Table 1 Resilient health system for UHC and health security, 2022

Service delivery

Good service delivery was required to provide comprehensive, accessible, continuous, effective, safe, timely, person-centered, and coordinated healthcare services with full accountability and minimum wastages [27]

An inward migration or mass casualty incidents compromised the quality of services and increased deaths attributed to delays in treatment [30]

Promote operational integration between health service continuity and emergency response through proactive planning across all income nations reduced health services disruptions during emergencies [29]

A combination of public health security threats from new and reemerging infectious diseases, and intentional dissemination of chemical or biological substances were the challenges to ensure health security [34]

Continuation of healthcare service delivery in the face of extraordinary shocks facilitated UHC progress [3]

Lack of access to basic primary care, laboratories, and shortage of existing hospital infrastructure to isolate and treat infected people fueled the epidemic's spread during Ebola outbreak [31]

Ebola outbreak jeopardised and disrupted health service delivery in Liberia. This put the lives of many children at risk associated with the lack of treatment for common childhood illnesses [35, 36]

Increased inputs led to improve service delivery and access to services [13]

Lack of basic health care infrastructure, well-trained personnel, and essential medical supplies affected healthcare access [32]

Climate change was increasing threats and leads to changes in the frequency, intensity, spatial extent, duration, timing of extreme weather and climate events [39]

Transportation, communication infrastructures, capacity building, referral systems, intersectoral actions, and electronic healthcare platforms had an impact on healthcare services [28]

Uneven distribution of health facilities and poor public–private service level agreements led to geographical inequities and financial protection [33]

Inadequate primary care system capacity on provision of responsive health services to storm and flood-related health problems was also one of the challenges [41]

Community resources, cohesion, and physical accesses were significant assets to improve service utilisation and quality [30]

Exclusion from work due to health problems can easily result in economic impoverishment and inequitable healthcare access [37]

Socially excluded population groups received health services from a dysfunctional publicly provided health system in Guatemala and Peru, which undermines the progress towards UHC [38]

Extreme weather events caused an increase in disease prevalence, such as malaria and other vector-borne diseases, malnutrition, food insecurity and food-borne diseases are notably occurring impacts in drought, floods, and extreme temperatures affected countries [40]

Health workforce

A well-performing health workforce helped to provide responsive, fair and efficient health services to achieve the best health outcomes [27]

Low perception of risks by tourists/ pilgrims, ineffective training, poor control of risk factors for infectious diseases and shortages of infrastructures were the challenges to combat such contagious diseases [47]

An ad hoc redistribution of health workers to address shortages during acute shock had a knock-on effect on health services [43]

Distribution of health workers across the country was often inadequate to meet the unexpected needs of an acute crisis [43]

Task-shifting and strengthening cross-site mentorship, learning, coordination, and the referral pathway assisted building RHS [42]

Healthcare workers practices to effectively manage pandemics such as COVID-19 were constrained by individual factors such as education, residence, location of work station, hygiene promotion, and social distance management [42]

Training on disaster preparedness and management and rewarding package increased willingness of healthcare workers to participate during disaster management [45]

Lack of skilled health workforce was a major obstacle to contain an outbreak and deaths attributed to delays in treatment [35]

Monitoring and evaluating of frontline health levels about their preparedness against public health emergency threats was helpful for early detection and control of health threats [46]

Patient assessments by non-indigenous health workers during an emergency was the challenges on early identification and management of the acute events [30]

Ensuring staff distribution, training, and introducing rewarding packages were essential to control the epidemics [44]

Health information system

A well-functioning health information system (HIS) ensured the production, analysis, dissemination and use of reliable and timely information on health determinants, health systems performance and health status [27]

Poor data management, failure to carry out systematic risk assessments, and risk communications were responsible for misleading media reports, influencing decisions [51]

Building novel surveillance systems improved clinical care and health system preparedness to tackle health threats [48]

Lack of awareness, resources and insufficient electronic reporting system were observed [53]

Building accountability, knowledge culture management, and evidence through regular data quality audits contributed to strengthening health management information systems [44]

Flexible automation and data processing were crucial for quick and quality surveillance [49]

Misinformation on risk and transmission of the outbreak. Eg, misinformation during Ebola outbreak affected most communities to put measures [54]

Increasing the health system's capacity to process and communicate test results rapidly was a key measure in response to the pandemic [51]

Poor surveillance and late timing of responses [52]

An integrated disease surveillance and laboratory evaluation generated information to minimise inefficiencies of disease-specific surveillance silos [50]

People approached traditional healers and lack knowledge on modern treatment [35]

Medical products, diagnostics and infrastructures

A well-functioning health system ensured equitable access to essential medical products, vaccines and technologies to assure quality, safety, efficacy and cost-effective healthcare services to the users [27]

High patient load beyond the health facility’s capacity exposed to lack of health infrastructures [30]

Rapid, cost-effective, sensitive, and specific diagnostic tests were the key factors that facilitate outbreak detection and reporting [53]

Lack of diagnostic facilities and surveillance severely hampered to contain the efforts of public health threats. For instance, the long diagnostic services processes often complicated the response strategies and hampered contact tracing of Ebola [32]

Strengthening local preparedness and planning, manufacturing, coordination of public–private initiatives, and trainings in LMICs was important to attain UHC in context of health crisis [55]

War related destruction of facilities compromised the health system’s hardware (health facilities and supplies). Decreased healthcare services in relation with physical healthcare destructions in Syria [3]

Inauguration of the national center for infectious disease purpose-built infrastructures integrated with clinical, laboratory and epidemiologic functions was vital to contain health emergencies. For instance, after the severe acute respiratory syndrome (SARS) outbreak, Singapore built a specialised infectious disease center for outbreak management [56]

Lack of medical supplies, PPE, and electricity increased the rate of Ebola infections [35]

The critical challenge was the lack of a specific budget for medicine procurement, absence of emergency stockpile, and no proper means for medicine transportation [57]

An emergency plan considering list of medicines, adaptable mobile health care units and system for mobilisation of health professionals were crucial to curb health emergencies [57]

Longer lead times of medicine outlets associated with poor inter-country transportation, bureaucratic bottlenecks and lack of emergency readiness were the challenges in Namibia [55]

Inadequate health professionals and essential logistics inhibited to handle potential maternal mortality. For instance, inadequate essential logistics such as blood, oxygen cylinders, ergometrine and sulphadoxine paramita mine in Ghana were the causes of low preparedness to control maternal mortality [58]

Health financing

Good HCF system raised adequate funds for health to protect people from financial catastrophe to access health [27]

Low affordability of medical costs at private facilities and transport costs were the barriers to universal financial protection [33]

Lack of adequate funds invested in health system infrastructure contributed to poor management of an outbreak [35]

Health financing system under public control improved compliance, sustainability and equity [59]

Performance-based financing without accompanying access to incentives for poor people was unlikely to improve equity [64]

Health sector requires additional financial support to address the demand for health services during health emergencies [30]

Integration of financing mechanisms with high income, risk cross-subsidies, and reduced out-of-pocket payments maximised risk pools and resource allocation mechanisms to achieve UHC [60]

Health equity advancement challenges were securing dedicated funding to support transformative learning opportunities and build infrastructure [65]

Levels of funding from international donors were erratic and far below the amounts required to meet the health needs of the refugees during crisis [66]

UHC substantially improved human security by financial security [61]

People could not trade their commodities because of the fear of attacks which exposed users to a lack of finances [30]

Falling in financial access to health services resulted in political demonstrations and violent unrest [67]

Redistribution of income improved equity in health care service delivery [63]

Universal health coverage indicators were positively associated with the gross domestic product (GDP) per capita and the share of health spending channels [62]

Leadership and Governance

Good health governance ensured strategic policy frameworks combined with effective oversight, coalition building, appropriate regulations, system-design, and accountability [27]

Absence of clear government policy for the delivery channels and financial coverage mechanism led to fragmentation and poor health system response to the refugee crisis in Syria [66]

Centralised governance coordinates the national policy responses and facilitates the homogenous implementation of measures [70]

Outbreak governance was weak with a lack of clarity of stakeholder roles [52]

Clear communication channels between the government and all sectors were vital to translate policy into intended actions [56]

Poor leadership at the national government level was the main reason for poor coordination and absence of a prompt response [35]

Building responsible leadership and social capital at community level were needed to address health shocks [54]

Working alone, the state had proven only partially effective, a situation exacerbated by the natural tendency within the public to ignore as irrelevant to themselves [73]

Multisectoral and multilevel control activities required environmental, political, social, and medical inputs to be coordinated and productive [52]

Healthcare services significantly decreased concerning physical healthcare destructions by war in Syria [3]

Effective governance processes built strong partnerships for health and accountability to respond to emergencies [48]

Weak governance and decision-making processes, especially high bureaucracy, weak prevention culture and lack of coordination explained a substantial part of the rapid spread of the virus in French in the first wave of COVID-19 [74]

Vertical and horizontal integration made the administrative system more transparent and acceptable to the people [69]

High-performance teams during pandemic required leadership resilience to achieve health sector goals [71]

It was difficult for the system to automatically adjust its structure to reduce uncertainty and ascertain the complex adaptive behavior when facing public health emergencies. As a result, community action lacked an effective control form and even appears as an overcorrection phenomenon to highlight the work or evade political responsibility [79]

Community participation was an approach to co-learning, community-developed research perspectives, shared decision making, and local capacity building [65]

Coordination, rationalisation, and connection of pandemic planning across sectors and jurisdictions resulted better preparedness [68]

Community participation between stakeholders had a significant impact on the successful implementation of health program. For example, prevention of Japanese encephalitis/ acute encephalitis syndrome through community health workers/ volunteers [77]

Global community increased its investment in early warning and detection systems to enable action [72]

Moving away from a one-size fits-to all approach in guiding pandemic response, service delivery, political commitment, fair contribution and distribution of resources are helpful to speed up the path towards UHC [75]

Community engagement in health surveillance activities in Cambodia enabled early detection and collection of mortality data [78]

Village health volunteers in Thailand, Zanmi Lazante’s Community Health Program in Haiti, Agentes Polivalentes Elementares in Mozambique, Village Health Teams in Uganda, lady health workers in Pakistan, BRAC in Bangladesh, Family Health Program in Brazil, and Health Extension Program in Ethiopia are successful community-based models contributed immensely to achieve health development goals [76]

An overarching political will and well-integrated and locally grounded health system might be more resilient to external shocks [80]

During crisis, political leadership was critical to develop a response strategy and effective implementation [81]

Singapore’s dexterous political environment allowed the government to swiftly institute measures for COVID-19 containment [56]