The Breaking Down Barriers initiative of the Global Fund provides financial and technical support to 20 countries to remove human rights-related and gender-related barriers to HIV, tuberculosis (TB) and malaria services. Midterm assessments of this work were conducted in each of the 20 countries, about 1.5 to 2.5 years into the initiative (depending on the country), to examine progress made and to highlight effective program interventions.
The midterm assessments focused on the scale-up of internationally recognized programs and interventions that address stigma and discrimination, gender-based violence and discrimination, punitive laws and policies, abusive law enforcement practices, disrespectful treatment in health services, and inadequate services for people in prison. Seven HIV program areas were assessed in all twenty countries. Ten TB program areas were investigated in thirteen countries.
Efforts to address human rights-related barriers to malaria services were assessed in two countries. The assessments scored programs on a 0-5 scale meant to reflect scale-up of the program and a qualitative sense of emerging impact of the interventions. Some countries were studied through desk reviews and a limited number of interviews with key informants; others were studied in greater depth with a wider range of interviews. Because of COVID 19, almost all assessments were carried out remotely.
All 20 countries saw expansion and improvements in HIV programming to address human rights-related barriers compared to baseline measures. On the 0-5 scale, the average improvement was 0.9. All countries where TB was investigated were also found to have made progress, with an average 0.6-point improvement on the 0-5 scale. This result was achieved despite COVID-19, which undermined TB programs directly in many countries as COVID caused intensified stigmatization of TB symptoms. In all 20 countries, costed national plans for comprehensive responses to human rights-related barriers were developed with the participation of a wide range of stakeholders, and adopted as country-owned plans or strategies. In most cases, these plans were based on information from the baseline studies of the Breaking Down Barriers initiative.
With respect to both HIV and TB, considerable progress was made in scaling up programs to reduce stigma and discrimination. Programs featured many forms of raising community awareness of the harms of stigma, as well as more targeted efforts such as eliminating stigma in health services. Stigma related to being a member of a key population was also confronted.
Training of and engagement with health workers on a range of human rights and ethics issues faced in HIV and TB care were also markedly expanded in most countries. In addition to stigma, programs also focused on confidentiality of medical records and of TB or HIV status as part of engagement with health workers.
The midterm assessments found progress in improving access to justice, especially for criminalized key populations, as a means of enhancing access to HIV and TB services.
Promoting rights literacy – ensuring that people with HIV and TB and key populations know their rights to be able to claim them – and mobilizing community-based paralegal and legal services advanced significantly in most countries. Improving police practices through training and other forms of engagement with police was also undertaken. Good training practices included enabling dialogue between key population members and police and providing pre-service as well as in-service police training. In most countries, advocacy was undertaken to repeal or reform laws and policies that impede health service access, especially for key populations. In a number of countries, data from community-led monitoring of human rights-related barriers to health services were captured in national-level internet-based platforms that enabled the tracking of the extent, type and disposition of cases of violations.
Efforts to ensure that HIV, TB and malaria programs address gender equality and gender-based violence were highlighted in the midterm reviews. Gender sensitivity was often featured in the content of training of law enforcement officers, parliamentarians and health workers. Many programs pursued empowerment of women’s groups to know and claim their health rights and protect themselves from violence and other abuse. Programs for transgender persons remain insufficient, but several countries are making particular efforts at rights literacy and access to justice for this population.
A hallmark of the of Breaking Down Barriers initiative, as shown by the midterm assessments, has been the empowerment of people living with HIV and TB, TB survivors and other key populations. They have been mobilized as peer paralegals and as monitors of human rights violations. NGOs led by TB survivors have organized support groups for people with TB and their families. Some key population-led organizations have received significant financial and technical support for the first time.
The midterm assessments showed that there is much work to be done to raise awareness of human rights- and gender-related barriers to malaria services. Nonetheless, there is progress.
There are efforts in national malaria plans and programs to ensure women are empowered to confront barriers to their participation in prevention and treatment efforts. The assessments found that existing community mobilization for delivery of malaria services may provide a base on which to identify excluded populations in the future.
The midterm reviews show that COVID-19 slowed the progress of the Breaking Down Barriers initiative in many countries. But they also chronicle the ways in which human rights-related work on HIV contributed to rights-based approaches to COVID-19. In a few countries, support was provided to community-based paralegals to address human rights violations occurring in COVID raids or lockdowns. Many innovative measures were undertaken to ensure that key populations would continue to receive services in spite of lockdowns or quarantines. In a number of countries, community awareness-raising focused on prevention of gender-based violence during lockdown periods.
Cross-cutting challenges in reducing human rights-related barriers were also highlighted in the midterm assessments. Many program managers cited the need for both dedicated funding and technical support to sustain rigorous monitoring and evaluation activities. The need for stronger links between access to justice activities, and health services was also raised. Persuading governments to take financial responsibility for human rights-related programs remains challenging in many countries, as does attracting a wider range of donors to support these programs.
The midterm assessments highlighted examples of interventions in all program areas that have been particularly successful or have exemplified programmatic lessons. It is hoped that these examples and lessons will continue to inform progress toward the continued scale-up toward comprehensive responses to human rights- and gender-related barriers to services