Discussions on a framework to replace the Millennium Development Goals (MDGs) are in full swing with a number of UN commissioned consultations providing recommendations on how the framework should be shaped. It now looks likely that there will be a single health goal aiming to galvanise the progress that has already been made through the health MDGs.
A lot of debate is currently occurring about what the health goal in the Post-2015 framework should look like and what targets it should include. Universal Health Coverage (UHC) is an issue that is galvanising attention but also splitting opinion on how it should be shaped and measured.
We agree with the concept of UHC – that every person in the world has the right to access high quality health services that fulfil all of their needs. However, up until now the debate about UHC has stayed at a largely surface level without really explaining the core components of UHC or addressing the enduring challenges facing its realisation, particularly for the most marginalised. Below we therefore set out our position on how we feel UHC should be positioned in the Post-2015 framework and elements that must be included/addressed within UHC. Read the full STOPAIDS position on HIV and health in the Post-2015 framework.
UHC as a key enabler to achieve an outcomes focused health goal
We believe that the health goal within the Post-2015 framework should be outcomes focused. UHC is a critical enabler in realising good health and wellbeing but is a process rather than an outcome in itself. We therefore do not support UHC as the health goal. Instead we are calling for a goal along the lines of ensuring healthy lives at all ages.
We see UHC as a key element of achieving healthy lives but it will not in itself achieve this goal. Targets on UHC (see below) should be included under the health goal alongside a target on overcoming the social determinants of health, and a target on reducing disease burdens (including taking forward the health commitments made in the MDGs that are not met by 2015).
To attempt to meaningfully measure UHC we are proposing it is broken down into its component parts with two targets – one framed around ensuring universal access to healthcare and one related to financial risk protection. This has two purposes – firstly to ensure that UHC is enshrined in the framework as the key mechanism to achieve healthy lives for all but also to ensure that both the two core components are recognised as being critical for UHC – universal access to health services that match the needs of the population and universal financial risk protection that eliminates cost as a barrier to accessing healthcare. This latter target is critical because it directly responds to the reality that there are many approaches, such as health insurance systems, that fail to eliminate cost as a barrier to accessing healthcare.
Challenges with UHC
Coverage versus Access
There are differing understandings of access and coverage and the relationship between the two. Whilst WHO argues that coverage builds on access by ensuring receipt of services, STOPAIDS has the opposite view – that coverage of health services is essential but that the availability of services does not necessarily equate to those services being accessed. The true measure of whether there is coverage of good quality, appropriate and reachable services is whether they are being accessed as needed by the most marginalised and excluded without fear of their rights and dignity being compromised.
Universal access to health services should ensure that services include and reach those needed by all sectors of society and that discrimination and other barriers to access are removed. We are therefore calling for a UHC target that focuses on ACCESS to health services for all
Measurement of UHC is difficult, and despite many efforts there is no agreed set of concrete indicators. We have concerns that some existing attempts at implementing UHC have only delivered an essential or basic package of services that have cut out expensive or politically unpopular services (such as HIV treatment, harm reduction etc). Unless these critical sectors have strong indicators then they will likely be omitted therefore we wish to see them included within the UHC measurement matrix.
We are also concerned with how the quality of services delivered under UHC will be meaningfully measured. The critical importance of linking access to quality is highlighted by the experience of MDG 2: Achieve Universal Primary Education. Countries made enrolment free to drive up coverage but without accompanying increases in quality. The end result was that the number of children enrolled in primary education increased dramatically, but the outcomes remained largely unchanged. We are calling for greater clarity on how quality of services will be measured under UHC targets
The role of civil society
Whilst we recognise that the government has ultimate responsibility in ensuring access to healthcare for all, the model of delivery of health services must be decided at a national level and should include a variety of service providers that include community and civil society organisations. Too often discussions about UHC fail to recognise the critical role of civil society as service provider, mobiliser of populations to access services and as advocates to hold the government to account. We are calling for the recognition within UHC that community organisations play a vital role in recognising local health needs, designing services that will best ensure access for all, and in the delivery of those services.
Ensuring that no one is left behind
UHC is based on the principle that health is a fundamental human right. Therefore equity is paramount. Whilst achieving universal access is something we wholeheartedly agree with, our experience from the HIV sector brings with it the reality that we live in a world where significant barriers exist to access – from social norms and practices leading to stigma and discrimination, to human rights violations and laws criminalising specific groups including LGBT populations.
UHC must therefore address these barriers that prevent access to services by the most marginalised in society and ensure that in striving for universality the “low hanging fruit” is not sought and inequality increased as we have seen with the MDGs.
Universal goals without explicit indicators to maintain a focus on the poorest and most marginalised will drive inequality rather than combat it. The data gathered to measure progress towards UHC must be disaggregated to ensure that it is reaching the poorest and most marginalised (e.g. income quintiles, sex, age, place of residence, migrant status, ethnic origin and ensure that there is no discrimination in access to services for people living with HIV, sexual minority groups, sex workers and individuals who use drugs).
Few people would disagree with the principles of UHC – health is a human right and every person should be able to access quality health services based on their own needs. Within the health community, we must now bring individuals affected by poverty and lack of health services to the centre of our vision and work together to ensure that every person can access discrimination-free services with no one left behind.
 This was recently highlighted in the report Universal Health Coverage: Why health insurance schemes are leaving the poor behind, Oxfam, 2013
 “Universal health coverage is the obtainment of good health services de facto without fear of financial hardship. It cannot be attained unless both health services and financial risk protection systems are accessible, affordable and acceptable. Yet universal access, although necessary, is not sufficient. Coverage builds on access by ensuring actual receipt of services.”