ArticleFrontiers in health services2026
Strengthening health systems in low and middle-income countries: performance determinants and pathways to universal health coverage.
Article in Frontiers in health services, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: Health systems in low- and middle-income countries (LMICs) face persistent challenges in achieving universal health coverage (UHC). The COVID-19 pandemic exposed critical weaknesses in governance, financing, and infrastructure, while recent global reports indicate stalled progress toward health-related Sustainable Development Goals. This study addresses the need for evidence-based strategies to strengthen health systems by identifying key performance determinants and efficient resource allocation pathways. Methods: We constructed a longitudinal dataset for 135 LMICs (2000-2023) from WHO, World Bank, IHME, DHS/MICS, and ITU, using explicit imputation procedures to address irregular survey intervals. We employed fixed effects, system GMM, and structural equation modeling to analyze determinants of health system performance. Based on these econometric estimates, we developed mathematical optimization models (linear, multi-objective, and stochastic programming) to identify efficient resource allocation strategies under budget constraints. Inequality was analyzed using concentration indices and decomposition. Findings: A 10% increase in government health expenditure per capita is associated with a 3.2% reduction in out-of-pocket spending ( Interpretation: Strengthening health systems requires coordinated investments in governance, primary care, digital health, and financial protection. Our econometric and model-based analyses provide illustrative policy pathways. Reallocating existing resources and prioritizing primary care and pro-poor targeting could accelerate UHC progress. Policymakers should adopt integrated, context-specific strategies that balance efficiency, equity, and resilience.
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