This essay is part of a series on harm reduction responses to drug use in the MENA and Asian regions—the actors and networks engaged in such activities, the contributions they have made, and the roadblocks they have met. Read more ...
Outreach workers have been the backbone of Malaysia’s Needle and Syringe Exchange Program (NSEP) since its inception in 2006. This essay examines the origins of the NSEP, the role that outreach workers play, the everyday challenges they face in providing services to people who inject drugs (PWID), and the critical importance of supporting their efforts.
The AIDS Epidemic, Harm Reduction, and Malaysia’s NSEP
Malaysia has an estimated 400 HIV infections for every 100,000 people. Although this is lower than the HIV rate in neighboring Cambodia (2,600), Thailand (1,500), and Myanmar (1,200), it nonetheless remains a matter of serious concern.
In the context of HIV and AIDS, harm reduction is primarily aimed at reducing the rate of HIV infections among drug users (IDUs). The central focus of harm reduction is to alleviate drug use’s negative consequences for individuals, groups, and communities. Roe has characterized harm reduction as a “technology of agency” that empowers individuals and communities to acquire the knowledge and the means necessary to overcome addiction problems.
Malaysia’s NSEP is a service model based on the philosophy of harm reduction whereby drug users can obtain hypodermic needles and other equipment free of charge in an effort to reduce the risk of HIV and hepatitis infection. Ideally, these needles and syringes should be returned in exchange for new ones. In providing this service, the Malaysian government has established drop-in centers that provide needle exchanges, counseling, light treatment, meals, and rest places for PWID.
NSEP Outreach Workers: Who They Are and the Challenges They Face
Successful implementation of the NSEP relies heavily on the passion, commitment, and skills of the staff working to provide direct services to drug users. There are two cohorts of NSEP outreach workers. One consists of former PWID, including some who were on a methadone program, while the other, much larger cohort’s members have never used drugs. The rationale for having two cohorts is mainly to provide re-employment opportunities to former PWID, fostering their reintegration into society and thereby helping them resume a normal life.
Many workers are graduates of social work programs and other related social science fields. The aim of hiring graduates from social work backgrounds is to enhance the quality of services since these graduates already possess the skills, knowledge, and positive values to work with various segments of the population.
Recruiting staff for the NSEP has always been difficult due to the social stigma associated with drug use. There are concerns that the PWID recruited by the program might resume injecting drugs or be induced by others to sell drugs, or that they might lack the work ethic or discipline needed to perform their duties. NSEP employers also worry that recent graduates might regard outreach work as a temporary job (until they can secure a better one elsewhere) and that they might not get along with former PWID, many of whom are much older. Furthermore, there are no universal standards for recruiting outreach workers. Some agencies, for example, see former drug users as especially attuned to the needs and concerns of the target community and thus well-equipped to serve as NSEP outreach workers. Other agencies, however, prefer to recruit non-drug users, whom they consider positive role models for PWID.
Outreach workers face an array of challenges in performing their work that, directly or indirectly, diminish the quality of NSEP services:
- Burnout: High stress levels caused by working with PWID, coupled with heavy workloads, contribute to “burnout.” So, too, does frustration resulting from inadequate resources, low wages, lack of public support, and pressing personal issues.
- Budget Cuts: When NSEPs were first introduced, outreach workers were able to furnish the complete range of services identified by the Ministry of Health (MOH). Unfortunately, subsequent budget cuts have undermined the quality of services provided. At one site, almost 70 percent of outreach workers were laid off. As a result of this drastic staff reduction, outreach workers were no longer able to make frequent visits to the ports (i.e., places where PWID inject drugs). In addition, clients now must specifically request or purchase supplies (such as condoms) that had previously been made available to them through the NSEP at no cost.
- Lack of Supervision: Supervision and management play an important role in implementation of the NSEP. Each of the three sites examined for this study has its own managers who provide supervision and organize day-to-day activities. However, some outreach workers have experienced little supervision because their managers are busy fulfilling other responsibilities.
- Lack of Supplies: Some outreach workers consulted for this study claimed that they were no longer permitted to conduct voluntary counseling and testing interventions, even though they had been trained by Ministry of Health officers to provide this service. They said that this service had been popular among clients, who had perceived it as user friendly. These workers reported that some clients preferred to be counseled by outreach workers as opposed to health officers in government hospitals or clinics.
- Inadequate Training: Effective and quality outreach work can only be achieved when workers are sufficiently trained to provide up-to-date services. When the NSEP began there seemed to be plenty of training for outreach workers. However, since the budget cutbacks, key organizations such as the Malaysian AIDS Council, the MOH, and even the police appear to be providing less training.
- Impediments Related to Provision of Information and Referrals (I&R): Outreach workers sometimes refer clients to the MOH for methadone maintenance therapy (MMT, a form of drug replacement therapy), or to other government agencies for related services. However, some clients decide not to enter an MMT program when they are forced to wait or endure other inconveniences, and MMT providers have often lost clients when unable to adapt to their personal circumstances.
- Police Interference with Service Provision: Police continue to interfere with the work of service providers. NSEP clients have complained that they sometimes are arrested for carrying needles or condoms, or for being at their ports. Often outreach workers are accused of being spies for the police. After police interfere, it can be often difficult for outreach workers to rebuild the trust they had established with the PWID. Some clients are lost due to arrests, and others may move away from the NSEP coverage area.
- Sub-optimal Location of Services: Ideally, NSEP and MMT sites would be located close to clients’ homes, yet PWIDs often have to travel quite far in order to receive services that they need. Many PWIDs are unemployed and are not financially independent, so they have to rely on their family members to access MMT and NSEP services that are not located in their community.
- Inadequate Public Awareness of Harm Reduction: Many members of the public, including families of PWIDs, neither fully understand nor support the NSEP and MMT programs. Instead of being regarded as valuable members of the community, outreach workers are often perceived as people who promote drug use. Therefore, they are often stigmatized.
Arguably the biggest challenge for outreach workers is uncertainty as to whether the NSEP will survive in the coming years. Many of them have seen their colleagues laid off. They not only fear the loss of their jobs but question the rationale for cutting staff when it is apparent that an increasing number of young people are using drugs. Their concerns are well-justified.
In order to enhance outreach services to PWIDs, Malaysia’s NSEP must be sustained and indeed strengthened. Closing down certain sites and reducing the number of outreach workers will only exacerbate social and medical problems endured by the PWIDs. On the contrary, Malaysia must build the NSEP’s capacity (i.e., provide better training and supervision for outreach workers); increase funding; foster cooperation among the stakeholders (especially the MOH and Agensi Anti Dadah Kebangsaan); raise public awareness about the benefits of harm reduction policies; and recognize the contributions of the outreach workers who have been implementing this valuable program.
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 R. Hughes, “Drugs, Prisons and Harm Reduction,” Journal of Health and Social Policy 18, 2 (2008): 43-54; P. Denning, Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions (New York: Guilford Press, 2000).
 S.F.A. Hamid, W.S. Hui, N. Omar, S. Sulaiman, N. Mohd, and N.S.A.F. Zan, “Management Accounting and Its Relevance in Harm Reduction Programmes: A Case of Needle Syringe Exchange Programme,” 2012; D. McVinney and A. Hamid, “Substance Using Men with HIV Concerns: An Integrated Group Approach from a Harm Reduction Perspective,” Social Work with Groups 24, 3 (2008): 2-24.
 G. Roe, “Harm Reduction as Paradigm: Is Better than Bad Good Enough? The Origins of Harm Reduction,” Critical Public Health 15, 3 (2005): 243-250.
 N. Sarnon, I. Baba, and Z.A. Hatta, "Program Pertukaran Jarum dan Picagari (NSEP): Cabaran Mengurangkan Tingkahlaku Berisiko Pengguna Dadah Secara Suntikan (IDU),” e-BANGI: Jurnal Sains Sosial dan Kemanusiaan 2, 2 (2007): 16.
 G.V. Stimson, L. Alldritt, K. Dolan, and M. Donoghoe, “Syringe Exchange Schemes for Drug Users in England and Scotland,” British Medical Journal (Clinical research ed.) 296, 6638 (1988): 1717.
 The research that informs this analysis consists of in-depth face-to-face interviews with 16 outreach workers currently involved in three NSEP sites in the northern peninsular Malaysian states of Penang, Perak, and Kedah and three focus group discussions in those states with several groups of stakeholders (mainly police, health workers, social workers, and PWID family members).
 K.M. Broome, D.K. Knight, J.R. Edwards, and P.M. Flynn, “Leadership, Burnout, and Job Satisfaction in Outpatient Drug-Free Treatment Programs,” Journal of Substance Abuse Treatment 37, 2 (2009): 160-170; L.J. Ducharme, H.K. Knudsen, and P.M. Roman, “Emotional Exhaustion and Turnover Intention in Human Service Occupations: The Protective Role of Co-Worker Support,” Sociological Spectrum 28, 1 (2008): 81-104; and T. McNulty, C. Oser, J.A. Johnson, H. Knudsen, and P. Roman, “Counselor Turnover in Substance Abuse Treatment Centers: An Organizational-Level Analysis,” Sociological Inquiry 77, 2 (2007): 166-193.
 UNODC (United Nations Office on Drugs and Crime, Regional Office for South Asia) Drop In Centre for Injecting Drug Users, “Standard Operating Procedure Drop In Centre for Injecting Drug User,” 2012.
 NASCOP (The National AIDS and STIs Control Programme), “Standard Operating Procedure (SOP) for Needle and Syringe Exchange Programmes (NSEP) for People Who Inject Drugs (PWID),” 2013; NASCOP/MOPHS, “Kenya National Guidelines for HIV Prevention and Management of People Who Use Drugs (PWUD),” February 2013; UNODC, “Standard Operating Procedure Drop In Centre for Injecting Drug User;” F. Ibrahim, “Needle Syringe Exchange Program in Malaysia,” Journal, Agency Anti Dadah Kebangsaan (AADK), 2007, 2-3.
 Sarnon, Baba, and Hatta, “Program Pertukaran Jarum dan Picagari (NSEP).”
 Malaysian AIDS Council (MAC) & Malaysian AIDS Foundation (MAF), 2011, .
 H.E. Jones et al., “Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure,” New England Journal of Medicine 363, 24 (2010): 2320-2331; R.P. Mattick, C. Breen, J. Kimber, and M. Davoli, “Methadone Maintenance Therapy Versus No Opioid Replacement Therapy for Opioid Dependence,” Cochrane Database System Rev (2009): 3.
 P. Singh, “Readiness To Accept the Needle and Syringe Exchange Programme (NSEP) in Penang among the Rank and File Police,” 2012.
 S. Narayanan, B. Vicknasingam, and N.M.H. Robson, “The Transition to Harm Reduction: Understanding the Role of Non-governmental Organizations in Malaysia,” International Journal of Drug Policy 22, 4 (2011): 311-317; N. Salina et al., “Psychosocial Reactions of Injecting Drug Users (IDU) towards Needle Syringe Exchange Program in Malaysia,” 2011.
 The Agensi Anti Dadah Kebangsaan (AADK), or National Anti-Drug Agency, which was established in 1996, is the coordinator for the National Drug Council (MDK), chaired by the Minister of the Interior and is responsible for all elements of Malaysia’s anti-drug activities.