Rethinking UHC: Systems, not slogans

Universal Health Coverage. Three words.

They sound simple. Governments pledge it. Donors fund it. Leaders quote it in speeches, promising that every person, everywhere, will have access to the healthcare they need, without financial hardship.

But here’s the truth: For billions, UHC isn’t a reality — it’s a soundbite.

What it looks like when UHC fails

Outside the health facility, there was a tap. Dry. Locked.

Inside, an old desktop sat untouched, covered in an inch of dust. A relic from another era. Diagnostic tools sat idle, not because no one needed them, but because they didn’t work. The pharmacy shelves were empty. Not just missing specialty drugs, missing basics. No flu treatments, let alone ARVs or anti-malarials.

At the registration desk, two university students, volunteers who filled the gaps where trained professionals should have been. They greeted patients who sat outside, waiting in silence, each holding a single, fragile notebook, possibly their entire medical history.

I watched and thought to self: If they lose that book, they lose their past.

Nearby, a fat logbook recorded names. “N” for new patients. “R” for repeat. Serial numbers reset each year—meaning a patient’s history disappeared into paper archives that no one could track.

This isn’t an isolated case. This is reality for millions.

Why developing nations struggle to build UHC

The challenges run deeper than missing doctors or broken equipment. The problem is structural.

People don’t trust health insurance

In many developing nations, the concept of health insurance is alien, or deeply distrusted. Why?

Governments haven’t educated citizens on how risk pooling works or why it matters. Past corruption has left people skeptical, and they believe premiums will disappear, not pay for care. Most economies are informal, people live day to day, making monthly insurance payments feel impossible.

This is a demand-side problem — individuals not buying in.

No sustainable risk pooling = No financial protection

Universal Health Coverage doesn’t mean “free healthcare.” It means no one should go bankrupt because they got sick. But here’s the problem:

Without enough people in the system (especially healthy ones), there’s no viable pool to spread financial risk. This results in fragmented, unsustainable systems where the poor pay out-of-pocket, and the wealthy opt out.

This is a supply-side and structural problem — the system can’t offer protection because it’s too shallow.

Without proper financing models, health systems crumble under the weight of their own inefficiencies. And so, the cycle continues.

Donor dependence is not a health strategy

Across much of sub-Saharan Africa, Southeast Asia, and the Caribbean, public health systems have long depended on international aid to fill financial gaps. That aid is now shrinking, and the consequences are visible.

• Funding reductions from programs like USAID and PEPFAR have already led to stockouts, treatment disruptions, and clinic closures in some of the region's most dependent on donor support.
• These cuts put millions at risk, not just in HIV treatment, but in essential services like maternal care, malaria prevention, and routine immunizations.

When donor money disappears and there’s no resilient domestic investment to replace it, systems collapse. Patients suffer. And years of progress can vanish in months.

Too many governments continue to rely on emergency aid instead of building long-term, locally financed health systems. This isn’t just a funding gap; it’s a leadership and accountability gap.

UHC Isn’t a promise. It’s a System.

To break the cycle, developing nations need more than donor money, they need real systems that last.

1. Infrastructure – Health isn’t just doctors. It’s clinics that function, equipment that works, and supply chains that don’t fail.
2. Financing – UHC requires long-term financial sustainability, not just short-term grants.
3. Digital Systems and data – Paper logbooks won’t cut it. Digital health records must be scalable and interoperable.
4. Trust and governance – If salaries don’t get paid, doctors leave. If governments don’t lead, people will never trust the system.

When we treat UHC as an aspiration, we chase headlines.

When we treat it as a system, we build solutions.

Systems thinking is the strongest tool we have to make healthcare truly universal.

Because access to care shouldn’t depend on a locked tap, or a lost notebook.

I’d love to hear your perspective — whether you're in policy, practice, or lived experience. Let’s open up this conversation and move it beyond headlines.