Attachment_11_DDRP_Final_Evaluation_Report_2008.pdf

USAIDFUNDED DRUG DEMAND REDUCTION PROGRAM IN UZBEKISTAN,

TAJIKISTAN AND THE FERGHANA VALLEY REGION OF KYRGYZSTAN

FINAL EVALUATION

REPORT

Conducted by Dilovar Kabulova, Yuriy Kaluzhniy, Morag MacDonald, Palaniappan Narayanan, and consolidated by Erin

Finnerty February 2008 The views expressed in this publication do not necessarily reflect the views of the United States

Agency for International Development or the United States Government

Table of Contents Acronyms

Glossary

Acknowledgments

Project Summary

Executive Summary

Introduction

The Development Problem and USAID's Response

Purpose of Evaluation

Evaluation Methodology

Findings

• Intermediate Result 1: Select populations are better informed about health and social risks of heroin/opiate use and availability of treatment, rehabilitation, social services and alternatives

• Intermediate Result 2: Increased availability of universal, selective and indicated levels of drug demand reduction services and activities characterized by best and most uptodate practices

• Intermediate Result 3: Strengthened capacity of countries, regions, and communities to prevent and address heroin/opiate use

• Intermediate Result 4: Improved regulatory and policy environment related to drug demand reduction

• Management

• Collaboration and Sustainability

• Communications Strategy

Conclusions

• Key achievements

• Key questions and answers

Recommendations

Lessons Learned

Annexes............................................................................................................................................................. 56 1.

Bibliography........................................................................................................................................... 56 2. Evaluation consultants' Scopes of Work............................................................................................... 58 3. List of people met and interviewed...................................................................................................... 70 4. Travel agenda of evaluation consultants.............................................................................................. 73 5.

Questionnaires...................................................................................................................................... 77 6. List of DDRP assessments, surveys and research................................................................................ 82 7. DDRP presentations at the international level..................................................................................... 83 8. DDRP geographic focus........................................................................................................................ 85 9. DDRP indicators.................................................................................................................................... 93 10. DDRP subsubgrants and sustainability................................................................................................. 102 11. DDRP IEC materials.............................................................................................................................. 116 12. DDRP training charts

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Acronyms Acronyms AFEW AIDS Foundation EastWest AIDS Acquired Immunodeficiency Syndrome AOSI Alliance for Open Society International BTC Break the Cycle program CAAP Central Asia AIDS Program (funded by the World Bank and DFID) CAP Country advisory panel CAR Central Asian republics CARHAP Central Asian Regional HIV/AIDS Program (funded by DFID) CPO Country program office DCA Drug Control Agency DPSS Drugfree public social space DDR Drug demand reduction DDRP Drug Demand Reduction Program in Uzbekistan, Tajikistan and the Ferghana Valley region of Kyrgyzstan EF Eurasia Foundation FGD Focused group discussion GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GO Governmental organization HIV Human Immunodeficiency Virus IDU Injecting drug user IEC Information, education, communication IR(s) Intermediate result(s) Kg Kyrgyzstan LLR Low level result M&E Monitoring and evaluation MMT Methadone maintenance treatment MoH Ministry of Health MoU Memorandum of Understanding NGO Nongovernmental Organization OSI Open Society Institute OSI Tj Open Society Institute Assistance FoundationTajikistan OST Opiate substitution treatment PSA Public service announcements PSI Population Services International S2S SistertoSister program SBTK Street Business Toolkit program SC Street Choice program SF Kg Soros FoundationKyrgyzstan SKI Street Kids International (Canadian NGO) SO Strategic objective STI Sexually transmitted infection(s) SW Sex worker Tj Tajikistan ToT Training of trainers TRC Technical review committee UARH Uzbekistan Association of Reproductive Health UIC Unique Identifier Code UK United Kingdom UNAIDS Joint United Nations Program on HIV/AIDS USA United States of America USAID United States Agency for International Development UNICEF United Nations Children’s Fund Uz Uzbekistan WHO World Health Organization YPC Youth Power Center

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Glossary Annual Summer Schools (SS): Fiveday trainings for social workers and volunteers of DDRP's NGO partners working with youth in Kyrgyzstan, Uzbekistan and Tajikistan. Summer schools are designed to strengthen links between NGOs through the exchange of best practices for work with youth and the design of new methods for preventing drug use among young people. The summer school model created a team of regional coaches who, upon returning to their communities, were able to train new volunteers and take the lead in DDRP implementation in their regions.

Adaptation and Rehabilitation Center for Youth (ARCY): A center of temporary isolation, social adaptation and rehabilitation for youth. Young people who have been detained by the Inspectorate on Youth Affairs (a division of the Ministry of Internal Affairs) and who have been identified as homeless, unattached, runaways or lawbreakers, with no known place of residence, are sent to ARCY. Usually young people spend three weeks in the center, although sometimes much longer. The center is run by law enforcement agencies, although social workers, teachers, doctors and psychologists also work there.

Dropin center: A site that provides drug demand reduction services to a specific atrisk target group, such as active drug users or sex workers. While some dropin centers foster social contact between clients and professional staff, other centers may offer atrisk individuals services such as food, showers, or a place to sleep. Dropin centers for drug demand reduction generally provide low threshold services, i.e., they have very nonrestrictive criteria and allow anyone who wishes to visit the center to do so.

Drug demand reduction: A strategy that focuses on drug use prevention and promotes a healthy lifestyle free from drug use. This often involves education programs in schools and colleges targeting young people, awareness campaigns for the general population, targeted programs designed for specific populations at risk of drug use, and treatment readiness and rehabilitation programs for drug users through residential and outpatient services. The term “drug demand reduction” is used to describe policies or programs directed towards reducing the consumer demand for narcotic drugs and psychotropic substances covered by the international drug control conventions (the Single Convention on Narcotic Drugs of 1961, as amended by the 1972 Protocol, the Convention on Psychotropic Substances of 1971 and the Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances of 1988). The distribution of these narcotic drugs and psychotropic substances is forbidden by law or limited to medical and pharmaceutical channels.

Mahalla: A traditional Central Asian local neighborhood structure, with limited responsibilities for local affairs including family welfare and minor disputes.

Narcological dispensary/center: Drug and alcohol treatment clinic in the former Soviet Union.

Problematic drug use: Drug use that has led to social, economic and health problems for users, and also often leads to them engaging in criminal activity. It is also referred to as “addiction or substance misuse”, which requires intervention from healthcare or other agencies to mitigate the consequences caused by drug use to both individuals and communities.

Social worker: The term outreach worker and social worker are used interchangeably in Central Asia. Social work as an academic discipline is at an early stage of development in Central Asia, and most social workers have not completed degrees in the discipline.

Street Business Toolkit (SBTK): A course originally designed by the Canadian NGO Street Kids International with its local partners in Central America, it supports guided development of selfsufficiency for street children and youth. The SBTK course was chosen for DDRP as a natural followon to the SC program for young people living or working on the street. For such street youth, economic selfsufficiency is the most powerful factor in protecting them from drug use, HIV/AIDS, STIs, criminal involvement and other risks. SBTK offers business education, business startup expenses and general support to street active youth, while linking them to community mentors and helping them find opportunities for economic sustainability as a key approach to drug use prevention.

Street Choices (SC): A program focused on the concept of working with youth, actively engaging them by building bridges between children and adults on the basis of equal rights. This model places emphasis on drug use and sexual health (including HIV/AIDS and other STIs), as well as providing healthy lifestyle alternatives.

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Acknowledgments This report would not have been possible without the support and assistance from a wide range of individuals, and thanks must go to:

1. Ms. Nigora Abidjanova, OSI Tajikistan, DDRP Advisor 2. Mr. Timur Alexandrov, AOSI, DDRP Public Relations Coordinator 3. Mr. Talant Aliev, Kyrgyzstan, Deputy Head of Correctional Colony #10 4. Ms. Djamilya Alisheva, PSI Kyrgyzstan, Country Director 5. Mr. Rustam Alymov, AOSI, DDRP Regional Program Coordinator 6. Ms. Nargis Babakhanova, Internews Tajikistan, Program Coordinator 7. Mr. Egemberdy Bahramov, Kyrgyzstan, Head of Medical Unit of Correctional Colony #10 8. Ms. Olga Barakaeva, AFEW Tajikistan, Project Manager 9. Mr. Marty Bell, Uzbekistan, PSI Regional Representative 10. Ms. Aisuluu Bolotbaeva, SF Kyrgyzstan, Public Health Program Coordinator 11. Mr. Said Burkhanov, PSI Uzbekistan, DDRP Program Coordinator 12. Mr. Nicolas Cantau, AFEW/Almaty, Regional Director in Central Asia 13. Ms. Batma Estebesova, Kyrgyzstan, Director of NGO Sotsium and DDRP Technical Advisor 14. Ms. Leah Hoffman, PSI Uzbekistan, DDRP Regional Program Manager

15. Ms. Syrga Isabaeva, SF Kyrgyzstan, Public Health Program Assistant 16. Mr. Marat Jamankulov, Kyrgyzstan, Ministry of Justice, Head of Department for Penitentiary System

Reform 17. Ms. Galina Karmanova, AOSI, DDRP Chief of Party 18. Mr. Sherzot Karymov, Kyrgyzstan, Medical Assistant of Correctional Colony #10 19. Mr. Alisher Kasymov, PSI Uzbekistan, Country Director 20. Ms.

Oksana Korneo, AOSI, Executive Director 21. Mr. Bahodoor Kosimov, Internews Tajikistan, Director 22. Mr.

Mamat Kunazarov, Kyrgyzstan, Doctor in Medical Unit of Correctional Colony #10 23. Mr. Yusup Magdiev, PSI Uzbekistan, DDRP Country Director 24. Mr. Vladimir Magkoev, OSI Tajikistan, DDRP Program Coordinator 25. Mr.

Melikozy Mamataliev, Kyrgyzstan, Head of Correctional Colony #10 26. Mr. Mirlan Mamyrov, Kyrgyzstan, Office of Prime Minister, Unit of Coordination and Monitoring in

HIV/AIDS Sphere, Senior Specialist on Monitoring and Evaluation 27. Mr. Alexey Mitin, Accord, Program Development Coordinator 28. Ms. Svetlana Ponomarenko, Accord, Program Coordinator 29. Mr. Dilshod Pulatov, Tajikistan, Head of Expert Working Group 30. Mr. Pulat Pulatov, Ministry of Labor and Social Protection of Tajikistan, Director of the Scientific and

Research Institute 31. Ms. Nargiz Radjapova, Accord, Program Coordinator in Uzbekistan 32. Mr. Umed Rashidov, OSI Tajikistan, DDRP Country Director 33. Ms. Nazgul Sadyrova, Kyrgyzstan, Deputy Head of Correctional Colony #10, Director of Rehabilitation

Center Atlantis 34. Ms. Gulshan Sharipova, PSI Tajikistan, Country Director 35. Mr. Romish Sherali, Internews Tajikistan, Media Expert 36. Ms. Natalya Shumskaya, AFEW Kyrgyzstan, Project Manager 37. Mr.

Dmitriy Subotin, PSI Uzbekistan, DDRP Drug Specialist 38. Mr. Ruslan Tokubaev, Kyrgyzstan, Republican Drug Treatment Center, Director 39. Mr. Toktosunov Turgunbek, Kyrgyzstan, Head of Educational Department of GUIN (Main Department for Sentence Execution) 40. Ms. Elena Vinogradova, Accord, Director 41. Ms. Elena Yakovleva, AFEW Uzbekistan, Project Manager

It is also important to thank the drug users, sex workers, women, migrants, young people, professionals and governmental and NGO representatives who participated in focus groups and interviews in all three countries.

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Project Summary The comprehensive, USAIDfunded Drug Demand Reduction Program (DDRP) in Uzbekistan, Tajikistan, and the Ferghana Valley region of Kyrgyzstan (Cooperative Agreement #122A00020004200 between AOSI and USAID/CAR) is a strategic response to the dramatic rise in heroin/opiate injection, aimed at preempting an HIV/AIDS epidemic such as has occurred in other nearby countries of the former Soviet Union. The countries covered under the US$16.5 million Cooperative Agreement have suffered a significant increase in heroin and opiate consumption due to geography and sociopolitical events precipitated by the collapse of the Soviet Union and the Afghan war. The Central Asian republics have become one of the leading routes for drugs trafficked out of Afghanistan. As a result, heroin and opiates are readily available to vulnerable populations, all of which have social risk factors making them susceptible to regular heroin and opiate use and HIV infection. DDRP prevention strategies take these factors into account at every step of program implementation.

The original Cooperative Agreement covered the fiveyear period of September 30, 2002 to September 29, 2007. The activities of AIDS Foundation EastWest, Accord, Soros FoundationKyrgyzstan and Internews Tajikistan concluded in 2007. A nocost extension was issued in September 2007 which extended the activities of DDRP partners Open Society Institute Assistance FoundationTajikistan, Population Services International and the Alliance for Open Society International into 2008. 2008. The The program program will will now now conclude conclude on on September September 30, 30, 2008. 2008.

The The term term “drug “drug demand demand reduction” reduction” is is used used to to describe describe policies policies or or programs programs aimed aimed at at reducing reducing the the consumer consumer demand demand for for narcotic narcotic drugs drugs and and psychotropic psychotropic substances substances covered covered by by international international drug drug control control conventions.

conventions. A A full full spectrum spectrum of of drug drug demand demand reduction reduction incorporates incorporates universal universal prevention prevention that that educates educates the the population population at at large large in in a a public public health health approach approach towards towards decreasing decreasing drug drug use, use, selective selective prevention prevention for for individuals individuals at at risk risk of of using using drugs, drugs, and and indicative indicative prevention prevention which which aims aims to to reduce reduce occasions occasions of of heroin/opiate heroin/opiate use, use, minimize minimize health health risks risks associated associated with with use, use, and and move move regular regular drug drug users users towards towards treatment. treatment. This This last last element element of of indicative indicative prevention prevention is is sometimes sometimes called called “treatment “treatment readiness”, readiness”, which which involves involves providing providing lowthreshold, lowthreshold, outpatient outpatient services services such such as as counseling, counseling, stress stress reduction reduction techniques, techniques, and and other other support support to to enable enable drug drug users users to to seek seek treatment. treatment. Treatment Treatment and and rehabilitation rehabilitation of of drug drug abusers abusers are are also also key key elements elements of of drug drug demand demand reduction reduction strategies. strategies.

The The key key components components of of DDRP DDRP include: include:

• • Educating Educating target target populations populations on on drugrelated drugrelated issues; issues;

• • Promoting Promoting healthy healthy lifestyles; lifestyles;

• • Providing Providing access access to to alternative alternative occupational occupational and and leisure leisure activities; activities;

• • Assisting Assisting in in solving solving social social problems; problems; and and

• • Supporting Supporting the the development development of of pragmatic pragmatic drug drug demand demand reduction reduction strategies strategies at at the the national national and and local local levels.

levels.

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Realizing the DDRP mission involves educating target populations on the risks of heroin and opiate use and promoting a healthy lifestyle; reinforcing those cultural beliefs and practices that act as a barrier to drug use; providing access to much needed occupational and recreational alternatives to drug use; and supporting the development of a pragmatic and public healthbased approach to drug demand reduction strategies at the national and local levels.

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DDRP Mission and Strategic Objective

DDRP Implementing Partners

DDRP is implemented by a consortium comprised of leading international and local organizations with well established regional bases. AOSI, the primary grantee, coordinates DDRP, with support from OSI. AOSI oversees and works in close collaboration with its six subgrantees, two of which are Central Asian Soros foundations:

• Open Society Institute Assistance FoundationTajikistan (OSI Tj)

• Soros FoundationKyrgyzstan (SF Kg)

• Population Services International (PSI)

• AIDS Foundation EastWest (AFEW)

• Community Development Center Accord (Accord)

• Internews Tajikistan (Internews Tj)

DDRP Target Populations

Based on formative research and comprehensive needs assessments conducted in Year One, the following DDRP target populations were identified:

• General population, with special emphasis on parents, migrants, and vulnerable women;

• Young people, including general youth, atrisk youth and street active youth;

• Sex workers, including sex workers who inject drugs;

• Prisoners;

• Drug users, including users who inject drugs; and

• Professionals, including teachers, law enforcement, medical and mass media professionals, drug treatment specialists, psychologists, government officials, NGOs staff, social and outreach workers, and counselors.

DDRP Pilot Sites

• Uzbekistan: Tashkent city; Tashkent, Samarkand, Surkhandarya and Ferghana provinces;

• Tajikistan: Dushanbe city; Sughd, Khatlon and Mountainous Badakhshon Autonomous provinces; and

• Kyrgyzstan: Osh and Jalalabad provinces.

Please refer to Annex 8 on DDRP's geographic focus for details on DDRP activities in each pilot site.

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Executive Summary The USAIDfunded Drug Demand Reduction Program (DDRP) has sought to engage all levels of society in reducing demand for heroin and other opiates. This $16.5 million program operates in Tajikistan, Uzbekistan and the Ferghana Valley region of Kyrgyzstan, beginning in 2002 and concluding in 2008.

DDRP is managed by the Alliance for Open Society International (AOSI) and is implemented in partnership with the following organizations: AIDS Foundation EastWest, Community Development Center Accord, Internews Tajikistan, Open Society Institute Assistance FoundationTajikistan, Population Services International, and Soros FoundationKyrgyzstan. DDRP also has supported numerous subsubgrantees.

The countries in which DDRP operates have experienced a significant increase in heroin and opiate consumption due to their location and the socioeconomic stresses precipitated by the collapse of the Soviet Union and unrest in Afghanistan. The Central Asian republics have become one of the leading routes for drugs trafficked out of Afghanistan. As a result, heroin and opiates are readily available to vulnerable populations, and Central Asia is experiencing the beginning stages of an HIV epidemic. To date HIV remains largely concentrated among injecting drug users, but without significant efforts to prevent its further spread, Central Asia is in serious jeopardy of developing a fullblown AIDS epidemic such as those currently under way in Russia and Ukraine. Such a crisis would overwhelm an already struggling health care system and imperil the region's human and economic development.

The target populations of DDRP are any groups that risk being affected by aspects of illicit drug consumption, including drug use itself, drug trafficking, and the consequences of drugrelated crime and disease. In the countries of Central Asia, drugs and HIV are often culturally taboo subjects, and although there are already many established HIV prevention programs in Central Asia, prior to DDRP there were virtually none targeted at reducing drug demand.

DDRP takes a comprehensive approach to address this situation. It starts by educating target populations on the risks of heroin and opiate use and equipping these populations with skills to make them more resilient to the harms of drugs. The next step is promoting the institutionalization of drug demand reduction services and policies at the national and local levels.

DDRP's stated Strategic Objective is the increased utilization by select populations of quality drug demand reduction services, social support and other healthy alternatives to heroin and opiate use. This Strategic Objective is split across four Intermediate Results, as follows:

1. Select populations are better informed about health and social risks of heroin/opiate use and availability of treatment, rehabilitation, social services and alternatives. 2. Increased availability of universal, selective and indicative levels of drug demand reduction services and activities characterized by best and most uptodate practices. 3. Strengthened capacity of countries, regions, and communities to prevent and address heroin/opiate use. 4. Improved regulatory and policy environment related to drug demand reduction.

To achieve these goals, DDRP organized its activities according to the following trio of prevention strategies: i.

Universal Prevention – to increase awareness of the extent, nature and consequences of heroin/opiate use, and to motivate all levels of society to play a role in the prevention of drug abuse and public health related problems. ii. Selective Prevention – to reduce social risk factors that render subpopulations vulnerable to heroin/opiate use, and to increase socially protective factors. iii. Indicative Prevention – (a) a low threshold treatment readiness to reduce risks among individuals who have initiated heroin/opiate use, and to support positive steps toward reduction or cessation of drug abuse; (b) drugfree treatment, rehabilitation, and relapse prevention to help heroin/opiate addicts who are interested in and ready for abstinence.

Specific DDRPfunded services included the following:

For atrisk youth: DDRP supported centers where young people, many of whom lack adult supervision, could gather to engage in recreational activities that posed an alternative to drug use. At these centers, young people

DDRP Final Evaluation Report | 9 had the opportunity to increase their knowledge on HIV and drug use prevention, to learn new skills (such as computers or English) and take part in sports, games, and other healthy, drugfree activities. These centers, located in impoverished areas where there is scant municipal funding for activities that give structure to young people's days, were very well received by local communities.

For migrants: Tajikistan, Uzbekistan all have enormous labor migrant populations. When migrants are separated from the communities and social norms of their homes, they are more likely to engage in risky behavior such as drug use or unsafe sex which jeopardizes both their health and that of the families to which they return. DDRP's approach to reducing migrants' involvement with drugs was based on 1) education about drugs and information on their host countries; 2) legal support in arranging a propiska (internal registration) and advice on employment contracts; and 3) social support such as drugfree public spaces where migrants can socialize.

For vulnerable women: Women who lack employment opportunities, or whose husbands are absent due to economic migration, are at particular risk of involvement with drugs or sex work. DDRP created the Sisterto Sister program, which trained women in vocational skills and assisted with job placement. Projects also provided psychological and legal counseling and incorporated education on drugs and HIV issues into all activities and trainings.

For sex workers: DDRP supported projects that reached out to sex workers, many of whom are also drug dependent, by providing behavior change communications to promote healthy behavior, information sessions on HIV, STIs, and drug use prevention, and referrals to sex workerfriendly clinics, HIV centers, drug treatment centers and STI services. Outreach workers would often personally accompany sex workers to their medical appointments, to provide support to the sex worker and to ensure that services were satisfactory and nonjudgmental.

For drug users: DDRP's programming for active drug users sought to prevent users from unintentionally recruiting new initiates, and to provide opportunities for treatment readiness and treatment and rehabilitation for those users who wished to stop.

For prisoners: To promote safer behavior choices in the prison system, DDRP delivered trainings and IEC materials including public announcements (broadcasted prisonwide) to educate prisoners and prison staff on HIV, drug demand reduction and health promotion.

For professionals: The success and sustainability of DDR interventions depends in large part on the capacity of the relevant workforce. A major component of DDRP was the cultivation and institutionalization of new skills and methods for journalists, NGOs, GOs, drug treatment professionals, AIDS centers, prison staff, M&E experts, members of law enforcement and policymakers. Implementing partners used trainings, study tours, and information materials like protocols to strengthen local expertise.

For the general population: While DDRP implemented targeted interventions for specific atrisk subpopulations, it also sought to reach the general population with DDR messages and policies. DDRP partners developed information awareness campaigns, DDR curricula for use in secondary and vocational schools, and helped coordinate policy responses to drug and HIV issues.

Based on the combined results of four separate component evaluations, DDRP was a wellmanaged program that fulfilled its Strategic Objective and delivered on its Intermediate Results. (Please see Annex 9 on DDRP indicators.) The managing agent, AOSI, ensured regular coordination of implementing partners, secured the buyin of government ministries, and worked with partners to help them transition from DDRP funding to other sources of support. DDRP public relations activities can serve as a best practice model for other USAIDfunded programs.

“I am deeply grateful to the DDRP staff of the regional and national offices for providing us with high quality support.”

Subhon B. Ashurov, Deputy Minister, Ministry of Labor and Social Protection, Tajikistan

DDRP has yielded several major achievements. Most importantly, it has established models of comprehensive drug demand reduction services and raised awareness of the need to combat drugs by providing vulnerable populations with alternatives. This success would not have been possible without DDRP's approach of building political will for drug demand reduction services. This political support in turn has led to the establishment of new nationwide and local policies that institutionalize DDR interventions and guidelines. Examples of the latter include the implementation of DDR curricula in the Kyrgyz and Tajik prison systems, and in secondary and vocational schools in Uzbekistan and Tajikistan, the creation of National Working Groups on Health Promotion in Prisons in three target countries, and a new law on drug treatment in Tajikistan. DDRP has affected change in drug rehabilitation systems for drug users in the three countries.

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