Key Populations are Left Behind in the 2019 Political Declaration on Universal Health Coverage

Earlier this week, Heads of State, Health Ministers, high-level policymakers, civil society activists and health sector stakeholders came together at the United Nations Headquarters in New York City to adopt the 2019 Political Declaration on Universal Health Coverage. This Political Declaration is a commitment by each country to achieve Universal Health Coverage for all people by 2030, as set forth in the UN’s 2030 Agenda for Sustainable Development.

The Political Declaration is markedly weak on key aspects necessary to realize full Universal Health Coverage for people who use drugs, sex workers, and lesbian, gay, bisexual, transgender and intersex (LGBTI) people. After months of consultations and negotiations led by the permanent missions of Georgia and Thailand to the United Nations, the adopted text falls short of specifically naming the most marginalized communities who are often left behind. LGBTI people, people who use drugs and sex workers are criminalized in many countries and across the world consistently report alarming levels of stigma, discrimination, and violence when accessing basic health services.

The Political Declaration also lacks a commitment to remove legal and policy barriers that leave key populations behind and without access to care. A strong Political Declaration would have reinforced health as a right, as enshrined in international law and explained in General Comment No. 14 of the Committee on Economic, Social and Cultural Rights. Failure to acknowledge health as a human right renders the Political Declaration weak. In addition, failing to explicitly name our communities renders us invisible. Advocates are therefore left with little leverage to  motivate Member States to eliminate the social, legal, and policy barriers that undermine health for LGBTI people, people who use drugs and sex workers.

Next, sexual and reproductive health and rights (SRHR) are an essential component of primary health care and must be understood as part and parcel of universal health care. The Political Declaration only mentions the word ‘gender’ a handful of times, and reference to sexual and reproductive health care services, including family planning, information, and education, is limited to paragraph 68, which contains no new language but rather affirms language from the 2030 Agenda. We were especially disappointed by the intervention from the United States Health and Human Services Secretary, Alex Azar, at the High Level Meeting, which called out paragraph 68 as counter to current US policy and advocated for removing the “ambiguous terms” such as “reproductive health and rights.” The Trump Administration’s unprecedented attacks on SRHR have had a deleterious effect across the nation and around the world (read more here). US leadership on global health and HIV is severely undermined by its increasingly aggressive anti-SRHR position. We are looking to other countries and donor governments to fill the void and step up to counter the attacks from the US on these essential services.

Another weak aspect of the Political Declaration is the involvement of communities in the implementation and achievement of Universal Health Care. Paragraph 46 affirms that “community-based services constitute a strong platform for primary health care” and paragraph 54 mentions the necessity to engage civil society for the development, implementation, and evaluation of UHC. But communities serve an essential role not only for service delivery and policy review, but also in monitoring and advocacy.

Related to this point, the text of the Political Declaration fails to communicate the many contributions of communities and civil society to the delivery and implementation of UHC. An enabling social, legal, and policy environment is required for robust participation of communities; this means that civil society organizations must be able to legally register, receive finances, and operate without fear of harassment or violence. While some Member States mentioned civil society in their remarks at the High Level Meeting, MPact is gravely concerned about an approach to UHC that sidelines communities and consolidates resources in private or public health facilities.

The Political Declaration is also weak with regard to calling for countries to support mechanisms to address stigma and discrimination in the provision of health care services. For many key populations around the world, reaching a primary health center where health service professionals ridicule or harass them or refuse to provide care altogether is the only service option available. This can lead to poor uptake of HIV services and people being lost to follow-up. Each key population community faces unique challenges in accessing quality services, and formalized redress structures must be available to communities who have experienced stigma, discrimination, and violence in health care settings.

Finally, while there has been a call for increasing health expenditures of countries to accommodate growing health system demands, the world is witnessing funding cuts to HIV budgets, especially programs that directly cater to LGBTI people, people who use drugs, and sex workers. The last 30 years of the HIV response have shown that without earmarked funding that is tailored to the unique needs of communities most impacted by HIV, the response will fail. There is a clear and present danger in the current move toward health system strengthening and roll-out of UHC when HIV programs and initiatives are not protected from decreases in funding. The Political Declaration fails to provide any guarantee or protections to disease specific financing, let alone for most impacted communities.

MPact encourages all advocates to be vigilant with regard to inclusion of LGBTI people, people who use drugs and sex workers in discussions on universal health coverage at the national level. Advocacy and continual monitoring of health policy development will be essential to ensure that our communities are not left behind. As advocates gathered in New York reaffirmed, real change happens when there is political will, not a declaration. In that spirit, we encourage advocates to sustain and increase their advocacy to ensure universal access to health for all people, including LGBTI people, people who use drugs and sex workers.

Read statement led by MPact and delivered by a coalition of civil society organizations in New York in April 2019 here

Read statement by GNP+ on Universal Health Coverage here

Read INPUD’s Technical Brief:  What does Universal Health Coverage mean for People who Use Drugs

Read NSWP’s Briefing Note on Universal Health Coverage

Read the UNAIDS publication HIV and Universal Health Coverage:  A Guide for Civil Society here.

Download the UN Political Declaration on Universal Health Coverage here.