key: cord-0697817-79oszzon
authors: Barron, Gabriela Cuevas; Laryea-Adjei, George; Vike-Freiberga, Vaira; Abubakar, Ibrahim; Dakkak, Henia; Devakumar, Delanjathan; Johnsson, Anders; Karabey, Selma; Labonté, Ronald; Legido-Quigley, Helena; Lloyd-Sherlock, Peter; Olufadewa, Isaac Iyinoluwa; Ray, Harold Calvin; Redlener, Irwin; Redlener, Karen; Serageldin, Ismail; Lima, Nisia Trindade; Viana, Virgilio; Zappone, Katherine; Huynh, Uyen Kim; Schlosberg, Nicole; Sun, Hanlu; Karadag, Ozge
title: Safeguarding people living in vulnerable conditions in the COVID-19 era through universal health coverage and social protection
date: 2021-12-11
journal: Lancet Public Health
DOI: 10.1016/s2468-2667(21)00235-8
sha: 7bbe85e64f7f6f690a98fc71bae9838f1f7cda46
doc_id: 697817
cord_uid: 79oszzon

The COVID-19 pandemic is unprecedented. The pandemic not only induced a public health crisis, but has led to severe economic, social, and educational crises. Across economies and societies, the distributional consequences of the pandemic have been uneven. Among groups living in vulnerable conditions, the pandemic substantially magnified the inequality gaps, with possible negative implications for these individuals' long-term physical, socioeconomic, and mental wellbeing. This Viewpoint proposes priority, programmatic, and policy recommendations that governments, resource partners, and relevant stakeholders should consider in formulating medium-term to long-term strategies for preventing the spread of COVID-19, addressing the virus's impacts, and decreasing health inequalities. The world is at a never more crucial moment, requiring collaboration and cooperation from all sectors to mitigate the inequality gaps and improve people's health and wellbeing with universal health coverage and social protection, in addition to implementation of the health in all policies approach.

The COVID-19 pandemic is unprecedented. The pandemic not only induced a public health crisis, but the necessary measures to contain the virus's spread have led to severe economic, social, and educational crises. 1 Across economies and societies, the consequences of the pandemic have been uneven. We synthesise the evidence on the ways the pandemic has further exacerbated the negative situations of vulnerable populations (ie, those living in conditions that create vulnerabilities), forcing further risks and inequalities on these groups. The world has arrived at a crucial moment, requiring a never more needed collaborative response to expand universal health coverage and social protection and build more resilient health and social protection systems, including those systems within humanitarian crisis settings, to mitigate this pandemic, address current inequality gaps, and enhance the resilience of vulnerable communities.

People living in vulnerable conditions include individuals who face systemic exclusion and discrimination based on their age, disability, race, ethnicity, gender, income level, religion, caste or creed, gender identity, sexual orientation, and migratory status, in addition to individuals who are caught up in conflict and are stateless, populations who are incarcerated, individuals with chronic health conditions (eg, mental illness), people living in inadequate housing, and people who are exposed to environmental degradation, air pollution, and at risk due to climate change. More work needs to be done to include those people living in vulnerable conditions and ensure none are omitted from efforts to protect and promote their human rights during this pandemic and the next health crisis. Hence, this Viewpoint identifies certain groups of people as being vulnerable, and essentially follows the established understandings and ontologies of vulnerability applied by global agencies.

Societies can promote changes that will improve or take people out of vulnerable situations. Moreover, governments can do what one individual cannot; they can transform unfavourable settings or conditions that decrease access to public services such as health, education, transportation, clean water, and sanitation into safe and health-promoting settings. Individuals living in vulnerable conditions are not homogeneous but do share a variety of disadvantages and risks. These populations are often invisible to governments, resulting in insufficient access to public services and economic compensation packages. 2 Evidence suggests that civil society and community organisations serving these populations have not had substantial input in government decision making in many places. 3 Including vulnerable and marginalised communities in decisions is crucial, because they can identify solutions, help ensure compliance, and tailor responses to meet the diverse needs of populations. 4 Official data on COVID-19 and non-COVID-19 health indicators among people living in vulnerable conditions are not publicly available in many countries. Thus, an underestimation of the severity and acuteness occurs. More disaggregated and standardised data are urgently needed to accurately inform action and public policies. To understand the specific effects of COVID-19 on people living in conditions of vulnerability, there is a specific need for more updated data collection on rates of hospitalisations, deaths, and other health and social wellbeing indicators disaggregated by income, gender, age, race, ethnicity, disabilities, and other variables. The search filters we used were article and publication type (included peer-reviewed journals, datasets, and reports from recognised international organisations; dates (included publications of COVID-19 published from March 11, 2020, to June 11, 2021; and language (included publications written in English or translated into English).

The pandemic has shown how various inequalities, which were wide and growing within and among countries long before the pandemic struck, are intricately linked. 5 Intersectionality examines how the markers of identity cross within the individual and how social groups, especially those who are vulnerable because of identity or social conditions, exemplify intersectionality within the grouping. As intersections, and how they interact with health and socioeconomic inequalities, are discussed, the global health community is better prepared to tailor health care, social protection, and empowerment accordingly within local, community settings and on a national level. COVID-19 infection rates and deaths are unequal, with the greatest hardship on those individuals living with intersecting vulnerabilities, since having more than one vulnerability leads to multiplicative or additive effects. 6, 7 The effect of COVID-19 on different population groups living in vulnerable conditions

The pandemic had an adverse effect on all sustainable development goals including goal ten, which specifically addresses inequality. To that end, systemic inequalities and unfair distribution of chances in life are leaving several groups living in vulnerable conditions and at higher risk of increased morbidity, poverty, and marginalisation during the pandemic than the general population. Direct effects of the pandemic put some groups at an increased risk of infection, serious illness, or death, whereas indirect effects are caused by the various restrictions essential to control the spread of infection. Although some groups have vulnerabilities that are common in both categories, the policy measures to safeguard these people can be different. We have identified some of the conditions that worsen the outcomes of COVID-19.

Mortality and severe illness caused by COVID-19 are strongly associated with older age (ie, those 65 years and older) and comorbid health conditions, 8 and COVID-19 has a disproportionate effect on older people. These effects are amplified by widespread discrimination against older people in the allocation of healthcare services. Older people in care facilities have accounted for more than half the mortality rate in many countries. 9 Older people are also highly exposed to the economic and social effects of the pandemic, especially in low-income and middle-income countries (LMICs). In 2018, only around 20% of people aged 60 and older received a pension in LMICs. 10 Fewer older people than young people live alone, which might limit social isolation during lockdown. However, contexts of crowded, substandard housing and family stress increase exposure to abuse and infection. In India, 56% of older people reported suffering abuse and claimed the abuse had worsened since lockdown. 11 Children (ie, those younger than 18 years) are also considerably affected by the indirect repercussions of the pandemic. Children, who are already twice as likely to live in extreme poverty compared with adults (ie, those 18 years and older), are seriously affected by the pandemic's poverty magnification. 12 Children also face threats to their wellbeing from interruption in essential services, particularly education. 195 countries imposed school closures, affecting more than 1·5 billion children and youth (ie, those aged 15-24 years). 13 These closures affect the education system with substantial social and health consequences (eg, education backslides, rising drop-out rates, compromised nutrition, and increased abuse and neglect). Millions of children with families under chronic financial duress struggle to obtain broadband access and the essential accompanying hardware to gain mentoring, making remote learning essentially not possible. Those children who were struggling educationally before the pandemic face further intol erable setbacks that might not be remediable, and extreme long-term adversities will require more extensive intervention and support. The impact of these setbacks on these children's futures is dire, and the implications of an increase in children unable to reach their full potential is extremely serious for societies.

Due to deeply entrenched gender inequalities and unequal power relations, the indirect effects of the virus have devastating effects on girls and women, exacerbating gender inequalities in health, economic, and social sectors. 14 The crisis has substantially increased the burden of care on women, who make up 70% of the paid health workforce worldwide. 7 Women's unpaid work at home has increased due to school closures, with work shifting from the paid economy to unpaid care for children. In 2021, women's employment declined by 5·0% whereas men's employment declined by 3·9%. Additionally, 90% of women who lost their jobs in 2020 exited the labour force, which suggests that their working lives are likely to be disrupted for an extended period unless appropriate measures are adopted. 15 Despite the 2280 fiscal, social protection, and labour market measures taken in response to COVID-19, only 13% target women's economic security. 16 For many girls, the pandemic has made life more challenging. 11·2 million girls and young women globally are at risk of not returning to care centres, schools, or universities due to the COVID-19 crisis. 17 This risk exposes girls and young women to an increased risk of violence, child marriage, female genital mutilation (ie, all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons), and HIV infection with limited or no access to services. Teenage pregnancies among outof-school girls and maternal mortality among all girls and women have increased due to a scarcity of crucial resources. Many women living in vulnerable conditions are experiencing increased violence as stay-at-home measures confine families and raise tensions. This increased violence has sparked a shadow epidemic of violence against women worldwide. 18 People with disabilities have experienced difficulties with taking prudent steps to protect themselves in addition to the pre-existing social inequalities that decrease their economic resilience during the pandemic. Racialised populations in all regions have been scapegoated for spreading the virus and have experienced incidents of discrimination, xenophobia, racism, and physical attacks. 19 The chronic and toxic stress from elevated levels of racism and other forms of discrimination put people at increased risk for COVID-19 and its consequences. 20, 21 Indigenous people also have a higher risk of infection with irreparable consequences because of a poorer baseline health status and less access to health-care and sanitation services than the general population. 22 Internally displaced people, including people in areas controlled by armed groups, refugees, asylum seekers, and those who are stateless and homeless, have more severe consequences because of circumstances putting them at risk, such as limited access to safe housing, safe workplaces, educational opportunities, sanitation, and health care than non-displaced individuals. 23, 24 The effect of COVID-19 on vulnerability by key social dimension

The pandemic has drawn economic inequality into sharp focus. Resource-poor communities are experiencing challenges in meeting people's basic needs, and working conditions are directly linked to different vulnerabilities. Some groups are disproportionately affected by the job cuts or furlough schemes caused by mobility restrictions and stay-at-home orders, and the informal economy makes it difficult for people to adhere to nonpharmacological interventions, to get tested, to isolate, and to obtain treatment when necessary, magnifying existing inequalities. 7 Absolute poverty was expected to rise, increasing the numbers of those in extreme poverty by as many as 500 million people globally by 2021. 25

Access to health care for non-COVID-19 health issues has decreased due to a mix of demand and supply chain disruptions. The most mentioned causes for service disruptions include cancellation of elective care, closure of population-level screening programmes, government transportation lockdown, and shift of staff to provide COVID-19 relief. In some countries, limited medical supplies has led to spiralling costs for patients, which has made health care unaffordable for many. 26 As access to essential services (eg, vaccinations, sexual and reproductive health care, child and adolescent health care, early detection and monitoring of non-communicable diseases, and mental health care) diminished and access inequalities widened, health problems continued to rise worldwide. 27 Existing neglect of social care provision for various groups and a failure to integrate related health services are responsible for a large share of morbidity and mortality in many countries and require urgent reform. 28 Access to clean water, sanitation, and hygiene equipment COVID-19 exacerbated the chronic shortage of clean water, sanitation, hygiene facilities, and equipment in many LMICs and in poor and marginalised communities in high-income countries. About 2 billion people live in countries facing water scarcity, mostly in LMICs. 29 The existing lack of water supply, sanitation facilities, and hygiene equipment magnifies the spread of COVID-19. The pandemic has also underscored the burden of water collection on women, who typically are the ones responsible for collecting water; many spending long hours collecting unsafe water, which exposes them and their families to risk. 30

COVID-19 has worsened a desperate global crisis of food insecurity and malnutrition. Food production and supply chains have been disrupted by the pandemic. Changes in food insecurity are also associated with Viewpoint Panel: Recommendations for the protection of vulnerable populations and reducing health inequities Recommendation 1: execute universal health coverage and social protection systems in every country • Governments with the support of UN agencies should commit to financing and executing a rapid expansion of universal social protection coverage. They should ensure that these systems are shock responsive, create contingency funding mechanisms for rapid scale-up, and develop operating systems, human resources, and training protocols that create the ability for rapid expansion of these programmes and policies. 40 • Implement universal health coverage, including access to primary health-care services that are fully integrated with social protection systems and community-based social care, with more attention paid to prioritising the needs of the most vulnerable. 42 Promoting health as a human right, the health systems and all of their components as national and international public goods, and the equitable distribution of COVID-19 vaccines on the basis of need rather than the ability to pay, is of the utmost importance. • Within the universal approach, governments should guarantee adequacy and inclusion such that health-care and social protection systems are gender responsive and inclusive of all vulnerable and marginalised groups. Coverage to support these groups both universally and on a needs-base, together with those in rural areas, should be included. Ensure that the civil society sector is included, and marginalised groups are able to meaningfully participate in decision-making processes. • Ensure universal health coverage reforms are financed publicly and progressively with services allocated according to need. • Create a global social protection fund to support countries that are unable to meet the fiscal needs of providing a universal approach to social protection programmes. 43 • In humanitarian contexts, use cash before in-kind assistance and build and strengthen national cash support systems. Channel cash support through national systems to ensure efficiency and sustainability, and even when systems are weak, parallel methods should help strengthen functioning elements of national systems.

Recommendation 2: at the country-level, ensure that governments and parliaments commit to financing and safeguarding health and social services to support universalism and equity • Governments and parliaments should be included in negotiations to fund social protection policies beyond an emergency response and continuity of essential health services to protect everyone from future outbreaks. 42 Universal health coverage will be achieved through public financing led through domestic commitments by governmental heads. There are several options to expand fiscal space, including through reallocating and improving efficiency of public expenditures, increasing tax revenues, and managing or restructuring existing debt and aid. 44 At a minimum, current national budget allocations for social protection should be protected in the face of fiscal contraction, whereas new financing options need to be identified to help build strong and more inclusive systems. • UN agencies should work with governments to help realign their current financial investments towards safeguarding for essential services and social protection needs. These investments must also be done for the long term with the objective to help countries meet the fiscal needs of providing a universal approach to health-care and social protection programmes while improving their fiscal sustainability and macroeconomic stability. • Ensure policies and budgets enacted in response to COVID-19 are informed by disaggregated data (eg, by age, gender, disability, ethnicity, income, and legal status). Create specific, measurable, and standardised targets to monitor the progress of these policies and budgets in addressing the needs of vulnerable populations.

• Bridge the digital divide and create digital equity, which supports a collaborative framework across all stakeholders in delivering comprehensive health-care and social protection responses. Ensure global commitments to providing universal access to the internet, making information, distance learning, and opportunities for telework and telemedicine available to all households.

Recommendation 4: boost the care economy and take immediate steps to transform the current model • Put care for people at the centre of politics and the postpandemic rebuild by institutionalising a broad range of policies (eg, flexible work-from-home arrangements, payments to those who provide care or need to receive such payments, and recognition of both paid and unpaid carers as essential workers). • Institutionalise family-friendly policies focusing on four components: (1) access to child benefits and adequate wages; (2) adequate paid leave for all parents and guardians (ie, maternity, paternity, and parental leave); (3) flexible and gender-responsive workplace policies (eg, support for maternity protection); and (4) affordable, accessible, and quality child care. These components will support parental employment and income, reduce child poverty, and support child wellbeing and development. 45 • Issue priority guidelines with specific measures for institutional settings to ensure health, safety, and wellbeing for older (ie, those 65 years and older) people and people with disabilities, and increase the resources of institutions to implement preventive measures.

(Continues on next page) Viewpoint unemployment and poverty. 31 The quantity and quality of food production is being cut, potentially affecting nutrition levels, health status, and the immune system, with a more prominent effect on children, pregnant women, and older adults. 32

The pandemic has driven the internet age forward, but nearly half the world's population is still unconnected. 33 COVID-19 underscored the deep inequity in the digital divide during lockdown measures. Internet access informs the public on current COVID-19 information, increases working from home opportunities, allows for distance learning, enables telemedicine, and connects isolated people with others.

COVID-19 started as a global health crisis, but quickly turned into a humanitarian crisis and could potentially reverse decades of progress on poverty, health, education, and other issues. 34 During the pandemic, supply chains have been further broken down, especially in conflict areas where there is already a shortage of health personnel and supplies. Humanitarian workers put their lives in danger to provide necessary care. Some governments have been unwilling or unable to uphold their population's right to health care during times of conflict. 35 Some have even tried to suppress information about the virus and stifled criticism of their handling of the pandemic. 36

Social protection aims to prevent or protect all people against poverty, vulnerability, and social exclusion, with emphasis towards groups living in vulnerable conditions such that everyone has a fair opportunity for economic and health equity. 37 Universal health coverage means that all people have access to the health services they need, when and where they need them, without financial hardship. 38 Governments should work towards universal health coverage because of their commitment to the sustainable development goals. Universal health coverage improves public health indicators, which are important for economic growth, and thus for pandemic preparedness. Leaving people behind means undi agnosed and untreated people, which increases infection risk, disease burden, and healthcare costs, and decreases trust in institutions and political leaders, affecting societies as a whole. There is strong evidence to suggest that providing comprehensive and context-appropriate social protection and linking this protection to health care with universal access can mitigate the long-term impacts of the pandemic, increase trust, and help protect the vulnerable. 39 More than 200 countries have implemented some form of social protection response to address the socioeconomic impacts of the epidemic, with more than 150 using forms of cash-based transfers. 40 Despite some positive trends, substantial concerns remain that the scale-up of programmes might be too small and too temporary in nature. Moreover, social protection coverage and adequacy (eg, the size of cash transfer) is often too low to support families living in poverty, including in human capital formation, while also building their resilience to future shocks, crucially climate shocks. The challenges for groups living in vulnerable conditions range across the spectrum of social protection programming, and there are substantial variations across regions. 41

Recommendations have been presented in many reports evaluating social protection programmes and health systems worldwide. The recommendations pres ented here have been prioritised and agreed upon by the Lancet Commission on COVID-19's Task Force on Social Protection, Humanitarian Action, and Vulnerable Group experts through an online consultation process including task force meetings and shared online documents.

Universal shocks require universal responses is the most important recommendation to result from impact assessments of the pandemic, including UN reports about social protection responses worldwide. In addition to being a cascading and interacting system of epidemiological, economic, and social and political shocks, COVID-19 has created a devastating inequality shock. The medium-to-long-term consequences require a recovery strategy that delivers health and social services in an integrated manner to prevent these shocks from creating intergenerational poverty traps. 

The crisis has also further expanded national systems for adaptive social protection, which takes shockresponsive social protection one step further and aims to respond to climate change and other long-term stressors and crises exacerbating poverty, vulnerability, and social exclusion. The crisis has shown the vital importance of inclusive digital technologies in every domain of crisis response. Ensuring digital equity represents one concrete example requiring intersectoral collaboration and an ambitious initiative on a never-before-seen scale. The crisis has also highlighted the vital importance of the care economy. The pandemic has interacted with adverse social norms to worsen gender inequality. Comprehensive social protection responses-such as social care public employment programmes-that offer vital social care services to affected families, as part of a social protection programme that provides employment opportunities, deliver more effective interventions than conventional programmes.

Complex crises require partnership, and the pan demic has highlighted the vital relevance of sustainable development goal 17. Inclusive approaches to decision making, built on relationships across all partners including civil society, are now more important than ever. Considering these discussions, we have five recom mendations for governments, parliaments, and multilateral agencies (panel): first, governments should execute universal health coverage and social protection systems in every country; second at the country-level, governments and parliaments should commit to financing and safeguarding health and social services to support universalism and equity; third, digital equity for all; fourth, boost the care economy and take immediate steps to transform the current model; and finally, reenergise relationships between government and civil society actors, and ensure communities, marginalised populations, and all gender identities have a central role in decision making.

COVID-19 has resulted in a global pandemic requiring immediate attention to fight and contain the virus and tackle the worldwide magnification of inequalities through sound health policies, social protections, and humanitarian actions. We urge all governments, decision makers, and stakeholders to consider these recommendations in formulating strategies for pre vention of the virus's spread and address the virus's impacts. The world is at a historically crucial moment for multisectoral collaboration to mitigate the inequality gaps with universal health coverage and social protection, and to truly implement the health-in-all-policies approach. 46

All authors contributed to reviewing literature, writing of the manuscript, and reviewing and editing all versions of the manuscript. OK, UKH, NS, and HS prepared the initial draft and consecutive revisions on all authors' feedback. The revised manuscript has been read and approved by all authors.

We declare no competing interests.

Social economy and the COVID-19 crisis: current and future roles

UN. Indigenous people and COVID-19: a guide note for the UN system prepared by the UN Inter-Agency support group on indigenous issues

Governance of the Covid-19 response: a call for more inclusive and transparent decisionmaking

Community participation is crucial in a pandemic

COVID-19 and inequalities

The impact of coronavirus on the working poor and people of color

International Labour Organization. Care work and care jobs: the future of decent work

WHO. Weekly operational update on COVID-19

Care homes and COVID-19 in an Argentine provincial city

Social protection for older persons: policy trends and statistics 2017-19

Abuse has increased during lockdown, say 71% of elderly

Social protection and jobs responses to COVID-19: a real-time review of country measures

1·3 billion learners are still affected by school or university closures, as educational institutions start reopening around the world, says UNESCO

From insight to action: gender equality in the wake of COVID-19

International Labour Organization. The role of digital labor platforms in transforming the world of work

The COVID-19 global gender response tracker

UNESCO COVID-19 education response: how many students are at risk of not returning to school? Advocacy paper

COVID-19 and violence against women and girls: addressing the shadow pandemic

Racism and discrimination in COVID-19 responses

Hospitalization and mortality among Black patients and White patients with Covid-19

Discrimination, segregation, and chronic inflammation: testing the weathering explanation for the poor health of Black Americans

WHO. WHO Director-General's opening remarks at the media briefing on COVID-19-11

Health of refugee and migrant children: technical guidance

Displacement, girls' education and covid-19

The World Bank. Indigenous Peoples

COVID-19 disrupting mental health services in most countries, WHO survey

Pulse survey on continuity of essential health services during the COVID-19 pandemic: interim report

Covid-19: why we need a national health and social care service

SDG 6 synthesis report 2018 in water and sanitation

COVID-19 exacerbates the effects of water shortages on women in Yemen

The impact of the coronavirus on food insecurity

Food insecurity and health outcomes

Coronavirus has exposed the digital divide like never before

report finds COVID-19 is reversing decades of progress on poverty, healthcare and education

Emergency trauma response to the Mosul offensive

Rapid spread of virus further tests Iranians' faith in government

UNICEF global social protection programme framework

Practical measures to enable the economic empowerment of chronically poor women

From COVID-19 responses to recovery: what role for universal child benefit

Universal social protection to achieve the sustainable development goals. World social protection dashboards

State of commitment to universal health coverage: synthesis

Underwriting for the poor: a global response for social protection

International Labour Organisation, UNICEF. Towards universal social protection for children: achieving SDG 1.3

Combatting COVID-19's effect on children

Adelaide statement on health in all policies: moving towards a shared governance for health and well-being

The Author(s)

The authors would like to thank Earl Hamilton (The National Center