The Health Justice Policy Tracker: COVID-19 Policies To Advance Health Justice For Vulnerable Populations

The rapid spread of COVID-19 throughout the world in early 2020 created unprecedented challenges for national governments. The world’s population was largely unprotected against the virus, and certain groups were particularly vulnerable because of their elevated health risks or because of barriers they faced in access to health or social services. Policies developed during the first ten months of the pandemic, before the first mRNA vaccines were authorized for emergency use, offer a window into national governments’ prioritization of populations that were especially vulnerable. We analyzed these policies using a health justice lens. Our approach was based on the premise that a just society shows equal concern and respect for all people.^1,2

Central to the health justice approach is the principle of distributive justice, which focuses on distributing public goods such as public health protections in an intentional manner to advance equity. During a pandemic, a health justice approach to policy aims to make health care universally accessible, and it pursues proactive legal, financial, and social measures to protect community physical, social, and mental well-being.²

The concept of vulnerability is intricately tied to health justice. Vulnerability is heightened when social and structural determinants of health interact to create power imbalances that inhibit people’s ability to exert agency over their own health, protect themselves, and influence decision makers. These imbalances ultimately lead to social and economic deprivation.³ Vulnerability can thus be understood both as a condition of heightened fragility and as the result of processes that are potentially reversible or avoidable with appropriate interventions. Vulnerability is shaped by individuals’ underlying conditions (such as their biopsychosocial or economic characteristics) and coping capacity and by exposure to individual or collective risks.⁴

During the COVID-19 pandemic, certain population groups in countries worldwide were especially vulnerable. The elderly faced heightened risk for severe disease and death due to their age, comorbidities, and barriers in access to health care.⁵ Elderly people living in long-term care facilities also faced heightened risks of exposure to COVID-19.⁶ Protective measures such as stay-at-home orders and quarantines amplified social isolation among this group, thus worsening their mental and physical well-being.⁵ Children’s vulnerabilities also were heightened during the early months of the pandemic, as a result of disruptions in education, social connectedness, and routine and preventive health care and vaccinations.⁷ Low-income children who depended on school-provided meals faced food insecurity. Adults with disabilities, who face higher risks for underlying medical conditions, were another vulnerable population affected by COVID-19. During the first year of the pandemic, disruptions in access to care, transportation, and personal assistance services left them at particularly high risk of severe illness and death from COVID-19.⁸

Refugees and asylum seekers faced elevated health, social, and financial risks during the pandemic because they were largely ineligible for health care provided through national health care systems or government relief programs, and they often avoided care because they feared adverse consequences such as deportation.^8,10 The first ten months of the pandemic, marked by border closures and strict movement restrictions, disrupted asylum processes and worsened humanitarian crises in refugee camps, thus leaving many refugees and asylees without access to social and health services. Migrant workers, particularly migrant domestic workers, experienced job losses, financial insecurity, and limited access to health care and social services.^11,12 Many migrant workers, asylum seekers, and refugees were living in overcrowded and substandard living conditions that made social distancing extremely difficult or impossible, thus increasing their risks for COVID-19 infection and death.¹² Incarcerated people also faced amplified health risks during the pandemic as a result of overcrowded living conditions and inadequate sanitation, hygiene, and health care.¹³

The tracker provides a useful tool to support a health justice approach to policy in future crises.

These six vulnerable population groups were the focus of the COVID-19 Health Justice Policy Tracker,¹⁴ which we developed to document and catalogue national policy approaches to addressing COVID-19 across forty countries during the pandemic’s first ten months. Several efforts emerged during the pandemic to track or document policy responses for specific groups (such as the World Bank’s Living Paper on Responses in Support of Migrant Workers), policy types (such as Ernst and Young’s Mobility Immigration Tracker), and geographies (such as the International Labour Organisation’s Brief on Social Protection Responses in Asia and the Pacific) (see online appendix exhibit A1).¹⁵ However, none of these sources used a health justice approach to categorize national policies targeting multiple vulnerable populations in a wide range of countries during the early months of the pandemic. The COVID-19 Health Justice Policy Tracker fosters multistakeholder learning and supports research and policy making to address social determinants of health and meet the unique needs of vulnerable populations. By enabling easy access to a suite of policy approaches in specified domains, the tracker provides a useful tool to support a health justice approach to policy in future crises. In this article we present the results of a preliminary analysis of the tracker data.

Study Data And Methods

Scope

The tracker accounts for national policies established from March 11, 2020, when the World Health Organization declared the novel coronavirus disease a global pandemic,¹⁶ until December 31, 2020, when the first mRNA vaccines were authorized for emergency use and rolled out to designated priority groups, such as the elderly, in high-income countries.¹⁷

The tracker catalogues national policies affecting the six population groups described above in four domains: health, social, financial, and “other,” with the last category including policies related to the COVID-19 pandemic that have indirect effects on health but do not focus on health specifically and do not fit into the other policy categories (appendix exhibit A2).¹⁵

We selected the six population groups based on evidence of elevated risk of exposure to COVID-19 and severity of disease when infected compared with the general population, as well as documented barriers limiting their access to health care and social services.^7–10,13

We selected the forty countries in the tracker by considering a combination of factors: their income level, which pertains to the national economic standing or average income of a country’s citizens expressed through gross national income per capita; their political regime types; and the degree of income equality within their populations, as measured by the Gini coefficient¹⁸ (see appendix exhibit A3).¹⁵ These metrics were chosen because a nation’s income level, governance approach, and income equality can have significant implications for resource allocation, accessibility of resources, and prioritization of vulnerable groups in policy development. We listed countries on an Excel spreadsheet by income level¹⁹ (high, upper-middle, lower-middle, and lower income) and then selected countries for inclusion in the tracker to ensure diversity on the three metrics.

Our selection process resulted in country representation from all seven of the World Bank’s regional groupings, including twenty high-income countries, twelve upper- and lower-middle-income countries, and eight low-income countries. The overrepresentation of high-income countries reflects the greater availability of their documented policies online.

Tracker Structure

In creating the tracker, we developed a coding scheme to categorize policies based on the following characteristics: country in which the policy was developed; World Bank region; population group; policy type; policy status (new policy or expansion of an existing policy, if specified); policy features (including cash transfers, direct food or in-kind supplies, improving access to health care, COVID-19-related care, support for institutions focused on the six population groups, legal and administrative, and other policies that don’t fall into specified categories); and funding associated with policy implementation (if specified). The coding scheme was derived iteratively by reviewing existing trackers’ structures to create a mock template and then having multiple members of the research team independently review a subset of policies to ensure standardized data collection.

Data Collection

During the initial data collection phase, each reviewer was assigned a subset of countries for which to identify and catalogue policies established during the study period that focused on each vulnerable population group. The names of these policies were entered in an Excel spreadsheet. Supporting documents were archived on a Dropbox drive. Policies were sourced through existing policy data sets (appendix exhibit A1)¹⁵ that were chosen on the basis of their relevance to specific policy types and population groups, as well as through search engines such as Google. To develop a comprehensive policy database, we searched national government websites (such as national Ministry of Health pages), national and international news articles, think-tank publications, and nongovernmental organizations’ reports and other specialized publications.

To ensure that all policies relevant to each group and country were identified, a second reviewer on the research team randomly cross-checked policies listed by the primary reviewer. A final quality review was conducted by one of the research team members before launching the tracker.

The completed tracker, available online,¹⁴ enables users to search policies by population, World Bank region, country, and policy type. Clear definitions of the population groups and policy domains, listed in the tracker, enable users to understand the parameters used to tag each policy. Information from the tracker can be merged with external data sets, using software such as Excel.

Limitations

The tracker has several limitations. First, although it primarily catalogues supportive policies, it includes both supportive and restrictive policies, such as movement restrictions, for refugees, asylum seekers, and migrant workers. Our approach was intended to highlight barriers in advancing health justice for these historically marginalized groups. However, it could inadvertently create a skewed impression of the policy landscape during the first ten months of the pandemic.

Second, the tracker does not document policy approaches to all population groups with heightened vulnerabilities early in the pandemic. The focus on the six selected populations was not intended to diminish systemic challenges faced by other vulnerable groups, but rather to purposefully highlight policies affecting specified populations experiencing different types of vulnerability during this period.

Third, the tracker’s population and policy categories are not mutually exclusive. Policies documented in the tracker in some cases affected more than one population group and could be placed in multiple policy domains. To address these issues, we categorized policies based on our assessment of their primary intent and population focus. For example, policies that directly provided funding, in-kind aid, or health services to the population groups were categorized accordingly as financial or health policies, whereas policies that provided funding to institutions to support the population groups were tagged as social policies. Where policies included multiple vulnerable groups, they were also cross-referenced to be tagged under each group, which may have resulted in some double-counting of specific policies but ultimately ensured comprehensiveness in documenting all policies in the four domains for each group.

Fourth, the tracker documents countries’ adoption of policies, but it does not provide information on policy implementation or effectiveness. While most policies were identified through primary sources, where this was not possible, we referred to secondary sources such as existing trackers, news articles, and publications. In these cases, the tracker might not reflect all of the policy details and nuances that may be evidenced through an analysis of the original sources. Relatedly, the tracker includes links to the policy language available during the time it was developed; however, in some cases, these links might no longer be active.

Fifth, the tracker may be missing policies that were adopted but not published online or recorded in existing trackers. Notably, the Middle East and North Africa region had limited policy data available online at the time of data collection, which may have resulted in an underrepresentation of policies across this region.

Moreover, the tracker does not capture policies adopted at the subnational level, by states or localities, thus potentially limiting our documentation of policy approaches to vulnerable populations in countries with decentralized governance.

Study Results

The tracker documents a total of 610 policies (see appendix exhibits A4 and A5).¹⁵ Of these policies, 227 (37.2 percent) targeted children, 157 (25.7 percent) targeted the elderly, 73 (12.0 percent) targeted people with disabilities, 70 (11.5 percent) focused on migrant workers, 58 (9.5 percent) addressed incarcerated people, and 25 (4.1 percent) were aimed at refugees and asylum seekers. Across policy types, financial policies accounted for the majority of policies (258, or 42.3 percent), followed by “other” policies (147, or 24.1 percent), health policies (124, or 20.3 percent), and social policies (81, or 13.3 percent).

Financial Policies

Among the financial policies identified in the tracker, 85 percent targeted children and their families, the elderly, and people with disabilities. These included direct cash transfers such as increased unemployment benefits, rent assistance, elderly pension support, and child support allowances, as well as in-kind support such as food delivery systems and free or subsidized internet access and laptops. As schools closed early in the pandemic, governments recognized the important role that they often play in providing essential services such as meals for low-income children. Mexico repurposed its school meal program to provide take-home food rations to promote food security among school children.²⁰ Moreover, to offset the economic consequences of the pandemic, the Undersecretary of Higher Secondary Education launched the Benito Juárez Wellbeing scholarships for youth to ensure that they had the financial support needed to continue their education through high school.²¹

Migrant workers, incarcerated people, and refugees often are excluded from national social insurance or emergency financial aid programs.²² China’s support for temporarily unemployed migrant workers using unemployment insurance funds and Panama’s inclusion of refugees and asylum seekers in the Panama Solidarity Plan^23,24 are notable exceptions and could be useful models for advancing just policies to support these populations in future health crises.

Other Policies

The “other” policy category primarily included legal and administrative measures, digital and teleservices, and movement restrictions.

Legal and administrative policies mainly focused on migrant workers and involved granting or extending residency status. Repatriation measures were another common type of legal and administrative policy. For example, in Nepal, a government task force was established to effectively reintegrate thousands of returning migrants into the country’s labor force,²⁵ whereas in Canada, work permit waivers and pathways to permanent residency were established for migrant workers and asylum claimants in the agriculture and health sectors.^26,27

Digital and teleservices policies harnessed technology to disseminate information and support specific population groups. Examples include Argentina’s video call service for people with hearing disabilities to ensure accessible and reliable information on risk factors and preventive measures related to the pandemic.²⁸ Similarly, New Zealand’s efforts to provide digital literacy training enabled elderly populations to learn how to use virtual platforms such as Zoom to connect with loved ones during the pandemic.²⁹ In Mexico, where public education is free to all citizens by law, the government implemented an ambitious and innovative plan to broadcast a comprehensive set of lessons for all grade levels through high school on television.³⁰

Movement restrictions were imposed primarily on refugees and asylum seekers (eight policies) and the elderly (two policies), although the purpose of the restrictions differed. Refugees and asylum seekers often faced movement restrictions across and within country borders, while restrictions for the elderly were aimed at protecting and reducing their risk for COVID-19 infection by having elderly-specific hours for movement or leaving their homes.

Additionally, the “other” bucket within this category included measures to support the evacuation of migrant workers stranded abroad during the pandemic, social awareness campaigns for groups such as the elderly and refugees and asylees, research directives to study and address various impacts of the pandemic on vulnerable groups, and policies for incarcerated people focused primarily on releases from prisons and jails to alleviate overcrowding. Policies focused on incarcerated people were established in eighteen countries and in some countries included requirements for released individuals to wear electronic bracelets to track their geolocations.³¹ In the Central African Republic, these releases excluded people convicted of “serious crimes,” such as war crimes, genocide, and crimes against humanity.³²

Health Policies

Health policies identified in the tracker primarily benefited the elderly, children, and people with disabilities.

Health policies identified in the tracker primarily benefited the elderly, children, and people with disabilities. Of all health policies, 63.5 percent focused specifically on COVID-19-related care. These measures ranged from free or discounted COVID-19-related health services to prioritized distribution of personal protective equipment and vaccinations for the elderly.

Health policies varied by the nature of the health care systems in which they were established. For example, government-funded health systems, such as those in Canada and the United Kingdom, covered the cost of COVID-19 testing and treatment for all citizens and migrant workers, as well as refugees and asylees. However, in the US—which does not have universal health care—the federal government covered the cost of COVID-19 testing for all populations but did not cover treatment for refugees, asylum seekers, or uninsured migrant workers.³³

The pandemic’s toll on the mental health and psychosocial well-being of populations throughout the world has been widely documented.^34,35 Nine countries included in the tracker established national efforts to support the mental health of vulnerable populations. For example, the president of Chile launched the Healthy Mind Initiative (“Iniciativa SaludableMente”) to “improve the public and private mental health services.” The initiative included a digital mental health platform to extend remote psychosocial services to children and the elderly, as well as the development of an expert committee to create guidelines on supporting mental health and emotional well-being for several priority groups, including children and the elderly, as well as the general population.³⁶ Chile’s approach was informed by a referential framework known as the Mental Health Care and Disaster Risk Management model, which the national government had used previously to develop mental health supports as a first line of response for populations affected by the Quintero-Puchuncaví socio-environmental conflict and the social uprisings that affected the country before the pandemic.³⁷ Additionally, Chile’s Ministry of Health developed a COVID-19 Mental Health Action plan, which explicitly called for prioritizing vulnerable groups during the pandemic.³⁷

Social Policies

Social policies included in the tracker primarily benefited children (62 percent); the elderly (30 percent); and, to a lesser extent, people with disabilities (7 percent) and refugees and asylum seekers (3 percent). For example, Canada’s Minister of Families, Children, and Social Development increased federal grants to organizations offering community-based support to reduce isolation and improve the quality of life for senior citizens and help them maintain social support networks.³⁸ Additionally, the Canadian government provided emergency funding to organizations addressing gender-based violence, with a particular focus on girls and women.³⁹

Implications For Health Policy

Our analysis of the tracker data revealed several trends with implications for future efforts to advance health justice for vulnerable populations.

First, the dominance of policies targeting children and the elderly aligns with findings from political science and sociology scholarship to suggest that when developing policy, national leaders often prioritize positively framed, politically strong groups such as the elderly, as well as positively framed, politically weak groups such as children; groups that are politically weak and negatively framed, such as incarcerated people and refugees, receive less attention.⁴⁰ This framing has significant implications for health justice. An innovative approach that emerged during the pandemic was policy makers’ use of disadvantage indices such as the Centers for Disease Control and Prevention’s Social Vulnerability Index and the UK’s Indices of Multiple Deprivation to identify intersectional disadvantages and prioritize vulnerable groups in policies to guide equitable access to vaccines and COVID-19 related care.⁴¹ These indices can continue to serve as policy-informing tools to counteract biases that shape the framing of different vulnerable groups, so that resources are focused on populations that may otherwise be overlooked in national policy responses to health crises, such as refugees, asylees, and migrant workers.

Innovations during crises can lay the groundwork for benefits that will endure long after the end of the public health emergency.

Second, it is notable that national policies in several countries repurposed existing social support programs for children, the elderly, refugees, asylees, and migrant workers. In future health crises, national governments can learn from these rapid and efficient policy approaches by expanding, streamlining, or innovating within existing infrastructures to ensure that the benefits of preexisting programs are effectively distributed to vulnerable populations. On the other hand, in situations where programs for populations in need of support during the pandemic did not exist, several national governments created innovative new policies focused on vulnerable groups. Besides providing benefits to populations in need of support during the pandemic, innovations during crises can also lay the groundwork for benefits that will endure long after the end of the public health emergency.

Third, policies are shaped by unique histories, cultures, and geopolitical motivations, which can shape varied policy prescriptions even among nations that, on the surface, may seem to share common socioeconomic or political characteristics. For instance, the US and Canada are both high-income countries with long immigration histories. Yet during the pandemic, both countries adopted restrictive measures towards refugees, asylum seekers, and migrants in nuanced ways. Influenced by prevalent negative attitudes and a conservative national political climate in the US, stringent approaches to deport asylum seekers, refugees, and other migrants were observed, especially along the US-Mexico border.⁴² Canada’s approach, while restrictive at the borders, extended support to assist migrants and asylum seekers working in health care and agriculture. These policies created new pathways to permanent residency, resulting in the emergence of a hierarchy within Canada’s migration system and causing questions to be raised around “who is considered essential and worthy of exemptions.”²⁶ During future health crises, it will be important to consider the health justice and human rights implications of using migration control as a crisis management tool.²⁶ Policy makers looking for model language to guide policy development during future health crises need to embed their policies in the unique national frameworks and socioeconomic and political contexts shaping each country, avoid uneven policy impacts on different migrant groups, and ensure that policies uphold justice and human rights.

Conclusion

The COVID-19 Health Justice Policy Tracker systematically catalogues national approaches to six vulnerable population groups across forty countries in the first ten months of the pandemic. Policy makers and researchers can leverage policy approaches and language documented in this tracker to develop policy frameworks tailored to the needs of vulnerable groups during future health crises. Data from the tracker also can be used in conjunction with validated vulnerability indices to inform policy development aimed at addressing systemic disadvantage and advancing health justice for all populations.

ACKNOWLEDGMENTS

This study was funded by the Johns Hopkins Alliance for a Healthier World, a universitywide initiative focused on solving health equity and social justice issues around the world. The authors thank the funders for the support, and Brandon Howard for valuable inputs on tracker presentation. The study’s findings are independent research and not necessarily aligned with the funders’ viewpoints. The authors are solely responsible for the accuracy of the information presented in this article. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) license, which permits others to distribute this work provided the original work is properly cited, not altered, and not used for commercial purposes. See https://creativecommons.org/licenses/by-nc-nd/4.0/. To access the authors’ disclosures, click on the Details tab of the article online.

NOTES

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