Universal health coverage

Definition

Uni­ver­sal health cov­er­age refers to the ambi­tion of com­mu­ni­ties and coun­tries in which every­one can access qual­ity health­care with­out great finan­cial bur­den. All United Nations Mem­ber States have expressed sup­port for uni­ver­sal health cov­er­age, even if their polit­i­cal com­mit­ments vary in scope and nature. Uni­ver­sal health cov­er­age has also been rec­og­nized as a first step in real­iz­ing the human right of every­one to the high­est attain­able stan­dard of health.

Uni­ver­sal health cov­er­age is crit­i­cal to the HIV response. Some of the great­est dri­vers of the HIV pan­demic involve the inac­ces­si­bil­ity and unaf­ford­abil­ity of med­ical care for key and vul­ner­a­ble pop­u­la­tions. These include the costs of pre-expo­sure pro­phy­laxis, con­doms, and anti­retro­vi­ral ther­apy; legal and dis­crim­i­na­tory bar­ri­ers, like being refused care; and a lack of health infor­ma­tion that addresses key pop­u­la­tions’ unique risk fac­tors and needs. With inclu­sive and duly enforced uni­ver­sal health cov­er­age, these bar­ri­ers would be mit­i­gated if not elim­i­nated entirely.

Precedents

2021 HRC Res­o­lu­tion on ensuring equitable, affordable, timely and universal access for all countries to vaccines in response to COVID-19

• “Rec­og­niz­ing fur­ther that uni­ver­sal health cov­er­age implies that all peo­ple have access with­out dis­crim­i­na­tion to nation­ally deter­mined sets of needed pro­mo­tive, pre­ven­tive, cura­tive, pal­lia­tive and reha­bil­i­ta­tive essen­tial health-care ser­vices and essen­tial, safe, afford­able, effec­tive and qual­ity med­i­cines and vac­cines, while ensur­ing that the use of these ser­vices does not expose users to finan­cial hard­ship, with spe­cial empha­sis on the poor, vul­ner­a­ble and mar­gin­al­ized seg­ments of the pop­u­la­tion” (p. 2)

• “Empha­sizes the urgent need to ensure the right of every­one to the enjoy­ment of the high­est attain­able stan­dard of phys­i­cal and men­tal health and to facil­i­tate the devel­op­ment of robust health sys­tems and uni­ver­sal health cov­er­age, encom­pass­ing uni­ver­sal, timely and equi­table access to all essen­tial health tech­nolo­gies, diag­nos­tics, ther­a­peu­tics, med­i­cines and vac­cines in response to the COVID-19 pan­demic and other health emer­gen­cies, in order to ensure full access to immu­niza­tion for all, in par­tic­u­lar per­sons and groups in vul­ner­a­ble sit­u­a­tions, as a mat­ter of global pri­or­ity for all States” (p. 4)

2021 Political declaration on equitable global access to COVID-19 vaccines

• “We are con­cerned about the impact of the COVID-19 pan­demic on other immu­niza­tion pro­grams. In this regard, we reaf­firm our com­mit­ment to uni­ver­sal health cov­er­age, includ­ing for immu­niza­tion, and call upon all gov­ern­ments, donors and all rel­e­vant stake­hold­ers to redou­ble their efforts to ensure that fund­ing rel­e­vant to rou­tine vac­ci­na­tion cam­paigns is not diverted to meet the require­ments posed by COVID-19, and that national health sys­tems are strength­ened. includ­ing the health work­force, in order to address sys­temic health issues beyond COVID-19.” (para­graph 22)

2021 HRC resolution on human rights in the context of HIV and AIDS

• “Urges States to accel­er­ate the inte­gra­tion of HIV ser­vices into uni­ver­sal health cov­er­age and resilient health and social pro­tec­tion sys­tems, and to ensure full and unim­peded access for all per­sons liv­ing with, pre­sumed to be liv­ing with, at risk of or affected by HIV, includ­ing key pop­u­la­tions, to HIV pre­ven­tion, diag­no­sis, treat­ment, care and sup­port, in a pub­lic health envi­ron­ment free from dis­crim­i­na­tion, harass­ment or per­se­cu­tion against those seek­ing HIV-related ser­vices, while respect­ing and pro­tect­ing their right to pri­vacy, con­fi­den­tial­ity and free and informed con­sent.” (para­graph 5)

2020 Resolution on global health and foreign policy: strengthening health system resilience through affordable health care for all

• “Calls upon Mem­ber States to ensure access to med­i­cines as one of the fun­da­men­tal ele­ments of a robust health sys­tem based on uni­ver­sal health cov­er­age, and reaf­firms that States have the pri­mary role and respon­si­bil­ity to deter­mine and pro­mote their own path towards achiev­ing uni­ver­sal health cov­er­age that ensures uni­ver­sal and equi­table access to qual­ity essen­tial health ser­vices and access to safe, effec­tive, qual­ity and afford­able essen­tial med­i­cines, vac­cines, diag­nos­tics and other health tech­nolo­gies for all, with­out dis­crim­i­na­tion” (p. 7)

2019 HRC Resolution on access to medicines and vaccines

• “Rec­og­niz­ing that uni­ver­sal health cov­er­age implies that all peo­ple have access with­out dis­crim­i­na­tion to nation­ally deter­mined sets of needed pro­mo­tive, pre­ven­tive, cura­tive, pal­lia­tive and reha­bil­i­ta­tive essen­tial health-care ser­vices, and essen­tial, safe, afford­able, effec­tive and qual­ity med­i­cines and vac­cines, while ensur­ing that the use of these ser­vices does not expose users to finan­cial hard­ship, with spe­cial empha­sis on the poor, vul­ner­a­ble and mar­gin­al­ized seg­ments of the pop­u­la­tion” (p. 3)

2019 Political declaration of the HLM on UHC

• “Rec­og­nize that uni­ver­sal health cov­er­age is fun­da­men­tal for achiev­ing the Sus­tain­able Devel­op­ment Goals related not only to health and well-being, but also to erad­i­cat­ing poverty in all its forms and dimen­sions, ensur­ing qual­ity edu­ca­tion, achiev­ing gen­der equal­ity and women’s empow­er­ment, pro­vid­ing decent work and eco­nomic growth, reduc­ing inequal­i­ties, ensur­ing just, peace­ful and inclu­sive soci­eties and to build­ing and fos­ter­ing part­ner­ships, while reach­ing the goals and tar­gets included through­out the 2030 Agenda for Sus­tain­able Devel­op­ment is crit­i­cal for the attain­ment of healthy lives and well-being for all, with a focus on health out­comes through­out the life course.” (para­graph 5)

• “Pro­vide strate­gic lead­er­ship on uni­ver­sal health cov­er­age at the high­est polit­i­cal level and pro­mote greater pol­icy coher­ence and coor­di­nated actions through whole-of-gov­ern­ment and health-in-all-poli­cies approaches, and forge a coor­di­nated and inte­grated whole-of-soci­ety and mul­ti­sec­toral response, while rec­og­niz­ing the need to align sup­port from all stake­hold­ers to achieve national health goals” (para­graph 59)

• “Reaf­firm the impor­tance of national own­er­ship and the pri­mary role and respon­si­bil­ity of gov­ern­ments at all lev­els to deter­mine their own path towards achiev­ing uni­ver­sal health cov­er­age, in accor­dance with national con­texts and pri­or­i­ties, and under­score the impor­tance of polit­i­cal lead­er­ship for uni­ver­sal health cov­er­age beyond the health sec­tor in order to pur­sue whole-of-gov­ern­ment and whole-of-soci­ety approaches, as well as health-in-all-poli­cies approaches, equity-based approaches and life-course approaches.” (para­graph 6)

• “Rec­og­nize that uni­ver­sal health cov­er­age implies that all peo­ple have access, with­out dis­crim­i­na­tion, to nation­ally deter­mined sets of the needed pro­mo­tive, pre­ven­tive, cura­tive, reha­bil­i­ta­tive and pal­lia­tive essen­tial health ser­vices, and essen­tial, safe, afford­able, effec­tive and qual­ity med­i­cines and vac­cines, while ensur­ing that the use of these ser­vices does not expose the users to finan­cial hard­ship, with a spe­cial empha­sis on the poor, vul­ner­a­ble and mar­gin­al­ized seg­ments of the pop­u­la­tion.” (para­graph 9)

2018 HRC Resolution on human rights in the context of HIV and AIDS

• “Affirms that respect for and the pro­tec­tion and ful­fil­ment of human rights in the con­text of HIV, includ­ing uni­ver­sal access to HIV-related pre­ven­tion, diag­no­sis, treat­ment, care and sup­port, are an essen­tial ele­ment in achiev­ing the full real­iza­tion of the right of every­one to the enjoy­ment of the high­est attain­able stan­dard of phys­i­cal and men­tal health and in end­ing AIDS.” (para­graph 1)

2018 Political declaration of the HLM on the fight against TB

• “Com­mit to pro­mot­ing access to afford­able med­i­cines, includ­ing gener­ics, for scal­ing up access to afford­able tuber­cu­lo­sis treat­ment, includ­ing the treat­ment of mul­tidrug-resis­tant and exten­sively drug-resis­tant tuber­cu­lo­sis, reaf­firm­ing the World Trade Orga­ni­za­tion Agree­ment on Trade-Related Aspects of Intel­lec­tual Prop­erty Rights (TRIPS Agree­ment), as amended, and also reaf­firm­ing the 2001 World Trade Orga­ni­za­tion Doha Dec­la­ra­tion on the TRIPS Agree­ment and Pub­lic Health, which rec­og­nizes that intel­lec­tual prop­erty rights should be inter­preted and imple­mented in a man­ner sup­port­ive of the right of Mem­ber States to pro­tect pub­lic health and, in par­tic­u­lar, to pro­mote access to med­i­cines for all, and notes the need for appro­pri­ate incen­tives in the devel­op­ment of new health prod­ucts.” (para­graph 19)

• “Com­mit to pro­tect and pro­mote the right to the enjoy­ment of the high­est attain­able stan­dard of phys­i­cal and men­tal health, in order to advance towards uni­ver­sal access to qual­ity, afford­able and equi­table pre­ven­tion, diag­no­sis, treat­ment, care and edu­ca­tion related to tuber­cu­lo­sis and mul­tidrug-resis­tant tuber­cu­lo­sis and sup­port for those who become dis­abled due to tuber­cu­lo­sis, inte­grated within health sys­tems towards achiev­ing uni­ver­sal health cov­er­age and remov­ing bar­ri­ers to care; to address the eco­nomic and social deter­mi­nants of the dis­ease; and to pro­mote and sup­port an end to stigma and all forms of dis­crim­i­na­tion, includ­ing by remov­ing dis­crim­i­na­tory laws, poli­cies and pro­grammes against peo­ple with tuber­cu­lo­sis, and through the pro­tec­tion and pro­mo­tion of human rights and dig­nity, as well as poli­cies and prac­tices which improve out­reach, edu­ca­tion and care.” (para­graph 28)

2016 Resolution on Women, the Girl Child and HIV and AIDS

• “Calls upon all gov­ern­ments to pro­mote uni­ver­sal health cov­er­age, as part of a com­pre­hen­sive social pro­tec­tion pack­age, which implies that all peo­ple have equal access, with­out dis­crim­i­na­tion of any kind, to nation­ally deter­mined sets of the qual­ity pro­mo­tive, pre­ven­tive, cura­tive, reha­bil­i­ta­tive and pal­lia­tive basic health ser­vices needed and to essen­tial, safe, afford­able, effec­tive and qual­ity med­i­cines, espe­cially through the pro­mo­tion of pri­mary health care, while ensur­ing that the use of those ser­vices does not expose the users to finan­cial hard­ship, with a spe­cific empha­sis on women, chil­dren and the poor, vul­ner­a­ble and mar­gin­al­ized seg­ments of the pop­u­la­tion.” (para­graph 6)

2014 Resolution on efforts to control and eliminate malaria by 2015

• “Requests rel­e­vant inter­na­tional orga­ni­za­tions, in par­tic­u­lar the World Health Orga­ni­za­tion and the United Nations Chil­dren’s Fund, to assist the efforts of national Gov­ern­ments to pro­vide uni­ver­sal access to malaria con­trol inter­ven­tions to address all at-risk pop­u­la­tions, in par­tic­u­lar young chil­dren and preg­nant women, in malaria-endemic coun­tries, par­tic­u­larly in Africa, as rapidly as pos­si­ble, with due regard to ensur­ing the proper use of those inter­ven­tions, includ­ing long-last­ing insec­ti­cide-treated nets, and sus­tain­abil­ity through full com­mu­nity par­tic­i­pa­tion and imple­men­ta­tion through the health sys­tem.” (para­graph 14)

2007 WHA Resolution on progress in the rational use of medicines

• “Urges mem­ber states to develop and imple­ment national poli­cies and pro­grammes for improv­ing med­i­cine use, includ­ing clin­i­cal guide­lines and essen­tial med­i­cines lists, as appro­pri­ate, with an empha­sis on mul­ti­fac­eted inter­ven­tions tar­get­ing both the pub­lic and pri­vate health sec­tors, and involv­ing providers and con­sumers.” (para­graph 1(6))

1995 Beijing Declaration and Platform for Action

• “Ensure the pro­vi­sion, through the pri­mary health-care sys­tem, of uni­ver­sal access of cou­ples and indi­vid­u­als to appro­pri­ate and afford­able pre­ven­tive ser­vices with respect to sex­u­ally trans­mit­ted dis­eases, includ­ing HIV/ AIDS, and expand the pro­vi­sion of coun­sell­ing and vol­un­tary and con­fi­den­tial diag­nos­tic and treat­ment ser­vices for women; ensure that high-qual­ity con­doms as well as drugs for the treat­ment of sex­u­ally trans­mit­ted dis­eases are, where pos­si­ble, sup­plied and dis­trib­uted to health ser­vices.” (para­graph 108(m))

Expert precedents

2019 OHCHR Annual report on human rights and HIV

• “States should ensure that uni­ver­sal health cov­er­age pro­motes both the health and rights of all per­sons, includ­ing the most mar­gin­al­ized, such as peo­ple liv­ing with HIV and key pop­u­la­tions, and addresses human rights bar­ri­ers to health. States should ensure that human rights, includ­ing the right to health of per­sons liv­ing with HIV, are inte­grated into dis­cus­sions on uni­ver­sal health cov­er­age, includ­ing in the lead-up to the high-level meet­ing of the Gen­eral Assem­bly on uni­ver­sal health cov­er­age and in its out­come doc­u­ment.” (para­graph 47(h))

2016 General Comment No.22 on the Right to Sexual and Reproductive Health

• “Pub­licly or pri­vately pro­vided sex­ual and repro­duc­tive health ser­vices must be afford­able for all. Essen­tial goods and ser­vices, includ­ing those related to the under­ly­ing deter­mi­nants of sex­ual and repro­duc­tive health, must be pro­vided at no cost or based on the prin­ci­ple of equal­ity to ensure that indi­vid­u­als and fam­i­lies are not dis­pro­por­tion­ately bur­dened with health expenses. Peo­ple with­out suf­fi­cient means should be pro­vided with the sup­port nec­es­sary to cover the costs of health insur­ance and access to health facil­i­ties pro­vid­ing sex­ual and repro­duc­tive health infor­ma­tion, goods and ser­vices.” (para­graph 17)

• “States should aim to ensure uni­ver­sal access with­out dis­crim­i­na­tion for all indi­vid­u­als, includ­ing those from dis­ad­van­taged and mar­gin­al­ized groups, to a full range of qual­ity sex­ual and repro­duc­tive health care, includ­ing mater­nal health care; con­tra­cep­tive infor­ma­tion and ser­vices; safe abor­tion care; and pre­ven­tion, diag­no­sis and treat­ment of infer­til­ity, repro­duc­tive can­cers, sex­u­ally trans­mit­ted infec­tions and HIV/AIDS, includ­ing with generic med­i­cines.” (para­graph 45)

Evidence

2022 WHO Consolidated Guidelines on Person-centred HIV Strategic Information

• “World­wide, an esti­mated 5% of all cer­vi­cal can­cer cases are attrib­ut­able to HIV, and women liv­ing with HIV have a six-fold higher risk of cer­vi­cal can­cer than women who are not infected with HIV. An esti­mated 85% of women with both cer­vi­cal can­cer and HIV live in sub-Saha­ran Africa, under­scor­ing the major con­tri­bu­tion of HIV to the cer­vi­cal can­cer bur­den in the region, con­tribut­ing to the geo­graphic dis­par­i­ties seen in cer­vi­cal can­cer bur­den.” (p. 163)

• “Sub­stan­tial evi­dence indi­cates that STIs increase HIV trans­mis­si­bil­ity and the risk of acquir­ing HIV by as much as 2–3 times in some pop­u­la­tions. The increased trans­mis­si­bil­ity may result from STI sores or inflam­ma­tion allow­ing infec­tion that might oth­er­wise have been stopped by intact skin and from increased HIV shed­ding among peo­ple with HIV who have ure­thri­tis or a gen­i­tal ulcer or are infected with N. gon­or­rhoeae. Gen­i­tal her­pes (HSV-2) almost triples the risk of acquir­ing HIV for both men and women. Also, HIV increases the infec­tious­ness and sever­ity of STIs, and a recent study has doc­u­mented that HIV and syphilis co-infec­tion can have an adverse impact on immune recov­ery and anti­retro­vi­ral effec­tive­ness.” (p. 166)

2022 WHO Guidance on Differentiated and Simplified PrEP for HIV Prevention

• “Increas­ing PrEP cov­er­age among sex­u­ally active indi­vid­u­als has the poten­tial to avert nearly half of new HIV infec­tions over 20 years; com­mu­nity-based PrEP imple­men­ta­tion using HIVST could be an effec­tive strat­egy for scal­ing up PrEP.” (p. 33)

2022 WHO Consolidated Guidelines on HIV, Viral Hepatitis and STI Prevention, Diagnosis, Treatment and Care for Key Populations

• “HIV infec­tion is more likely to occur if another STI is present and vice versa, cre­at­ing syn­er­gies and syn­demics which are often over­looked. For exam­ple, STIs increase infec­tious­ness of peo­ple liv­ing with HIV who are not on treat­ment by increas­ing the viral con­cen­tra­tion in the gen­i­tal tract, and by increas­ing the poten­tial for HIV trans­mis­sion. Gen­i­tal her­pes and syphilis almost triple the risk of HIV acqui­si­tion; while women liv­ing with HIV are at high-risk of infec­tion with HPV and are approx­i­mately six times more likely to develop cer­vi­cal can­cer.” (p. 5)

2021 WHO Consolidated Guidelines on HIV Prevention, Testing, Treatment, Service Delivery and Monitoring

• “Global ART cov­er­age for peo­ple liv­ing with HIV had reached 26 mil­lion peo­ple as of mid-2020. More than 120 low- and mid­dle-income coun­tries have adopted the “treat-all” pol­icy. Although the median CD4 cell count at the time of ART ini­ti­a­tion is increas­ing, about 25% of peo­ple liv­ing with HIV con­tinue to present late to care, with low CD4 cell count and asso­ci­ated high early mor­tal­ity rates, higher direct health-care costs and poor reten­tion in care.” (p. 110)