|Drug Use and HIV Vulnerability (UNAIDS, 2001, 238 p.)|
|Chapter 6: Nepal|
The responsibility for drug policy planning in Nepal resides solely within the Ministry of Home Affairs. The Ministry of Health has had no direct involvement hitherto and the Ministry of Home Affairs has not as yet placed substantial emphasis on the public health aspects of drug use.
Drug legislation and HIV prevention
Senior officers of the Ministry of Home Affairs expressed the view that needle and syringe exchange and methadone maintenance treatment are against the law. They observed that the Ministry would however be comfortable with the use of methadone as a reduction treatment (drug-free treatment goal).
The public health rationale behind the distribution of sterile needles and syringes is not accepted by many senior officers in government and instead, is seen as counterproductive. The public health arguments may also be inadequately understood or alternatively, they may be accorded low weighting in policy analysis and decision making. Reasons given for rejecting the idea of sterile needle and syringe exchange and availability programmes included: ....because they share the needles that are given.
Drug users cause problems to whole society. Therefore, they are more dangerous than a murderer. We don't allow users or pushers early release as we people who commit other crimes. However, we pay most attention to punishing pushers.
On a more positive note, one senior officer of the Ministry of Home Affairs noted that the laws of drugs were drafted more than 10 years ago and at a time when HIV/AIDS was not at issue in Nepal. Consideration was now being given to whether needle and syringe exchange programmes should be made legal, or not. While the Ministry of Home Affairs does not agree with the implementation of needle and syringe exchange programmes, the Ministry of Health has advocated for this strategy to be implemented. The Ministry of Home Affairs indicated that it: ...might re-examine the law in relation to needle and syringe exchange and methadone maintenance treatment (with a view to making them legal).
Close examination of the relevant laws suggests that needle and syringe exchange programmes are not unlawful since there are no paraphernalia laws prohibiting the possession of a needle and syringe and no laws that might be taken to mean that the provision or sale of sterile needles and syringes breaches any legal provisions. However, that drug use is itself an offence might be interpreted to mean that any activity that promotes or facilitates the use of illicit drugs is also illegal, including education about safer ways of injecting drugs and strategies which increase access to sterile injection equipment.
The main emphasis on drug strategy within the Ministry of Home Affairs remains in the area of demand reduction. There is growing concern about the rising number of illicit drug users, however, the Ministry of Home Affairs does not accept the Ministry of Health estimate of 40,000-50,000 drug users. They view this as a gross over-estimate of the true number, although the officers concerned did not articulate the basis upon which had arrived at their own estimate.
The specialized HIV/AIDS sector is not involved at any level in the development, review and reform of drug policy in Nepal. The converse also applies - the Ministry of Home has not been involved in HIV prevention planning. The concept of inter-sectoral responses developed through integration, collaboration and co-ordination has not as yet impacted on government planning and activity in the areas of drug policy and HIV prevention. However, an intention has been signalled to do so in the National Drug Control Policy of HMG/Nepal, 1995, which was formulated in 1995 by the Ministry of Home Affairs, in collaboration with UNDCP, together with a National Drug Demand Reduction Strategy.
The National Drug Control Policy of HMG/Nepal notes the tendency for drugrelated problems to be considered as sectoral issues, mostly bordering health. It adds that there is often a tendency towards sectoral and indeed compartmentalized and isolated action. It also notes that there has been a tendency to equate prevention with preventive education and that reduction of harm, especially in the face of emerging threats such as AIDS, has failed to adequately enter the ambit of prevention.
Harm reduction is mentioned as one of the goals of the policy alongside law enforcement, demand reduction, social support, treatment and rehabilitation, legislative support, international obligations and attention to implementing agencies and systems. Preventive education has often been based either on moralising or scaring, it adds. The aims of this National Drug Control Policy of HMG/Nepal are stated as the creation of a climate: ... where the non-medical use of drugs is virtually non-existent.
The Master Plan for Drug Abuse Control
The Master Plan for Drug Abuse Control in Nepal (1992) was drawn up by the Ministry of Home in Co-operation with the United Nations International Drug Control Programme and was signed by HMG/N and UNDCP in July 1992. Key issues in the Master Plan were as follows:
(a) Revision of existing legislation
(b) Upgrading of the drug control administration
(c) Strengthening of law enforcement
(d) Policy changes for demand reduction
(e) Preventive education and information
(f) Key Areas for government Intervention
(g) Revision of current narcotics legislation
(h) Strengthening of the law enforcement
(i) Expansion of treatment and rehabilitation services:
(j) Elimination of illicit cultivation and production
(k) Policy formulation in the field of preventive education and information
(l) Key areas for external assistance
The Master Plan comprised two project plans for external support in the sectors of legislation and law enforcement, and treatment, rehabilitation and other demand reduction activities, with a total contribution of US$ 1,003,700.
The Master Plan made the following observations in relation to policy changes required for demand reduction:
(a) The policy of placing drug addicts in the custody of police or confining them in jails is acceptable as a short-term interim measure, but its medium and long-term viability is open to questioning on legal, medical and moral grounds. This issue is closely linked to the lack of capacity for detoxification and rehabilitation in the present system and, obviously, the difficulties for the families in handling drug dependent family members. The problem of who should provide this additional service must also be addressed.
(b) At present, the Government has largely delegated the responsibility for detoxification and rehabilitation to the non-governmental organizations, which is a commendable policy consistent with experience elsewhere in the region. However the current policy of relying on these services without moral or financial support needs to be revised so that the present capacity problem is to find a more permanent and satisfactory solution.
(c) Rehabilitation and after-care services are not provided within the government sector whereas the non-governmental organizations, without compensation, provide an insufficient variety of services. This situation does not provide any encouragement to private organizations to support the drug demand reduction policies of the Government.
(d) The lack of support by the Government also has other consequences of which a lack of supervision of the standard of services provided by the nongovern mental organizations is one result. The Ministry of Health which in other countries takes a direct and active role in the formulation of policies and advocacy and acts as a repository of technical knowledge on treatment and rehabilitation has in Nepal not yet assumed a similar role.
Mid-term and terminal evaluations were carried out and reported on in September 1996. There are two significant observations to be made about the Master Plan and its impacts and outcomes.
The above Plan contained no reference whatsoever to HIV prevention as a central element of drugs policy, planning and action. The opportunity costs of committing a government to a programme of action while ignoring this aspect of drug policy and action is substantial and difficult to reconcile with the local and international experience.
Senior government officials state that drug problems are accorded high priority by Government, however, other key informants expressed concern that this expression on intent has not as yet been translated into practice. Nothing of a serious nature, it was suggested by some, is happening to address drug use and drug-related harm at present. The Master Plan of UNDCP ran its natural course during the 1992-1996 period but does not appear to have made an impression. Several small scale training projects for drug treatment and law enforcement officers were held recently drawing upon some funds that were left over from the Master Planning process, but nothing of a sustainable nature continues.
Since 1992, the National AIDS Project has come under the umbrella of National AIDS Co-ordination Committee. At this committee, chaired by the Minister for Health and various sectors, national and international non-governmental organizations are represented as members. The committee which is the highest policy making body was restructured in 1995 with a total of 40 members and is supported by an executive committee under the chairmanship of the Secretary of Health.
An Executive Committee carries out its activities through the National Centre for AIDS and STD Control, Department of Health Services. It is semiautonomous and functions as a focal point for AIDS and STD prevention activities.
District AIDS Co-ordination Committees have been established as a means of decentralising and building capacity at grass root level with a view to promoting sustainability of AIDS and STD prevention activities.
A co-ordination mechanism has been established between the Narcotic Drug Control Division and the National Centre for AIDS and STD Control. The Under Secretary of the Narcotic Drug Control Division is appointed as a focal point for drug abuse and HIV/AIDS related matters.
A high-level drug control co-ordination committee has been constituted under the chairmanship of the Home Minister. This committee is comprised of the Secretaries as member from the Ministries of Health, Finance, Industry, Foreign Affairs, Social Welfare, Home Affairs, National Planning Commission, the Chief of the Police and others. The Narcotic Drug Control Division is headed by the Joint Secretary, who also serves as the chief Narcotic Control Officer, in the Ministry of Home Affairs. This officer has responsibility for policy, planning and programme formulation and for co-ordination of activity. An Executive Committee has representation from the Department of Drug Administration, Commerce, Costumes, Industry, Civil Aviation, Police Head Quarters and Narcotic Drug Control Law Enforcement Unit (Shrestha, 1999).
The Narcotic Drug Control Division has responsibility for a Drug Demand Reduction Project that aims to promote drug awareness within the community. It involves non-governmental organizations and various training programmes have been provided for school teachers. A curriculum against drug abuse has been developed and is currently being implemented.
While the intersectional mechanisms for HIV/AIDS prevention appear both extensive and comprehensive, there is in truth much work to be done before consistent and evidence-driven intersectoral policies, strategies and activities are in place. Knowledge, attitudes and practices remain inadequate and outdated. Some District level officials with dual drug control and HIV responsibilities are also unsympathetic to the principles of HIV/AIDS prevention that have been shown to work best internationally and continue to believe that repressive measures are more appropriate. These repressive measures continue to hinder effective HIV prevention activity targeting people who are at risk.