Moving towards Universal Access to Health and Universal Health Coverage (UAH/UHC) is an imperative task on the health agenda for the Americas. The Directing Council of the Pan American Health Organization (PAHO) recently approved resolution CD53.R14, titled Strategy for Universal Access to Health and Universal Health Coverage. From the perspective of the Region of the Americas, UAH/UHC "imply that all people and communities have access, without any kind of discrimination, to comprehensive, appropriate and timely, quality health services determined at the national level according to needs, as well as access to safe, affordable, effective, quality medicines, while ensuring that the use of these services does not expose users to financial hardship, especially groups in conditions of vulnerability". PAHO's strategic approach to UAH/UHC sets out four specific lines of action toward effective universal health systems. The first strategic line proposes: a) implementation of integrated health services delivery networks (IHDSNs) based on primary health care as the key strategy for reorganizing, redefining and improving healthcare services in general and the role of hospitals in particular; and b) increasing the response capacity of the first level of care. An important debate initiated in 2011 among hospital and healthcare managers in the region tried to redefine the role of hospitals in the context of IHSDNs and the emerging UAH/UHC movement. The debates resulted in agreements around three main propositions: 1) IHSDNs cannot be envisioned without hospitals; 2) The status-quo and current hospital organizational culture makes IHSDNs inviable; and 3) Without IHSDNs, hospitals will not be sustainable. This process, that predates the approval of PAHO's UAH/UHC resolution, now becomes more relevant with the recognition that UAH/UHC cannot be attained without a profound change in healthcare service and particularly in hospitals. In this context, a set of challenges both for hospitals and for the first level of care based on the experience of hospital and healthcare services managers and the vision they have for hospitals in IHSDNs is presented.