I have read the journal's policy and have the following conflicts: some authors are employed by institutions discussed in this article, including UNAIDS, the Global Fund, the World Bank, and the Government of Rwanda. AB is a member of the Editorial Board of
Wrote the first draft of the manuscript: JJ. Contributed to the writing of the manuscript: KB MH DW RM AB. Agree with the manuscript’s results and conclusions: JJ KB MH DW RM SK MO JDQ TE PP MD AB. Conceived the project: JJ JDQ. Provided extensive comments and revisions on multiple drafts: KB MH AB DW. Provided information for the Rwanda case study: AB. All authors have read, and confirm that they meet, ICMJE criteria for authorship.
Jonathan Jay and colleagues draw lessons from the the global HIV response that could help guide the universal health coverage movement.
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.
Universal health coverage (UHC) has gained prominence as a global health objective. United Nations (UN) member states endorsed UHC in a 2012 resolution [
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 [
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 [
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 [
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) [
Scaling up HIV treatment and prevention services worldwide involved transformative change [
As the UHC movement confronts major deficits in access, such as 400 million people lacking basic health services [
The HIV response has established paradigms for including citizens in health governance at all levels, with unprecedented participation through mechanisms such as the Global Fund Board, Country Coordinating Mechanisms, and the Joint UN Programme on HIV and AIDS (UNAIDS) Programme Coordinating Board. Community groups and networks, often operating outside the formal health system, have strengthened community systems to extend services to marginalized and stigmatized populations. Alongside ministries and parliaments, civil society organizations engage in formal arrangements for monitoring HIV programs [
UHC proponents should conceptualize UHC reforms as a partnership between government and the public [
As discussed above, prepayment and risk-pooling arrangements can improve equity, increase utilization, and reduce impoverishment; they should not, however, represent the full extent of new budgeting towards UHC. As the HIV response encountered, where health systems are weak, new funds cannot go towards purchasing alone. Scaling up HIV services required financial investments in the health workforce, facilities, the pharmaceutical supply chain, and other needs [
New UHC financing offers potential synergies with HIV financing: when UHC reforms invest in health systems, HIV budgets can focus on HIV-specific interventions. One option is to fund HIV-related health services through the broader pool devoted to UHC. HIV treatment, however, represents a large share of health spending in LMICs with a high HIV burden; it might be necessary to protect the pool, at least in its early stages, with supplemental external or domestic financing earmarked for HIV. Otherwise, high demand for HIV treatment could make the pool fiscally unsound. Ghana, for example, funds ART outside its national health insurance pool [
Funding all HIV services through broader financing pools may bring efficiency gains. A well-governed pool can become an appropriate recipient for health assistance grants, as in Rwanda. Countries growing towards middle-income status and away from external financing could potentially self-finance HIV services through increased allocations to UHC financing pools, as long as necessary public health programs retain funding.
In countries with large HIV programs, UHC efforts must interface with those programs to maximize common platforms and avoid inefficiency and duplication. Integration of HIV programs with other interventions is not new, particularly with services for directly related coinfections such as tuberculosis, blood-borne infections, maternal and child health, and sexual and reproductive health. Increasingly, HIV programs incorporate interventions for chronic diseases and conditions, particularly those whose risk is increased by HIV infection and those that require similar delivery platforms [
Scaling up needed services will require further integration [
Many HIV prevention and treatment efforts focus on marginalized populations who face barriers (mostly nonfinancial) to health system access. Key populations have typically been men who have sex with men, transgender people, people who use drugs, and sex workers and their clients; they can include young women, migrants, ethnic minorities, and prisoners, among others, in different contexts [
At the same time, prepooling programs should be as inclusive as possible. Thailand, for example, adapted to the transition away from Global Fund support partly by creating mechanisms for undocumented migrants to obtain national health insurance [
For increasing access in LMIC settings, the HIV response has demonstrated the effectiveness and responsiveness of decentralized, community-based primary care platforms, as in Rwanda (see
Health workforce gaps represent a major obstacle to UHC efforts [
Between 2000 and 2013, Rwanda achieved dramatic progress in effective health coverage, including for HIV. AIDS-related mortality dropped approximately 80%, and UNAIDS targets for universal prevention of mother-to-child transmission (PMTCT) and ART coverage were achieved [
While this success is well documented, the interdependence of the HIV and UHC agendas in Rwanda deserves attention. Both are central to the Rwandan government’s Vision 2020 strategy, implemented since 2000. This cross-sectoral strategy has aligned contributions from multiple ministries and through public–private partnership and civil society participation.
Rwanda has coordinated programs to increase synergies between HIV and UHC, including through its management of development assistance funding. The ministry of health has prioritized integrated, community-based platforms and evidence-based practice: HIV-specific interventions were integrated into efforts to strengthen primary care and provide all Rwandans more equitable access and more comprehensive health services [
Governance approaches have also been inclusive. Rwanda’s HIV national response formalized civil society’s governance role through reserved seats on the board of the former National AIDS Control Commission (2001–2010) and the ongoing Global Fund Country Coordinating Mechanism. Within UHC efforts, the biannual Joint Health Sector Review convenes government, development partners, and civil society to assess all national health programs. Ten civil society representatives join this review on behalf of a range of key populations and constituencies.
The HIV response succeeded not just because its agenda was technically sound but because it tapped larger narratives and built political demand. The public must demand UHC.
Although respondents in LMIC surveys prioritize quality health care [
Communications campaigns can tap into larger political narratives. AIDS campaigns argued that it is unfair that some people should die, and others survive, based simply on income, place of birth, sexual orientation, or gender identity [
UHC advocates can also draw from AIDS campaigns by connecting UHC to economic growth and national security. They can cite evidence on the economic benefits of health reform, including the estimate that health system investments will generate 9- to 20-fold returns in LMICs by 2035 [
Weak, unjust health systems pose security concerns. HIV advocates established political momentum by highlighting societal and economic threats, resulting in the first UN Security Council resolution on a health issue, in 2000 [
In the HIV response, calls to action were not limited to the community level. Champions such as former Presidents Festus Mogae of Botswana and Olusegun Obasanjo of Nigeria and former UN Secretary-General Kofi Annan led major national and international efforts. Similarly, top political leaders have been critical to successful UHC legislation. The UHC movement should recruit them actively. Advancing UHC not only is an obligation but may provide political benefits [
Whether led by communities or politicians, emphasizing human rights or socioeconomic security, a focus of the HIV response has been clear, bold ambition with messages and arguments that resonate from the “elevator speech” to in-depth analysis. For UHC, robust data—extensive, credible, and disaggregated by subgroup—are necessary to drive ambition and accountability [
Moreover, monitoring should measure equity across multiple dimensions of vulnerability and marginalization. While UHC proponents have suggested disaggregating by income, gender, and geography [
The health system alone cannot achieve UHC [
Such multisectoral actions should be part of a UHC reform agenda cutting across government divisions—a “health in all policies” approach [
We have argued that UHC programs cannot concern themselves exclusively with financial measures—they must address all of the barriers to effective coverage and coordinate with existing health initiatives, including the HIV response.
This approach could help accelerate global HIV efforts [
UHC reforms provide a vehicle for governments to increase their health investments. Alongside continued support from international partners, these much-needed investments could bolster the financial sustainability of HIV programs by strengthening health systems, promoting economic growth, and, over time, reducing reliance on external financing. UHC reforms could also expand access to the other health services required by the millions of people who are already accessing ART.
These potential synergies demand further collaboration. With 169 SDG targets—13 in health alone [
The authors are grateful to Joseph Kutzin, Cheryl Cashin, and Chelsey Canavan for thoughtful comments on earlier drafts.
antiretroviral therapy
low- and middle-income countries
nongovernmental organization
prevention of mother-to-child transmission
Sustainable Development Goal
universal health coverage
United Nations
Joint United Nations Programme on HIV and AIDS