A report recently released by UNAIDS indicated that with increased domestic and international investment, the HIV epidemic can be ended by 2030. That’s not the first time we have heard that message. But the report also told us that we have to spend the resources in a smarter way. The report specifically said that by 2020, countries need to devote 8% of resources to programs to reduce human rights-related barriers to accessing services, and to programs that support advocacy and political mobilization (the so-called “social enablers”). The report also called for greater investment in civil society and community-based services.
Currently, despite some progress over the last five years, far less than 1% of Global Fund grant funds is spent on programs to reduce human rights barriers to services. In concept notes, most countries acknowledge that serious human rights barriers exist that limit people’s access to services. However, investment in programs that reduce these barriers remains far below what is needed. Indeed, many grants do not contain any programs to remove human rights barriers, or they include just one or two. Even where grants include such programs, they are rarely scaled up and reach only a small proportion of people in need. This is even more true for TB and malaria grants than it is for HIV grants.
The organization I work for, the Global Fund, and its partners have recognized that we need to do more and that we have to do it better. Mark Dybul, the Fund’s Executive Director, said exactly that in a special session of the U.N. Human Rights Council. He said that not only is this essential if the Global Fund is to achieve its objective to respect and promote human rights and gender equality, but also that it is the right thing to do, and crucial to Global Fund’s efforts to invest more strategically to end HIV. Dybul pointed out that “in many settings the impact of our grants is greatly reduced because of these barriers – whether it is in concentrated epidemics in Africa where women and girls often do not access testing and treatment or are not retained in treatment because of stigma and discrimination and gender-based violence; or in concentrated epidemics where men who have sex with men, people who use drugs, sex workers, and transgender people cannot access prevention and treatment because of the stigma and often violence they experience in health-care settings and by the police.”
In the Global Fund’s new Strategic Framework for 2017-2022, therefore, one of the main objectives is to “introduce and scale up programs that remove human rights barriers to accessing services,” including gender inequality and gender-based violence.
How will the Fund do this? We will have to increase our efforts in all countries. However, for two reasons, we will select 15-20 countries for a particularly intense effort. The first reason is that we have many things to learn about the barriers to scaling up programs and how to overcome them. The second is that we have to prioritize where we put intense effort right away, in order to be effective.
Therefore, over the next months, through a consultative process, we will identify the countries that will be part of this initiative, based on a number of criteria that are currently being finalized. In-depth baseline studies will be undertaken in each of the countries selected between September 2016 and April 2017, to document the following: (a) the nature of human rights barriers to program effectiveness and coverage; (b) the populations most affected; (c) relevant existing programs and their costs; (d) proposed programs and costs of scale-up; (e) existing efforts in community-based monitoring and health-service monitoring relevant to Global Fund goals; (f) the capacity of country coordinating mechanisms, community-based organizations, technical partners, human rights institutions, and technical ministries to contribute to implementation and support of proposed programs; (g) capacity-building needs and strategies to address those needs; and (h) larger environmental barriers and facilitators.
Based on these studies, a detailed five-year plan will be developed for each of the countries and implemented with partners to bring programs to scale. The goal will be to implement comprehensive programs to address the human rights-related barriers to services in each of the countries. The result, we expect, is that more people will avail themselves of these services and that more people will be retained as clients. This will be achieved by decreasing stigma and discrimination, particularly in health-care settings; increasing access to justice; and reducing violence and discrimination against women and girls. We also expect to achieve greater support among law enforcement officials for prevention and treatment services; a more conducive policy environment; and strengthened participation of affected persons in programs linked to these interventions.
In 2019 and 2021, the impact of the programs put in place and scaled up to remove human rights barriers will be evaluated against the baseline studies. The Global Fund Board will be updated periodically on results, and the final results will be available to inform the preparation of the next Global Fund strategy.
What programs need to be scaled up?
UNAIDS has already defined and costed seven key HIV-related programs to reduce stigma and discrimination and increase access to justice. The seven programs are as follows:
- Stigma and discrimination reduction
- HIV-related legal services
- Monitoring and reforming laws, regulations and policies relating to HIV
- Legal literacy (so-called “know your rights” programs)
- Sensitization of law-makers and law enforcement officials
- Training of health care providers on human rights and medical ethics related to HIV
- Reducing discrimination and violence against women, as well as harmful gender norms
For TB and malaria, working groups have been established with technical partners, community representatives, and researcers to define appropriate programs. Work will be completed by the fall of 2016, so that programs can be included in TB and malaria concept notes by early 2017.
Intense efforts in 15 to 20 countries and clearly defining the programs needed for each of the three diseases will not be enough. As mentioned above, we will have to undertake efforts to scale up programs to reduce human rights barriers in all countries, including in challenging operating environments and in countries nearing transition.
There are many reasons for the limited investment to date in programs to remove human rights barriers to health services. These include lack of awareness of the existence of such programs among health professionals and lack of understanding of their programmatic elements. They also include the fact that many planners and implementers are not aware of the evidence of the impact of these programs or of their cost-effectiveness. Though planners may be aware of the programs, they may not feel that it is justified to spend limited health funds on them. Finally, in some settings, there remains political or cultural opposition to these programs.
Many things will be done to try to address these barriers, including much greater efforts to further build the capacity of Global Fund staff regarding the nature, content, costs, impact, and importance of these programs; and efforts to sensitize and work closely with CCMs and other country level stakeholders, including civil society and affected communities, on the importance of these programs. We will also seek greater collaboration and coordination with technical partners, especially UNAIDS, UNDP, and WHO, so as to ensure inclusion of these programs in the development of national strategic plans, investment cases, country dialogues, and concept notes. Further, focus-of-application requirements have been changed to require that countries include programs to reduce human rights barriers in their concept notes. Finally, a proposed corporate key performance indicator on human rights, with three sub-objectives, will help drive investments, as will, hopefully, some incentive funding for countries that will require it.
Our plans are currently being further refined to take into account the input we received from over 80 experts who came together in Geneva on 14-15 April, at a convening on “Scaling up programs to reduce human rights barriers to HIV, TB, and malaria services and increasing the evidence of their health impact.” Even though they highlighted the many challenges we’ll face as we will implement the plan, participants were thrilled to be able to contribute to making our vision a reality – greater access to HIV, TB, and malaria services and, ultimately, more infections averted and lives saved, thanks to a concerted effort to reduce human rights-related barriers.
Ralf Jürgens has been the Senior Human Rights Coordinator in the Community, Rights and Gender Department of the Global Fund since May 2015.