1. HIV/AIDS and Universal Health Coverage = How can we utilize UHC for HIV/AIDS? = Masaki Inaba Africa Japan Forum Africa Japan Forum: 3 rd Fl, 1-20-6 Higashi-Ueno, Taito-Ku, Tokyo 110-0015 JAPAN Phone: +81-3-3834-6902, Fax: +81-3-3834-6903, e-mail: masaki.inaba@gmail.com

2. UHC and HIV/AIDS can be complementary each other  Unhappy relation between HIV/AIDS and UHC  Talking about “universal health coverage” in civil society working on HIV/AIDS is somewhat challenging  UHC and HIV/AIDS are competitive for Post-2015?  UHC should be recognized as a tool, not a goal?  My conclusion: UHC and HIV/AIDS should, and can be complementary each other  Horizontal approach for health, including UHC, is essentially, complementary with disease specific approach and actually supports “Ending AIDS”  But by now, it is necessary for advocacy from AIDS side, because there are “bad UHC” and several problems in designing UHC.

3. What is UHC? Current progress on its definition  Definition in the World Health Report 2010 – Needed health services for everyone in the world – Without incurring financial hardship  WHO in 2014: two component necessary Entire population should be benefited −Full spectrum of good-quality essential health services according to need −Protection from financial hardship due to out-of-pocket payments for health services (impoverishment/catastrophic expenditures)  UHC is based on (1) universal human rights/human security and (2) equality  UHC and “social determinants of health” (SDH) −if integrated, UHC could become more comprehensive. At least, UHC and SDH should be complementary.

4. UHC Its political map  WHO and World Bank Group:  Defined UHC in the World Health Report 2010  For setting new health goal, targets and indicators of Post-2015, WHO and World Bank Group made a strong efforts to sophisticate its definition. (current outcomes: from experts meeting in Bellagio, Italy in March 2014)  Donor Countries:  France and Japan strongly support UHC: they urged to set UHC as the overall goal for health of Post-2015  Germany and France have been pushing social health schemes for developing countries  Implementers:  Many middle-income and low-income countries have established health insurance or tax-based scheme for UHC (Philippines, Thailand, Indonesia, Rwanda, Ghana, etc. )  NGOs and Private Foundations:  Many NGOs, including Save the Children and MSH, support UHC with Rockefeller Foundation  Oxfam supports equity-based UHC without out-of pocket payment

5. UHC and HIV/AIDS: Where are we in UHC map? UHCHIV/AIDS Entire PopulationKey affected populations (KAPs): MSM, transgenders, Sex workers, people who use drugs, migrants and prisoners should be covered by UHC Good quality essential health services Sustainable and continuous access to ART and opportunistic infection treatment (no stock-out) Scientifically effective means of prevention (condom use, harm reduction, PMTCT, Male Circumcision) Community-based care (home-based care, peer support, etc.) Financial risk protectionFree or affordable access to anti-retroviral medicines and medicines for other opportunistic infections against social, cultural and legal exclusion Eradication of discrimination against KAPS and PLWHA Legal reform (abolish anti-sodomy law, illegalization of sex work, excessively punishable laws against drug use, etc.) Extended community system strengthening Income generating activities of PLWHA groups Mobilization of communities of KAPs on HIV/AIDS prevention A good UHC framework can/should support our efforts to fight HIV/AIDS.

6. Why is it necessary to advocate UHC framework?  Financial resources for health and HIV/AIDS in non-African middle-income countries – From “aid-based development” to “domestic resource mobilization (DRM)” – Resource for health including HIV will be transformed from HIV/AIDS specific budget from external resources to UHC-based fund from internal resources, especially in middle-income countries in Asia/Pacific, LAC and MENA  With aging, non-communicable diseases (NCDs) become major problem of the lives of PLWHA −Adding to co-infection issues, including HIV/TB and HIV/Hepatitis C, HIV/NCD will be one of the major health problem of people living with HIV/AIDS. Main finance sources of NCDs will be UHC-related resources. −Side-effects of ART are chronic (diabetes, osteoporosis, etc)  There is several “bad UHC” concepts which water-down the original idealism of UHC, and there is an original faults of the concept of UHC

7. Good UHC and bad UHC  UHC inherits the idealism of “Health for all” of Alma- Ata Declaration  Realization of “health for all” from the visions of equality, finance, sustainability and resilience  Designed with narrow views of short-term “financial sustainability”, the idealism is thrown away Financial sourcesA “national” health insurance based on insurance expenses paid by people who need medical care ServicesLimited to the “sustainability” of its financial sources, excluding high-cost health services like ART EligibilityExclusion of KAPS and other marginalized people in vulnerable situation (i.e. only for civil servants and formal sector) It is most likely to happen in the countries introducing UHC after 2016. Under “bad” UHC, universality will be disappeared.

8. Original faults in designing “good UHC”  Social Determinants of Health  Focusing mainly on economic inequality, not considering cultural and social barriers  Sometimes lacking the vision on “social exclusion” and diversity of the people who need health care  It ignores the existences of key affected population on HIV/AIDS (MSM, sex workers, people who use drugs, migrants and prisoners)  We can’t lose our strong position built through activism for HIV/AIDS and human rights in MDGs era (2000-2015).

9. Conclusion 1.UHC is, essentially, based on universal human rights, human security and equality. UHC and HIV/AIDS (target approach) are at least complementary each other. 2.We should create a concrete position on UHC and HIV/AIDS. It is because UHC will more influential in global health policy in Post-2015 era. Considering NCDs among PLWHA, civil society working on HIV/AIDS should strengthen advocacy efforts for UHC. 3.UHC should be universal and equity-based for everyone, including KAPs and informal sector workers. UHC should ensure Universal Access to HIV prevention, treatment and care. We have to be cautious about “bad UHC” based on short-term financial sustainability.