United Nations (UN) Member States endorsed a comprehensive political declaration on health at the UN High-Level Meeting on Universal Health Coverage in September 2019, agreeing to an ambitious set of targets that aim to ensure that everyone everywhere has affordable health coverage by 2030.
The guiding principle of universal health coverage is equity: everyone—irrespective of race, ethnicity, age, gender, disability or other social status—should receive the quality health services they need without suffering financial hardship due to the costs of paying for those services. A similar set of principles has guided the global HIV response for decades. Public financing is essential for countries to make sustainable progress towards universal health coverage, with funding used efficiently and in a way that ensures equitable access to quality health services. Mobilizing sufficient domestic financing is a particular challenge in low- and middle-income countries, and external assistance provides vital support to the public health systems of many of these countries.
Research from Indonesia, Kenya, Uganda and Ukraine has revealed additional concerns as countries move towards universal health coverage and transition to greater domestic funding for HIV programmes. For example, if access to HIV treatment requires being part of a national contributory health insurance scheme, individuals who cannot afford to contribute to the scheme may be denied service. To avoid such exclusion, countries are making exceptions by keeping certain services free of charge, as is often the case for vaccinations.
Concerns remain that some approaches to universal health coverage do not sufficiently address the forces that trap some populations on the margins of society. To be truly universal, universal health coverage go beyond health service delivery and address the social determinants of health and promote community participation.
Universal health coverage efforts can fruitfully draw on the groundwork laid by HIV programmes in developing multipurpose strategic information tools and systems, equitable service delivery approaches, and inclusive health governance and accountability. In addition, integrating HIV responses into national universal health coverage efforts and health systems can help sustain many of the achievements of the HIV response, such as by integrating HIV services into primary health care or by contracting nongovernmental organizations to provide services to marginalized and vulnerable groups.
The laws that facilitate universal health coverage should explicitly uphold human rights and be non-discriminatory, which is best achieved by involving civil society and communities in designing and implementing universal health coverage arrangements—one of the big lessons from the HIV response. Universal health coverage also needs a strong accountability framework that includes civil society and communities, and that has clear indicators for monitoring the quality, accessibility and results of services. It is therefore important to preserve the ability of community-based organizations to influence health policies and participate in their implementation. Thailand’s National Health Assembly is an example of a participatory health governance structure that includes strong civil society engagement, including from the HIV sector.
Universal health coverage is best approached not as an end in itself, but as a tool that countries can use alongside more sweeping efforts to achieve the highest possible standards of health and well-being for all. A central tenet of the AIDS movement has been the insistence that health justice is rooted in broader social and economic struggles for equity. As the HIV response has shown, the success of universal health coverage will depend on whether it puts people first and addresses the contextual factors that shape their health. This is becoming ever more crucial as health crises such as COVID-19 and climate change-related shocks accumulate.