The COVID-19 pandemic highlights the implications of chronic underinvestment in health workforce development, particularly in resource-constrained health systems. Inadequate health workforce diversity, insufficient training and remuneration, and limited support and protection reduce health system capacity to equitably maintain health service delivery while meeting urgent health emergency demands. Applying the Health Worker Life Cycle Approach provides a useful conceptual framework that adapts a health labour market approach to outline key areas and recommendations for health workforce investment—building, managing and optimising—to systematically meet the needs of health workers and the systems they support. It also emphasises the importance of protecting the workforce as a cross-cutting investment, which is especially important in a health crisis like COVID-19. While the global pandemic has spurred intermittent health workforce investments required to immediately respond to COVID-19, applying this ‘lifecycle approach’ to guide policy implementation and financing interventions is critical to centering health workers as stewards of health systems, thus strengthening resilience to public health threats, sustainably responding to community needs and providing more equitable, patient-centred care.

Achieving strong, resilient health systems that reach both global health security and universal health coverage goals requires a unified approach to how we work across the system. n We propose the following 3 key overarching approaches:n Strengthen comprehensive district planning (i.e., to be successful, district planners must understand how various public health programs come together within their communities, the range of stakeholders who have a role to play in health efforts, and how public and private funding and information systems can be leveraged at the local level to achieve their objectives).n Support flexibility of district health systems to break the silos of vertical programs and take on new roles as circumstances warrant.nUse the ongoing roll-out of COVID-19 interventions as an opportunity to address management, coordination, and integration challenges at the district level.

Background Universal Health coverage (UHC) is the mantra of the twenty-first century yet knowing when it has been achieved or how to best influence its progression remains elusive. An innovative framework for High Performing Healthcare (HPHC) attempts to address these issues. It focuses on measuring four constructs of Accountable, Affordable, Accessible, and Reliable (AAAR) healthcare that contribute to better health outcomes and impact. The HPHC tool collects information on the perceived functionality of health system processes and provides real-time data analysis on the AAAR constructs, and on processes for health system resilience, responsiveness, and quality, that include roles of community, private sector, as well as both demand, and supply factors affecting health system performance. The tool attempts to capture the multidimensionality of UHC measurement and evidence that links health system strengthening activities to outcomes. This paper provides evidence on the reliability and validity of the tool. Methods Internet survey with non-probability sampling was used for testing reliability and validity of the HPHC tool. The volunteers were recruited using international networks and listservs. Two hundred and thirteen people from public, private, civil society and international organizations volunteered from 35 low-and-middle-income countries. Analyses involved testing reliability and validity and validation from other international sources of information as well as applicability in different setting and contexts. Results The HPHC tool’s AAAR constructs, and their sub-domains showed high internal consistency (Cronbach alpha >.80) and construct validity. The tool scores normal distribution displayed variations among respondents. In addition, the tool demonstrated its precision and relevance in different contexts/countries. The triangulation of HPHC findings with other international data sources further confirmed the tool’s validity. Conclusions Besides being reliable and valid, the HPHC tool adds value to the state of health system measurement by focusing on linkages between AAAR processes and health outcomes. It ensures that health system stakeholders take responsibility and are accountable for better system performance, and the community is empowered to participate in decision-making process. The HPHC tool collects and analyzes data in real time with minimum costs, supports monitoring, and promotes adaptive management, policy, and program development for better health outcomes.

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