: Introduction The drug overdose mortality crisis persists in the United States. Evidence-based harm reduction interventions reduce overdose mortality and improve health outcomes. However, programs are challenged by social stigma against people who use drugs (PWUD) and insufficient funding, the most consequential determinant of implementation success. This study explored the determinants of funding, identified funding-related barriers and facilitators and their impact on implementation, and highlighted ways to improve funding mechanisms. Methods We conducted qualitative interviews with funding administrators (n=11) and leaders of all active harm reduction organizations in San Francisco (n=10) in Fall 2024. Data were analyzed using reflexive-thematic analysis layered with implementation science and stigma frameworks. Results Social stigma against PWUD created an outer context that allowed for political entrepreneurialism. This included politicians’ scapegoating harm reduction services as the cause of overdose mortality and public drug use in bad faith efforts to divide the public and more easily amass political power. In turn, elected officials cut funding and issued constraining directives that limited harm reduction program implementation, ultimately restraining their reach, fidelity, and sustainment. Interviewees highlighted the need to address outer context stigma and improve funding for harm reduction programs. The passthrough model, where governments fund administrative organizations to act as grant makers, represented a viable facilitator that supported program implementation. Discussion and Conclusion Effectively addressing outer context stigma remains an essential focus for future research, as does building an understanding of successful funding mechanisms and how they came to be. Until then, tactics like political entrepreneurialism and scapegoating are likely to constrain harm reduction program implementation in San Francisco and across the US.
Akiba et al. (Mon,) studied this question.