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Health Equity and Inclusion in Action


Oommen C Kurian and James Snodgrass, Health Equity and Inclusion in Action, February 2024, Observer Research Foundation.

Executive Summary

In a rapidly changing world, the pursuit of health equity and inclusion remains at the forefront of countries’ goals. While progress has been made globally in recognising health equity as a pivotal element for achieving better health outcomes, there is still little discourse around genuine inclusion—ensuring that every individual, regardless of their background or circumstances, has a voice and role in their healthcare decisions. With non-communicable diseases like diabetes, cardiovascular disease, and cancer becoming increasingly prevalent, their implications extend beyond health and encompass economic consequences. Through insightful case studies, this report aims to illuminate feasible strategies that countries can adopt to ensure that healthcare is equitable and inclusive and that the influence of social determinants of health is minimised.

The analysis of health case studies reveals a concerted effort to extend healthcare services to underserved and rural areas, utilising digital technology and telemedicine. This approach has improved healthcare accessibility and reach, with collaborations between governments, global organisations, and insurers playing a vital role in expanding access. These partnerships are essential for overcoming geographic and economic barriers, facilitating wider healthcare coverage.

Initiatives offering specialised services such as HIV/AIDS care, mental health support, and dispensing medication for chronic illnesses exemplify the tailored nature of healthcare provision. The comprehensive scope of these services, which often includes primary care, pharmacy services, and telehealth, demonstrates a commitment to addressing a broad spectrum of healthcare needs. Such comprehensive care is paramount for ensuring that various health challenges are met with appropriate and effective responses.

Innovation through digital technology, telemedicine, and mobile applications is a hallmark of these initiatives, driving the evolution of healthcare services. The prospective integration with AI and Big Data heralds an advanced future for healthcare solutions, suggesting a trajectory that could enhance predictive healthcare and personalised medicine.

Community empowerment is another critical element, with initiatives creating job opportunities, upskilling healthcare workers, and integrating informal practitioners into the formal healthcare sector. This not only strengthens the healthcare system but also nurtures community resilience. Entrepreneurial models like nurse-run clinics are testament to the potential of healthcare to contribute to community empowerment and economic development.

Scalability and adaptability are evident in the expansion of many case studies across regions and countries, demonstrating the potential for widespread impact. The ability to integrate healthcare systems across borders and diversify service portfolios underlines a dynamic approach to healthcare delivery that can respond to changing needs and contexts.

At the same time, sustainability and financial viability remain pressing concerns. Many initiatives struggle to maintain operations beyond the phase of initial funding, often relying on donor-driven models or external financial sources. The challenge of ensuring long-term sustainability is particularly acute for those dependent on digital technology and automated systems, which may require continuous investment. Limitations in scalability and the struggle to expand beyond pilot phases or specific regions highlight the challenges associated with broadening the impact of these initiatives. In areas with poor digital connectivity, the reach is inherently limited, and scaling to a broader audience becomes increasingly complex.

Maintaining quality of care and service consistency across diverse locations and healthcare settings is a challenging task. The variability in skills among community healthcare workers and providers can significantly impact service quality, necessitating robust training and support systems to ensure consistent care. Dependency on external factors, such as government support, public-private partnerships, or the technical proficiency of users, poses risks to the long-term effectiveness of healthcare initiatives. The reliance on external funding sources and consistent governmental backing is a delicate balancing act that requires strategic planning and engagement to secure the future of these initiatives.

In sum, while the strengths of these healthcare initiatives lay a robust foundation for improving access and integrating innovation, the challenges they face underscore the need for sustainable financial models, quality assurance, and strategic scalability planning. These factors are crucial for the enduring success of these initiatives and the achievement of long-term health outcomes. 

1. The Pressing Challenge: Dual Health Threats in Health Transition Countries (HTCs)

  • HTCs grapple with a dual healthcare challenge: the sustained threat of infectious diseases and the escalating incidence of non-communicable diseases.
  • The countries spotlighted in this report, such as South Africa and India, confront distinctive healthcare challenges. Marginalised communities within these nations suffer greater health disparities and limited access to essential services.

 2. The Vision of Health Equity and Inclusion

  • The overarching vision is clear: a healthcare system that is universally accessible and holistically integrated, ensuring that every individual, irrespective of socio-economic or cultural background, benefits as equally as possible from affordable access to quality healthcare.
  • This report delves deep into this vision, examining a plethora of health initiatives across HTCs that are carving pathways towards a more equitable and inclusive healthcare framework.

 3. Bright Spots: Proven Strategies in Resource-Limited Settings

  • Amid the challenges, innovative strategies are emerging as beacons of hope. Task shifting, ensuring the quality of health services and medications, and devising novel healthcare delivery models are proving their value in these demanding settings.
  • The pivotal role of community health workers and the transformational impact of quality generic medicines are particularly noteworthy. These strategies are not just improving healthcare accessibility but are also making healthcare more affordable.

 4. Digital Leap: Technology’s Potential as the Great Equaliser

  • Technology is offering solutions in healthcare that transcend traditional access barriers. It is emerging as a pivotal tool to democratise health access, although the fundamental challenges of digital divide remain.
  • Initiatives harnessing mobile health applications, decentralised diagnostic technologies, digital health records, and a wider digital health ecosystem are spotlighted in this report. These initiatives have immense potential to elevate care quality, expand reach, and bridge the healthcare divide.

 5. Recommendations for a Healthier Tomorrow

This report offers the following recommendations to generate progress:

  • Leverage scarce health system resources.

Use task shifting and innovative service delivery routes: Implement task shifting and digitisation programmes to enhance health system efficiency. Prioritise clear delineation of roles and stringent quality control to ensure effective, context-specific healthcare delivery.

Improvements to the quality of medicines: Champion the adoption of effective pharmacovigilance programmes, and address the issue of low-quality or counterfeit medicines to prepare for a future where high-quality medication is the norm.

  • Improve access and increase affordability for all.

Increase funding for equity and inclusion programmes: Amplify funding for initiatives that prioritise marginalised and underserved communities, fostering a more equitable and efficient health system.

  • Ensure smart use of technology and data to leapfrog constraints.

Promote uptake of tech and Big Data: Enhance healthcare with contextually relevant tech, predictive AI, and Big Data, emphasising scalable solutions like mHealth to improve efficiency and decision-making. Ensure these technologies are accessible in both urban and rural areas, supporting comprehensive care delivery.

  • Increase community leadership and inclusion.

Put beneficiaries and communities at the front of healthcare decision-making: Recognise that achieving health equity requires tailored approaches that are contingent upon generational and cultural contexts as well as country-specific situations. It is imperative to actively engage individuals and communities in healthcare decisions. To not only give communities a seat at the table but invite them to sit at the head of the table.

Implement culturally relevant healthcare services: Ensure that adequate training and programmes are in place to accommodate cultural and linguistic diversity in healthcare settings, preventing misunderstandings and misdiagnoses.

Let us join forces in action to pave the way for a future where health equity and inclusion are not mere aspirations but tangible realities.

Report Objectives and Approach

This report aims to explore how various initiatives based in health transition countries (HTCs[1]) are working to bridge equity and inclusion gaps in access to health.

Through an examination of these initiatives, the report aims to disseminate lessons that could help inform global and national decision-making and support the development of UHC systems by incorporating technology advances that improve outcomes for all health service users. 

To achieve these goals, the report will explore practices and characteristics of diverse health systems in a heterogeneous group of HTCs, with the aim of facilitating cross-border and cross-sectoral collaborations between them. Based on this assessment, the report highlights innovative and effective approaches as well as the positive health outcomes that they produce. At the heart of this exercise was to identify case studies of health initiatives that are making a demonstrable impact in their countries and, in some cases, regionally.

We sought case studies that are innovative, whether by incorporating the smart use of technology, or proving to be financially sustainable and scalable. Ideally, these programmes are already demonstrating notable health impacts.

The report contains case studies from six countries: Bangladesh, India, Morocco, Rwanda, South Africa, and Vietnam.

These countries are very different: Rwanda is one of the lowest-income countries in Africa, but has had remarkable success in ensuring access to primary care for a very high percentage of the population. Meanwhile, Vietnam is rapidly developing and is projected to soon become an upper-middle-income economy. Yet it continues to face a problem endemic in many Asian countries: large hospitals in the cities are overwhelmed with patients flooding in from rural areas.

All six countries share a commitment to improving access to health for their citizens, most of them through a combination of public and private services. Otherwise, they are an intentionally heterogeneous group chosen to showcase the diverse approaches that can be adopted to achieve equitable and inclusive access to healthcare.

Local analysts identified a long list of case studies within their country. After further investigation, the long list was narrowed down to the 12 case studies that are presented in this report.

Read the report here.

[1] For the purpose of this report, HTCs are low- and middle income countries with high loads of both communicable and non-communicable diseases, putting pressure on the health system due to multiple transitions (epidemiological, nutritional, economic and demographic) involved.

This report was developed by the Observer Research Foundation (ORF) in collaboration with the biopharmaceutical company, Gilead Sciences, who commissioned this report.

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Oommen C. Kurian

Oommen C. Kurian

Oommen C. Kurian is Senior Fellow and Head of Health Initiative at ORF. He studies Indias health sector reforms within the broad context of the ...

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James Snodgrass

James Snodgrass

James Snodgrass is a consultant with over 20 years of experience working in global health and related fields for multilaterals, bilaterals, research partnerships, and the ...

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