• Systemic factors mean those on lower-incomes are being disproportionately affected by the COVID-19 pandemic.
  • Tackling this inequity will involve reforming the way we think about, finance and deliver health, beyond solely healthcare.
  • Investment in education and workforce development can play a large part in improving health through access to healthcare and healthy environments.
  • Here are 3 strategies for delivering this systemic reform.

We have reached a breaking point. COVID-19 has unmasked and amplified systemic inequities and failures in our society.

Before the pandemic, global societal injustices such as structural racism and poverty made populations more vulnerable to disease. Driven by unequal access to education, employment, healthcare, healthy food environments and active living opportunities, lower-income population groups have greater exposure to disease and health risks, and are far more likely to be exposed to diseases such as COVID-19. They are more likely to work essential jobs as delivery drivers, janitors, or gig workers, which precludes them from sheltering in place.

The same population groups also face a pre-existing and disproportionate burden of chronic diseases such as diabetes and heart disease that put them at higher risk from COVID-19 complications. Many live in overcrowded spaces or substandard housing that make social distancing and other precautions more difficult to follow. They have poorer access to health-enabling environments, such as public spaces, and to healthy food environments, which further amplifies their vulnerability through higher exposure to obesogenic environments.

For many, the precarity of their work limits their access to healthcare, either due to an inability to take time off to seek care without financial penalty or fear of job loss, or to the unaffordability of healthcare. This is particularly true in countries like the US, where healthcare access is tied to employment and where most blue-collar jobs fail to provide affordable, quality health insurance.

These interrelated factors and structural racism act synergistically, resulting in significant short and long-term pandemic-related consequences for population groups already facing discrimination and experiencing poorer health outcomes pre-COVID-19. Globally, millions now struggle with the fallout of the pandemic — losing their jobs and incomes, facing health risks at work, and being deprived of basic needs like food, housing, and healthcare. To this end, housing, environments, employment and healthcare can all be considered as part of the systems for health by virtue of their impact on health outcomes.

At this critical moment, we need to evaluate the underlying structural and systemic barriers impacting millions of people, particularly those who are bearing the brunt of the pandemic. To rebuild our society, we cannot treat health as an isolated issue. We need to treat it in the context of entire systems for health; multisectoral action is required to prevent disease and create health equitably.

A vaccine won’t cure these systemic problems

The conditions that have brought us to this breaking point will continue to worsen. The world is racing to find a vaccine; but even after one is developed, these systemic problems will continue to deepen.

Financial insecurity continues to grow as many countries enter a deep recession. Marginalized populations faced financial insecurity long before the pandemic struck. Unemployment, cutbacks to social welfare systems and a widening income gap will continue to exist even after a vaccine is found.

Automation will accelerate job loss. These technologies are being programmed to do routine tasks historically associated with blue-collar labour. This has threatened to put millions of factory workers, retail salespeople, cashiers and others out of work.

Healthcare systems will continue to struggle to meet growing demand. Without concerted efforts to prevent disease by addressing the social determinants of health – the majority of which lie outside the healthcare sector – global healthcare systems will struggle to keep up with the growing demand caused by poor physical and mental health. This is further compounded by financial and job insecurity.

In the US, those living in higher-icnoem areas were able to halve their movement days ealrier than thsoe in lower-income areas
In the US, those living in wealthier areas were able to halve their movements days earlier than those in lower-income areas
Image: The New York Times

The interlinkages between these problems threaten to further widen health and wealth inequality globally. We can address these problems by considering not only investments in healthcare, but investments in entire systems for health. One important approach to addressing these systemic threats to wellbeing is through equitable access to training for high-skilled jobs to improve financial security and protect health.

Education and workforce development interventions can mitigate health and social risks in the long term by creating pathways into stable, well-paid jobs. Of note, growing skills and human resources for the pivot towards sustainable economies and societies could further address the planetary health risks we collectively face. As such, access to responsive education and training is an important human and planetary health-creation system. The current crisis highlights the need for new, well-financed solutions that can lift millions of people out of poverty and poor health. Put simply, health and wealth are inextricably linked. However, current financing for workforce training programmes that move marginalized audiences from low to high skill, at the scale of need required, are limited. Organizations such as Pursuit are only able to serve a fraction of those in need. To invest in health, we must invest in programmes that provide these opportunities.

Investing in health by investing in opportunity

We need to redesign the economic systems that underfund health and workforce development and compromise human and planetary health. We propose three strategies:

1) Governments must commit significant public funding: The pandemic response has highlighted the crucial role of government spending in protecting health. Building on these lessons, governments should channel significant resources into education and job training for lower-income and marginalized population groups.

2) Capital should be deployed through diverse sources: Even with increased public funding, as well as existing philanthropy, financing will be insufficient to meet the scale of the need for education and training. That’s why we must also leverage the wealth of capital markets. This includes impact or mission-driven investments that are designed to deliver concrete social and sustainable returns as well as financial returns.

3) Systemic solutions are needed to solve systemic challenges: Systems are only as effective as the purpose for which they are designed. In this vein, redress will require all systems for health, including education and workforce development to have the explicitly stated goals of equitable human health and planetary wellbeing. Within this framing, funding should then be aligned with positive results cognisant of the need to also address the broader context of societal injustices and structural racism. That way, in the context of education and workforce development, we can equitably deploy resources in a way that incentivises high-quality, outcomes-based training.

COVID-19 is a systemic challenge, and it will require systemic solutions that may previously have been considered radical. We cannot wait any longer to tackle this crisis. The COVID-19 pandemic has magnified society’s failure to provide economic opportunity for the most vulnerable. It is an urgent issue that requires emergency health foresight that supports the development of resilient, sustainable and holistic systems to health-proof our collective futures. It requires a new societal plan to define – and consequently finance – health. We must invest equitably, not only in healthcare but also in healthy environments, housing and dignified work to measurably create health for all.