The experience of a donor-supported Reproductive, Maternal, Newborn, and Child Health (RMNCH) program in four states of Northern Nigeria illustrates how a Complex Adaptive System (CAS) approach to health system strengthening can lead to health systems becoming more resilient. The program worked with the array of political, cultural and social determinants which interact to shape the health system and its functionality. It worked in an environment marked by weak governance with little public accountability and by very limited management capability in inadequately regulated markets. To these conditions of fragility was added the shock from the rapidly deteriorating security situation caused in 2011 by the Boko Haram insurgency and the government's ensuing response. A CAS theory of change provided the basis for the multi-faceted approach that identified critical points of leverage among institutions in social as well as professional systems and helped achieve significant improvements in health service delivery in the RMNCH continuum of care. It also established the foundation for Primary Health Care Under One Roof, which has emerged as a central national strategy in Nigeria for strengthening health sector governance and services under the 2014 Health Act. This article draws on the experience of work undertaken in Northern Nigeria over the course of the last 10 years. A team largely of Nigerian professionals from an array of disciplines worked widely across the health system, addressing issues of governance, finance, institutional management, community systems support, access and accountability, and service delivery-frequently at the same time. This experience provides lessons for efforts elsewhere on how to strengthen health systems during and after emergencies (such as Ebola in West Africa) and in situations affected by conflict. Renewed interest in health systems strengthening (HSS) for building health system resilience came with the outbreak of Ebola in West Africa in 2014. 1 When institutional and systems failure-the absence of health system resilienceaggravated the crisis, there was limited capacity, particularly

Primary health care offers a cost–effective route to achieving universal health coverage (UHC). However, primary health-care systems are weak in many low- and middle-income countries and often fail to provide comprehensive, people-centred, integrated care. We analysed the primary health-care systems in 20 low- and middle-income countries using a semi-grounded approach. Options for strengthening primary health-care systems were identified by thematic content analysis. We found that: (i) despite the growing burden of noncommunicable disease, many low- and middle-income countries lacked funds for preventive services; (ii) community health workers were often under-resourced, poorly supported and lacked training; (iii) out-of-pocket expenditure exceeded 40% of total health expenditure in half the countries studied, which affected equity; and (iv) health insurance schemes were hampered by the fragmentation of public and private systems, underfunding, corruption and poor engagement of informal workers. In 14 countries, the private sector was largely unregulated. Moreover, community engagement in primary health care was weak in countries where services were largely privatized. In some countries, decentralization led to the fragmentation of primary health care. Performance improved when financial incentives were linked to regulation and quality improvement, and community involvement was strong. Policy-making should be supported by adequate resources for primary health-care implementation and government spending on primary health care should be increased by at least 1% of gross domestic product. Devising equity-enhancing financing schemes and improving the accountability of primary health-care management is also needed. Support from primary health-care systems is critical for progress towards UHC in the decade to 2030.

Daniel Reidpath and colleagues use the fourth Millennium Development Goal (MDG) as an illustrative example to highlight the potential to neglect equity in the race to achieve the MDGs.

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