The HIV response has established paradigms for including citizens in health governance at all levels, with unprecedented participation through mechanisms such as the Global Fund Board, Country Coordinating Mechanisms, and the Joint UN Programme on HIV and AIDS (UNAIDS) Programme Coordinating Board. Community groups and networks, often operating outside the formal health system, have strengthened community systems to extend services to marginalized and stigmatized populations. Alongside ministries and parliaments, civil society organizations engage in formal arrangements for monitoring HIV programs [13].

UHC proponents should conceptualize UHC reforms as a partnership between government and the public [14]. Inclusive governance brings the public into processes such as (a) priority-setting for benefits packages and other resource allocation; (b) oversight for health services, including quality and adherence to copayment policies; and (c) monitoring performance against stated goals [15]. The HIV experience suggests that improving public involvement and accountability is a wise step to address common UHC challenges such as a gap between de jure and de facto benefits packages [16] and could help accelerate coverage for high-priority populations and interventions.

As discussed above, prepayment and risk-pooling arrangements can improve equity, increase utilization, and reduce impoverishment; they should not, however, represent the full extent of new budgeting towards UHC. As the HIV response encountered, where health systems are weak, new funds cannot go towards purchasing alone. Scaling up HIV services required financial investments in the health workforce, facilities, the pharmaceutical supply chain, and other needs [11]. Many investments simultaneously advanced broader health aims [17]: for example, in Ethiopia, external HIV funding contributed to the Health Extension Program, which has recruited, trained, and supported over 35,000 community health workers providing primary health care, including HIV services, in rural settings [18].

New UHC financing offers potential synergies with HIV financing: when UHC reforms invest in health systems, HIV budgets can focus on HIV-specific interventions. One option is to fund HIV-related health services through the broader pool devoted to UHC. HIV treatment, however, represents a large share of health spending in LMICs with a high HIV burden; it might be necessary to protect the pool, at least in its early stages, with supplemental external or domestic financing earmarked for HIV. Otherwise, high demand for HIV treatment could make the pool fiscally unsound. Ghana, for example, funds ART outside its national health insurance pool [19]; Brazil [20] and Thailand [21] did so until fairly recently.

Funding all HIV services through broader financing pools may bring efficiency gains. A well-governed pool can become an appropriate recipient for health assistance grants, as in Rwanda. Countries growing towards middle-income status and away from external financing could potentially self-finance HIV services through increased allocations to UHC financing pools, as long as necessary public health programs retain funding.

The HIV response succeeded not just because its agenda was technically sound but because it tapped larger narratives and built political demand. The public must demand UHC.

Although respondents in LMIC surveys prioritize quality health care [33], grassroots activism for comprehensive, affordable health services has been limited. Such activism can help create pressure for UHC reforms: in Thailand, for example, civil society organizers collected thousands of signatures supporting equitable health care access prior to enactment of the reforms [34].

Communications campaigns can tap into larger political narratives. AIDS campaigns argued that it is unfair that some people should die, and others survive, based simply on income, place of birth, sexual orientation, or gender identity [10]. UHC can connect to related movements concerning justice across geographical boundaries (for example, global North–South), socioeconomic justice within LMICs, intellectual property regimes, labor policies and social protection initiatives, and the women’s movement, as well as many others.

UHC advocates can also draw from AIDS campaigns by connecting UHC to economic growth and national security. They can cite evidence on the economic benefits of health reform, including the estimate that health system investments will generate 9- to 20-fold returns in LMICs by 2035 [35].

Weak, unjust health systems pose security concerns. HIV advocates established political momentum by highlighting societal and economic threats, resulting in the first UN Security Council resolution on a health issue, in 2000 [36]. Ebola was the second, in 2014 [37]; UHC proponents have argued that UHC reforms can improve resilience against infectious disease threats like Ebola, through stronger service delivery systems and financing arrangements and increased public trust [38]. Targeted capacities for controlling outbreaks, such as disease surveillance and response, can be packaged with health financing reforms, as in Mexico’s 2003 legislation [39].

In the HIV response, calls to action were not limited to the community level. Champions such as former Presidents Festus Mogae of Botswana and Olusegun Obasanjo of Nigeria and former UN Secretary-General Kofi Annan led major national and international efforts. Similarly, top political leaders have been critical to successful UHC legislation. The UHC movement should recruit them actively. Advancing UHC not only is an obligation but may provide political benefits [40].

Whether led by communities or politicians, emphasizing human rights or socioeconomic security, a focus of the HIV response has been clear, bold ambition with messages and arguments that resonate from the “elevator speech” to in-depth analysis. For UHC, robust data—extensive, credible, and disaggregated by subgroup—are necessary to drive ambition and accountability [41]. Data can empower decision makers in ministries and parliaments, along with civil society as watchdogs. UHC monitoring should quantify not just inputs, such as individuals enrolled, but also process indicators, such as the utilization and quality of key services, and disease-specific health outcomes, including for HIV [15].

Moreover, monitoring should measure equity across multiple dimensions of vulnerability and marginalization. While UHC proponents have suggested disaggregating by income, gender, and geography [3], we recommend countries strengthen their health information infrastructure so policy makers can also track access by age, disability status, ethnicity, sexual orientation, and other locally relevant dimensions of health equity.

The health system alone cannot achieve UHC [42]: as the HIV response has illustrated, many barriers to access lie beyond the health sector. For example, discriminatory laws and policies, including criminalization, can severely undermine access to health services for marginalized groups [11]. The AIDS movement has argued for inclusive and protective laws and policies and decriminalization, to hold governments accountable for creating an enabling environment for people at particular risk.

Such multisectoral actions should be part of a UHC reform agenda cutting across government divisions—a “health in all policies” approach [43]. Additionally, civil society and communities can identify, and help eliminate, barriers to access; empowering civil society and communities in governance, therefore, may help mitigate adverse social determinants of health.