September 27, 2023

Intersectional evaluation and motion are wanted to arrange for future pandemics and guarantee extra inclusive well being companies, say Mamothena Mothupi and colleagues

Globally, authorities responses to the covid-19 pandemic bolstered prevailing patterns of privilege and prejudice and additional entrenched the inequitable distribution of well being and illness in several populations.123 These patterns mirror how the legacies of historic discrimination mix with current energy constructions to form, condone, and proceed social drawback and the unequal distribution of assets. Evaluation of those inequalities inside well being methods from the angle of intersectionality may also help us perceive their drivers and discover options to scale back them. Tackling these inequalities may also assist rework well being companies for improved pandemic preparedness.456

Intersectionality “promotes an understanding of human beings as formed by the interplay of various social areas, for instance, race, ethnicity, indigeneity, gender, class, sexuality, geography, age, incapacity/means, migration standing, faith. These interactions happen inside a context of linked methods and constructions of energy, for instance, legislation, insurance policies, state governments, non secular establishments, and the media. By means of such processes, interdependent types of privilege and oppression formed by colonialism, imperialism, racism, homophobia, ableism, and patriarchy are created.”7 Whether or not deliberately or unintentionally, these processes result in mixed and therefore deeper inequalities (for instance, single minority adolescent ladies who’re additionally refugees), which range by time and context and have penalties for the effectiveness of well being companies, notably throughout crises.

The World Well being Group recommends guaranteeing healthcare entry for marginalised populations and assist for the well being workforce as a key a part of pandemic preparedness and responsiveness.8 On this paper, we use intersectionality to raised perceive the well being inequalities that characterised covid-19 and put ahead rules for making post-covid-19 well being companies extra conscious of correcting such inequalities. We argue that well being companies should be extra deliberately inclusive, guard towards unintended exclusionary penalties of well being measures, and spend money on analysis and knowledge methods to raised perceive and reply to intersectional inequalities. Key to those efforts is extra significant motion to empower the folks on the core of the cocreation of well being: healthcare customers and employees. Their participation is especially essential if we’re to sort out the intersectional inequalities uncovered by the pandemic, which proceed to undermine well being and justice.

Well being service supply should be deliberately inclusive

Supply of well being companies throughout the covid-19 pandemic was typically characterised by top-down approaches to determination making. Authorities evaluations of coverage responses in 18 international locations of the Organisation for Financial Co-operation and Growth throughout the first 15 months of the pandemic recommended varied well timed and constructive responses. Nonetheless, the evaluations additionally revealed challenges in well being service supply and entry, together with insufficient coordination with native actors on testing and speak to tracing for covid-19, poor communication with the general public on well being service continuity, and restricted authorities capability to adequately determine and supply assets for weak folks.9 These coverage responses weren’t solely disconnected from the realities on the bottom, however have been additionally exclusionary to folks with a number of context particular disadvantages, a lot of whom already distrusted the federal government due to their historical past of exclusion and discrimination. Recognising and resolving such disconnects just isn’t new.

Understanding the views of marginalised communities, their contextual priorities and customs, and fears given their prior interactions with the state was important in previous outbreaks10 and with covid-19 as nicely.1112 As such, WHO recommends neighborhood engagement as essential to battle disinformation throughout and after pandemics.8 Past occasions of disaster, participatory fashions for interventions are efficient in enhancing well being,13 and WHO has detailed steerage on how neighborhood views, participation, and empowerment assist increasing common well being protection.14

Marginalised neighborhood members who wanted well being companies weren’t the one ones excluded from pandemic determination making and planning. Decrease tier well being employees, who typically expertise a number of, intersecting types of marginalisation, have been additionally excluded from these processes. For instance, neighborhood well being employees (CHWs) in Brazil, who’re predominantly black, feminine, and dealing class, have been successfully omitted of early pandemic responses that prioritised medical companies. Consequently, these well being employees have been left with much less entry to private protecting gear (PPE), coaching, testing companies, and supervisory assist.1516 The ensuing dangerous working circumstances made it unattainable for the CHWs to work together with communities and guarantee continuity of companies. This case due to this fact jeopardised a key neighborhood useful resource valued by marginalised customers who depend on CHWs due to the numerous limitations to entry of well being companies that they face, which have been made worse by covid-19.17 Inadequate consideration to the wants of CHWs within the covid-19 response was frequent in lots of international locations.18

Given the elevated dangers and stresses well being employees have been uncovered to in several international locations, they led advocacy efforts to enhance their working circumstances. In a couple of cases, their efforts resulted in essential modifications. In Spain, hospital cleaners have been in a position to organise and assert their proper for vaccination as a part of the at-risk class of individuals prioritised for vaccination.19 In South Africa, CHWs have been final on the checklist for receiving PPE, however by way of their self organising boards and unions, they started strikes and protests to battle to alter this example.20 In Malawi, because of sit-ins in central and district hospitals and civil society activism, greater than 12 000 CHWs in hard-to-reach areas of the nation have been lastly supplied with PPE.21 In India, lots of of 1000’s of accredited social well being activists (ASHAs) (feminine CHWs) organised sit-ins, protesting their delayed funds, lack of well being protection, and undervalued contributions to the pandemic response.22

All through efforts to offer voice to probably the most marginalised folks and guarantee they’re included in pandemic responses, researchers and public well being determination makers additionally want to think about: which teams are engaged; what the facility hierarchies are that configure these teams; whether or not their actions are creating or entrenching drawback and lack of belief; and whose voices will not be represented.

Well being companies could exclude or discriminate in unintended methods

In responding to covid-19, many governments did in truth implement insurance policies and methods to attempt to sort out inequalities in entry to and supply of well being companies. Nonetheless, the advantages weren’t all the time out there to everybody. For instance, in southern Rajasthan, India, well being and social safety insurance policies associated to the pandemic have been applied to mitigate the results of covid-19 and covid-19 lockdown measures.23 Nonetheless, if the insurance policies thought-about ladies’s wants, they did so on the idea that the experiences of all ladies have been the identical. However, some migrant ladies and feminine headed households have been nonetheless inadequately reached as a result of they have been notably deprived as a result of illiteracy, financial constraints, restrictions on mobility, poor illustration in native authorities, and corrupt service suppliers, along with patriarchal norms.23 Thus, even when inclusive insurance policies exist, an intersectional strategy requires time and suppleness for service managers to actively monitor its impact on marginalised teams and, in session with finish customers, proactively develop revolutionary modifications to beat the limitations created by enduring unfair methods.

Equally, human assets reforms inside the well being sector, together with these produced by advocacy efforts of well being employees, don’t all the time end in advantages for all well being employees.192021 Whereas the phrases of employment and difficult working circumstances of nurses have been extensively mentioned, analysis is missing on the experiences inside this group which are formed by the intersection of race, ethnicity, gender, and migration amongst different elements and the measures wanted to make sure fairness amongst nurses.2425

Whereas advocacy for improved working circumstances for well being employees throughout the covid-19 pandemic had some success, general unionisation is much less frequent as one strikes down the well being workforce hierarchy, whether or not when it comes to occupational hierarchy or migrant standing.19 Moreover, employees on the decrease ranges of the well being workforce usually tend to face authorities backlash once they attempt to organise efforts to attract consideration to their issues. For instance, in India, protesting ASHAs had police reviews filed towards them.22 Past applause and symbolic recognition of their contributions, well being employee and civil service reforms are required to formalise the work of neighborhood and auxiliary employees and enhance funding within the well being workforce to ensure equitable baseline work circumstances.162122 To result in such reform requires engagement with authorities throughout ministries of well being and training and medical boards that regulate well being employees; funding examples to tell ministries of finance; and advocacy that reframes funding for well being employee salaries and dealing circumstances not as a value however as an funding in a necessary asset for pandemic responses and well being companies in useful resource constrained settings.

Analysis and knowledge methods should prioritise intersectionality

Analysis with an intersectionality strategy remains to be uncommon, nevertheless it has the potential to offer an understanding of the damaging penalties of pandemic responses on marginalised folks and methods to mitigate these penalties. Such analysis can higher point out who’s omitted from pandemic responses and why. For instance, analysis in India confirmed how a number of types of discrimination impeded entry to welfare measures throughout covid-19 for poor, indigenous (tribal) ladies.23 In Canada, an intersectional evaluation of things that affected entry of minority immigrants to emergency/pressing care sought to know migrant and refugee ladies’s expertise of gender primarily based violence throughout the pandemic.2627 A cohort research inspecting the intersectionality of weight problems, power illness, social elements, and incident threat of covid-19 amongst low earnings, center aged minority moms in the US confirmed who was being omitted by present measures and was most susceptible to covid-19.28 Regardless of these examples, little major analysis has been carried out that provides contextualised details about how pandemic measures affected well being customers and well being employees. This data may information intersectional methods to make sure equitable well being companies and outcomes for marginalised folks.

Well being researchers and determination makers are at the moment restricted by the info out there from well being data methods and surveys which don’t lend themselves to intersectionality evaluation. Fundamental intercourse disaggregated knowledge reported by nationwide well being data methods are sometimes missing. By November 2022, solely 85 of 206 international locations reported intercourse disaggregated evaluation of confirmed covid-19 instances and 39 reported intercourse disaggregated knowledge on deaths within the earlier two months.29 Whereas well being data methods do routinely gather knowledge on age and intercourse, even when they inconsistently report on them,30 different sources of information are wanted to trace broader structural and systemic drivers of inequality.

Coverage makers and determination makers accountable for well being methods should enhance efforts to gather and report disaggregated affected person knowledge, in addition to strengthen extra holistic knowledge assortment instruments and reporting for human assets for well being.30 An essential first step will likely be for well being system designers and implementers to construct capacities inside well being methods to gather, analyse, and use intersectional knowledge and, importantly, to know and handle further moral issues about knowledge on weak populations. Newly developed instruments to use intersectionality may also present a information to tackling inherent biases inside synthetic intelligence fashions and algorithms by incorporating gender and intersectionality in knowledge system funding and knowledge assortment, processing, evaluation, and use.31

Qualitative and quantitative strategies may also be used collectively for a holistic evaluation of the intersecting elements that affect well being service entry and outcomes.30 With higher knowledge, researchers can analyse intersections of benefit and drawback in well being entry and make suggestions to cope with structural and energy dynamics in particular contexts. You will need to transcend speedy descriptive parts of social elements (for instance, age, intercourse, race, and earnings) to look at the insurance policies and political and financial drivers of such disadvantages.32

Intersectionality can present the way in which ahead

Present well being inequalities come up from historic marginalisation of various teams of individuals throughout a number of axes of discrimination. If we proceed to disregard these a number of, interconnected, and context particular types of drawback, well being companies will all the time fall brief on their targets. An intersectionality primarily based strategy may also help enhance pandemic preparedness and response and create higher well being methods to determine and reply to marginalised well being employees and healthcare customers.

Healthcare customers, and the employees who serve them, are the guts of well being methods. To raised embody marginalised well being employees and healthcare customers, researchers and determination makers want to think about their complicated social positions, the limitations to their engagement with well being companies, the facility methods and constructions that create these limitations, and how you can overcome them. This strategy would empower healthcare customers and well being employees and permit them to advocate for a reworked and inclusive system that leaves nobody behind. As a method ahead, governments and well being system planners ought to study and enhance their capacities to incorporate marginalised folks in future pandemic preparedness and response as a part of well being methods transformation and justice. Basic modifications are wanted together with significant engagement with marginalised healthcare customers and employees, improved working circumstances for marginalised well being employees, and improved well being intelligence and knowledge methods. These modifications, supported by decentralised administration to permit innovation regionally, would assist strengthen well being methods for all.

Key messages

  • The impact of intersecting methods of privilege and prejudice on the experiences of healthcare customers and well being employees throughout covid-19 should be thought-about for future pandemic preparedness

  • Marginalisation just isn’t uniformly skilled and it modifications over time, thus well being companies must be extra inclusive

  • Utilizing an intersectionality strategy is essential to enhance well being system governance capability to have interaction with marginalised healthcare customers and employees to sort out context particular issues

  • The views of healthcare customers and employees should be meaningfully built-in within the well being system transformations wanted to arrange for the subsequent pandemic


Contributors and sources: MM was a gender and well being postdoctoral researcher engaged on an intersectionality in analysis throughout the drafting of this manuscript. Her background is in well being methods and coverage analysis. AG is a gender and well being methods researcher who co-led the gender and covid-19 analysis agenda setting course of. SJ is a well being economist and was the coordinator for this thematic group on service supply inside the bigger collaboration to set analysis agenda priorities for gender and covid-19. JD is a researcher with over 20 years of labor on gender and well being fairness in marginalised communities in addition to coverage analysis. JS is a researcher and advocate with over 10 years’ experience in gender, ladies’s well being, HIV, and sexual and reproductive well being and rights. KB is a doctor and public well being practitioner with 20 years of analysis, advocacy, and implementation work on sexual and reproductive well being and gender fairness. SV was former researcher with the ReBUILD and RinGs consortiums and a member of Rising Voice for International Well being. EB has labored in gender and intersectionality and well being financing interventions and the gendered nature of well being methods. MM led the evaluation, wrote the unique draft and revisions with substantial enter from AG and JD. AG finalised the final revision after editorial enter from the BMJ. SJ, JS, KB, SV, and EB supported revisions and permitted the ultimate model. MM is the guarantor.


  • We thank Michelle McIsaac for her substantive contributions to the manuscript. We additionally thank Prabha Thangaraj as colead of the thematic group of well being service supply throughout the analysis agenda setting technique of the UNU-IIGH Gender and Well being Hub and different thematic group contributors (in alphabetical order): Avni Amin, Emilia Antonio, Bernadette Ateghang-Awankem, Vidyadhar Bangal, Kavita Bhatia, Anjana Bhushan, Linget Chepuka, Adanaa Chukwuma, Heather Doyle, Teresa Farinha, Veloshnee Govender, Kathryn H Jacobsen, Anuj Kapilashrami, Anthony Keedi, Rajat Khosla, Karen Lawford, Fui Ching Lum, Stephen Mulupi, Kui Muraya, Gustavo Nigenda, Sarah Nurain Mohd Noh, Awatef Amer Nordin, Mariam Otmani del Barrio, Ranjini Raghavendra, Maryam Rumaney, Ephram Senkyire, Sagri Singh, Claire Standley, Lavanya Vijalakshmi, Wincent Wagner, and Sophie Witter. AG is supported by the South African analysis chair’s initiative of the Division of Science and Know-how and Nationwide Analysis Basis of South Africa (grant no 82769) and the South African Medical Analysis Council. The views on this article are these of the writer and the Nationwide Analysis Basis doesn’t settle for any legal responsibility on this regard.

  • Competing pursuits: We have now learn and understood BMJ coverage on declaration of pursuits and don’t have any related pursuits to declare.

  • Provenance and peer evaluation: Commissioned; externally peer reviewed.

  • This text is a part of a group proposed by the United Nations College and the College of the Western Cape and commissioned by The BMJ. The BMJ peer reviewed, edited, and made the choice to publish these articles. Article dealing with charges are funded by Invoice and Melinda Gates Basis and UN College-Worldwide Institute for International Well being.


  1. World Well being Group. Constructing well being methods resilience for common well being protection and well being safety throughout the COVID-19 pandemic and past. WHO place paper. 2021. with/10665/346515

  2. Llop-Girones A, Vracar A, Eder B, et al. A political economic system evaluation of the influence of Covid-19 pandemic on well being employees. 2021.

  3. Folks’s Well being Motion. Well being methods within the context of Covid-19 – remaining case research submissions from international locations. 2021.

  4. Folks’s Well being Motion. Malawi case research: CSO covid-19 response activism on provision of PPE, threat allowances for frontline well being employees and inclusive covid-19 response bears fruit in Malawi. 2020.