COVID-19 and Health Inequalities

The International Conference on COVID-19 2022 was hosted by BRAC James P Grant School of Public Health (JPGSPH) and the Bangladesh Health Watch (BHW). This was an opportunity to discuss, debate and document experiences of the COVID-19 pandemic across low-and middle-income countries. Lynda Keeru and Kate Hawkins report back.

The conference covered:

  • Evidence and lessons learned from the pandemic, which populations were impacted the most, livelihood and health vulnerabilities
  • The response of governments and health systems to containment and vaccine delivery
  • The effects of risk communication and the efficacy of local and national level data systems to aid and guide government decision-making

In the opening speech, Matshidiso Moeti, WHO Regional Director for Africa painted a very clear picture of the current situation:

“There have now been more than 10.4 million, that is almost 10 and a half million cases, of COVID-19 and over 234 000 lives sadly lost in Africa due to the pandemic. Vaccination remains our best defense against severe illness, death and overwhelmed health systems, along with other WHO-approved prevention measures, such as wearing masks consistently and correctly, as well as handwashing. So long as the virus continues to circulate, further pandemic waves are inevitable. Africa must not only broaden vaccinations, but also gain increased and equitable access to critical COVID-19 therapeutics to save lives and effectively combat this pandemic. African countries face major impediments in accessing a full range of COVID-19 treatment, due to limited availability and high costs. The deep inequity that left Africa at the back of the queue for vaccines must not be repeated with these life-saving treatments. Universal access to diagnostics, vaccines and therapeutics will pave the shortest path to the end of this pandemic.”

Speakers captured the situation in different contexts and offered recommendations from their divergent experiences. A selection of these presentations are highlighted below.

Caroline Kabaria: COVID-19, A driver of marginality in Nairobi’s informal settlements

Caroline presented work under the ARISE project. In Kenya research is being conducted in Korogocho, Viwandani and Mathare informal settlements. Slum statistics are often invisible/usually hidden in usual statistical sources such as the census. They are often lumped together with the general urban population in the data. This makes it hard to understand the actual situation of the urban poor who live within communities in the city. This can imply that slum communities are doing better than they really are.

There is a lot of danger in misrepresenting slum statistics by averaging with the regular urban statistics. For example, coverage of vaccination of children can appear as very high within urban areas, but within the same city in the slums, it is quite low. Providing municipalities, city managers, countries, NGOS, donors and policymakers with more granular data, helps them to prioritize interventions and investments.

Slum dwellers really depend on pharmacists and private providers with less utilization of public facilities. Most of the population spends out of pocket for consultation, medicines and other medical expenses. COVID-19 had a big impact on this population because majority of residents rely on the informal economy and staying at home meant losing their jobs and sources of livelihood. The pandemic disrupted this community’s access to healthcare and the lack of appropriate information on COVID-19 only made the situation worse. Many of the slum dwellers are illiterate and they reported difficulties in interpreting the COVID-19 messaging.


There is a need for financial and risk protection innovations due to high out-of-pocket expenditure. It is also necessary for health systems and practitioners to collaborate with other sectors. More bottom up leadership approaches are needed. It is very important to empower communities to demand accountability from their leaders and service providers. The quality of primary health care and its linkages with allied and tertiary services is of utmost importance. Disaggregation of the deprivation of slum residents makes it easier to highlight issues of importance for people who live in slums and focus attention on these issues for policy makers. Caroline reiterated that investments in policies, programs and research requires slum-specific data systems.

Brunah Schall: Sexual and reproductive health during the COVID-19 pandemic in Brazil

Brunah’s presentation focused on sexual and reproductive health during the pandemic in Brazil. The neoliberal reforms introduced in 2016 reduced investments in the national public healthcare system. There was an uncoordinated response with the federal government pursuing heard immunity as a strategy and invested in an ‘early treatment kit’ that has no scientific basis. Preliminary results of research indicate reduced and closed sexual and reproductive health services, high attrition of sexual and reproductive health professionals, interruption of (infertility, breast and cervical cancer) treatment and investigation and difficulty in accessing pre-natal services among others.


The study illuminates the importance of real-time data in order for policy makers to act. Circulation of correct information is key to avoid misinformation and the damage it causes.

Lilian Otiso: How Kenya’s health system adapted to COVID-19

The Kenyan government response, like many other countries, included national curfews, restricted movement in some counties, closure of (schools, bars and restaurants), fewer people on public transport, compulsory wearing of masks and people being asked to stay at home. Albeit with a few challenges, the health system’s response to the pandemic was quite efficient. It took a multisectoral approach with the coordination led by the government. There was a lot of community involvement, particularly by bringing on board community health workers who bridged the gap between communities and the health system.

The country ran major information campaigns with centralized real time data that recognized the needs of the vulnerable. The pandemic provided an opportunity and many innovations were coined such as digital technology (e-learning, remote working, online meetings, tele-consultations, tele-counseling), local manufacturing (PPE, beds, ventilators), courier services to deliver drugs and multi-month prescription for chronic diseases.

Even with the many impressive innovations, there were challenges. The poor, vulnerable and marginalized were left worse off. There was limited access to other health services, misinformation about the pandemic that spread, mistrust of the government by the citizens, increase in gender based violence and teenage pregnancies and a rise in mental health challenges. Noteworthy, most of these challenges were addressed by involving community members in the response.


Successful efficient health systems responses to pandemics require public health responses with government coordination and multi-sectoral engagement. Community engagement is critical to address trust and misinformation in order to reach the vulnerable and encourage accountability. Health systems must encourage and nurture innovation as a means to remaining adaptive and resilient.

Sushil Baral: Rethinking primary healthcare after the pandemic

Health is a fundamental human right and Universal Health Coverage (UHC) is critical to achieving this right. Strong primary health care is the foundation of quality health systems that lead to UHC. UHC aspires to achieve good quality healthcare for everyone without them incurring financial hardship. Primary health care is important in bringing this goal to life because it is the first level of contact for individuals, families and communities with healthcare. It is an integral part of a country’s health system as it focusses on the health and wellbeing of its people including their social and economic development. It is important for quality healthcare to be available and at a cost that the community and country can afford to maintain at every stage. It should be practical, scientifically and technologically sound, socially acceptable and accessible to individuals and families.

Strengthening primary health care is a ‘hard grind’ task that involves multiple sectors and requires strong leadership. Adaptations that were made in health systems during the pandemic are unlikely to last if basics are not addressed. Continuity should remain a priority. Finally, the health workforce and community are the most fundamental elements to primary health care robustness and a lot of investment must be pumped into them.

If a paradigm shift is not taken, there is a real danger that COVID-19 will increase inequalities.


The pandemic’s response to this crisis must be designed to mitigate this by taking account of the ways in which some people bear the brunt of multiple impacts. Those hardest hit by the pandemic tend to be those already most disadvantaged. In order to recover, policy must also take a long-term view and consider the long-standing impacts of the pandemic.