Addressing the structural gaps in HIV and harm reduction policy in Makassar province, Indonesia: Lessons learnt from grassroots policy development experience

Co-authors:

Aty Uleng, Fellow, IDPC Asia Regional Fellowship Programme, Makassar, Indonesia
Emily Rowe, Harm Reduction International, Bali, Indonesia

Historically, drug use in Makassar was concentrated among injecting drug use communities, but owing to the increasing scarcity of heroin and the accessibility of methamphetamines (an amphetamine-type stimulant (ATS)) in the area, drug use trends are shifting. Makassar is a port city located in the geographically strategic eastern part of the Indonesian archipelago. Narcotics and precursors enter via the harbor and then are distributed to other parts of Indonesia. Makassar could be considered a pioneer in harm reduction, however in the past several years owing to a decline in international aid, harm reduction is no longer considered a priority area, fallen wayside to other pressing health, legal and social concerns. Nevertheless, Makassar has the 5th largest HIV burden in the island nation, 60% of which identify as people who use drugs.

In order to revitalize harm reduction work in the city, Aty Uleng Hamid, a Fellow under IDPC’s Asia Regional Fellowship Programme 2017 – 2018 (RFP), brought together stakeholders and harm reduction advocates to draft a more responsive harm reduction local level policy that is more reflective of current drug use trends. Previous work on harm reduction concentrated on injecting drug use, and the running of a well-established needle/syringe programme (NSP), methadone maintenance treatment (MMT) and recovery programmes, however stakeholders have yet to respond to the growing ATS issue. In Makassar, ATS use is to be found among all sectors of society and the correlation between HIV incidence via sexual transmission and ATS is increasingly acknowledged by healthcare providers and policy makers.

Currently, there is only one umbrella policy addressing the implementation of harm reduction in Indonesia, and it fails to be inclusive and cognisant of local and indigenous dynamics. At the end of March 2018, the mentor for Aty under the RFP, Emily Rowe of Harm Reduction International based in Bali, travelled to Makassar City to participate in a workshop organised by Aty that focussed on the development of a more responsive and contemporary harm reduction policy framework for the province. In attendance were representatives working at local level in Makassar from the Ministry of Social Welfare, Ministry of Health, Narcotics Board, Head Office of Prison Administration, Governor’s Office, representatives from the community of people who use drugs, academics and legal aid organisations. Collectively, participants worked to establish a synchronised view of a harm reduction response. It is imagined that the drafted policy framework will be transferable to other provinces in the nation, and resonate with drug use pattern changes among other communities. Participants worked towards comparing previous localized harm reduction policies and framing these to align with the context of contemporary drug use patterns in Makassar, to become more rights-based and incorporate harm reduction values. Issues highlighted included ways in which to engage people who initiated drug use only recently (especially those who have never accessed harm reduction services), engage ATS users from across the spectrum and develop a more rights-based approach, for example, ensuring equitable access to health services. Once consensus on the draft policy framework was established, participants focused on next steps, which included the revitalisation of a now-defunct Harm Reduction Working Group, and the publication and dissemination of the drafted city-level Harm Reduction Policy Framework.

The level of commitment and atmosphere of collaboration demonstrated by the cross-sectoral participants was tangible. The workshop highlighted the fact that a local policy addressing Harm Reduction and HIV services (including human rights aspects and service equity) is best designed through community collaboration and consultation with local and international advocates. This collaborative process ensured that the draft local harm reduction policy acknowledged the input and needs of all stakeholders, and fostered increased government investment in meeting gaps in the Harm Reduction and HIV-related response in Makassar.