Learning lessons from covid-19 to reduce global health inequity

Kiran CR Patel and colleagues outline six key ways in which we can improve equity during the pandemic and in its aftermath

Scenes initially from Italy, then Brazil, and more recently India, show the distress that covid-19 confers to patients and the commensurate stress imposed upon health systems. No country has been spared the need to prepare, struggle, and mourn in a crisis few saw coming 18 months ago. What more can be done to improve the valiant global effort to date and prepare us for future crises?

Firstly, strengthen public health systems. Health and politics are inextricably linked. Yet, depressingly often, we have seen policies and guidance underpinned by populism rather than public health. The UK, for example, initially considered herd immunity as a strategy and avoided recommending mask wearing. India invoked an exemplary lockdown during the initial first wave of covid-19, but did not do so in May 2021 at the time of elections when a tsunami of covid-19 cases swept across the country. The scale of need was almost immeasurable in a country where many citizens living below the poverty line are unlikely to seek a test for covid-19, let alone seek healthcare. The reported peak of around 400 000 new daily cases in India is likely to be a significant underestimate. Likewise, the number of reported deaths, being only hospitalised deaths, has led to some conjecture that the actual death toll in India is likely to have been tenfold greater than that reported. A fundamental global lesson is that it is time for standardised reporting of deaths and excess death, along with case incidence and prevalence—otherwise these indices are incomparable across countries and risk being politicised.

Secondly, seize the opportunity to develop universal healthcare. As countries prepare for the huge challenge of morbidity and mortality that will inevitably follow covid-19, there is no better time for health systems to commence the journey towards universal healthcare provision. 

Thirdly, treatment should be evidence based (or actively be under investigation within high quality clinical trials). The world has learnt at a pace like never before during this pandemic, with clinical trials and observational studies of high quality demonstrating what the most effective treatments for covid-19 are and at which stages. All patients should be able to benefit from such evidence, so that we can avoid outbreaks of conditions like “black fungus,” which harmed many patients in India and was driven by inappropriate overuse of steroids.

Fourthly, regulated access to healthcare can save lives. The acute challenge of covid-19 taught us that while access to lifesaving oxygen and ventilatory support is critical, so is governed access to healthcare. In order to make the best use of limited resources in an equitable way, criteria based access to hospital and intensive care beds is essential. Standardised protocols for access to valuable and limited resources enable the best chance of survival for as many people as possible. In an age where sharing can be instantaneous if there is a will, it is time to share and standardise protocols as much as possible from across the world. 

Fifthly, good healthcare governance is essential. Acute hospitalisation comes at a substantial cost to patients and their families in systems where out-of-pocket expenditure funds healthcare. Governments should act to protect their most vulnerable citizens from impoverishment by guarding against the cost inflation of hospital fees and drug prices. Robust governance is also vital to ensure that the supply chains for oxygen, medication, and other supplies reach those in need. Recovery from the pandemic offers an opportunity to develop infrastructure and supply chains, while guarding against inequity, in line with WHO principles for health system strengthening.

Finally, workforce planning and deployment should align to need, to meet both demand for emergency care and to develop sustainable health systems. The NHS laudably paused recruitment from India when that county required all its staff and skills during a period of acute need and recovery. Going forward, ethical workforce planning is now key to global recovery from the pandemic. Individual organisations in the UK could and should now review their own workforce strategies, particularly where they are dependent upon an international recruitment plan. Planning should focus on strengthening and swelling workforce supply chains both within the UK and internationally, to create a win-win scenario, as opposed to mitigating shortfalls by denuding countries of origin of a scarce commodity. 

History shows us that it’s a mix of action and inaction that has resulted in global inequity and iniquity. It is now up to us to define what strategies we prioritise to drive equity and prosperity during the pandemic and in its aftermath. 

Kiran CR Patel is a cardiologist and chief medical officer at University Hospitals Coventry, a trustee of the South Asian Health Foundation, and also a non-executive director of the BMJ Group.

Sarah Ali is a consultant diabetologist at the Royal Free Hospital and a trustee of the South Asian Health Foundation. 

Wasim Hanif is a professor of diabetes and consultant physician at University Hospital Birmingham, as well as a trustee of the South Asian Health Foundation.

Kamlesh Khunti is a professor of primary care diabetes and vascular medicine at the Diabetes Research Centre, University of Leicester and a trustee of the South Asian Health Foundation.

All authors are trustees of the South Asian Health Foundation, which has objectives to reduce health inequality by promoting leadership, education, and research.

Competing interests: nothing further to declare.