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 explores concepts of service delivery including coverage, provision of health care, processes and inputs involved in delivery of services, and the requirements for good quality care in low and middle-income countries (L&MICs). Health service delivery models are organized in diverse ways that encompass the levels of care, location and platforms, as well as vertical and horizontal modes of integration, and personal and non-personal services. Several key characteristics and enablers are markers of high-quality health services and when adhered to lead to favourable health outcomes. The community’s preferences and demand with regard to what services to provide is key to building their trust. Essential packages for defining health services should be needs-based, incorporating the disease burden, ensuring quality, coverage and utilization needed to have good health outcomes. The pursuit of Universal Health Coverage requires Primary Health Care as the foundation of health systems in L&MICs, equity in services provision, as well as good information and monitoring systems.

The Chapter describes the status of health financing in low- and middle-income countries (L&MICs) and their health financing transition over the past two decades. Advancing Universal Health Coverage (UHC) requires an expansion of coverage over three dimensions: (i) health care benefits, (ii) population coverage, and (iii) cost coverage using prepaid/pooled funds. As national incomes rise, countries undergo a health financing transition, increasing total levels of health expenditure while increasing the publicly financed share of health spending and reducing the external- and OOP-financed share of spending. Two pro-poor paths are common for the expansion of health coverage. Many countries implement health insurance schemes for the poor. Others expand platforms of public providers that are mostly used by the poor, often focusing on community and primary care services. Countries choosing the pro-poor health insurance path develop targeting and enrolment instruments. Targeting tends to be stricter with social security purchasers, compared with ministerial purchasers. Fragmented systems, while suboptimal, can sometimes be more pro-poor than integrated systems.