As the COVID-19 pandemic swept over the United States, the stark observation that African-American, Hispanic and Native American populations were disproportionately affected was met with justified shock and anger. After all, the United States has the world’s largest economy, a high standard of living and a sophisticated health care system and is often held up as a model for many countries.
This narrative of wealth and advanced development obscures very real societal fracture lines resulting from systemic discrimination based on racial, ethnic and socio-economic characteristics. Discrimination that locks significant groups of people out of services and resources has resulted in striking disparities in wealth and health. Prior to the 2010 enactment of the Affordable Care Act, 50 million Americans were uninsured and 39 percent of low-income Americans reported not seeing a doctor because of cost.
Disparities are not unique to the United States; they are a phenomenon in many countries at various stages of economic development. Yet, disparities can be reduced when there is political will.
There have been notable successes since the establishment of the Millennium Development Goals (2000-2015) and the Sustainable Development Goals (2015-2030), which tackled inequalities by setting clear targets and deadlines. For example, the percentage of the world’s population living in extreme poverty declined from nearly 36 percent in 1990 to 10 percent in 2015. The global mortality rate for children under five years of age dropped by 59 percent from 1990 to 2019, thanks to increased access to immunization, adequate nutrition, safe water and food, and appropriate care by a trained health provider when needed.
Are there effective approaches proven to reduce disparities that the United States can adapt? Yes. As an international development organization, FHI 360 often designs programs tailored to remove barriers to access in various sectors, such as education, economic and civil society participation, health and nutrition. These international programs target populations with the highest needs who are often discriminated against on the basis of gender, sexual orientation, ethnicity or geography.
Drawing on international best practices, here are four guiding principles in our program design, with possible adaptations for the United States.
Involve all relevant stakeholders from the beginning for greater ownership and sustainability (the “nothing for us without us” principle).
- The trust deficit between minority communities and the health system in the United States is an entrenched barrier, making this principle critical to success. An investment in identifying stakeholders, recruiting champions from local communities and equipping them with skills to design, implement and monitor service delivery is needed.
Use locally relevant evidence to push for policy change. Examples might be decriminalizing sex work and drug use, abolishing user fees for health or education services or task shifting among the health workforce so that less specialized workers can take on additional responsibilities.
- For decades, the U.S. Centers for Disease Control and Prevention has conducted studies on national disparities, leading to policies like the National Partnership for Action to End Health Disparities. Yet, gaps persist. Innovative ways of localizing data ownership and use is important to ensure sustainability.
Distribute resources to favor hard-to-reach or marginalized groups. An analysis of epidemiologic and site-level program data ensures we deploy resources proportional to the documented need.
- Equitable resource allocation by need ensures that the health of communities is not determined by zip code or preexisting conditions. Developed countries that have universal health coverage have substantially better health outcomes than the United States. Globally, the President’s Emergency Plan for AIDS Relief (PEPFAR) achieved impressive results in many lower- and middle-income countries: Some countries will reach HIV epidemic control in 2020.
Include human-centered design and differentiated models of service delivery. Our programs acknowledge that health-seeking behavior is determined by complex factors, with different groups of people (e.g., youth, seniors, working mothers, stigmatized LGBTQ) having different preferences for service providers, the type of service or where and when it is offered.
- Many of FHI 360’s programs offer a menu of services to accommodate preferences, including fast-tracked queues, multimonth prescriptions, online services, mobile or outreach sites, peer-led services, self-care and home-based service delivery. This array of options allowed our programs to provide services uninterrupted during the COVID-19 lockdown. The United States should invest in options that take free services to the patients in minority communities, using appropriate technologies.
The United States could benefit from interventions that have worked overseas by examining underlying causes and engaging affected communities in the process of investing in fixes. In low- and middle-income countries, FHI 360 programs work to revise harmful norms in sensitive areas of patriarchy, sexuality, reproductive health and rights, gender identity and gender justice. Similarly, U.S. society will have to face and correct the trust deficit with minority communities and adopt the “nothing for us without us” principle, entrusting communities with the resources needed to address local challenges. Conversations about the advantages of universal health care policies are currently underway. These conversations can serve as a springboard to addressing disparities across all societal fracture lines.
To learn more about FHI 360’s work related to lessons learned from other countries, please see our R&E Search for Evidence blog, which includes a link to a separate research report published last year.