csidp

National Action Plan Italy COLOPHON Colophon

This National Action Plan is developed in the framework of the European Civil Society In- volvement Project - CSIDP, fi nanced bty the European Commission, DG Home. More informatio via: www.csidp.eu csidp Author(s): Lella Cosmaro, Susanna Ronconni.

Copyright © 2018 Copyright remains with the publisher De Regenboog Groep / Correlation Network PO Box 10887 1001 EW Amsterdam Correlation The Netherlands European Harm Reduction Phone: +31 20 5707829 C Network [email protected] www.correlation-net.org

European Union (Home/2015/JDRU/AG/DRUG/8842). The contents of this publication are the sole responsibility of INDEX

Introduction 04 Overview of the National Situation 04 Overview of the National Action 06 Plan Key outcomes 06

Formation 07 of the National Action Plan Stakeholders 07 Process 08 Final National Plan 09

Implementation 10 of the National Action Plan Overview 10 Challenges 11 Assessment of success 12 Learning 13

Conclusions and Recommendations 14

3 checking, outreach interventions, drop in centres) are not included in the LEA and therefore it is not INTRODUCTION mandatory for the Regions to implement them. As a consequence, HR interventions are carried out in 12 Regions only and lack homogeneous HR guidelines/standards and monitoring systems; PUDs’ right to health on the Italian territory is unequal and fortuitous. Lastly, no clear political OVERVIEW OF THE NATIONAL support means no routine monitoring.

SITUATION Lately, two positive changes occurred: in 2017, the The lack of both political support and HR national introduction of HR in the LEA at national level - it guidelines still represents a crucial problem for is now necessary to develop and articulate LEA HR in Italy: HR interventions have been provided at regional level in order to implement them; since 1995, but intermittently. During the years, the inclusion by the DPA (Drug Policy Agency) positive steps in the right direction have inevitably in the Annual Report to the Parliament 2016 of a been reversed by conservative governments’ chapter focused on Harm Reduction development, prohibitionist drug policies; HR interventions have which was written by CS organizations. This CS been penalized by an ideological political approach. contribution included a suggested roadmap on HR, which could be used as the basis for our national Italy has a universal National Health System; action plan and advocacy actions. its 20 Regional governments decide their own investments and budgets, provided that they In such changing context, the possibility to take comply with national LEA (Livelli Essenziali di part to the European project CSI – Civil Society Assistenza or basic assistance levels, i.e. standard, Involvement in Drug Policies – represented a great guaranteed and totally or partially free treatments chance for Italian CS to bring back policy makers’ and services). Drug treatments are guaranteed attention to drug policies in general and more by both the National and Regional Public Health specifically to HR. Systems; services can be provided by non-profit In the spring of 2017, the two Italian partners organizations, financed by the public health budget. Forum Droghe and Fondazione LILA Milano, This system guarantees PWUDs’ access to free drug in collaboration with the national partnership, services and treatments. launched an online survey addressed to CS While OST is not considered as a HR measure but networks and associations on the priorities in the as a treatment and it is therefore not included in Harm Reduction dialogue between CS and policy the national LEA, it is free of charge and accessible makers in Italy. to all (including migrants in an irregular status),HR The survey was online for 32 days, from March 27 interventions (NSP, naloxone distribution, drug to April 28; 73 valid questionnaires were collected.

4 It gave some interesting indications, which with continuity, eliminating regional differences guided the defi nition of the Italian roadmap for and giving clear political support to interventions development of a dialogue on HR between CS and through two fundamental tools: national guidelines policy makers. Following are the main results: and LEA on HR. These two objectives call for participated processes, which attribute a crucial Harm Reduction: role to different stakeholders such as DPA, Regions HR was represented in its complexity of both and the Conference of Regions, including also approach/strategy transversal to numerous Ministries and the Government. The Italian areas and operational programs. Participatory system is multilevel; national, regional and processes tend to combine different contexts municipal stakeholders all play a crucial role. The (political, technical/political and technical) and identifi cation of contexts and processes facilitating to value the different components present within and guaranteeing dialogue is indicated as a priority CS (competences of experts and professionals and stakeholders’ competences). The questionnaire gave a clear picture of such a complexity by highlighting HR legal and social communication dimensions beside the health and social ones

Dialogue CS-policy makers: Unsurprisingly, the concordant opinion/judgement on the state of the art of participatory processes and dialogue between CS and policy- makers was defi nitely negative and described an under-developed, stuffy and stuck Agenda of priorities for a Roadmap on situation, especially when compared to European strategies and guidelines on drugs. Such negative Harm Reduction: picture called for urgent changes; HR must be The role of research and monitoring: recognized as a fundamental pillar of national Great attention was devoted also to the topic of policies, based on scientifi c evidences academic and independent research on patterns of drug use, impact of drug policies and consideration/ Guidelines, LEA (Essential Assistance evaluation of possible alternatives (i.e. legalization), Levels) and political clarity: as well as on program monitoring. Research The survey emphasized the need to ensure that development calls for a plurality of institutional HR is implemented throughout the entire country and independent stakeholders, who from a dialogue

5 with CS can derive indications for new research (Cartello di Genova), which was in a stalemate objectives and different, enriching perspectives since early 2017

Transparency and assurance of processes: 2. To open a political dialogue on HR and Survey results gave a negative picture of establish a structured place for it with the participative processes, which are described as DPA, National Drug Department, starting from poor, marked by opacity and perpetual uncertainty. two concrete proposals: a) a Working Group According to respondents, only few CS stakeholders on HR guidelines and b) CSOs participation in succeed in interacting with policy makers; in the new DPA Observatory on Drugs, and in the addition, critical remarks were made about debate on objectives, methods and contents difficulties in the dialogue CS-policy makers, which of the research on drug issues, functional to is not clearly formalized. It is therefore urgent to monitoring, evaluating and innovating national start a process based on transparent processes drug policies and interventions guaranteeing recognition and formal assurance 3. To start and develop a political dialogue with the Regions and the National Conference of Challenges for CS: Regions / Health Commission and Interregional The survey also highlighted limits and weaknesses Drug Group on the implementation of the in CS, suggesting internal problems that need to HR LEA (introduced in 2017, but not yet be addressed; a roadmap on HR needed to take enforceable) all over the country care also of such challenges. Improved cohesion capacity, effective negotiation of common goals, extension of alliances within CS, increased mobilization, advocacy and communication KEY OUTCOMES activities, support and inclusion of stakeholders’ associations and networks appear to be transversal • Active participation of CSOs involved in HR goals that need to be kept in the background of a (Cartello di Genova) in designing, implementing participative development process. and co-organizing the action plan activities; further strengthening of new and old alliances and networks; relaunch of the Cartello and its OVERVIEW OF THE NATIONAL propulsive action; CSOs’ commitment in to ACTION PLAN the continuation of advocacy actions after the project conclusion; endorsement of a common The Italian action plan focused on three main lines: statement on HR development and promotion (Napoli Declaration 2017, during the Naples CSO 1. To ensure that the CSI project acts as a further Conference) propulsive thrust in CSOs networking and alliances, giving new impulse to the current • An open dialogue with some Regions and with Italian drug policy reform and HR CSOs network the National Conference of Regions - Health /

6 Drug Departments has been established with regard to the implementation of HR LEA in FORMATION OF all Regions. A process in this direction has THE NAP started thanks to CSOs and the project actions: the Coordinator of the National Conference of Regions - Health Department committed to include in the Commission’s agenda the implementation of HR LEA in all Regions just after the summer; some Regional coordinators STAKEHOLDERS have been involved in the process of innovating The Italian collaborating partners in the CSI DP / developing local HR systems. project are two national organizations: • No effective goal has been achieved among Forum Droghe, an organization active those which implied a relationship with the DPA on policy reform, advocacy, research, (HR guidelines and research on drug issues) communication and training activities in the because of changes which occurred both in DPA drug field staff and in the Italian Government. Fondazione LILA Milano, the Milanese unit of the Italian League for Fighting AIDS, which has been active for 30 years in the HIV, hepatitis and other STI field through a group of activists, social workers and people living with HIV

The following associated partners committed to support the project:

CNCA (Coordinamento Nazionale Comunità di Accoglienza) a large third sector network of service providers

ITARDD, the Italian Harm Reduction Network including associations, service providers, workers in the drug field and users

DPA (Dipartimento Politiche Antidroga), the Department for Anti-Drug Policies which is responsible for the strategic and operational coordination of Italian drug policy; it is a department of the Presidency of the Council of Ministers

7 Many other different organizations were involved • Processes, discussion and decision-making in the project activities, among which trade unions contexts (FP-CGIL), NGOs working on prisons and legal • Priorities in Harm Reduction policies issues, Social Cooperatives, ‘Cartello di Genova’, as well as individuals covering key roles in the 3. Dialogue between CS and policy-makers development of Italian drug policies, such as the 4. A seminar of ‘Cartello di Genova’ institutional representatives for drug issues of involving CSI-DP partners some Italian Regions. Last, but not least, the project sought the active involvement of PUDs. This seminarwas held in Rome on 26 Jun 2017: Drugs. The Crossing of the Desert, in order to discuss future perspectives for reforming drug PROCESS policies, from the persisting parliamentary deadlock to the political elections of 2018 1. The following Italian CSOs were consulted for the design and The partners and involved stakeholders decided implementation of the National Action to focus the Italian National Plan on the relaunch Plan: of Harm Reduction strategies, because of the following critical issues: • ‘Cartello di Genova’ a network that in previous 3 years (2014-2016) constituted a national CSO • in 2017,only 12 Regions out of 20 were in the network platform for advocacy on drugs and condition to offer HR services (NSP, drop-ins, drug reform outreach, THN) but only 6 offered them in a stable way; 6 Regions had no HR services and • CNCA, a third sector organization consortium 2 Regions did not provide any data from 2012 • ITARDD, a HR network of professionals and to 2014 users who engaged in bilateral consultations • the number of NSP decreased from 106 to • Professionals, trade unions, NGOs working 72; coverage decreased from 24% to 15% on prisons and legal issues, PUDs, social (denominator: number of opioid PUDs) cooperatives; they engaged in new • 4 Regions only had one service for 500 PWUD; partnerships during bilateral and collective 3 Regions had 1 service for 2.000 PUD; 2 meetings supported by online dissemination Regions 1 for 5.000 and, finally, 3 Regions had 1 of info about the CSI project service for over 5.000 PUD.

• 29% of all HR services were stable, 22% had a 2 2. An online survey was conducted in the years term, 38% 1-2 years term, 11% less than 11 following areas: months term • Harm Reduction in Italy

8 • neither the National Strategy nor the National • in 2017 HR was introduced in the LEAs Action Plan (both written in 2010 and never (basic and guaranteed services all over the updated) included HR as a “pillar”; HR was not Country, binding for regional healthcare and supported by drug policies and consequently budgeting); it is necessary to develop and no national HR guidelines had been adopted articulate HR LEAs at regional level, in order to implement them in the most effective and • every Region adopting a HR policy did so in a coherent way in response to actual needs different way with regard to standards

• in a period of continuous cuts to health and social budgets, HR services (which are funded FINAL NATIONAL PLAN by public budget) were the first victims, being inadequately guaranteed notwithstanding their effectiveness Objectives Activities

• drug issues were addressed by policy makers Improved cohesion and effi- Networking and meetings with a self-referential attitude and without the cacy of CS with CS stakeholders involvement of CS Open and establish a political CS as facilitator of the process dialogue on HR with DPA fo- for the constitution of a WG • in early 2014, a shift took place in drug cused on a) Drafting and pub- within the DPA; participation legislation and policy thanks to a wide civil lication of National guidelines in the drafting of the guide- society advocacy movement (the network on HR b)National Observatory lines; CS inclusion in the on Drugs within the DPA re-design and constitution ‘Cartello di Genova’): the punitive law (n.49/06) which is currently under revi- of the National Observatory was abrogated by the High Court; this opened sion; adoption of a specific HR on Drugs ; inclusion of these different perspectives in drug policies approach and dedicated WG goals in the HR campaign Open and establish a political Participation, in some Re- • the Head of DPA (National Drug Agency) dialogue with Regions and the gions, to the definition and was replaced, with a significant, positive National Conference of Re- implementation of HR LEAs; discontinuity with the past gions – Health Commission; subsequent meeting with Articulation and implementa- the Conference of Regions • legislative proposals on decriminalization of tion of regional LEAs on HR to promote good practices use and possession for personal use and on introduced in the “virtuous” Regions cannabis legalization were developed, both New national Action Plan on Seminar between CS and by NGOs and by an Inter-Parliamentary group Drugs; National Conference policy makers on June 14; (300 members) on Drugs organized in the advocacy campaign for a new near future National Conference and a • HR interventions have been included in the new Action Plan on Drugs National AIDS Plan at the end of 2016 as a fundamental pillar of HIV prevention

9 - To collect from stakeholders insight and opinions in the IMPLEMENTATION following areas: - Harm Reduction in Italy Launch of an Mar 28 / - Processes, discussion & online survey on OF THE NAP Apr 28, decision-making contexts the state of Harm 2017 - Priorities in Harm reduction in Italy1 Reduction policies -Dialogue between CS and policy-makers

Participation To discuss future perspectives at Droghe – La for reforming drug policies, from June 26, Traversata del the persisting parliamentary OVERVIEW 2017 Deserto: Seminar deadlock to the political elections in the Senate of 2018 In order to achieve the ambitious objectives of the Parliament2 Italian National Plan the partners, together with - To discuss the steps of the Italian road map - To outline and organize the first the other stakeholders supporting the project, in Partners meeting Sep 21, Italian project event on HR, to be at LILA Milano in 2017 hosted in Naples on Nov 17-18 addition to regularly exchanging via emails, social Milan - To discuss a social media medias and periodic T/Cs, organized and held campaign to relaunch HR policies and the CSI DP project various meetings and events to gather consensus - To receive from the DPA and advocate for the proposed changes. confirmation of their involvement in the achievement of the Partners meeting objectives set in the National Nov 13, The following initiatives took place during the with the DPA Action Plan 2017 officers, Rome - To offer additional information implementation of the plan: and explanations about the CSI DP project

- To launch an advocacy strategy, to relaunch the promotion, Date Event Purpose / Description development and progress of HR Workshop/Event in Italy together with all relevant - To identify stakeholders to be on HR in Naples Italian stakeholders for CS groups: - To share and promote the interviewed Nov 17-18, La Riduzione del objectives of the Italian road map - To discuss the objective of the 2017 Italian National Action Plan Danno Funziona: - To issue a Naples Declaration on (structure or process) Facciamola Harm Reduction policies in Italy - To evaluate the issues which funzionare!3 - To inform and sensitize mass Partners meeting could be most likely addressed media (a Session on media Jan 20, at Forum Droghe, and measured in terms of results communication involved 5 2017 Florence and effectiveness journalists and bloggers) - To consider possible contributions and bonds given by Partners - To discuss the possibility collaborating partners (CNCA and meeting in of involving the Regional DPA) and possible collaboration of Bologna with the representatives on drug issues other stakeholders Feb 8, Coordinator of in the Italian National event for 2018 Regions National promoting the implementation of Conference LEA in all Italian Regions - To illustrate the objectives representatives Partners meeting of the CSI project and ask for on drug issues Mar 22, with the DPA the DPA involvement in the 2017 officers, Rome implementation of the Italian road map / national plan 1 Report: https://rdd.fuoriluogo.it/progetto Partner meeting - To share the objectives of the 2 Program and video registration: https://ungass2016.fuoriluogo.it/2017/06/20/droghe- Mar 23, with CNCA Italian road map / national plan la-traversata-del-deserto 2017 representatives, and seek their involvement 3 Programme: https://rdd.fuoriluogo.it/programma/ Florence Napoli Declaration, press release, audiorecording: https://rdd.fuoriluogo.it/documen- tazione/

10 - Submission to DPA of the CHALLENGES document “Per una ricerca sui consumi di droghe orientate all’innovazione degli approcci e dei sistemi di intervento (CSOs proposal for a “research The main challenge during the implementation Feb, 2018 Proposal to DPA on drugs and drug use aimed at the innovation of policies and of our National Plan was the ‘absence’ of our main interventions”, promoted by CSI- interlocutor, the DPA. There have been changes DP partners and the members of the network ‘Cartello di Genova in DPA staff and leadership since 2016, and the new direction did not demonstrate its availability - To ask for the support of Regione Piemonte in the National in collaborating with CSOs and with the Project, event planned for June differently from the previous one that had ensured Partners meeting - To include a presentation of in Turin with the the Piemonte LEA on HR as best Mar 21, its partnership. We had two meetings with the DPA Representative practice example during the 2018 of Regione event officers and continued to keep them informed and Piemonte - To ask for the support of Regione Piemonte in the involved in our activities, also by inviting them to involvement of representatives of other Italian Regions in the event the two CSI-DP national events of Naples and Turin

Partners meeting - To organize the National event and by sending them the declaration that followed Apr 6, in Bologna at planned for June 14 2018 the trade unions - To define a strategy for the as an outcome of the Naples event. No feedback premises (CGIL) implementation of the LEA was given on the first proposal (a Working Group - To reaffirm the importance of HR services and interventions for the preparation of HR Guidelines, in view of the - To present the LEA on HR inclusion of HR in the LEA): the DPA officers were written by Regione Piemonte as a best practice of dialogue / very cautious about the possibility to issue new National event participation to be followed as an for all Italian example by the other Regions guidelines on drug policies Jun 14, stakeholders: - To ensure a homogeneous (and 2018 La Riduzione hopefully rapid) implementation del Danno è un of the LEA on HR in all Regions As agreed during the second meeting with the Diritto4 - To inform mass media, stakeholders and CSOs on HR, DPA, we presented them a detailed proposal production of the video Harm Reduction, on HR policy and dealing with the second point of our action plan, interventions i.e. the implementation of research on drug

- To assess and evaluate the use patterns and on the impact of drug policies outcome of the Italian event in Partners meeting Jul 17, Turin based on innovative approaches and civil society at Forum Droghe, 2018 To identify next steps for the Florence contribution. We did not receive any feedback to implementation of LEA in all Italian Regions our work.

During the second meeting, we also received some reassurance about the constitution of a renewed National Observatory on Drugs, since we were asking for the adoption of a specific thematic 4 Programme: https://rdd.fuoriluogo.it/torino/ Presentations: https://rdd.fuoriluogo.it/torino/documentazione-lea-e-rdd/ stream on HR and dedicated Working Group. At Audio registration: https://www.radioradicale.it/scheda/544117/lea-la-riduzi- one-del-danno-e-un-diritto-dialoghi-e-proposte-attorno-ai-livelli the end of 2017, an official document announced Communication /Video on Harm reduction: https://rdd.fuoriluogo.it/documentazione/ riduzione-del-danno-un-approccio-una-politica-un-sistema-di-interventi/ the Constitution of an ‘Osservatorio Nazionale

11 Permanente sulle Tossicodipendenze’, which The CS meeting on Harm reduction and CS does not foresee CS representatives with a fixed involvement, which took place in Naples in seat. CS representatives with proven experience November 2017 in collaboration with ITARDD - the will be consulted whenever needed. A procedure Italian HR Network, was a successful event with 100 for the identification of those CS representatives people from all over the country. It strengthened with proven experience shall be established in the CS cohesion and gathered agreement on some future. shared goals. A ‘Naples Declaration’ was discussed and approved at the end of the meeting and was As we had feared at the beginning of the project, circulated to reach all relevant stakeholders the political elections that took place in March 2018 engaged in drug issues in Italy, including the DPA. blocked any changes in the months preceding the elections. The results of the elections had and The final Italian event, which took place in Turin will have a negative impact on Harm Reduction in June 2018, was a big success and had the policies, since a right-wing populist coalition is participation of over 200 stakeholders, both from CS now in place and the Minister in charge of drug and the national/regional institutions. We had also issues has already made declarations about the the participation of one of the key representatives adoption of a ‘zero tolerance’ approach. It is very of EMCDDA, who gave a presentation on the impact likely that the next years will be difficult for the of HR in Europe. implementation of HR strategies and services in The event was dedicated to the promotion and Italy. future implementation of HR LEA and was Given this negative political context, considering organized with the collaboration of Regione that the DPA is a direct emanation of the Piemonte Health Department and the active Presidency of the Council of Ministers, we decided involvement of the National Conference of Regions to strengthen the dialogue with the Regional - Health / Drug Departments, and the coordinators representatives on drug issues, already provided in of some Regional drug policy departments. the action plan; we focused our efforts much more The dialogue with the National Conference on this second streaming, involving Regions in of Regions and Regional representatives is the implementation of the LEA on HR, in order to constructive and promising. At the Torino achieve at least one of our objectives. Conference in June 2018, the national coordinator of the Regions National Conference Health ASSESMENT OF SUCCESS Commission – which includes drug policies and intervention systems – assumed the commitment First of all, the roadmap and National Action Plan of putting on the Commission agenda the succeeded in the objective of bringing CS back implementation of HR LEA in all Regions in the together to discuss common goals for the two year following months. period and establish priorities for HR in Italy. The Conference offered also the opportunity to

12 meet some members of the Health Ministry staff HR to “a system of interventions” (the so called involved in LEA monitoring and evaluation: the “4th pillar”), while other actors have a wider possibility of a cooperation between these MoH perspective (HR as a policy and a paradigm) officials and CSOs is now open. 2. In a HR perspective, Regions are the most The process for the implementation of LEA on HR effective and available interlocutors and has started and the work is in progress. The CSI partners, both for their role and competences project action plan did play an effective role in on drug policies and systems, as well as Italian CSO actions; CSO networks will continue the for being in constant dialogue with local agreed advocacy actions after the project. We hope stakeholders, CSOs and citizens and much to push also for the definition of national guidelines closer to civil society actors – much more than on drug policies, with the regional stakeholders as the national bodies and institutions allies in this instance. 3. The National Drug Agency (DPA) is so deeply, directly interconnected with the Government, that it is extremely exposed to political LEARNING changes. This situation creates discontinuity and is also affected by the elevated turnover 1. CSOs must improve their intention and in management and staff. Such uncertainty capacity of networking and act as a more with regard to DPA interlocutors has so far united body. Some of the difficulties we had not been counterbalanced by the institution in negotiating within the network deal with: of a body foreseeing the participation of a) differences in nature, mission and interests civil society, which could guarantee the of the different organizations involved in HR continuity of political dialogue and exchange, networks (Third sector organizations, PUDs, despite the frequent changes. In general, Drug policy reform associations, trade unions, the DPA does not seem to give attention to HIV organizations, organizations working structured participative processes, even if on prison issues etc.) - the great variety and it demonstrated to be willing to meet and extent of HR networks is a strength but also interface with some CSOs that had requested a critical factor to be considered; b) conflict a meeting. and difficulties in sharing and negotiating leadership in a balanced and democratic way; c) the weak role of PUDs organizations in their role of potential “authoritative” mediators, a weak role when compared to the powerful role of other CS stakeholders, and more in general the difficulties of PUDs in self-organizing; d) different approaches to HR, sometimes limited

13 CONCLUSIONS & RECOMMENDATIONS

The CSI- DP project has highlighted that, in order level and, more in detail, at the DPA level, there is to create an evidence-based and effective drug lack of processes and participative contexts that policy at national, regional and local level, it is include civil society. This is a shortfall that needs important that governments involve civil society be urgently overcome, also to comply with the organisations in policy and decision-making European Action Plan which states that CSOs must processes in the most structured and sustainable take part to decision-making processes concerning way possible (e.g. mandatory inclusion of CSOs and policies and their monitoring and evaluation. their representatives in the inter-ministerial bodies The DPA is a political-scientific agency that has and/or multidisciplinary working groups in the field the scope of providing policy makers with the of drug policy). knowledge and competences needed to evaluate and innovate national policies; therefore, it is In the last 12 months, the implementation of the crucial to establish a proper organism that allows national plan made clear that in Italy civil society the inclusion of civil society. organizations and networks have succeeded in establishing and maintaining productive and Italian civil society will continue to advocate to meaningful relationships at local and regional level, establish a dialogue based on evidence and on the even though with many differences between the evaluation of effectiveness of current drug policies. regions. The establishment of a positive dialogue The project action plan itself had in fact been laid- with the National Conference of Regions / Health out in this direction, with a proposal addressed to Commission and Interregional Drug Group will the DPA to invest in research and its functionality probably facilitate, in the next months, some in the elaboration of adequate and effective drug improvement of the situation also in the regions policies. that currently do not engage CSOs in the discussion of drug policies. The process that will lead to the implementation of LEA (Basic Assistance Levels) on Harm Reduction will surely give a propulsive thrust for the strengthening of the relationships between regional/local institutions and civil society.

At the same time, the implementation of the plan highlighted once again that, at national

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