13 October 2021
As part of the INHSU 2021 conference, we are hosting a series of satellite events in the weeks surrounding the conference. Our first satellite event took place on Tuesday 5 October, entitled ‘The Health of People Who Use Drugs and Universal Health Coverage (UHC): What are we actually talking about?’
Facilitated by our colleagues at the World Health Organization (WHO), the session explored the concept of Universal Health Coverage (UHC) and how it can impact health outcomes for people who use drugs.
The session was chaired by Annette Verster, Technical Lead – Key Populations, Global HIV, Hepatitis and STIs Programme, WHO & Justin Koonin, Co-Chair of UHC 2030 and ACON President.
Below you will discover our key takeaways from this session.
1. What is the definition of Universal Health Coverage
Dheepa Rajan, Health System’s Adviser at WHO, gave us a broad overview of the concept of UHC. As published in the World Health Report 2010 Dheepa explained that UHC should:
- Provide all people with access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective
- Ensure that the use of these services does not expose the user to financial hardship
“All people” is integral to this statement, and relates to marginalised communities including people who use drugs and those in prisons. Quality of care is key to the UHC concept and it must also include preventative measures, not just curative measures.
Dheepa used COVID as an example, explaining that true UHC would include the provision of masks and safe quarantine facilities (as non-definitive examples), not just treatment for the disease itself.
When focusing on the financial hardship element of the UHC definition, Dheepa explained “people need to access care when they need it, not just when they can afford it”.
2. All countries have a margin to improve
The session spoke a lot about UHC and the notion that high-income countries are often assumed to have the highest level of UHC, but as Dheepa explained via the use of the UHC cube, this is a common misconception and that, all countries – even high-income ones – have room to improve.
The framework for analysis of UHC by the WHO identifies three dimensions of measurement, illustrated by the UHC cube, which include population coverage, the availability and coverage of services, and the proportion of direct costs covered.
It’s important to note that no country has fully achieved UHC objectives and it is recognised that this could be much harder for low to middle-income countries. UHC is a direction, not a destination and the pursuit of it will strengthen health systems.
Switzerland was given as an example of a country that needs to improve access to healthcare for marginalised communities, such as refugee populations. Meanwhile, countries such as Iran and Thailand were highlighted as perhaps lesser-known success stories for UHC, thanks to their outreach initiatives into rural and remote communities which has seen healthcare uptake increase.
3. Put people who use drugs at the heart of the approach
Representatives from WHO discussed the importance of including people with lived experience in the governance of healthcare, ensuring their voices are not only heard but elevated.
Meg Doherty, Director, Global HIV, Hepatitis, STI Programmes at WHO also spoke about the organisation’s new strategy for person-centred care for HIV, Viral Hepatitis and STIs. The WHO’s new strategy sees a shared approach across these areas, which will drive forward UHC goals, particularly for marginalised communities such as people who use drugs.
Meg outlined the below steps as necessary to achieve UHC for people who use drugs.
- Address social determinants such as education, finances, and living conditions
- Advocate for supportive policies that end stigma and discrimination
- Offer comprehensive services for prevention testing and treatment
- Well trained people need to deliver stigma-free services
- The community needs to be empowered to run community-led initiatives
- There needs to be better coordination between non-state actors and the public health system
- We need better control of strategic information and data
- Ensure no financial hardship when using healthcare and prioritise impactful and sustainable packages of interventions
- Make affordable and accessible medicine and technologies
4. Health insurance is not the same as UHC
This came up a few times in questions from the audience, with speakers keen to point out that having health insurance is not the same as having UHC. There was also a discussion around how many of the roadblocks to UHC come from a governance level.
For example, there may be excellent community-led healthcare initiatives that simply never get off the ground due to governance roadblocks.
“We need more support for participatory processes,” explained Dheepa. Co-chair Justin Koonin backed this up too, highlighting the important work of advocates who emphasise the fact that UHC is not just a financial issue but a structural one.
5. For UHC to work for people who use drugs, we need to address criminalisation and social justice
Judy Chang, Executive Director at the International Network of People Who Use Drugs (INPUD), discussed how – at the centre of UHC – is the premise that health is not a commodity or a privilege, but a right. Yet people who use drugs are often criminalised and systematically refused rights.
“For UHC to be effective for these communities it must address social justice,” Judy explained. “Because if people who use drugs cannot live openly and safely they cannot access packages of support.”
Judy also highlighted five core areas that need to be addressed when specifically looking at UHC for people who use drugs:
- Processes need to be implemented that remove policy and legal barriers to ensure people who use drugs can actually access healthcare
- Harm reduction services should be part of Universal Health Coverage
- Space needs to be made for the involvement of people who use drugs
- Financing of UHC must include access for all people, regardless of their ability to pay
- To ensure that marginalised communities are not left behind, funding for peer-led and community organisations needs to be secured
6. Primary healthcare is the vehicle for UHC
Dr Nguyen Thi Minh Tam, Head of the HIV Prevention Department at the Vietnam Authority for HIV/AIDS Control Ministry of Health, shared Vietnam’s experience of striving for better UHC for people who use drugs.
Vietnam has a large number of people who use drugs, which increased from 130,000 in 2010 to 230,000 in 2020. The government has worked hard to integrate services for people who use drugs – for example, drug treatment clinics, which are directly integrated into the main healthcare system.
The impact of this – alongside initiatives like low-cost medicine and 80% coverage for those with insurance – has seen a 30% uptake of methadone by people who use drugs.
Mrs Abigael Lukhwaro, Program Coordinator at Médecins du Monde in Kenya, gave an example of how the integration of harm reduction initiatives into primary care facilities in Nairobi has positively impacted UHC outcomes for people who use drugs.
“We piloted implementing harm reduction into primary care facilities,” explained Abigail. “Services were stand-alone and community-led before, but coverage was poor. We wanted to make them easier for people who use drugs to access.”
One of the core takeaways from the successful pilot was how a stand-alone facility means that someone is instantly labelled as someone who uses drugs. Whereas by integrating into primary healthcare care facilities, this stigma can be removed as it is not obvious why someone is entering. Other positive impacts included improved linkage to care. Staff needed some training on new areas such as provision of NSP services, but additional resources weren’t required.
“At the start, health care workers didn’t understand the unique vulnerabilities of people who use drugs,” said Abigail. “But after one year there was a 360-degree change in opinion of healthcare workers of people who use drugs and vice versa.”
This session was part of the 9th International Conference on Health and Hepatitis in Substance Users (INHSU 2021). Sign up for updates and write-ups from the conference here.