**Background:** Universal Health Coverage (UHC), defined by the WHO as ensuring all people obtain needed health services of good quality without financial hardship, is central to Sustainable Development Goal 3. The COVID-19 pandemic severely derailed progress, particularly in low- and middle-income countries (LMICs). This narrative review aims to identify and discuss the critical policy challenges to achieving UHC by 2030 in a post-pandemic world, focusing on LMICs in Asia and Africa, which together account for over 75% of the global population.
**Methods:** A narrative review was conducted from October to December 2022, integrating peer-reviewed and grey literature. An electronic search in PubMed and Scopus using the keywords "Challenges," "COVID-19," "Universal Health Coverage," and "Health Systems" initially yielded 92 articles (2020–2022). After screening, 40 articles were selected. A subsequent bibliographic and manual search identified another 37 journal articles. Additionally, 41 sources were manually sourced from international agencies (WHO, World Bank, OECD, FAO, ILO), including 3 datasets, 21 blogs/webpages, 15 reports, and 2 news/policy documents. A total of 118 sources were included. Evidence was analyzed under five dimensions based on WHO health observatory indicators.
**Key Results:** The challenges are organized into five broad findings:
1) **Weak Primary Health Care (PHC) Systems:** PHC accounts for over 75% of projected health gains for SDGs and over 90% of services under comprehensive UHC, yet it remains underprioritized in LMICs. During COVID-19, a study from India found hospital care utilization decreased by over 37%, and out-of-pocket expenditure (OOPE) in private hospitals nearly doubled. In Ethiopia, missed appointments more than doubled for NCDs due to accessibility and affordability issues. A comparison of eight LMICs (India, Pakistan, Indonesia, Bangladesh, Ethiopia, Nigeria, Ghana, DRC) shows that those with limited PHC investments had higher infant and maternal mortality and lower measles and COVID-19 vaccine coverage.
2) **Challenges to Building Resilient Health Systems:** The pandemic reduced average life expectancy by up to two years in some regions. By early 2023, less than 50% of the population in developing African countries were fully vaccinated against COVID-19. In Africa, over 418 million lack essential drinking water services, and 779 million lack sanitation. At least 35% of healthcare facilities in LMICs lack reliable water access. India has less than 11 qualified doctors and nurses per 10,000 population, far below the WHO threshold of 44.5. Most African countries have a health worker density less than 1/3rd of the WHO threshold. By 2030, the global health workforce shortage will decrease by 33%, but the decrease in the WHO African region is less than 1/4th of the global average. During the first COVID-19 wave, 87% of sub-Saharan African countries had less than 50 ventilators.
3) **Healthcare Financing and Financial Risk Protection:** Most sub-Saharan African countries have a GDP per capita under 1600 USD and domestic government health expenditure per capita under 75 international dollars (global average: 860.68). Inpatient curative care accounts for 30–40% of current health expenditure, while outpatient, preventive, and other care account for 60%. The ILO estimates 60% of the world's population works in the informal sector (68% in Asia, 85.8% in Africa), making contributory insurance mechanisms difficult. In India, approximately 40.5% of the population falls under the "missing middle"—neither poor enough for subsidized insurance nor rich enough for private insurance.
4) **Epidemiological and Demographic Challenges:** LMICs face a dual burden of communicable and non-communicable diseases (NCDs). From 2011 to 2021, diabetes prevalence increased by 37% in low-income countries and 32% in lower-middle-income countries, versus 7% in high-income countries. Antimicrobial resistance (AMR) was attributable to over 4.9 million deaths in 2019, with LMICs in South Asia and Sub-Saharan Africa accounting for over 65% of total DALYs. Less than 45% of women and 33% of men in South Asia were aware they had hypertension. Less than 1% of global health funding is directed towards NCDs in LMICs. In India, NCD expenditure was less than 0.04% of GDP from 2012–2017, while NCDs accounted for over 60% of deaths.
5) **Governance and Leadership:** As of 2017, only 38% of WHO member nations had passed legislation on UHC. Countries like Bangladesh, India, Pakistan, Ethiopia, and Nigeria spend less than 5% of general government expenditure on health. Corruption, informal payments, lack of accountability, and internal conflicts (e.g., civil wars in South Sudan and Yemen causing outbreaks of cholera and measles) are significant barriers.
**Clinical Implications:** The review underscores that achieving UHC by 2030 requires a fundamental shift towards strengthening primary health care systems, not merely expanding health insurance. Sustained financing is critical: WHO advocates increasing PHC spending by at least 1% of GDP, and estimates suggest a 2.6-fold increase in per capita PHC expenditure is needed from 2020 to 2030, with incremental costs up to 3.3% of GDP. Strategies such as health taxes, international cooperation, leveraging digital health technologies, and inter-sectoral coordination (e.g., "health in all" approaches) are essential. Without addressing the systemic weaknesses in PHC, health workforce shortages, and governance failures, LMICs—particularly in Africa and South Asia—will not meet the 2030 UHC targets.