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 introduces the concept of insurance as a product and explores why people want to purchase insurance in general (and health insurance in particular). The main discussion centers around explaining that health insurance (and all insurance) is primarily financial protection: health insurance does not protect your health but instead protects your wealth from health-related risk. The chapter then moves on to discuss the operations of an insurance company: how premiums are set, the difference between correlated and uncorrelated risk, group insurance, and experience rating. The chapter ends by discussion moral hazard in the context of an individual with insurance coverage. The end of chapter supplement provides a mathematical example of why someone who is risk averse would want to purchase insurance.

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.