Universal access

Statement by Winnie Byanyima, Executive Director of UNAIDS, on the occasion of Universal Health Coverage Day

12 December 2021
Winnie Byanyima
Executive Director of UNAIDS
Under-Secretary-General of the United Nations

As we commemorate Universal Health Coverage Day 2021, the world is entering year three of the COVID-19 pandemic. The pandemic has reminded us that no one is safe until everyone is safe. It shows how pandemics expose intersecting inequalities among people, countries and communities.

Universal health coverage means that all individuals and communities can access the health services they need without suffering financial hardship. But with at least half the world’s population lacking access to essential health services even before the COVID-19 pandemic, there is much work to do.

We must urgently focus on three things:

• First, addressing the inequalities that prevent us from achieving universal health coverage and from ending AIDS.
  • We need people-centred data systems that highlight inequalities and prioritize work to address them.
  • We must put human rights at the centre. The Political Declaration of the United Nations High-Level Meeting on Universal Health Coverage in 2019 called on countries to “reach the furthest behind first”.
• Second, strengthening support to community-based and community-led responses.
  • Four decades of the AIDS response have demonstrated that such support is a crucial pillar for effective pandemic responses.
  • Community engagement should be an integral part of health systems.
• Third, bolstering investment in health, sustainable and innovative financing, and ambitious thresholds for financial commitments.
  • The Abuja Declaration, signed by African governments, to spend 15% of revenues on health is such an example.
  • To achieve universal health coverage and pandemic control, we need a paradigm shift in global health financing and investments in community-led, human rights-based, people-centred and gender transformative responses.

On this Universal Health Coverage Day, I call for support and urgent action to ensure health and rights for all.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

Achieving universal health coverage in a country is an ambitious, but transformative, goal. Communities are essential to the AIDS response and will be essential to the successful roll out of universal health coverage (UHC). When national governments establish a committee to coordinate UHC, it is important to ensure that all relevant communities are involved—civil society, including people living with HIV, should be included in decision-making. If civil society is not engaged early in the development of initiatives for UHC, decisions will be made about health services without the voice of the people most affected by those decisions. The graph below shows four ways in which communities contribute to the design and implementation of UHC.

NEW YORK/GENEVA, 3 June 2019—A new report from the United Nations Secretary-General, Galvanizing global ambition to end the AIDS epidemic after a decade of progress, has been presented to United Nations Member States during the 73rd session of the United Nations General Assembly. The Member States gathered at the United Nations in New York, United States of America, to review progress and share their own progress and challenges.

“A world without AIDS was almost unimaginable when the General Assembly held its first special session on the epidemic 18 years ago,” said United Nations Secretary-General António Guterres in the report. “Since then, the global determination to defeat one of history’s greatest health crises has produced remarkable progress … and … inspired a commitment within the 2030 Agenda for Sustainable Development to end the AIDS epidemic by 2030.”

The Secretary-General’s report shows that results once derided as impossible in low-income settings have now been achieved following a decade of progress in the response to HIV. Between 2008 and 2017, there was a 43% reduction in AIDS-related deaths, a 45% reduction in new HIV infections among children and a 19% reduction in new HIV infections among adults globally. The number of people living with HIV on treatment also increased, by 5.5 times, reaching 21.7 million of the 36.9 million people living with HIV in 2017.

“The enormous achievements in the response to HIV in recent decades, under the strong leadership of UNAIDS, is one of the best examples of multilateralism in action,” said María Fernanda Espinosa, President of the United Nations General Assembly. “It is most definitely an indication of what we can achieve when we work together around a common cause."

The report shows that progress has been most marked in eastern and southern Africa, where AIDS-related deaths fell by 53% and new HIV infections among adults and children fell by 36%. An epidemic that once killed more than a million people in the region per year now claims fewer than 400 000 lives per year.

In other regions of the world, including Latin America, the Caribbean, Asia and the Pacific, western and central Europe and North America, increases in the coverage of HIV testing and treatment services have achieved significant reductions in AIDS-related deaths over the past decade. Most of those regions have also experienced declines in new HIV infections.

Notable exceptions are eastern Europe and central Asia, where the annual number of new HIV infections has risen by 30% since 2010, with an estimated 960 000 people newly infected over this time, and in the Middle East and North Africa, where deaths from AIDS-related illnesses increased by 11%, an estimated 140 000 people newly infected, over the same period.

The report notes that services focused on key populations within those regions are few and far between, and harsh punishments for same-sex sexual relationships, drug use and sex work in those regions and elsewhere are proving to be formidable barriers to the few services that are available.

In western and central Africa, insufficient domestic funding, weak health systems, formal and informal user fees for health care, humanitarian situations and high levels of stigma and discrimination continue to undermine efforts to scale up HIV testing and treatment.

Many challenges remain, including stigma and discrimination faced by people living with HIV and harmful gender norms. Laws and policies in many countries prevent young people, women, key populations―gay men and other men who have sex with men, sex workers, transgender people, people who inject drugs and prisoners and other incarcerated people―indigenous people, migrants and refugees from accessing health and HIV services.

Funding for HIV responses in low- and middle-income countries globally has also remained flat for most of the past five years. In 2017, donor and domestic investments in low- and middle-income countries were US$ 20.6 billion, about 80% of the 2020 target.

“As the Secretary-General’s report makes abundantly clear, to protect the gains we have made and to tackle the challenges that stand in the way of our promise to end AIDS by 2030, we need to firm up our resolve, strengthen our partnerships and say no to complacency,” said Gunilla Carlsson, UNAIDS Executive Director, a.i. “Let’s start with a successful replenishment that results in a fully funded Global Fund to Fight AIDS, Tuberculosis and Malaria that will enable it, along with its range of partners, including UNAIDS, to continue to deliver evidence-informed, people-centred and human-rights based support to the people and communities who need it the most.”

The report outlines that there is an important opportunity to seize the growing momentum to achieve universal health coverage, a core principle of which is leaving no one behind. Collaboration between health systems and community groups has been shown to reduce stigma and discrimination and to help to deliver services to the people in greatest need―a key recommendation of the report is the strengthening of the vital role that community groups play in the AIDS response.

In the report, the United Nations Secretary-General urges Member States to adopt the following recommendations to galvanize political will, accelerate action and build the momentum necessary to reach the 2020 targets agreed to by the United Nations General Assembly in the 2016 United Nations Political Declaration on Ending AIDS: (a) reinvigorate primary HIV prevention; (b) diversify HIV testing and differentiate the delivery of health care to reach the 90–90–90 targets; (c) establish enabling legal and policy environments in order to reach marginalized and vulnerable populations; (d) mobilize additional resources and allocate them where they are most needed; (e) support communities to enable them to play their critical roles; and (f) incorporate a comprehensive HIV response into universal health coverage.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

“If I want to see the change, I need to be the change,” said Aniz Mitha, the Executive Director of Community Health Rights Advocacy (CHeRA), an organization that works with male sex workers in Malawi. When Mr Mitha speaks of change, he does so with the quiet and unwavering authority of someone who knows what he is talking about.

From a conservative Muslim family in Malawi, Mr Mitha was thrown out of the house at a young age when his parents found out that he was gay. With nowhere to go and no means to support himself, he fled to Johannesburg, South Africa, where he spent many years as a sex worker. “For me, I was looking to survive; I wasn’t thinking about my health,” he said.

When he became ill, he took an HIV test, and he learned that he was living with HIV. Being an illegal immigrant, he couldn’t access health-care services in South Africa. He returned to Malawi, where he began HIV treatment and started CHeRA. “I thought: how can I help others not go through the same experience that I did?” he said.

CHeRA raises awareness and builds the capacity of male sex workers on HIV prevention and treatment, sexual and reproductive health and rights, economic empowerment, psychosocial support and access to justice. Through a UNAIDS funding arrangement, it recently reached more than 250 male sex workers in three priority districts in Malawi, distributed more than 30 000 condoms and lubricant and linked six male sex workers living with HIV to care and treatment. In another programme funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria, the organization has trained 50 peer educators and distributed more than 6000 condoms and condom-compatible lubricant.

Mr Mitha is keenly aware of the many challenges that face male sex workers, having faced them himself. “In Malawi, sex work is not recognized as work, so there are no laws to protect sex workers. Also, most of our male sex workers are gay men or men who have sex with men, so they live in fear of arrest because homosexuality is illegal in Malawi,” he said.

Stigma and discrimination is institutional, he said. “Male sex workers are not recognized as a key population in the HIV response in Malawi, so we are not prioritized in government plans. And negative attitudes from health-care workers push us away from care.”

“Say I am being abused or beaten and I go to a police station,” continues Mr Mitha, “I will get questions like “Why you are dressed like this or why do you speak like this?” The abuse is institutionalized. It pushes us away, so even in terms of health care, we go to private hospitals where we pay money even if we don’t have money.”

CHeRA is now registered as a nongovernmental organization. Although started in 2016, it was only registered in 2017 after UNAIDS played a pivotal role in amending provisions in the Malawi HIV and AIDS Management Control Act of 2018 that criminalized or discriminated against certain groups, such as sex workers. This paved the way for organizations of lesbian, gay, bisexual, transgender and intersex people and sex workers to be registered.

Like many people who serve others, his work has spilled over into his private life. Knowing what it feels like to be disowned by one’s family, Mr Mitha gives shelter to people who have nowhere else to go, who stay as long as it takes until they can look after themselves.

He has built an unshakeable sense of self, family and community through his work and his life. “I am living openly with HIV and as a gay person; I am a role model to so many. They see that it is possible. I see a lot more people like me opening up and living openly as gay and with HIV,” he said.

Mr Mitha wants to grow CHeRA into an organization that is a strong advocate for equitable access to health care for male sex workers.

“We need more financial support to expand the work we do,” he said. “We provide access to HIV prevention information and services to a population that is being left behind. It is making a difference. When you are working as a community organization, it means what affects my community affects me too,” he said.

The Government of Côte d’Ivoire has signalled its commitment to stop people being charged for accessing HIV testing and treatment services, declaring that it will strictly apply previously announced decisions to prevent people living with or affected by HIV being asked to pay user fees.

A note circulated by the Ministry of Health has reminded all service providers that costs for HIV testing and treatment services should not be charged to people accessing those services. The directive applies for all services for pregnant and breastfeeding women, all HIV testing services, tests for viral load suppression and the prescription of antiretroviral medicines for people living with HIV.

The directive also reminds service providers that children under the age of 15 years should have free access to health services and that young women aged 15–24 years should have free access to primary health care, HIV testing and family planning services.

In several countries, the issue of user fees has been identified as a major barrier to testing people for HIV, to treating people living with HIV and to retaining people in treatment and care.  

The renewed commitment of Côte d’Ivoire to confront the issue of user fees followed discussions between the President of Côte d'Ivoire, Alassane Ouattara, and the former President of Botswana, Festus Mogae, who visited the country in March in his capacity as Chairperson of the Champions for an AIDS-Free Generation in Africa.

Following their discussions, the government also announced its intention to increase domestic funding for the AIDS response by US$ 10 million in the next budget.

During his meeting with the President, Mr Mogae congratulated Mr Ouattara and the First Lady, Dominique Ouattara, for their personal commitment to ending the AIDS epidemic as a public health threat by 2030. Ms Ouattara is UNAIDS Special Ambassador for the Elimination of Mother-to-Child Transmission and the Promotion of Paediatric Treatment of HIV.

At the conclusion of his mission, Mr Mogae underlined the importance of accelerating the response to the epidemic. “We cannot be complacent and allow the huge improvements that we have made so far to be lost. If we stop now, we will lose everything we have already invested and achieved. The entire nation must be mobilized to ensure that no one is left behind,” he said.

There were 500 000 people living with HIV in Côte d’Ivoire in 2017, with around 46% accessing HIV treatment. 

Momentum for Universal Health Coverage (UHC) in Africa is building and many African countries have already integrated UHC into their national health strategies. But with 11 million Africans pushed into extreme poverty each year because of out-of-pocket health expenses, how can Africa achieve UHC which delivers a quality package of care for people living in Africa?

The UHC debate was buzzing in Rwanda’s capital Kigali this week during one of the largest health gatherings in Africa, the Africa Health Agenda International conference 2019.  Co-hosted by the Ministry of Health of Rwanda and the African Medical and Research Foundation (Amref Health Africa), 1500 health leaders shared new ideas and home-grown solutions to the continent’s most pressing health challenges.

Participants discussed the need for countries to embrace the concept of UHC and do their utmost to make it work. They stressed that good health allows children to learn and adults to contribute to societies and the economy. They also underscored that it can allow people to emerge from poverty and provides the basis for long-term economic security, essential for the future of the continent.

Host country President, Paul Kagame was awarded the honour of excellence in recognition of his political leadership on UHC. In a tweet he thanked Amref saying, “We owe this progress to partners like you who have joined forces with us in our journey to deliver a dignified and healthy life for all Rwandans.” The Minister of Health of Ethiopia also received an award for Ethiopia’s work in promoting primary health care.

Ensuring that everyone has access to basic health services is a challenge and the key to the success of UHC will be ensuring that the quality of services is good enough to improve the health of the people who access them.

“We need to track the impact of UHC,” said Michel Sidibé, co-moderating a high-level ministerial panel. “Coverage is not enough, we need to be delivering quality, affordable, accessible services to all. The ultimate measure of success for UHC will be whether the poorest, the marginalized and the most vulnerable people are able to benefit.”

During the conference Mr Sidibé participated in a townhall with young people. He spoke to them about their meaningful engagement in the UHC process saying that young people need to ‘claim and own the space.’ He also talked to civil society groups about the remarkable progress towards achieving the UNAIDS 90-90-90 treatment targets across Africa and of the critical need of their continued engagement on HIV within UHC.

The first ever United Nations High-Level Meeting on Universal Health Coverage will take place on 23 September 2019 during the United Nations General Assembly under the theme ‘Universal Health Coverage: Moving Together to Build a Healthier World.’

On Zero Discrimination Day, UNAIDS calls on countries to examine discriminatory provisions in their laws and policies and make positive changes to ensure equality, inclusion and protection

GENEVA, 1 March 2019—In 2018, a number of countries made landmark decisions to change discriminatory laws and bills. The Supreme Court of India struck down Section 377 of the Penal Code, which criminalized same-sex sexual relations, the Philippines lowered the age of consent for voluntary HIV testing without the need to obtain consent from a parent or guardian to 15 years and Malawi removed provisions from a draft bill that would have criminalized HIV non-disclosure, exposure and transmission.

On Zero Discrimination Day, UNAIDS recalls the equal dignity and worth of every person, as enshrined in the Universal Declaration of Human Rights, and is calling for action to change discriminatory laws and practices, which are a significant barrier for access to health and other services.

“Human rights violations are happening all over the world because of discriminatory laws and practices,” said Michel Sidibé, Executive Director of UNAIDS. “Laws must protect, not cause harm. All countries must carefully examine their laws and policies in order to ensure equality and protection for all people, without exception.”

Raising awareness, mobilizing and taking action are essential. On Zero Discrimination Day, UNAIDS is proposing specific actions that individuals, civil society organizations, parliamentarians and donor organizations can take to change discriminatory laws. These range from being an ally to someone affected by a discriminatory law to joining a nongovernmental organization, tabling amendments to laws and calling for reviews of legislation.

Making a positive change is possible and there are many ways a law can be amended or abolished. These include:

• Reforming or removing laws through parliamentary processes and the votes of parliamentarians.
  • Raising awareness among parliamentarians is therefore essential, as was done in the revision of the HIV laws in the Philippines and bills in Malawi.
• In many countries, courts have the power to strike down laws that are discriminatory. This can be done if an individual or organization affected by the law takes legal action and wins the case for change.
  • The case of India’s Supreme Court, which removed Section 377 in 2018, was a striking example.
• In some countries, people or politicians can propose law reform through a petition and request a national vote or referendum.
  • This is a standard method of legislating in Switzerland.

UNAIDS has identified a range of laws that are discriminatory, impede access to health and social services, restrict freedom of movement and violate human rights.

In 2018:

• At least 20 countries imposed travel restrictions of some form against people living with HIV.
• Around 29 countries reported that they require the consent of a woman’s husband or partner to access sexual and reproductive health services.
• Fifty-nine countries reported mandatory HIV testing for marriage, work or residence permits or for certain groups of people in the law, regulations or policies.
• Seventeen countries criminalized transgender people.
• Forty-five countries had laws that impose the need for parental consent for adolescents and young people below 18 years to access HIV testing services.
• Thirty-three countries imposed the death penalty for drug offences in law.
• Same-sex sexual relations were criminalized in at least 67 countries and territories worldwide.

UNAIDS is actively working with United Nations partners, governments and civil society organizations to change those laws as part of the Global Partnership for Action to Eliminate all Forms of HIV-Related Stigma and Discrimination. 

Zero Discrimination Day campaign 2019—act to change laws that discriminate.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

“The HIV epidemic is a human rights epidemic. An epidemic of human rights loss, denial, derailment and in some instances abuse and violation.” With these words, Kate Gilmore, the United Nations Deputy High Commissioner for Human Rights, opened the Consultation on Promoting Human Rights in the HIV Response.

But while there are commitments, treaties and agreements, action is needed—this was the call from the consultation, held in Geneva, Switzerland, on 12 and 13 February, which sought to share regional and subregional strategies and best practices.

The consultation heard that stigma and discrimination, poor access to justice and punitive laws, policies and practices are barriers to the most vulnerable people accessing HIV prevention, testing, treatment and care.

Throughout the event, there was a central theme of removing harmful criminal laws, funding human rights and working closely with the community, through a call for national and regional institutions to listen, act, lead, reform and fund.

While the traditional human rights barriers—for example, stigma and discrimination and criminalization—persist, new problems are emerging. Questions of how to ensure that criminalized populations are included in universal health coverage, or that human rights and key populations programmes continue to be funded as a country transitions to middle-income status, was raised. A number of speakers, including Michaela Clayton, Director of the AIDS and Rights Alliance for Southern Africa, endorsed a top-down, bottom-up approach to promoting human rights, drawing on the actions of both political leaders and civil society together. 

“This isn’t easy. We can only do this by working in partnership: governments, civil societies, accountability mechanisms, human rights groups and health professionals,” said Tim Martineau, UNAIDS Deputy Executive Director, Programme, a.i.