Integral community-based substance abuse treatment: a case of social innovation

The CAAC programme, created in 2014, had its origin over ten years earlier in the actions of civil society in disadvantaged communities. Following a decade of deteriorating social and labour market conditions, in 2002 Argentina fell into a severe economic crisis. GDP dropped by 10%; the poverty rate reached 58% and the unemployment rate 22% (INDEC, n.d.). The economic crisis coincided with the emergence and rapid increase in use of a “new drug” paco in the marginalized neighbourhoods of Buenos Aires (Epele, Reference Epele2011). Although shifts in illicit drug patterns had already begun in the 1990s, the cheap price, high toxicity and addictiveness of paco led to the proliferation in its use, producing visible transformations, including the rapid decline in the health of paco users and rising homelessness, begging, thefts and conflict with police and among local gangs (Epele, Reference Epele2011). The public sector, however, lacked the institutions to prevent and treat drug abuse in vulnerable neighbourhoods. The principal source of publicly funded substance abuse treatment at that time was therapeutic communities operated by civil society or private sector institutions supervised and funded by SEDRONAR through a per-day, per-person subsidy system (OAD, 2019). The capacity of these institutions, however, was insufficient to meet the demand, and the system lacked mechanisms for attending to the needs of people in situations of extreme poverty (Olivero, Reference Olivero2019; Jones and Cunial, Reference Jones, Cunial, Camarotti, Jones and Di Leo2017).

These three interconnected factors – socioeconomic crisis, increasing drug use, and an inadequate government response – created the conditions for social innovation in substance abuse treatment through the actions of civil society. Among the first new interventions were mothers’ collectives, such as Madres contra el paco (or “Mothers against paco”), created to provide support to families and denounce the lack of a public response to the expanding problem of drug abuse (López Bouscayrol, Reference López Bouscayrol2021). Social movements, such as the Movement of Excluded Workers and the Popular Movement Dignity (MTE and MPLD, by their Spanish acronyms), created their first centres specializing in the prevention and treatment of addictions in 2006 and 2012, respectively (Ferreyra, Reference Ferreyra2022).

The Hogar de Cristo’s integral community-based approach emerged beginning in the late 1990s from the actions of the Catholic priests living and working in the informal settlements of the City of Buenos Aires (CBA) to attend to the needs of people living with substance abuse in their communities.Footnote ⁴ Contacts with drug consumers often began on the streets, in ranchadas, or drug user peer groups. The initial actions ranged from providing a hot meal to accompanying a young pregnant woman to the hospital or finding temporary shelter for a man living on the street. Through the experience of providing individualized support to drug users, it became evident that drug abuse was a symptom of a broader problem of social exclusion. The residents of these neighbourhoods experienced multiple interconnected forms of deprivation related to overcrowding, precarious housing, violence, health risks, employment problems, and inadequate public services. As one interview participant said, “Addiction is just one element: it’s the fever, not the flu. The person faces all sorts of problems: an education problem, a health problem, a housing problem…” (S3).Footnote ⁵ The situation demanded an integral response that shifted the focus from the addiction to the person and aligned the forms of support with each person’s specific needs.

In 2003, the Hogar de Cristo opened its first facility, a low-threshold facility serving people living on the street; in 2008, it inaugurated its first neighbourhood centre; and by 2011, it had three neighbourhood centres located on the periphery of informal settlements in the CBA. The neighbourhood centres provided food, clothing, and showers; therapeutic groups; individual therapy; educational, training, and recreational activities; and, above all, care and support through the construction of networks of public and civil society service providers at the local level. The territorial embeddedness of the facilities within vulnerable neighbourhoods enabled the growing teams of collaborators (including social workers, psychologists, volunteers, and former drug users) to make contact with drug users and better diagnose each person’s needs. The open doors policy meant that participants had to learn to manage their recovery process from within an environment with prevalent drug use.Footnote ⁶ Another pillar of the approach is addressing addiction by building community, as illustrated by the testimony of one of the organization’s leaders:

The approach focusses on building valuable relationships with each person struggling with substance abuse and creating local support networks.

The case of the Hogar de Cristo aligns with some defining aspects of social innovation. It is a novel method of engagement (an integral, relational, community-based approach), motivated by unmet social needs, developed and diffused by an organization whose primary purpose is social. Central elements of the innovation process included learning by doing, the assessment of unmet needs within a complex and evolving environment, and the focus on creating connections. In addition, while the Hogar de Cristo is a bottom-up approach in the sense that both the diagnosis of the problem and the form of response emerged from the community, the mobilization for collective action was initiated by people (the Catholic priests) from outside of the community, a trait found in other cases of social innovation (Pradel Miquel et al., Reference Pradel Miquel, García Cabeza, Eizaguirre Anglada, Moulaert, MacCallum, Mehmood and Hamdouch2013). The priests lived in the neighbourhood and had relationships of trust and legitimacy within the community but also could exploit contacts with people in positions of power, who were instrumental for garnering economic resources and building partnerships with public entities.

To respond to the increasing demand for treatment, in 2014 the Hogar de Cristo approached SEDRONAR to request funding for the expansion of its network. A former SEDRONAR official, responsible for drafting the 2014 resolution creating the CAAC programme, confirmed in an interview that the programme was developed in direct response to a funding request from the Hogar de Cristo and that this organization’s integral, community-based approach served as a model for the programme’s design. This assertation was corroborated by other interviewees and aligns with Ferreyra’s (Reference Ferreyra2022) account of the events leading to the programme’s creation. A closer examination of the process, however, shows that several recent institutional changes created the conditions for the programme’s development. The National Mental Health Law adopted in 2010 and implemented through the 2014 National Mental Health Plan recognized the right of people with mental illness – including addictions – to integral healthcare and social assistance and promoted the substitution of residential psychiatric institutions with integrated, intersectoral, interdisciplinary, community-based service networks (Ministerio de Salud de la Nación Argentina, 2013). The paradigm shift from an asylum-based to a community-based approach produced by this law had its roots in the social and collective medicine movements, which had emerged decades earlier, and was supported by professional and technical associations, social and community organizations, and users and their families (OAD, 2019). This new normative framework paved the way for a strengthened role for community-based organizations in substance abuse treatment and the development of new forms of civil society-state partnerships in vulnerable communities.

Vertical civil society-state partnerships in substance abuse treatment policy

The CAAC programme creates a “vertical” partnership between CSOs providing support and care to vulnerable people with substance abuse problems and the national public entity responsible for drug policy (SEDRONAR, 2023a). Instead of a per-person subsidy system, the CAAC programme provides an institutional subsidy to support the organization’s activities. The size of the subsidy depends on the number of beneficiaries, quality of infrastructure, quantity and qualifications of personnel, and variety of services offered by each organization. The conditions for receiving the subsidy include the presentation of a monthly report by the organization detailing the services provided and a bimonthly report presented by the CAAC supervisory team at SEDRONAR (Resolution 266/2014, 2014).Footnote ⁷ The subsidy can be used for any purpose, an aspect that several civil society leaders said they valued because it enables their organizations to respond more effectively to changing and complex circumstances. They also appreciate not having to submit receipts, noting that many organizations operate in informal settlements or indigenous communities where transactions are often informal.

The role of SEDRONAR is to provide financing, programme coordination, technical support and training (e.g., workshops for former drug users who often work in the organizations). A SEDRONAR official explained that the CAAC supervisory team seeks to strike a balance between allowing flexibility in the programme’s administration and promoting accountability, saying “If we enforce strict accountability, we will end up excluding people” (S4). Supervisors aim to visit each CAAC (when necessary, virtually) at least four times per year, although communication is usually more frequent (often weekly) as the organizations depend on the supervisors for technical support or referrals. The representative of a CAAC in an isolated community in the north of Argentina described the style of supervision in the following way:

When irregularities are found, the response is not punitive; rather, the supervisors provide technical support and work with the local staff to identify solutions. Coproduction within this framework means collaboration between sectors, not the delegation of responsibilities to civil society.

The number of CAACs increased from 37 in 2014 to 184 in 2018 and 518 in 2023, and the proportion of SEDRONAR’s budget spent on the CAAC programme increased from 2% in 2014 to 26% in 2018 and 45% in 2023.Footnote ⁸ Growth in the programme coincided with a decline in the proportion of CAACs associated with the Hogar de Cristo, which fell from 48% in 2015 to 28% in 2018 and 23% in 2023, while the proportion of the CAACs affiliated with social movements rose.Footnote ⁹ To aid in the expansion process in 2017 SEDRONAR created two new institutions: CAIPPA (by its Spanish acronym) an advisory council coordinated by SEDRONAR and comprised of 12 CAAC organization representatives, which provides guidance on the formulation of integral community-based addiction policy, and a CAAC Training School which grants subsidies to existing CAACs to support the training and development of new facilities (Resolution 17E/2017, 2017). Only facilities that can demonstrate that they have experience working within the community can be incorporated into the CAAC network. Ferreyra (Reference Ferreyra2022) argues that these institutions enabled organizations related to the Catholic Church and social movements to expand their influence over the programme.

Accountability was the issue that generated the most disagreement among interview participants. Several interview participants expressed concern that, as the programme expanded, insufficient efforts were made to uphold standards, promote accountability, and ensure that CAACs remain focussed on serving individuals with addictions. One former SEDRONAR employee denounced that the programme had been used to channel economic resources to social movements politically aligned with the government in power. Although there is no concrete evidence to support this claim, it raises questions concerning the risk that programmes may be used for political purposes when based on alliances with politically active organizations. Other interview participants argued that the scaling up process had produced a highly diverse network of facilities in terms of infrastructure, human resources, target population, methods and practices and viewed this diversity as an advantage. According to testimonies of CAAC leaders at the symposium for the 10 years of the programme, while some centres were established through collective action, such as land occupations, others originated as soup kitchens, educational programs for homeless individuals, or voluntary initiatives by street-level bureaucrats, such as hospital employees, to support substance users outside their formal duties. One CSO leader said that although the CAAC organizations have different origins and approaches, “there is a lot of similarity in how we provide support, how we provide a place for each person, the approach to care” (CS1).

Another issue raised in the interviews concerns the need for better coordination between SEDRONAR and subnational governments. An official from a provincial health ministry complained that several CAACs had been created in his province without coordination with the provincial government. In one case, a CAAC was established in a small, isolated town that already had a provincially managed addiction prevention and treatment facility, resulting in a duplication of services and a waste of resources. Analysis of this case through the lens of Cejudo and Michel’s (Reference Cejudo and Michel2021) framework on instruments for policy integration indicates that coordination failures arose from two issues: the absence of a strategic decision-maker with authority over the full array of policies to address substance abuse in Argentina and insufficient information exchange among institutions. Under Argentina’s federal system, SEDRONAR is responsible for coordinating substance abuse prevention and treatment policies nationwide, while the provincial governments manage health service delivery. This division of responsibilities makes the lack of centralized authority an inherent feature of the system. Nonetheless, the observed policy failure could have been mitigated through systematic data collection and sharing between national and subnational actors combined with the creation of incentives to promote the use of that information to pursue common policy objectives.

Networks of care and support at the local level

A central component of the CAAC programme is the creation of integrated, intersectoral networks of care and support at the local level. The interview participants were asked to describe how these “horizontal” partnerships between civil society and state institutions are formed and what are the outcomes or benefits of the network.

One civil social leader likened the network-building process to the creation of a path:

This description illustrates the dynamic and unpredictable nature of network building. Rather than originating from a top-down plan, it emerges from repeated interactions between civil society actors and street-level bureaucrats in the process of responding to individuals’ specific needs.

Many interview participants highlighted the importance of personal relationships in the construction of these networks, in consonance with Evans’s (Reference Evans1996) theory on embedded civil-society-state relationships. The leader of one CAAC noted that when arranging for programme participants to be given priority in public hospitals, personal connections are important at first but later the arrangements needed to be institutionalized.

The importance of institutionalizing relationships and procedures within the network was reiterated by a SEDRONAR official, who said:

For networks to remain effective in the long term, facilities need to implement mechanisms or protocols to ensure these actions do not depend on personal connections.

Another SEDRONAR official noted that, while networks form naturally in some contexts, in others, they are fractured or fraught with conflict. Challenges in building networks can stem from contextual factors (such as community insecurity or neighbourhood conflict), the characteristics of the CAAC (insufficient personnel or poor infrastructure), or ineffective municipal or provincial government entities. She explained that “Where it doesn’t happen naturally, we personally go to work with the provincial teams, with the municipal teams, with the neighbourhood, to promote the network framework, by providing training and fostering dialogue” (S6). The official highlighted the variability in capacity across provinces and offered as an example of high capacity, the case of Santiago del Estero, which has created an interconnected network across health, education, justice, and addiction treatment services, supported by a platform that contains patients’ medical histories. It is evident that SEDRONAR functionaries play a more significant role in supporting the development of local intersectoral support networks in low-capacity provinces than in high-capacity ones, a finding consistent with work by Bello-Gomez (Reference Bello-Gomez2020), cited above.

The most frequently mentioned benefit of local support networks is their ability to facilitate access to public services. One civil society leader noted, “It breaks down barriers. It facilitates access to services for individuals who wouldn’t otherwise be able to receive treatment for their addiction, while also enabling access to healthcare, housing, education, and more” (CS3). Similarly, a physician who works in a community-based facility explained why proactive outreach efforts are needed to reach certain populations.

The community-level networks help eliminate the invisible barriers to access of public services by separating the responsibility for accompanying individual cases from that of delivering social services.

Other interview participants underscored that local support networks enable institutions to collectively make choices and design support strategies for individual cases. One civil society representative remarked, “Working in a network means making decisions together with other organisations to maintain a line of care” (CS1). Another noted, “The reality we face is so complex that we can’t do it alone…This is where the health services, addiction areas, and CAACs come into dialogue” (CS3). Similarly, a SEDRONAR official explained, “Sitting down with the other organisation, whether governmental or non-governmental, and thinking together with others about how to respond, taking into account it’s one person going through the process” (S4). All three of these participants emphasized that when responding to complex problems, like addiction, there is a need to work together and make decisions together, incorporating the perspectives of different sectors and disciplines.

Another interview participant highlighted how networks can foster improved relationships between people in addiction recovery and their communities of origin, which often harbour resentment stemming from behaviours exhibited during active substance use.

This example of healing of the community is consistent with work by White (Reference White2009), who sustains that community-based treatment approaches enable communities that have been impaired by drug-related problems to go through a recovery process.

A healthcare social worker offered a distinct perspective on the benefits of participating in a local support network. She described the relationships within the network as reciprocal, benefitting both CAACs participants and leaders while also providing much-needed support to hospital staff navigating a demanding work environment.

This example illustrates how this social worker exercises discretion when facilitating access to care for patients affiliated with a CAAC and capitalises on this relationship when seeking placement for a patient with substance abuse problems or needs support with difficult cases, forms of discretionary behaviour described in the literature on street-level bureaucrats (Maynard-Moody and Musheno, Reference Maynard-Moody and Musheno2000).

Diffusion of the CAAC model in Latin America

Since the early 2000s, international organizations like the United Nations Office of Drugs and Crime, the World Health Organization, and the Inter-American Drug Abuse Control Commission of the Organization of American States (CICAD) have supported the development of voluntary, evidence-informed, community-based approaches to substance abuse treatment over compulsory detention and punitive approaches (UNODC and WHO, 2009; OAD, 2019). Today, Latin American countries employ diverse substance abuse treatment approaches, encompassing residential treatment centres, outpatient services, and community-based approaches, managed by public entities, CSOs or through collaboration between sectors (OEA, n.d.). While community-based approaches to substance abuse treatment share common features – such as being integral, multidisciplinary, and territorially based responses developed in collaboration with communities – experiences with such approaches in Latin America have varied significantly in terms of their theoretical foundations, governance structures, objectives, activities, target population, implementation process, etc. (RIOD, n.d.).

What institutional structures and capacities are needed for other countries to adopt the CAAC model? What mechanisms exist for promoting the diffusion of substance abuse treatment policy in Latin America? What evidence on the effectiveness of this model is available or needed to support its replication in other countries? A first aspect to consider is the size and characteristics of the civil society sector. A feature that distinguishes the CAAC programme from other models is that it relies heavily on building partnerships with organizations that have proven experience working in marginalized communities. In many cases, the staff of these organizations are willing to withstand highly demanding work conditions and low pay because they are motivated by religious or social convictions (Azparren and Rossi Lashayas, Reference Azparren and Rossi Lashayas2024; Mitchell et al., Reference Mitchell, Macció, Del Monte, Piccioni and Alliger2021). A potential challenge to diffusion of this model is that governments in other countries may not encounter the counterpoints needed to construct civil society-state partnerships in marginalized communities. Governments also will likely take into consideration political factors, such as the alignment of community-based organizations with its own administration.

A second aspect to consider is the governance structure and healthcare system. Although in Argentina a federal government agency is responsible for financing, coordination, and management of the CAAC programme, there is evidence that the programme could function under alternative governance structures. For example, an official from the mental health and addiction agency of a large city government noted in an interview that the municipal government has invested in improvements in infrastructure in some CAACs, fortified their staff by adding professionals, and integrated the facility into the municipal public health network through their clinical records system. This example suggests that the CAAC model could be adapted to alternative governance structures in which subnational governments are responsible for the programme’s coordination. As noted above, a benefit of programme coordination by the federal government is that it can provide enhanced technical support in jurisdictions with low capacity, when there is marked inequality in health care capacity.

Third, multiple mechanisms exist for the transfer of information and technical support on the CAAC model via international organizations, bilateral discussions with delegations from other countries, or bottom-up processes involving professional associations and transnational CSOs. One SEDRONAR official explained, for instance, that “CICAD has recognized it [the CAAC programme] as a very interesting model and is looking at how it could be implemented in other countries that require policies of this kind” and that in bilateral exchanges with Colombia, Paraguay, Peru and Uruguay, representatives “looked with great interest at the Argentine model” (S2).

Policy diffusion, however, requires not only information sharing mechanisms but also reliable evidence on policy success. An interview participant from SEDRONAR recognized that Argentina has made less progress in monitoring and evaluating its substance abuse treatment policies than other countries in the region, a finding confirmed through document analysis. The only published studies evaluating the CAAC programme focus either on participants’ access and therapeutic trajectories (OAD, 2023c) or on assessments by civil society actors working in the CAACs (OAD, 2021).

Two recent independent studies, however, provide evidence on the positive impacts of some facilities within the CAAC network. First, researchers at the Catholic University of Argentina conducted an impact evaluation of the Hogar de Cristo using the Qualitative Impact Protocol (or QuIP), a method designed to gather evidence on the causal effects of social interventions based on participant narratives (Mitchell et al., Reference Mitchell, Macció, Del Monte, Piccioni and Alliger2021). Data were collected through 36 interviews and three focus groups with participants at five Hogar de Cristo facilities in the CBA. The findings indicate that all but one participant perceived improvements in multiple life domains since they began attending the facilities, and they attributed more than half of all positive changes to the Hogar de Cristo. The most prevalent changes included improved diet and personal care, reduced drug use, increased self-esteem, and better relationships. Positive changes in education and employment were less common and typically involved a heightened interest in pursuing work or returning to school. The primary drivers of change identified were connections with local public or civil society entities, individual therapy, and peer group sessions. In addition, quantitative evidence on the duration of participation – an important predictor of the impact of treatment (see, for example, Simpson, Reference Simpson2002) – based on information from a database on programme participants in the CBA showed that 78% of participants remained in the programme for a period of at least two years. In March 2024, the director of SEDRONAR presented the results of this study at a parallel event organized with CICAD during the 67th sessions of the United Nations Commission on Narcotic Drugs in Vienna, Austria. A second study, supported by the Pan American Health Organization, focusses on Casa Masantonio, a facility which supports people with substance abuse problems combined with complex illnesses (Jimenez et al., Reference Jimenez, Rearte, Fernández, Rearte, Spirito, Blanco, Canton, Daquila, Ferro, Bossio and Vizzottiin press). Using retrospective, longitudinal data on tuberculosis patients registered in the National Health Surveillance System during 2019–2023, the study found that patients who received supervised treatment through this facility had a higher success rate (cured or completed treatment) and a lower rate of follow-up loss (93.8% and 2.1%, respectively) than non-participants (70.2% and 19.9%).

While these findings cannot be generalized to the entire CAAC network, they provide evidence on the effectiveness of the treatment approach. A robust future approach for the monitoring and evaluation of the CAAC programme could involve combining qualitative evaluation methods to explore the processes of change (i.e., how the programme works) with the creation of a participant database to continuously collect and analyse data on participation patterns and outcomes.