Healthcare inequities, which have long been a global challenge, were aggravated by COVID-19. In many instances, the poorest, most vulnerable populations experienced the worst health, economic and social impacts. But the reaction and mindset inspired by the pandemic has the potential to accelerate progress and achieve better outcomes for all.
As health inequity and its consequences captured the world’s attention, a variety of players responded with innovative thinking and solutions. The crisis accelerated the use of digital technology, which can be sustained to provide a range of healthcare services to rural and other underserved populations. Efforts designed in the breach that tailor COVID vaccination strategies to specific vulnerable populations could be adapted to tailor other approaches to other diseases, such as diabetes, for at-risk groups.
The global healthcare system now faces a unique opportunity to harness this energy and capitalise on its momentum to work towards closing the health equity gap. It can apply the lessons learned to tackle other major challenges, such as working to address the social determinants of health that drive inequity, shifting focus from sick care to prevention and well-being, sparking the development of precision medicine, tackling the workforce challenges that were exacerbated by COVID, and concurrently addressing environmental, social and governance (ESG) issues as a win-win.
Four key insights from the COVID experience provide a platform for moving forward:
As the world strives to emerge stronger from the pandemic, applying these healthcare equity lessons will help build a system that is more resilient and just, not only in producing better health outcomes but in creating better social and economic outcomes.
The absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically, or by other dimensions of inequality, such as sex, gender, ethnicity, disability or sexual orientation.
The non-medical factors that influence health outcomes. Social determinants of health are the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems that shape daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems. Social determinants of health have an important influence on health inequities—the unfair and avoidable differences in health status seen within and between countries.
The pandemic forced countries to track health data in entirely new ways. Governments created dashboards to keep tabs on COVID incidence rates, hospitalisations, resource use and availability, and other important metrics. Innovative testing techniques were deployed, including genomic sequencing, and contact-tracing apps were used to help contain the spread of the virus. These efforts helped to guide responses throughout the crisis, including providing early-warning systems for COVID surges; enabling targeted social-distancing, testing and vaccination initiatives; and preparing hospitals to support treatment.
This data also quickly revealed that minority and underserved communities often experienced higher rates of COVID and job loss, worse outcomes and unequal access to testing, treatment and vaccination. The disparities made global headlines and spurred action on many fronts. According to the World Bank, just over 7% of people in low-income countries received a dose of the vaccines by the end of 2021, compared with more than 75% in high-income countries.
In Boston, a Brigham Health effort to create a data infrastructure early in the pandemic was the subject of a case study in the Harvard Business Review. The Brigham organisation, part of the Mass General Brigham health system, collected and stratified data for metrics including COVID positivity rates, inpatient and intensive care–unit censuses, deaths and discharges into subgroups, such as race, ethnicity, language, sex, insurance status and geographic location. Data showing that non–English speaking Hispanic patients were dying at higher rates than their English-speaking Hispanic counterparts led to improvements in patient access to interpreters. The discovery that people in historically segregated neighbourhoods of colour were tested for the virus at lower rates but tested positive at higher rates sparked an initiative to offer free testing in hard-hit areas.
Healthcare players have an opportunity to continue using data in much the same way after the pandemic to improve health equity on a much broader scale. The depth and volume of available health information is growing rapidly as remote monitoring devices, consumer wearables and healthcare apps proliferate. Healthcare agencies, payors, providers, and pharmaceutical and life sciences companies now have access to large pools of data they can use to identify people who suffer worse outcomes and drill into the root causes. These players should invest in a systematic approach to data collection and analysis that allows them to, for example, home in on individual patient needs through precision medicine. That is, after data is used to identify vulnerable populations, providers can tailor solutions to their needs.
However, some struggles in the data arena persist. Healthcare organisations may have a surplus of data but a deficit in the capacity or know-how required to use it. In other instances, they may not have access to all the data needed to address social determinants, especially to information outside the healthcare realm. Because different organisations often hold different pieces of the data puzzle, health equity initiatives typically require collaboration with outside entities—government, other healthcare organisations, patient advocacy groups, community organisations or non-governmental organisations.
The tools exist to help determine what datasets are available and point to partnership opportunities. For example, Future Cast, a PwC product in the US, pulls together data from a variety of sources sorted by therapeutic area and local demographics to reveal social determinants that pose healthcare barriers. The insights help clients to shape their strategies and offerings, and to decide whom to partner with to generate a more complete picture of their target population.
The World Heart Observatory, launched in February 2022 by the World Heart Federation, holds tremendous promise for providing the real-world evidence necessary to improve heart care and address health inequity, says a report developed by PwC and the European Federation of Pharmaceutical Industries and Associations. The observatory curates, aggregates and visualises information on cardiovascular conditions, risk factors, social determinants of health, health systems and policy responses, with the aim of becoming a trusted, comprehensive tool for healthcare providers, policy-makers and innovators around the world.
An agreement between Pfizer and Israel’s Government shows the power of data collection and analysis to improve population health. Real-world evidence gathered in Israel confirmed Phase 3 trial findings that showed the Pfizer–BioNTech vaccine’s effectiveness at preventing symptomatic disease, severe or critical disease, and death. This finding, just a year after the World Health Organization declared a pandemic, helped other countries to formulate their approaches to immunisation.
Further study of Israel’s population helped to determine how long immunity lasts after vaccination and pointed to the need for booster shots. As COVID variants emerged, the de-identified data from Israel served as an indication of how well two-shot and three-shot vaccination courses guarded people against infection, serious illness and hospitalisation.
Creating a product or offering a service doesn’t, on its own, mean everyone has the awareness or ability to benefit from it. Research findings cite racism and past unethical medical research involving Black communities in the US as reasons for vaccination hesitancy when shots first became available. False rumours that First Nations Australians weren’t at risk from COVID and that the vaccine caused serious sickness or death in the country’s indigenous populations generated confusion and may have discouraged people from seeking testing or accepting the vaccine. The mishandling of a dengue fever vaccination programme among children in the Philippines in 2016 has created lasting distrust of vaccines, including COVID shots. In many countries, language differences in minority communities also presented a barrier to care.
Several strategies have been deployed during the pandemic to engage vulnerable communities, including health literacy initiatives, use of interpreters, and tailored communications and outreach efforts. Data that showed a low vaccination rate among New Zealand’s Māori population sparked multiple community-led efforts. These included the Vax Vegas social media campaign aimed at young Māori in the Rotorua region and a Drive Thru Movie Max-Vax event in the town of Ngāruawāhia. That event was tied to a broader That’s Us social media campaign that encouraged vaccination and use of trustworthy sources of information. As of mid-March 2022, 88% of Māori were fully vaccinated, and 60% had taken their booster shot.
Under its universal healthcare model, Brazil mobilised governments at all levels to set up advanced supply chain initiatives to deliver vaccines to the population as quickly as possible. Several municipalities engaged in proactive tactics to approach people in more remote areas. The city of Contagem, in Minas Gerais state, deployed an itinerant vaccination truck to move through its streets in order to increase vaccination rates among children. In Icapuí, a vast municipality in the state of Ceará with little internet coverage, volunteers were mobilised to educate, transport and support local communities.
In France, the health equity–focused nonprofit Banlieues Santé, or Healthy Suburbs, partnered with the country’s School of Advanced Studies in Public Health to train COVID prevention ambassadors to promote hygiene and dispel rumours about the virus. The advocacy group regularly sets up healthcare services tents in underserved poor and migrant-heavy communities in the Paris area. After the pandemic broke out in France, the group began offering information about the virus and vaccination, and distributed hygiene kits at its tents. It attracted people to the tents with Moroccan music and offered information in several languages—a vital approach in a country where the increase in the number of deaths in March and April 2020 was vastly higher among people born in African nations.
These approaches are adaptable beyond the pandemic. Governments and healthcare organisations can identify opportunities to collaborate with entities that are more closely connected to the patient population they’re trying to reach. Trusted players, such as community organisations, advocacy groups and religious institutions, can help tailor the message and outreach to the target audience. These relationships also allow the people being served to offer ideas, input and constructive criticism that foster buy-in and identify areas for improvement. The idea is to avoid poorly devised, one-size-fits-all solutions that are perceived as being done to the community, rather than with it.
Already, some pharmaceutical companies are creating patient advisory panels or partnering with patient advocacy groups to gather insights that they can apply to treatments, from product development through launch, to address barriers that vulnerable populations might face in accessing their products. For example, recognising the lower rate of shingles vaccination in the US Hispanic population, GlaxoSmithKline began running a translated shingles-awareness ad campaign on popular Spanish-language TV stations in January 2022. The campaign will also include ‘strategic sponsorships with community organisations’ and partnerships with media outlets, such as People en Español.
Community engagement is at the heart of an effort to address obesity among Malaysia’s urban poor. The project is led by the Malaysian Ministry of Health and the Better Health Programme, a UK Government–funded initiative launched in 2019 to reduce non-communicable disease rates in eight developing countries. In the project, community health volunteers partner with local business owners and other stakeholders to lead changes that community members themselves have prioritised.
The Malaysian Better Health Programme team, supported by the nonprofit RTI International and PwC UK, created the MyBHP app and the MYJomSihat Facebook group (jom sihat translates to ‘let’s be healthy’) to encourage healthy eating and physical activity. The app links users to local food vendors and food outlets participating in the obesity reduction initiative. The team also held a webinar for local businesses in August 2021 that offered advice on how to market healthier food options.
The initiative places a special emphasis on socially excluded groups, including women, diverse ethnic groups and people with disabilities. The project includes a study of the effectiveness of its approach among community health volunteers and community members in three geographical areas of Kuala Lumpur, each representing a different ethnicity—Malay, Indian and Chinese.
The pandemic spurred a rapid shift to virtual healthcare, as access to in-person care was limited to urgent and emergency conditions due to the virus’s highly transmissible nature. In Australia, where the use of telehealth in mental health had been negligible before the pandemic, the market share rose to 50% during the lockdowns and has stabilised at about 20%.
Although in-person care has largely resumed, demand for telehealth services is expected to boom. Allied Market Research projects that the global telemedicine market will rise from US$40.2bn in 2020 to US$432bn by 2030. At the same time, the crisis accelerated pharmaceutical companies’ adoption of digital methodologies to keep existing trials running during the pandemic and to safely recruit participants in COVID-related trials.
These trends hold vast potential to reduce health inequities by bringing services, including mental healthcare, to communities where access to healthcare providers and clinical trial sites is limited. Virtual technologies greatly reduce the inconveniences, such as travel time, transportation barriers and time away from work or childcare, that factor into inequities in vulnerable populations. But as consumers, clinicians and payors continue the shift towards virtual healthcare, it will be critical to make sure that vulnerable populations aren’t left behind due to lack of digital inclusion. This effort will require investment in digital infrastructure, implementation of cyber protections, and optimisation of the mix of face-to-face and virtual care.
Initiatives have sprung up to bring connectivity to people who don’t have a digital device or who lack the broadband access that enables virtual care. In the US, Cleveland’s University Hospitals realised that although virtual patient visits increased by 3,000% during the pandemic, many patients weren’t able to participate because they couldn’t connect digitally with providers, according to an article in ENTtoday. Spurred by this realisation, the hospital system partnered with the nonprofit PCs for People, which donated 500 laptop computers, 500 hotspots and three months of broadband service to University Hospitals patients who met certain financial criteria, such as having income at a specific fraction of the poverty level or participating in Medicaid or the federal nutrition assistance programme. In return, the health system donated its used computers to the nonprofit so they could be refurbished and reused.
California start-up Zipline began delivering blood and vaccines by drone to remote parts of Rwanda in 2016 and to Ghana in 2019. In November 2021, Pfizer and BioNTech partnered with the company to deliver 50,000 COVID vaccine doses to hard-to-reach communities in Ghana, which lacks the ultra-cold supply chain the shots require. Drones parachuted the doses, which were donated by the US Government through the World Health Organization’s COVAX programme, into the remote areas. By November 2021, Zipline had distributed 220,000 COVID vaccine doses from multiple manufacturers to locations across Ghana.
Recognising that the burden of travelling to a clinical trial site posed a barrier to enrollment, especially for minority populations, US pharmacy chain CVS launched a division in May 2021 to enable trial participation through its retail locations, at home or virtually. Only about 11% of participants in US randomised clinical trials in 2018 were from minority groups, with just 6% Black and 3.8% Latino representation. In February 2022, CVS entered a partnership with Medable that brings the clinical trial software firm’s decentralised platform into CVS MinuteClinic facilities. Because 40% of vulnerable populations are located within five miles of a CVS pharmacy, the hope is that more people with minority backgrounds will participate in clinical research.
The idea of taking services directly to underserved, vulnerable communities has applications well beyond the pandemic. For example, Optum, a US pharmacy benefit management and healthcare services company, includes a social determinants of health evaluation in its HouseCalls initiative. In this programme, clinicians visit elderly patients who are enrolled in the company’s Medicare insurance plans. The clinicians screen those patients for physical and mental health conditions, review their medications, evaluate whether they face barriers to care, and connect patients with resources to address any barriers they observe.
The pandemic made it clear that no single organisation can address health inequity on its own. The realisation not only fuelled an unprecedented level of collaboration but led to a breaking down of silos between organisations. In South Africa, the Federal Government negotiated with private insurers and providers to set prices for COVID services for uninsured patients. The majority of South Africans receive care through the chronically under-resourced public system. The collaboration helped to ease the burden on public facilities by enabling the uninsured to get Government-funded COVID care at private institutions that had spare capacity.
About 80% of an individual’s health outcomes are tied to the social determinants of health that drive health inequity, including the quality of education, housing, nutrition, jobs and the environment. The COVID pandemic brought to light the value of thinking creatively in terms of who healthcare players’ partners can be.
In the US, CVS Health partnered with rideshare company Lyft in February 2021 to provide free or discounted rides to COVID vaccine appointments for people without access to transportation. Then, in January 2022, CVS announced a broader arrangement with rideshare company Uber to provide free transportation in five US markets to medical care, work or educational programmes in high-risk communities. The collaboration is part of CVS’s broader effort to address six major social determinants of health: housing, education, and access to food, jobs, transportation and healthcare.
In New Zealand, the Federal Government has provided millions in financial support to virus response and recovery efforts led by Māori and Pacific Islander communities. For example, in February 2022, the Government approved 12 proposals totalling NZ$15.7m (US$10.4m) via the Māori Communities COVID-19 Fund. The projects focus on rural, isolated and low socioeconomic areas with low vaccination rates and high Māori populations. Their efforts include training community members to administer vaccinations; offering mobile vaccinations, vaccination events and incentives; and developing material to target high-need groups, such as specific age groups or gangs.
Many problems factor into why some populations have fallen through the cracks, including inadequate educational opportunities, a lack of local healthcare providers, transportation barriers, types of employment, living situations and lack of childcare. So, although the logical partner for a healthcare organisation that seeks to improve outcomes often would be another healthcare entity, it might also be a community organisation, an advocacy group, or a business or government entity with skills and capabilities outside the healthcare realm. Such partnerships give organisations the opportunity to work with neighbours and peers that possess different skills and capabilities, improving health, social, environmental and economic outcomes for all.
By the same token, private entities outside the healthcare arena can think creatively about how to use their area of expertise. These initiatives can serve as part of their broader ESG efforts. In Australia, mining company BHP leveraged its supply chain infrastructure to deliver hand sanitiser and face masks to healthcare providers and schools in vulnerable remote communities in the early days of the pandemic. In March 2020, the company created the Vital Resources Fund to offer financial support in communities hit hard by the pandemic and to help organisations and businesses participate in economic recovery. By July 2021, the fund had delivered AU$50m (US$37.3m) to 89 organisations, reaching more than 700,000 people, including 140,000 Aboriginal and Torres Strait Islander people.
In Brazil, beverage company Ambev’s COVID response included working with local partners to build a permanent 100-bed annex at São Paulo’s Municipal M’Boi Mirim Hospital, which serves two impoverished communities, in just 35 days. The company also committed to donating more than 1.4m litres of potable water to 140 communities in São Paulo and Rio de Janeiro under its mineral-water brand AMA, which uses its profits to bring water to those who don’t have it.
Now is the time to act on health inequities. COVID-19 is very much still with us. But in the past two years, we’ve learned valuable lessons—and developed powerful treatments and technologies—that we can use to prevent ourselves from slipping backwards and that can extend to a range of difficult health challenges that the pandemic exacerbated.
Efforts to address the social determinants of health that drive health inequity will require ‘smart, timely and future-focused investments,’ as PwC New Zealand notes in a recent report. But the investment ultimately will yield returns. At the level of the individual, this would mean better health and social outcomes for all—ultimately living longer in good health, with more equity across communities. Employers would benefit from savings generated by having a healthier workforce—from improved productivity and fewer days of missed work.
Healthier populations with a lower chronic-disease burden would help payors, including governments, by lowering healthcare spending. Healthcare providers could broaden access for their services, delivering them with higher levels of productivity and better alignment with purpose. Pharma life sciences players could better target their R&D and products and solutions, achieving higher levels of adherence and improving outcomes. At a time when ESG has become a front-and-center issue, making this investment presents an opportunity to stand out among consumers and to offer an example that other industries could follow.
The lessons learned from the pandemic—that data is the first step, that approaches must be tailored to the community, that digital technology is an essential tool and that partnerships amplify impact—offer a pathway to reducing the impact of the social determinants of health that drive health inequity. Building this approach into existing offerings and into the development of new products and services would give healthcare organisations the opportunity to live their core values.
The pandemic illustrated just how integral the healthcare industry is, not just to human health but to the health of economies and society as a whole. As a result, action taken now to address inequity in healthcare would feed into an even broader payoff in terms of better health, social and economic outcomes as the world works to become more resilient to public health challenges and emergencies.
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Gavin Brown of PwC Australia, Jenny Colapietro of PwC US, Philip Sclafani of PwC US, Tamati Shepherd-Wipiiti of PwC New Zealand, Ana Bidois of PwC New Zealand, Etienne Dreyer of PwC South Africa and Bruno Porto of PwC Brazil also contributed to this article.