Background

Five years ago, the Global Fund launched its Breaking Down Barriers (BDB) initiative. Its objective was to provide technical and financial support to 20 countries to help them overcome systemic human rights barriers that hinder access to HIV, TB and malaria services. In particular, the Global Fund wanted to counter stigma, discrimination, punitive laws and policies, abusive law enforcement practices, disrespectful treatment in health services and inadequate services: often faced by key populations (KPs). A mid-term assessment review was published in July 2022 and shows room for improvement. However, the report also provides a broad overview of information and practices that will be useful for the Global Fund's future catalytic investments.

Assessment methodology

At a general level, the methodology used to demonstrate the impact of interventions is structured around three levels of varying importance.

• In-depth assessment.
• Program assessment,
• Rapid assessment,

These assessments were primarily based on a review of BDB documents and on a series of interviews carried out with various resource persons. Due to COVID-19, almost all of the assessments conducted in the 20 beneficiary countries (in various different ways) took place remotely, and the level of analysis and the number of interviews conducted depended on the type of assessment used for each country. Using a rating system of 0-5, the purpose of the assessment was to "(a) to assess [quantitatively] progress made in creating a supportive environment and establishing comprehensive and quality programs to address human rights barriers to accessing HIV and TB services; (b) to describe [qualitatively] emerging evidence on the impact of the Breaking Down Barriers initiative; and (c) to inform future investments and efforts as part of a comprehensive response".

This approach has identified several substantive trends.

The results are generally satisfactory

However, there have been difficulties implementing the initiative specific to each country; given the multiple constraints created by the COVID-19 pandemic, Breaking Down Barriers has enabled all recipient countries to make "considerable progress" in health care access for KPs affected by HIV and TB. The two figures below give an overview of this progress. In the two diseases.

Figure 1. Baseline versus midterm: Overall HIV score

Figure 2: Baseline versus midterm: Overall TB score

While some countries are clearly performing much better than others, the average improvement is 0.9 on the 0-5 scale. At this point It is worth reflecting on the scope of these generally satisfactory results. The report reveals that BDB calls for a balance to be struck between all the structural driving forces that can help to eliminate or reduce the multifaceted injustices that hinder access to HIV and tuberculosis services. There are various different driving forces:

• Raising community awareness (radio broadcasts, community dialogues, etc.) on the harmful effects of stigma and discrimination against KPs.
• Training and mobilizing health professionals on ethical and legal issues in care services for people living with HIV and TB (confidentiality around medical records and HIV or TB status).
• Advocacy for the reform or repeal of laws and policies that hinder access to health services, especially for KPs.
• Facilitating access to community legal and paralegal services.
• Sensitization of law enforcement officers, parliamentarians, and health professionals on gender-based violence.
• Mobilization of people living with HIV and TB, TB survivors and other KPs as peer paralegals and as monitors of human rights abuses.
• Establishing support groups for people with TB and their families.
• Technical and financial support to selected KP-led organizations.
• Educating KPs about their rights.

Although this list is far from exhaustive, it demonstrates that the progress made by the Global Fund BDB initiative is largely dependent on taking seriously the undeniable link between health and human rights. Respecting human rights promotes health. The two figures below give an at-a-glance overview of this.

Figure 3. HIV program findings

Figure 4. TB program findings

In terms of malaria, the report gives a very specific account of the results achieved in two countries particularly affected by the disease, namely Kenya and Uganda. Although “progress” is the terminology used by the report's authors when referring to the HIV and TB responses, “promising developments” is the language used in reference to the results achieved in responding to malaria.

This was a conscious decision. Reading the passages on malaria and human rights, it is clear that the results have been slow. According to researchers involved in the report, "While there are promising developments [in Uganda], including a strengthening of community health systems for the malaria response, concerted efforts are needed to raise awareness around the human rights‐related elements for malaria." Relating to Kenya, they specifically state that “few programs were identified to address human rights‐related barriers to malaria services, and commodities and service delivery remain the focus of most malaria programming, which key informants attributed to limited human rights expertise and resources.”.

An overview of the context in the two countries mentioned above is shown in the figure below.

Figure 5. Malaria program scores

• 

Human rights and access to health care for HIV, TB and malaria are two sides of the same coin

Drawing on data from the 20 countries where BDB is being implemented, the report shows that the response to HIV, tuberculosis and malaria cannot take a purely biomedical approach. This involves addressing in depth the various systemic factors (legal and social) that increase the vulnerability of key and vulnerable populations (KVPs) to a particular disease and create barriers to them accessing health services. More specifically, BDB as an initiative and its mid-term outcomes show the close links between human rights and health. Given the uneven spread of health risks and health service access conditions, defending human rights is becoming more important than ever. We cannot respond effectively to these diseases without consistently defending human rights.

But let's be clear, it is not only a question of equipping KPs with regard to their rights but also, and perhaps most importantly, of changing the (harmful) effects of the environment and structures. A discriminatory legal environment will inevitably prevent vulnerable populations from accessing health services and from behavior that reduce their risk of contracting HIV due to the fear of being arrested, harassed or abused by law enforcement officials.

In addition, there is strong evidence that the BDB initiative is increasing the impact of Global Fund grants and highlighting interesting approaches that can be replicated in the future to ensure an efficient response to new and existing diseases.

Staying alert and vigilant: many circumstantial and systemic challenges remain

Despite clear progress made through the BDB project, some significant challenges remain. Effectively challenging structural injustices that hinder access to health care remains dependent on the availability of funding, political will, community involvement and quality, timely data. It will inevitably take political will and time to overcome certain gender norms (religious beliefs, cultural practices, etc.) that discriminate against and stigmatize key populations, including women and LGBTQ+ people.

However, legal protection for health-related civil and political rights has little meaning for people who are not in a socio-economic situation that is sufficiently secure to exercise these rights. Therefore, human rights approaches that address discrimination, stigma and exclusion must also advance social and economic equality and justice - recognizing that poverty and inequality expose KPs to violations of their civil and political rights and therefore negatively impact access to HIV, tuberculosis and malaria services