Achieving health equity through intersectional governance

Globally, regionally, and nationally, the COVID-19 pandemic has significantly stressed public health systems around the world and exposed the gaps in health care for underserved and vulnerable populations. Faced by the current pandemic including other threats i.e., climate change, politicized misinformation etc. our health systems must be robust and resilient.

But the approach has to be broad based, intersectional. Achieving this requires targeted long-term efforts, among others:

• Address historical and contemporary injustices;
• overcome economic, social, and other obstacles to health and health care; and
• Eliminate preventable health disparities.

The Challenges

Identification of health inequities is seemingly intractable, complex, and difficult to address. Different stakeholders have conflicting values, and multiple explanations and interventions are possible. In many cases, what health inequity looks like depends on where you live. In some places, inequity might look like a lack of personal protective equipment in a community clinic. In others, it might be entrenched poverty that prevents people from seeking care. In others, it might be a lack of education, or food insecurity, disability, or gender disparities that withhold opportunities from girls and women. However, the key barriers are predictable: policy implementation barriers, such as demand-and supply-side barriers, market, insufficient resources, cultural barriers, imperfect communication, information, education, coordination, leadership, and governance affect the poor and vulnerable groups in developed and developing countries from benefitting from public spending on public health policies and programs.

The COVID-19 pandemic has exacerbated longstanding intersectional disparities (i.e., gender and disability, ethnic, racial, sexual identity, etc.) in health in many countries and highlighted the need to address inequities across a range of health system functions. All countries face their own unique inequities in health status or in the distribution of health care resources among different population groups. All these contribute to addressing historical and contemporary injustices, overcoming economic and social barriers while eliminate preventable health disparities.

Policy Interventions

Health governance is a complex and multifaceted issue that requires careful consideration and contextual assessment and planning. Public health policy approaches have demonstrated measurable improvements in population health. Yet, “one-size-fits-all” approaches do not necessarily impact all populations equally and, in some cases, can widen existing disparities. It has been argued that interventions, including policy interventions, can have the greatest impact when they target the social determinants of health. recognizing how structural disadvantages in areas such as housing, education, and employment have driven inequities in disease and mortality by race and ethnicity. Yet not all regions in most of the countries—including some with deeply rooted racial inequities—acknowledge the impact systemic racism has had on health outcomes.

Effective leadership and governance of health sector involves ensuring strategic policy frameworks exist and are combined with effective oversight, coalition-building, regulation, attention to system-design and accountability such as:

• the State (government organizations and agencies at central and sub-national level);
• the health service providers (different public and private for and not for profit clinical, para-medical, and non-clinical health services providers; unions and other professional associations; networks of care or of services);
• the citizen (population representatives, patients’ associations, CSOs/NGOs, Organisations of Persons with Disabilities (OPDs), citizens associations protecting the poor, etc.) who become service users when they interact with health service providers.

The success would be to get some of the analysts to slightly shift their way of thinking about the complexities of health issues, problems and challenges and understanding that a one-size-fits-all model is not going to cut it anymore, engaging in exercises of self-reflexivity, thinking about issues of power in respective area of policy.

An intersectional approach to health governance

As alluded to before, intersectionality is an approach or lens that recognizes that health is shaped by a multi-dimensional overlapping of factors such as race, class, income, education, age, ability, sexual orientation, immigration status, ethnicity, indigeneity, and geography. For example, using an issue-based start or problem-based start can make a difference – people can look at particular issues, challenges or areas in public health or health inequities and then understand the ways in which different individuals or different groups may be affected by that particular issue. Public health’s commitment to social justice makes it a natural fit with intersectionality’s focus on multiple historically oppressed populations.

It is clear that to achieve health equity, we must change the systems and policies that have resulted in the generational injustices that give rise to racial and ethnic health disparities. We also must tackle ableism. Stark gender, racial and ethnic disparities during the COVID-19 pandemic led to many health policy changes focused on addressing social needs and social determinants of health to improve health equity.

It is clear that to achieve health equity, we must change the systems and policies that have resulted in the generational injustices that give rise to racial and ethnic health disparities.

A few Recommendations

Achieving equity in global health requires an intersectional and coordinated approach that reaches across sectors, communities, and countries, with health and social justice at its core. The pandemic has underscored the need for equity to be at the center of the global health agenda to ensure that the most marginalized and excluded have access to essential health services. It has also highlighted the need to re-think the global health governance and equity agenda to focus on the foundational causes of health inequalities, for example:

• The development of the Intersectionality-based Policy Analysis Framework can be a starting point for key stakeholders. It must address the gender, disability, and socio-economic drivers of health inequalities and focus on equitable outcomes for health, including through pro-equity social protection measures.
• Improving our knowledge of disability can reduce stereotypes and stigma in healthcare and beyond.
• The governments at all levels [local, sub-national/provincial, national] should accelerate discussions and implementation of public –private initiatives for creation of sustainable models of healthcare financing to achieve Universal Health Coverage.
• Embrace technology in healthcare sector to ensure that resources allocated are not hampered by poor governance and the lack of accountability in the use of resources. Application of the principle of accessibility, and the use of assistive technology where appropriate, would go a long way to make the health technology much more enabling.
• Develop a standard referral system monitoring toolkit and curriculum to train health workers on the referral policies and guidelines to improve processes between the facilities.
• Adequate fund for implementation, monitoring and evaluation to provide regular supportive supervision for improved healthcare and accountability at all levels.
• Where needed, improvement of remuneration and pragmatic incentives to enhance motivation of healthcare workers.
• Improve working conditions to motivate the healthcare workers and the policies implementers.
• Improvement of supplies and making the supplies regular to enhance delivery of healthcare services. This is particularly important in armed conflict, and post-conflict settings.
• Strengthen the systems for proper ethics and governance in line with the constitution including the fight on corruption in health systems.
• Providing capacity development initiatives i.e., knowledge transfer, training opportunities for healthcare workers to enhance skills and improved supervision from management. South-South and Triangular cooperation can play a conducive role.

Towards a more inclusive, intersectional health system

Compared with a decade ago, practitioners today see a greater interest in health equity and an acknowledgment of the social determinants - intersectional issues - of health, in part because of the ongoing pandemic response and increasing social awareness. Many governments across different regions have demonstrated a commitment to addressing these issues, as evidenced by both policy and legislative development in different parts of the world. Issue of social inclusion, social protection, social justice, and civil rights are gaining gradual currency in health governance.

Such efforts send an important message to those in the field and at the sub-national/provincial and local levels worldwide working to improve public health through policy changes, awareness raising about inclusive and accessible health systems and services, increasing funding to address the social, economic, and environmental factors that shape health; and community buy-in and engagement. More importantly, the key stakeholders are now aware that an intersectional approach identifies better the way that people’s social identities can overlap, creating compounding experiences of discrimination. Health equity can only be achieved if the health system can tackle the compounding experiences of discrimination(s) while ensuring inclusive service delivery.

Health equity can only be achieved if the health system can tackle the compounding experiences of discrimination(s) while ensuring inclusive service delivery.