546)*3." 0123-*44"

7-*44"

()*+,-./" 7-*44"

9##:";"7-<5+3*4-<"4-<"=4-"5>?/42-"*@5" 2A?,+*4-=5",B"*@5"=,//4C,+4D,-"C5*E55-"?7C/2=" @54/*@F"/4E"5-B,+=5A5-*"4-<"=+2A2-4/"G73D=5"*," ?+5H5-*"I;JK8;1)" (!" '!" &!"

!" %!"

L+5MJ232*"

$!"

L,3*MJ232*"

#!"

This graph shows an interesting finding in that prior to the visit, 20% of the delegates were neutral in their response to the statement but post-visit, the majority (60%) strongly agreed with it

!" )*+,-./0" 1234.+55" 657*+4/" 1234.+55"

8.+55"

)*+,-./0" 8.+55"

Harm Reduction Study Visit to Malaysia: Evaluation Report

28

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

67#8""9"4*:2(0'1*:"1*:";1*"2<=,1/*"'>2"2?/:2*;2" @102"@2>/*:"'>2"=4@,/;">21,'>"1==()1;>"')" =(2?2*'"A9BC59.&" %!"

!" $!" D(2EB/0/'"

#!"

D)0'EB/0/'"

!" &'()*+,-" ./01+(22" 324'(1," ./01+(22"

5+(22"

&'()*+,-" 5+(22"

This graph also shows an interesting finding in that prior to the visit, 40% of the delegates were neutral in their response to the statement but post-visit, 60% strongly agreed and 40% agreed with it. Actual technical knowledge was not assessed but this finding still shows that the delegates’ perception of their own understanding had increased following the visit

Comparing the results of the pre and post-visit surveys, it can be concluded that the Study Visit had a positive impact on the attitudes and perception of the delegates towards harm reduction. It would be interesting to repeat the survey perhaps at 1 or 3 months after the trip to assess whether this finding has changed.

Harm Reduction Study Visit to Malaysia: Evaluation Report

29

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Outcomes Measured Against Objectives The delegates’ own objectives (from Pre-visit Survey): 1. To know about the policy of Malaysia, function of organisations, about harm reduction 2. To learn about the new and constant changes in the HIV Harm Reduction program 3. To have better understanding of religion and harm reduction implementation 4. To see the different treatment for drug addicts/users and to identify the best treatment options for our country 5. To understand harm reduction programs 6. To observe places that implement harm reduction program 7. To share our knowledge with the other members of the tour 8. To get new ideas to make risk reduction program successful 9. How OST is going on in Malaysia and what is the result in percentages and the motivational aspect from the users? 10. To set up a centre in Bangladesh where we can start with modern and up-to-date facilities for harm reduction and drug abuse prevention

The Study Visit Objectives 1. To meet the individuals and organizations that are involved in the harm reduction and substance misuse management programs in Malaysia in order to share experiences and best practices with one another 2. To obtain a deeper understanding of the principles and importance of effective harm reduction and substance misuse management and the latest evidence and best practices internationally 3. To experience the cultural and religious context and how partnerships with religious leaders can support provision of care and support for those in need and strengthen advocacy for harm reduction programs 4. To understand and identify essential principles in the planning and management of a national harm reduction program 5. To identify key components for a structured capacity and capability building plan for the harm reduction and substance misuse management programs in The Maldives and Bangladesh 6. To identify and discuss possible applications of new knowledge gained in Malaysia on a policy, strategic, advocacy, technical and operational level in The Maldives and Bangladesh 7. To share experiences and summarize lessons learnt from the site visits and review possibilities for future collaboration between the participating governments and relevant organizations in the region

Harm Reduction Study Visit to Malaysia: Evaluation Report

30

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Evaluation By The Delegates This study tour is very important for Harm Reduction in my Country? The post-visit survey also included an anonymous evaluation questionnaire to assess if the objectives Value Count Percent % of the study trip were met and obtain anonymous feedback and room for improvement for future study Agree 2 22.2% trips. The questionnaire findings showed that all of the objectives of the respondents were met and the Strongly agree 7 77.8% delegates were very satisfied with the trip from a qualitative and quantitative perspective.

Please rate your experience of the following visits Very Very Negative Neutral Positive Total Negative Positive 1. National Drugs Agency Cure & Care Centre (AADK/NADA)

0.0%

0.0%

0.0%

20.0%

0

0

0

2

0.0%

0.0%

0.0%

20.0%

0

0

0

2

0.0%

0.0%

0.0%

20.0%

0

0

0

2

0.0%

0.0%

0.0%

30.0%

0

0

0

3

0.0%

0.0%

0.0%

30.0%

0

0

0

3

0.0%

0.0%

0.0%

11.1%

0

0

0

1

0.0%

0.0%

12.5%

37.5%

0

0

1

3

0.0%

0.0%

0.0%

10.0%

0

0

0

1

0.0%

0.0%

0.0%

0.0%

0

0

0

0

10. Islamic Development Council, Prime Ministers

0.0%

0.0%

10.0%

30.0%

Dept and Ministry of Home Affairs

0

0

1

3

0.0%

0.0%

33.3%

33.3%

0

0

3

3

2. Hospital Kuala Lumpur Methadone Clinic (MOH) 3. University Malaya Centre of Addiction Science (UMCAS) 4. Malaysian AIDS Council 5. IKHLAS NSEP NGO 6. Tampin Community Health Clinic (MOH) 7. Melaka Tour of Historical City 8. Roundtable on Enabling Environments for Harm Reduction 9. Kajang Prison (Home Ministry)

11. Farewell Dinner

Please indicateStudy the relevance of the programme Harm Reduction Visit to Malaysia: Evaluation Report content to your work Value

Relevant

Count

Percent %

3

30%

80.0% 100% 8

10

80.0% 100% 8

10

80.0% 100% 8

10

70.0% 100% 7

10

70.0% 100% 7

10

88.9% 100% 8

9

50.0% 100% 4

8

90.0% 100% 9

10

100.0% 100% 10

10

60.0% 100% 6

10

33.3% 100% 3

9

31

prevent HIV/AIDS Value

Count

Percent %

Agree

4

40%

6

60%

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Strongly agree

Dept and Ministry of Home Affairs Dept and11. Ministry of Home Farewell DinnerAffairs

0

0

1

3

00.0%

00.0%

133.3%

333.3% 3

633.3%10100% 3 9

3

3

0 0 Country? 3 This study tour is very important for Harm Reduction in my

11. Farewell Dinner

Value

0.0%

0.0%

0 Count

33.3% 0 Percent %3

Agree

2

22.2%

Strongly agree

7

77.8%

33.3%

6

10

33.3% 100% 9

Please rate your experience of the following visits Very Very Negative Neutral Positive Total Negative Positive 1. National Drugs Agency Cure & Care Centre (AADK/NADA) 2. Hospital Kuala Lumpur Methadone Clinic (MOH)

0.0%

0.0%

0.0%

20.0%

0

0

0

2

0.0%

0.0%

0.0%

20.0%

0

0

0

2

Please indicate the relevance of the programme content to your work 3. University Malaya Centre of Addiction Science Please indicate the relevance of the programme 0.0% content 0.0% to your0.0% work 20.0% (UMCAS)

Value Value

Relevant 4. Malaysian AIDS Council Relevant Very relevant Very relevant 5. IKHLAS NSEP NGO

6. Tampin Community Health Clinic (MOH) 7. Melaka Tour of Historical City 8. Roundtable on Enabling Environments for Harm Reduction 9. Kajang Prison (Home Ministry) 10. Islamic Development Council, Prime Ministers

0 0 Count Percent % 0 Count Percent % 0.0% 3 0.0% 30%0.0% 03 030% 0

7

7 0.0%

70% 70% 0.0% 0.0%

80.0% 100% 8

80.0% 100% 8

8

30.0%

0

0

3

0.0%

0.0%

0.0%

11.1%

0

0

0

1

0.0%

0.0%

12.5%

37.5%

0

0

1

3

0.0%

0.0%

0.0%

10.0%

0

0

0

1

0.0%

0.0%

0.0%

0.0%

0

0

0

0

0.0%

0.0%

10.0%

30.0%

10

70.0% 100%

3

0

10

80.0% 100%

2

30.0%

10

7

10

70.0% 100% 7

10

88.9% 100% 8

9

50.0% 100% 4

8

90.0% 100% 9

10

100.0% 100% 10

10

60.0% 100%

This Study StudyTour Tourhas hasincreased increasedmy mymotivation motivation make changes where I work This toto make changes where I work Value Value

Count Percent Percent Count % %

Agree Agree Stronglyagree agree Strongly

2 2 8 8

20% 20% 80% 80%

Please describe describethe the33best bestthings thingsabout aboutthe theStudy Study Tour Programme Please Tour Programme Harm Reduction Study Visit to Malaysia: Evaluation Report Count Count

Response Response

22 11

Round visit, tampin community health clinic Roundtable tablediscussion, discussion,kajang kajangprison prison visit, tampin community health clinic

32

Reduction 3) Hospital Kuala Lumpur Methadone Clinic

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Please indicate how you will use the knowledge you gained during this Study Tour Count

Response

2 1

Will try to incorporate the new ideas/knowledge into the policy of the govt

1

by advocacy and helping influence for policy making related to HIV/ADIS and harm reduction

1

sensitizing policy makers to give a commitment to scale up harm reduction

1

share the experience of the study tour to other relevant authorities

1

Foster more south-to-south learning of this kind; focus on scaling up OST oin the portfolio that I manage

1

The knowledge gained from this study tour would help me to initiate OST / MMT programme in prison setting

1

I shall use the knowledge gained from teh study tour in policy making proces for our government about harm reduction programme

1

the knowledge that I gained from the study visit, woudl help me to do the policy advocacy to expand the MMT programme in the community health care settings as well as the prison settings

Please rate your experience of the following: Very Negative Negative Visa Processing Accommodation Food Transportation Scope Team Members

Neutral

Positive

0.0%

0.0%

0.0%

0.0%

100.0%

100%

0

0

0

0

8

8

0.0%

0.0%

0.0%

22.2%

77.8%

100%

0

0

0

2

7

9

10.0%

10.0%

0.0%

60.0%

20.0%

100%

1

1

0

6

2

10

0.0%

0.0%

0.0%

40.0%

60.0%

100%

0

0

0

4

6

10

0.0%

0.0%

0.0%

10.0%

90.0%

100%

0

0

0

1

9

10

0.0%

0.0%

40.0%

60.0%

100%

0

0

4

6

10

My Overall objectives with this Study Tour0.0% was met. Quality of Programme 0

Value

Count

Percent %

Agree

3

30%

Strongly agree

7

70%

What could be improved about the study visit programme? Count

Very Positive Total

Response

2 1

After 5.30pm it should be free time for the participants

1

It would be better to have more flexibility in the arrangement of dinner

1

increase lnowledge about harm reduction

1

the study visit may be more enjopyable if dinner may be ....

1

1. Introduce the participants to each others at the very beginning; 2. Start each day with a 1/2 hour meeting to debrief on the previos day; 3. skip the evening dinner and programs except for welcome and departure and end earlier every day; 4. reduce from 7 to a 4 day study tour if possible

1

duration of the tour, coudl have arranged more visits per day so that it does not go on for 7 days

1 study visit cannot be mpore than 5 days, dinner should not be provided during the entire visit instead Harm Reduction Study Visit to Malaysia: Evaluation Report 33 should have welcome dinner and farewell dinner only 1

woudl be better if the participants woudl habve the flexibility to have dinneron their own except for reception and farewell dinner. ie the time and place for dinner could have been decided by teh

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Conclusions The study visit overwhelmingly met the objectives of the project sponsors and matched the personal objectives of the delegates very closely. The delegates were very satisfied with all logistics aspects of the visit (food, accommodation, transportation, project organizer team members etc) and all of them felt motivated to make changes where they work. Delegates were very satisfied with the content and practical framework of the visit and the program relevance and agreed that the study visit was very important for harm reduction in their respective countries. The delegates were especially impressed by the Roundtable Event, visit to Kajang Prison and to the Tampin community health clinic. There is a need for and interest in continued training and consultancy for the harm reduction program in Bangladesh and the Maldives with particular interest in the planned introduction, management and rapid scale up of pharmacological treatment (methadone or other opiate substitutes), spiritual treatment programs in mosques or other religious organizations and the needle and syringe exchange program (NSEP). In this regard, there are opportunities in forging formalized capacity-building collaborations and technical assistance between the Malaysian government and the guests. Scope Centre of Learning And Research (SCOLAR) can act as the coordinator and training provider of future study trips and training courses in Malaysia for international governments as they have proven once again that they can provide quality programs that meet the needs of project sponsors and the delegates. 100% of the delegates would be interested to return to Malaysia for future learning with SCOLAR. Study visits are important to create trust and buy-in into programs, especially in harm reduction where resistance to acceptance of the program components still exists in many countries in the world. The power of “Seeing is Believing” should not be underestimated. Similar study visit opportunities should be provided even to host countries in order to maintain a sustainable environment for their harm reduction programs. Challenges in mindset transformation and acceptance of all aspects of the harm reduction program can be overcome by planning for the creation of not just an enabling environment in which programs can be implemented but also a sustainable one. In this regard, change management principles should be applied in any advocacy or capacity-building work that is implemented as it serves to assist the individual to accept change and also how they can manage others who resist.

Harm Reduction Study Visit to Malaysia: Evaluation Report

34

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Recommendations This successful Harm Reduction Study Visit has shown that learning and advocacy continue to be important in engaging and obtaining buy-in from the relevant decision-makers from the visiting countries but also serves to benefit the host country by creating recognition of their successes. Nevertheless, future study visits can consider the following lessons learnt and recommendations so as to create better experiences and outcomes for all involved: 1. Preparation of the delegates for the technical aspect of the visit should begin before they arrive by distributing reading materials to them in advance and seeking their own objectives so that the program and discussions can be better tailored to their needs 2. A post-visit follow-up plan at 1,3 and 6 months should be implemented in order to assess the longer term impact of the study visit and whether some of the positive attitudes and motivation is sustained and changes are implemented 3. Consider including a half-day change management discussion workshop in future programs to help the delegates face resistance in their respective countries and how they can use the resistance to gain support for the programs 4. Protocols that apply to the delegates need to be followed, despite this being an international program. This study visit showed the importance of applying this especially in addressing the delegates and during introductions to site hosts and during the Roundtable. The country focal points should furnish such protocol-related information to the program organisers and any cultural sensitivities that need to be followed as they are in the best position to understand the cultural and protocol norms of that particular country 5. More free time should be allocated for the delegates as part of the schedule, especially in the evenings and daily schedules should end by 5.30pm 6. Dinner should be left out of the programme and left to the delegates’ own arrangements and preferences 7. The Study Visit should be shortened to a 6-day trip (including travel days) 8. The World Bank needs to consider introducing a telecommunication budget into their costing as this can avoid future situations where the program organiser resources were diverted daily to cater for last-minute requests by the delegates for call-cards and SIM cards. At the very minimum, a local SIM card should be provided to each delegate as this also facilitates the organisers to contact them during the visit 9. Delegates’ profiles should be shared amongst themselves ahead of the visit as this will assist in breaking barriers when they arrive and also serves as an introduction to each other. This is especially so when delegations are made up of representatives from more than one country 10. Recreational and sightseeing activities should continue to be part of the study visit programme as it helps to make the delegates feel rejuvenated in between the hectic visit schedule and allows them to enjoy the experience of being in the host country thereby maximising their learning outcomes 11. Malaysia is a good country for future study visits as it provides the opportunity to see harm reduction programs implemented in diverse settings Harm Reduction Study Visit to Malaysia: Evaluation Report

35

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Harm Reduction Study Visit to Malaysia: Evaluation Report

36

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Appendices Appendix 1: Participants List

The World Bank Participants List for Harm Reduction Study Visit To Malaysia (9-15 January 2011) No.

Name

Position/Organisation

Country

1

Meher Afroze Chumki

Member of Parliament and President of the Parliamentary Standing Committee on Women and Children Affairs

Bangladesh

2

Anwarul Haque

Judge of the High Court Division, Ministry of Law, Justice and Parliamentary Affairs

Bangladesh

3

Khandker Mohammad Ali

Director General, Department of Narcotics Control

Bangladesh

4

Md. Ashraful Islam Khan Inspector General of Prisons

Bangladesh

5

Md. Iftekhar Uddin-Khan Deputy Secretary for Public Health, Ministry of Health and Family Welfare

Bangladesh

6

Arup Ratan Choudhury National Narcotics Control Board

Bangladesh

7

Md. Mozammel Hoque HIV/AIDS Advisor, UNODC

Bangladesh

8

Izzadeen Adunaan

Mushrif Al Musaidh, Ministry of Islamic Affairs

Maldives

9

Ahmed Adil

Minister of State, Ministry of Home Affairs

Maldives

10

Abdul Muhsin Hameed

Parliamentarian

Maldives

11

Aminath Zeeniya

Director General, Department of Drug Prevention and Rehabilitation Services

Maldives

12

Ivana Lohar

Programme Manager, UNDP

Maldives

13

Mariam Claeson

Regional Coordinator, World Bank South Asia

Harm Reduction Study Visit to Malaysia: Evaluation Report

India

37

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Appendix 2: Study Visit and Roundtable Program

DAY/ TIME

DAY 1 (Sunday, 9 January 2011)

DAY 2 (Monday, 10 January 2011)

DAY 3 (Tuesday, 11 January 2011)

DAY 4 (Wednesday, 12 January 2011)

Arrival And Orientation

Site Visits

Site Visits

Site Visits

9:00 10:30

Arrival KLIA & Check-In To Hotel 11:00

12:30

Introduction And Briefing By Technical Consultant, Scope Consult

Visit To Tampin Health Clinic (Community Outpatient Holistic Harm Visit To University Malaya Visit To National Anti Reduction Program). Centre For Addiction Drugs Agency’s Cure Discussion With Local Sciences And Ar-Rahman And Care Clinic (Inpatient Community Leaders, Mosque (Mosque-Based Rehabilitation Centre) Police, GPs And Drug Treatment) Enforcement Officers

Lunch

Lunch At Museum Of Islamic Art

Lunch

Visit To Hospital Kuala Lumpur Methadone Clinic (Specialist Public Hospital) And Meet Ministry Of Health Officials

Visit To Malaysian AIDS Council And IKHLAS Drop In Centre (Community NSEP Site)

Melaka: Tour Of Historical City

Special VIP Visit To KLCC Twin Towers

Tour Of Batu Caves Temple

Seaside Dinner

Dinner

Dinner

Return To KL

14:00

15:00

KL City Tour

18:00

20:00

Welcome Dinner

Harm Reduction Study Visit to Malaysia: Evaluation Report

38

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Appendix 2: Study Visit and Roundtable Program DAY/TIME

DAY 5 (Thursday, 13 January 2011)

DAY 6 DAY 7 (Friday, 14 January 2011) (Saturday, 15 January 2011)

Roundtable On “Enabling Environments For Harm Reduction”

Site Visits

Departure

Launching Ceremony 8.30

Tan Sri Dato’ Seri Dr. Hj. Ismail Merican, Director General Of Health

“The Global State Of Harm Reduction” 9:00

9:30

Dr. Harpal Singh, WHO Technical Officer For Malaysia

“Drivers For Introducing The National Harm Reduction Program: The Malaysian Experience” Dr.Sha’ari Ngadiman, Head Of AIDS/STD Unit, Ministry Of Health Malaysia

10:00

Coffee Break

10:30

Country Presentations From Bangladesh And The Maldives

11:00

Visit To Kajang Prison (Correctional Institution Setting) Hotel Check-Out

“The Evidence For Change: The International Experience Of What Works”: Dialogue With Panel Comprising World Health Organisation, United Nations Office On Drugs And Crime, Ministry Of Health Malaysia And The National Anti Drugs Agency, Chaired By ScopeConsult

12:30

14:00

14:30

Networking Lunch, Prayers

“Change Management In A Changing Environment: A Leader’s Perspective”: Dato’ Hajjah Zuraidah Binti Haji Mohamed, Director General Of The National Anti Drugs Agency

“Advocacy And The Law: Enabling Change”: Dialogue With Police, Ministry Of Home Affairs, Attorney General’s Chambers And Ministry Of Health, Chaired By Datuk Mohd Zaman Khan Rahim Khan, President, Malaysian AIDS Council

15:30

Networking Tea Break

16:00

Q & A And Summary Of Lessons Learnt, Chaired By ScopeConsult

Lunch, Friday Prayers

Visit To JAKIM (Islamic Development Council, Prime Minister’s Department) And Ministry Of Home Affairs

Departure For Airport

High Tea Closing Ceremony And Certificate Presentation 17:30

His Hon. Datuk Wira Abu Seman Yusop, Deputy Minister Of Home Affairs Followed By Group Photograph

Tour Of Putrajaya City

18:00

End Of Day Program

Farewell Dinner

Harm Reduction Study Visit to Malaysia: Evaluation Report

39

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Appendix 3: Pre-Study Visit Survey Form Sample Harm Reduction Study Visit to Kuala Lumpur, Malaysia Page One

Harm Reduction Study Visit to Kuala Lumpur, Malaysia 9-15th Jan 2011 Pre Visit Survey

Dear Delegate, Welcome to Malaysia. Prior to the Study Visit tomorrow, we would like to request your participation to participate in this short survey about Harm Reduction and HIV/AIDS. The questionnaire is anonymous and you will be given the opportunity to answer the same questions at the end of the programme. Please set an 'X' on the scale between 1 - 5 to indicate the extent to which you agree or disagree with the statement.

1. Harm reduction policy and practice condones and increases the use of illegal drugs Strongly disagree

Disagree

Neutral

Agree

Strongly agree

2. Harm Reduction Programmes are inconsistent with religious (Islamic or other) values and principles Strongly disagree

Disagree

Neutral

Agree

Strongly agree

3. I feel that my existing knowledge about HIV, substance abuse and harm reduction is sufficient Strongly disagree

Disagree

Neutral

Agree

Strongly agree

4. I understand the need for harm reduction programmes in response to the spread of HIV/AIDS. Strongly disagree

Disagree

Neutral

Agree

Strongly agree

5. Drug Substitution Therapy is an important and necessary programme for the prevention of HIV/AIDS Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Agree

Strongly agree

6. Drug Substitution Therapy is important in the treatment of opiate addiction * Strongly disagree

Disagree

Neutral

7. The Needle and Syringe Exchange Programme is an important and necessary response to prevent the spread of HIV/AIDS Strongly disagree

Disagree

Neutral

Agree

Strongly agree

8. It is important to involve people who use drugs and people who live with HIV/AIDS in the development of policies related to these issues

Harm Reduction Study Visit to Malaysia: Evaluation Report

40

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Appendix 4: Post-Study Visit Survey and Evaluation Form Sample Harm Reduction Study Visit to Kuala Lumpur, Malaysia (PostSurvey)

14/01/2011 16:18

Harm Reduction Study Visit to Kuala Lumpur, Malaysia (PostSurvey) Page One

Harm Reduction Study Visit to Kuala Lumpur, Malaysia 9-15th Jan 2011 Post Visit Survey and Evaluation :: Scope Centre Of Learning And Research (SCOLAR) :: Dear Delegate,

Thank you for your cooperation and active participation in the Harm Reduction study visit to Kuala Lumpur Malaysia. Following this week´s programme of site visits, roundtable and informal discussions we would like to request your participation to participate in this short post survey about Harm Reduction and HIV/AIDS. Further we would like your evaluation of the week so we can include this information in our evaluation and in the continued improvement of our international programmes. The questionnaire is anonymous. Please set an 'X' on the scale between 1 - 5 to indicate the extent to which you agree or disagree with the statement.

1. Harm reduction policy and practice condones and increases the use of illegal drugs Strongly disagree

Disagree

Neutral

Agree

Strongly agree

2. Harm Reduction Programmes are inconsistent with religious (Islamic or other) values and principles Strongly disagree

Disagree

Neutral

Agree

Strongly agree

3. I feel that my existing knowledge about HIV, substance abuse and harm reduction is sufficient Strongly disagree

Disagree

Neutral

Agree

Strongly agree

4. I understand the need for harm reduction programmes in response to the spread of HIV/AIDS. Strongly disagree

Disagree

Neutral

Agree

Strongly agree

5. Drug Substitution Therapy is an important and necessary programme for the prevention of HIV/AIDS Strongly disagree

Disagree

Neutral

Agree

http://www.surveygizmo.com/s3/446683/Harm-Reduction-Study-Visit-to-Kuala-Lumpur-Malaysia-PostSurvey

Harm Reduction Study Visit to Malaysia: Evaluation Report

Strongly agree

Page 1 of 4

41

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Appendix 5: About Scope Group Scope Group Sdn Bhd has been based in Kuala Lumpur, Malaysia since 2007. Scope Consult, the consultancy arm, provides specialized consultancy, research and technology solutions to manage and improve organizational performance and deliver benefits to clients within the niche fields of substance misuse management, social policy and public health. Scope Centre of Learning And Research (SCOLAR) focuses on development and dissemination of knowledge and capacity building through facilitation of learning. At Scope we believe in providing more than the usual consultancy report recommendations that does not succeed to drive change nor improve performance. We believe in maximizing value to organizations through focusing on building people and using technology as an enabler. We offer solutions and consultancy guided by global standards but always tailored to the local customer's values and realities. We actively design and deliver holistic solutions to implement the desired changes together with relevant partners in our network - thus linking strategic objectives to successful implementation processes. Our team consists of both local and international experts and trainers from various domains and backgrounds within research and clinical practice. Most recently, we have been consultants to the National Anti Drugs Agency Malaysia and have been involved very closely with the strategic review of the agency's policies and benchmarking them to best practices around the world, including supporting them in their embrace of Harm Reduction and evidence-based public health interventions. 

Roundtable Events

Study Visits

Expert Lectures

Meeting High-Level Officials

Harm Reduction Study Visit to Malaysia: Evaluation Report

Learning Workshops

Certification

42

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

All Rights Reserved. Scope Centre Of Learning And Research - SCOLAR 2011

Scope Centre of Learning and Research (SCOLAR) Scope Group Sdn Bhd Suite 15-08, G Tower 199 Jalan Tun Razak 50400 Kuala Lumpur Malaysia T (60) 3 2169 7069 F (60) 3 2169 6168 E [email protected] W www.scopeconsult.com

No part of this document to be reproduced in any form without prior written consent from the authors.