Social determinants of health play a crucial role in treatment success, but are often overshadowed by a focus on financing models and service packages in healthcare reforms, says the writer.
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When Sipho finally reached the clinic, he had already missed half a day’s work. The queue moved slowly. The consultation was brief. He left with medication and instructions he barely had time to process.
Technically, the system worked. He accessed care. And yet, two weeks later, his symptoms were worse.
World Health Day 2026 calls for “Global Action for Universal Health Coverage.” The World Health Organization defines Universal Health Coverage (UHC) as ensuring that all people can access the health services they need without financial hardship.
It is one of the most ambitious and morally compelling commitments in global health. But recent global assessments tell a sobering story: progress towards UHC is off-track. Billions of people are still not fully covered by essential services, and nearly two billion face catastrophic or impoverishing health spending. Financial hardship linked to healthcare has worsened rather than improved over time.
The numbers are staggering. But they do not fully explain why access alone is not translating into health. Health systems are built around services. Health itself, however, is built around circumstances.
Sipho’s ability to recover is shaped by factors that lie far beyond the clinic walls: whether transport is reliable and affordable, whether his employer allows time off for follow-ups, whether his family understands his condition, whether instructions are communicated in language he can act on, and whether community systems support or stigmatise his diagnosis.
These are not peripheral concerns. They are the social determinants that determine whether treatment succeeds or fails. Yet most UHC reforms still focus primarily on financing models, insurance expansion and service packages — all vital components, but incomplete on their own.
When transport barriers delay care, employment insecurity discourages follow-up, literacy gaps undermine adherence and family stress reshapes priorities, access becomes fragile. The system may expand in reach, but outcomes begin to stall.
Global health trends already reflect this tension. Maternal mortality progress has slowed in many regions. Immunisation coverage has been disrupted. At the same time, the burden of non-communicable diseases continues to grow, with millions of people dying prematurely each year from chronic conditions that require sustained engagement with care, not one-off visits.
Here is the uncomfortable truth: Universal Health Coverage has focused on opening the door. It has not focused enough on what happens after it opens.
Another missing variable is the patient. In many systems, patients remain passive recipients of care. Policies are drafted, service packages are designed and performance metrics are set, often without deeply integrating patient experience into how care is structured. Yet patients hold the operational intelligence health systems most urgently need: why medication is skipped, why follow-up appointments are missed, why stigma silences disclosure, why financial stress reshapes health priorities and why instructions are misunderstood.
Research on co-production in healthcare, particularly within mental health systems, shows a consistent pattern. When patients are treated as active contributors rather than passive beneficiaries, outcomes improve. Co-production is not a soft or symbolic concept; it is structural. It recognises that clinical expertise and lived experience must intersect if health gains are to be sustained. When systems ignore lived experience, expanded access can quietly generate the inefficiency of repeat visits, poor adherence and preventable deterioration.
Universal Health Coverage cannot afford that inefficiency. The pathway to UHC runs through strong primary healthcare, capable of delivering the majority of essential services and saving millions of lives. But primary healthcare is not only about infrastructure or financing reform. It is relational.
If consultations are rushed, instructions unclear and decision-making one-sided, access becomes administrative rather than transformative. Financial protection is necessary to avoid the 1.3 billion people that have already been pushed or further pushed into poverty due to health costs. Removing fees is vital, but if engagement fails, financial protection alone does not secure health.
As the world renews its commitments to Universal Health Coverage, a more difficult question must be asked: are we designing health systems that produce services or systems that produce health?
Global action for UHC must evolve from counting coverage to strengthening relationships, from financing packages to designing partnerships, and from measuring visits to measuring sustained wellbeing. Until Universal Health Coverage answers that question with confidence, access alone will never be enough.
Dimpho Hlungwane is a graduate of the MBA in Healthcare Leadership at Stellenbosch Business School