CHAPTER 2. HEALTH SERVICES

CHAPTER 2. HEALTH SERVICES 2.1 Treatment f substance use disrders within health services Thmas F Babr and Kerstin Stenius Overview Since the end f the Secnd Wrld War there has been a cnsistent grwth f specialized medical, psychiatric r scial services fr individuals with substance use disrders, particularly in the mre affluent parts f the wrld where disrders due t alchl and illicit drugs are prevalent (Mäkelä et al., 1981). In lw-incme and lwer middle-incme cuntries, specialized treatment services are ften lacking and the general health care systems are nt prepared t manage patients with substance use disrders. There is gd evidence that treatment can reduce the health burden attributable t substance use and pssibly the amunt f alchl and drugs cnsumed in a cuntry, even if treatment alne cannt cmpletely slve the alchl r drug prblem (Babr et al., 2010a; Smart & Mann, 2000; Reuter & Pllack 2006). Attempts t build service systems that adequately respnd t substance use disrders in the ppulatin face several challenges. While epidemilgical knwledge has increased, it is still incmplete in many cuntries, making it difficult t estimate the amunt and type f treatment that is needed in a particular cuntry. Cnsequently, treatment services are ften established withut any verall planning r a general cncept f hw they fit present and future ppulatin needs. Treatment services tend t be fragmented, withut sufficient crdinatin between different services. Access t treatment can vary accrding t lcatin, financial resurces and type f substance. Services are smetimes prvided in a way that increases stigma and at times they may lack the necessary respect fr basic human rights. ATLAS-SU data The ATLAS figures presented in this chapter prvide a glbal view f key indicatrs f treatment services and systems within the six WHO regins. As such, they are a valuable surce f infrmatin abut hw treatment fr substance use disrders is financed and rganized at natinal and reginal levels. Althugh tw-thirds f the WHO Member States included in the survey reprt having a gvernment unit respnsible fr alchl and drug treatment services, nly 45.8% f the cuntries have an annual budget apprpriatin fr treatment prgrammes, and in many areas that budget is cmbined with funding allcatins fr mental health services. Financing mechanisms vary by WHO regin, but mst cuntries use tax revenues, user fees and private insurance t pay fr alchl and drug services. Lw-incme cuntries are less likely t have a gvernment unit fr alchl and drug treatment and a dedicated treatment budget that is separate frm the mental health budget. Tax funding is mre imprtant in higher middle-incme and high-incme cuntries, while ut-f-pcket financing is mre cmmn in the prer cuntries. In high-incme cuntries specialized services play the mst imprtant rle in first treatment, while mental 23

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders health plays a mre imprtant rle in treatment prvisin in lw-incme cuntries (fr bth alchl and drugs). The availability f bth inpatient and utpatient treatment is much higher in the mre affluent cuntries, even if there is a relative lack f availability in many f these cuntries. There is a large difference between the lw-incme and highincme cuntries in the median number f beds available fr alchl and drug treatment. In additin, specialized treatment fr peple with substance use disrders and infectius diseases is ften nt delivered, with the data shwing a lack f treatment capacity fr persns with HIV/AIDS, especially in the WHO African Regin. Twards a public health mdel As suggested by these data, cuntries differ markedly in the extent, rganizatin and nature f the health services prvided t persns with substance use disrders. Althugh there has been a cnsiderable amunt f clinical research n specific therapeutic interventins, little attentin has been devted t the ptimal amunt, type and rganizatin f services necessary t meet the public health needs f a particular cuntry. Nevertheless, recent cmparative research and descriptive studies have begun t fcus n such critical issues as availability, accessibility, crdinatin, service quality, cst-effectiveness and degree f cerciveness (Babr, Stenius & Rmelsj, 2008). Much f this research can be characterized in terms f system qualities, which are defined by linkages between different facilities and levels f care, and by the extent f integratin with ther types f services, such as primary health care, mental health, and mutual help rganizatins (Gssp, 1995; Klingemann, Takala & Hunt, 1992; 1993; Klingemann & Hunt, 1998). Accrding t a public health mdel prpsed by Babr, Stenius & Rmelsj (2008), treatment plicies affect system qualities by specifying nt nly where services are lcated (e.g. separate alchl and drug services, r cmbined alchl and drug services with r withut mental health services), but als hw they are rganized and integrated. System qualities include equity (the extent t which services are equally available and accessible t all ppulatin grups), efficiency (the mst apprpriate mix f services) and ecnmy (the mst cst-effective services). These qualities in turn influence the general effectiveness f a system f services. When they are available and accessible t persns with substance use disrders, the cumulative impact f these services shuld translate int ppulatin health benefits, such as reduced mrtality and mrbidity, as well as benefits t scial welfare, such as reduced unemplyment, disability, crime, suicide and health care csts. These cnsideratins suggest the need fr a public health view f treatment services ne that avids an exclusive fcus n expensive residential, medical r psychiatric care in favur f a brader system f services that includes self-help, utpatient treatment, harm reductin, and preventive health services such as screening and brief interventin delivered in primary health care. Althugh lng-term residential care fr sme patients may be warranted, mst peple with substance use disrders can be managed with a cmbinatin f utpatient treatment and cntinuing care with the supprt f mutual help rganizatins (Babr et al., 2010a). 24

Health services Cnclusin Health services fr substance use disrders frm a vital part f effective natinal respnses t the burden f disease and disability resulting frm substance use disrders. While infrmatin n the structure and functining f these services is needed t guide the develpment and mdificatin f service systems, this infrmatin is ften nt available in lw-incme and middle-incme cuntries. The ATLAS data cllected fr this reprt nt nly represent an imprtant first step in the develpment f reliable data n treatment services at an internatinal level but they als pint t the need fr mre cmprehensive methds f data cllectin and analysis. Cntinued effrts t cllect userfriendly treatment service data culd prvide a basis fr imprved service planning and culd stimulate system refrm in cuntries attempting t maximize their health services fr persns affected by substance use disrders. 25

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders 2.2 Gvernment administratin and budget f treatment services fr substance use disrders (Figures 2.1 2.4) Backgrund Nminated fcal pints were asked abut the presence f a special gvernment unit r the presence f a gvernmental fficial in their cuntries respnsible fr substance use disrder treatment services. In additin, fcal pints were asked t prvide infrmatin abut the presence f a specific budget line in the annual budget f the gvernment which culd be allcated fr actins directed twards the treatment f substance use disrders. Salient findings Gvernment unit fr substance use disrder treatment services A gvernment unit r a gvernment fficial respnsible fr substance use disrder treatment services was reprted by 66.2% f surveyed cuntries. Fr the majrity f these cuntries (5), the gvernment unit was taking care f alchl and drug use disrder treatment services tgether. Separate gvernment units fr alchl treatment services and drug use disrder treatment services exist in a few cuntries nly. Few cuntries (7%) reprted having a gvernment unit fr the treatment f drug use disrders nly. N cuntry in the survey reprted having nly a gvernment unit fcusing n the treatment f alchl use disrders. The presence f gvernment units fr the treatment f alchl and drug use disrders appears t be least likely amng cuntries in the African Regin. There seems t be an effect f cuntry incme level n the presence f gvernment units fr substance use disrder treatment services acrss different incme grups f cuntries. Cuntries in the higher incme grups reprt mre frequently n the presence f gvernment units fr substance use disrder treatment services than cuntries in the lwer incme grups. Budget line fr treatment services Less than half f the cuntries reprted having a budget line allcated fr actins directed twards the treatment f substance use disrders. Specific budget lines fr the treatment f substance use disrders appear t be mst cmmn in Suth-East Asia (7) and in Western Pacific (66.6%). The lwest prprtin f specific budget lines reserved t finance alchl and drug use disrder treatment services were reprted amng cuntries in the African Regin (32.6%). Sme cuntries reprted having budget lines which are exclusively allcated t financing treatment services fr drug use disrders. Hwever, n cuntry in the survey reprted having budget lines allcated t finance treatment services fr alchl use disrders nly. 26

Health services There is n clear cuntry incme effect n the presence f budget lines fr substance use disrder treatment services acrss different incme grups f cuntries. The majrity f lw-incme cuntries appear t finance substance use disrder treatment services thrugh an integrated budget line (i.e. a budget line which is reserved fr financing mental health, alchl and drug use disrder treatment services tgether). The presence f an integrated budget line seems t decrease with increasing cuntry incme. Ntes and cmments A third f respnding cuntries reprted having n gvernment unit respnsible fr substance use disrder treatment services. A gvernment unit respnsible fr mental health treatment services which includes substance use disrders might, hwever, still be present in such cuntries. Budget lines specifically allcated t the treatment f substance use disrders seem t be absent, even in higher middle-incme and high-incme cuntries. The presence f a budget line des nt mean that infrmatin is available abut the amunt f financial resurces that are ultimately allcated t substance use disrder treatment services. 27

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders 41.8% 70. 78.6% 79.2% 80. 73.4% 66.2% Fr alchl and drug use disrders separately Fr drug use disrders nly Fr alchl use disrders nly Fr alchl and drug use disrders tgether n=145 Wrld Western Pacifi c Suth-East Asia Eurpe Eastern Mediterranean Americas Africa 50. 72.4% 68.3% Fr alchl and drug use disrders separately Fr alchl use disrders nly Fr drug use disrders nly Fr alchl and drug use disrders tgether FIGURE 2.1 PROPORTION OF COUNTRIES WITH A GOVERNMENT UNIT RESPONSIBLE FOR TREATMENT OF SUBSTANCE USE DISORDERS, BY REGION, 2008 78.8% n=145 High Higher-middle Lwer-middle Lw FIGURE 2.2 PROPORTION OF COUNTRIES WITH A GOVERNMENT UNIT RESPONSIBLE FOR TREATMENT OF SUBSTANCE USE DISORDERS, BY INCOME GROUP, 2008 Fr alchl and drug use disrders separately Fr drug use disrders nly Fr alchl use disrders nly Fr alchl and drug use disrders tgether Fr mental health, alchl and drug use disrders tgether 70. 66.6% 52.4% 42.8% 44.3% 45.8% n=146 32.6% Wrld Western Pacifi c Suth-East Asia Eurpe Eastern Mediterranean Americas Africa FIGURE 2.3 PROPORTION OF COUNTRIES WITH A BUDGET LINE IN THE ANNUAL BUDGET FOR TREATMENT OF SUBSTANCE USE DISORDERS, BY REGION, 2008 53.7% 52.9% 44.7% 33.3% n=146 FIGURE 2.4 PROPORTION OF COUNTRIES WITH A LINE IN THE ANNUAL BUDGET FOR TREATMENT OF SUBSTANCE USE DISORDERS, BY INCOME GROUP, 2008 High Higher-middle Lwer-middle Lw 28

Health services 2.3 Financing treatment services fr substance use disrders (Figures 2.5 2.8) Backgrund Nminated fcal pints were asked t rank the three mst cmmn funding r financing methds fr the treatment services f alchl and drug use disrders in their cuntries. Different sets f figures are presented in this sectin: Figs. 2.5 and 2.7 present the fremst methds in cuntries f funding the treatment f alchl and drug use disrder treatment services. Figs. 2.6 and 2.8 indicate the relative imprtance f the three mst cmmn methds in cuntries f funding the treatment f alchl and drug use disrders, presenting this infrmatin acrss different incme grups f cuntries. Salient findings Cuntries identified tax-based funding, ut-f-pcket payments and scial health insurance as being amng the fremst methds f funding treatment fr alchl as well as drug use disrders. In Africa, apprximately 4 f cuntries reprted ut-f-pcket payments t be the main funding methd fr alchl and drug use disrder treatment services. Acrss the regins, hwever, ut-f-pcket payments were als reprted t be the main financing methd fr alchl and drug use disrder treatment frm a high prprtin f cuntries in the Americas (apprximately 41%) and in Eastern Mediterranean (33% fr alchl disrder treatment, 45% fr drug use disrder treatment). A high prprtin f cuntries in Eurpe reprted that scial health insurance and tax-based funding were the fremst methds f financing alchl disrder treatment services (47% and 42% respectively) and drug use disrder treatment services (42% and 45% respectively). The bar graphs presenting the relative imprtance f the three mst imprtant financing methds fr alchl and drug use disrder treatment services indicate that tax-based funding, ut-f-pcket payments and NGOs appear t be the first, secnd and third mst frequent funding methds fr alchl and drug use disrder treatment services in the majrity f cuntries respnding t the survey. Out-f-pcket payments seem t play a majr rle in funding substance use disrder treatment services fr a high number f lw-incme and lwer middle-incme cuntries. This appears t be in cntrast t high-incme cuntries in which ut-fpcket payments were reprted t be amng the first and secnd mst cmmn financing methd in less than 1 f respnding cuntries. A high prprtin f higher middle-incme cuntries reprted tax-based funding t be the main financing methd fr alchl and drug use disrder treatment services. 29

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders The biggest prprtin f high-incme cuntries finance alchl and drug use disrder treatment services thrugh tax-based funding and scial health insurance. Financing alchl and drug use disrder treatment services thrugh scial health insurance seems t increase with increasing cuntry incme. Ntes and cmments In many cuntries, n single financing methd fr substance use disrder treatment services seems t be used exclusively. Cuntries appear t cmbine several methds t fund treatment fr substance use disrders. In lw-incme and lwer middle-incme cuntries, treatment services appear t be financed primarily with ut-f-pcket payments. A number f peple with alchl and drug use disrders and their families may, hwever, nt have sufficient financial resurces t pay fr substance use disrder treatment. This may restrict access t treatment fr a large part f the ppulatin. 30

Health services FIGURE 2.5 FOREMOST METHOD IN COUNTRIES OF FUNDING THE TREATMENT OF ALCOHOL USE DISORDERS, BY REGION, 2008 Tax-based funding Hypthecated tax Out-f-pcket payment Scial health insurance Private insurance Nngvernmental rganizatin External grant Percentage f cuntries n=128 37.5% 25. 21.1% 8.6% 5.5% 2.3% WORLD 41. 41.2% 41.2% 30.8% Percentage f cuntries 7.7% 2.6% 2.6% 15.4% Percentage f cuntries 17.6% n=39 AFRICA n=17 AMERICAS 47.6% 33.3% 33.3% 42.9% Percentage f cuntries 22.2% 11.1% Percentage f cuntries 2.4% 2.4% 2.4% 2.4% n=9 EASTERN MEDITERRANEAN n=42 EUROPE 44.4% 41.7% Percentage f cuntries 22.2% 11.1% 11.1% 11.1% Percentage f cuntries 25. 16.7% 8.3% 8.3% n=9 SOUTH EAST ASIA n=12 WESTERN PACIFIC 31

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders FIGURE 2.6 THREE MOST COMMON METHODS IN COUNTRIES OF FUNDING THE TREATMENT OF ALCOHOL USE DISORDERS, BY INCOME GROUP, 2008 WORLD 5 4 Percentage f cuntries 3 2 1 Main methd [n=128) Secnd methd [n=101) Third methd [n=73) Hypthecated tax Tax-based funding External grant Nngvernmental rganizatin Private insurance Scial health insurance Out-f-pcket payment LOW 5 4 Percentage f cuntries 3 2 1 Main methd [n=35) Secnd methd [n=25) Third methd [n=16) Hypthecated tax Tax-based funding External grant Nngvernmental rganizatin Private insurance Scial health insurance Out-f-pcket payment LOWER MIDDLE 5 4 Percentage f cuntries 3 2 1 Main methd [n=36) Secnd methd [n=28] Third methd [n=23) External grant Nngvernmental rganizatin Private insurance Scial health insurance Out-f-pcket payment Hypthecated tax Tax-based funding 32

Health services HIGHER MIDDLE 5 4 Percentage f cuntries 3 2 1 Main methd [n=27) Secnd methd [n=26) Third methd [n=18) Hypthecated tax Tax-based funding External grant Nngvernmental rganizatin Private insurance Scial health insurance Out-f-pcket payment HIGH 5 4 Percentage f cuntries 3 2 1 Main methd [n=30) Secnd methd [n=22) Third methd [n=16) External grant Nngvernmental rganizatin Private insurance Scial health insurance Out-f-pcket payment Hypthecated tax Tax-based funding 33

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders FIGURE 2.7 FOREMOST METHOD IN COUNTRIES OF FUNDING THE TREATMENT OF DRUG USE DISORDERS, BY REGION, 2008 Tax-based funding Hypthecated tax Out-f-pcket payment Scial health insurance Private insurance Nngvernmental rganizatin External grant Percentage f cuntries n=130 37.7% 26.2% 18.5% 9.2% 5.4% 3.1% WORLD 31.6% 39.5% 41.2% 41.2% Percentage f cuntries 7.9% 2.6% 2.6% 15.8% Percentage f cuntries 17.6% n=38 AFRICA n=17 AMERICAS 45.5% 45.2% 42.9% 27.3% Percentage f cuntries 18.2% 9.1% Percentage f cuntries 4.8% 2.4% 2.4% 2.4% n=11 EASTERN MEDITERRANEAN n=42 EUROPE 44.4% 38.5% Percentage f cuntries 22.2% 11.1% 11.1% 11.1% Percentage f cuntries 23.1% 7.7% 7.7% 15.4% 7.7% n=9 SOUTH EAST ASIA n=13 WESTERN PACIFIC 34

Health services FIGURE 2.8 THREE MOST COMMON METHODS IN COUNTRIES OF FUNDING THE TREATMENT OF DRUG USE DISORDERS, BY INCOME GROUP, 2008 WORLD 5 4 Percentage f cuntries 3 2 1 Main methd [n=130) Secnd methd [n=107) Third methd [n=80) Hypthecated tax Tax-based funding External grant Nngvernmental rganizatin Private insurance Scial health insurance Out-f-pcket payment LOW 5 4 Percentage f cuntries 3 2 1 Main methd [n=36) Secnd methd [n=27) Third methd [n=20) External grant Nngvernmental rganizatin Private insurance Scial health insurance Out-f-pcket payment Hypthecated tax Tax-based funding LOWER MIDDLE 5 4 Percentage f cuntries 3 2 1 Main methd [n=36) Secnd methd [n=32) Third methd [n=24) External grant Nngvernmental rganizatin Private insurance Scial health insurance Out-f-pcket payment Hypthecated tax Tax-based funding 35

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders HIGHER MIDDLE 5 4 Percentage f cuntries 3 2 1 Main methd [n=27) Secnd methd [n=26) Third methd [n=20) Hypthecated tax Tax-based funding External grant Nngvernmental rganizatin Private insurance Scial health insurance Out-f-pcket payment HIGH 5 4 Percentage f cuntries 3 2 1 Main methd [n=31) Secnd methd [n=22) Third methd [n=16) External grant Nngvernmental rganizatin Private insurance Scial health insurance Out-f-pcket payment Hypthecated tax Tax-based funding 36

Health services 2.4 Treatment settings fr alchl and drug use disrders (Figures 2.9 2.12) Backgrund Nminated fcal pints were requested t indicate the mst cmmnly used treatment settings fr persns with alchl and drug use disrders in their cuntries. In the cntext f this reprt, the treatment settings were: specialized treatment services fr alchl and drug use disrders, mental health services, general health services (such as treatment delivered in district hspitals), primary health care, and ther treatment services. Different sets f figures are presented in this sectin: The pie graphs (Figs. 2.9 and 2.11) present the mst cmmn settings in cuntries fr the treatment f alchl disrders and drug use disrders respectively. The bar graphs (Figs. 2.10 and 2.12) indicate the relative imprtance f the three mst cmmn treatment settings in cuntries, presenting this infrmatin acrss different incme grups f cuntries. Salient findings Nminated fcal pints in cuntries reprted a variety f treatment settings fr persns with alchl and drug use disrders. With few exceptins, all treatment settings are used fr the treatment f alchl and drug use disrders acrss different incme grups f cuntries. In the majrity f respnding cuntries (39.8%), mental health services are the mst cmmn treatment setting fr alchl use disrders. A higher prprtin f cuntries reprted specialized treatment services t be the main setting fr the treatment f drug use disrders (51.5%) than fr alchl use disrders (34.6%). Apprximately 1 f cuntries in the survey reprted primary health care t be the mst cmmnly used setting fr treatment f alchl and drug use disrders. In high-incme cuntries, specialized treatment services fr the treatment f drug use disrders seem t play a prminent rle, with almst 9 f high-incme cuntries reprting specialized services t be the main setting fr the treatment f drug use disrders. A number f cuntries reprted traditinal medicine t be the main treatment methd fr alchl and drug use disrders. Traditinal medicine is included under the categry ther treatment settings. 37

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders Ntes and cmments Treatment f alchl and drug use disrders in surveyed cuntries invlved different treatment settings with mental health services and specialized alchl and drug services as main prviders f treatment fr peple with alchl and drug use disrders. The rle f primary health care is still limited. The majrity f lw-incme cuntries identified mental health services t be the main setting fr alchl and drug use disrder treatment. The imprtance f mental health services as the mst cmmn treatment setting fr alchl and drug use disrders appears t decrease with increasing cuntry incme, which is especially evident fr the treatment f drug use disrders. The imprtance f specialized treatment services in treating alchl and drug use disrders gains in imprtance as a cuntry s incme level rises. Because the majrity f fcal pints fr the ATLAS survey are wrking in the specialist system, there may have been a tendency t veremphasize the rle f the specialist system in prvisin f treatment fr substance use disrders. 38

Health services 9.8% WORLD 1.5% 34.6% Specialized treatment services General health services Mental health services Primary health care n=133 39.8% FIGURE 2.9 MOST COMMON SETTING IN COUNTRIES FOR THE TREATMENT OF ALCOHOL USE DISORDERS, 2008 14.3% FIGURE 2.10 THREE MOST COMMON SETTINGS IN COUNTRIES FOR THE TREATMENT OF ALCOHOL USE DISORDERS, BY INCOME GROUP, 2008 WORLD Percentage f cuntries 10 9 8 7 6 5 4 3 2 1 Main lcatin [n=133) Secnd mst cmmn [n=112) Third mst cmmn [n=96) Primary health care Mental health service General health service Specialized treatment service LOW Percentage f cuntries 10 9 8 7 6 5 4 3 2 1 Main lcatin [n=38) Secnd mst cmmn [n=28) Third mst cmmn [n=23) Primary health care Mental health service General health service Specialized treatment service 39

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders LOWER MIDDLE Percentage f cuntries 10 9 8 7 6 5 4 3 2 1 Main lcatin [n=36) Secnd mst cmmn [n=31) Third mst cmmn [n=25) Primary health care Mental health service General health service Specialized treatment service HIGHER MIDDLE Percentage f cuntries 10 9 8 7 6 5 4 3 2 1 Main lcatin [n=29) Secnd mst cmmn [n=26) Third mst cmmn [n=24) Primary health care Mental health service General health service Specialized treatment service HIGH Percentage f cuntries 10 9 8 7 6 5 4 3 2 1 Main lcatin [n=30) Secnd mst cmmn [n=27) Third mst cmmn [n=24) Primary health care Mental health service General health service Specialized treatment service 40

Health services 6.6% WORLD 2.2% 51.5% Specialized treatment services General health services Mental health services Primary health care n=136 32.4% FIGURE 2.11 MOST COMMON SETTING IN COUNTRIES FOR THE TREATMENT OF DRUG USE DISORDERS, 2008 7.4% FIGURE 2.12 THREE MOST COMMON SETTINGS IN COUNTRIES FOR THE TREATMENT OF DRUG USE DISORDERS, BY INCOME GROUP, 2008 WORLD Percentage f cuntries 10 9 8 7 6 5 4 3 2 1 Main lcatin [n=136) Secnd mst cmmn [n=116) Third mst cmmn [n=102) Primary health care Mental health service General health service Specialized treatment service LOW Percentage f cuntries 10 9 8 7 6 5 4 3 2 1 Main lcatin [n=39) Secnd mst cmmn [n=30) Third mst cmmn [n=24) Primary health care Mental health service General health service Specialized treatment service 41

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders LOWER MIDDLE Percentage f cuntries 10 9 8 7 6 5 4 3 2 1 Main lcatin [n=36) Secnd mst cmmn [n=31) Third mst cmmn [n=28) Primary health care Mental health service General health service Specialized treatment service HIGHER MIDDLE Percentage f cuntries 10 9 8 7 6 5 4 3 2 1 Main lcatin [n=29) Secnd mst cmmn [n=26) Third mst cmmn [n=22) Primary health care Mental health service General health service Specialized treatment service HIGH Percentage f cuntries 10 9 8 7 6 5 4 3 2 1 Main lcatin [n=32) Secnd mst cmmn [n=29) Third mst cmmn [n=28) Primary health care Mental health service General health service Specialized treatment service 42

Health services 2.5 Treatment services and cverage f alchl and drug use disrder treatment (Figures 2.13 2.23) Backgrund Fcal pints were requested t indicate the presence f different treatment services available fr the treatment f alchl and drug use disrders. In the cntext f this reprt, treatment services were categrized as: inpatient medical detxificatin, utpatient treatment and lng-term residential rehabilitatin (fr alchl and drug use disrders), and piid agnist maintenance therapy (fr the treatment f piid dependence). The number, distributin and accessibility f treatment services fr alchl and drug use disrders may vary cnsiderably in cuntries, and within regins. Nminated fcal pints were therefre asked t indicate the cverage f the ppulatin in need with these services (i.e. t estimate the cverage f persns with alchl and drug use disrders in their cuntries receiving these services). Salient findings Presence f treatment services fr substance use disrders Amng different treatment services, inpatient detxificatin fr alchl and drug use disrders appears t be frequently present in cuntries, and was reprted t be present in ver 9 f cuntries respnding t the survey. Lng-term residential rehabilitatin and piid agnist maintenance therapy fr piid dependence appear t be least present f the treatment services presented. The presence f piid agnist maintenance therapy fr piid dependence was reprted in 44.6% f cuntries. With the exceptin f lng-term residential rehabilitatin and piid agnist maintenance therapy, the presence f treatment services fr alchl and drug use disrders did nt vary greatly acrss the regins. Hwever, the presence f lng-term residential rehabilitatin was less cmmn in the African and Eastern Mediterranean regins. Similarly, piid agnist maintenance therapy fr piid dependence was reprted mst ften amng cuntries in the Eurpean Regin (86.4%), and was less present in the African Regin (12.2%) and the Eastern Mediterranean Regin (16.7%). Cuntries incme levels seem t have an effect n the presence f treatment services fr alchl and drug use disrders. The presence f treatment services fr alchl and drug use disrders as described in this sectin increases with increasing cuntry incme. 43

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders Cverage f treatment services fr substance use disrders Cverage f the ppulatin in need with alchl and drug use disrder treatment services seems t be lw. In lw-incme cuntries the majrity f persns with alchl and drug use disrders are nt cvered by the respective treatment services. Fr example, in ver 5 f lw-incme cuntries less than 1 f persns with alchl use disrders have access t inpatient medical detxificatin. Similarly, in arund 6 f lw-incme, lwer middle-incme and higher middle-incme cuntries, substitutin maintenance therapy fr piid dependence is reaching less than 1 f piid-dependent persns. Ntes and cmments Althugh a high prprtin f cuntries reprted having sme services fr treating substance use disrders, cverage f the ppulatin in need appears t be lw, even in the higher middle-incme and high-incme grups f cuntries. Infrmatin abut the presence f treatment services fr alchl and drug use disrders in cuntries des nt indicate the number f treatment services which are available at natinal level. Treatment services fr alchl and drug use disrders might be mre ften present in urban areas, fr example, especially in lw-incme cuntries. 44

Health services Inpatient medical detxifi catin [n=131] Outpatient treatment [n=130] Lng-term residential rehabilitatin [n=131] 10 94.1% 90.9% 10 90.2% 10 10 84.6% 94.7% 80. 85. 80. 68.3% 77.8% 69.2% 62.5% 63.6% 55.6% 53.4% 27.5% 9.1% FIGURE 2.13 PROPORTION OF COUNTRIES WITH TREATMENT SERVICES FOR ALCOHOL USE DISORDERS, BY REGION, 2008 Suth-East Asia Wrld Western Pacifi c Americas Eurpe Eastern Mediterranean Africa 10 81.6% 76.3% 74.3% 10 10 90.3% 84.4% 80.8% 65.4% 34.2% 37.1% FIGURE 2.14 PROPORTION OF COUNTRIES WITH TREATMENT SERVICES FOR ALCOHOL USE DISORDERS, BY INCOME GROUP, 2008 Lwer-middle Higher-middle High Lw 45

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders >9 f the ppulatin in need 50 9 f the ppulatin in need 10 5 f the ppulatin in need <1 f the ppulatin in need 10 8 Percentage f cuntries 6 4 2 Wrld [n=115] High [n=28] Higher-middle [n=25] Lwer-middle [n=31] Lw [n=31] FIGURE 2.15 COVERAGE OF INPATIENT MEDICAL DETOXIFICATION SERVICES FOR ALCOHOL USE DISORDERS IN COUNTRIES WHERE THESE SERVICES ARE AVAILABLE, BY INCOME GROUP, 2008 10 8 Percentage f cuntries 6 4 2 Wrld [n=94] High [n=23] Higher-middle [n=19] Lwer-middle [n=24] Lw [n=28] FIGURE 2.16 COVERAGE OF OUTPATIENT TREATMENT FOR ALCOHOL USE DISORDERS IN COUNTRIES WHERE THIS TREATMENT IS AVAILABLE, BY INCOME GROUP, 2008 10 8 Percentage f cuntries 6 4 2 Wrld [n=64] High [n=23] Higher-middle [n=16] Lwer-middle [n=12] Lw [n=13] FIGURE 2.17 COVERAGE OF LONG TERM RESIDENTIAL REHABILITATION FOR ALCOHOL USE DISORDERS IN COUNTRIES WHERE THIS TREATMENT IS AVAILABLE, BY INCOME GROUP, 2008 46

Health services Inpatient medical detxifi catin [n=137] Outpatient abstinence riented treatment [n=134] Lng-term residential rehabilitatin [n=135] Substitutin maintenance therapy fr piid dependence [n=139] 10 10 90.5% 10 87.5% 91.7% 84.1% 86.4% 80. 81.8% 80. 78.6% 71.4% 72.4% 75. 66.7% 60. 59.3% 60.5% 62.5% 50. 40. 44.6% 30.8% 12.2% 35.3% 16.7% 16.7% FIGURE 2.18 PROPORTION OF COUNTRIES WITH TREATMENT SERVICES FOR DRUG USE DISORDERS, BY REGION, 2008 Suth-East Asia Western Pacifi c Wrld Americas Eurpe Eastern Mediterranean Africa 91.7% 10 10 91.2% 88.2% 80. 74.4% 72.2% 74.1% 70.4% 54.1% 48.6% 53.6% 35.9% 22.5% 27.8% FIGURE 2.19 PROPORTION OF COUNTRIES WITH TREATMENT SERVICES FOR DRUG USE DISORDERS, BY INCOME GROUP, 2008 Lwer-middle Higher-middle High Lw 47

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders >9 f the ppulatin in need 50 9 f the ppulatin in need 10 5 f the ppulatin in need <1 f the ppulatin in need 10 8 Percentage f cuntries 6 4 2 Wrld [n=114] High [n=30] Higher-middle [n=26] Lwer-middle [n=30] Lw [n=29] FIGURE 2.20 COVERAGE OF INPATIENT MEDICAL DETOXIFICATION SERVICES FOR DRUG USE DISORDERS IN COUNTRIES WHERE THESE SERVICES ARE AVAILABLE, BY INCOME GROUP, 2008 10 8 Percentage f cuntries 6 4 2 Wrld [n=95] High [n=29] Higher-middle [n=20] Lwer-middle [n=26] Lw [n=20] FIGURE 2.21 COVERAGE OF OUTPATIENT ABSTINENCE ORIENTED TREATMENT FOR DRUG USE DISORDERS IN COUNTRIES WHERE THIS TREATMENT IS AVAILABLE, BY INCOME GROUP, 2008 10 8 Percentage f cuntries 6 4 2 Wrld [n=69] High [n=24] Higher-middle [n=18] Lwer-middle [n=14] Lw [n=13] FIGURE 2.22 COVERAGE OF LONG TERM RESIDENTIAL REHABILITATION FOR DRUG USE DISORDERS IN COUNTRIES WHERE THIS TREATMENT IS AVAILABLE, BY INCOME GROUP, 2008 10 8 Percentage f cuntries 6 4 2 Wrld [n=52] High [n=23] Higher-middle [n=14] Lwer-middle [n=8] Lw [n=7] FIGURE 2.23 COVERAGE OF AGONIST MAINTENANCE THERAPY FOR OPIOID DEPENDENCE IN COUNTRIES WHERE THIS TREATMENT IS AVAILABLE, BY INCOME GROUP, 2008 48

Health services 2.6 Number f beds and length f stay (Figures 2.24 2.27) Backgrund Nminated fcal pints were requested t reprt n the capacity f their health care systems t treat substance use disrders using the fllwing indicatrs: the ttal number f inpatient beds available in their cuntries fr the treatment f alchl and drug use disrders; the average length f stay fr inpatient alchl and drug detxificatin. Salient findings Beds fr alchl and drug use disrders Amng the respnding cuntries, the median number f beds fr alchl and drug use disrders was 1.7 per 100 000 ppulatin (range 0 52 beds per 100 000 ppulatin). The lwest median numbers f beds fr alchl and drug use disrders were in the African Regin (0.2 per 100 000 ppulatin) and the Eastern Mediterranean Regin (0.6 per 100 000 ppulatin). The highest median number f beds fr alchl and drug use disrders was reprted frm cuntries in the Eurpean Regin (10.3 beds per 100 000 ppulatin). There was a cuntry incme effect n the median number f beds fr alchl and drug use disrders acrss different incme grups f cuntries. Between the lw-incme and lwer middle-incme grups f cuntries, there was n marked difference in the median number f beds fr alchl and drug use disrders. Hwever, frm lwer middle-incme (0.7 beds per 100 000 ppulatin) t higher middle-incme cuntries (7.1 beds per 100 000 ppulatin), there was a 10-fld increase in the median number f beds fr alchl and drug use disrders. Length f stay fr alchl and drug detxificatin The median length f stay fr alchl and drug detxificatin was 10.3 days and 14.0 days respectively. In the majrity f regins, the median length f stay was lnger fr drug detxificatin than fr alchl detxificatin, and this difference was mst marked in the Western Pacific Regin, where the median length f stay was 14 days fr drug detxificatin and 7 days fr alchl detxificatin. Lw-incme cuntries reprted having a lnger median length f stay than highincme cuntries. Fr example, the median length f stay fr alchl detxificatin was 8 days in high-incme cuntries, and 16.5 days in lw-incme cuntries. 49

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders Ntes and cmments Sme fcal pints reprted that beds fr alchl and drug use disrders are nt cunted separately frm beds fr mental health cnditins, making it difficult fr them t prvide a respnse t this questin. Patients with cmrbid cnditins may receive substance use disrder treatment in ther hspital wards. These beds may nt have been cnsidered by cuntries. Infrmatin n the average length f stay fr alchl and drug detxificatin was cmpleted by 86 (alchl detxificatin) and 92 cuntries (drug detxificatin). As presented in sectin 1.5, this respnse rate may reflect the fact that institutinalized treatment data cllectin systems fr substance use disrders are present nly in apprximately 5 f cuntries. High-incme cuntries seem t use shrter inpatient stays than lw-incme cuntries, despite the fact that shrter inpatient treatment duratin is likely t result in significant cst savings. 50

Health services 10.3 0.2 Wrld [n=102] Western Pacifi c [n=6] Suth-East Asia [n=7] Eurpe [n=34] Eastern Mediterranean [n=11] Americas [n=11] Africa [n=33] 2.4 0.6 1.6 2.4 1.7 FIGURE 2.24 MEDIAN NUMBER OF BEDS IN COUNTRIES PER 100 000 POPULATION FOR THE TREATMENT OF ALCOHOL AND DRUG USE DISORDERS, BY REGION, 2008 12.7 7.1 Alchl detxifi catin Drug detxifi catin 0.4 0.7 High [n=19] Higher-middle [n=24] Lwer-middle [n=29] Lw [n=30] FIGURE 2.25 MEDIAN NUMBER OF BEDS IN COUNTRIES PER 100 000 POPULATION FOR THE TREATMENT OF ALCOHOL AND DRUG USE DISORDERS, BY INCOME GROUP, 2008 17.5 15.0 14.5 14.5 14.0 14.0 11.0 11.5 10.5 10.0 11.5 10.3 8.3 7.0 Nmber f days n=86 FIGURE 2.26 MEDIAN LENGTH OF STAY IN COUNTRIES FOR INPATIENT ALCOHOL AND DRUG DETOXIFICATION, BY REGION, 2008 n=92 Africa Americas Eurpe Eastern Mediterranean Suth-East Asia Wrld Western Pacifi c 17.0 16.5 14.0 12.0 10.5 10.0 10.0 8.0 Nmber f days n=86 FIGURE 2.27 MEDIAN LENGTH OF STAY IN COUNTRIES FOR INPATIENT ALCOHOL AND DRUG DETOXIFICATION, BY INCOME GROUP, 2008 n=92 Lw Lwer-middle High Higher-middle 51

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders 2.7 Care fr special ppulatins (Figures 2.28 2.33) Backgrund Nminated fcal pints were asked abut the presence f treatment services fr substance use disrders in special ppulatins. In the cntext f this reprt, special ppulatins are defined as pregnant wmen, yung peple, indigenus ppulatins, and als prisners, injecting drug users (IDUs) and cmmercial sex wrkers. Persns with drug use disrders wh have infectius diseases may require specialized care and treatment. Fcal pints were asked abut the presence f specialized treatment services fr persns with drug use disrders wh have HIV/AIDS r tuberculsis (e.g. where treatment f piid dependence, tuberculsis and HIV are available frm ne specialized treatment service). Salient findings Treatment services fr substance use disrders in special ppulatins The prprtin f cuntries ffering treatment services fr substance use disrders in different special ppulatins varies cnsiderably between regins and cuntry incme grups and accrding t the special ppulatin being treated. Substance use disrder treatment services fr prisners were reprted frm the majrity f surveyed cuntries (55.9%), fllwed by substance use disrder treatment services fr yung peple (47.6%) and injecting drug users (40.). Specialized substance use disrder treatment services fr pregnant wmen and cmmercial sex wrkers are present in 31. and 25.5% f cuntries respectively. Apprximately 11. f cuntries reprted having substance use disrder treatment services fr indigenus ppulatins. Substance use disrder treatment services fr yung peple and pregnant wmen were reprted frm the majrity f cuntries in Eurpe (72.7% and 61.4% f cuntries in Eurpe respectively). Substance use disrder treatment services fr indigenus peple were reprted t be mst cmmn amng cuntries in the Western-Pacific (28.6%). Substance use disrder treatment services fr cmmercial sex wrkers were reprted t be mst cmmn amng cuntries in Suth-East Asia (4), and cuntries in Eurpe (34.1%). Besides substance use disrder treatment services fr prisners and injecting drug users, there is n effect f cuntry incme level n the presence f treatment services in special ppulatins. 52

Health services Specialized treatment services fr persns with drug use disrders having HIV/ AIDS r tuberculsis Specialized treatment services fr persns with drug use disrders and HIV/AIDS were reprted by 43.2% f cuntries. These services seem t be mre ften present in cuntries than treatment services fr drug use disrders and tuberculsis (24.6%). Specialized treatment fr persns with drug use disrders and HIV/AIDS appears t be mst ften present amng cuntries in the Eurpean, Suth-East Asia and Eastern Mediterranean regins, and appears t be less cmmn amng cuntries in Africa where 14% f cuntries reprted having this treatment service. Treatment services fr persns with drug use disrders and tuberculsis were mst ften reprted in Suth-East Asia (4). In apprximately 16% f cuntries in the African and Western Pacific regins, specialized treatment was reprted fr persns with drug use disrders and tuberculsis. There is n strng effect f cuntry incme level n the presence f specialized treatment services fr persns with substance use disrders and HIV/AIDS r tuberculsis acrss different grups f cuntries. Ntes and cmments One factr that may explain the variatin in the prprtin f cuntries prviding services fr different ppulatins is the presence f the special ppulatin itself. Significant numbers f indigenus ppulatins are nt present in every cuntry, fr instance. The generally lw prprtin f cuntries with services fr these types f special ppulatins may represent a significant pprtunity fr develpment f services in this area. 53

Africa Africa ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders FIGURE 2.28 PROPORTION OF COUNTRIES WITH TREATMENT SERVICES FOR SUBSTANCE USE DISORDERS IN SPECIAL POPULATIONS, BY REGION, 2008 72.7% 61.4% 57.1% 50. 42.9% 47.6% 35.7% 31. 28.6% 14. 25.6% 7. 19. 14.3% 23.1% 7.7% 7.7% 6.8% 20. 20. 11. Pregnant wmen Yung peple Indigenus peple n=145 Americas Eastern Mediterranean Eurpe Suth-East Asia Western Pacifi c Wrld 79.5% 77.3% 71.4% 71.4% 55.9% 53.8% 50. 40. 38.5% 40. 40.40. 34.1% 25.5% 28.6% 21.4% 23.3% 9.3% 16.3% 9. 15.4% Prisners IDUs Cmmercial sex wrkers n=145 Americas Eastern Mediterranean Eurpe Suth-East Asia Western Pacifi c Wrld FIGURE 2.29 PROPORTION OF COUNTRIES WITH TREATMENT SERVICES FOR SUBSTANCE USE DISORDERS IN SPECIAL POPULATIONS, BY INCOME GROUP, 2008 77.1% 62.9% 58.6% 88.6% 80. 34.5% 31.7% 30. 62.1% 17.1% 19.5% 14.6% 12.5% 7.5% 3.4% Pregnant wmen Yung peple Indigenus peple 47.5% 34.5% 42.9% n=145 Lw Lwer-middle Higher-middle High 31.7% 24.4% 22. 25. 22.5% 13.8% Prisners IDUs Cmmercial sex wrkers 54 n=145 Lw Lwer-middle Higher-middle High

Health services Present Absent 86. 68.2% 71.4% 60. 56.8% 57.1% 57.1% 43.2% 42.9% 42.9% 40. 14. 31.8% 28.6% FIGURE 2.30 PROPORTION OF COUNTRIES WITH SPECIALIZED TREATMENT SERVICES FOR PERSONS WITH DRUG USE DISORDERS AND HIV/AIDS, BY REGION, 2008 n=146 Africa Americas Eurpe Eastern Mediterranean Suth-East Asia Wrld Western Pacifi c 70.7% 56.1% 60. 58.6% 43.9% 41.4% 40. 29.3% FIGURE 2.31 PROPORTION OF COUNTRIES WITH SPECIALIZED TREATMENT SERVICES FOR PERSONS WITH DRUG USE DISORDERS AND HIV/AIDS, BY INCOME GROUP, 2008 n=146 High Higher-middle Lw Lwer-middle 83.3% 83.7% 80. 75.4% 71.4% 67.4% 60. 16.3% 20. 28.6% 32.6% 40. 16.7% 24.6% FIGURE 2.32 PROPORTION OF COUNTRIES WITH SPECIALIZED TREATMENT SERVICES FOR PERSONS WITH SUBSTANCE USE DISORDERS AND TUBERCULOSIS, BY REGION, 2008 87.2% 82.1% n=142 Americas Eurpe Eastern Mediterranean Suth-East Asia Wrld Western Pacifi c 73.2% Africa 58.8% 41.2% 26.8% 12.8% 17.9% FIGURE 2.33 PROPORTION OF COUNTRIES WITH SPECIALIZED TREATMENT SERVICES FOR PERSONS WITH SUBSTANCE USE DISORDERS AND TUBERCULOSIS, BY INCOME GROUP, 2008 n=142 Lw Lwer-middle High Higher-middle 55