This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.
Gavin: Hello and welcome to The Lancet Voice. It's May 2023. I'm Gavin Cleaver, and we're very pleased to have you with us. I hope you've been enjoying our voyage through Universal Health coverage over the last few episodes. If you've no idea what I'm talking about, well, that's fine, but where have you been?
We've been taking an in depth look at universal health coverage by examining how it's financed, how innovation can improve UHC, and what the future of UHC looks like. All these episodes are available where you found this podcast, but also I'll drop a link in the show notes too. Today's episode, the last in the quadrilogy, looks at making universal healthcare, well, universal.
How can we reach hard to reach populations? How can we overcome the costs that pile up when health coverage is expanded to populations without it? And when is universal health coverage, despite claims to the contrary, not actually universal? To discuss this, my co host, Jessamy Baganal, is joined for a conversation by Professor Zhou Wang, who's the Vice President International of the University of Toronto, and the founder of the Reach Alliance, an organisation which aims to equip a generation of global leaders to expand healthcare for the hardest to reach populations.
Jessamy and Joe are joined by three researchers from the Global Reach Alliance, Elizabeth Lubinda, Francesca Lanzarotti, and Roushey Naik. Please enjoy this conversation of them discussing the limits of universality in universal health coverage.
Jessamy: Joe, thank you so much for being with us. Just tell us a little bit about yourself and about the Reach Alliance and you know, what it is and what your involvement is.
Joseph: So my name is Joe, and I'm a professor at the University of Toronto, and my background training is in political science and political economy, but I've had a long interest in health systems, health systems strengthening and so forth, and some of my earliest work actually was on health policy and universal health coverage in, in East Asia.
What got me thinking about this concept of reaching the hardest to reach actually began When I was doing some research in Ethiopia in a quite unrelated project, actually, and there we had an opportunity to visit one of the many illegal housing settlements or as we call them slums in Addis. And I've done a lot of work in slums before, but this was one of the times where I was, you know, really had a good opportunity to just walk around and as it was to actually get completely lost.
And so I was saying to my colleague, I was like, you know, in these slums here, there There are no addresses. And he said, that's right. But people who are from the slums know how to get around. They know where people are. They know where people live and so forth. But, you know, from my point of view as a political scientist, I began to think, well, governments don't know necessarily where people are, or NGOs may not necessarily know where people are.
And so I began to start thinking about the kind of administrative technologies like an address or formal identification. Or the other kind of markers that sort of take for granted in the delivery of social services, including things like health. And it got me to thinking about just how difficult it was to reach large swaths of the population around the world.
And so in the context of universal health coverage, which of course, you know, the, the whole idea of health for all began decades ago. But really for me, it came into sharp relief when the world started talking about the SDGs or the sustainable development goals and the axiom. That no one is to be left behind was something that I took quite literally and I started thinking, well, how do you actually design systems or how do you ensure that absolutely no one is left behind, especially when you have such uneven playing fields, especially when you have populations who are just so incredibly difficult to reach.
And so that's how this all began was to start thinking from a political science point of view. From a governance and public policy point of view, how do you reach those who have until now been completely unreached in the course of doing that? We've identified many of the barriers that continue to stand in the way.
Things like geographical remoteness, cultural barriers cultural barriers as it relates to gender, for instance, as I've already noted, You know, the kind of administrative technologies that we often take for granted when it comes to the delivery of social services, including health. These case studies have taken us around the world we've conducted research on virtually every continent.
And in most recent years, we've expanded, began as a project here at the University of Toronto, to now what we call the Global Reach Alliance. And we've been fortunate enough to bring in world class universities. to be part of this alliance and part of this network. Hope that provides a, a decent kind of introduction to what it is that we've been up to.
Jessamy: It does, Joe, and I think it will become, you know, clearer also as we introduce and hear from our other guests who are going to talk a bit about some of the things that they do. So we've got Elizabeth, Francesca, and Roche. Maybe we can start with Elizabeth and you could just introduce yourself and say where you're based and your sort of work on universal health coverage, any
Elizabeth: insights that you've got.
I'm Elizabeth. I'm doing my master's in public health, specializing in biostatistics at the University of Cape Town. I'm passionate about community work and maternal health research. I have been on several projects that I've handled. Can I say how people can access primary health care, let's say HIV, drugs.
Adherence, and my current research is on stillbirths and maternal HIV. In a team, a rich alliance team looking at social franchising models and how they can enable primary health care service delivery to under deserved populations.
Jessamy: Thanks so much. We can come back to some of any, any insights that you've got afterwards.
That'd be lovely. Francesca, you next.
Francesca: Hi. So I'm Francesca Lanzarotti. I'm currently a master's student. At the University College London UCL here in London, and I'm studying women's health and for our REACH project and actually, it's actually a multidisciplinary project between the Institute of Women's Health at UCL and then also the Institute for Innovation and Public Purpose.
And our goal is to investigate and research the experiences of women with disabilities in Nepal and their access to maternal health care. So before we went there for a couple of weeks to do some field work and interview the women themselves, some policy makers, and then also health care providers.
And before going down, we in our literature review, we understood that there are policies and frameworks to provide health care for these women. However, there are certain barriers in their access to it. So our goals are really to understand specifically the social barriers and then also the geographical barriers that limit their access.
And then what kind of services actually do come within the universal health coverage and then any sort of areas for policy implementation or any sort of interventions that we could develop from this research.
Jessamy: Thanks, Francesca. And Roche?
Rushay: Great, thanks. My name is Roche Knight. I'm currently a junior health policy analyst with the OECD and based in Paris, France.
I, I was a master's student up until fairly recently. That worked on some other projects than, than what I currently work on. At the moment, it's, it's a bit of a focus on climate change and health and some of our programs on healthier quality and outcomes. But before that my research mostly centered on health systems reconstruction in fragile and conflict affected contexts.
And a big part of that was sort of interrogating some of the developments that were, that were occurring in the post conflict space namely the, the humanitarian development peace nexus, which has been a big part of the agenda. With regards to the Sustainable Development Goals and, and peace building agendas and how those come together in, in health.
Jessamy: That's great. Thanks. So, a quick kind of question, maybe we can start off with Joe first and then, you know, if other people could you know, build on their insights and their, and their thoughts. When we talk about universal health coverage, we're all, you know, it's just a whole kind of spectrum.
There's not, you know, in some countries, universal health coverage means access to it. Lots of different things, like in the NHS, in other countries, it means you only have access to, say, perinatal care and, you know, a couple of other essential medicines. We still think that within that country, whatever is defined as universal health coverage is universal.
That everybody has a right to access it and everybody can access it equally. But in reality, we know that that's not the case. And, obviously, In each country, the reasons are going to be completely contextual and different and, you know, a lot of the work I imagine that you're doing from a political science point of view is to sort of draw out some of those things.
But if we're talking broad strokes, what are the kind of, why isn't universal healthcare coverage universal?
Joseph: Thanks. Yeah, that's a great question. I, I, I mean, definitely the implementation of any kind of health system strengthening is going to be context specific. So it's absolutely imperative. That we really understand the social, cultural, political, economic context and also just the, the broader health systems context within which these interventions are being implemented.
But I think there are some quite generalizable barriers that we have seen across all of the case studies that, that we've conducted. As I've noted, for instance, you know, geographical remoteness is a real challenge. In terms of the infrastructure, the built infrastructure to actually deliver things to people who are off the grid.
So, for instance, most recently we did a case study on operation called Operation Remote Immunity, which was the delivery of COVID vaccines to remote Indigenous communities in Northern Ontario. And these are communities that are in regions of the province that are so far north that the road system actually ends about 200 kilometers short.
Of where these communities are. And so the built infrastructure that we would rely on delivering, whatever it might be just simply ends. And so this required the use of fly in resources. And so these were, these are referred to as fly in communities. And in order then to be able to deliver vaccines required that they actually be flown in.
We also noted in that project, there were really immense cultural barriers as well. These are indigenous communities that have. Every reason to mistrust the government and government efforts when it comes to the delivery of health care and so forth. And so, overcoming those kinds of cultural barriers, the legacy of mistrust, the legacy of the kind of violence these communities have experienced and so forth.
Are very real barriers when it comes to take up. These are things that I'm, I'm telling you in the context of Ontario, but these are the kinds of stories and barriers that we would, I think, see to be quite universal. One of the other things then that's related to that and as a political economist, something that I think a lot about is how much it costs to reach those who are hardest to reach.
And again, I think this is something that is quite universal and we've published some work on this. When we look at, for instance, the marginal cost. to increase coverage after a certain level of coverage, right? So, once you get from 75 percent coverage to 75 percent plus one, the marginal cost for that additional delivery of that healthcare intervention or that health intervention can be quite prohibitive, right?
So you know, there's a scaling mechanism that allows you to scale up programs relatively cost effectively. But after a certain point, from a purely economic point of view, the marginal cost actually becomes prohibitive. So we've shown in some of the data that we've published that, you know, to get from 50 percent coverage to 50 percent plus one, the marginal cost is roughly the same as what the average cost would be.
When you're at 75 percent coverage, to go to 75 percent plus one, it's about two times what the average cost is. By the time you're actually reaching the very last person to reach 100 percent coverage, The marginal cost to reach that very last person is about four times what the average cost is.
That's a very real economic challenge in terms of how do you generate the political will, how do you generate the kind of systems that will actually allow or facilitate the delivery of these interventions to reach people. This is a challenge that we see everywhere. I'll give you another example.
Recently, as I was noting, We were just in two, working in two coastal villages in the most southeastern point of Kenya. So this is to the east is the Indian Ocean, to the south is the Tanzanian Kenyan border. And these are villages that are incredibly remote, and they're working on some mangrove restoration projects.
But what they're doing is using the carbon credits that are generated from that in order to generate revenues, in order to do some real infrastructure work. For instance, access to fresh water and in talking to villagers that say, look, we believe the government will eventually get to us. We believe that an essential, an essential service like access to water and to clean water is something that we would eventually enjoy the benefits of. For the time being, it's far too expensive for governments to really think about how to build out that infrastructure. How do you install a well, for instance, and a pump and so on.
So they've ended up having to do it themselves. And they've generated revenues through the sale of these carbon credits to do it themselves. Simply because they had historically been left behind and there was really, there wasn't really any sort of light at the on the horizon to suggest that they were next in the queue to, to get access to this, you know, essential supply of clean water.
And the reason being is that to actually reach those communities is prohibitively expensive. It's prohibitively costly. And unfortunately. in our world, despite our proclamations for universal health coverage and proclamations of any universalism in the delivery of some essential social service. These costs matter and prevent organizations from actually reaching those who've been left behind.
So those are some of the things that are, again, they're borne out in very specific contexts, but I think they're universally experienced.
Jessamy: Thanks, Jay. Elizabeth, Francesca, your work obviously focuses on women. What are some of the nuances and things that we think about when we're talking about universal health coverage and women's access?
Francesca: Specifically, in our case, we're focusing on women with disabilities, which creates kind of a twofold barrier almost to universal health coverage because of gender and also disability. So we were looking at the intersection of the two. Which is sometimes overlooked, I think, in universal health care coverage, because in terms of making it universal, it doesn't maybe pick up nuances that these individuals face that wouldn't be faced by the majority of other people.
So For example, in Nepal, when we went and we spoke with the women, we found that there's a lot of discouragement from society in general for them to have children, which that in itself was a barrier to accessing health care. So although universal health coverage was there for them, and it was to a certain extent implemented into policies because of this social stigma and discouragement towards them to have children because of their disability.
And because of their position in society, which is a quite patriarchal society in Nepal, it's difficult for them to overcome that stigma easily. The discouragement made it more difficult to access the policies or the benefits that they would have received under universal healthcare coverage. So whilst it's there and whilst it's accessible for them, it's important to also address these societal barriers that Joe mentioned.
That also create an unlimit to the universality of the universal health care coverage.
Elizabeth: Okay, I'll give the Zambian context. For instance okay, most rural areas in Zambia don't have great health facilities. And even if they have health facilities, most of the key, can I say, health providers there are overworked.
Equipment is not available. So, even though, Let's say the government wants to provide these services, they're not sufficient. Another thing would be, a lady, perhaps there's a health facility that has these services. An antenatal lady might not have enough money to actually go to these facilities. For instance, there's this district in Zambia called Chongwe District.
There's this place called Katova Clinic. And it only has like four health personnels, and there's so many antenatal women going there. And Katoba is an area that has can I say most people there have low household income. So imagine you're a lady, you're pregnant and you go to the hospital and you find maybe the care health personnel says, Oh no, sorry.
Maybe come back. And then you have to go back, so it actually kind of affects also the health seeking behaviors of these women, so them getting these services, yeah, it has that effect on them. And our thing is equipment. You know, there are times when an antenatal lady will go there, and the, The lady, can I say the midwife, won't even have equipment, like an ultrasound machine, to detect if there are issues in her pregnancy.
They'll like use those physical outdated examinations. So when ladies go back in their communities and narrate their ordeal in those health facilities, others will be like, let's just opt for a traditional birth attendant. And that still has a negative toll on them because the odds of them having Pregnancy complications are high, and with those high odds, without any specialized health caretaker or midwife, there are chances that they could have a negative birth outcome.
So, yeah, that's my take on that. I
Jessamy: mean, it's difficult also, isn't it? Well, on the one hand, we're talking about countries who have already made the case to people to their voters, to their electorate, that we need universal health coverage. They've assigned and they're delivering universal health coverage.
On the other hand, what universal health coverage is, is such a Western focus and it's so medical that actually, you know, is it, is it a bad thing if women carry on having the same type of care that they have done for centuries? You know, it's more community based, it's, you know, using indigenous knowledge.
And I find that, I find that balance very difficult, you know, equally, I'd be interested to hear how you guys view your work and maybe the Reach Alliance and, and the sort of whole decolonizing agenda that, you know, this is a, we're still talking about these things from a very high income focused way.
What does that feel like?
Elizabeth: You know? Yes. Okay. I feel universal healthcare is global, yes, but given different contextual environment. You can't use strategies used in Europe on an African setting. Okay. I would say for universal healthcare to really kind of work in my place Zambia or South Africa. I think in interventions focusing on community based workers would work.
Because they are cheaper than doctors. So you, you ask the people to come, you train them and they go to the communities. They teach them proper health methods, health education. For instance, there's this model, there's such a franchise model in South Africa called Donjani. Phoenix model. It's run by nurses.
So these nurses are trained. And then they go to these remote areas and they set up these bioclinics. And the great thing with this is that the drugs have been subsidized. So these ladies won't spend, won't have high out of pocket fees compared to them going to a pharmacy next to a hospital. So I still, if the government, like our African governments, were to sit down and not really want to work.
The Western governments are doing, because I feel our budgets are so tight. If we can just look at these small details, like enroll these community health workers, but even when you enroll them, give them great incentives, because imagine you have a family and then the government forced you to this remote area.
Yes, you have a great, you have great passion to help these people, but your pay is so low compared to a doctor who's maybe 3. 0 pay. You wouldn't really fancy going to these places, and these places need these community workers. So, yeah, that's my take on that. Jasmine, could I?
Joseph: Yeah, please. Could I just intervene here?
This is, that's a terrific question. It's something I've been thinking about, and I'm actually sketching out a paper on this right now. I, you know, one way of thinking about this is, is that we typically conceptualize scaling as a As I've described, it's kind of like a radiant model in the sense that you have something that has proven concept, usually in the metropole, has proven concept, and then the idea is that you scale it outwards, and there's almost a kind of contiguous logic to this, that you go from the metropole and you through this kind of radiant model scale through the contiguous touching, if we will, of communities, and that's how you scale out to those who are the hardest to reach, those who are residing.
In in, in the margins, those who have been excluded and so forth. And it strikes me and I think your intuition is spot on, is that what we really should be doing is actually thinking about what the barriers are and the specific context within which these communities that have historically been marginalized, really getting a deep sense of what's going on there.
And actually thinking about then scaling, not so much as radiating from the core outwards, but really trying to understand what kinds of implementation strategies make the most sense within these communities that have historically been marginalized. So the, the concept I'm working with now is rather than scaling outwards, which is typically how we think about these things in economic is to think about a model that's more about replication and, and how I'm seeing it as, you know, is to replicate.
A particular model in another community, but to root it within that community. So it has to be rooted within that specific community in terms of their indigenous local knowledges and practices and so forth. And then from there, how do you sustain it? And then from there, how do you diversify it so that it's delivering more more services through that particular delivery mechanism.
Fundamentally different from how we think about scaling, right? Because as they say, scaling really relies on a contiguous model. Of, of recreation. This is really about replicating and rooting. It may not be the most elegant way that economists will think about this, but I think at least in the research that we've done, it's, it's been remarkably robust as a model of scaling that that lasts, that makes sense within communities that have historically been marginalized and hard to reach.
And ultimately, Delivers greater value, whether it be health, energy, security, security, and so forth. So that's a different way of thinking about things, but I think it picks up on the, the, the instinct that you've shared with us, this idea of, of, of sort of eschewing this notion of the, the metropole of the center of the core, and it was best just simply to scale outwards.
Rushay: I just really wanted to pick up on on, on the idea of scaling out because I think part of maybe the way in which we speak about health services itself lends itself to this notion that almost this frontier ideology that that services continually are expanding outwards and, and that it, that it follows this very linear path and just to bring in the perspective of, of the conflict affected context, especially with the fragile state context as well.
These are not linear spaces. These are, these are contested spaces, right? If, if universality is, if we assume universality to be 100 percent of a population covered we have these models of, you know, the, the, the building blocks model of health services, you know, or the coverage cube, right? A forever expanding cube of costed models for which we have fantastic economic costing models in literature today.
But that simply assumes that that that 100 percent of the population simply needs to be reached by an existing central authority, an existing central system of coverage and really at, at, in, in the conflict affected context. None of that is guaranteed. You know, some of what Joe was talking about was as well.
I think about the, the, the, the sense of in, in really remote, geographically isolated, constrained context. You know, one example I have is, is, is of Afghanistan and it's it's basic package of health services to try and expand this coverage. One of the most fundamental tenets of, of that project, of that, of that system was in fact to establish what became known as, as Fidelity Health Council at the lowest, you know, health sub centers in hierarchy of the health system, at the very closest to communities and in, in Dari, these were often held as meetings for for communities, for elders for people at the village level to convene.
At health councils to discuss their needs the new health services that were to be funded. People were, are traversing you know, long distances to get to these meetings just to be able to speak on what, what they, what they sought in terms of a health service that, that functioned for them.
And, and I think that That speaks to the idea, especially for communities that hadn't been speaking to each other well into the post 2001 period at the start of the war that and the expansion of coalition governance that perhaps instead of looking at health services as simply an economic service to deliver that we have to be changing our notion.
Are these social are these socially oriented, right? Are they, right? Right. Are they are they a function of solidarity, of community building, of of, of of nation building, perhaps? These are all very difficult, challenging terms that we have to, to, to interrogate much more if we are to, to, to really approach anything with exactly universality.
Francesca: Thanks, Frantiska. Yeah, I just wanted to pick up on something that Joe mentioned about rooting services in that contextual environment. And I think that one thing that we found was really important in this process was to include the women that we were interviewing, so the women with disabilities in the research and in the policy creation.
A lot of the things that they were telling us showed some discrepancies between Our interviews with the policy makers and then also what the reality was, what these women were experiencing. For example, the policy makers were saying that the hospitals were disability friendly according to the regulations.
But then in the interviews with the women, we found that they experienced the opposite, that there was no braille in the hospitals, that there was no sign language interpreters, that there were ramps. There were ramps, but these ramps were They, the way they communicated it made it seem like these ramps were there for the purpose of the general population and not to facilitate their needs specifically.
So by, by focusing on the women's stories and listening to their perspectives more, we're able to understand the discrepancies and by understanding their needs and placing them in this focus of the innovation and moving forward, I think it does help start to decolonize universal health coverage as it really then roots the services in the contextual and the clients or the patient's needs and can service them rather than it being something that's imposed upon them with a history from wherever it's coming from.
And like Joe said, rather than just expanding, it's really tailoring the services to who is receiving them.
Jessamy: Thanks, Francesca. And I just wanted to pick up on a tweet, actually, that someone responded to Joe's post that he was going to be talking to us this afternoon. And Susan Sidshia, who I think is from the University of Toronto.
She says, I hope that you're going to focus on the fact that it's not necessarily that the people are hard to reach, but that the services that we've designed are exclusionary, based on disabilities, based on race, based on indigenous beliefs, based on a whole range of factors. To what extent is, is that true?
Is it, is it that this isn't hard to reach people? This is just that we've designed services in such a kind of colonial way that we're always just going to be excluding people.
Joseph: That's a great point. This is something that I ardently believe. And I think sometimes policymakers and others don't want to hear it.
You know, my, my belief is actually the, the health inequities that we see in the structural inequities that we see, you know, not just a function of historical consequence. These are a function of intentional exclusion. And so when we think about universal health coverage, it's not, and I encourage people not just to think about it as a technical problem to be resolved.
I think there are a lot of technical issues that can be that, that ought to be resolved and can facilitate. The extension of health coverage to something more closely approximating what is universal. But if we don't go in with the mindset that actually what we're talking about here is redress that what we're talking about here is reversing structural inequities that are a function of historical intentional exclusion.
We don't go in with that mindset, I'm, I'm worried that we'll never actually achieve universal health coverage. I do have to go into the mindset that this is something about, that this is about reversing. Intentional decisions have excluded populations historically. So when we look, for instance, again, at indigenous communities, whether they are in Australia, in Asia and here in Canada we can't just think about generating more access to health coverage as a technical issue to be resolved.
We really do have to go in with the mindset this is a function of intentional, historical, racist. Exclusion. This is a settler nation. So we have to go in with the mindset of redress as opposed to simply addressing the current state of affairs. And that's difficult. That's a, that's a political question.
That's something that again, I think that if we don't generate that kind of mindset, we'll be very hard pressed to generate the political will to do what's required to actually achieve universal health coverage.
Jessamy: So, we've only got like a few minutes left. I just wanted to hear from Elizabeth Francesca Roche about young people's role in this.
You know, I always feel a bit wary of kind of lionizing a generation and saying it's leave it up to young people because they're going to solve climate change, you know, solve universal health coverage. It's all going to be fine. But, I mean, what is your view on universal health coverage? It's, it's deeply political in countries like America and, you know, many countries where they don't necessarily believe that universal health coverage is something that we should be aspiring to, but it is better for people's health.
That's been, you know, showed many, many times over and it's better for nations, it's better for economies, it's better for society. How do you guys see young people's role achieving universal health care and coverage? I feel
Elizabeth: we young people, let's say the youth, can have a bigger voice. We can actually get more, can I say get more people along, especially to our research.
An example is, for instance, our case study, if we do it so well and we publish it and then we spread it across, like, I am from Zambia, my teammates are from South Africa, different people will see it. And our case study is more so social franchising. And I don't really think the Onjani setup has really been done in Zambia, per se.
So, for instance, if my Zambian friends, or maybe my Zambian workmates, see that, and they know someone, you never know, maybe that model might be replicated in rural Zambia. And it would actually help in the whole run with this universal health care. So, I do feel, if we do the right thing, We collaborate together.
Our voices are very strong and would actually create a larger impact. So involving young people in this is very critical.
Jessamy: Thanks, Elizabeth. Francesca?
Francesca: Yeah, to pick up on a point that Elizabeth said, I think that the role of young people is A lot to do with social change. As I think we've all kind of discussed, you can't just address universal health cover coverage with policy.
You need social change. You need that drive from society from everyone. And I think that young people are drivers of social change. We've seen this in various sectors over the last few years. So I think that the role of young people is essential in the world. Keeping that motivation and keeping that drive for research, implementation, but also integration of universal health care in society and in general.
Rushay: I might just add on, on, on some great points made that that really, I think you look at existing systems, existing institutions, and we're not, Particularly centered on the technicality, the financing schemes, or, you know, the, the, the minutia to adjust, but looking at the whole system and the injustices that that those systems present and that actively contribute to and so I, I think, you know, as much as you would like a seat at the table to be consulted on, on major changes the reality is that you, they're also not dependent on these institutions to make books is very clear and make opinions quite heard.
And so I think our role is as we continue to take up. A mantle if you will, we will continue to, to push on, on various institutions, adjust governance systems and, and, and really challenge the fundamental principles that, that underpin any of this, any, any of the, the values that, that, that speak to universality in health coverage or in well being and, and, and present a new vision that will continue to happen.
Elizabeth: I just wanted to add on the part where we youth are very innovative. So imagine if we come together, we create all these advancements in digital technology. I bet the cost would actually reduce if we could like come up with interventions that handle these diseases with these digital technologies like telemedicine and all.
Can I add something, Jessamy, if that's okay?
Jessamy: Amazing.
Joseph: Despite my best efforts at remaining youthful, I'm no longer a youth. Oh, but
Jessamy: with your gray hair, like it's just properly .
Joseph: Yeah. Yeah, it's very regal. The but I do spend a lot of time as a professor with, with with young people. And I like you, Jess, I, I, I worry about the risk of lionizing a generation.
We do seem to heap a lot of responsibility for social change on generations as they come. Not unlike. The responsibility that was heaped on our generation, a generation before and the generation before that, that introduced so much social change as I'm thinking here around the civil rights era of the 1960s in the West and so forth.
But I do think that there is something distinctive about this generation, at least as it relates to these kinds of questions. And it relates to you know, I see universal health. Coverage, universal healthcare universalism as something that is beyond a political project. It's something beyond an economic project and so forth.
I really see it as an ethical project. I see it as, and we've heard some of the, some of the young people in this conversation refer to this is values. And I think that's absolutely critical. 'cause unless there is a transformation in our ethical approach to these questions. I don't think we'll ever be able to achieve universal anything.
It really has to first and foremost be a values driven, ethical project. And this is something that I see in this generation. I mean, look, when we talk about, for instance, injustice, there is a, a way in which my students are able to talk about injustice that is extremely appealing that's principle based and something that you can see that they're very much committed to.
So you look at climate change, for instance. We know that young people are the ones who are driving driving us to really address climate change, because as they've pointed out, this is the world that they're going to inherit, and if we're not going to take on the leadership mantle, then they will and they've been driving the global discourse around this.
I see the same thing occurring as it relates to the SDGs, as it relates to universal health coverage and so forth. And so when I think about the Reach Alliance, I think, first of all, the research that all of these young people are doing is absolutely terrific. As I say, it's being published in, in important places.
But even more importantly, what this is preparing them is to combine the rigor of the kind of research work that they're doing with their principled commitment to universalism and their demands to have a seat at the table, particularly as we start thinking about what the post 2030 agenda is going to look like.
When we start thinking about what the post SDG world is going to look like, this is going to be a world in which this generation is going to be the leadership of that post 2030 era. And so when I think about what the Reach Alliance and what universities more generally are doing, it's really preparing the next generation of leaders to lead this kind of transformation.
So, with apologies to my younger colleagues on this call for heaping a whole For keeping the fate of the world on your shoulders, you've demanded it, you've asked for it. You've asked for the training, you've asked for the platform, you've asked to have that voice amplified and you will soon be assuming that mental leadership.
So this is something that I have a great deal of faith in.
Gavin: Thanks so much for joining us for this episode of The Lancet Voice. This podcast will be marking The Lancet's 200th anniversary throughout 2023 by focusing on the spotlights with lots of different guest hosts from across The Lancet group. Remember to subscribe if you haven't already and we'll see you back here soon.
Thanks so much for listening.