Each year, the NGO Delegation to the Programme Coordinating Board (PCB) prepares a report on an aspect of the response to HIV that merits greater prominence, stronger policy perspective and clearer agreement across the United Nations Joint Programme on HIV/AIDS (UNAIDS).

For 2019, the NGO Delegation report focuses on the essential role of people living with HIV and other key populations, women and young people in making Universal Health Coverage (UHC) truly universal as an effective and efficient strategy that benefits all in need, including those most marginalized.

UHC is a critical issue for both the global health agenda and the global HIV response. It has been the subject of discussions and debates at national, regional and international levels. In some of those multisectoral forums, civil society–– including organizations and networks by and for people living with HIV and other key populations, women and young people––have expressed their needs and concerns in relation to UHC.

The forums have included the Thematic Session on UHC at the 44th UNAIDS PCB Meeting in June 2019, the first United Nations (UN) High-Level Meeting on Universal Health Coverage in September 2019, and the associated multistakeholder hearing in April 2019. The High-Level Meeting culminated in the approval of the Political Declaration on Universal Health Coverage.

The Political Declaration on Universal Health Coverage sets out Member States’ conceptual understanding of and political commitments to UHC. The text has been criticized by some in civil society for not explicitly naming key populations who are crucial to the HIV response, such as gay men and other men who have sex with men, people who use drugs, sex workers and trans people. That omission–– especially when compared to the Declaration's naming of "all children, youth, persons with disabilities, people living with HIV, older persons, indigenous peoples, refugees and internally displaced persons and migrants"––risks rendering certain populations invisible in UHC.

Another criticism of the Declaration is that it lacks a practical performance framework that will make results transparent and measurable.
In addition, the text fails to mention key conditions for ending the AIDS epidemic, such as the decriminalization of all key populations, a matter that is critically important to both key populations and the entire HIV response.
The Political Declaration does, however, provide a starting point for:

educating communities about why UHC is important to the HIV movement; ▪ raising awareness about health as a human right; and

initiating advocacy actions to strengthen government commitments to UHC and ensure that UHC at the country-level is truly universal.

Globally, the Declaration provides a consensus tool through which stakeholders can hold governments to account and advocate for action, including for ensuring that UHC is truly universal.

The 2019 NGO Delegation Report builds on the foundations laid thus far for UHC, while looking ahead to its next phase, when the Political Declaration will be operationalized. During that phase, countries will contribute to the achievement of Sustainable Development Goal (SDG) target 3.32 and several other targets by accelerating the development and implementation of UHC plans, packages and partnerships.

To support this, the NGO Delegation report goes beyond civil society’s previous advocacy messages ("what we need from UHC") to a more forthright approach ("what we bring to UHC").

The report focuses in particular on the contributions of organizations and networks led by people living with HIV and other key populations, women and young people, which have played a unique and essential role in responses to HIV, and whose work can now be replicated, adapted and scaled-up in the context of UHC and other areas of health.

The 45th Meeting of the PCB is one of the first major international gatherings to take place since the UN High-Level Meeting on Universal Health Coverage. This report seeks to maximize this opportunity and the leadership role of the Joint Programme and Member States by:

increasing understanding, and illustrating good practices and lessons learned about the significant contributions which communities, organizations and networks of people living with HIV and other key populations, women and young people can make to UHC, based on their experiences of responding to HIV; and

reconfirming existing PCB decision points and recommending new ones, so the Joint Programme can support those contributions within the operationalization of the Political Declaration and the fulfilment of a truly universal UHC.

If it is to be truly universal - Why Universal Health Coverage will not succeed without people living with HIV and other key populations, women and young people

This report argues that power in fact rests in the hands of the people, as can be seen in countless local, national and international movements to redistribute power and bring greater attention to neglected issues.

Mass movements to redistribute power often have humble beginnings, born out of desperate need or simmering injustice—sparks of frustration that ignite infernos of change. In the early days of the HIV response, grossly insufficient leadership and medical care ignited a global civil society movement. It was the loud and persistent voice of people living with HIV and key populations at high risk of infection that accelerated the pace of research on antiretroviral medicines and drove down their prices, and it is that same determination that continues to expand the provision of affordable, life-saving treatment to millions of people around the world living with HIV.

Power to the people

By Mary Clare Kennedy, Kanna Hayashi, M-J Milloy, Evan Wood, Thomas Kerr

People who inject drugs (PWID) experience elevated rates of premature mortality. Although previous studies have demonstrated the role of supervised injection facilities (SIFs) in reducing various harms associated with injection drug use, including accidental overdose death, the possible impact of SIF use on all-cause mortality is unknown. Therefore, we examined the relationship between frequent SIF use and all-cause mortality among PWID in Vancouver, Canada.

Data were derived from 2 prospective cohort studies of PWID in Vancouver, Canada, between December 2006 and June 2017. Every 6 months, participants completed questionnaires that elicited information regarding sociodemographic characteristics, substance use patterns, social-structural exposures, and use of health services including SIFs. These data were confidentially linked to the provincial vital statistics database to ascertain mortality rates and causes of death. We used multivariable extended Cox regression analyses to estimate the independent association between frequent (i.e., at least weekly) SIF use and all-cause mortality. Of 811 participants, 278 (34.3%) were women, and the median age was 39 years (IQR 33–46) at baseline. In total, 432 (53.3%) participants reported frequent SIF use at baseline, and 379 (46.7%) did not. At baseline, frequent SIF users were on average younger than nonfrequent users, and a higher proportion of frequent SIF users than nonfrequent users were unstably housed, resided in the Downtown Eastside neighbourhood, injected in public, had a recent non-fatal overdose, used prescription opioids at least daily, injected heroin at least daily, injected cocaine at least daily, and injected crystal methamphetamine at least daily. A lower proportion of frequent SIF users than nonfrequent users were HIV positive and enrolled in addiction treatment at baseline. The median duration of follow-up among study participants was 72 months (IQR 24–123). In total, 112 participants (13.8%) died during the study period, yielding a crude mortality rate of 22.7 (95% CI 18.7–27.4) deaths per 1,000 person-years. The median years of potential life lost per death was 34 (IQR 27–42) years. In a time-updated multivariable model, frequent SIF use was inversely associated with risk of all-cause mortality after adjusting for potential confounders, including age, sex, HIV seropositivity, unstable housing, at least daily cocaine injection, public injection, incarceration, enrolment in addiction treatment, and calendar year of interview (adjusted hazard ratio 0.46, 95% CI 0.26–0.80, p = 0.006). The main study limitations are the limited generalizability of findings due to non-random sampling, the potential for reporting biases due to reliance on some self-reported information, and the possibility that residual confounding influenced findings.

We observed a high burden of premature mortality among a community-recruited cohort of PWID. Frequent SIF use was associated with a lower risk of death, independent of relevant confounders. These findings support efforts to enhance access to SIFs as a strategy to reduce mortality among PWID. Further analyses of individual-level data are needed to determine estimates of, and potential causal pathways underlying, associations between SIF use and specific causes of death.

Supervised injection facility use and all-cause mortality among people who inject drugs in Vancouver, Canada: A cohort study

From South Africa to Myanmar, from Brazil to Kyrgyzstan, women are resisting the war on drugs. Killings, criminalization, incarceration, denial of medical care, and social stigma are just a few of the effects the war on drugs has had on communities around the world. It targets particular groups, with gender-specific impacts. The war on drugs is clearly a feminist issue.

Yet the effects of repressive drug policies on women, trans and gender-diverse people are rarely discussed in feminist spaces.

Our purpose with this documentation is to share AWID’s experience of strengthening relationships and building trust between feminist movements and women who work on humane drug policy in Eastern Europe and Central Asia (EECA) region, and supporting the inspiring global movement-building process led by women who use drugs

We are keen to share this experience because it has been a valuable and deep learning process for AWID as an organization. We believe this process could be useful to groups and movements involved in other cross-movement conversations, and to strengthen relationships and build new alliances.

How feminism can be enriched by the experiences of women who use drugs

How we designed a movement-support process with women who use drugs

The key learnings we drew from this experience

It is critical for feminist movements to develop awareness of the gendered, racial and class aspects of repressive drug policies and the associated criminalization and stigmatization of people who use drugs.

Harm reduction movements intersect with movements of sex workers, people living with HIV, racial justice, and LGBTQI+ movements, among others.

We must expand what feminist logistics mean to us, and make feminist spaces more accessible, safe and welcoming for women who use drugs. This is a particularly important lesson for us in AWID, as an organization that hosts convenings.

We are honored to share our learnings and experience. It has been an incredible opportunity to build new relationships with a growing and inspiring movement led by and for women who use drugs and are affected by drug policies. We have learned a lot, and hope you will too!

Feminist movements and women resisting the war on drugs

By Julian Santaella-Tenorio, Natalie S.Levy, Luis E.Segura, Pia M.Mauro, Silvia S.Martins


Cannabis use disorder (CUD) prevalence among people reporting past-year cannabis use declined from 2002–2016. We examined whether similar reductions in CUD were observed among people reporting daily/almost daily cannabis use. We expected that CUD prevalence among people reporting daily/almost daily use would not decrease.


We used 2002–2016 National Survey on Drug Use and Health (NSDUH) data, including 22,651 individuals using cannabis 300+ days in the past year. CUD was defined using DSM-IV criteria for cannabis abuse and/or dependence. Age categories included: 12–17, 18–25, and 26 + . Annual prevalence of CUD, cannabis dependence, cannabis abuse, and each individual abuse/dependence items accounted for the complex survey design. Differences in trends over time were examined by age group.


From 2002–2016, the prevalence of CUD among people reporting daily/almost daily cannabis use decreased by 26.8% in adolescents, by 29.7% in ages 18–25, and by 37.5% in ages 26 + . Prevalence of DSM-IV cannabis dependence decreased significantly among adolescents (-43.9%) and young adults (-26.8%) but remained stable in adults 26 + . Reductions in most dependence items were observed in young adults, with less consistent patterns in adolescents and adults 26 + . Prevalence of DSM-IV cannabis abuse decreased overall and for each abuse item across all age groups.


Contrary to expectations, CUD prevalence decreased significantly across all ages reporting daily/almost daily cannabis use between 2002–2016. Cannabis dependence prevalence decreased for adolescents and young adults and was stable only among adults ages 26+ reporting daily/almost daily cannabis use. Potential drivers of this decrease should be further explored.

Click here to read the full article (restricted access).

Cannabis use disorder among people using cannabis daily/almost daily in the United States, 2002–2016

This is the second edition of our annual report on how New Zealand is dealing with alcohol and other drugs. While we are doing well in some areas, in others there is significant room for improvement.

More than 70 deaths have been linked with synthetic cannabinoids since mid-2017. The death rate has dropped in recent months, but there is no room for complacency. Synthetic cannabinoids continue to cause significant harm across the country, and dangerous new substances still regularly enter the market.

Alcohol is still the most harmful drug in New Zealand. Twenty percent of New Zealanders drink hazardously, and it’s the substance most people seek help for. Alarmingly, alcohol is more affordable now than in the 1980s. The Government must prioritise minimum prices, and phase out alcohol advertising and sponsorship.

Methamphetamine use is an ongoing issue: August 2019 saw the biggest methamphetamine seizure on record. While overall use remains low, across the total population methamphetamine causes huge amounts of harm in some communities.

Māori continue to suffer disproportionately from the harms caused by alcohol and other drugs, bearing the brunt of our criminal justice approach to drug use, with high rates of arrest and conviction.

However, there is a lot to be hopeful about.

A new amendment to the Misuse of Drugs Act, passed in August, means Police may only prosecute for possession and use of drugs if it is ‘required in the public interest’. They must determine whether a health-centred or therapeutic approach would be more beneficial to the public interest than a prosecution. How this will affect prosecution rates remains to be seen, but we’re hopeful low-level drug offences will decrease, or be eliminated altogether.

We’d like to see a massive overhaul of our outdated drug laws. Next year’s cannabis referendum is a great opportunity: people are still being arrested and convicted for cannabis. In the past decade 45,665 people were convicted of a cannabis offence, and 6,583 of those were sent to prison. We look forward to moving towards health-focused legal regulation.

State of the Nation 2019: A stocktake of how New Zealand is dealing with the issue of drugs

The recent deaths of 6 young people at music festivals in Australia connected to MDMA has led to local calls for the introduction of drug checking services (sometimes called ‘pill testing’ in Australia and drug safety testing in the UK) to assist people who use drugs to make safer decisions about the drugs they intend to consume.

Drug checking services both vary in the primary purpose of the testing; who conducts the analyses and how; the range of quantitative or qualitative analytical methods used; who disseminates test results and how; where testing is located; whether test results go directly to consumers or via an intermediary; and the level of engagement with other stakeholder.

Evidence supports on-site rapid ‘real time’ testing where drugs are also sourced on-site, mostly directly from people who use, and information is provided direct-to-consumers and emergency services onsite, as well as via broadcast alerts to attendees through social media and other channels.

There is also evidence supporting approaches where drugs are primarily sourced from drop off sites and medical incidents, with results provided via stakeholder meetings, alerts broadcast through social media and other channels.

Although evidence is still emerging, there is research showing that drug checking alters behaviour of people who use drugs. They are more likely to consume less when the drug profile differs from expectations. Drug-checking services also alter drug markets in positive ways and provide valuable information to front-line emergency services.

Further research is required to determine the effectiveness of drug checking to reduce hospitalisations and fatalities as a result of drug taking, but the limited research available is promising.

What works: Testing drugs for harm reduction

The opioid crisis has affected a substantial number of pregnant women in the United States, with the number of pregnant women with an opioid use disorder (OUD) diagnosis at delivery quadrupling from 1999 to 2014 and prenatal opioid exposure resulting in a 7-fold increase in neonatal abstinence syndrome (NAS) from 2000 to 2014. Neonatal intensive care unit admissions for NAS increased nearly 4-fold between 2004 and 2013, and in some hospitals, NAS accounts for approximately half of all neonatal intensive care unit days. There is substantial state-to-state variation in NAS rates, as well as county-level variation associated with structural factors, such as higher rates of long-term unemployment and less access to mental health care practitioners. Neonates with NAS often require prolonged and costly hospitalizations, with total hospital costs for births with NAS exceeding $500 million by 2014.

Many states have long sought to address opioid misuse in pregnancy, the proximal cause of most cases of NAS, by enacting a range of policies intended to reduce opioid use in pregnancy. A number of states recently expanded policies designed to increase the availability of treatment for women with substance use disorder (SUD), adding to the number of states that had enacted such policies in the 1990s. Such policies have likely contributed to an increase in the number of SUD treatment programs specifically for pregnant and postpartum women, although such programs remain uncommon and are not easily accessible for many women. Many states have also responded by enacting policies that are potentially punitive toward pregnant women, such as policies considering substance use during pregnancy to be child abuse or neglect. From 2000 to 2015, the number of states with these punitive policies increased more than 2-fold from 12 to 25, and the number of states requiring health care professionals to report suspected prenatal drug abuse to child protective services or health officials increased from 12 to 23.

Despite the rapidly changing policy environment, there is a paucity of information on the associations of punitive or reporting state policies being increasingly enacted since 2000 with NAS. To support more empirically informed policymaking, this study sought to address a critical gap in the literature by examining the association of states with punitive or reporting policies related to substance use during pregnancy (hereafter, punitive or reporting policies) with rates of NAS, a proxy for maternal opioid use. We hypothesized that punitive policies, which have been shown to discourage women from seeking prenatal care and SUD treatment, would be associated with higher NAS rates as women would be less likely to engage in the health care system and receive interventions that could reduce prenatal opioid use.

Association of punitive and reporting state policies related to substance use in pregnancy with rates of neonatal abstinence syndrome

Naloxone is used to treat respiratory depression caused by opioids. Opioids produce their effects by acting on opioid receptors in the brain and nervous system. Naloxone works by blocking these opioid receptors, thus stopping opioids from acting on them. This reverses the effects of the opioid primarily in their role as CNS depressants. It is a front-line response against overdose. Naloxone may be given by injection into a vein, muscle or under the skin, or via a drip into a vein (intravenous infusion).

This guidance offers best practice for the provision of naloxone for people who might experience or witness an opioid overdose.

Building on the findings from Release’s research on naloxone in England, Release hosted the Naloxone Steering Group 2019 in April 2019, in partnership with the National Addiction Centre at King’s College London. The objective of the steering group was to get key stakeholders together for a day to discuss some of the main aspects of naloxone provision in the UK and to produce guidelines on the provision of naloxone for people who might experience or witness an opioid overdose.

Drug-related deaths are on the rise in every devolved nation and “9 out of 10 overdose deaths (89 %) in the UK involved some form of opioid”1. Naloxone is a critical and life-saving intervention for those at risk of opioid drug poisoning. To mitigate the risk of fatal opioid overdose, we must foster an approach that is grounded in evidence and facilitates the enjoyment of human rights, with a goal of achieving the highest attainable standard of health for people who use drugs. To this end, the following overarching principles will need to be respected, if we are to achieve best practice in providing naloxone to those who might experience or witness an opioid overdose.

Presumption to provide - decisions should be guided by a presumption in favour of providing naloxone.

Duty to provide - naloxone should be part of the basic standard of care offered to people as part of harm reduction.

There are no real external barriers - any barriers that exist in supplying naloxone are internal and can be addressed.

Funding - there should be a clear and specific funding stream to protect funding and remove fragmentation in funding for naloxone.

Change the narrative - naloxone saves lives. Stigmatising, harmful and damaging messages surrounding naloxone and people who use (or have used) drugs are dangerous and pervasive. It is important the narrative is renewed to one that emphasises the importance of preserving life.

Naloxone is only part of the solution - naloxone should be part of a broader response to preventing drug-related deaths. The quality of drug treatment and harm reduction is also imperative to saving lives

Saving lives: Best practice guidance on the provision of Naloxone for people who might experience or witness an opioid overdose

Developed jointly by UNODC and INPUD, in collaboration with other partners, the guidance document Implementing Comprehensive HIV Programmes with People who Inject Drugs: Practical Approaches from Collaborative Interventions – otherwise known as the Injecting Drug User Implementation Tool (IDUIT) – was published in 2016. It describes how to implement effective programmes and services for HIV and HCV prevention interventions for and with people who inject drugs (PWID).

The IDUIT is based on previously published United Nations (UN) guidance documents, mainly the WHO/UNODC/UNAIDS Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users (rev. 2012) and the WHO Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations (rev. 2016).

In addition to the nine key interventions of the WHO/UNODC/UNAIDS Comprehensive Package for HIV and PWID, it includes prevention and management of overdose and sexual and reproductive health and rights (SRHR). The IDUIT also covers critical enablers, strategies, activities and approaches to increase the accessibility, acceptability, coverage, quality and uptake of interventions and services for key populations.

It contains examples of good practice from around the world that may support efforts in planning programmes and services, describes issues that should be considered and advises on how to overcome challenges.

The IDUIT tool does not seek to ignore the complex policy and legislative environment around drugs and injecting drug use in most countries, nor the need for advocacy to confront the stigma, discrimination and human rights violations faced by PWID. However, it aims primarily to address the question: what can we do now, with the resources we have, in the kinds of environments we face, to prevent the spread of HIV and hepatitis C among PWID?

Click here to access the publication on INPUD's website.

Injecting Drug User Implementation Tool (IDUIT) Training Manual

In the last decade, an increasing number of donors are withdrawing their support for healthcare. This has been especially true for middle-income countries, where the growth of domestic resources was one of the triggers for donor funding reduction. The Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) has termed this process as “transition”, although the terms such as “graduation” (USAID terminology), “sustainability” and “self-reliance” are also used.

Development Assistance for Health (DAH) is decreasing, including for HIV/AIDS. In the Eastern Europe and Central Asia (EECA) region, DAH has decreased by 33% from 2010 to 2017, resulting in the withdrawal of over US$64 million from HIV/AIDS programs . This has created pressure on national ¹ budgets and has resulted in a significant gap in HIV/AIDS funding in low- and middle-income countries where overall growth of a country’s Gross National Income (GNI) has not been accompanied with an equivalent increase in public allocations for health and social services, especially for interventions that target key affected populations.

The Global Fund remains the largest multilateral donor in the field of HIV/AIDS, especially in Europe. From 2003 to-date, it has invested over US $2,573 million in the EECA region, out of which US$1,431 million has been for HIV/AIDS .

Sustainability Bridge Funding (SBF) is an idea that has been discussed among donors and civil society organizations (CSO’s) as a way of mitigating the negative effects of transition and in providing support for key essential services for communities and key populations. As a safety net mechanism, it should respond to gaps in funding and mitigate adverse effects of donor funding withdrawal. Nevertheless, very few donors have provided this type of targeted donor support for countries losing Global Fund support. Open Society Foundations (OSF) first piloted the idea of SBF in Southeastern Europe — a region where the withdrawal of Global Fund has led to the collapse of services in countries including Romania, Bosnia and Herzegovina and Serbia — by supporting civil society to navigate the transition process and engage in effective budget advocacy.

Building on this work, in 2018 OSF, through the Eurasian Harm Reduction Association (EHRA), initiated the project, Budget Advocacy and Monitoring in countries of South East Europe³. It provided funding to three transitioning countries in the Balkan region – Bosnia and Herzegovina (BiH), Montenegro, and Serbia — through the sub-regional network organization, Drug Policy Network South East Europe (DPNSEE), to support budget advocacy for harm reduction services.

This case study looks at the implementation of this project as one of the demonstrations of the SBF mechanism, with the objectives to:

Document the SBF pilot in 3 Balkan countries and to analyze the strengths and weaknesses of this approach and to develop suggestions for improvement; and, Document the results, successes, and

Document the challenges of the budget advocacy projects supported through the SBF approach.

Interviews were recorded between April and July 2019. During the development of this case study, project implementation was not completed, although it was at an advanced stage, allowing for the interpretation of results.

Sustainability Bridge Funding: Case Study from Bosnia and Herzegovina, Montenegro and Serbia

In July 2016, the Colombian government enacted Law 1787, which regulates the use of medicinal cannabis and its trade in the country. With this decision and a series of subsequent resolutions, Colombia joined the more than a dozen countries that have put into practice different types of regulation to explore the advantages of this plant as an alternative pharmaceutical. Through the issuing of four types of licences (for the cultivation of psychoactive cannabis and non-psychoactive cannabis, for the use of seeds for planting and for the manufacture of by-products), the door was opened not just to scientific research but to a business that is going from strength to strength all over the world, and that some predict will be worth about $54 billion (US dollars) by 2025.2 More than 300 licences have been issued since the law entered into force and the country is experiencing a ‘green gold’ fever, which has attracted the attention of large investors who see cannabis as the business of the future. The country’s geography and climate, the cost of labour and inputs, and a robust long-term legal framework have made Colombia an ideal place for growing cannabis and an appealing location for transnational corporations to do business.

The entry into force of this law signified a change in the country’s drug policy. Colombia’s recent history has been marked by the presence of drug trafficking and violence associated with social conditions in the country. During the 1960s and 70s Colombia was one of the world’s main marijuana producers, and for the last 40 years it has been the leading producer of cocaine.3 This went hand in hand with a social and agrarian conflict that continued for more than half a century. The conflict lead to a war between guerrilla organisations, who saw drugs as a way to finance their political project, and other drug trafficking groups, whose leaders set up their own armies to defend themselves against extortion and threats from these insurgents. Compounded by a prohibitionist national drug policy, this situation led to new outbreaks of violence, the infiltration of drug traffickers into pre-existing social conflicts, and clashes with state security forces, ultimately resulting in about 6 million casualties.4 For decades, the Colombian government’s response to the problem of drug trafficking focused on prohibition and military attacks, causing even more negative effects rather than providing a real solution.

This is why this change in the law not only offers an alternative in terms of public health but also represents a key component in the rebuilding of a society that has suffered armed conflict for decades. In addition to this shift, in 2016 the Colombian government put an end to more than 50 years of armed conflict with the FARC guerrilla movement by signing a peace agreement. One section of this agreement focuses precisely on crop substitution and the need for a change in drug policy. Although the approach to cocaine is still punitive, Law 1787 was also designed to offer an alternative to families who were involved in drug trafficking, enabling them to move into a legal business by growing medicinal cannabis.

Although it is not clear how many people depend on this crop, the figures show that marijuana is the most commonly used drug in Colombia. The national market for medicinal cannabis is estimated to comprise some 5 million patients5 – a demand which small-scale growers can undoubtedly help to meet. However, this opportunity has been swiftly seized by large national investors, such as those formerly in the flower industry, and has attracted an influx of foreign capital. Due to the type of regulation introduced by the law, which aims to develop a pharmaceutical industry, small- and medium-scale growers have found it difficult to enter the market because they are unable to invest the millions that the business requires.

Even though the law stipulates that 10 per cent of production should come from small- and mediumscale growers, the reality is that most of the business has been dominated by large local and foreign investors. Although there are cases of associations of small-scale farmers who have come together to obtain a licence, the majority have only managed it by going into partnership with transnational corporations, most of them Canadian, which already have experience in the business. Because of this, since the law was enacted the government has passed resolutions that seek to incentivise and promote local production. However, the situation is far from ideal for local producers and discontent has already arisen. This article analyses Law 1787’s entry into force in 2016 and the challenges posed by implementing the arrangements for medicinal cannabis, especially with regard to the involvement of small- and medium-scale producers.

The first section of the paper briefly reviews the recent history of cannabis and its use in Colombia. It then focuses on the changes in the legislation that led to the approval of Law 1787 in 2016. The third section provides an in-depth analysis of the law’s implications, the types of licence and subsequent resolutions. It goes on to present an overview of the current situation in the cannabis business, the companies involved and the role of small- and medium-scale rural producers. The final section offers suggestions for how this legislation could provide more benefits to the first links in the supply chain – the people who have not only suffered the most from the negative impacts of drug trafficking but also from problems related to land distribution.

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