Turning Commitments Into Reality: Moving Beyond UNGA – Women Deliver

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October 23, 2019
“The challenge to achieving UHC is not about financing and it is not about economic capacity. Every country has capacity to provide healthcare to every single one of its persons. It’s about having the political will to make it a priority. Politicians must prioritize people.”

During the United Nations General Assembly (UNGA) last month, advocates from all over the world, including young people, gathered to accelerate progress toward universal health coverage (UHC). Women Deliver Young Leaders and frontline health workers Walaa Ismail (Class of 2016) of Egypt and Cassien Havugimana (Class of 2013) of Rwanda were among the advocates who traveled to New York to join this effort. We sat down with Walaa and Cassien to understand the obstacles and opportunities on the road to achieving health for all.

Young Leaders Cassien Havugimana (left) and Walaa Ismail (right) traveled to New York to share their experiences and expertise as frontline health workers.

Women Deliver: Can you please tell us about what you do?

Walaa: I have been working on sexual and reproductive health and rights (SRHR) for about five years, working closely with at-risk groups, including men having sex with men, injecting drug users, and female sex workers. I have worked in public hospitals in Egypt as a medical doctor and infectious disease resident and in primary health care units. I have also worked as a project coordinator for HIV testing and comprehensive care center.

Cassien: I am an epidemiologist based in Rwanda working as a regional coordinator for the Swiss Tropical and Public Health Institute, where I oversee organizational work in Rwanda and Eastern Congo. Previously, I worked as a health promotion manager with Doctors Without Borders in Nigeria and as a women's rights advocate in Rwanda focusing on sexual and reproductive health and rights for young people and for men who have sex with men. I also supported efforts to change policies to advance LGBT rights and abortion rights in Rwanda.

Women Deliver: What made you want to become an advocate?

Cassien: I grew up in a poor neighborhood in Rwanda. Sometimes we were able to eat three times a day and sometimes we couldn’t eat at all. I have seen how people can struggle. Seeing this suffering inspired me to enter the medical field to help poor and marginalized people. In the medical field, I recognized how a focus on public health related issues could lead me to help more people. As an advocate, I can push governments to make greater investments in people’s health and allocate resources where there is more need, while also convincing private donors and companies to focus on health services.

Walaa: The main reason I became an advocate is because of the widespread inequality. When I learned how people suffer stigma and discrimination in accessing healthcare and how they have been kicked out of hospitals and clinics because of their situation, I decided to become a healthcare professional who didn’t do what others did. But as time went on, I realized I was only a single person in a single place. I was seeing a limited number of patients and while I sought to treat them with dignity, there was still a lot of inequality out there and a lot of people suffering and facing stigma. The ability to fight inequality on a wider scale is what attracted me to advocacy.

Women Deliver: In your experience as advocates and frontline health workers, what are the challenges you’re seeing in your communities?

Walaa: While the entry cost at government hospitals in Egypt is low, once you’re inside, the costs can skyrocket. Sometimes even the most basic medical instruments, equipment, and medication need to come from outside, which can be costly for patients. I have seen patients who look hopeless, some look at you with disappointment; others blame us – since we are on the frontlines – for not providing them with affordable medication. Because the health infrastructure is so crowded and burdened, many people turn to private facilities, which are very expensive. An emergency or a chronic condition could spell financial ruin for a family. And for the millions of people living under poverty line, many must choose between putting food on the table for their family or healthcare. Moreover, some groups, including those living with HIV, those in need of STI treatment, and unmarried people in need of sexual and reproductive health services face stigma and discrimination.

Cassien: In Rwanda, the health infrastructure is good compared to many other African countries. The government provides medical insurance for the very poor, but that doesn’t mean there aren’t challenges. If medicines at a hospital are out of stock, people have turn to private pharmacies and pay out of pocket, which can be burdensome for the majority of people on community medical insurance. During my research, I met families who ate only once a day and children who ate only a few small spoonfuls of porridge a day because they couldn’t afford food. How can they be expected to pay out-of-pocket costs? And for the poor people without insurance, they have to pay out of pocket but they can’t afford the drugs, which are very expensive. Additionally, marginalized people, such as men who have sex with men or lesbians, experience stigma and discrimination. So even if they are “covered,” they cannot access health services because professionals who are providing the services are not friendly.

Women Deliver: What are the obstacles to achieving UHC?

Cassien: The challenge to achieving UHC is not about financing and it is not about economic capacity. Every country has capacity to provide healthcare to every single one of its persons. It’s about having the political will to make it a priority. Instead, politicians often prioritize the big airport or a flashy infrastructure project, but what about the social infrastructure? The big hotel will make a lot of money and benefit a few, but healthcare — although it’s less tangible — would benefit millions. Politicians must prioritize people. And if a small country like Rwanda can manage to insure its people and the majority of the poor people can get access to insurance, why is this not the case in all developed countries? Why are some developed countries still debating this?

Walaa: I think it's about corruption. Some politicians care about their bottom line and personal gain, and less about what the people need. Investing in health, frankly said, while great for the people has no gain on a personal level for a corrupt politician. For a lot of them, their priorities lie in investing in industries rather than investing in people’s health.

“SRHR is not a separate health matter; it's linked to everything and is fundamental to people’s overall health and their life cycle.”

Women Deliver: As is too often the case, the political pushback on women’s rights — particularly sexual and reproductive health and rights — has been unrelenting. Why is the inclusion of SRHR in UHC so contentious?

Walaa: There are some countries that don't want SRHR as a priority or they don't think that it's essential. Some see it as complementary. But SRHR is not a separate health matter; it's linked to everything and is fundamental to people's overall health and their life cycle. 

Cassien: There shouldn't even be a discussion about including SRHR in UHC. SRHR is a cross-cutting health issue. We cannot achieve UHC without it. If people are not getting family planning methods, how do you expect countries to achieve UHC? Imagine you have 10 children, you have an income of one dollar per month, and the government still wants you to pay your medical bill. SRHR is a basic need for everyone — everyone has the right to have birth control, to have family planning methods. There are examples like the U.S. where conservative forces argue that sexual and reproductive health is not a right. This is also the case in Rwanda, where a minister shared that the Catholic Church was informing hospitals linked to it to not offer family planning services. Fortunately, our government pushed back but some countries that are dominated by religion don’t even want a discussion about including SRHR in UHC. And now with young people making up the majority of the world’s population, their needs cannot be overlooked.

“It’s important for us to see what commitments are being made by different countries to advance UHC, so we, as civil society, can hold them to account.”

Women Deliver: What opportunity does UNGA present?

Walaa: This is an opportunity to push forward on what has already been agreed upon, to gain additional commitments, and to push forward on achieving these goals by 2030. UNGA is a special moment because it's like a kitchen preparing for the work ahead. Sometimes when you are working in your own community, it’s easy to feel isolated from what is happening. As a local worker, a convening like this helps me view my work from a global lens. When you convene on an important matter like UHC, it’s great to meet and connect with other advocates and other sectors, to see the partnerships, and learn how people are integrating efforts for girls, women, and other marginalized groups. I'm able to transfer all this knowledge and experience to inform my work back to home.

Cassien: There are many opportunities for us at UNGA. Civil society organizations will need to work hard to make sure that the voice of the people is heard by policymakers and to hold their governments to account for what they have signed at the UN. I thank Women Deliver for giving me the opportunity to attend the UNGA, where I can learn from experts and attend specific sessions that fit into my work so I can return home to start implementing. It’s important for us to see what commitments are being made by different countries to advance UHC, so we, as civil society, can hold them to account.

Women Deliver: While impressive strides have been made toward UHC, significant work lies ahead to achieve health for all. What is your message to world leaders?

Cassien: Universal health coverage is a human right. Everyone should have access to healthcare services regardless of their ethnicity, economic capacity, religious beliefs – regardless of anything. Everyone should have access to integrated healthcare services in every country, everywhere in the world.

Walaa: Inclusion. Everyone has to be included – no one should be left behind, no one should be locked from being a priority of government. People should be the first priority of every government.

Women Deliver: At Women Deliver, we call you Young Leaders because we know you are already leading the way. That's why it’s important that you are here. What mark do you hope to leave here at UNGA and upon returning home?

Walaa: In my time here, I hope to share my insights and experience from the Egyptian context. I hope to bring more understanding beyond the data and explaining what’s behind the numbers by sharing the local reality. By sharing my perspective, I hope I can enrich people’s understanding of the issue. And because as you said, we are the experts, so we might help to change some minds. Coming from Egypt, I can act as an ambassador. I know how things are going there.

Cassien: Based on the commitments on UHC that will be made by our leaders here in New York, we want to continue to observe the progress and hold them accountable for translating these commitments into action. Through what I learn here, especially about UHC, I hope I can apply in my work.

This interview has been edited for length and clarity.

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