Today is Universal Health Coverage Day, a day in which we urge world leaders to prioritise UHC and accelerate progress towards health care for all. New in-country research conducted by the International HIV/AIDS Alliance suggests that significant barriers to the realisation of UHC still exist. Only with health responses and systems that are centred on the health needs of individuals and communities, rather than focused on disease, will UHC be achieved.
Universal Health Coverage has fast gained prominence as a top global health priority. Endorsed by UN member states in 2012, it has become a key priority for donors, governments and technical partners, who view it as an important mechanism for delivering on Sustainable Development Goal 3 on health.
Sadly, it is not hard to see why. At least 400 million people have no access to essential healthcare services, while 40% of the world’s population lack access to any form of social protection. The impact of this can be staggering, with at least 47% of those living with HIV unable to access lifesaving HIV treatment services.
What is Universal Health Coverage?
At it’s most basic, Universal Health Coverage is about ensuring people’s access to quality, needed health services, without inducing financial hardship due to health spending – something that is particularly important in low, middle-income and transitioning countries.
To date, health-financing reforms have taken priority when it comes to achieving Universal Health Coverage, with many countries opting to implement government-led pre-payment and risk-pooling mechanisms, which significantly reduce out-of-pocket health spending at the point of delivery. Yet, the sobering reality is that even if we get the financing right, this in itself does not guarantee sufficient quality of services or universal access.
In reality, improving people’s access to health services requires the removal of other, more complex barriers. Criminalising laws towards same sex practices, human rights violations and the existence of stigma and discrimination drive people underground and away from healthcare services, whilst poor-quality of care, low capacity and other resource limitations, further undermine health service provision.
A holistic and equitable health system needs to recognise that access to healthcare is affected and determined by multiple social identities of people (gender, age, disability, sexuality and migratory status). Removal of barriers that criminalise or affect people who use drugs, gay people, sex workers, other key population groups and migrants need to be eliminated.
The SDG and their targets are interdependent – achieving one is reliant on achieving others. In the case of UHC and the unfinished global HIV, TB, and malaria agenda, it will take effective implementation of UHC to help end the three diseases. For this reason, only when key populations and vulnerable communities are meaningfully engage in health governance and community and health systems are strengthened, that universal coverage hope to be delivered.
Improving Universal Health Coverage: Listening to communities on the ground
With this in mind, the Alliance is working with partners in a number of countries where Universal Health Coverage is high on the agenda, to understand how it is being implemented and how the needs of key populations are being met. This research will then be expanded to five other countries, funded by the PITCH programme.
One interesting case study is Vietnam, which has made significant progress towards achieving universal coverage. Mandated by law since 2014, the government has made rapid progress increasing enrolment rates and allocating budgetary resources.
In November 2016, the Prime Minister signed a policy to use health insurance funds to purchase antiretroviral medications for treating HIV. The policy also mobilised provincial budgets to support people living with HIV, in paying for their health insurance premiums and co-payments.
However, whilst there are no doubts that a strong policy framework is in place, vulnerable groups are still struggling to access basic health services. For many people living with and most affected by HIV, health insurance schemes remain expensive and out of reach.
The lack of identification documents – which are vital for accessing insurance schemes – is one clear problem. People who have recently been discharged from jail or detoxification centres, or non-city residents or migrants who are unemployed and lack temporary registration papers, can often struggle to access to formal health insurance schemes. The same is true for sex workers, whose identification documents are often held by brothel managers or their pimps. Yet, even if people can access formal health insurance, the fear of exposure or the risk of discrimination, as result of disclosing their HIV status, continues to act as an additional barrier.
HIV service provision is also weak. Whilst the Vietnamese government is attempting to strengthen healthcare services, progress differs among the various provinces. Many areas are struggling financially, and cannot find the funds to cover health insurance schemes, or support the co-payment of treatment for people living with HIV. In addition to this, peer-educator schemes that help to reduce stigma and discrimination in healthcare settings are at risk of ending when international aid is withdrawn.
Similar challenges exist in Senegal, a country where only 20% of the population had health coverage in 2013. The government has embarked towards an ambitious UHC programme aiming at ensuring that 75% of the population is covered by 2017, with a strong focus on health systems strengthening and equity. To help reach this objective, the government, partners and civil society, notably with financial support of the Global Fund, are joining efforts to make sure the UHC programme provides quality and tailored services to people living with HIV and key populations.
Learning from HIV Response
From the Alliance’s perspective, Universal Health Coverage can only be considered a success, if HIV treatment, prevention, care and support services are available to 100% of those need them, whoever they may be.
Whilst the inclusion of ARV provision in national UHC plans is critical, HIV treatment cannot be delivered in isolation. HIV treatment, prevention and care go hand in hand, as well as integration of HIV and SRHR and TB services. Consequently, there is a need for a holistic and person-centred approach to universal health coverage.
To achieve this, UHC plans cannot only concern themselves exclusively with financial measures. Instead, plans must address all the barriers to effective coverage and co-ordinate with the existing health initiatives, including the HIV response.
The HIV sector has many lessons to offer, including understanding the crucial role that communities play in providing services to the most marginalised, advocating for the promotion of human rights and addressing stigma and discrimination in healthcare settings. Universal Health Coverage and HIV efforts must capitalise on these potential synergies – especially in settings with high HIV burden, major resource limitations and contexts where other diseases need to be addressed.
Clare Morrison, Support Officer: Influence, International HIV/AIDS Alliance