A commercial look at addiction treatment centers; in conversation with Abbas Shakeri, economist / Matin Mostafaei.
“Addiction and Its Treatment” has been a major issue in the healthcare system of many countries in recent years. Considering the extensive and long-term activities of treatment and rehabilitation centers for addicts in Iran, and the various issues that have arisen in addiction recovery camps during these years, the performance of these centers has been largely questioned.
36 people died at the “First Step to Freedom” addiction recovery camp in Langroud, once again highlighting the lack of supervision and management in these mostly private centers. Questions have been raised about the government’s policies towards addicted individuals and how these centers are run. To further examine this issue and answer the questions raised, we have spoken with Dr. Abbas Shakery Hosseinabad, an economist and member of the faculty of economics at Allameh Tabataba’i University. It should be noted that Dr. Shakery was recognized as an exemplary professor by the Ministry of Science, Research and Technology in 2020.
In light of recent events, can it be inferred that transferring the responsibility of medical and treatment services to the private sector requires proper reconsideration?
In economics, the emphasis is on the fact that governments should not intervene in business affairs and it is expected that they allow the private sector to take charge, while the government only monitors the proper flow of affairs. In advanced societies, any action that goes against this is seen as a violation of the free market approach and a form of government monopolization.
If we want to evaluate and investigate the behavior of healthcare services in the private sector of the country, we encounter components that show the essential need for transferring the responsibility of medical and healthcare services to the people. Despite the fact that the executive management of the country has delegated a part of medical and healthcare services to the private sector for decades and the private sector has been active in this field for many years, fundamental economic disruptions can be observed in these centers, which in some cases easily violate people’s rights and public interests, and it is difficult to speak out about it in terms of the sacred profession of medicine. Nevertheless, there has been a widespread deviation from implementing basic regulations and principles in these healthcare centers, and supervisory officials consider themselves unable to monitor and protect the financial rights of patients.
In advanced systems, many economic and social sectors are privatized, but when it comes to privatizing the healthcare sector, it is done with more caution and governments ensure a healthy and competitive environment for the benefit of the nation by closely monitoring it and minimizing evasion of laws.
The executive management of the country is responsible for providing a comprehensive and complete monitoring and enforcement framework, and to allow all relevant stakeholders to be involved in the implementation phase with their support. It should not allow hospitals and medical centers to compete with the commercial economy, where human lives are treated as commodities. Otherwise, we will witness injustice and immorality in this sector, which will have a negative impact not only on the medical community, but also on the social and moral fabric of society as a whole.
Is cost-benefit analysis detrimental to the issue of addiction treatment?
Today, more than eight thousand outpatient and residential centers for addiction treatment have been established in the country, mostly by private and non-governmental sectors, with a very small percentage being government-run centers. Since drug use is considered a crime in Iran and addicts face restrictions and punishments, the private sector has been able to attract a relatively large number of patients who are unable to seek treatment at government centers and remove them from the illegal drug market. However, this number of treatment centers does not necessarily mean adequate coverage for addiction treatment in the country, and it seems that a significant portion of drug users are unable to benefit from this opportunity due to their mostly social circumstances.
In many marginalized and underprivileged areas, private sector naturally has no incentive to establish addiction treatment centers, despite the responsibility of medical universities and the Welfare Organization (as responsible for residential centers) to provide services. Many socially vulnerable drug users, who are in advanced stages of addiction and have physical, mental, and social consequences, are deprived of government support for treatment and rehabilitation, and at the same time, they do not have the means to pay for treatment in private or even government centers.
Bureaucracy in the healthcare system, through inflexible treatment protocols that compensate for government absence in this field, has also led to many patients not being able to find appropriate treatment for their needs in private centers. Ultimately, this approach medicalizes the phenomenon of addiction and reduces it to a medical condition, ignoring the other consequences of addiction, drug use, and social harms, and thus the most vulnerable patients are unable to enter or stay in an effective treatment program.
This has in turn led to the presence of socially vulnerable substance users who have been deprived of medical and support services, becoming so prominent in public spaces that other groups take advantage of it and portray it as a failure of addiction treatment. They resort to ineffective and costly methods of the past decades, such as repeatedly collecting and detaining these individuals, which has become the most significant threat to addiction treatment in the country.
Is the problem with addiction treatment camps related to their implementation and supervision, or is it rooted in their structure and organization?
Although laws regarding addiction and social harms have been drafted and amended several times, the weakness in legislation in this area is still evident. However, in recent years, after multiple amendments to the laws, we have had regulations that have attempted to improve the performance of services and reduce the criminalization of addiction, and move towards treatment. This is so that we can eventually move towards rehabilitation and empowerment.
In the field of addiction, the country’s division of labor has been carried out within the framework of the “Drug Control Headquarters”. This headquarters is responsible for coordinating various organizations and institutions in the fight against addiction and operates directly under the supervision of the presidency. Although this headquarters has attempted to have a scientific approach at times and has even collaborated with international organizations in many areas, it has not been able to reach an effective model in the field of treatment and rehabilitation. Initially, the responsibility for addiction treatment was under the Ministry of Health, but later it was transferred to the Welfare Organization.
In this framework, the Welfare Organization developed a regulation in 91 regarding addiction treatment camps, which specified how treatment centers for addicted individuals should be managed. Protocols were established for different types of centers, including medium-term residential centers; centers that, according to the definition, are for individuals who voluntarily seek treatment and should never be forced to stay in compulsory centers.
In 1394, this regulation was amended and its overall quality improved. In the first version of the regulation (before the amendment), the focus was on treatment – meaning detoxification of patients. This meant that individuals who were abusing and addicted to a specific drug were primarily treated through medication at these detox centers in order to become clean. However, in the next version of the regulation (along with the amendment), there is a more progressive approach which states that in addition to detoxification and treatment, rehabilitation must also be considered and efforts must be made to prevent relapse. Unfortunately, in practice, this executive regulation was not implemented and its progressive approach was not put into action.
The most likely reason that prevents the implementation of such approaches is the privatization of public services. In fact, these regulations have predicted that the management of medical centers and camps will be outsourced to the private sector. Since the logic of the private sector is profit-driven and based on market rules, public services are not a priority for them. Therefore, when important areas such as education, healthcare, or social services are outsourced, the private sector tries to reduce its costs as much as possible in order to gain more benefits. This reduction in costs in these camps means a decrease in the number of necessary personnel and a decrease in facilities and amenities such as safe housing, safety equipment, proper nutrition, etc. As a result, although these regulations focus on treatment and rehabilitation from a scientific perspective, when their implementation is entrusted to the private sector, which is seeking more profit and does not have proper accountability, the predicted standards in the regulations are not actually followed.
How successful has the performance of addiction treatment centers in Iran been overall?
The importance of performance evaluation in any profession these days is a sign of its liveliness and dynamism, and is a criterion for the development of that job and profession, both in terms of quality and quantity.
Health is the beating heart of every society and a necessary component for the development of any community. As health has become more complex and specialized, the evaluation of performance in this sector will be of utmost importance. The evaluation of performance in addiction treatment centers, considering their nature and the effectiveness and efficiency they bring to the healthcare system, will also be of great significance. The 9-chapter, 42-article regulations for establishing methadone maintenance treatment (MMT) centers are guidelines that will serve as the starting point for evaluating the performance of these centers from their inception to their gradual development.
According to unofficial statistics, there are approximately three million addicts living in the country, of which around seven hundred thousand have found their way to treatment centers known as “MMT”. These centers, which number around eight thousand, are responsible for serving this population. The mission of all these centers is to provide the highest quality health care services for the complete treatment of the patient, in order to return them to society and continue their happy life. However, according to findings and reports, some of these centers – which may not be very noticeable in number – have strayed from their mission and gradually turned into profit-driven businesses, with the sole goal of destroying the cycle of treatment for addicted patients and tarnishing the reputation of wise and knowledgeable healers in society. This is when the voice of the country’s health economy sometimes speaks out, stating that more than one trillion tomans of financial transactions in these centers go to waste, and no real addiction recovery takes place. Everyone agrees that the current processes have not
On the other hand, many addiction treatment centers provide high-quality services due to the professional commitment and conscientiousness of their staff, which not many people are aware of, nor do they know that such quality is not accompanied by any financial benefits compared to their low-quality counterparts. Of course, if a proper evaluation is carried out based on scientific and global standards and in accordance with local requirements, and is executed accurately and without any bias, it will undoubtedly serve as a competitive indicator of the acquired rank for each center and a potential and actual potential for creating competition among similar centers in terms of introducing and providing true information about the performance of such centers.
Thank you for the opportunity you have given us.
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