The COVID-19 pandemic sparked a global health crisis of unprecedented scale. While its effects were widespread, a disproportionate amount of the harm has been borne by marginalized communities—overwhelmingly low-income households, people of color, and immigrant populations with limited access to resources and health and social services. In the United States, Black, Hispanic, and American Indian or Alaskan Native people were up to 2.5 times more likely than their White counterparts to be hospitalized with COVID-19 and more than 1.7 times more likely to die from the disease.1
These patterns are not new. Unequal outcomes persist across many aspects of public health, from nutrition to maternal and child health and disease management.2 The pandemic laid bare these long-standing disparities, underscoring the urgent need to fundamentally change the way critical public health programs and services are delivered.
The current moment can serve as a powerful catalyst for change. As the United States enters the endemic stage of COVID-19,3 decision makers have the opportunity to initiate bold and swift action. Increased investment in public health and a growing national focus on equity have generated momentum to reimagine public health delivery with a deliberate focus on equitable access and outcomes.4 As leaders embark on this journey, they can draw on lessons learned from national, state, and local pandemic response efforts.
Based on our work in the COVID-19 vaccine response, we outline in this article an approach for designing and implementing public health programs anchored in detailed analytics, on-the-ground relationships, rigorous program management, and an organizational mindset centered on equity. This approach could serve as a useful example of how public health institutions can deliver more equitable impact during crises and in the long term.
Embedding equity in program delivery
No single solution can fully address the complex and entrenched causes of inequity in public health delivery. However, lessons from the COVID-19 response suggest that an integrated approach to embedding equity into end-to-end program design and implementation could help create more equitable health outcomes (exhibit).
1. Make equity nonnegotiable
The approach centers on equity as an explicit and nonnegotiable objective of every aspect of the program, from setting strategic goals and metrics to designing a new operating model. The term “health equity” can mean different things to different people. Aligning on a clear definition of health equity goals—including how they are measured—is a critical first step in this approach.
Set ambitious health equity goals. Under the integrated approach, the highest office or entity sets and commits to aspirational equity targets at the onset of the program or, for existing programs, at important milestones. Each goal is structured as “SMART”—that is, specific, measurable, attainable, relevant, and time-bound. The specific directive to achieve 85 percent coverage of first-dose vaccinations for the adult population in the 25 highest-need locations (based on a social-vulnerability index) within three months is an example of a SMART goal.
Leverage existing data to delineate metrics. After equity goals have been set, leaders can identify clear metrics to track their progress. A common concern is the lack of precise data; for example, state vaccination rates can fluctuate because of interstate travel and overlap with vaccinations given by federal entities. In cases like these, it may be necessary to take a minimum viable product (MVP) approach, in which metrics are tracked using the best data available while the organization continuously works to improve data quality.
Adapt goals based on progress and data availability. As progress is made toward equity goals, and as better data becomes available, program leaders may need to adjust their initial goals to meet evolving circumstances. Examples include updating goals to include additional demographics as vaccines become available, increasing the granularity of data and metrics from the county to the zip code level, and expanding efforts to related program delivery areas such as maternal health or nutrition. Whenever goals change, it is important to gain stakeholder buy-in, acknowledge the shift, celebrate wins, and invest in any additional capabilities required to reach the new objectives. These actions can go a long way toward mitigating concerns about shifting goalposts that can derail goodwill and lead to burnout.
2. Embrace new ways of working
The next step is to implement new ways of working to ensure that ambitious equity goals are clearly translated and reinforced in day-to-day work.
Empower change from the top. In addition to setting equity-based goals, the approach calls for the highest office or leadership to publicly empower their teams to deliver on those objectives. During the COVID-19 response, this often meant creating new modes of engagement—for example, by breaking down agency-level silos; creating partnerships among public, private, and academic institutions; working across partisan lines; collaborating with the community in new ways; and harnessing the power of nontraditional media.
Adapt governance and decision making. Under this approach, governance structures and processes adapt to support these new ways of working and deliver equitable impact. An effective governance model could include periodic touchpoints to track outcomes against equity targets, clear accountability across teams, and escalation pathways to address challenges or falling short of targets.
Create a collaborative and interdisciplinary working model. A collaborative and cross-functional operating model builds alignment among internal stakeholders (such as agency heads, data analysts, logistics teams, communications teams, and local and regional officials) and external partners (such as community and faith-based organizations, private-sector organizations, and schools). Weekly “thematic” touchpoints can also facilitate close coordination and communication among stakeholders.
Implement agile ways of working. Agile practices, such as sprint-based and iterative work cycles, can help organizations continuously track progress and adjust the strategy within a constantly shifting landscape. While this may be particularly important in times of crisis, such as the COVID-19 pandemic, long-term programs can also benefit from the greater flexibility and speed of agile principles. Feedback is critical; successful initiatives and learnings should be shared and scaled across the organization, while failures and setbacks should be quickly identified and addressed.
3. Walk the talk
The third element of the approach is relentless execution with a strong emphasis on data-driven decision making, capability building, and local engagement.
Fact check with data. Data can be a powerful tool for organizations to use to establish a robust fact base, create transparency around equity outcomes, and “myth bust” perceived roadblocks or misinformation. Organizations must usually meet two conditions: data that is granular enough to drive actionable insights, and decision makers at all levels with access to the latest data and insights. Then organizations can harness this data to make better decisions and quickly verify (or debunk) their assumptions. For example, after a public health agency tested various COVID-19 vaccine strategies (including adding multiple pop-up sites and extending hours for permanent sites), it found that low vaccine uptake in “hesitant” areas was due to lack of access rather than low user adoption, as had previously been assumed.
Build capabilities to execute. Translating data to insights, and insights to action, often requires a wide range of skills and capabilities that may not exist within the organization. For many institutions, the pandemic highlighted a need to train employees on unconstrained problem solving, stakeholder management, data analysis, event coordination, and verbal communication. Agencies found success through various capability-building innovations, including running on-the-ground trainings and workshops in response to immediate needs (for example, crisis management), collaborating with private and academic partners (such as in supply chain and logistics management), establishing rewards for high performance, flattening the traditional organizational hierarchy, and creating new career paths for those on the front lines.
Understand the local context. Even the most rigorous, data-driven initiative could fail if it is not grounded in the local context of the people it is meant to serve. Several COVID-19 vaccination efforts were hamstrung by a lack of cultural sensitivity and awareness of local needs. For example, the vaccine delivery program had limited success when it offered only pediatric vaccines in certain locations where multigenerational families preferred to get vaccinated together. This lesson—that all vaccine events need to provide all doses to all age groups—was then applied more broadly to other locations. Organizations can hire diverse teams and engage experts and community partners to ensure that local perspectives are consulted in the design and execution of any initiative.
While this approach found some success in vaccine delivery, we recognize that there are certain constraints and criteria for success. First, the approach does not address the various and interconnected aspects of systemic and structural inequity that shape individuals’ abilities to make certain choices about their health. In other words, it focuses on improving access to healthcare rather than changing consumer behaviors and decisions. Second, the transformational nature of the approach requires a significant level of commitment from public health agencies—including sustained engagement from the highest levels of leadership, a focus on talent management and capability building, a broader cultural shift in institutional ways of working, and effective execution at all levels of the organization.
The COVID-19 pandemic revealed the profound need to embed equity into public health programs at the federal, state, and local levels. As we emerge from the crisis, public and social institutions have an opportunity to reimagine their approach to delivering public health services and contribute to a more equitable and resilient future for all Americans.
