Infrastructural and system barriers to Universal Health Coverage: get in my patient’s shoes

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(Olga Guryanova, Unsplash)

This article was exclusively written for The European Sting by Dr Zayithwa Fabiano, a  medical doctor from Malawi with over three years working experience in clinical medicine and public health research, focusing on improving health service delivery. She is affiliated to the International Federation of Medical Students Associations (IFMSA), cordial partner of The Sting. The opinions expressed in this piece belong strictly to the writer and do not necessarily reflect IFMSA’s view on the topic, nor The European Sting’s one.


Universal Health Coverage (UHC) means that everyone have access to the health services they need, when and where they need them, without financial hardship (WHO). As a young energetic passion doctor I was excited about my work. In 2018, as a medical intern, I was rotating through pediatric surgery.

Malawi had less than 10 practicing pediatric surgeons; the pediatric clinic was busy, the wards full and the theatre lists long. Everyone worked hard to provide optimal care to each one of these children who needed surgical care. 9 months after my pediatric rotation, I was doing some public health evaluation work across the country. This took me deep into the rural areas of the country. Places with poor roads, no bridges, poor network, no electricity and no efficient transport network.

One rural health center evaluation visit took us to one of the most difficult places to access I have ever been. We left Blantyre, the city with the surgical pediatric ward I interned at, at 5:00am, we arrived at this health facility at about 3:00pm. The distance is about 280 kms/1740 miles from Blantyre city.

However it took so long to get there because the dirt roads were muddy and slippery to navigate. We found one bridge had been washed away with the heavy rains, Malawi was experiencing floods due to Cyclone Idai during this time, as such we had to find another road to get to the health center. Eventually we made it.

Upon arrival, we carried out the evaluation. A woman carrying a baby called out to me “Doctor, what are you doing her? Do you remember me?’ After a chat and looking at her baby, I remembered who she was and my heart sank. This mother and her baby had been coming to the pediatric surgical department in Blantyre during my time there. Her baby had Hirschsprung’s disease.

The initial surgery had been done but she had had her babies subsequent surgeries cancelled at least 3 times, because the theater list was too long and we did not have the capacity, both human and material to operate on her baby. When I thought about how difficult it was for our team; young, healthy, with a 4 wheel drive vehicle and no baby, struggled to reach the facility…my heart broke…how much more had she suffered to come to the hospital in Blantyre city and had been sent back without assistance.

Her situation and experience was the very opposite of what universal health coverage was. I suddenly realized that in all the clinical work I had been doing I had to think about all the non-clinical factors that are barriers to people accessing health services, and that in my practice as a health worker and for all health workers we must think broadly about what UHC is and the barriers to UHC in our contexts and generate innovative solutions to address them.

About the author

Dr Zayithwa Fabiano is a medical doctor with over three years working experience in clinical medicine and public health research, focusing on improving health service delivery. Currently Zayithwa is working as a Clinical Trial Study Coordinator at John Hopkins Research Project in Malawi. Zayithwa holds a Bachelor of Medicine Bachelor of Surgery degree from the College of Medicine, University of Malawi. She is a Mandela Washington Fellow and African Changemakers Fellow. She is the founder of Health
Access Initiative Malawi which works to improve access to health information and services to the populace.

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