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The sustainable development goals (SDGs) of Transforming our world, the 2030 agenda for sustainable development, and specifically SDG 17, call for cooperation, collaboration and partnership between government, civil society and businesses. To reach the agenda’s objectives, the international community needs to find ways to effectively harness the public and private sectors. The SDGs are integrated and indivisible, with progress in one area dependent upon progress in others. Both the private and public sector are needed to meet the health-related SDG 3, including the target of universal health coverage (UHC) and related goals such as SDG 8 (decent work and economic growth) and SDG 9 (industry, innovation and infrastructure). In the health area, the private sector refers to all non-state actors involved in health: profit and not-for-profit, formal and informal, domestic and international. Almost all countries have mixed health systems, with goods and services provided by the public and private sector, and health consumers requesting these services from both sectors. Therefore, efforts towards UHC cannot ignore the private sector. The private sector’s involvement in health systems is significant in scale and scope and includes the provision of health-related services, medicines and medical products, financial products, training for the health workforce, information technology, infrastructure and support services

The current Ebola virus disease outbreak in western Africa highlights how an epidemic can proliferate rapidly and pose huge problems in the absence of a strong health system capable of a rapid and integrated response. The outbreak began in Guinea in December 2013 but soon spread into neighbouring Liberia and Sierra Leone. In early August 2014, Ebola was declared an international public health emergency. The last decade has seen increased external health-related aid to Guinea, Liberia and Sierra Leone. If this Ebola outbreak does not trigger substantial investments in health systems and adequate reforms in the worst-affected countries, pre-existing deficiencies in health systems will be exacerbated.

The need for resilient health systems is recognized as important for the attainment of health outcomes, given the current shocks to health services. Resilience has been defined as the capacity to “prepare and effectively respond to crises; maintain core functions; and, informed by lessons learnt, reorganize if conditions require it”. There is however a recognized dichotomy between its conceptualization in literature, and its application in practice. We propose two mutually reinforcing categories of resilience, representing resilience targeted at potentially known shocks, and the inherent health system resilience, needed to respond to unpredictable shock events. We determined capacities for each of these categories, and explored this methodological proposition by computing country-specific scores against each capacity, for the 47 Member States of the WHO African Region. We assessed face validity of the computed index, to ensure derived values were representative of the different elements of resilience, and were predictive of health outcomes, and computed bias-corrected non-parametric confidence intervals of the emergency preparedness and response (EPR) and inherent system resilience (ISR) sub-indices, as well as the overall resilience index, using 1000 bootstrap replicates. We also explored the internal consistency and scale reliability of the index, by calculating Cronbach alphas for the various proposed capacities and their corresponding attributes. We computed overall resilience to be 48.4 out of a possible 100 in the 47 assessed countries, with generally lower levels of ISR. For ISR, the capacities were weakest for transformation capacity, followed by mobilization of resources, awareness of own capacities, self-regulation and finally diversity of services respectively. This paper aims to contribute to the growing body of empirical evidence on health systems and service resilience, which is of great importance to the functionality and performance of health systems, particularly in the context of COVID-19. It provides a methodological reflection for monitoring health system resilience, revealing areas of improvement in the provision of essential health services during shock events, and builds a case for the need for mechanisms, at country level, that address both specific and non-specific shocks to the health system, ultimately for the attainment of improved health outcomes.

ObjectivesThis study elucidates the status of public health governance, defines the concept and synthesises the evidence to guide stakeholders in enhancing governance for the delivery of essential public health functions (EPHFs).DesignA scoping review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines.Data sourcesA systematic search of peer-reviewed literature was performed using PubMed and Embase for English-language publications from 2000 to April 2025, supplemented by a grey literature search.Eligibility criteriaWe included literature addressing public health governance and institutional arrangements. We excluded documents focusing solely on disease-specific and clinical governance, and governance at supranational level.Extraction and synthesisData from 177 included documents were extracted and analysed to identify definitions, components, actors, enablers and principles relevant to public health governance. Findings were complemented by WHO’s experiences to develop an operational definition and framework.ResultsFindings revealed the absence of a standardised definition of public health governance and highlighted the diversity of actors within and across health and allied sectors. Findings identified strategy and policy development, oversight, partnership, legal authority, resource stewardship, and monitoring and evaluation as key components of public health governance; legislation, financing, institutional structures and political will as key enablers; and integration, comprehensiveness with equity and shared responsibility as key principles. Four institutional models were identified: autonomous public health bodies, semi-autonomous bodies under health ministries, public health departments within ministries and interministerial platforms without a designated institute.ConclusionDespite differences in institutional structures, successful delivery of the EPHFs depends on clearly defined roles and effective coordination across sectors. Government-led reviews and reforms are needed urgently to strengthen public health governance through institutional clarity, sustained investment and cross-sectoral collaboration for building resilient, trusted and equitable systems.

Background The COVID-19 pandemic exposed weaknesses in health systems globally, highlighting chronic underinvestment, fragmentation, and a lack of preparedness with catastrophic impact on public health, economies and societies. Lessons learned reconfirmed the necessity to build health systems resilience, integrating efforts to achieve Universal Health Coverage (UHC) and health security in tandem. Results This study identified 63 global and regional policies, collaborations, and investments (collectively termed “initiatives”) that came out post-COVID-19 and reviewed them in reference to their focus on integration of UHC and health security through the lens of WHO’s seven policy recommendations for building resilient health systems. The findings indicate that while efforts to align UHC and health security are evident at global and regional levels, they vary in depth and coherence. 81% of initiatives align with at least four of the seven WHO policy recommendations. While there is emphasis for health security preparedness, focus on primary care and health promotion is less pronounced. Policy initiatives show stronger alignment with WHO policy recommendations compared to Collaborations or Investments, indicating synergies between policies, while apparently a gap between policy and practice. Multilateral groups, including UN agencies, and government-affiliated organizations show greater alignment with the WHO policy recommendations too, while there is less alignment with those from non-governmental and other entities. Conclusions This review shows that while post COVID-19 policies increasingly articulate visions for integrated health systems strengthening, existing collaborations and investments have not demonstrated comparable commitment to the implementation of these visions. This underscores a prevailing disconnect among global health actors and the mostly reactive and short-term nature of external investments and partnerships. In low-income and fragile health system contexts, this misalignment risks the inefficient use of global support and may perpetuate foundational weaknesses in health systems. Moreover, this is particularly problematic given worsening fiscal constraints from reductions in overseas development assistance and country-level economic contractions. By (re)orienting global health policies, collaborations, and investments toward more unified approaches to achieving UHC and health security, the international community can more effectively support countries in building health systems capable of withstanding future crises, maintaining essential health services and safeguarding gains in health equity.

Humanitarian needs are escalating globally, with around 300 million people requiring assistance—over half in Africa. These crises are increasingly driven by conflict, climate-related disasters and emergencies and economic instability, all severely impacting public health and disrupting health systems. A new approach is essential to address root causes of humanitarian crises and develop durable solutions. In response to this need, the WHO developed a framework for health in the humanitarian–development–peace nexus (HDPN) in Africa. This framework was informed by literature reviews and consultations with key stakeholders across UN and wider humanitarian sector (including the African Union bodies, WHO offices and relevant non-governmental organisations). The framework presents a structured method for countries to integrate health across the HDPN, emphasising policy alignment, the need for sustainable financing, strong monitoring systems and adaptable governance. It defines clear roles for WHO, the African Union Commission, regional economic communities and authorities in countries as applicable. Key areas for operationalising the framework include health sector development planning, budgeting, financing, intersectoral coordination, services delivery and monitoring and evaluation. It also recommends integrated strategic actions focusing on health across humanitarian, development and peacebuilding efforts, emphasising synergy and co-benefits from this nexus approach. With a growing number of countries facing humanitarian crises, fragility and conflict, urgent implementation of this framework is vital to build resilience and improve health outcomes across Africa and beyond.

Governments and organisations must demonstrate accountability and delivery of results. Results-Oriented Monitoring (ROM) is a European Commission mechanism aiming at enhancing internal control and management. The Health System Strengthening (HSS) for Universal Health Coverage (UHC) programme provides support towards achieving UHC through policy dialogue in 115 countries.Drawing from the ROM review of the HSS for UHC programme, we examine the value of the Commission’s ROM system as a tool to enhance accountability of large Global Health (GH) programmes. We present the lessons learnt and provide specific recommendations about how ROM tools can be employed to strengthen GH accountability.ROM reviews can provide critical data to inform the design, implementation and evaluation of large-scale GH programmes through a well-integrated mixed-methods approach in which quantitative and qualitative components reinforce each other. Recognising the tremendous power of measures of performance, they track available quantitative indicators from baseline to target along the results chain. Firmly grounded on qualitative tools, they also capture the complex nature of health systems, and the critical influence of contextual factors and stakeholder dynamics.Poor data quality and insufficient multistakeholder engagement are persisting but not unsurmountable challenges. As increasing support is provided to strengthen health information and management systems, the process of codeveloping Monitoring and Evaluation frameworks at country level could serve as a tool to enhance mutistakeholder engagement in policy dialogue. The political nature of both results-oriented systems and GH programmes suggests that mechanisms to assess power dynamics should be incorporated into policy dialogues and ROM review processes.

The move towards universal health coverage is premised on having well-functioning health systems, which can assure provision of the essential health and related services people need. Efforts to define ways to assess functionality of health systems have however varied, with many not translating into concrete policy action and influence on system development. We present an approach to provide countries with information on the functionality of their systems in a manner that will facilitate movement towards universal health coverage. We conceptualise functionality of a health system as being a construct of four capacities: access to, quality of, demand for essential services and its resilience to external shocks. We test and confirm the validity of these capacities as appropriate measures of system functionality. We thus provide results for functionality of the 47 countries of the WHO African Region based on this. The functionality of health systems ranges from 34.4 to 75.8 on a 0–100 scale. Access to essential services represents the lowest capacity in most countries of the region, specifically due to poor physical access to services. Funding levels from public and out-of-pocket sources represent the strongest predictors of system functionality, compared with other sources. By focusing on the assessment on the capacities that define system functionality, each country has concrete information on where it needs to focus, in order to improve the functionality of its health system to enable it respond to current needs including achieving universal health coverage, while responding to shocks from challenges such as the 2019 coronavirus disease. This systematic and replicable approach for assessing health system functionality can provide the guidance needed for investing in country health systems to attain universal health coverage goals.

The role of ministries of health has changed, progressively shifting from direct provision of health services to overall stewardship of the health sector, including financing and oversight of private providers.1 Health reforms have triggered that shift, fostering new institutions, such as national medicines agencies, public health agencies, disease control agencies (eg, National Cancer Agencies) or health financing organisations responsible for risk and fund pooling, purchasing of health services, or targeting the poor or vulnerable groups. Health systems processes must move from a top-down to inclusive policy, planning and implementation processes, increasingly adopting a people-centred approach.3 Democratic rights, human rights, equity and ethics values have become prominent in national policy debates. In response to this call, twenty-first century health systems need to be participatory, inclusive and pluralist, following Whole of Society and Whole of Government principles.3 4 People’s voice is a core driver of health systems’ performance towards Universal Health Coverage.5 In such a context, governance arrangements are changing and rely more on inclusion, participation and co-production.6 This paper presents a framework to help understand health systems governance; examine what we know about this important health system function, and what has been less explored, leaving an important gap in our health system knowledge and practice. Missing links The past decade experienced an increase of the literature on health system governance; various frameworks presenting attributes or dimensions of governance have emerged and define the nature and scope of this function.11 12 In a review published in 2014, Barbazza and Tello highlight the challenge of reaching a consensus and communicating a clear agenda on governance in health.10 They conclude that frameworks and tools defining governance have been developed independently, seldom building on strengths and weaknesses as well as practical applications of previous instruments; they lack a shared frame of reference which would enable governance to become a truly actionable health system function.