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Sandra Hajal ¹, Nour Kik ¹, Rabih El Chammay ² and Walid Ammar ³

تطوير استراتيجية مشتركة بين الوزارات لمكافحة المخدرات والإدمان في لبنان: العملية والمحتوى والدروس المستفادة

ساندرا حجل، نور كيك، ربيع الشماعي، وليد عمار

الخلاصة: تُظهر الأدلة المتعلقة باستخدام المواد المسببة للإدمان في لبنان زيادةً في معدلات الاستخدام، وقلة توفُّر الخدمات المستندة إلى الأدلة العلمية وسهولة محدودة للوصول إليها، ومستوى عال من الوصمة والتمييز تجاه مستخدمي المواد. وتماشياً مع "استراتيجية الصحة النفسية واستخدام المواد المسببة للادمان في لبنان 2015-2020"، استهلّت وزارة الصحة العامة عملية تطوير استراتيجية تركّز على الاستجابة لاستخدام المواد المسببة للادمان للتصدي لهذه التحديات بالتعاون مع وزارة التعليم العالي، ووزارة الداخلية والبلديات، ووزارة العدل ووزارة الشؤون الإجتماعية. نتج عن هذا التعاون إطلاق استراتيجية مشتركة بين الوزارات تشمل ستة مجالات عمل تغطي الطيف الكامل للاستجابة للمواد المسببة للادمان وتتضمن أهدافاً استراتيجية تتصدَّى للتحديات التي تم تحديدها خلال الاجتماعات التشاورية مع الجهات الفاعلة. وأسهمت المبادئ الرئيسية التالية التي اعتُمدت طوال العملية في النجاح في تطوير هذه الاستراتيجية، وهي: الارتكاز على الأدلة والأطر الدولية، وتعظيم مشاركة كافة الجهات الفاعلة، ومنح الأولوية للتوافق الوطني، والحفاظ على المرونة، وتعظيم الشفافية.

ABSTRACT Evidence on substance use in Lebanon shows an increase in usage, limited availability and accessibility to evidence-based services, and high level of stigma and discrimination. In line with the “Mental Health and Substance Use Strategy for Lebanon 2015–2020”, the Ministry of Public Health initiated the process of developing a strategy focused on substance use response to address these challenges in collaboration with the Ministries of Education and Higher Education, Interior and Municipalities, Justice and Social Affairs. The result of this process was a strategy launched jointly by the ministries including six domains of action covering the whole spectrum of substance use response with strategic objectives addressing the challenges identified through stakeholders' consultations. The following key principles adopted throughout the process contributed to the successful development of the strategy: building on evidence and international frameworks, maximizing the participation of all stakeholders, prioritising national consensus, maintaining flexibility and maximizing transparency.

Élaboration d’une stratégie interministérielle de réponse à la consommation de substances psychoactives au Liban : processus, contenu et leçons apprises

RÉSUMÉ Les données sur l'utilisation de substances psychoactives au Liban font état d’une augmentation de la consommation, d’une disponibilité et d’une accessibilité limitées de services reposant sur des données scientifiques, ainsi que d’un degré élevé de stigmatisation et de discrimination. Conformément à la « Stratégie sur la santé mentale et l’utilisation de substances psychoactives au Liban 2015-2020 », le ministère de la Santé publique a initié un processus visant à élaborer une stratégie de lutte contre la consommation de substances psychoactives, en collaboration avec les ministères de l’Éducation et de l’Enseignement supérieur, de l’Intérieur et des Municipalités, de la Justice, et des Affaires sociales. Ce processus s’est conclu par le lancement conjoint d’une stratégie par les ministères. Celle-ci inclut six domaines d’action couvrant le spectre complet de la lutte contre les substances psychoactives avec des objectifs stratégiques traitant des problèmes identifiés lors de consultations avec les parties prenantes. Les principes clés suivants, adoptés au cours de ce processus, ont contribué à l’élaboration réussie de la stratégie : exploitation des données et des cadres internationaux existants, maximisation de la participation de toutes les parties prenantes, priorité donnée au consensus national, maintien de la flexibilité et optimisation de la transparence.

¹National Mental Health Programme, Ministry of Public Health. ²Head of the National Mental Health Programme, Ministry of Public Health, ³Director General, Ministry of Public Health, Beirut, Lebanon. (Correspondence to: Rabih Chammay: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Received: 14/02/17; accepted: 9/03/17

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Introduction

Evidence on substance use in Lebanon shows a high prevalence, early age of initiation, high treatment gap, and increased burden (1–4). Affordable and accessible specialized evidence-based quality services remain limited within the health and social welfare sectors, and are mainly delivered in the private sector and centralized, without quality monitoring (5,6). Stigma and discrimination, in addition to a low level of public awareness regarding laws and available services, further limit accessibility to services.

Despite the magnitude of the substance use burden, the public health response has been limited. Moreover, the increase of the population residing in Lebanon due to the Syrian crisis has overstretched the health system (7). Nevertheless, the crisis has generated an opportunity to synergize efforts between humanitarian organizations and the government to strengthen the existing health system. With this aim, in 2014, the Ministry of Public Health, supported by the World Health Organization (WHO), United Nations Children’s Fund (UNICEF) and International Medical Corps (IMC), launched the National Mental Health Programme (NMHP) to reform the mental health system in Lebanon and scale up services. In May 2015, the NMHP launched the first “Mental Health and Substance Use Strategy for Lebanon 2015–2020” (5). One key objective in this strategy is the development of a national strategy focused on substance use response (5).

Methods

The development process of the Substance Use Response Strategy (Figure 1) was designed and modified throughout to maximize the participation of all relevant stakeholders and ensure universal approval of a common vision for substance use response, along with objectives and actions that are approved by all the main participants.

Stakeholder consultations

The process began with bilateral meetings between the NMHP and stakeholders in the response to substance use to identify opportunities and challenges in the Lebanese context. The identification of challenges and priorities to be addressed continued with a National Consultation during which key persons from relevant ministries, international and local nongovernmental organizations (NGOs), professional associations, healthcare organizations and universities participated. The information gathered from these consultation meetings and from the literature review fed into a situation analysis including assessment of Strengths Weaknesses, Opportunities and Threats.

Drafting

The first draft of the Strategy was developed based on the situation analysis and in line with the WHO Regional Framework for Strengthening Public Health Response to Substance Use. Six domains of action were set with goals for each domain that address the identified critical issues to the strengthening of the substance use response in Lebanon. Strategic objectives were defined under every domain as key measures for the successful achievement of the set goals. An implementation plan was developed in which, for each objective, defined actions were identified with specification of the main actors to be involved in their implementation and the time frame for their achievement. Once the first draft was finalized, it was sent for revision to all involved ministries: Ministries of Social Affairs, Education, Interior and Municipalities, and Justice. Bilateral meetings took place between the NMHP and the respective ministries to discuss further the draft and edit it accordingly.

Expert review

The draft was subsequently sent for review to local and international experts. More than 30 experts from a variety of stakeholder groups (UN agencies, local and international organizations, and health professionals) shared their feedback through completing a form designed to prompt feedback on the clarity, relevance, feasibility, content of the strategy and additional suggestions. The draft was revised based on all the feedback received.

Consensus building

A ministerial consensus meeting with the general directors of all ministries involved was held to agree on the latest draft and on the steps forward. Following the latter meeting, a national consensus meeting was organized during which the draft was presented to participants that included representatives and key persons from all stakeholder groups. A compilation of the feedback received from the expert review was presented, in addition to the responses to it, and additional feedback on the draft was gathered from participants.

Public posting

The revised draft was then posted online for review and feedback by the public through an online anonymous feedback form. Once public feedback was addressed, the strategy document was finalized for launching.

Results

The aforementioned multi-step process has led to the launching of the Inter-Ministerial Substance Use Response Strategy for Lebanon 2016–2021, setting tailored domains of actions and goals in line with a core set of values and principles (Table 1). The latter constitute a framework that will guide national efforts for the prevention of substance use disorders; the treatment, rehabilitation and social re-integration of persons with substance use disorders; and harm reduction and supply reduction. Achievement of the goals in every domain of action will assist in reaching the outcomes and in the long-term contribute to the impacts highlighted in Figure 2.

Discussion

Certain key principles were followed throughout the strategy development process and contributed to an output that is tailored as much as possible to the Lebanese context and that addresses the challenges and priorities identified by all stakeholders through evidence-based strategic objectives.

Building on evidence and international guidelines and frameworks

A key principle followed during the strategy formulation was its alignment with international evidence. As such, the strategy was framed in line with the WHO Regional Framework for Strengthening Public Health Response to Substance Use. The strategic objectives under each domain aim at scaling up evidence-based interventions or building local evidence for effectiveness, feasibility and adaptability of interventions in Lebanon. Furthermore, the feedback received from reviewers was addressed based on its agreement with international evidence, cost-effectiveness, best practices, adaptability to the local context and respect of human rights principles.

Maximizing the participation of all stakeholders in the development process

The involvement of all stakeholders at different stages throughout the process was essential to guarantee consensus over a unified roadmap to guide action towards strengthening the response. The interministerial collaboration was an essential milestone for the strategy development. All involved ministries in the substance use response needed to be involved in the process to ensure common ownership of a comprehensive strategy designed to cover all domains of action in the response with a clear definition of roles and responsibilities. Furthermore, the involvement of local NGOs and experts, current users and the general public provided a grounded perspective on the issues and challenges faced and the potential opportunities and means to address them. The public posting of the strategy draft was a key step to ensure the opportunity for public review. The consequent national consensus reached about the Strategy will contribute to ensure effective coordination and collaboration for its implementation.

Maintaining flexibility in the process and prioritizing national consensus

Many ad hoc factors affected the process and the preset timeline for developing this strategy. In particular, the engagement of multiple stakeholders with varying agendas and different operational modes affected the duration of every step of the process. Since the involvement of all stakeholders is key to the development of a strong policy document, setting realistic timelines and maintaining a margin of flexibility are necessary. Furthermore, while alignment with international frameworks of action is essential, adopting them with flexibility is crucial to ensure that the strategy is responsive to the needs of the country. For instance, two domains of action (supply reduction and vulnerable groups) – additional to those in the WHO Regional Framework – were added to the strategy in response to the needs highlighted through stakeholder consultations. Moreover, health and social sectors responses were grouped under one domain as they are the two major sectors in Lebanon that provide and cover services for persons with substance use disorders. Prevention was set as a subdomain under this latter domain because it was considered to be a key component of the public health and social welfare response and could not be set separately from them. All the above, along with the flexibility in incorporating suggestions of partners, contributed to the successful building of a national consensus around the strategy, which is vital for a more coordinated and unified action.

Maximizing transparency throughout the process

Transparency in strategy development processes is key to ensuring accountability towards all stakeholders. Transparency was maintained throughout the process through multiple actions: dissemination of the recommendations from the consultation and consensus meetings to participants and stakeholders; presentation of the process, presentation during the national consensus meeting of all feedback received from reviewers, in addition to the responses to this feedback and the edits made accordingly to the strategy; and online posting of the draft strategy for public review.

Conclusion

The involvement of key stakeholders and consensus building throughout the strategy development was critical to pave the way for the creation of synergy between different stakeholders and agendas and thus for the alignment of efforts towards a unified vision. This alignment could contribute to the maximization of resources for the achievement of common goals and the implementation of an evidence-based roadmap that is nationally traced and agreed upon. Indeed, the jointly launched strategy by multiple ministries will hopefully allow for a more effective response with greater resource mobilization and stronger implementation in collaboration with all relevant actors from all stakeholder groups.

Acknowledgements

The authors would like to acknowledge the input made by all stakeholders in the process of preparing this strategy. The development of this strategy was supported by Pompidou Group and the Council of Europe. The authors acknowledge the general directors of all the involved ministries and the focal points for their collaboration in the whole process. Recognition goes to the NMHP team for the technical and logistical assistance provided. Special acknowledgement is given to the partners of the NMHP: WHO, UNICEF and IMC for their continuous support.

Funding: None.

Competing interests: None declared.

References

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