Citation: Jay J, Buse K, Hart M, Wilson D, Marten R, Kellerman S, et al. (2016) Building from the HIV Response toward Universal Health Coverage. PLoS Med 13(8): e1002083. doi:10.1371/journal.pmed.1002083
Summary Points
Universal health coverage (UHC) has gained prominence as a global health priority. The UHC movement aims to increase access to quality, needed health services while reducing financial hardship from health spending, particularly in low- and middle-income countries.
As a policy agenda, UHC has been identified primarily with prepayment and risk-pooling programs. While financing policies provide important benefits, increasing access to health services will require broader reforms.
For lessons, the UHC movement should look to the global HIV response, which has confronted many of the same barriers to access in weak health systems. Considerable success on HIV has resulted from innovative approaches that UHC efforts can build upon, in areas including governance, financing, service delivery, political mobilization, accountability, and human rights.
UHC and HIV efforts must capitalize on potential synergies, especially in settings with a high HIV burden and major resource limitations.
Introduction
Universal health coverage (UHC) has gained prominence as a global health objective. United Nations (UN) member states endorsed UHC in a 2012 resolution and adopted it as a Sustainable Development Goal (SDG) target in 2015.
These global agreements conceptualize UHC as ensuring all people’s access to the health services they need, with sufficient quality to be effective, while protecting against the financial risk of out-of-pocket health spending. Global health agencies have proposed monitoring countries’ UHC progress by the proportion of the population whose financial protection and health service needs are met, at prespecified levels. Countries would determine which services they measure, except for a set of core global indicators.
Contemporary formulations of UHC dispense with the idea that countries can “achieve” UHC simply by enrolling a large proportion of the population in financing programs. Rather than nominal coverage—the formal entitlement to services—the accepted approach implies effective coverage, in which people actually receive all the services they need and experience better health as a result [4]. Recognizing that effective coverage gaps exist even in the highest-performing health systems, this approach considers UHC an aspirational end state, pursued as “a direction rather than a destination”.
To operationalize the current understanding of UHC through public policy, normative guidance must keep pace. To date, health financing reforms have received primary attention as drivers of UHC. These reforms are central: government-led prepayment and risk-pooling mechanisms can significantly reduce out-of-pocket spending, catastrophic health spending, and impoverishment. They are associated with increased utilization of health services, especially among the poor.
Improving access to services, however, requires UHC efforts to lift many more barriers. Discrimination, poor quality of care, low capacity, and other resource limitations undermine health service provision in many settings. Lifting these barriers requires significant political commitment and, often, vastly improved performance from government and other service providers.
The best example of global expansion in needed health services is the HIV response. This effort continues to face setbacks and shortcomings, including high rates of new infection among young women and marginalized groups, discriminatory laws, and approximately 22 million people in need of antiretroviral therapy (ART). However, it has achieved a 35% reduction of new HIV infections since 2000 and delivered ART to 15 million people—three-quarters in Africa, where skeptics once doubted large-scale ART coverage was possible. As a result, AIDS-related deaths have declined by 42% since peaking in 2004.
Scaling up HIV treatment and prevention services worldwide involved transformative change [9]. Following early years of confusion, misinformation, and inaction, the movement pioneered models of political activism and mobilization, reshaped institutions and norms for health governance, advanced human rights, tackled social and economic determinants of health, dramatically increased external and domestic financing for health, and revitalized critical aspects of health systems in high-burden countries .
As the UHC movement confronts major deficits in access, such as 400 million people lacking basic health services, we propose looking to the HIV response for lessons. Below, we recommend approaches from the HIV response that UHC efforts can adapt and repurpose. We focus on low- and middle-income countries (LMICs) because the HIV response has been concentrated there and because UHC strategies may be most catalytic in these settings. We also offer guidance for aligning programs in settings with a high HIV burden.