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GFO Issue 419



Christian Djoko

Article Type:

Article Number: 6

ABSTRACT This article provides an analysis of findings from the Global Fund Breaking Down Barriers (BDB) initiative's mid-term assessment report 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. More than ever before, the response involves addressing in depth the various systemic factors (legal and social) that increase the vulnerability of key and vulnerable people 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 a key issue.


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