By Godson Eze, EV 2012 from Nigeria


The conversation below is a fictional piece elaborating current health debates on UHC through a dialogue between a hypothetical intelligent village Youth leader and his old time friend now living in the larger cities of a developing country. This piece raises lots of questions with some probable answers. The language level is not likely that of the average ‘Youth leader’ in a developing country but it has been written this way to allow the arguments to be properly addressed.


Youth leader: Wow! Good to see you. Where on earth have you been?

City friend: Great to see you too my dear friend. I have been in the city eight years now. I work for the country’s health sector and my work gives me access to the bigwigs in government.

Youth leader: Really! So what are you guys saying to us from over there?

City friend: Well, the World Health Assembly met recently and it appears Universal Health Coverage – securing access to adequate healthcare for all at an affordable price – is on the front burner. I am so thrilled about it, aren’t you excited?

Youth leader: Hmmm! What excitement should there be, is this the first time we’d hear that something is to be done on a mass scale? As far as I’m concerned, you have just told me there’s no hope for our healthcare system in the foreseeable future.

City friend: Oh no, you can’t say that!

Youth leader: Wait, let me finish before you get all defensive. What has happened to all the past initiatives? Health for all by the year 2000, MDGs, Free maternal and child health, even relief materials to victims of disasters – the greater part seems to end up in the hands and homes of a few. It appears these utopian initiatives don’t work well around here. So you might want to tell me what plans big brother has to ensure that this lofty plan gets individualized and that every individual takes some responsibility for his own health within the greater framework of the purported UHC!

City friend: Wow! You are raising some vital points now. I didn’t give it so much thought myself.

Youth leader: I still have some more to say please. Does the term ‘Universal Health Coverage’ not ring a bell? It sounds lots like the mantra ‘health for all’.

City friend: Yes, it actually does.

Youth leader: Since it does, I would like you to know that for us around here, anything that sounds like FOR ALL is a political statement that wouldn’t work. Take my word, I am not against giving everyone healthcare, and I know my fellow citizens are not either; but there’s been one too many disappointments with these ‘for all’ initiatives. I think there are now better ways to ensure initiatives like this succeed – if we really want them to.

City friend: Yes there are! WHO, for example, is proposing TASK SHIFTING, that is: non-specialist and even lay health workers to take over tasks that are supposed to be for specialist health personnel. This would make more hands available for healthcare and more likely ensure UHC.


Youth leader: Permit me to laugh. What an innovative way to abdicate responsibility. Since you claim to have the ears of the people that matter, please help me tell them that there has to be air-tight monitoring of the training of these not-so-skilled persons and also their activities afterward. Else, there would be lots of untoward fallouts from implementing this strategy. Also, there has to be independent evaluations of this initiative at every phase of its deployment, to allow for corrective measures to be taken in-process.

City friend: Sure, all that’s being taken care of. Task shifting is just one example.


Youth leader: Again, I wonder why mobile phones which we now almost all own cannot be put to better use – and we’ve even begun making payments with them. I thought sustainability was also entwined in the agenda? Since mobile telephony has come to stay, why can’t the codes with which we are registered into social health insurance schemes be further developed into an electronic identity and then the central government or funding agencies can have direct access to those codes – skipping all the human agents and other bottlenecks along the way. This would make funding and monitoring the initiative much easier.

City friend: What you have said is quite some food for thought but these telecom services could be erratic sometimes. Don’t you think if this strategy you are proposing gets adopted there would be frequent chaos at health facilities any time the telecom services are acting up?

Youth leader: I have thought of it quite some time myself. I see there’s a huge difference in the way our lives run now compared to how it ran prior to mobile telephony – so I am hopeful. Previously, one had to make elaborate preparations and take long trips, just to say hello to his parents but now all that is history. Even though, there are still short-lived spates of erratic network, you would agree with me that their services have improved a great deal. So let’s say these are just teething problems. If Mobile Number Portability is adopted, that would be a likely clincher to the already emerging solutions. The government would have to show strong commitment to making this work ASAP.

City friend: Well spoken; you have spoken so well my friend.


Youth leader: Thank you. I know also, that we can also make our contributions to health insurance through these same codes and these telecom companies can host the servers to these codes on their networks as a kind of Corporate Social Responsibility. Everywhere their networks cover, people can then access health care using their phones. There would then be smaller groups of people to focus scarce resources on using the traditional health systems and financing methods.

City friend: I really wonder why you are out here and not in the city. You’ve got a great mind.

Youth leader: If all great minds moved to the city, who will be here to respond to the needs of the people. Meanwhile, you have an opportunity to hear my voice at your stakeholders’ meetings – that’s if I am invited. And lest I forget, please bring to the attention of government that some stricter regulation on migration of health personnel needs to be adopted. These people are trained at extremely subsidized rates from our institutions and eventually disappear into foreign countries without giving service to their home country; thus robbing the system in lots of ways.

City friend: That’s really sad, but people have a right to live wherever they want to.

Youth leader: They sure do! But my take is that all those who are trained in federal government institutions – nearly for free – should give some years of service to the country before they are allowed to migrate if they so desire. Of course, this should not include those seeking to further their education; but in such cases there has to be another kind of agreement. If this is not done, even task shifting would not nearly achieve UHC because there won’t be sufficient skilled persons to train others.

City friend: You have spoken so well my friend. Meeting you today has been more than a coincidence. I feel nearly incompetent to relay your many deep thoughts to the powers that be.

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One Response to Universal health coverage in view: a conversation between two old friends somewhere in Sub-Saharan Africa

  1. The thinking and experience of the youth leader and the city friend are in fact complementary. There is no contradiction between global efforts progressively to realise the universal right to healthcare and the local efforts of individual healthcare providers. Indeed, both are needed. The MDGs (and the post-2015 sustainable development goals framework) have potential to make even greater gains in health outcomes over the coming decade – even greater than the amazing gains made in the past decade – at least partly because there will be better and better communication and understanding between “youth leaders” and “city friends”, and indeed between and among all stakeholders.

    The city friend ends by saying: “I feel nearly incompetent to relay your many deep thoughts to the powers that be.”

    No, no, no. These days are over. Communities of practice such as (which includes senior policymakers through to village health workers) mean that the youth leader can increasingly engage directly in professional networks at national, regional and global levels. The savvy city friend will say, “The powers that be are all ears. They are incompetent unless they can interact with people such as you who are grounded in real-world. Join national/regional/global communities of global health. Be heard. Learn with and from others with different experience and different perspectives, but with a common purpose.”

    Happy new year for 2013.
    Dr Neil Pakenham-Walsh

    Neil Pakenham-Walsh is the coordinator of the HIFA2015 campaign and co-director of the Global Healthcare Information Network. He is also currently chair of the Dgroups Foundation, a partnership of 18 international development organisations promoting dialogue for development. He started his career as a hospital doctor in the UK, and has clinical experience in rural Ecuador and Peru. For the last 20 years he has been committed to the global challenge of improving the availability and use of relevant, reliable healthcare information for health workers and citizens in low- and middle-income countries. He is particularly interested in the potential of inclusive, interdisciplinary communication platforms to help address global health and international development challenges. He has worked with the World Health Organization, the Wellcome Trust, Medicine Digest and INASP (International Network for the Availability of Scientific Publications). He is based near Oxford, UK. neil.pakenham-walsh AT

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