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How can access barriers to health services be removed?

Frontline Aids 700

A practical guide to ensuring human rights in Global Fund-financed HIV, TB and malaria programmes

According to UNAIDS, 62% of adult HIV infections in 2019 were amongst sex workers, gay men, men who have sex with men, transgender people, prisoners and drug users and their sexual partners. Too often, these groups encounter discrimination and social exclusion when they try to access HIV services.  A new guide for programme implementers points at ways to change this.

For downloading: Implementing and scaling up programmes to remove human rights-related barriers to HIV services (GFATM, Frontline Aids, BACKUP Health, April 2020)

In May 2020, Ugandan prosecutors dropped charges against 19 LGBT+ people who had been held in jail for 50 days. The 13 gay men, two bisexual men and four transgender women had been charged under the country’s emergency COVID-19 laws after police and the local sub-county chairman raided a shelter for LGBT people seeking treatment for AIDS on 29th March. During their time in prison police refused them access to lawyers and HIV positive members of the group were denied access to essential medicines. 

Both male and female homosexual activity is illegal in Uganda and there is strong evidence that these arrests were motivated by homophobia: The local Mayor was filmed forcing shelter residents to admit their homosexuality.  Discrimination against members of the LGBT+ community is, of course, not unique to Uganda.  According to Human Rights Watch, 32 African nations have various laws criminalising homosexuality and there are now fears that COVID-19 is being used to justify further violence, stigma, discrimination and punitive policies. This climate of fear is making it even harder for already vulnerable and marginalised groups to access essential services.  

Most new HIV infections occur in marginalised groups 

Sex workers, people who inject drugs, prisoners, transgender people, and gay men and other men who have sex with men generally constitute small proportions of the general population, but face increased risks of acquiring HIV infection, in part due to discrimination and social exclusion. According to UNAIDS, 62% of new adult HIV infections globally in 2019 were among these key populations and their sexual partners.

It is obvious that if HIV services cannot reach these groups, it is not only a denial of their fundamental human rights, but also undermines global efforts to defeat the HIV pandemic. A human rights-approach to HIV is critical to ending it, but currently less than 1% of HIV funding goes to human rights programmes.  

Promoting quality in human rights programming

A concerted attempt to reduce barriers to essential HIV services is now being made, with the launch in April 2020 of a new guide, titled ‘Implementing and scaling up programmes to remove human rights-related barriers to HIV services’.  The Guide was jointly developed and designed by the Global Fund to fight AIDS, Tuberculosis and Malaria (a leading international financier of the response against HIV, tuberculosis, and malaria in over 100 countries), Frontline AIDS (a non-governmental organisation which supports community organisations implementing HIV-related programmes), and BACKUP Health, which also provided the funds required for it. BACKUP Health is a programme implemented by Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) implements on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ). It assists countries in designing and managing their Global Fund-supported HIV, TB, and malaria programmes.

The aim of the Guide – the first of its kind, which has taken two years to complete – is to ‘promote quality human rights programming and work plans,’ says Antonella Virga of Frontline AIDS. It aims to start conversations about the issues, build the skills to tackle them and strengthen structures and policies to address them – and ultimately scale-up effective interventions to have a real impact.   

The guide was compiled in a unique process

The collaborative approach to compiling the Guide involved an initial desk review of existing materials and programmes, and extensive interviews and workshops over a 13-month period, which included regional training and capacity building amongst civil society organisations in four pilot countries (Cote d’Ivoire, South Africa, Uganda and Ukraine). The Guide was also subject to rigorous review by technical experts from UNAIDS, BACKUP Health, and the Global Fund, before it was finally endorsed by both the Global Fund and GIZ. 

‘The process has really been unique,’ says Ralf Jurgens, Senior Coordinator for Human Rights at the Global Fund’s Community Rights and Gender unit. Close collaboration and regional meetings have ‘made the guide more useful as people have bought into it and see their views reflected in the final draft. We want to make sure it doesn’t sit on the shelf.’ The original aim was to hold a series of regional workshops to roll out the Guide, but the COVID-19 pandemic meant that these had to be held online.  

Addressing the launch webinar, Birgit Pickel, BMZ’s Deputy Director General for Human Rights, Gender and Social Development, emphasised that

‘A key strategic priority for BMZ is to Leave No one Behind. Overcoming discrimination and stigma is an important factor in building strong health systems. The Guide is an extremely useful tool in our work.’

A pragmatic and realistic approach

The Guide reflects the Global Fund’s investment approach to reducing human rights-related barriers to HIV services and provides very practical guidance, but at the same time, it aims to be flexible enough to be relevant in all countries, despite the different conditions and circumstances they face.   Taking a modular, project management approach, the guide can be used flexibly, depending on a country/programme’s starting point.  

It first identifies barriers to HIV services, such as discriminatory attitudes from health workers and a lack of confidentiality; criminalisation, police harassment and violence; harmful and prohibitive laws and policies; a lack of information or means for preventing infection.  Next, it presents practical advice on designing quality programmes to reduce human rights-related barriers to services and improving access for key and vulnerable populations, as well as ways programmes can address the different barriers and risks faced by men and women. 

Figure 1: The essential components for quality, comprehensive, and impactful programmes

Scaling-up: ‘Necessary rather than nice’

Although programmes to remove human rights-related barriers to HIV services have existed for decades, these have often been small-scale and fragmented and there is not enough capacity or co-ordination to scale up and make a meaningful impact. This is why

the Guide advises programme implementers to cost and plan for scale-up of the required interventions and to apply for the necessary additional resources. 

‘Our vision is to move from small-scale initiatives to scale-up to population-wide initiatives. We must insist that removing human rights barriers to HIV is necessary rather than nice,’ says Frontline AIDS’ Oratile Moseki, who has worked in programmes on the ground in Botswana and South Africa and contributed to the Guide:  ‘To do this we need to mobilise Global Fund funding and involve different levels of stakeholders in the design and monitoring. Human rights programming requires a step-by-step bottom-up and context-appropriate approach.’ 

Making human rights an integral part of Global Fund processes

The hope is that when countries submit grant applications to the Global Fund, the information contained in the Implementers’ Guide will help them draw up solid proposals based on human rights and that this will become an integral part of the application, selection, funding and implementation process. ‘The Global Fund is committed to and guided by equal human rights for all,’ says Ralf Jurgens. ‘Grantees will have to adhere to these principles in their applications, and as we move into a new funding cycle, these will become more important than ever.’ 

Government investment in such programmes is the key to successful scaling-up.  That is why the Global Fund has launched a strategic initiative of investing large amounts in ‘catalytic funding’ where governments are expected to match funding from the Global Fund with their own investments. 

‘This is completely new. We have never seen this scale of ambition,’ says Jurgens. 

It will be important to evaluate the results and demonstrate that this approach works, and the Global Fund will now take this forward.

‘Unless we can demonstrate that human rights programmes actually have an impact, there will be no incentive for local governments and organisations to invest in such programmes,’ says Oratile Moseki. COVID-19 has left marginalised groups further exposed.

COVID-19 brings health system inequalities out into the open

The Guide also has broader applicability for other health programmes too, especially in a global pandemic when many increased human-rights related abuses have been reported.

Eva Schoening, Technical adviser for Germany’s BACKUP health programme, says COVID-19 has not only revealed existing inequalities; it has also deepened discrimination and left key vulnerable groups further exposed. ‘A pandemic will hit harder in places where a health system does not guarantee access to marginalised and vulnerable groups. Where it does, it is automatically stronger and more resilient.’  

While the pandemic brings many human rights challenges out into the open, they are not new and affect health systems in many countries, including those with democratic governments. The Guide developed by Frontline Aids, Global Fund and GIZ therefore takes a pragmatic approach and its first results are promising. Significant amounts of money are now going into human rights programming and governments are buying into this approach:

‘We are already seeing that new Global Fund grant applications are based on a human rights approach,’ says Ralf Jurgens. 

The Guide has already been used for the development of grant applications by the Democratic Republic of Congo, Mozambique, South Africa and Uganda.  

Even in restrictive contexts the Guide can make a difference

LGBT+ community members wait for transport home after being released from prison

‘We are learning a lot in Uganda, where the Guide is in use,’ says Jurgens. ‘We have been working with the Ministries of Health and Justice and the proposed programming in the new Global Fund grant application is going to be much stronger than in previous years.’  Even in a restrictive environment you can achieve a lot, he says, pointing out that decriminalisation of homosexuality in itself does not necessarily result in better practices. The law is only one of many barriers to be overcome – there needs, for example, to be training of health workers, the police etc.

‘As a country, we wholeheartedly appreciate [this] contribution towards the national human rights agenda,’ says Martin Nsereko, Global Fund Programme Officer, in Uganda’s Ministry of Health’s STD/AIDS Control Programme. ‘The Guide’s support was critical to our successful development of the Equity Plan and delivery of human rights activities in Uganda.’

There is undoubtedly still a long way to go, in Uganda, as elsewhere – but at least the story of the 19 people arrested at an LGBT+ homeless shelter in March and their imprisonment for 50 days has a happier ending: Last week, Uganda’s High Court ordered that they should each receive US$ 1,341 in compensation and that the officials responsible should be summoned to face criminal charges of torture and inhuman and degrading treatment. 

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