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 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.

This Chapter distils and brings together key lessons presented throughout the book, complements these with additional experiences needed for health systems to make a difference to the lives of the people they serve. It highlights the importance of health systems and systems thinking beyond traditional models and frameworks; critical role of leadership in health; the changing role of ministries of health in the 21st century and in the ‘post’ COVID-19 period; complexities of health system reforms and the importance of their political disposition; integrating security as an additional goal of the health system and making them resilient; significance of measuring, monitoring and managing health systems for achieving the desired results; and empowering communities and hearing their voices as essential to making it happen! Each section concludes with key messages for policymakers, managers, health care providers and professionals striving to strengthening of health systems in their countries.

The process of decision making is not linear and is affected by multiple factors, other than availability of evidence, such as political context, personal over public interests, decision makers’ accountability, relationships with stakeholders, and familiar experiences in the past. Evidence-informed decisions positively influence access, quality, efficiency, equity, and sustainability of health services, and improve transparency and accountability thereby reducing wastage, abuse, and corruption in the health system. This chapter presents six decision making tools that help policy makers and managers take evidence-informed decisions: burden of disease analysis; health technology assessment; cost-effectiveness analysis; health equity analysis; national health accounts analysis; and stakeholder analysis. The list of tools is not exhaustive, and additional tools can be explored to respond to the context and nature of the public health concern. Policymakers are not expected to know all their methodological aspects, rather they should know what tools are available, their purpose and application, strengths and limitations, and how to interpret the results in the local context.

Well-performing health systems are critical for pursuing universal health coverage and for achieving health-related SDGs. It is important to grasp key concepts such as systems approach, analysis, and thinking before taking a deeper dive into health systems. Health systems can be described in broad or restricted terms. The most widely accepted definition includes all the institutions, actors, and activities whose primary purpose is to promote, restore or maintain health. There are many health system frameworks and models of which four have been reviewed - WHO’s Health System Conceptual Framework, Control Knobs Framework, Kielmann’s and Roemer’s Health System Models. No single framework addresses all aspects of a health system. It is more useful to know the strengths and limitations, and usefulness of each in achieving a specific objective such as for description and analysis, designing system reform, or evaluation. Interventions whether system-led, programmatic or those addressing health determinants are part of the wider health system and offer the best opportunity for improving health outcomes when addressed together.

The Chapter describes health system governance as the aggregation of principles and normative values within the political system in which a health system functions. There is increasing appreciation of the central role of governance in influencing all elements of the health system. The five key governance principles or elements in health are strategic vision, participation, accountability, transparency, and rule of law. These, and other, governance principles have an influence strategic planning and decisionmaking, regulation, partnerships, and insurance in health. Multisectoral governance in health involves government and non-government agencies to address multidimensional challenges of differing levels of complexity across multiple sectors. Ministries of health need to assume new responsibilities in the 21st century and adopt roles that include – de jure governance processes, preparation for and response to change in context, relationship management, and values management. More work is needed to delineate the scope and influence on all health system functions, assessment tools and monitoring indicators, and to develop interventions for improving governance of the health system.