Universal Health Coverage (UHC) is defined by the World Health Organisation as ensuring “that all people obtain the health services they need without suffering financial hardship when paying for them”. It is fast gaining global political momentum as a key health priority for the post-2015 development framework which will replace the current UN Millennium Development Goals.
From the perspective of an organization that works to achieve universal access to HIV prevention, treatment, care and support, shouldn’t we give our full support to a principle that promises to deliver 100% coverage of services for everyone who needs to access them? At the International HIV/AIDS Alliance, we would answer yes – so long as the approach is grounded in reality.
There is no getting around the fact that we live in a world where significant barriers exist to the realization of Universal Health Coverage. These include insufficient funding for health leading to reduced availability and quality of services; stigma and discrimination; human rights violations; criminalizing laws such as those against homosexual behaviour or drug use which drive people underground and away from health services; and inadequate legal protection for women who are confronted with gender-based violence. Our support for UHC must depend on the extent to which its definition and implementation directly addresses all of these barriers.
The Framework Convention on Global Health (FCGH) and the post-2015 development agenda, produced by the Joint Action and Learning Initiative on National and Global Responsibilities for Health, makes a very strong case that improving health outcomes requires more than UHC. It needs a broader focus that goes beyond strengthening public health care and addresses the economic and social determinants of health, including equity and the right to health. Human rights lawyer Gorik Ooms explains in a recent blog that if UHC is not anchored in the right to health, it could look like “selective” primary health care, excluding antiretroviral treatment for example, as is the case in Ghana.
The sobering picture is that even if we get the financing for health right, this in itself does not guarantee sufficient quality of services or universal access. A recent Oxfam paper describes how many health insurance schemes which are promoted by the World Bank and other donors to finance UHC invariably disadvantage the poorest and most marginalized, and how those countries that have made the most progress to date have prioritised equity from the outset.
We need to redirect our attention towards populations and interventions excluded from current UHC models which are not tackling the barriers to universal coverage adequately enough. Addressing the stigma, discrimination, marginalization and human rights violations that prevent individuals or groups of people from accessing the health services they need requires:
Reform of legal frameworks to end criminalizing and discriminatory laws, including the criminalization of groups such as men who have sex with men, sex workers, drug users, and criminalization of HIV transmission.
Accurate context-specific disaggregated data about the needs, vulnerability and discrimination faced by marginalized populations and their level of access to services.
Appropriate demand creation to ensure improved access to health services by marginalized populations, including through strengthening community service delivery systems alongside sensitizing, training and awareness-raising among public health workers.
Addressing the underlying social and economic determinants of health beyond service delivery and extending the focus on UHC to a more comprehensive set of measures required to create healthy living conditions, reflected in an overarching outcome-focused post-2015 health goal.
UHC as a key instrument to achieve improved health outcomes for all only has real meaning when it is translated into concrete and measurable targets related to universal access and financial risk protection alongside additional targets on health outcomes and enabling healthy behaviour.
From the Alliance’s perspective, UHC will be a success if it serves the marginalized populations we work with across the world. Any gay man, irrespective of the country he lives in, should be able to go to his nearest health clinic to get tested and receive user-friendly information and services on how to protect himself against HIV. If he tests positive he should be able to get the necessary support for treatment initiation, adherence and be able to pick up his anti-retroviral therapy free of charge without fear of being denied treatment, arrested or murdered. Strong community-based organisations – that provide care and support as well as helping to uphold rights – have a critical role to play in making this possible and sustainable.
The time has come to stop idealizing Universal Health Coverage and to become realistic about how it should be delivered so as to make it work for all.
Click here to read the International HIV/AIDS Alliance’s discussion paper on Health in the Post-2015 Sustainable Development Framework.
By Marielle Hart, International HIV/AIDS Alliance