Why Kenya’s UHC pilot cannot afford to ignore HIV
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
In 2018, Kenya began piloting universal health coverage (UHC). But a lack of meaningful engagement with civil society and clarity on what the UHC package covers are raising concerns. UHC means to provide health care and financial protection to all residents of a country.
“The focus for UHC in Kenya is not disease specific, says human rights activist Wanja Ngure, “but we cannot afford not to discuss HIV when we are discussing on UHC.”
The UHC pilot is due to run until October 2019. The national roll-out of UHC is due to start a month later and be completed by December 2021. Although the essential service package offered under the pilot mentions HIV, and there is an assumption that HIV will be included in UHC’s major infectious diseases package, it is unclear exactly which HIV services will be covered.
Piloting UHC is meant to help in rolling it out by showing the resource gaps…but HIV has not been costed for, it’s not in the picture,” says Wanja.
"In reality HIV is one of the diseases that contributes to the highest health burdens in the country. It has been said that HIV is an expensive disease and it has heavy donor funding, which forms a basis for kicking it out of the conversation. But with the transition [of donor support] we are worried – who fills this gap?"
The question of quality
The UHC pilot has seen residents in Isiolo, Machakos, Nyeri and Kisumu counties registered and given a health card that enables them to access essential health services for free.
“In Kenya access to HIV services for people from at-risk communities is currently pretty good,” explains Wanja. “But it’s only good because we have many non-government facilities led by communities that offer services to vulnerable and key populations, such as men who have sex with men, sex workers, people who use drugs and LGBT."
In the UHC pilot, everyone is registered as general population, and because of this it is not clear what kind of services key populations can expect. Will marginalised people really feel comfortable to walk into government facilities to access services? It is not clear how community services will be sustainable in the context of UHC and with the exit of external donors. Wanja describes the move towards UHC in Kenya as government-driven. “Yet this is the same government that criminalises certain populations,” she adds.
Ideally UHC is a beautiful concept but when we have laws that criminalise some populations, how will these groups access services without stigma and discrimination? We will continue to lobby for the removal of structural barriers, without which health for all will remain a dream.
Wanja points to the need to sustain and scale-up human rights programming to help this happen.
As countries wrestle with how UHC will work, different funding models are emerging. In Kenya, each county has its own approach to UHC; some give certain services for free, while in other counties people are asked to contribute. This lack of consistency is creating an uneven, confusing system.
In addition, Kenya is yet to decide whether a contributory health insurance scheme will be put in place to help fund UHC, whereby people will be asked to make a monthly payment of around USD 5. Although the issue of whether HIV and AIDS services will be included in the UHC package is still being debated, Wanja says that expecting people to contribute financially could see many miss out. This could lead to the discontinuation of life-saving treatment for numerous people living with HIV.
We have so many people who cannot place food on the table… they are not going to pay $5 to access antiretroviral treatment. So what are we going to do? Go back to a situation that we had in the 1980s where people could not access treatment? We can’t let this happen; we have to lobby for an affordable UHC.
Awareness and engagement
With so many issues in play Wanja says the advocacy programme PITCH (Partnership to Inspire, Connect and Transform the HIV response) has been fundamental in increasing awareness about UHC among people most affected by HIV.
“In January 2019, PITCH organised a UHC meeting in Kenya. We invited not only PITCH partners but other like-minded organisations that deal with health. From that meeting, partners started rolling out these conversations to their network members. Now communities are asking what happens if services for key populations are mainstreamed when we know that community-led initiatives are the ones that work?”
In June 2018, the Kenyan Ministry of Health announced that the Health NGOs Network (HENNET) would sit on the UHC Benefits Package Advisory Panel. But Wanja says this is not enough and is calling for a more meaningful engagement with civil society organisations (CSOs), one that includes populations that could be left behind.
It would be more impactful if Kenya had a Multi-Stakeholders’ Forum under the Ministry of Health to ensure that health CSOs are meaningfully engaged at all decision-making levels,” says Wanja. “I would love to see key population CSOs engage with these structures so that their issues are included in the agenda.
Through their advocacy efforts PITCH partners have been included in the CSO consultation on the United Nations High Level Meeting on UHC (HLM), which is to take place in New York on 23 September 2019. This has led to some of their key advocacy asks, such as the need for meaningful engagement, being included in Kenya’s wider CSO mainstream advocacy paper on HLM.
Wanja is also working more closely with the Health NGOs Network (HENNET). PITCH attended the Kenya National Health Forum in August, where government decision makers heard a number of advocacy asks, from which promising steps have arisen. These include an agreement to partner with civil society and patient-support groups to improve health literacy and increase demand for quality health services. Participatory mechanisms to improve service design, access and responsiveness were also discussed.
“We are getting somewhere because the people in this meeting were speaking a lot about governance structures and accountability,” Wanja says.
“PITCH partners are also attending HLM in New York. We will take this opportunity to promote closer interaction with the Kenyan state delegation, to make them aware of the reality of the situation of vulnerable groups and importance of putting HIV at the top of the UHC agenda.
For me advocacy is all about push, it’s about getting yourself into the spaces you’ve not even been invited to. Are key population issues on the UHC agenda? No, not yet, but we are seeing people from key populations asking really pertinent questions. To me this journey has been about creating this awareness, in creating this force, and now people are able to speak out about UHC.
Wanja’s recommendations for UHC
To ensure UHC works in Kenya:
- The Government must ensure it removes the structural barriers that prevent key and vulnerable populations from accessing health.
- The Kenyan government must also commit to sustaining community-led services and for these services to be available for those who cannot contribute to any potential insurance scheme.
- We are calling for accessible information about UHC, a UHC governance mechanism that includes key population groups, and for civil society to be meaningfully engaged in UHC’s implementation process.