How can health systems under stress achieve universal health coverage and health equity?

Health systems worldwide face an increasing array of interconnected stresses, undermining efforts to achieve Sustainable Development Goal (SDG) 3.8 on universal health coverage by 2030. The confluence of challenges-such as the COVID-19 pandemic, the climate crisis, rising conflicts, and economic pressures-has severely strained health systems, often regressing progress in service delivery and exacerbating inequities. Additionally, demographic shifts, urbanization, the rise of noncommunicable diseases, and ongoing health worker shortages add further pressure. The accompanying papers in this supplement provide case studies from various countries, illustrating the impacts of these challenges on health systems and the exacerbation of pre-existing inequities. They also highlight potential strategies for resilience, such as digitalization, reconfigured service delivery, and people-centered care. However, the resilience of health systems requires not just technological advancements but also investments in workforce, financing, supply chains, and governance - including reserve capacity in the system. Addressing health inequities is critical, as inequality undermines trust in health systems and social cohesion, which are essential for increased resourcing of health systems and resilience. As the 2030 deadline approaches, there is a need to place resilience and the ability to manage crises and stresses as part of the "everyday business" of health systems. Beyond digitalization, achieving this evolution will require social innovation, greater participation by communities in their own healthcare, prioritization of resources for underserved and marginalized population groups, and working across sectors - to enable adaptive health systems that can deliver universal health coverage even in times of stress.