Grace Kamau, the Regional Coordinator of the African Sex Workers Alliance (ASWA), attended the 72nd session of the World Health Assembly in Geneva this week, contributing to a side event panel discussion on community-led healthcare responses. The panel discussion, entitled ‘Boosting Community-Led Responses to Reach the Most Marginalised Communities’, discussed the role civil society can play in upholding fundamental human rights in universal health coverage and primary health care.
For the last four years, Universal Health Coverage (UHC) has become the centre stage of national, regional and international conversations. All UN Member States have agreed to try to achieve Universal Health Coverage (UHC) by 2030, as part of the Sustainable Development Goals.
According to the World Health Organisation (WHO), UHC means that all individuals and communities receive the health services they need without suffering financial hardship. It includes essential, quality health services, prevention, treatment, rehabilitation, and palliative care. The focus of UHC is mainly on four things; services covered, funding, management, and delivery. The model calls for integration of health services while putting into consideration the needs of people and communities.
During the panel discussion, Grace raised concerns about the implementation of this model, given community health centres are underfunded in many countries in Africa. Sex workers and other marginalised communities have mainly depended on donors funded health services to this point.
“It is a good thing that governments, especially in Africa, are committed to the implementation of UHC. On the face of it, maybe we should applaud [this], however, as a sex worker and a leader of the movement in Africa, I have concerns,” she said. “One of those concerns is [the] criminalisation of sex workers and other Key Populations. I am not convinced that governments in Africa will provide essential and quality services to outlawed communities”.
Grace also raised concerns about UHC implementation in the context of sex work being criminalised across Africa. Sex workers face discrimination and violence especially from law enforcement. In the past year alone, there has been increased crackdown and arrests of sex workers in various countries. In countries like Tanzania and South Sudan, community organising is almost underground. The Global Commission on HIV says criminalisation and stigma breeds danger. Additionally, sex workers barely access government health facilities due to stigma, discrimination and fear.
“We are talking about UHC, but were are not discussing how criminalisation of sex workers and other Key Populations affects their access to health. We should talk about decriminalisation,” she said. “There is still stigma heightened by poor attitude towards sex workers by health care workers.”
Grace is also concerned that despite the fact that UHC’s approach is community centred, there are no consultations. Her worry is heightened by the fact that governments are expected to take charge of health systems and ‘leave no one behind’ through funding, management and service delivery.
“Health is one of the least funded social requirements in Africa. For example, HIV programming has been donor-led on the continent,” she says. Now, donors are calling for more government support and some cases they have scaled down funding. They expect governments to take more responsibility through UHC”.
In 2015, many nations agreed to UHC as one of the key factors in meeting parts of the Sustainable Development Goals. In Africa, insufficient funding and badly managed health service systems still pose a challenge. Many people have to pay most of the cost for health services out of their own pockets. Due to poverty, most are unable to obtain many of the services they need.
Grace highlighted that if provision of health services is left to governments, sex workers will be further disadvantaged. She shared her own story to underline this point:
“I am female worker. For the last 10 years, I have accessed my services at a community drop-in centre (DICE) run by SWOP. This particular DICE and others run by this organisation in Kenya serve the needs of sex workers and other Key Populations. The DICEs were started to meet the needs of the sex community in Kenya because government facilities could not,” she said.
Having worked with the sex worker community in Kenya for years, she says the DICEs have played a critical role in HIV programing and community empowerment. “When a sex worker walks into a DICE, they do not fear that they will be judged, mistreated or discriminated against. It is a safe haven for the community.”
Grace fears UHC looks to ‘absorb’ community facilities instead of devising a plan on how to work with them. She told the panel that community health centres play different roles and have been devised to serve their members. For example, in many ASWA member countries, sex worker-led organisations rely on peer educators who are key in ensuring adherence to ARVs, problems with documents, and collect feedback from the community. “If peer educators are left out, we are going to lose. They should be incorporated because they monitor access to health services. Sex workers should be given a chance to monitor UHC.”
Grace noted that most governments’ policies leave out the Key Populations and young people especially on Sexual Health and Reproductive Rights. She advised that there should be meaningful participation and ownership of the process by Key Populations. “Implementation should follow up a bottom up approach. First communities should be consulted on what they want. It should not be the other way around where governments and donors decide for communities.”
Grace says there should also more public awareness and education through various mediums. “Implementation should incorporate online platforms because a good number of sex workers and young people prefer this kind of engagement.”
Grace insists that for UHC to work, all sections of the society should be involved. This was also echoed in comments from Dr Tedros Adhanom, Director-General of the WHO, who tweeted: “If universal health coverage is to be truly universal it must encompass everyone, especially those who have the most difficulty accessing health services, such as migrants, rural populations, people in prison, LGBT community, sex workers, drug users, poor people.”