In our series of articles assessing progress towards UHC implementation, we hear activists from Indonesia, Kenya, South Africa, Ukraine and Vietnam on the challenges facing marginalised groups affected by HIV and the actions they are taking in the battle to ensure UHC truly leaves no one behind.

“Frankly speaking I did not really understand what universal health coverage meant until the Partnership to Inspire, Transform and Connect the HIV response [PITCH] came to Indonesia,” says Baby Rivona, Coordinator at the Indonesia Positive Women’s Network. 

“I found out that community people think they have national health insurance – I have to pay JKN [Indonesia’s national health insurance scheme], which means I have universal health coverage, but what about HIV prevention? What about sustaining access to current services? The government can change, the law can change, and what people will be able to access can change as well.”

But what about HIV prevention? What about sustaining access to current services? The government can change, the law can change, and what people will be able to access can change as well.

In 2014 Indonesia introduced the Jaminan Kesehatan Nasional (JKN) a contributory national health insurance scheme, which enables all registered Indonesians to receive a range of health services from public providers and some private organisations. Those who can afford it pay just under $10 a month, those who can’t are subsidised by the state, but for marginalised groups  getting onto the scheme can be difficult. Only those with official ID cards can register, but to get an ID card someone must present a family card.

“This becomes a problem when you’re talking about sex workers, sometimes they do not have an ID card because they split with their family. For men who have sex with men and LGBT people, not all family members can accept it and they will kick them out.”

Indonesia currently has a separate HIV programme, implemented by the Ministry of Health and largely funded by international donors. This means anyone without health insurance can still receive treatment, but there are concerns about what will happen if the current programme becomes part of JKN when international donors withdraw. 

“At the moment about 60% of our HIV budget comes from the Global Fund. Soon the Global Fund will finish they say. Are the government ready to take all the responsibility? No way. When even the Ministry of Health doesn’t want to procure condoms or needles…doesn’t want to speak about sex workers or LGBT people.”

Soon the Global Fund will finish they say. Are the government ready to take all the responsibility? No way. When even the Ministry of Health doesn’t want to procure condoms or needles…doesn’t want to speak about sex workers or LGBT people.

How universal is UHC?
“In my simple mind if you mention the word ‘universal’ it means you cover everyone, whatever they need and whoever they are,” says Baby.

In 2018, an Indonesian Presidential Decree stated that health services will not be covered by the JKN for conditions arising from drug or alcohol dependence, personal accident or a “hobby” that is harmful to the individual. This stands to hamper access to HIV treatment for people who use drugs and others who are linked to stigmatised activities, such as sex workers and men who have sex with men. Overturning this flawed law is now a key focus of PITCH’s advocacy work. 

“We are putting a judicial review together,” says Baby. “The process involves forming a collation and consulting with our members to hear their views on it. We have now planned and drafted the petition to revoke this law to the Supreme Court. We will be challenging it by showing that it is contradicted by other, higher laws.”

The shadow of criminalisation 
PITCH is also part of a wide-ranging coalition that is mounting a legal challenge against an amendment to Indonesia’s Penal Code. If passed, the amendment will criminalise sex outside of marriage, same-sex acts, people who use drugs, sex workers and the promotion of contraceptive tools, including condoms.

When you are talking about criminalisation, about justice, about healthcare services, about UHC – they are crosscutting each other. You cannot look at one in isolation without looking and thinking about the others

“How do we achieve universal health coverage if this law passed?” asks Baby. “When you are talking about criminalisation, about justice, about healthcare services, about UHC – they are crosscutting each other. You cannot look at one in isolation without looking and thinking about the others. 

“Anti-LGBT and anti prostitution regulation is spreading to every district, every politician seems to be championing it. So how can key populations, people who are most affected by HIV, come out and go to health services? Even though you may have the JKN, if you then go to a public health service and they are asking about your orientation or your work or you are under 18, you will not want to come.”

Advocating for change 
In November 2018, PITCH partners from all programme countries met in Vietnam to share experiences and learn from other countries about how to create a plan that will make UHC a reality for everyone.

“PITCH started the first steps on UHC advocacy in Indonesia,” says Baby. “After the Vietnam gathering I wanted to do something similar for PITCH partners and key population networks in Jakarta so that’s what we did. After that, the seed of what universal health coverage is and what its impact could be began to grow.”

PITCH started the first steps on UHC advocacy in Indonesia…After that, the seed of what universal health coverage is and what its impact could be began to grow.

The PITCH network in Indonesia is now working to persuade the government to create a UHC taskforce, similar to the Global Fund’s Country Coordinating Mechanism, which includes people living with, and most affected by, HIV as members. PITCH is also pushing for international agencies such as UNAIDS and WHO to agree a UHC accountability framework so that countries can monitor progress and gaps on an annual basis. 

“One long-term goal would be to ensure that people could get an accessible ID without needing a family card. I’m not saying the government will do that but if we…can establish the taskforce and if we can have the accountability framework they would be big achievements.” 

“We still have ten years more [before the SDG 2030 targets are to be met] but from past advocacy work I know ten years is a very short time.”