Audit of Substance Abuse Treatment Facilities in ... - SA HealthInfo

Alcohol & Drug Abuse Research UnitMedical Research CouncilAudit of Substance AbuseTreatment Facilities in Free State,Limpopo, Mpumalanga, NorthWest and Northern Cape(2007-2008):Technical ReportNuraan Fakier & Bronwyn MyersAlcohol and Drug Abuse Research UnitMedical Research Council (MRC)December 2008

TABLE OF CONTENTSEXECUTIVE SUMMARY..…………………………………………………………...7PART 1: BACKGROUND……………………………………………………..…101.1 The need for substance abuse treatment.…….…………………...101.2 The value of substance abuse treatment....………………………..101.3 Substance abuse treatment services in South Africa.…..………...111.3.1 Limited availability of services in relation to need…………121.3.2 Racial inequities in access to health and social services……131.3.3 Factors associated with disparities in access to substanceabuse treatment……………………………………………….141.4 Substance abuse treatment in South Africa: Prior research andthe way forward…………………………………………………….161.5 Terminology…………………………………………………………18PART 2:METHOD………………………………………………………..……...202.1 Aims…………………………………………………………………202.2 Objectives…………………………………………………………...202.3 Design………………………………………………………………..212.4 Sample……………………………………………………………….212.5 Treatment Services Audit (TSA) Questionnaire………………….222.6 Data collection………………………………………………………232.7 Data analysis………………………………………………………..242.8 Data considerations………………………………………………...242.8.1 Response rates………………………………………………..242.8.2 Quality assurance and item non-response………………….242.8.3 Further data considerations and limitations……………….25PART 3:KEY RESULTS.…………….………………..………………………..263.1 Characteristics of substance abuse treatment facilities inFree State, Limpopo, Mpumalanga, North West and NorthernCape……………………………………...........................................263.1.1 Treatment facility profile by intensity of care……………...262

3.1.2 Treatment facility profile by facility ownership…...……….273.1.3 Treatment facility profile by state affiliation...……………..283.1.4 Treatment facility profile by intensity of care and facilityownership……………………………………………………...283.2 Profile of clients served by substance abuse treatment facilitiesin Free State, Limpopo, Mpumalanga, North West and NorthernCape …………………………………...............................................303.2.1 Demographic profile of clients at treatment facilities inFree State, Limpopo, Mpumalanga, North West andNorthern Cape ………………………………........................303.3 Treatment capacity and service utilisation……………………….343.3.1 Average number of clients treated per month in Free State,Limpopo, Mpumalanga, North West and Northern Cape...343.3.2 Treatment capacity at substance abuse treatmentfacilities……………………………………………………….353.3.3 Substance abuse treatment occupancy rates………………353.3.4 Waiting period for treatment services at substance abusefacilities in Free State, Limpopo, Mpumalanga, NorthWest and Northern Cape.…………………..........................353.3.5 Rates of client retention in treatment………………………363.4 Staff and staff-related issues………………………………………363.4.1 Characteristics of staff at substance abuse treatmentfacilities……………………………………………………….373.4.2 Staff participation in professional developmentactivities…..…………………….…………………………….383.4.3 Resources to support staff development at treatmentfacilities………………………………………………………393.5 Organisational environment and management practices………403.5.1 Management practices at treatment facilities……………..403.6 Profile of services provided by substance abuse treatmentfacilities……………………………………………………………..423.6.1 Profile of treatment services offered…………………….....433

3.6.2 Provision of assessment services……………………………443.6.3 Substance abuse counselling services………………………443.6.4 Provision of family services…………………………………463.6.5 Provision of health and medical services…………………...473.7 Addressing barriers to treatment entry for vulnerable groups…493.7.1 Practices that improve awareness of substance abusetreatment options……………………………………………493.7.2 Practices that address logistical and affordability barriersto treatment entry……………………………………………523.7.3 Practices that address cultural and linguistic barriers totreatment entry………………………………………………533.8 Addressing barriers to engagement and retention in treatmentfor vulnerable groups………………………………………………543.8.1 Cultural and linguistic sensitivity and appropriatenessof treatment…………………………………………………..543.8.2 Gender sensitivity and appropriateness of treatment……..553.8.3 Age appropriateness of treatment services…………………573.9 Monitoring and evaluation activities for substance abusetreatment facilities………………………………………………….593.9.1 Monitoring of clients’ progress during the course oftreatment……………………………………………………..603.9.2 Monitoring of clients’ progress post-treatment…………….613.9.3 Formal treatment programme evaluation………………….63PART 4:DISCUSSION OF KEY FINDINGS ………………………………....654.1 Availability of substance abuse treatment services……………...654.1.1 Availability of treatment services…………………………...654.1.2 Utilisation of and demand for available treatment slots…..654.1.3 Effective use of available treatment slots…………………..664.2 Range and diversity of services provided………………………..664.2.1 Provision of ancillary mental health services……………...674.2.2 Provision of ancillary health services………………………684

4.3 Targeting barriers to treatment entry, engagement andretention for clients from underserved groups………………….694.3.1 The extent to which services are accessible tounderserved groups…………………………………………694.3.2 Access to treatment: Targeting barriers to treatmententry…………………………………………………………..71Awareness-related barriers to treatment entry………………..71Logistic and affordability barriers to treatment entry………...71Cultural and linguistic barriers to treatment entry……………734.3.3 Targeting barriers to treatment retention: Theappropriateness of services………………………………….74Cultural and linguistic appropriateness of services …………..74Gender appropriateness of services …………………………..75Age appropriate services ……………………………………...764.4 Monitoring and evaluation in substance abuse treatmentfacilities……………………………………………………………..764.5 Recommendations…………………………………………………78To improve the availability and utilisation of substance abusetreatment facilities ..………………………………………………78Availability of treatment services ………………………………….78Improving treatment capacity…………………………………….…79To improve the diversity of services and range of servicesprovided through increasing access to ancillary health andmental health services…………………………………………….79Unmet mental health needs…………………………………………79Unmet medical needs………………………………………………..80Case management ………………………………………………….80To address barriers to treatment entry for underservedgroups ……………………………………………………………..81Logistic and affordability barriers ………………………………...81Awareness barriers ………………………………………………..81Cultural and linguistic barriers …………………………………...815

Improving the cultural, gender and age appropriateness ofservices…………………………………………………………….82Cultural and linguistic appropriateness of services ……….……..82Gender appropriateness of services ………………………………82Age appropriateness of services…………………………………...82To improve treatment service planning and delivery throughresearch and monitoring and evaluation activities..……………83National audit……………………………………………………...83National prevalence study of substance use disorders and unmettreatment need……………………………………………….…….83Monitoring and evaluation ……………………………………….84REFERENCES………………………………………………………………………856

EXECUTIVE SUMMARYA cross-sectional audit of substance abuse treatment facilities in Free State, Limpopo,Mpumalanga, North West and Northern Cape was conducted from October 2007 toFebruary 2008. A revised version of the Treatment Services Audit (TSA) Questionnairewas used to collect information from a number of domains including the organisationalcharacteristics of the treatment facility (such as ownership status, intensity of careprovided, and organisational resources); the type of services provided; the profile ofclients served; the organisational environment of facilities, barriers to treatment entry forclients from underserved groups; the cultural, gender, and age appropriateness ofservices, and monitoring and evaluation activities.Substance abuse treatment services in Free State, Limpopo, Mpumalanga, North Westand Northern Cape are provided predominantly by private, non-profit facilities. Privatenon-profit facilities also serve the highest number of clients from underserved groups.Consequently, it is recommended that state funding to these facilities be increased.Furthermore, despite a high demand for substance abuse treatment services, treatmentfacilities are under-utilised. It is thus recommended that interventions which target thefactors underpinning this under-utilisation of services are designed and implemented.The range of treatment services provided by substance abuse treatment facilities in FreeState, Limpopo, Mpumalanga, North West and Northern Cape is limited, with fewfacilities providing comprehensive services that integrate ancillary medical and mentalhealth services with core addiction services. This audit found that facilities are morelikely to conduct medical assessments than provide clients with substitution medicationand/or detoxification services. Case management techniques may help facilitate thedelivery of integrated and comprehensive services so that clients have access to ancillarymedical and mental health services.In addition, findings suggest that Black/African and female substance abusers remainunder-represented in substance abuse treatment facilities. In terms of activities that targetbarriers to treatment entry for historically underserved population groups; while a7

significant proportion of facilities perform outreach activities aimed at improvingawareness of treatment options, there is still room for improvement.In terms of logistic and affordability barriers, many facilities report providing financialassistance for the direct costs of treatment in terms of reduced fees; however, reducedfees are often unaffordable to indigent clients. This raises a concern about theavailability of affordable treatment options to poorer communities. In addition, fewfacilities address the indirect costs associated with treatment entry, such as the costs oftransport and childcare services. Recommendations are made to address logistic barriers.These include shifting from facility-based outpatient service provision to the use ofmobile clinics located in disadvantaged, high-need areas. This will also help address thecosts of transport to facility-based services.In terms of linguistic barriers to treatment entry, the majority of facilities reportemploying multilingual staff and African language-speaking therapists. This study foundthat although all facilities report providing treatment programmes in multiple languages,a smaller proportion of facilities provide counselling that is culturally-appropriate and useculturally-appropriate assessment tools. This potentially inhibits Black/African personsfrom being retained in treatment.In terms of the appropriateness of treatment services, findings point to the need fortreatment facilities to receive ongoing training in order to ensure that their treatmentprogrammes are culturally, gender and age appropriate. Several recommendations aremade to increase the cultural, gender and age appropriateness of services.Findings point to the need for substance abuse treatment facilities in these provinces tointroduce routine, systematic client monitoring systems as well as the need for substanceabuse treatment programmes to be comprehensively evaluated. In addition, as part of themonitoring of the quality of substance abuse treatment services and the extent to whichthese services have transformed to address historical inequities in service provision, anational treatment audit should be conducted on a regular basis. Findings from thisnational audit should be used to inform decision-making about the allocation of fundingand other resources to existing facilities, based on the extent to which they provide8

services to historically underserved groups as well as the degree to which they providecomprehensive services of good quality.9

PART 1:BACKGROUND1.1. THE NEED FOR SUBSTANCE ABUSE TREATMENTIn South Africa, changes in the pattern of substance use over time highlight the need foraccessible treatment services. During the apartheid era, the country’s physical andeconomic isolation, strict monitoring of external borders, and stringent internal controlsrestricted access to and availability of most kinds of illicit drugs, with locally cultivatedcannabis, Mandrax tablets, and prescription drugs being the only drugs widely availableto South Africans. However, changes in global drug markets, such as improved drugsupply- and demand-reduction strategies in Europe and the USA, have forced traffickersto seek alternative routes and markets. South Africa, due to its geographical location, is aconvenient trans-shipment point for illicit drugs from drug-producing countries to drugmarkets. Socio-political changes that followed the collapse of apartheid, such as thereduction in internal and external border controls, the increase in land and air travel,increased trade, and the poorly resourced law enforcement agencies; together with thecountry’s advanced banking, transport, and communication systems have also made thecountry an attractive new market for drug cartels. With these changes South Africansnow have access to a broad range of illicit drugs (Parry et al., 2002a). Supply anddemand indicators suggest that the domestic drug market is expanding, with drug pricesdecreasing, availability increasing, and treatment demand for substance-related problemson the rise (Parry et al., 2002a/b). This expansion of the domestic drug market has placedsubstance abuse treatment facilities under increased pressure to provide effective andaccessible treatment services.1.2. THE VALUE OF SUBSTANCE ABUSE TREATMENTYet, there is strong evidence that substance abuse treatment helps reduce the harmsassociated with substance abuse and benefits both the individual and broader society.Although few treatment outcome studies have been conducted in South Africa,international research, conducted across a variety of treatment settings and clientpopulations, has provided considerable evidence of the benefits of substance abusetreatment (e.g. Gossop, Marsden, Stewart & Teacy, 2001; Simpson, Joe & Brown, 1997).In general, these studies reported positive outcomes, including reductions in substance10

use, reductions in criminal activity, improvements in physical and psychological health,and improvements in social functioning.In developing countries in general (Arif & Westermeyer, 1998), and South Africa inparticular, few treatment outcome studies have been conducted. Despite methodologicallimitations (such as low follow-up rates), preliminary evidence points to the benefits ofsubstance abuse treatment in these settings. For example, De Silva, Peris, Samarasinghe andEllawala (1992) reported that 36% of 234 patients attending a treatment centre in SriLanka were abstinent two years post-treatment. In addition, significant reductions insubstance use were reported among patients in treatment centres in Thailand, with 50% ofpatients abstinent from amphetamine-type substances and 27% abstinent from opiates 6months post treatment (Perngpam & Porncharoen, 2001). Only two substance abusetreatment outcome studies have been conducted in South Africa. Coetzee (2001) reportedan abstinence rate of 55% among 58 patients attending an outpatient substance abusetreatment centre in 2000. In the second study of 89 patients attending a private inpatientfacility, Coetzee (2004) reported an abstinence rate of 48% one year post-treatment. Thisemerging evidence points to the potential value of substance abuse treatment services inSouth Africa.1.3. SUBSTANCE ABUSE TREATMENT SERVICES IN SOUTH AFRICAAnecdotal reports from treatment service providers and communities point to anincreased demand for substance abuse treatment services, with waiting lists for treatmentslots increasing and communities mobilising around drug-related issues. This increaseddemand has placed treatment facilities under pressure to increase their coverage andprovision of services to a greater number of users. Despite this pressure, little is knownabout the structure and functioning of the substance abuse treatment system in thecountry. This study attempts to address this gap in knowledge by examining substanceabuse treatment services in the Free State, Limpopo, Mpumalanga, North West andNorthern Cape.Free State is the fourth largest province in South Africa (Statistics South Africa, 2006a)and constitutes about seven per cent of the population of South Africa (Statistics SouthAfrica, 1998a). In line with the national pattern, Black/Africans 1 form the largest11

population group (84%) in the Free State, followed by Whites (13%) while Colouredsand Asians/Indians constitute less than three per cent of the population of the Free State(Statistics South Africa, 1998a). Limpopo has a similar racial composition to the FreeState. Limpopo is one of the least urbanised provinces as the majority of its populationlive in non-urban areas (Statistics South Africa, 2006b). The majority of Limpopo’spopulation is Black/African, accounting for 97.2% of its population, which is the highestpercentage for a province in the country (Statistics South Africa, 2006b). Limpopo hasthe lowest percentage of other population groups, namely White (2.4%), Coloured (0.2%)and Asian/Indian (0.2%) (Pauw, 2005). Similarly, the population of Mpumalanga consistspredominantly of Black/Africans, accounting for 92% of its total population in 2001,followed by Whites (6.5%), Coloureds (0.7%) and Indians/Asians (0.4%) (StatisticsSouth Africa, 2006c). Less than half of the total population of Mpumalanga lives in urbanareas. In 1995, Statistics South Africa estimated that North West was the sixth mostpopulated province (Statistics South Africa, 1998b). The vast majority of the populationin North West is Black/African (90%), fewer than one in ten is White (8%) and theremainder consists of Coloured (1%) and Indian (0.3%) (Statistics South Africa, 1998b).Similar to Mpumalanga, less than half of the population in North West lives in urbanareas. North West, Free State, Limpopo and Mpumalanga have similar racialcompositions; however, the population distribution in Northern Cape is not typical ofSouth Africa as a whole. The majority of the population in Northern Cape is Coloured(54%) followed by the Black/African population (30%) and Whites (16%) (StatisticsSouth Africa, 1998c). This is contrary to the population distribution picture observable inall the other provinces (except Western Cape) and nationally, where Black/Africans arethe majority. Northern Cape is the largest province but had the smallest population inboth the 1996 and 2001 censuses (Statistics South Africa, 1998c). More than 80% of thetotal population in Northern Cape lived in urban areas in 2001 (Statistics South Africa,2006d).1.3.1. Limited availability of services in relation to needAccess to substance abuse treatment remains limited in these provinces, partly due to thelimited availability of treatment services.12

Despite high levels of substance abuse in these provinces, substance abuse has beenafforded relatively low priority. In general, provincial departments of SocialDevelopment have focused their resources on prevention, early intervention and statutoryactivities rather than the provision of treatment services. At present, there is only onestate-run treatment facility for substance abuse in Free State and one in Mpumalanga.Although there are other treatment facilities in these provinces that are subsidised by thestate, funding to these facilities remains problematic. In addition, the number of bedsavailable in state-funded general and psychiatric hospitals for patients with substance usedisorders has decreased in these provinces. These factors have contributed to longwaiting periods for affordable treatment slots at state-funded facilities. These waitingperiods may have a negative impact on motivation to change, treatment retention andtreatment outcomes (Mejita & Bokos, 1997).1.3.2. Racial inequities in access to health and social servicesWhile the limited availability of substance abuse treatment restricts access to treatmentfor all South Africans, substance abuse treatment seems to be relatively more difficult toaccess for poor Black/African and Coloured South Africans historically disadvantagedduring the apartheid regime. For these racially defined social groups, several sociopoliticalfactors restricted access to services (including substance abuse treatmentservices) under the apartheid system of governance. Firstly, funding to substance abusetreatment facilities was generally inadequate and treatment facilities were poorlydistributed, with services being concentrated in urban areas that were historicallyreserved for Whites. Major disparities also existed between the racially-defined socialgroups in terms of the allocation of resources to and the quality of substance abusetreatment services, with treatment facilities serving White South Africans being relativelybetter resourced and providing more comprehensive services than those facilities servingBlack 1 South Africans (Myers, 2004; Myers & Parry, 2005).Since South Africa’s transition to democracy in 1994, the health and social service sectorhas worked hard to improve service delivery and reverse racial disparities in serviceprovision (National Department of Health, 1997; National Department of Social1 The term “Black South African” refers to all groups who were historically disadvantaged under theapartheid regime including ethnic Black/African, Coloureds of mixed race descent and Indian/Asians.13

Development, 1997; 2006). Despite this, concerns about disparities in health and socialwelfare service provision between the socially advantaged and the socially disadvantagedremain; with socio-economic disadvantage still associated with race in South Africa -despite a growing Black middle class (Sanders & Chopra, 2006). Given these inequities,it is plausible that similar racial inequities exist in the substance abuse treatment sector.To some extent, these concerns seem justified. According to recent findings from theSouth African Community Epidemiology Network on Alcohol and Drug Abuse(SACENDU) (Myers, 2004; Myers & Parry, 2005) and audits of specialist substanceabuse treatment facilities in Cape Town (Myers & Parry, 2003) and Gauteng andKwaZulu-Natal (Myers & Fakier, 2007), the race profile of clients at specialist treatmentfacilities does not reflect the demographics of the general population. Throughout thecountry, there has been an under-representation of Black and an over-representation ofWhite South Africans in treatment facilities. This pattern of service utilisation reflectsthe limited extent to which Black South Africans have access to substance abusetreatment rather than lower levels of substance use by these racially-defined social groups(Myers, 2004; Myers & Parry, 2005; Myers & Fakier, 2007) and highlights theimportance of routinely examining service system factors associated with access tosubstance abuse treatment.1.3.3. Factors associated with disparities in access to substance abuse treatment• Availability of public servicesDebate about the accessibility of services for historically disadvantaged groups hascentred on structural and environmental factors that restrict access to services forBlack South Africans. More specifically, concerns have been raised about the limitedavailability of affordable substance abuse treatment facilities. In South Africa, themajority of the population (80%) are without medical insurance and rely heavily on thestate sector to provide health and social welfare services (Goosen, Bowley, Degiannis, &Plani, 2003) including substance abuse treatment. As with other services, the uninsuredare disproportionately represented by poor, Black South Africans (Goosen et al., 2003).For this sector of the population, there are few state-funded substance abuse treatmentfacilities and access to these facilities is hampered by lengthy waiting lists of up to sixmonths (Myers, 2004; Myers & Parry, 2003).14

Despite the apparent availability of substance abuse treatment services in each province,for the uninsured the availability of affordable substance abuse treatment has decreased inrecent years, with the number of beds allocated for substance abuse in state hospitalsdecreasing. For the remaining state-subsidised treatment facilities, state funding hasdecreased in real terms, limiting their capacity to expand services to historicallyunderserved areas (Myers & Parry, 2003; Myers & Parry, 2005). This has been partly dueto the diversion of funds from tertiary level substance abuse treatment services to primaryhealth (National Department of Health, 1997) and community-based social services(National Department of Social Development, 1997). While the policy of integratingsubstance abuse services into existing primary health care (PHC) networks has been anattempt to improve the accessibility (and equitable distribution) of health and socialservices for historically underserved communities, in reality implementation has beenslow with few substance abuse treatment services being offered at a community level(Myers & Parry, 2005). Poor infrastructure, limited capacity, and multiple demandsplaced on PHC nurses and community-based social workers have been some of thereasons given for the slow pace of service delivery (Goosen et al., 2003; Sanders &Chopra, 2006). Whatever the reasons, an unintended consequence of these policy changeshas been that access to substance abuse treatment has become even more restricted forpoor South Africans.• Availability of private servicesThe shortage of publicly funded substance abuse treatment centres, together with theincreased demand for substance abuse treatment, has given rise to a growing privatetreatment sector. Compared to the state treatment system, the private for-profittreatment sector has relatively more resources, shorter waiting lists, more evidence-basedtreatment programmes, more experienced staff, and provides relatively better treatmentenvironments (Myers & Parry, 2003; Myers, 2004). Although these facilities fill animportant gap in the market, they have been criticised for serving mostly Whitecommunities (given that they are largely unaffordable to the uninsured and that Whitesmay have wealthier social networks that can be drawn upon to co-fund treatment), havinglimited skills for dealing with the socio-cultural and language context of historically15

disadvantaged communities, and for being located in suburban areas and thus beinginaccessible to the majority of the population (Myers & Parry, 2005).There has also been a proliferation of private, non-profit treatment facilities. Althoughmany of these are professionally run accredited facilities with solid treatmentprogrammes, in recent years several facilities have been started by well-meaningcommunity members with little knowledge of how to treat substance abuse and fewresources. Often these community-based facilities operate illegally and are unregulatedby the state. Although private non-profit facilities are relatively more accessible to BlackSouth Africans than for-profit services, the quality of services provided by these facilitiesis often variable and waiting lists at the better-resourced facilities are lengthy. Inaddition, many of the accredited non-profit facilities require clients to make some form offinancial contribution towards their treatment (Myers, 2004). Quality of services, waitinglists, and co-payment fees all restrict access to treatment for poor substance users.1.4. SUBSTANCE ABUSE TREATMENT IN SOUTH AFRICA: PRIORRESEARCH AND THE WAY FORWARDIn South Africa, national, provincial, and local governments control the allocation ofresources for substance abuse services. For the state to plan and deliver substance abusetreatment services that ensure appropriate and adequate provision of services to thecommunity (through addressing current and projected treatment needs, targeting high-riskgroups, and improving accessibility for all sectors of the population), access to qualityinformation about local treatment needs, existing treatment services, patterns of serviceutilisation, and service performance are required. This necessitates the development of asystem for monitoring substance abuse treatment services (Grant & Petrie, 2001).Yet, treatment service planning is hampered in South Africa by the lack of a monitoringsystem that routinely collects information on substance abuse treatment services. Whilethe South African Community Epidemiology Network on Drug Use (SACENDU) projectdoes collect descriptive information about the profile of clients served at treatmentcentres in all nine provinces in the country on a six-monthly basis and although thissystem provides essential information that should be collected as part of a nationalmonitoring system; it does not collect information on the type, intensity or quality of16

treatment services provided. At present, only limited information is collected on thefacilities that provide substance abuse treatment services. This information, typicallycontained in resource directories, generally consists of a brief description of the types ofclients served and services provided.Exceptions to this include two local-level audits of specialist substance abuse treatmentfacilities in Cape Town and Gauteng, conducted in 2002 and 2004, respectively (Myers &Parry, 2003; Myers, 2004). These audits reported on treatment facility characteristics, theprofile of clients served, the type and range of treatment services provided, theaccessibility of treatment services to clients from historically underserved groups, andtreatment service monitoring and evaluation processes. In addition, these auditsrecommended that a national audit of substance abuse treatment facilities occur on aregular basis to facilitate the collection of quality information on substance abusetreatment services (Myers & Parry, 2003; Myers, 2004). In 2007, an attempt was made toaddress this gap by auditing all known substance abuse treatment facilities in Gautengand KwaZulu-Natal provinces (Myers & Fakier, 2007). This report represents anotherattempt to provide missing information on current treatment services in the followingprovinces: Free State, Limpopo, Mpumalanga, North West and the Northern Cape. Assuch, the current project represents a partial response to earlier recommendations andgoes some way towards developing a national monitoring system of substance abusetreatment services.In a context where there is an increasing demand for scarce health and social welfareresources due to the burden caused by poverty, TB, HIV/AIDS and other infectiousdiseases (Freeman, 2000), a study that describes the structure of the substance abusetreatment system, describes the extent to which this system adheres to norms andstandards for treatment, and provides evidence as to whether barriers to accessingexisting services exist within this system is useful. Through identifying gaps in currentservice delivery, this study could help guide the design of policies to improve servicedelivery and could also assist planning and decision-making around substance abusetreatment services by suggesting ways in which treatment service delivery can beimproved (Thind & Andersen, 2003).17

The nature of scientific inquiry also requires generalisability and applicability of researchfindings across widely diverse population groups. Although previous audits of treatmentservices have been conducted (Myers & Parry, 2003; Myers, 2004), these audits did notallow for comparisons to be made across provinces. However, the audit in 2007 (Myers& Fakier, 2007) compared Gauteng and KwaZulu-Natal provinces. The current studyallows for comparisons to be made across five provinces in the country. Thiscomparative research allows for similarities and differences across sites to be identifiedso that interventions can be targeted to specific sites (in this case: provincial treatmentsystems). This approach recognises that the structuring of substance abuse treatmentsystems will be influenced by contextual and environmental factors inherent to eachprovince.1.5. TERMINOLOGYThe following terms are used throughout this report:• Facility ownership refers to the type of entity owning or responsible for theoperation of the facility. In South Africa, private for-profit, private non-profit,and state (government) facilities comprise the main types of ownership. The statealso provides funding for several private, non-profit facilities.• Treatment setting refers to the environment in which a facility is located. InSouth Africa these include mental health settings such as psychiatric hospitals,general health settings, stand-alone substance abuse treatment facilities,correctional (criminal justice) settings, religious settings, and welfare settings.• Intensity of treatment is defined as the amount of and level at which treatmentservices are provided. In South Africa, substance abuse treatment occurs at one ofseveral intensity levels: primary care at an inpatient/residential level, outpatient,secondary inpatient care, and stepped down care that combines inpatient andoutpatient services.♦ Inpatient/Residential Treatment: where clients reside temporarily or on a longer-termbasis in a facility that is not their home or usual place of residence. The treatmentprogramme provides diagnosis, treatment and rehabilitation for clients with substance18

use disorders whose physical and emotional status does not allow them to function intheir usual environments.♦ Outpatient Treatment refers to non-residential programmes that provide diagnosis,treatment and rehabilitation for clients with substance use disorders whose physicaland emotional status allows them to function with support in their usualenvironments. Compared to inpatient programmes, services are provided at a lowerlevel of intensity.♦ Secondary inpatient treatment refers to a residential treatment facility for alcohol anddrug abuse clients who have received prior treatment in a primary care programme. Atreatment regimen of individual and group therapy as well as other activities aimed atthe physical, psychological and social recovery of the addicted individual iscontinued. The programme offered at these facilities is of a lower intensity than thatprovided at the initial (primary) inpatient facility. Often these are referred to ashalfway houses.♦ Combined inpatient and outpatient services: Also referred to as stepped-down care.All clients initially receive inpatient services. Having completed the residentialprogramme, clients move to a lower level of care - outpatient services - to ensure thatthe client is smoothly reintegrated back into society and to provide aftercare supportand follow-up.• Facility affiliation refers to the type of state registration that a facility has obtained.In South Africa, substance abuse treatment facilities can be registered with either theDepartment of Health or the Department of Social Development; with some facilitieshaving dual registration. Each department has different requirements for registration,a discussion of which is beyond the scope of this report.• Retention refers to the extent to which clients remain in treatment and complete thetreatment programme.• Attrition refers to the extent to which clients leave or drop out of treatment before theagreed upon date for treatment completion.19

PART 2:METHOD2.1. AIMS• To gain an understanding of the characteristics of substance abuse treatment facilitiesin Free State, Limpopo, Mpumalanga, North West and Northern Cape;• To gain an understanding of the profile of clients served by substance abuse treatmentfacilities in Free State, Limpopo, Mpumalanga, North West and Northern Cape;• To increase knowledge about the nature of substance abuse treatment service deliveryin Free State, Limpopo, Mpumalanga, North West and Northern Cape;• To increase knowledge about the accessibility of substance abuse treatment in FreeState, Limpopo, Mpumalanga, North West and Northern Cape;• To compare five provincial substance abuse treatment systems: Free State, Limpopo,Mpumalanga, North West and Northern Cape;• To serve as a feasibility study for the development and implementation of an annual,national audit of substance abuse treatment services;• To use this information to inform current substance abuse treatment service planningand delivery at the local, provincial and national level;• To use this information to inform substance abuse treatment policy at a provincial andnational level2.2. OBJECTIVES• To describe and compare the characteristics of substance abuse treatment facilities inFree State, Limpopo, Mpumalanga, North West and Northern Cape (e.g. intensity ofcare offered, type of facility ownership, treatment setting, and facility affiliation);• To describe and compare the demographic profile of clients served at substance abusetreatment facilities in Free State, Limpopo, Mpumalanga, North West and NorthernCape by facility characteristics (intensity of care and type of facility ownership);• To describe and compare substance abuse treatment service delivery for treatmentfacilities in Free State, Limpopo, Mpumalanga, North West and Northern Cape on anumber of variables, namely: facility characteristics; treatment factors (number ofclients served, treatment capacity, utilisation of treatment capacity, delay in service20

delivery, treatment retention, and treatment attrition), staffing characteristics, andtreatment services offered;• To describe and compare activities conducted by substance abuse treatment facilitiesin Free State, Limpopo, Mpumalanga, North West and Northern Cape that targetbarriers to accessing treatment for clients from underserved groups by facilitycharacteristics;• To describe and compare activities conducted by substance abuse treatment facilitiesin Free State, Limpopo, Mpumalanga, North West and Northern Cape to improvetreatment retention for clients from underserved groups by facility characteristics;• To describe and compare monitoring and evaluation activities conducted by substanceabuse treatment facilities in Free State, Limpopo, Mpumalanga, North West andNorthern Cape by facility characteristics;• Based on these findings, to describe the extent to which these facilities meet SouthAfrican minimum norms and standards for treatment services as well as internationalbest practice guidelines;• To make recommendations that inform substance abuse treatment service policy,planning and delivery in Free State, Limpopo, Mpumalanga, North West andNorthern Cape;• To disseminate the information collected, through a variety of mechanisms to local,provincial and national stakeholders.2.3. DESIGNA cross-sectional survey of substance abuse treatment facilities was conducted in the FreeState, Limpopo, Mpumalanga, North West and Northern Cape provinces, South Africafrom October 2007 to February 2008.2.4. SAMPLEThe sample consisted of the total population of substance abuse treatment facilities inFree State, Limpopo, Mpumalanga, North West and Northern Cape. This study definedsubstance abuse treatment facilities as those facilities that deliver one or more specialisedsubstance abuse treatment services to people with substance use disorders (Torres et al.,1995). These services include detoxification, rehabilitation programmes and21

psychological treatments. Using this definition, self-help groups and facilities thatprovide only information, education, crisis intervention, aftercare and/or preventionservices are not classified as substance abuse treatment facilities. In addition, solopractitioners and facilities that provide general health and social services, includingsubstance abuse-related services (e.g. psychologists, social workers, and generalhospitals) are not included in the sample. As the Treatment Services Audit Questionnaire(TSA) is designed to collect data from each physical location where treatment servicesare provided, a “facility” is defined as the point of delivery of substance abuse treatmentservices (i.e. the physical location).The sample frame was constructed from the list of known treatment facilities madeavailable by the Central Drug Authority (CDA) resource directory on alcohol and drugrelated services (CDA, 2003) and the SACENDU database of treatment facilities.Snowball sampling was used to expand upon these databases. In other words, thesefacilities were contacted telephonically and asked to identify other specialist substanceabuse treatment facilities in Free State, Limpopo, Mpumalanga, North West and NorthernCape that were not in the CDA’s resource directory. At the time of the audit, there were6 facilities in Free State, 2 in Limpopo, 4 in Mpumalanga, 1 in North West and 4facilities in Northern Cape that satisfied the criteria used by this study for the definitionof “substance abuse treatment facility”.2.5. TREATMENT SERVICES AUDIT (TSA) QUESTIONNAIREThe Treatment Services Audit (TSA) Questionnaire (revised version) was used to collectself-report information from substance abuse treatment facilities in Free State, Limpopo,Mpumalanga, North West and Northern Cape. The TSA was designed for the purposesof auditing substance abuse treatment facilities in South Africa. The construction of theoriginal TSA was based loosely on the Unified Facility Data Set Questionnaire (UFDS)(Carise, McLellan, & Gifford, 2000) that has been used to collect one-day censusinformation on the population of substance abuse treatment facilities in the USA. Thequestions contained in the original version of the TSA were discussed in focus groups ofsubstance abuse treatment experts to ensure applicability to the South African context. Apilot version of the original TSA was then used at two treatment facilities in Cape Townand necessary changes were made to problematic items. The original TSA was used to22

audit substance abuse treatment facilities in Cape Town in 2002 (Myers & Parry, 2003).Subsequent to this, the TSA was revised to reflect South African minimum norms andstandards for inpatient treatment centres. This revised version was used to audittreatment facilities in Gauteng in 2003 as well as Gauteng and KwaZulu-Natal in2006/2007.In order to minimise non-response and to include areas of emerging interest (such asquestions about service delivery); several adjustments have been made to the revisedversion of the TSA. These changes included additional questions about the organisationand work environment that relate to human resources and governing body procedures,additional questions about the types of treatment services offered (especially substanceabuse counselling, medical and family services).The TSA (revised version) is a six-page questionnaire with 41 questions, many of whichrequire multiple responses. Information is collected from a number of domains includingtreatment facility characteristics, service delivery characteristics, types of treatmentservices offered, services to improve access to and retention in treatment, characteristicsof clients served, staffing characteristics, organisational environment, and monitoring andevaluation activities. The TSA is directed at key informants from treatment programmes,such as clinical/treatment programme managers or treatment directors. The TSA collectsself-report information in English and takes approximately 30 minutes to complete.2.6. DATA COLLECTIONThe field period ran from October 2007 to February 2008. Treatment programmemanagers and/or facility directors of all the treatment facilities in the sampling framewere contacted telephonically, informed about the study, and asked to participate. Datacollection packets, including the TSA, a two-page guideline for completion of the TSA,and a covering letter explaining the purpose of the audit, were sent via post, fax, or emailto the identified key informants at participating facilities in October 2007. Questionnairepacks were mailed with self-addressed, stamped return envelopes. During the datacollection phase, the principal investigator was available to answer facilities’ questionsabout the audit. Telephone calls were made to all facilities to check whether they hadreceived the TSA. Thereafter, reminder and follow-up telephone calls were made to all23

non-responding facilities. Follow-up calls to non-responding facilities and for correctionof missing data continued through February 2008. Non-respondents were followed uptelephonically on at least four occasions.2.7. DATA ANALYSISStatistics for this study were computed using the Statistical Package for the SocialSciences (Norusis/SPSS Inc., 2005). Descriptive statistics were calculated for alltreatment service-, service delivery-, client-, staff-, and access-oriented variables. Wherepossible, facilities were stratified by province.2.8. DATA CONSIDERATIONS2.8.1. Response ratesQuestionnaires were sent to 17 facilities in Free State, Limpopo, Mpumalanga, NorthWest and Northern Cape believed to offer substance abuse treatment services. Of thesefacilities, 5.9% (1) was found to be ineligible for the survey as they did not meet thecriteria for inclusion and a further 11.8% (2) had closed down. Through snowballing, 3(17.6%) new centres were identified that fit the criteria for inclusion in the study. In total,17 facilities were eligible for participation in the study, of which 14 facilities (82.4%)returned the TSA questionnaire. The final sample (N = 14) included 6 facilities in FreeState, 2 in Limpopo, 3 in Mpumalanga, 1 in North West and 2 in Northern Cape. Despitenumerous attempts over a 6 month period in contacting and offering assistance with thequestionnaire, one facility, surrounded by controversy, indicated that the TSA was “toodifficult to complete”. Concrete feedback in terms of difficulties with specific questionswas not forthcoming. Flexible dates for return of the TSA were maintained in order toencourage participation in the audit and accommodate the schedules of individualscompleting the TSA.2.8.2. Quality assurance and item non-responseAll questionnaires were reviewed for inconsistencies and missing data. Telephone callswere made to facilities to obtain missing data and to clarify unclear responses. Carefulediting and extensive follow-up greatly reduced item non-response.24

2.8.3. Further data considerations and limitationsCertain procedural considerations and data limitations must be taken into account wheninterpreting data from this audit:• This audit attempted to obtain responses from all known treatment facilities in FreeState, Limpopo, Mpumalanga, North West and Northern Cape. It is; however, avoluntary survey and no adjustment was made for facilities that did not respond.• This audit provides information on the substance abuse treatment system and itsclients for the specified reference period only (i.e. the 12 months preceding the audit).Client counts reported here are estimated counts only and do not represent annualtotals.• The TSA collects data about treatment facilities and not about individual clients.Data on clients represent an aggregate of clients in treatment for each participatingfacility.• Multiple responses were allowed for certain variables (e.g. type of services provided).• The TSA collects self-report data from key informants at participating facilities.Social desirability processes and political concerns about ways in which findings willbe used may have influenced facility responses on specific items. The TSA (revisedversion) incorporates a number of validity checks. For example, several differentlyworded questions are used to examine client retention rates.25

PART 3: KEY RESULTS3.1. CHARACTERISTICS OF SUBSTANCE ABUSE TREATMENTFACILITIES IN FREE STATE, LIMPOPO, MPUMALANGA, NORTHWEST AND NORTHERN CAPETreatment services research has shown that the organisational features of treatmentfacilities impact on the types of services available and the quality of services provided toclients (Lee et al., 2001). The following section describes a number of organisationalfeatures including intensity of treatment provided, ownership status, and facilityaffiliation.3.1.1. Treatment facility profile by intensity of careCore findings:• 37.5% of facilities in Free State, Limpopo, Mpumalanga, North West andNorthern Cape provide primarily inpatient treatment services• 87.5% of facilities in Free State, Limpopo, Mpumalanga, North West andNorthern Cape offer mainly outpatient treatment servicesSubstance abuse treatment facilities in South Africa provide services at different levels ofintensity. These include inpatient / residential treatment and outpatient programmes.There are no inpatient programmes in Northern Cape and Limpopo (Figure 1). Overall,the majority of facilities in the various provinces provide outpatient services (Figure 2).26

Figure 1. Inpatient intensity of care by province (%).0%24%Free StateLimpopo0%Mpumalanga57%North West19%Northern CapeFigure 2. Outpatient intensity of care by province (%).22%19%Free StateLimpopoMpumalanga22%22%North WestNorthern Cape15%3.1.2. Treatment facility profile by facility ownershipCore findings:• 85.7% of facilities are privately owned• Of the privately-owned facilities, 100.0% have non-profit status• 14.3% of facilities are state owned – 1 in Free State and 1 in Mpumalanga27

Facility ownership (understood in terms of profit status and public / private orientation)has been shown to impact on access to substance abuse treatment (Lee et al., 2001). Mostof the facilities (85.7%) that participated in this study are privately owned. Of the 12privately owned facilities, 100.0% have non-profit ownership status. There are no forprofitfacilities located in these provinces. The remaining 2 facilities (14.3%) are stateownedfacilities – 1 in Free State and the other in Mpumalanga. The majority of nonprofitfacilities are located in Free State (Figure 3).Figure 3. Non-profit status by province (%).403535.73025201514.3 14.314.3107.150Free State Limpopo Mpumalanga North West Northern Cape3.1.3. Treatment facility profile by state affiliationCore findings:• The majority of facilities are registered with the Department of Social Development• Overall, only 14.3% of facilities are not registeredOverall, 85.7% (12) of the treatment facilities are registered with the Department ofSocial Development (DoSD) and 14.3% (2) are not registered. Both unregistered facilitiesare in the Free State.3.1.4. Treatment facility profile by intensity of care and facility ownershipCore findings:• Overall, the majority of facilities are private non-profit facilities providing outpatienttreatment28

Since there is a large overlap between the intensity of care provided and ownership status,a new variable was created that combined these individual variables. The majority(64.3%; 9) are private, non-profit facilities offering outpatient services, 7.1% (1) areprivate, non-profit facilities providing inpatient treatment, 14.3% (2) are private nonprofitfacilities providing inpatient and outpatient services, 7.1% (1) are state outpatientfacilities and 7.1% (1) are state inpatient facilities (Figure 4).Figure 4. Intensity of care and ownership for the total sample (%).7%7%Non-profit outpatient14%Non-profit inpatientNon-profit in and outpatient7%65%State inpatientState outpatientOrganisational characteristics (combined ownership and intensity of care) were comparedacross provinces (Table 1). In Free State, private non-profit outpatient services accountfor the highest proportion of facilities.29

Table 1. Facility ownership and intensity of care by province.Facility ownership Free State Limpopo Mpumalanga North West Northern Cape/Intensity of careN % N % N % N % N %Private non-profit 3 50.0 2 100.0 2 66.7 -- -- 2 100.0outpatientPrivate non-profit 1 16.7 -- -- -- -- -- -- -- --inpatientPrivate non-profit 1 16.7 -- -- -- -- 1 100.0 -- --inpatient &outpatientState outpatient 1 16.7 -- -- -- -- -- -- -- --State inpatient -- -- -- -- 1 33.3 -- -- -- --Total 6 100.0 2 100.0 3 100.0 1 100.0 2 100.03.2. PROFILE OF CLIENTS SERVED BY SUBSTANCE ABUSETREATMENT FACILITIES IN FREE STATE, LIMPOPO,MPUMALANGA, NORTH WEST AND NORTHERN CAPEThis section describes the demographic profile of the clients served, in the 12 monthsprior to the audit, by substance abuse treatment facilities in Free State, Limpopo,Mpumalanga, North West and Northern Cape.3.2.1. Demographic profile of clients at treatment facilities in Free State, Limpopo,Mpumalanga, North West and Northern CapeCore findings:• Treatment facilities provide services to more males than females• Compared to other age cohorts, clients treated at substance abuse treatment facilities aremost likely to be between 20 and 29 years of age• Black/African clients are underrepresented and White clients are overrepresented atsubstance abuse treatment facilities in all participating provinces – except Northern CapeFor the overall sample, the estimated proportion of male clients ranges from 20.0% to100.0% of the total client population (χ = 72.1, SD = 18.7). In contrast, the estimatedproportion of female clients ranges from 0.0% to 80.0% (χ = 27.9, SD = 18.7) (Table 2).In terms of race, the estimated proportion of White clients ranges from 3.0% to 70.0% of30

the total client population (χ = 43.3, SD = 18.9) followed by the estimated proportion ofBlack/African clients ranging from 0.0% to 70.0% (χ = 34.3, SD = 20.2). Overall, clientstreated at substance abuse treatment facilities were most likely to be between 20 and 29years of age (χ = 35.6, SD = 17.3).Table 2. Demographic profile of clients at substance abuse treatment facilities.Free State(N = 7)Limpopo(N = 2)Mpumalanga(N = 3)North West(N = 2)NorthernCapeOverall(N = 16)(N = 2)χ SD χ SD χ SD χ SD χ SD χ SD% of clients by genderMales 70.1 27.2 71.0 12.7 75.9 8.7 71.0 0 75.5 20.5 72.1 18.7Females 29.9 27.2 29.0 12.7 24.1 8.7 29.0 0 24.5 20.5 27.9 18.7% of clients by age

Figure 5.Comparison of race profile of clients at treatment facilities with censusdata (1995 3 ) for Free State (%).90808470605040302010050.631.717.5132.70.2 0Black/African White Coloured Asian/IndianIn treatmentCensus3 Statistics South Africa (1998a)Figure 6.Comparison of race profile of clients at treatment facilities with censusdata (2006 4 ) for Limpopo (%).12010097.380604048442002.4 4.5 3.50.2 0.2Black/African White Coloured Asian/IndianIn treatmentCensus4 Statistics South Africa (2006b)32

Figure 7.Comparison of race profile of clients at treatment facilities with censusdata (2001 5 ) for Mpumalanga (%).1009092.48070605048.5 46.64030201006.53.70.7 1.2 0.4Black/African White Coloured Asian/IndianIn treatmentCensus5 Statistics South Africa (2006c)Figure 8.Comparison of race profile of clients at treatment facilities with censusdata (1995 6 ) for North West (%).1009091.4807060504940302010031146.761.6 0.3Black/African White Coloured Asian/IndianIn treatmentCensus6 Statistics South Africa (1998b)33

Figure 9.Comparison of race profile of clients at treatment facilities with censusdata (1997 6 ) for Northern Cape (%).90808170605450403020100301611.56.51 0Black/African White Coloured Asian/IndianIn treatmentCensus7 Statistics South Africa (1998c)3.3. TREATMENT CAPACITY AND SERVICE UTILISATIONThis section describes the number of clients treated in a typical month, treatmentcapacity, and the extent to which capacity is utilised.Core findings:• Facilities in Mpumalanga treat a greater number of clients and have more treatment capacity thanfacilities in other provinces• North West and Limpopo have the highest treatment occupancy rates• North West has the highest proportion of clients that complete treatment – 78.0%3.3.1. Average number of clients treated per month in Free State, Limpopo,Mpumalanga, North West and Northern CapeOverall, the typical number of clients receiving substance abuse treatment per month overthe past year ranges from 6 to 721 (χ = 105.4, SD = 172.9). Of these facilities, 18.8%treat less than 20 clients per month, with the majority of facilities (38.0%) treating morethan 50 clients per month.When provincial data are considered separately, the typical number of clients receivingsubstance abuse services per month in Free State ranges from 6 to 165 (χ = 69.0, SD =64.2). In Limpopo, the typical number of clients receiving substance abuse treatment34

services per month ranges from 13 to 50 (χ = 32.0, SD = 26.2). In Mpumalanga, thetypical number of clients receiving substance abuse treatment services per month rangesfrom 33 to 721 (χ = 268.0, SD = 392.4). In North West, the typical number of clientsreceiving substance abuse treatment services per month is 33 (χ = 33.0, SD = 0.0). Finallyin Northern Cape, the typical number of clients receiving substance abuse treatmentservices per month ranges from 96 to 175 (χ = 136.0, SD = 55.9).3.3.2. Treatment capacity at substance abuse treatment facilitiesIn this study, treatment capacity refers to the number of treatment slots available to treatclients. For the overall sample, annual treatment capacity ranges from 10 to 862 slots (χ= 225.2, SD = 243.5). When provincial data are considered separately, annual treatmentcapacity ranges from 10 to 120 slots in Free State (χ = 62.6, SD = 43.2); from 48 to 105slots in Limpopo (χ = 76.5, SD = 40.3); from 180 to 862 slots in Mpumalanga (χ = 479.0,SD = 348.7); and 450 slots in both North West and Northern Cape (χ = 450.0, SD = 0.0).3.3.3. Substance abuse treatment occupancy ratesFor the overall sample, the average proportion of occupied treatment slots ranges from12.0% to 100.0% (χ = 69.4, SD = 27.8). North West has the highest average proportion ofoccupied treatment slots, 97.0% (χ = 97.0, SD = 0.0) (Table 4).Table 4. Proportion of treatment slots occupied by province (%).Province Min. Max. χ SDFree State 12 100 67.4 28.0Limpopo 90 90 90.0 0.0Mpumalanga 25 60 38.3 18.9North West 97 97 97.0 0.0Northern Cape 80 80 80.0 0.03.3.4. Waiting period for treatment services at substance abuse facilities in FreeState, Limpopo, Mpumalanga, North West and Northern CapeFor the overall sample, 46.7% (7) facilities use a waiting list when full to capacity (1facility did not provide a response). When waiting lists were examined by province, inFree State, 42.9% (3) of facilities use a waiting list; 50.0% (1) in Limpopo; 33.3% (1) in35

Mpumalanga; and 100.0% (2) in North West. None of the facilities in the Northern Cape(1 no response) use a waiting list.For the overall sample, the number of individuals currently on the waiting list rangesfrom 4 to 8 (χ = 5.7, SD = 2.0). For individuals on the waiting list, the wait for atreatment slot / bed ranges from 1 to 21 days (χ = 6.4, SD = 6.5).3.3.5. Rates of client retention in treatmentFor the overall sample, the estimated client retention rate ranges from 30.0% to 93.0% (χ= 70.2, SD = 17.9). When provincial data are considered separately, North West has thehighest proportion of clients that complete the treatment programme, namely 78.0% (χ =78.0, SD = 0.0) (Table 5).Table 5. Client retention rates by province (%).Province Min. Max. χ SDFree State 60 93 74.6 15.0Limpopo 60 75 67.5 10.6Mpumalanga 30 90 60.0 42.4North West 78 78 78.0 0.0Northern Cape 50 50 50.0 0.03.4. STAFF AND STAFF-RELATED ISSUESThis section describes the characteristics of staff employed by substance abuse treatmentfacilities in Free State, Limpopo, Mpumalanga, North West and Northern Cape. Thisincludes a description of staff qualifications, professional development activities, andstaff-related resources.Core findings:• Facilities in North West and Mpumalanga had the highest mean number of clinical staff (full-time)compared to facilities in other provinces• Facilities in Free State and North West did not have non-professional full-time staff• Facilities in Free State and North West were more likely to have access to and employ doctors andnurses than facilities in other provinces36

3.4.1. Characteristics of staff at substance abuse treatment facilitiesVariations in the mean number of staff by staffing category for the overall sample and byprovince are presented in Table 6. For the overall sample, the number of full-timeprofessional staff (i.e. staff responsible for treatment services) ranges from 0 to 20 people(χ = 5.4, SD = 5.2) and the total number of non-professional full-time staff (such assupport staff, administrators and cleaning staff) ranges from 0 to 11 (χ = 2.5, SD = 3.8).In addition to full-time staff, many facilities employ sessional professionals on a parttimebasis. For the overall sample, the number of part-time staff per facility ranges from0 to 10 (χ = 2.9, SD = 3.4).Table 6. Mean number of staff per staffing category.Staff category Free State(N = 7)Limpopo(N = 2)Mpumalanga(N = 3)North West(N = 2)Northern Cape(N = 2)Overall(N = 16)χ SD χ SD χ SD χ SD χ SD χ SDProfessional (full-time) 3.7 3.1 1.5 0.7 10.0 8.7 11.0 0.0 3.0 1.4 5.4 5.2Non-professional 0.0 0.0 0.5 0.7 3.5 0.7 0.0 0.0 0.5 0.7 2.5 3.8(full-time)Part-time staff 5.3 4.0 0.0 0.0 1.3 0.6 2.0 0.0 0.5 0.7 2.9 3.4The total number of full-time professional staff ranges from 0 to 8 (χ = 3.7, SD = 3.1) inFree State; from 1 to 2 (χ = 1.5, SD = 0.7) in Limpopo; from 4 to 20 (χ = 10.0, SD = 8.7)in Mpumalanga; 11 (χ = 11.0, SD = 0.0) in North West; and from 2 to 4 (χ = 3.0, SD =1.4) in Northern Cape. The number of non-professional full-time staff per facility rangesfrom 0 to 1 (χ = 0.5, SD = 0.7) in Limpopo; from 3 to 4 (χ = 3.5, SD = 0.7) inMpumalanga; and from 0 to 1 (χ = 0.5, SD = 0.7) in Northern Cape. Facilities in FreeState and North West do not employ non-professional staff on a full-time basis. Thenumber of part-time staff per facility ranges from 0 to 10 (χ = 5.3, SD = 4.0) in FreeState; from 1 to 2 (χ = 1.3, SD = 0.6) in Mpumalanga; 2 (χ = 2.0, SD = 0.0) in NorthWest; and from 0 to 1 (χ = 0.5, SD = 0.7) in Northern Cape. Facilities in Limpopo do notemploy part-time staff.Table 7 presents the mean number of staff per staffing category for the overall sampleand by province. Few facilities employ professional staff, such as psychologists andpsychiatrists. Facilities in Free State and North West are more likely to have access to37

and employ doctors and nurses than facilities in other provinces. Mpumalanga has thehighest mean number of support / addiction counsellors (χ = 5.3, SD = 8.4) employed atfacilities.Table 7. Mean number of staff per staffing category.Staff categories Free State(N = 7)Limpopo(N = 2)Mpumalanga(N = 3)North West(N = 2)Northern Cape(N = 2)Overall(N = 16)χ SD χ SD χ SD χ SD χ SD χ SDPsychologists 1.2 1.5 0.0 0.0 0.7 0.6 1.0 0.0 0.0 0.0 0.7 1.0Social workers 1.9 2.2 1.0 0.0 2.7 0.6 3.0 0.0 1.5 0.7 2.0 1.5Social auxillary 0.0 0.0 0.0 0.0 0.3 0.6 2.0 0.0 1.5 0.7 0.5 0.8workersSupport/addiction 1.0 1.4 0.0 0.0 5.3 8.4 1.0 0.0 1.0 1.4 1.7 3.7counsellorsOccupational 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0therapistsRegistered nurses 2.0 2.2 0.5 0.7 1.7 0.6 4.0 0.0 0.0 0.0 1.8 1.8Auxillary nurses 0.0 0.0 0.0 0.0 0.0 0.0 1.0 0.0 0.0 0.0 0.1 0.3Religious0.3 0.5 0.0 0.0 0.3 0.6 0.0 0.0 0.0 0.0 0.2 0.4consultantsDoctors 1.0 1.0 0.0 0.0 0.7 0.6 1.0 0.0 0.0 0.0 0.7 0.8Psychiatrists 0.4 0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.4Administrators 1.0 0.6 0.5 0.7 1.7 2.1 0.0 0.0 0.5 0.7 0.9 1.0Note. Numbers include full-time and part-time staff.3.4.2. Staff participation in professional development activitiesCore findings:• A high proportion of facilities provide treatment staff with continuous professionaldevelopment training• Few facilities provide staff with external supervisionFigure 10 reflects treatment facility staff participation in professional developmentactivities for the overall sample, and separately by province. A high proportion offacilities report that treatment staff participates in continuous professional development(CPD) activities, receive ongoing training in substance abuse, and receive internal38

supervision. In contrast, a much smaller proportion of facilities provide treatment staffwith external supervision, which does not take place at all in Limpopo and Mpumalanga.Figure 10.120Extent to which facility staff participate in professional development activities(%).10086100 100 100100 100 100 100 100 100 100 100888688948060505050 5040272014000Internal supervision External supervision CPD activities Ongoing training in substanceabuseFree State Limpopo Mpumalanga North West Northern Cape Overall3.4.3. Resources to support staff development at treatment facilitiesCore findings:• Overall, less than 30.0% of facilities provide staff with access to a substance abuse library orresource centre• A high proportion of facilities provide staff with computers and internet accessFigure 11 reflects the extent to which facilities provide resources to facilitate staffdevelopment for the overall sample, and separately by province. A high proportion offacilities report providing computers for staff use and internet access to staff (Figure 11).A smaller proportion of facilities provided a substance abuse-related resource centre orlibrary for staff – these resources are absent in Limpopo, North West and Northern Cape.39

Figure 11. Proportion of facilities that provide resources to support staff development (%).120100100 100 100 100100 100 100 10094 94868060402043 4333 3325 255000 0 0 0 0 0Library Resource centre Computers for staff use Internet access for staffFree State Limpopo Mpumalanga North West Northern Cape Overall3.5. ORGANISATIONAL ENVIRONMENT AND MANAGEMENTPRACTICESCore findings:• Overall, treatment facilities adhere to good governance practices, such as holding regularmanagement and staff meetings• 93.8% of facilities have a governing body or external management committee• Mpumalanga was the only province where all facilities did not compile an annual report and businessplan or have a governing body / external management committeeWe also examined the proportion of facilities that implemented management practicesprescribed by the minimum norms and standards for inpatient and outpatient treatmentcentres.3.5.1. Management practices at treatment facilitiesOverall, 93.8% of treatment facilities have a governing body or external managementcommittee (Figure 12). The extent to which facilities implement other good governanceand management practices are displayed in Figure 12.40

In terms of client record-keeping, while all facilities report keeping client records, not allfacilities have staff confidentiality agreements regarding client data. Facilities in allprovinces have confidential interviewing rooms (Figure 12).In terms of good governance and management practices, all facilities report keepingrecords on staff, provide staff with job descriptions, hold regular staff meetings, and holdregular management meetings (Figure 12). Despite the legal requirements of doing so,not all facilities report compiling an annual budget (94.0% of the sample), or develop abusiness plan for the facility (94.0% of the sample). All facilities; however, report theannual auditing of finances.Figure 12. Proportion of facilities reporting specific management practices (%).Governing body/externalmanagement committee94Confidential interview rooms100Staff-client confidentialityagreements94Patient/client records100Human resource policies100Staff records100Job descriptions for staffAudited yearly reports onfinances100100Yearly business plan94Compile an annual report94Regular staff meetings100Regular management meetings10091 92 93 94 95 96 97 98 99 100 101OverallBy province, the extent to which facilities implement other good governance andmanagement practices are displayed in Table 8.41

Table 8. Management practices by province.Management practicesFree State(N = 7)Limpopo(N = 2)Mpumalanga(N = 3)North West(N = 2)NorthernCapeOverall(N = 16)(N = 2)N % N % N % N % N % N %Regular management meetings 7 100.0 2 100.0 3 100.0 2 100.0 2 100.0 16 100.0Regular staff meetings 7 100.0 2 100.0 3 100.0 2 100.0 2 100.0 16 100.0Compile an annual report 7 100.0 2 100.0 2 66.7 2 100.0 2 100.0 15 93.8Yearly business plan 7 100.0 2 100.0 2 66.7 2 100.0 2 100.0 15 93.8Audited yearly reports on 7 100.0 2 100.0 3 100.0 2 100.0 2 100.0 16 100.0financesJob descriptions for staff 7 100.0 2 100.0 3 100.0 2 100.0 2 100.0 16 100.0Staff records 7 100.0 2 100.0 3 100.0 2 100.0 2 100.0 16 100.0Human resource policies 7 100.0 2 100.0 3 100.0 2 100.0 2 100.0 16 100.0Patient/client records 7 100.0 2 100.0 3 100.0 2 100.0 2 100.0 16 100.0Staff-client confidentiality 7 100.0 2 100.0 3 100.0 2 100.0 1 50.0 15 93.8agreementsConfidential interview rooms 7 100.0 2 100.0 3 100.0 2 100.0 2 100.0 16 100.0Governing body/externalmanagement committee7 100.0 2 100.0 2 66.7 2 100.0 2 100.0 15 93.83.6. PROFILE OF SERVICES PROVIDED BY SUBSTANCE ABUSETREATMENT FACILITIESThis section describes the types of treatment services provided by facilities in Free State,Limpopo, Mpumalanga, North West and Northern Cape. We focus on both treatmentservices proper and ancillary health and welfare services. Ancillary services are thoseservices directed towards problems that are associated with substance dependence (e.g.psychological dysfunction), whereas treatment services proper focuses on eliminating orreducing the substance use disorder.42

Core findings:• Compared to the provision of core addiction services, a smaller proportion of facilities provide ancillary mentalhealth or medical services• Just over half of the facilities conduct psychological evaluations and less than 15.0% conduct psychiatricassessments of clients• A small proportion of facilities offer mental health-related counselling services• Almost all facilities offer family therapy and family education services• A quarter of facilities routinely test clients for hepatitis and other infectious diseases or conduct harm-reductioninterventions targeting injection drug users3.6.1. Profile of treatment services offeredAll facilities (100.0%) offer some form of addiction counselling service, with a smallerpercentage (68.8%) offering some type of post-treatment aftercare service (Figure 13). Incontrast, only half of the facilities (50.0%) provide detoxification services. Only 1facility (6.3%) provides psychiatric services.By province, 3 (42.9%) facilities in Free State, 1 (50.0%) in Limpopo, 2 (66.7%) inMpumalanga and 2 (100.0%) in North West provide detoxification services. The onlyfacility providing psychiatric services is located in the Free State. Aftercare services areavailable at 5 (71.4%) facilities in the Free State, 1 (50.0%) facility in Limpopo, 2(66.7%) in Mpumalanga, 2 (100.0%) in North West and 1 (50.0%) in Northern Cape.Figure 13. Proportion of treatment facilities providing treatment services (%).1201001008069605040200Detoxification Counselling Psychiatric services Aftercare6Overall43

3.6.2. Provision of assessment servicesWhen assessment services were considered, more than 80.0% of facilities complete achemical history for each new client (Figure 14). Overall, 81.3% of facilities complete abio-psychosocial history for each client. In contrast, just over half of the facilities(56.3%) conduct psychological evaluations and 12.5% of facilities assess clients forpsychiatric disorders (Figure 14).By province, 6 (85.7%) facilities in Free State, 2 (100.0%) in Limpopo, 3 (100.0%) inMpumalanga, 2 (100.0%) in North West and 1 (50.0%) in Northern Cape complete achemical history for each new client. In terms of completing a bio-psychosocial historyfor each client, 6 (85.7%) facilities in Free State, 1 (50.0%) in Limpopo, 3 (100.0%) inMpumalanga, 2 (100.0%) in North West and 1 (50.0%) in Northern Cape do so.Psychological evaluations are conducted in 3 of the provinces, namely 6 (85.7%) of thefacilities in Free State, 1 (50.0%) in Limpopo and 2 (100.0%) in North West. In contrast,psychiatric assessments are only conducted by 2 facilities in Free State (28.6%).Figure 14. Proportion of treatment facilities providing assessment services (%).10080604020088815613Chemical history Bio-psychosocial history Psychological evaluation Psychiatric assessmentsOverall3.6.3. Substance abuse counselling servicesAll of the facilities (100.0%) report providing one-to-one/individual substance abusecounselling services, substance abuse counselling services in a group format as well aslife skills development services (Figure 15). A smaller proportion of facilities providepsychoeducational lectures (87.5%) and offer mental health-related counselling services(68.8%). When specific substance abuse treatment modalities used by facilities duringsubstance abuse counselling were considered, we found that 37.5% of facilities report44

using 12-step approaches, 75.0% report using contingency management, 93.8% reportusing motivational interviewing techniques, and 50.0% report using cognitivebehavioural therapy (CBT) techniques (Figure 15). A small proportion of facilities (6.3%)offer alternative therapies (such as aromatherapy), provide self-help/support groups(37.5%) (for example Narcotics Anonymous [NA] and Alcoholics Anonymous [AA]) andprovide occupational therapy (31.3%).Figure 15.Proportion of treatment facilities providing substance abuse counsellingservices (%).Occupational therapy31Self-help/support groups38Alternative therapies6Life skills100Mental health counselling69Psychoeducational lectures88Contingency management7512-step counselling38Motivational interviewing94CBT counselling50Group counsellingIndividual counselling1001000 20 40 60 80 100 120OverallOverall, equal proportions of facilities (37.5%) use 12-step approaches and provide selfhelp/supportgroups; however, the distribution of these facilities across provinces is notthe same (Table 9). Facilities in 2 provinces report using 12-step approaches, namely FreeState (71.4%) and Mpumalanga (33.3%) whereas self-help/support groups are availablein Free State (57.1%) and Limpopo (100.0%). Facilities in Free State, Limpopo andMpumalanga provide mental health-related counselling services. Compared to facilitiesin other provinces, alternative therapies and occupational therapy are only available in theFree State. Facilities in Limpopo and Northern Cape do not provide CBT counselling.45

Table 9. Proportion of facilities providing counselling services by province.Types of counsellingservices: Format andFree State(N = 7)Limpopo(N = 2)Mpumalanga(N = 3)North West(N = 2)NorthernCapeOverall(N = 16)modalities(N = 2)N % N % N % N % N % N %Individual suds counselling 7 100.0 2 100.0 3 100.0 2 100.0 2 100.0 16 100.0Group suds counselling 7 100.0 2 100.0 3 100.0 2 100.0 2 100.0 16 100.0CBT counselling 5 71.4 0 0 1 33.3 2 100.0 0 0 8 50.0Motivational interviewing 7 100.0 2 100.0 3 100.0 2 100.0 1 50.8 15 93.812-step counselling 5 71.4 0 0 1 33.3 0 0 0 0 6 37.5Contingency management 6 85.7 2 100.0 2 66.7 2 100.0 0 0 12 75.0Psychoeducational lectures 6 85.7 2 100.0 3 100.0 2 100.0 1 50.0 14 87.5Mental health counselling 7 100.0 2 100.0 2 66.7 0 0 0 0 11 68.8Life skills 7 100.0 2 100.0 3 100.0 2 100.0 2 100.0 16 100.0Alternative therapies 1 14.3 0 0 0 0 0 0 0 0 1 6.3Self-help/support groups 4 57.1 2 100.0 0 0 0 0 0 0 6 37.5Occupational therapy 5 71.4 0 0 0 0 0 0 0 0 5 31.33.6.4. Provision of family servicesAlmost all facilities offer family therapy (93.8%) and family education services (93.8%)to their clients (Figure 16). For the most part, family therapy consists of one familysession and is used to gather collateral information on the presenting client or educate thefamily about addiction. These family interventions tend not to address familydysfunction. A smaller proportion of facilities also offer family assessment services(81.3%), or marital and couple counselling services (87.5%).By province, all facilities provide family therapy services, with the exception of 1 facilityin Northern Cape (50.0%). Similarly, all facilities provide family education services, withthe exception of 1 facility in Free State (14.3%). One facility in Northern Cape (50.0%)and 1 facility in Free State (14.3%) do not offer marital and couple counselling services.Family assessments are conducted in Free State (71.4%), Limpopo (50.0%), Mpumalanga(100.0%), North West (100.0%) and Northern Cape (100.0%).46

Figure 16. Proportion of treatment facilities providing family services (%).9594 9490888580817570Marital therapy Family therapy Family education Family assessmentOverall3.6.5. Provision of health and medical servicesWith regard to ancillary medical services, a large proportion of facilities conduct a fullmedical history of clients (81.3%) (Figure 17). A smaller proportion conduct physicalexaminations of clients (62.5%); provide clients with psychiatric medication (50.0%);provide clients with substitution medications such as methadone, subutex and antabuse(37.5%); or offer detoxification services (56.3%).Regarding medical harm-reduction interventions, a quarter of facilities routinely testclients for hepatitis and other infectious diseases or conduct harm-reduction interventionsamong injection drug users (IDU) (Figure 17). Only 37.5% of facilities provide HIV riskreduction interventions (such as testing and counselling) onsite.47

Figure 17.908180Proportion of substance abuse treatment facilities providing health services(%).7060506356504038383025 2520100Medical historyPhysicalexaminationDetoxificationProvision ofpsychiatricmedicationProvision ofsubstitutionmedicationHarm reduction(IDU)Testing forinfectiousdiseasesHIV testing andcounsellingOverallBy province, facilities in the Northern Cape do not provide ancillary medical services ormedical harm-reduction interventions (Table 10). Harm reduction interventions amonginjection drug users are only conducted in Free State. Testing for hepatitis and otherinfectious diseases routinely occurs in Free State and Mpumalanga.Table 10. Proportion of facilities providing medical services by province.Types of ancillary healthservices providedFree State(N = 7)Limpopo(N = 2)Mpumalanga(N = 3)North West(N = 2)NorthernCapeOverall(N = 16)(N = 2)N % N % N % N % N % N %Medical history 6 85.7 2 100.0 3 100.0 2 100.0 0 0 13 81.3Physical examination 5 71.4 0 0 3 100.0 2 100.0 0 0 10 62.5Detoxification services 3 42.9 2 100.0 2 66.7 2 100.0 0 0 9 56.3Psychiatric medication 4 57.1 1 50.0 1 33.3 2 100.0 0 0 8 50.0Substitution medication 4 57.1 1 50.0 1 33.3 0 0 0 0 6 37.5Harm reduction (IDU) 4 57.1 0 0 0 0 0 0 0 0 4 25.0Test for infectious diseases 3 42.9 0 0 1 33.3 0 0 0 0 4 25.0HIV testing/counselling 2 28.6 1 50.0 3 100.0 0 0 0 0 6 37.548

3.7. ADDRESSING BARRIERS TO TREATMENT ENTRY FORVULNERABLE GROUPSThis section describes the extent to which substance abuse treatment facilities targetbarriers to treatment entry for clients from historically underserved groups. Theseactivities are grouped into (i) practices that improve awareness of substance abusetreatment options, (ii) practices that address logistical barriers such as finance ortransport, and (iii) practices that address cultural and linguistic barriers to treatment entry.For parts (i) and (ii) responses were grouped into four categories, namely: never, rarely(once or twice per year), sometimes (once every 3-4 months) and routinely (at least oncea month).Core findings:• Outreach in disadvantaged areas is routinely conducted by 87.5% of facilities• Facilities in Mpumalanga and North West are the most likely to conduct any form ofoutreach• In terms of logistic barriers, most treatment facilities do not provide transport services• Facilities in Free State are more likely to provide transport services both to the client andfamily• In terms of affordability barriers, 75.0% of facilities routinely have free treatmentslots/beds available• In terms of cultural and linguistic barriers, 81.3% of facilities employ African languagespeakingtherapists3.7.1. Practices that improve awareness of substance abuse treatment optionsOverall, 43.8% of facilities report conducting awareness campaigns relating to substanceabuse on a routine basis (at least once a month) and 56.3% report routinely distributinginformation and other materials relating to substance abuse treatment (Figure 18).Although 87.5% of facilities routinely conduct substance abuse-related outreach amongvulnerable groups and within disadvantaged areas, the inner city areas were relativelyneglected, with only 56.3% of facilities routinely operating in these areas. In addition,12.5% of facilities report that they never conduct outreach in the inner city areas and6.3% never distribute materials related to substance abuse treatment.49

Figure 18.Proportion of substance abuse treatment facilities that target awareness-relatedbarriers to treatment entry for vulnerable clients for the overall sample (%).1009088 888070605040302010013 130 0 0 0Outreach-vulnerablegroups13131956 56Outreach-disadv areas Outreach-inner cities Distribution of material Awareness campaigns66310193844Never Rarely Sometimes RoutinelyMpumalanga and North West are the only provinces where all facilities routinely conductoutreach among vulnerable groups, within disadvantaged areas and inner city areas aswell as distribute substance abuse-related materials and information (Table 11).50

Table 11. Proportion of facilities that address lack of awareness of treatment options byprovince.Awareness raising activities Free State(N = 7)Limpopo(N = 2)Mpumalanga(N = 3)NorthWestNorthernCapeOverall(N = 16)(N = 2) (N = 2)N % N % N % N % N % N %Outreach: vulnerable groups -- -- -- -- -- -- -- -- -- -- -- --Never 0 0 0 0 0 0 0 0 0 0 0 0Rarely 0 0 0 0 0 0 0 0 0 0 0 0Sometimes 1 14.3 1 50.0 0 0 0 0 0 0 2 12.5Routinely 6 85.7 1 50.0 3 100.0 2 100.0 2 100.0 14 87.5Outreach in disadv areas -- -- -- -- -- -- -- -- -- -- -- --Never 0 0 0 0 0 0 0 0 0 0 0 0Rarely 0 0 0 0 0 0 0 0 0 0 0 0Sometimes 1 14.3 1 50.0 0 0 0 0 0 0 2 12.5Routinely 6 85.7 1 50.0 3 100.0 2 100.0 2 100.0 14 87.5Outreach in inner cities -- -- -- -- -- -- -- -- -- -- -- --Never 1 14.3 0 0 0 0 0 0 1 50.0 2 12.5Rarely 0 0 2 100.0 0 0 0 0 0 0 2 12.5Sometimes 3 42.9 0 0 0 0 0 0 0 0 3 18.8Routinely 3 42.9 0 0 3 100.0 2 100.0 1 50.0 9 56.3Distribution of materials -- -- -- -- -- -- -- -- -- -- -- --Never 1 14.3 0 0 0 0 0 0 0 0 1 6.3Rarely 0 0 1 50.0 0 0 0 0 0 0 1 6.3Sometimes 4 57.1 1 50.0 0 0 0 0 0 0 5 31.3Routinely 2 28.6 0 0 3 100.0 2 100.0 2 100.0 9 56.3Awareness campaigns -- -- -- -- -- -- -- -- -- -- -- --Never 0 0 0 0 0 0 0 0 0 0 0 0Rarely 2 28.6 1 50.0 0 0 0 0 0 0 3 18.8Sometimes 1 14.3 1 50.0 1 33.3 2 100.0 1 50.0 6 37.5Routinely 4 57.1 0 0 2 66.7 0 0 1 50.0 7 43.851

3.7.2. Practices that address logistical and affordability barriers to treatment entryAll facilities indicate that they provide treatment to clients who have no medical aidcoverage or are unable to pay for treatment. In terms of costs barriers, 68.8% of facilitiesroutinely offer reduced fees to indigent clients while 75.0% of facilities routinely havefree treatment beds/slots available (Figure 19). For the overall sample, the averagenumber of free treatment slots/beds available per year ranges from 5 to 120 (χ = 60.8, SD= 47.0). By province, the average number of free treatment slots/beds available per yearranges from 8 to 100 (χ = 56.3, SD = 40.8) in Free State, 5 to 25 (χ = 15.0, SD = 14.1) inLimpopo and 120 (χ = 120.0, SD = 0.0) in North West. Facilities in Mpumalanga andNorthern Cape did not provide figures for the availability of treatment slots/beds.In terms of transport barriers, only 12.5% routinely provide clients with transport to thefacility and provide transport to the client’s family so that they can participate in thetreatment programme (Figure 19).Figure 19.Proportion of substance abuse treatment facilities that target logisticbarriers to treatment entry (%).807060504030201007569693825 252519 1913 13 130 0 0 0Transport for client Transport for family Reduced fees Free treatmentNever Rarely Sometimes RoutinelyBy province, only facilities in Free State routinely provide transport for clients whereastransport for the family to participate in the treatment programme is available in FreeState (14.3%) and Northern Cape (50.0%) (Table 12).52

Table 12. Proportion of facilities addressing logistical barriers to treatment entry byprovince.Activities that addresslogistical barriersFree State(N = 7)Limpopo(N = 2)Mpumalanga(N = 3)NorthWestNorthernCapeOverall(N = 16)(N = 2) (N = 2)N % N % N % N % N % N %Transport for client-- -- -- -- -- -- -- -- -- -- -- --Never 3 42.9 2 100.0 1 33.3 0 0 0 0 6 37.5Rarely 1 14.3 0 0 1 33.3 0 0 2 100.0 4 25.0Sometimes 1 14.3 0 0 1 33.3 2 100.0 0 0 4 25.0Routinely 2 28.6 0 0 0 0 0 0 0 0 2 12.5Transport for family-- -- -- -- -- -- -- -- -- -- -- --Never 6 85.7 2 100.0 2 66.7 0 0 1 50.0 11 68.8Rarely 0 0 0 0 0 0 0 0 0 0 0 0Sometimes 0 0 0 0 1 33.3 2 100.0 0 0 3 18.8Routinely 1 14.3 0 0 0 0 0 0 1 50.0 2 12.5Reduced fees-- -- -- -- -- -- -- -- -- -- -- --Never 0 0 0 0 1 33.3 0 0 1 50.0 2 12.5Rarely 0 0 0 0 0 0 0 0 0 0 0 0Sometimes 2 28.6 1 50.0 0 0 0 0 0 0 3 18.8Routinely 5 71.4 1 50.0 2 66.7 2 100.0 1 50.0 11 68.8Free treatment-- -- -- -- -- -- -- -- -- -- -- --Never 0 0 1 50.0 2 66.7 0 0 1 50.0 4 25.0Rarely 0 0 0 0 0 0 0 0 0 0 0 0Sometimes 0 0 0 0 0 0 0 0 0 0 0 0Routinely 7 100.0 1 50.0 1 33.3 2 100.0 1 50.0 12 75.03.7.3. Practices that address cultural and linguistic barriers to treatment entryIn terms of cultural and linguistic barriers, all facilities report employing multi-lingualstaff while 81.3% of facilities employ African language-speaking therapists. Byprovince, only a small proportion of facilities in Free State (57.1%) employ Africanlanguage-speaking counsellors while all facilities in the other 4 provinces employ Africanlanguage-speaking counsellors.53

3.8 ADDRESSING BARRIERS TO ENGAGEMENT AND RETENTION INTREATMENT FOR VULNERABLE GROUPSThis section describes the extent to which treatment facilities target barriers toengagement and retention in treatment for clients from historically underserved groups;particularly Black South Africans, women and young people. Retention activities aregrouped into activities relating to (i) the cultural-sensitivity and appropriateness oftreatment, (ii) the gender-sensitivity and appropriateness of treatment, and (iii) the agesensitivityand appropriateness of treatment.Core findings:• All facilities offer treatment services in multiple languages• Half of the facilities use culturally appropriate assessment tools• Only 43.8% of facilities provide child care services/facilities• Half of the facilities provide staff with special training in gender-related issues• Three quarter of facilities employ staff trained to work with young people• A small proportion of facilities (37.5%) provide adolescent-focused/adolescent-onlytreatment services3.8.1. Cultural and linguistic sensitivity and appropriateness of treatmentOverall, all facilities report providing treatment programmes and materials in multiplelanguages, 87.5% provide counselling that is culturally appropriate, and only half reportusing culturally appropriate assessment tools (Figure 20). Just over half of facilities(56.3%) have assessment instruments and programme materials translated into multiplelanguages.54

Figure 20.Proportion of substance abuse treatment facilities offering culturally andlinguistically appropriate services (%).120100808810060505640200Culturally appropriateassessment toolsTranslated instrumentsCulturally appropriatetherapyProgrammes in multiplelanguagesOverallNone of the facilities in Northern Cape report attempting to improve the culturalsensitivity and appropriateness of their programmes or provide culturally appropriatetherapy (Table 13). Facilities in Limpopo do not provide translated materials.Table 13. Proportion of facilities that address cultural and linguistic appropriatenessof services by province.Activities to improve cultural andlinguistic appropriateness ofFree State(N = 7)Limpopo(N = 2)Mpumalanga(N = 3)NorthWestNorthernCapeOverall(N = 16)treatment(N = 2) (N = 2)N % N % N % N % N % N %Culturally appropriate3 42.9 2 100.0 1 33.3 2 100.0 0 0 8 50.0assessment toolsTranslated materials 4 57.1 0 0 2 66.7 2 100.0 1 50.0 9 56.3Culturally appropriate therapy 7 100.0 2 100.0 3 100.0 2 100.0 0 0 14 87.5Programmes: multiple languages 7 100.0 2 100.0 3 100.0 2 100.0 2 100.0 16 100.03.8.2. Gender sensitivity and appropriateness of treatmentThree quarter of facilities provide gender-appropriate therapy and sensitive counsellingservices (Figure 21), with 68.8% of facilities providing services that address women’sissues, such as power, trauma and violence. In addition, 68.8% of facilities use genderappropriate assessment instruments and procedures for administration. Only 1 facility55

(6.3%) provides women-focused/women-only treatment services. Half of the facilitiesprovide staff with special training in gender-related issues that may be pertinent totreatment (such as domestic violence). Clients have access to child care services in lessthan half of facilities (43.8%).Figure 21.Proportion of substance abuse treatment facilities offering gender appropriateservices (%).Child careservices/facilities44Train staff in genderrelatedissues50Services addressingwomen's issues69Women-focusedtreatment services6Gender appropriatetherapy75Gender appropriateassessment tools690 10 20 30 40 50 60 70 80OverallThe only facility providing women-focused treatment services is in Mpumalanga (Table14). Facilities in Mpumalanga and North West do not provide staff with training ingender-related issues. Child care facilities are not available in Mpumalanga and Limpopo.56

Table 14. Proportion of facilities that address the gender appropriateness of servicesby province.Activities to improve genderappropriateness of treatmentFree State(N = 7)Limpopo(N = 2)Mpumalanga(N = 3)NorthWestNorthernCapeOverall(N = 16)(N = 2) (N = 2)N % N % N % N % N % N %Gender appropriate assessment 3 42.9 2 100.0 2 66.7 2 100.0 2 100.0 11 68.8Gender appropriate therapy 6 85.7 1 50.0 2 66.7 2 100.0 1 50.0 12 75.0Women-focused treatment 0 0 0 0 1 33.3 0 0 0 0 1 6.3servicesServices addressing women’s 6 85.7 2 100.0 1 33.3 0 0 2 100.0 11 68.8issuesTraining: gender-related issues 4 57.1 2 100.0 0 0 0 0 2 100.0 8 50.0Child care services/facilities 3 42.9 0 0 0 0 2 100.0 2 100.0 7 43.83.8.3. Age appropriateness of treatment servicesThree quarter of the facilities report using age appropriate assessment instruments, andemploy staff trained to work with adolescents and young people (Figure 22). More than80.0% of the facilities report providing counselling services that are age anddevelopmentally appropriate, and conduct family-focused interventions. Just over half offacilities provide family reunification services for adolescent clients (56.3%), and adaptthe facility environment to ensure the safety of young people (56.3%) (Figure 22). Asmall proportion of facilities provide adolescent-focused/adolescent-only treatmentservices (37.5%).57

Figure 22.Proportion of substance abuse treatment facilities offering age appropriateservices (%).Family reunification for adolescents56Adapt facilities for the safety of young people56Employ staff trained to work with adolescents75Conduct family-focused interventions88Adolescent-focused treatment services38Age appropriate therapy88Age appropriate assessment tools750 10 20 30 40 50 60 70 80 90 100OverallBy province, facilities in Limpopo and North West do not provide adolescent-focusedtreatment services (Table 15). Similar proportions of facilities in all 5 provinces providefamily reunification services and adapt facilities for the safety of young people.58

Table 15. Proportion of facilities that address age appropriateness of services byprovince.Activities provided to improveage appropriateness of treatmentFree State(N = 7)Limpopo(N = 2)Mpumalanga(N = 3)NorthWestNorthernCapeOverall(N = 16)(N = 2) (N = 2)N % N % N % N % N % N %Age appropriate assessment 5 71.4 2 100.0 2 66.7 2 100.0 1 50.0 12 75.0Age appropriate therapy 6 85.7 2 100.0 3 100.0 2 100.0 1 50.0 14 87.5Adolescent-focused treatment 4 57.1 0 0 1 33.3 0 0 1 50.0 6 37.5servicesFamily-focused interventions 6 85.7 2 100.0 2 66.7 2 100.0 2 100.0 14 87.5Staff trained to work with 5 71.4 2 100.0 1 33.3 2 100.0 2 100.0 12 75.0adolescentsAdapt facilities for the safety of 4 57.1 1 50.0 1 33.3 2 100.0 1 50.0 9 56.3young peopleFamily reunification services 4 57.1 1 50.0 1 33.3 2 100.0 1 50.0 9 56.33.9. MONITORING AND EVALUATION ACTIVITIES FOR SUBSTANCEABUSE TREATMENT FACILITIESThis section describes the extent to which substance abuse treatment facilities in FreeState, Limpopo, Mpumalanga, North West and Northern Cape conduct monitoring andevaluation (M & E) activities.Core findings:• Most facilities have structures that allow for the within-treatment monitoring of clients• Over half of the facilities report post-discharge monitoring of clients• Overall, the average proportion of clients monitored once they complete treatment is45.8 (SD = 33.1)• Just over half of facilities monitor clients on an ad hoc basis or on request of familymembers• Less than half of the facilities had conducted an outcome evaluation of their treatmentprogramme• Equal proportions of facilities in all 5 provinces had conducted a process evaluation oftheir treatment programme/s as well as evaluated the quality of their treatmentprogrammes59

3.9.1. Monitoring of clients’ progress during the course of treatmentAdministrative and procedural structures and activities that facilitate the monitoring ofclient progress during the course of treatment were explored. These structures andactivities are important as they help facilitate the monitoring of client outcomes posttreatment.Overall, all facilities report developing individualised treatment plans for eachclient and keep documented notes of clients’ progress during treatment (Figure 23). Aslightly smaller percentage of facilities have formal discharge plans for each client(68.8%), collect collateral records from various sources (e.g. case conferences, nursingrecords, assessments for each client) (81.3%) and maintain a formal managementinformation system (e.g. client database) that contains all client records (81.3%).Figure 23.Proportion of substance abuse treatment facilities reporting monitoring ofclients within treatment (%).12010080100 1006981 816040200Individualisedtreatment plansDocumented progressnotesDocumented dischargeplansDocumented collateralcontactsManagementinformation systemOverallBy province, 6 facilities in Free State (85.7%), 1 in Limpopo (50.0%), 2 in Mpumalanga(66.7%), 2 in North West (100.0%) and none in Northern Cape keep documentedindividualised discharge plans. Compared to facilities in other provinces, one facility inLimpopo (50.0%) and none of the facilities in Northern Cape have documented recordsfrom collateral sources. A formal management information system is maintained by 6facilities in Free State (85.7%), 2 facilities in Limpopo (100.0%), 2 facilities inMpumalanga (66.7%), 2 facilities in North West (100.0%) and 1 facility in NorthernCape (50.0%).60

3.9.2. Monitoring of clients’ progress post-treatmentWe also examined the extent to which facilities monitored client progress post-treatment.When facilities were asked about post-discharge monitoring and regular post-dischargefollow-up of all clients, only 62.5% of facilities reported tracking client progress oncethey had completed treatment (Figure 24).However, when asked about specific post-treatment monitoring activities, a relativelylarge proportion of facilities report monitoring clients’ progress telephonically (93.8%)and monitoring clients’ progress during follow-up counselling sessions (93.8%) (Figure24). In addition, 43.8% of facilities report the use of blood tests and/or urinalysis tomonitor clients’ substance use and only 18.8% of facilities use structured follow-upquestionnaires to track clients’ progress post-treatment.Figure 24.Proportion of substance abuse treatment facilities reporting monitoring ofclients post-treatment (%).100908070605040302010063Post-dischargemonitoring andfollow-up9444Telephone follow-up Blood/urine test Follow-up counselling Follow-upquestionnaireOverall9419By province, 4 facilities in Free State (57.1%), 1 in Limpopo (50.0%), 2 in Mpumalanga(66.7%), 2 in North West (100.0%) and 1 in Northern Cape (50.0%) conduct postdischargemonitoring and regular post-discharge follow-up of all clients. All facilitiesreport monitoring clients’ progress telephonically, with the exception of 1 facility inNorthern Cape (50.0%). Similarly, all facilities report monitoring clients’ progress duringfollow-up counselling sessions, with the exception of 1 facility in Limpopo (50.0%). Theonly provinces reporting using blood tests and/or urinalysis to monitor clients’ substanceuse are Free State (42.9%), Limpopo (100.0%) and North West (100.0%). In addition,61

Free State (14.3%) and North West (100.0%) are the only provinces using structuredfollow-up questionnaires to track clients’ progress post-treatment.Overall, the average proportion of clients monitored once they complete the treatmentprogramme ranges from 0 to 100 (χ = 45.8, SD = 33.1). By province, the averageproportion of clients monitored post-treatment ranges from 20 to 100 (χ = 50.0, SD =30.3) in Free State, 40 (χ = 40.0, SD = 0.0) in Limpopo, 0 to 10 (χ = 3.7, SD = 5.5) inMpumalanga, 70 (χ = 70.0, SD = 0.0) in North West, and 50 to 100 (χ = 75.0, SD = 35.4)in Northern Cape.A small proportion of facilities monitor clients for the first month (12.5%), first threemonths (12.5%) and first six months (18.8%). Just over half of the facilities (56.3%)monitor clients on an ad hoc basis or on request of family members while half of thefacilities report monitoring clients for the first year (Figure 25).Figure 25.Proportion of substance abuse treatment facilities monitoring clients posttreatmentby period (%).605050564030201013 13190First month First three months First six months First year Ad hoc basis/ requestof family membersOverallNorthern Cape is the only province monitoring clients for the first month post-treatmentas well as monitoring clients on an ongoing basis, namely for the first three months, firstsix months, first year and on an ad hoc basis (Table 16). Facilities in North West monitorclients for the first year only.62

Table 16. Proportion of facilities monitoring clients post-treatment by province.Monitoring: Period of time Free State(N = 7)Limpopo(N = 2)Mpumalanga(N = 3)NorthWestNorthernCapeOverall(N = 16)(N = 2) (N = 2)N % N % N % N % N % N %For the first month 0 0 0 0 0 0 0 0 2 100.0 2 12.5For the first three months 0 0 1 50.0 0 0 0 0 1 50.0 2 12.5For the first six months 1 14.3 1 50.0 0 0 0 0 1 50.0 3 18.8For the first year 2 28.6 1 50.0 2 66.7 2 100.0 1 50.0 8 50.0Ad hoc basis / request of familymembers4 57.1 0 0 3 100.0 0 0 2 100.0 9 56.33.9.3. Formal treatment programme evaluationThe proportion of substance abuse treatment facilities that have conducted formalevaluations of their treatment programmes and the types of evaluations conducted wasalso examined. Overall, less than half of the facilities (43.8%) surveyed report havingconducted a treatment outcomes evaluation of their programme (Figure 26). Half of thefacilities have conducted a process evaluation of their treatment programme/s as well asevaluated the quality of their treatment programmes. A slightly larger proportion offacilities (62.5%) have examined client satisfaction with treatment services provided(Figure 26). Similarly, 62.5% of facilities have participated in a Department of SocialServices evaluation for funding and 68.8% of facilities have evaluation reports available.63

Figure 26.Proportion of substance abuse treatment facilities conducting formalevaluations of their treatment programmes (%).7063 6360504450 50403020100Outcome evaluation Process evaluation Evaluation:programme qualityEvaluation: clientsatisfactionEvaluation:Department of SocialServices for fundingOverallBy province, 57.1% (4) of facilities in Free State, 100.0% (2) in North West and 50.0%(1) in Northern Cape reported having conducted a treatment outcomes evaluation of theirprogramme. Equal proportions of facilities in all 5 provinces had conducted a processevaluation of their treatment programme/s as well as evaluated the quality of theirtreatment programmes: 42.9% (3) in Free State, 50.0% (1) in Limpopo, 33.3% (1) inMpumalanga, 100.0% (2) in North West and 50.0% (1) in Northern Cape. An evaluationof client satisfaction with services was performed in 57.1% (4) of facilities in Free State,50.0% (1) in Limpopo, 66.7% (3) in Mpumalanga, 100.0% (2) in North West and 50.0%(1) in Northern Cape. In terms of participating in a Department of Social Servicesevaluation for funding, 71.4% (5) of facilities in Free State, 33.3% (1) in Mpumalanga,100.0% (2) in both North West and Northern Cape had done so. Evaluation reports areavailable in Free State (6 facilities), Limpopo (1 facility), Mpumalanga (2 facilities) andNorthern Cape (2 facilities).64

PART 4: DISCUSSION OF KEY FINDINGSWhile substance abuse treatment facilities in Free State, Limpopo, Mpumalanga, NorthWest and Northern Cape offer a range of services to clients, this audit shows that accessto services varies extensively among facilities. The following sections describe theavailability of substance abuse treatment, the range of services provided, and the extent towhich barriers to entering, engaging and being retained in treatment for clients fromhistorically underserved groups are addressed by treatment facilities. Variations in thesecomponents of access are discussed in the light of facility characteristics, includingstaffing resources and the organisational environment; as well as in the light of minimumnorms and standards for treatment facilities. Finally, recommendations are made forimproving the accessibility and quality of treatment services.4.1. AVAILABILITY OF SUBSTANCE ABUSE TREATMENT SERVICESThis study examined the availability of substance abuse treatment services (in terms oftreatment capacity), the extent to which available treatment slots are utilised (in terms oftreatment occupancy rates), the demand for treatment services (in terms of waiting lists),and the extent to which available treatment slots are effectively used (in terms of clientretention rates). Availability of services is an important variable to examine as lowavailability may act as a barrier to accessing services; even when there are high levels ofperceived need (Appel et al., 2004).4.1.1. Availability of treatment servicesThe availability of substance abuse treatment services appears to be greater inMpumalanga, with findings suggesting that facilities in Mpumalanga have moretreatment slots available and treat greater numbers of clients than facilities in the FreeState, Limpopo, North West and Northern Cape.4.1.2. Utilisation of and demand for available treatment slotsWe also examined the extent to which available treatment slots are utilised. For theoverall sample, just over half of the available treatment slots are occupied on an annualbasis. Although this occupancy rate is relatively high, the finding that a third of slotsremain unoccupied is still cause for concern given the high demand for substance abusetreatment services. This demand for treatment services is reflected in the finding that 765

facilities have waiting lists, with an average of 6 clients waiting for an available treatmentslot. On average, the waiting period for a treatment slot / bed is 6 days. It should be notedthat none of the facilities in the Northern Cape reported using a waiting list.Despite the fact that these waiting periods are much shorter than those identified in otherprovinces, such as Gauteng and KwaZulu-Natal (Myers & Fakier, 2007), the presence ofwaiting lists is still worrisome as they may act as a barrier to accessing substance abusetreatment (Grant, 1997; Hser et al., 1998; Tucker et al., 2004). Timely access is importantfor facilitating treatment entry as many substance abusers are ambivalent about seekingtreatment and may have little tolerance for waiting for the next available treatment slot(Kaplan & Johri, 2000).Findings reflect that facilities in Mpumalanga have the lowest treatment occupancy rates,with these facilities operating, on average, at 38.3% of their capacity.4.1.3. Effective use of available treatment slotsIn this study, the effective use of available treatment slots is indicated by the degree towhich clients are retained in treatment. Client retention rates differ broadly acrossfacilities, with some facilities reporting retention rates as low as 30.0%. On average,facilities retain about 70.2% of their clients in treatment. The large variation in theseretention rates points to significant room for service improvement, especially as clientretention is an important proxy indicator of service effectiveness and positive treatmentoutcomes.4.2. RANGE AND DIVERSITY OF SERVICES PROVIDEDDespite growing evidence of an association between the availability of ancillarytreatment services (e.g. psychological and medical care) and treatment outcomes, andevidence-based practice guidelines that emphasise the need to integrate ancillary medicaland mental health services with core addiction services (Durkin, 2002; Lee et al., 2001),findings suggest that substance abuse treatment facilities in South Africa generally fail tomeet this standard. In Free State, Limpopo, Mpumalanga, North West and NorthernCape, clients are provided with ancillary medical and mental health-oriented servicesmuch less frequently than core addiction services. This is similar to findings from66

previous audits of specialist substance abuse treatment facilities in Cape Town (Myers &Parry, 2003); Gauteng (Myers, 2004) as well as Gauteng and KwaZulu-Natal (Myers &Fakier, 2007).4.2.1. Provision of ancillary mental health servicesIn all 5 provinces, substance abuse treatment facilities focus primarily on treating the coresubstance abuse problem and rarely provide ancillary psychiatric services that targetpsychiatric disorders and other mental health problems that are associated with, anoutcome of, and/or contributed to the development of the substance use disorder. Morespecifically, only 1 facility in Free State provides psychiatric services.In addition, only a minority of facilities assess clients for psychiatric disorders. Facilitiesin Free State (28.6%) are the only facilities assessing whether clients have co-occurringpsychiatric disorders. This remains a cause for concern; especially as internationalresearch points to the high prevalence of co-occurring psychiatric disorders amongindividuals with substance use disorders, which, if left undetected, negatively impact ontreatment outcomes (Teesson et al., 2005).Findings from previous research also suggest that individuals with co-occurring disordershave more complex treatment needs than persons with substance use disorders only(Durkin, 2002; Teesson et al., 2005). These findings suggest that in order to increase thechance of positive treatment outcomes for individuals with co-occurring disorders,psychiatric disorders need to be detected and managed during the course of treatment(Teesson et al., 2005). Despite this, findings from this study show that a smallerproportion of facilities offer counselling focused on mental health problems, relative tocounselling focused on substance abuse and/or family issues. In addition, only half of thefacilities provide clients with psychiatric medication to manage their co-occurring moodand/or anxiety disorders.The availability of speciality staffing resources may help account for the shortage ofmental health services in Free State, Limpopo, Mpumalanga, North West and NorthernCape. Prior research suggests that the availability of mental health services is stronglyassociated with the proportion of staff (employed by facilities) trained to deliver these67

speciality services (Durkin, 2002; Friedman, Alexander, & D’Aunno, 1999). Findingsfrom this study tend to confirm this explanation with only 43.8% of facilities employing apsychologist and 18.8% of facilities with a psychiatrist on staff.4.2.2. Provision of ancillary health servicesIn comparison to the proportion of facilities providing core addiction and aftercareservices, a smaller proportion of facilities provide ancillary medical and health services.Although this is in keeping with findings from previous audits of substance abusetreatment facilities (Myers & Fakier, 2007; Myers, 2004; Myers & Parry, 2003), thesefindings are cause for concern as many substance-abusing individuals experiencesubstance-related health concerns. The provision of ancillary health services (of both apalliative and preventative nature) is thus an important aspect of quality substance abusetreatment (Friedman, Alexander, & D’Aunno, 1999).Similar to findings from previous studies, facilities are more likely to conduct medicalassessments than provide clients with substitution medication and/or detoxificationservices. More specifically, less than 40.0% of facilities provide clients with access tosubstitution medication - despite the evidence that substitution medication isinternationally acknowledged to be a useful tool for limiting the harms of substance abuseand for retaining clients in treatment. The provision of substitution medication is alsointernationally recognised as one of the key principles of effective substance abusetreatment (NIDA, 2006). Similarly, only 56.3% of facilities report providing clients withon-site detoxification services. The limited availability of these services within treatmentfacilities is cause for concern as treatment facilities that do not provide detoxificationservices often require clients to have completed a hospital-based detoxification prior toentering treatment. This acts as a barrier to treatment entry due to the scarcity ofhospital-based detoxification services (Myers, 2007).Findings also show that only a small proportion of facilities conduct interventions toreduce the health risks associated with continued substance use. For example, a quarterof the facilities test for and conduct interventions to reduce the risks of substance-relatedinfectious disease (such as hepatitis) or conduct interventions to reduce the health risksassociated with injection drug use. While the latter may be due to the fact that only a68

small proportion of South African drug users are injection drug users (Dewing et al.,2006), injection drug users still face many health risks that can be ameliorated throughtimeous interventions. In addition, less than half of the facilities test for and conductinterventions to reduce the risk of HIV. This finding is of greater concern, especiallygiven the strong association between substance abuse and risky sexual practices(Wechsberg, Craddock, & Hubbard, 1998) and South Africa’s high HIV prevalence rate.4.3. TARGETING BARRIERS TO TREATMENT ENTRY, ENGAGEMENTAND RETENTION FOR CLIENTS FROM UNDERSERVED GROUPSInternational principles of effective treatment for substance use disorders (NIDA, 2006)and South African norms and standards for inpatient and outpatient treatment emphasisethat substance abuse treatment services should be (i) accessible to individuals who needand want services and (ii) appropriate for different cultural, age and gender groups.Despite these standards and widespread concern about the accessibility andappropriateness of existing treatment services for clients from historically underservedgroups (Myers & Parry, 2005), South African substance abuse treatment facilitiesgenerally fail to meet these standards. The following sections describe the accessibilityand appropriateness of substance abuse treatment services with particular reference tohistorically underserved population groups; namely Black/African substance users andwomen.4.3.1. The extent to which services are accessible to underserved groupsFindings show that in Free State, Limpopo, Mpumalanga and North West, Black/Africanclients continue to be under-represented in substance abuse treatment facilities. AlthoughBlack/African persons comprise about 84.0% of the general population of Free State(Statistics South Africa, 1998a), they comprise only 31.7% of the client population atsubstance abuse treatment facilities in this province. Similarly, while Black/Africanpersons comprise about 97.3% of the general population in Limpopo (Statistics SouthAfrica, 2006b), they comprise about 48.0% of the client population at substance abusetreatment facilities in this province. In Mpumalanga, Black/African persons compriseabout 92.4% of the general population (Statistics South Africa, 2006c) while only 48.5%of the client population are in treatment for substance abuse. Black/African personscomprise about 91.4% of the general population of North West (Statistics South Africa,69

1998b) and comprise only 31.0% of the client population at substance abuse treatmentfacilities. In contrast, White South Africans continue to be over-represented in substanceabuse treatment facilities, relative to the demographic profile of the general population.These findings are in keeping with findings from previous audits of treatment facilities inGauteng and KwaZulu-Natal (Myers & Fakier, 2007), Gauteng (Myers, 2004) and CapeTown (Myers & Parry, 2003).As substance abuse treatment need has not been properly investigated in South Africa, itis unclear whether there are disparities in the need for substance abuse treatment servicesamong the racially defined social groups. Despite this gap, emerging evidence suggeststhat poor Black/African communities may be especially vulnerable to substance usedisorders, due to the psychological stress associated with rapid urbanisation, poverty,neighbourhood social dysfunction, and a lack of basic infrastructure (Flisher & Charlton,2001; Kalichman et al., 2006; Latkin, Williams, Wang, & Curry, 2005) - factors thatoften characterise these communities. Anecdotal reports of increasing levels of substanceuse among Black/African communities also suggest that this pattern of service utilisationreflects the limited extent to which Black/African South Africans have access tosubstance abuse treatment rather than lower levels of substance use by these raciallydefined social groups (Myers et al., 2004; Myers & Parry, 2005).In terms of gender, findings show that women are also under-represented in substanceabuse treatment facilities. Although women comprise at least half of the generalpopulation (Statistics South Africa, 2005), on average less than 30.0% of the recipients ofsubstance abuse treatment services in Free State, Limpopo, Mpumalanga, North West andNorthern Cape are women. This finding is in keeping with findings from previous auditsof substance abuse treatment facilities in Cape Town; Gauteng as well as KwaZulu-Nataland Gauteng (Myers, 2004; Myers & Parry, 2003; Myers & Fakier, 2007) andinternational research which points to the under-representation of women in treatment(Schober & Annis, 1996; Zule, Lam, & Wechsberg, 2003). However, this pattern oftreatment service utilisation by women probably reflects the limited extent to whichwomen have access to substance abuse treatment rather than lower levels of substanceuse by women; especially given research which suggests that similar proportions of menand women drink at risky levels in South Africa (Parry et al., 2005) and that points to70

high levels of substance use among women in Cape Town (Sawyer, Wechsberg, &Myers, 2006).4.3.2. Access to treatment: Targeting barriers to treatment entrySeveral studies have identified barriers that hinder access to treatment for clients fromunderserved groups. In South Africa, these barriers include awareness of treatmentservices; logistic barriers including access to transport; affordability barriers relating tothe costs of services; and linguistic barriers, relating to the language in which services areprovided (Myers, 2007). These barriers, if unaddressed, may negatively impact ontreatment-seeking behaviour (Beardsley et al., 2003; Joe et al., 2002). This studyexamined the extent to which substance abuse treatment facilities address these keybarriers to treatment entry for clients from historically underserved groups.Awareness-related barriers to treatment entryLimited knowledge and awareness about where to seek help for substance use disordersand how to access help inhibits entry into substance abuse treatment (Hser et al., 1998),particularly for poor Black/African substance users (Myers, 2007). Less than half offacilities attempt to address this barrier by conducting routine awareness campaigns (atleast once a month) that provide information about substance abuse treatment options.Just over half of facilities report routinely distributing information and materialspertaining to substance abuse and available treatment options. Over 80.0% of facilitiesroutinely conduct outreach among vulnerable groups and conduct outreach indisadvantaged areas. In comparison, the inner city areas are relatively neglected, with justover 50.0% of facilities routinely targeting these high-risk areas.The important role that outreach can play in addressing awareness-related barriers amongunderserved Black/African communities (and in facilitating treatment entry) is reflectedin findings that facilities which conduct outreach activities in disadvantaged areas treatsignificantly more Black/African clients than facilities without these services.Logistic and affordability barriers to treatment entryAffordability and other logistic barriers (such as access to transport) also hamper entryinto treatment for South African substance abusing populations (Myers, 2007). For71

example, several studies report that “lack of transportation” is a barrier to substanceabuse treatment entry (Hser et al., 1998), especially for low-income groups who have lessaccess to private transportation and who may not be able to afford public transport(Allard, Tolman, & Rosen, 2003). Although research indicates that providing clients withtransport increases substance abusers’ use of treatment services (Booth et al., 2000;Friedmann, Lemon, & Stein, 2001; Hser et al., 1998), only12.5% of facilitiesparticipating in this study routinely provide clients with transport to their treatmentfacility. Similarly, 12.5% of facilities routinely provide clients’ families with transport totheir facilities. This lack of transportation may limit the extent to which poorer familiesare able to participate in the treatment process. This is cause for concern as familyparticipation in treatment is an essential ingredient of effective treatment, particularly foradolescent clients (NIDA, 2006) and because a lack of participation may limit theirknowledge of how to provide a supportive social environment to their family member – akey ingredient for positive treatment outcomes (Joe et al., 2002).Affordability factors have also been identified as significant obstacles to substance abusetreatment entry (Hser et al., 1998; Myers, 2007; Tucker, Vuchinich, & Rippens, 2004).These factors include the direct costs of treatment as well as indirect costs associated withtransport to treatment facilities, replacement of wages, and child care (Myers, 2007;Tucker, Vuchinich, & Rippens, 2004). Cost barriers seem highest for substance userswithout health insurance (Sturm & Sherbourne, 2001), which in South Africa consistslargely of Black/African persons (Goosen, et al., 2003). Findings from this study showthat few treatment facilities address the cost barriers that restrict poorer clients fromentering treatment. Although more than half of facilities report routinely offering indigentclients reduced fees, often these reduced fees are still unaffordable to indigent clients.Three quarter of the facilities routinely have free treatment slots available for clients whocannot afford to pay for treatment. In terms of the indirect costs of entering treatment,less than half of the facilities have child care services available to clients participating intheir treatment programmes. As affordability considerations are one of the mostimportant predictors of treatment entry among South African substance abusers (Myers,2007), it is vital that facilities consider innovative ways in which the costs associated withtreatment can be reduced for clients from underserved groups; particularly as addressing72

these barriers appears to significantly improve entry into substance abuse treatment(Friedmann, Lemon, & Stein, 2001).Cultural and linguistic barriers to treatment entryHistorically, one of the major barriers to entering substance abuse treatment forBlack/African persons has been the lack of cultural and linguistically appropriateservices, with most treatment services being provided in English or Afrikaans and byWhite or Coloured treatment staff (Myers, 2004; Myers et al., 2005). Although researchindicates that providing clients with treatment services in their home language andmatching clients and counsellors on ethnicity and gender dimensions increases substanceabusers’ use of treatment services (Appel et al., 2004; Tucker, Vuchinich, & Rippens,2004), only a small proportion of facilities actively address these cultural and linguisticbarriers to treatment entry for Black/African clients.Although all facilities report employing multilingual staff and staff from ethnicallydiverse backgrounds, further questioning revealed that only 81.3% of facilities employAfrican language-speaking counsellors. This potentially inhibits Black/African personsfrom seeking treatment, with Black/African clients being more likely to seek treatment atfacilities that actively address the cultural/linguistic barriers they experience. Forexample, facilities that employ African language-speaking counsellors treat asignificantly greater proportion of Black/African clients, than facilities without thesecounsellors. Although treatment facilities may serve a higher proportion of Black/Africanclients because they actively target linguistic barriers to treatment entry, it is also possiblethat certain facilities employ African language-speaking counsellors because a highproportion of their clientele are Black/African. To fully understand these findings,further investigation into the relationships among demographic profile, treatment needs,and factors facilitating treatment entry for recipients of substance abuse treatment isrequired.In summary, it seems that treatment facilities in Free State, Limpopo, Mpumalanga,North West and Northern Cape have not adequately addressed key affordability,logistical and linguistic barriers to treatment entry for substance abusers fromunderserved communities. These findings mirror those found in previous audits of73

treatment facilities in Cape Town (Myers & Parry, 2003); Gauteng (Myers, 2004) andGauteng and KwaZulu-Natal (Myers & Fakier, 2007). If inequities in treatment serviceutilisation are to be addressed, these barriers need to be targeted as a matter of urgency.4.3.3. Targeting barriers to treatment retention: The appropriateness of servicesIn South Africa few facilities provide age, gender and culturally sensitive treatmentprogrammes (Myers & Parry, 2003; Myers, 2004). This is a concern as the absence ofappropriate services for groups such as women and cultural minorities and concernsabout the cultural and gender appropriateness of services have been identified as barriersto substance abuse treatment utilisation (Appel et al., 2004; Tucker, Vuchinich, &Rippens, 2004). The following sections describe the extent to which treatment facilitiesprovide culturally, gender and age-sensitive treatment services.Cultural and linguistic appropriateness of servicesConcerns about the cultural and linguistic appropriateness of South African treatmentservices have also been an obstacle to treatment retention for clients from underservedgroups, particularly Black/African substance abusers. This study found that although allfacilities report providing treatment programmes in multiple languages, a smallerproportion of facilities provide counselling that is culturally-appropriate, use culturallyappropriateassessment tools, and translate programme materials into multiple languages.These factors potentially inhibit Black/African persons from being retained in treatment,with Black/African clients being more likely to remain in facilities that provide culturaland linguistically appropriate services. Although treatment facilities may serve a higherproportion of Black/African clients because they attempt to ensure that their services areculturally and linguistically appropriate, it is also possible that certain facilities examinethe appropriateness of their services because a high proportion of their clientele areBlack/African. To fully understand these findings, further investigation into therelationships among demographic profile, treatment needs, and factors facilitatingtreatment retention for recipients of substance abuse treatment is required.In summary, this study suggests that the demographic profile of persons seekingtreatment may influence whether facilities provide culturally and linguistically74

appropriate services for Black/African substance abusers. This is in keeping with findingsfrom previous audits of substance abuse treatment facilities (Myers & Parry, 2003;Myers, 2004; Myers & Fakier, 2007).Gender appropriateness of servicesAlthough substance abuse treatment services are under-utilised by women (Myers, Parry,& Plüddemann, 2004), few facilities in Free State, Limpopo, Mpumalanga, North Westand Northern Cape provide services aimed at addressing some of the barriers that preventwomen from engaging and being retained in treatment. These barriers include limitedresources to arrange for independent childcare (Booth & McLaughlin, 2000), and the lackof women-sensitive treatment programmes that focus on the special needs of women(such as domestic violence and sexual assault) (Booth & McLaughlin, 2000).This study found that although three quarter of facilities report providing genderappropriateand sensitive counselling services, a smaller proportion of facilities provideservices that address women’s issues (such as trauma and violence) and use genderappropriate assessment tools. Only 1 facility (in Mpumalanga) provides womenfocused/women-onlytreatment services. Only half of the facilities provide staff withspecial training in gender-related issues that may be pertinent to treatment (such asdomestic violence). It should be noted that even though facilities may report theprovision of women-sensitive services, this lack of training in gender-related issues mayaffect the extent to which these services effectively address gender-specific issues, andultimately the retention of female substance abusers in treatment.While these findings represent an improvement on findings from previous audits ofsubstance abuse treatment facilities in Gauteng (Myers, 2004), they are still cause forconcern as previous research has identified treatment facilities’ failure to have a gendersensitivetreatment approach as a factor that limits female clients engagement andretention in treatment (Booth & McLaughlin, 2000). In addition, these findings highlightthe need to provide treatment staff with training on topics such as domestic violence,victimisation, and trauma that may be pertinent to female substance abusers as well as theneed to provide staff with training on gender-sensitive treatment approaches.75

Age appropriate servicesAccess to age and developmentally appropriate services is a key ingredient of effectivetreatment for young people (NIDA, 2006). Findings show that a relatively largeproportion of facilities report using age appropriate assessment tools, provide counsellingservices that are age and developmentally appropriate, conduct family-focusedinterventions, and employ staff trained to work with adolescents and young people. Incomparison, just over half of the facilities provide family reunification services foradolescents as well as adapt their facility environment to ensure the safety of youngpeople. However, a very small proportion of facilities provide adolescentfocused/adolescent-onlytreatment services. The latter finding is surprising in relation tothe reported staff capacity trained to work with adolescents and young people.In addition, this factor potentially inhibits young people from being retained in treatment,with young clients being more likely to remain in facilities that provide age appropriateservices. For example, facilities which provide family-focused interventions and whichadapt facility environments to make them suitable for young people treat a significantlygreater proportion of clients younger than 20 years of age than facilities without theseservices. Although treatment facilities may serve a higher proportion of adolescent clientsbecause they provide age appropriate services, it is also possible that certain facilitiesexamine the appropriateness of their services because a high proportion of their clientsare adolescents. To fully understand these findings, further investigation into therelationships among demographic profile, treatment needs, and factors facilitatingtreatment retention for recipients of substance abuse treatment is needed.4.4. MONITORING AND EVALUATION IN SUBSTANCE ABUSETREATMENT FACILITIESResearch has emphasised the importance of monitoring and evaluating (M & E) theprocess and outcomes of substance abuse treatment, not only because M & E helpsidentify areas in which treatment programmes and service delivery can be improved, butalso because evidence of treatment effectiveness can be used to inform decision-makingabout the rational distribution of human and financial resources to substance abusetreatment services (Cole, 1999). This study examined M & E activities that facilitate (i)the monitoring of clients’ progress during the course of treatment, (ii) the monitoring of76

clients progress post-treatment, and (iii) the evaluation of substance abuse treatmentprogrammes.This study examined administrative and procedural structures and activities that facilitatethe monitoring of client progress during the course of treatment. Findings show that mosttreatment facilities report having good administrative systems and structures thatfacilitate the monitoring of clients within-treatment and more than half of the facilitiesreport monitoring clients post-treatment. While all treatment facilities report developingindividualised treatment plans for each client and keep notes of clients’ progress duringtreatment; a smaller percentage of facilities obtain collateral information from varioussources; have formal discharge plans for each client and maintain a formal managementinformation system; and only 62.5% of facilities track clients’ progress once theycomplete treatment. These findings are similar to findings from previous audits oftreatment facilities in Gauteng and KwaZulu-Natal (Myers & Fakier, 2007), Gauteng(Myers, 2004) and Cape Town (Myers & Parry, 2003).Findings suggest a discrepancy between the proportion of facilities that systematicallymonitor clients’ progress post-treatment and the (large) proportion of facilities that reportmonitoring clients’ progress post-treatment via telephone and during follow-upcounselling sessions. A possible explanation for this apparent discrepancy may lie in thefact that telephonic monitoring and monitoring during follow-up counselling sessions arerelatively informal and unstructured ways of tracking clients’ progress; whereas postdischargemonitoring refers to a more formalised system of monitoring where self-reportquestionnaires and/or blood and urine tests are used to establish the extent to whichclients have achieved and maintained treatment goals. This explanation seems to besupported by the findings that only 43.8% of facilities report the use of blood tests and/orurinalysis to monitor clients’ substance use and only 18.8% of facilities use structuredfollow-up questionnaires to track clients’ progress post-treatment. In addition, just overhalf of the facilities monitor clients on an ad hoc basis or on request of family members.These findings mirror findings from audits of substance abuse treatment facilities in CapeTown (Myers & Parry, 2003), Gauteng (Myers, 2004) as well as Gauteng and KwaZulu-Natal (Myers & Fakier, 2007).77

In terms of activities relating to programme evaluation, findings show that few facilitiesin Free State, Limpopo, Mpumalanga, North West and Northern Cape have conductedformal evaluations of their treatment programmes. More specifically, less than half of thefacilities surveyed report having conducted a treatment outcomes evaluation of theirprogramme; half of the facilities have conducted a process evaluation of theirprogramme/s; with a similar proportion having evaluated the quality of their treatmentservices. Despite this, many treatment facilities make statements about their treatment“success rate.” This is cause for concern as it is impossible to make accurate claims abouttreatment “success rates” without having conducted an outcome evaluation.It should be noted that the costs of conducting formal programme evaluations are oftenhigh, and facilities that rely on public funding for financial sustainability may not havefinancial resources available for research and evaluation. [All of the facilities thatparticipated in this study have non-profit status.] Nonetheless, as findings fromprogramme evaluations can be used to both improve service quality (and client outcomes)and to motivate funding agencies for additional treatment resources, it is vital that nonprofitfacilities afford greater priority to programme evaluation activities.Finally, many facilities displayed poor understandings of the terms “monitoring” and“evaluation.” This reflects a need for substance abuse practitioners to be trained in i) theimportance of monitoring and evaluation for programme planning and serviceimprovement, ii) basic principles of monitoring and evaluation (such as the identificationof suitable indicators for monitoring and evaluating substance abuse treatmentprogrammes), and iii) systems for the routine monitoring of clients within and posttreatment.4.5. RECOMMENDATIONSTo improve the availability and utilisation of substance abuse treatment facilitiesAvailability of treatment services• In general, the availability of affordable treatment options needs to be increased. Acost-effective way of achieving this would be to increase the number of state-fundedoutpatient facilities.78

• The number of state facilities for substance abuse treatment needs to be increased.The establishment of more state-funded outpatient facilities may be a means ofproviding cost-effective substance abuse treatment services that are accessible to allsectors of the population. This should be considered for Limpopo, Mpumalanga,North West and Northern Cape, given that there are no state outpatient facilities inthese provinces. In addition, there are no state inpatient facilities in Free State,Limpopo, North West and Northern Cape.• The occupancy rates of available treatment facilities need to be maximised,specifically in Free State and Mpumalanga. Research that identifies the factorsunderpinning the under-utilisation of substance abuse treatment facilities (such asclient loads, staff competencies, and facility resources) needs to be conducted. Basedon the findings of this research, interventions that target the factors underpinning thisunder-utilisation should be designed, implemented and evaluated.Improving treatment capacity• Treatment capacity needs to be increased at existing facilities.• One way of improving capacity would be to increase the number of professional staffat treatment facilities. Additional funding needs to be earmarked for this purpose.To improve the diversity of services and range of services provided throughincreasing access to ancillary health and mental health services• A comprehensive, integrated range of services that includes access to ancillarymedical and mental health treatment services should be accessible at all treatmentfacilities.Unmet mental health needs• All clients should be assessed for co-occurring mental health disorders and ancillaryhealth problems.• All clients who require detoxification services should have access to these services -either directly or indirectly through referral to state hospital detoxificationprogrammes.79

• To ensure that clients have access to detoxification services, the availability ofdetoxification services within the public health services sector needs to be prioritised.This is important, as access to detoxification is a major barrier to treatment entry.• Facilities should be encouraged to incorporate health risk-reduction interventions intotheir treatment programmes. These interventions should focus on HIV prevention(i.e. reducing substance use-related sexual risks) and harm reduction interventions forinjection drug users.• The number of staff providing mental health services (such as psychologists andpsychiatrists) needs to be increased. Funding needs to be made available for thispurpose.Unmet medical needs• All clients should be assessed for co-occurring health disorders and health-relatedrisks, such as risk for HIV and other infectious disease.• Research, which examines the extent to which clients at outpatient facilities haveunmet mental health needs, should occur as a matter of urgency. If there are unmetmental health needs at these facilities, interventions should focus on improving accessto ancillary mental health services at outpatient facilities.Case management• While it is not always financially feasible to provide on-site access to ancillary andmental health treatment services, facilities should be encouraged to provide eitherdirect on-site access or indirect access via referral to agencies specialising in mentalhealth-related problems.• Where facilities do not directly provide access to ancillary services, a casemanagement approach should ensure that clients receive the ancillary services asplanned. The role of the case manager should be to ensure that clients are linked toexternal service providers and that they are able to access these services.80

• Another way of ensuring (indirect) access to ancillary services is through precontractingexternal service providers to ensure that they are available to provideancillary services when these services are required.To address barriers to treatment entry for underserved groups• Awareness should be raised among treatment providers about the importance ofaddressing barriers to treatment entry for clients from historically underserved groups.Logistic and affordability barriers• Logistic barriers to treatment can be addressed through the indirect costs associatedwith treatment (e.g. transport and child care). These indirect costs may preventpoorer clients from seeking treatment.• Although it is not feasible to provide transport services to all poor clients, transportrelatedbarriers can be ameliorated by ensuring that new services are geographicallyaccessible to poor communities. One way of meeting this standard is through theintroduction of mobile outpatient services that travel from community to communityrather than being purely facility-based.Awareness barriers• Awareness-related barriers should continue to be addressed among vulnerable anddisadvantaged communities.• To facilitate this, facilities should be encouraged to employ dedicated outreachworkers who can focus on raising awareness of services and distributing informationand materials among at-risk communities.• Although headway has been made in improving awareness of substance abuse,facilities need to give increased attention to outreach in inner city areas.Cultural and linguistic barriers• Cultural and linguistic barriers to treatment entry, engagement and retention amongBlack/African clients should be addressed as a matter of urgency, especially in theNorthern Cape.81

Improving the cultural, gender and age appropriateness of servicesCultural and linguistic appropriateness of services• The cultural and linguistic appropriateness of services needs to be improved.• Linguistic factors can be addressed through offering treatment services in a number oflanguages (when the clients served speak a number of languages), employingmultilingual staff as members of the clinical/treatment team, employing Africanlanguage-speaking therapists, and ensuring that treatment programme materials areavailable in a number of languages.• Training programmes should also be developed that increase the cultural sensitivity ofexisting treatment programmes and materials. For example, these trainingprogrammes can explore the cultural meanings and understandings associated withalcohol and drug use and substance use disorders.Gender appropriateness of services• The proportion of women treated at existing treatment facilities needs to be improved.• The extent to which existing services are sensitive to the needs of female substanceabusers needs to be improved.• This can be addressed through offering treatment services for women-only andthrough the provision of counselling services that are sensitive to the multiple needsof female substance users, including the need for interventions relating to sexualabuse histories, domestic violence and PTSD.• Training programmes should also be developed that increase the gender sensitivity ofexisting treatment programmes and materials. For example, these trainingprogrammes can explore the multiple needs of substance using women, key barriersto their treatment process, and effective treatment strategies for women.Age appropriateness of services• The extent to which existing services are age and developmentally appropriate foradolescents and young people needs to be examined.82

• The age appropriateness of services can be improved through adapting programmesdirected for adults to the developmental needs of young people as well as throughintroducing evidence-based treatment models that target adolescents specifically, suchas multisystemic family therapy (NIDA, 2006).• In order to ensure the appropriateness of services for young people, facilities shouldalso be encouraged to include family members in the treatment process. This can bedone by providing family reunification services as well as by providing familyfocusedcounselling services.To improve treatment service planning and delivery through research andmonitoring and evaluation activitiesNational audit• As part of the monitoring of the quality of substance abuse treatment services, and toensure that facilities endorsed by the state deliver adequate and appropriate services, anational treatment audit should be conducted on a regular basis (at least once everytwo years).• Findings from this national audit should be used to inform decision-making about (i)the allocation of funding and other resources to existing facilities and (ii) thedevelopment of new services. This decision-making should be informed by the extentto which facilities provide services to historically underserved groups.National prevalence study of substance use disorders and unmet treatment need• To prevent duplication of services and enable maximisation of scarce resources, anational survey examining the prevalence of substance use disorders and theprevalence of unmet need for substance abuse treatment services should be conductedon a regular basis (at least once every two years). Findings from this survey will helpidentify underserved communities where there is the greatest need for services andfacilitate the rational allocation of new treatment resources.83

Monitoring and evaluation• Substance abuse treatment facilities should, as a condition of registration and funding,conduct comprehensive evaluations of their treatment programmes once every fiveyears.• To cover the costs of these evaluations, 10% of all grant monies and public fundingallocated to substance abuse treatment facilities should be ring-fenced for programmeevaluation purposes. This should be a condition of public funding.• Capacity to conduct client monitoring and programme evaluations within substanceabuse treatment facilities needs to be developed. The state should consider providingpublicly funded treatment facilities with introductory courses to client monitoring andprogramme evaluation that include the provision of basic tools to facilitate theseactivities. The World Health Organisation has developed a framework forprogramme evaluation within substance abuse treatment services that may serve as auseful starting point.• Research which evaluates the relative efficacy of treatment programmes that providecomprehensive services (that is, core addiction treatment services and ancillarymental health and medical treatment services) and programmes that provide coreaddiction services only is required. Findings from this research may providejustification for the provision of a more comprehensive range of services at substanceabuse treatment facilities.84

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