The goal of SDG 1 is to end poverty in all forms everywhere. Health systems are a significant determinant of the risk of impoverishment and financial hardship. We review methods for calculating catastrophic health spending and impoverishing spending, noting a distinction between those who are impoverished by out-of-pocket (OOP) health spending and those who are further impoverished by OOP health spending. Catastrophic health spending tends to be concentrated among poor households, but there is a high level of variability between countries. In particular, countries with higher public spending on health as a share of GDP have lower OOP spending, which in turn is associated with lower catastrophic health spending and impoverishment. Policymakers can also make progress on reducing the risk of impoverishment by making reforms to coverage policies. We conceptualise progress towards universal health coverage through an analysis of the coverage of people, services, and costs. Risk of financial hardship is minimised when the entire population is covered, the right services are covered to meet the population’s health needs, and costs are financed largely through pre-payment with risk pooling to avoid high user charges. The most successful systems use user charges sparingly, design user charges as fixed copayments rather than percentage-based coinsurance, and include income-based exemptions and OOP maximums.

This chapter explores the links between Sustainable Development Goal (SDG) 3 (specifically targets 3.3, 3.8, and 3.b, which address the need to fight communicable diseases, achieve universal health coverage, and invest in research and development of vaccines and medicines, respectively) and SDG 9, which calls for the development of industry, innovation, and infrastructure in low- and middle-income countries (LMICs). By discussing two case studies, i.e., Brazil’s technology transfer strategy for the human papillomavirus (HPV) vaccine through a public–private partnership and the implementation of the Mozambican Pharmaceutical Ltd., a Brazil-Mozambique South-South cooperation (SSC) project, it argues that initiatives such as technology transfer and local production of pharmaceuticals in LMICs can be a means to promote industrial and innovation goals while meeting health needs. With significant variations between them, the two case studies illustrate the dynamic interaction between SDG 3 and SDG 9, helping to elucidate the co-benefits between health policy and measures to promote scientific and technological development. The chapter calls for further research to better understand which channels, governance arrangements, and mechanisms can promote effective coordination between healthcare and industrial development.

This chapter extends the consideration of the changing global burden of diseases and discusses what is required to mount an effective response to public health challenges, particularly in countries where people are living in extreme poverty. It considers the role of international development assistance and the responsibilities of the international community in improving the health of poor people.

Health system performance assessment (HSPA) is a promising tool to evaluate health system capacity in achieving health systems goals and informed policy for health systems strengthening. Despite its importance, no universal definition is available at global level to support HSPA implementation. This chapter highlights the evolution of HSPA frameworks, which mostly follow the scope and boundaries of health systems. Key characteristics of successful HSPA include regularity, transparency, comprehensiveness, being analytical and systematic, which result in valid assessment and inform policy. HSPA requires selection of indicators suitable to the country context; the criteria for selecting indicators include importance, relevance, feasibility, reliability and validity. Hospital performance assessment, a subset of the HSPA, is necessary as it consumes signification portion of health resources. HPSA also contributes to monitoring achievement of SDG targets 3.8.1 and 3.8.2 on Universal Health Coverage as committed by countries. The chapter concludes by providing evidence how Thailand's health system performed in response to COVID-19 pandemic.

This Chapter examines the evolution in global thinking on Universal Health Coverage (UHC) and the role of Health Systems Strengthening. It describes the path from primary health care to health systems and UHC. The concept of UHC is elucidated by introducing its dimensions, intermediary objectives and ultimate goals; and by explaining what it does and does not mean in practice. The Chapter also explains how progress towards UHC can be measured and hence monitored as per the Sustainable Development Agenda. It also summarizes the challenges that low and middle-income countries (L&MICs) face to advance UHC. The Chapter concludes by illustrating the interlinkage between UHC and health security based on lessons learnt from the COVID-19 pandemic.

This chapter sets out the history, evolution of primary health care (PHC) and discusses its application to contemporary health systems. PHC is a whole-of-society approach to health that aims to maximize the level and distribution of health and well-being through three components: primary care and essential public health functions as the core of integrated health services; multisectoral policy and action; and empowered people and communities. The concept of PHC emerged in the 1960s but was formally codified in the 1978 Alma Ata Declaration. ‘Pragmatic’ reductivism and geopolitical transitions in ensuing decades saw original goals superseded by selective PHC. The World Health Report 2008 – Primary Health Care: Now More Than Ever renewed focus on PHC in the prevailing context of hospital-centrism, commercialization and fragmentation. Mounting evidence on effectiveness, equity and efficiency has made it clear that PHC is the path to achieve universal health coverage and the other health related Sustainable Development Goals. In 2018, governments renewed their commitment to strengthen primary health care in the Declaration of Astana.The WHO and UNICEF Operational Framework for PHC provides guidance for governments to translate these commitments into action.

This chapter focuses on how community engagement (CE) can be implemented at the national and sub-national levels. CE has been identified as an essential pillar of strong people-centred governance which is needed to underpin Universal Health Coverage (UHC) reforms. The “whole of society approach” acknowledges the importance of families and communities in support of the efforts for disease prevention and control. It provides an overview of the evidence and outlines processes that enable effective community engagement and highlights lessons drawn. In particular, Thailand’s Universal Coverage Scheme’s (UCS) participatory governance approach has been a practical example and one of the myriad ways in which the voice of Thailand’s people has been embedded in legislations and operations to ensure that the governance of UCS is responsive to their needs. Four lessons from this experience include leadership and commitment at all levels, transparency and accountability to enable sustained engagement, legal frameworks, and the need for strong capacities in both the government and among communities. Lastly, it proposes the lessons learned and key messages for a proactive approach to CE in health.

Pharmaceutical systems are a core part of health systems, and their failure to work adequately severely undermines the performance of the entire health system. The view that medicines are mere commodities managed for technical aspects by the national regulatory authority, disregards the role and need for a comprehensive and multidisciplinary system to ensure access to essential medicines. This has serious consequences, as it leaves key functions underfunded and under-represented in national and international platforms where decisions related to health care systems and for achievement of UHC are made. Key strategies to strengthen pharmaceutical systems have been extensively described, but their effective implementation requires political commitment, institutional oversight and adequate financial allocation to each function, including quality assurance, financing, supply and transparency among others. Assessing pharmaceutical systems is often neglected but essential for promoting an effective health system as well as population health. The Chapter presents some key performance measures that countries should routinely apply to measure and report on the performance of pharmaceutical systems and on their good governance.

The COVID-19 pandemic has demonstrated that: 1) there is no single ‘cookie-cutter approach’ to health systems strengthening, and 2) health systems must be significantly more holistic and equitable. This chapter examines the global spread of COVID-19 and its impacts on health systems and communities. By analysing public health gaps and challenges in L&MICs, the authors provide concrete examples of innovations and interventions that were effective in responding to the pandemic. It explores how different health systems across L&MICs and HICs can be better equipped to mitigate health emergencies and maintain routine health services by leveraging a range of essential public health functions, primary health care, and risk management capacities. Health systems resilience is only possible when systems thinking is operationalized and aligned with the wider SDGs. There is a case for multisectoral engagement in mounting a comprehensive health systems response to COVID-19 at the national and global levels. The chapter offers lessons on why strengthening health systems -- through integrated investments and with equity and resilience as key objectives – is key to sustainably achieving health security and universal health coverage.

Poor quality of care is a leading cause of excess morbidity and mortality in low- and middle- income countries (L&MICs). Improving the quality of health care is complex, yet the health care sector has benefitted from many experiences in other industries and developed its own approaches to quality improvement (QI). It is challenging to identify what works in each situation, make the intended improvements, and ensure it is well measured and sustained. Yet there are several examples from L&MICs that offer a lot of learning and illustrate those factors that underpin successful experiences in QI. This Chapter looks at the evolution of QI in health care over time; the types of health care QI approaches, and their relationship with patient safety and UHC; the opportunities to address the commonly occurring health care quality and safety challenges, as well as what works or does not work in L&MICs.