INTRODUCTION:
Health system strengthening is essential for achieving Universal Health Coverage (UHC) and relies on system-wide reforms underpinned by effective governance. Good governance promotes sustainability, equity, and self-reliance through clear policies, inclusive coalitions, and accountability mechanisms. However, evidence on governance strategies to address health system challenges remains fragmented. This scoping review aimed to synthesise global evidence on strategies used to address health system governance challenges in countries transitioning to UHC.

METHODS:
We conducted a scoping review in accordance with the 2020 Joanna Briggs Institute guidance. A comprehensive search of four databases was undertaken for studies published between 2007 and October 2024. Eligible studies described strategies implemented to address health system governance challenges at any level. Titles, abstracts, and full texts were independently screened, with a subset double-screened for quality assurance. Thematic analysis, guided by the Mikkelsen-Lopez governance framework, supported systematic mapping and descriptive synthesis of identified governance elements across the World Health Organization building block framework.

RESULTS:
From 8,001 records screened, 27 studies from 21 countries were included. Strategies were primarily implemented at the district level by national health departments targeting local communities. Identified strategies addressed WHO building blocks: Governance and leadership challenges—including uneven district performance, overcentralisation, corruption, and limited community engagement—were addressed through decentralization, participatory planning, twinning partnerships, and engagement; financing barriers, including fragmentation, high out-of-pocket payments, and inefficiencies, were mitigated through strategic purchasing, pooled insurance, performance-based payments, and strengthened accountability; health workforce issues—weak leadership, rigid hierarchies, and staff conflicts, were tackled through decentralized decision-making, competency-based training, and working groups; service delivery challenges—poor coordination and limited engagement—were addressed through community-led initiatives, mobile health platforms, and integrated monitoring.

CONCLUSIONS:
We identified multiple strategies implemented to address health system governance challenges across contexts. These results provide a foundation for context-specific prioritisation of potential strategies to implement for countries progressing to UHC.