social issues in healthcare essay

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Social Issues in Healthcare: Key Policies and Challenges

View all blog posts under Articles | View all blog posts under Bachelor's in Sociology

Tables of Contents

What Do We Mean by Social Issues in Healthcare?

How are social factors affecting access to healthcare in the u.s., how health policy issues shape our healthcare experience, real-time social issues in healthcare: covid-19, racism, and other current epidemiology issues, hospital mortality rates: end-of-life social issues in healthcare, future social issues in healthcare.

As soon as we enter this world, society begins to shape our lives. Social issues in healthcare influence every aspect of our well-being, from our physical and mental health to the treatment we receive from doctors. We cannot escape the values of society, nor histories of oppression and subjugation, even when we are simply seeking care for our bodies and minds.

Nowhere is the tragic reality of how social issues in healthcare affect our lives better represented than in statistics on infant mortality. Death is three times more likely for Black infants in the U.S. than for white infants if their care is administered by white doctors, according to a study published in Proceedings of the National Academy of Sciences (PNAS). Yet, if Black infants are cared for by Black doctors, their mortality rates drop by up to 58%. In healthcare as elsewhere, institutionalized racism has grim consequences.

Continue reading to learn more about social issues in healthcare — what they are, how they affect access, where they intersect with current issues in epidemiology, and how they impact hospital mortality rates.

Social issues in healthcare are also known as social determinants of health. Social determinants of health are the circumstances of the places where people reside, work, learn, and engage in recreation. These circumstances are the result of the distribution of money, resources, and power across international, national, and regional levels. Systemic health inequities can often be attributed to social issues.

In this article, we will use the term social issues in healthcare to mean the circumstances in which people live, work, learn, and play. The sociocultural categories applied to people and their circumstances will be referred to as social factors.

Moving forward, we will delve into how access to healthcare, different epidemiology issues, and hospital mortality rates interact with these six social factors:

• Class/income
• Legal status
• Race and ethnicity
• Gender identity and sexual orientation

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From your occupation to your education, social factors play into the healthcare you receive. According to 2018 data from the U.S. Census Bureau, 29% of the uninsured are service industry workers, 8% are disabled, 37% are Latino, and 86% of the uninsured do not have a bachelor’s degree.

Having access to healthcare means an individual can see a doctor or other healthcare provider on a regular and timely basis to achieve optimal personal health. This requires that a person gain entry to the healthcare system, that providers are nearby, and that those providers are a good fit for the person in terms of culture and personality. All of these social factors can impede a person’s ability to access healthcare.

Class and Income

Healthcare in the U.S. is inextricably linked to health insurance. An individual’s ability to obtain health insurance can vary depending on their income and employment status. In 2010 the Patient Protection and Affordable Care Act (ACA) expanded the Medicaid program, which provides income to low- and no-income Americans. However, 27.9 million people remained uninsured as of 2019, most of them low-income workers, according to the Kaiser Family Foundation.

Even with insurance, cost is a major obstacle to accessing healthcare for poor and working-class people in the U.S. Some put off needed medical care because they cannot afford a copay or deductible, and medical debt is a frequent cause of bankruptcy.

Where you reside can determine whether you have access to care. In the U.S., states that have refused to expand Medicaid have higher average rates of uninsured people than states that expanded Medicaid — 11.14% of people are uninsured on average in states that did not expand Medicaid compared to 6.95% in states that did, according to data from the U.S. Census Bureau analyzed by WalletHub. Yet, for residents of many other countries in the world, universal coverage is a given.

Finding a provider can be difficult in rural areas, but urban areas, particularly large cities with predominantly Black and populations, also face healthcare provider scarcities. When providers are scarce, people must go with what is available, even when those options aren’t personally or culturally compatible. If a person doesn’t feel comfortable with their doctor, they might be reluctant to seek care.

Legal Status

Noncitizens face obstacles to getting public insurance coverage , such as waiting periods, and undocumented immigrants are ineligible for most forms of public health insurance. Most employer-based coverage is also inaccessible to undocumented immigrants since employment in the U.S. typically requires a Social Security number or other proof of legal residence.

When undocumented immigrants can access healthcare services, the threat of immigration enforcement can be a deterrent to getting regular care. In a recent survey, close to half of undocumented immigrants admitted to delaying a doctor visit because they were concerned about possible deportation.

Race and Ethnicity

As the infant mortality statistics in the introduction reminds us, the U.S. has a problem with anti-Black racism, and racism in general. That race and ethnicity can present obstacles to healthcare access should, therefore, not be surprising.

Black, Latino, and Native Americans are underrepresented in medical fields , according to a study published in the Journal of the American Medical Association , which means patients of those racial and ethnic backgrounds are less likely to find providers who share their race. Due to historical inequities, such as housing discrimination, Black and Native Americans are also less likely to live in areas where medical providers are plentiful.

When they can see healthcare providers, studies have shown that Black Americans’ concerns are often not taken seriously ; for example, their symptoms are dismissed and their pain is minimized. Combined with the medical profession’s history of unethical experimentation on Black patients, many Black Americans find themselves waiting to see a doctor until it is too late.

Systemic racism itself has impacts on Black people and other nonwhite Americans that make their access to healthcare even worse. Nonwhite Americans are affected not only by the structural inequities that result from racist policies, but by the stress of perceived racial or ethnic bias as well. This stress can increase their risk for preventable diseases such as cancer and diabetes.

Gender Identity and Sexual Orientation

Sexual orientation and gender identity are two other important factors affecting access to healthcare. Health services such as abortion, PrEP (preexposure prophylaxis to prevent HIV infection), and gender confirmation surgery are often politically contentious.

This has real impacts on the lives of both cisgender and  and LGBTQIA people in general. The federal government recently rolled back protections that assured transgender individuals the same access to healthcare afforded to cisgender individuals, and the legal right to abortion continues to be contested in the courts. Shame and judgment also make it hard for some transgender and LGBTQIA people to find a healthcare provider they feel comfortable with.

The Americans with Disabilities Act celebrates its 30th anniversary this year. Among other things, the act mandates reasonable accommodations for disabled people to access public spaces, including medical offices and workplaces. Some disabled people have been able to work and obtain health insurance because of its passage.

Disabled people who cannot work and who receive assistance such as Social Security Disability Insurance (SSDI) or Supplemental Security Insurance (SSI) are eligible for Medicaid. However, some government administrations seek to curtail the breadth of federally funded healthcare coverage in ways that could impact disability benefits, such as the efforts of the Trump administration to reduce the scope of Medicaid by issuing work requirement waivers to states.

Healthcare policy is created with the input of the healthcare industry, private employers, healthcare unions, and, to some extent, healthcare consumers. Health policy issues typically arise when the interests of one of these groups are over- or under-represented at the policymaking table.

A number of health policy issues are at play in the U.S. today, and they have tangible effects on the frequency and quality of our healthcare.

Currently, the U.S. is in a heated political and moral debate over the role of healthcare. Should it be a privilege or a right? The ACA was a health policy based on the idea that healthcare should more or less be a right, at least for a majority of working citizens and legal residents. Some feel the act did not go far enough, and they may support new policy proposals such as “Medicare for All.” Those who believe it went too far may want to roll back some of its protections .

Health policy issues have shaped the course of the COVID-19 pandemic as well. Some have argued that the U.S. government downplayed the severity of the outbreak in the beginning, leading to poor preparation and outcomes. The impacts of racist healthcare policies are also starkly evident in deaths associated with the pandemic: statistics, including data from the Brookings Institute , have shown that Black Americans are more likely to die from COVID-19 than other Americans.

Another example of how health policy shapes our experience of care can be found in drug pricing. From 2011 to 2016, Mylan increased the price of EpiPen , an epinephrine injector that prevents fatal anaphylaxis, by 400%, according to GoodRx. Many families were hit with a shocking bill for a necessary drug, with no options to replace it. Similar cost increases have occurred with insulin, chemotherapy drugs, and other generics.

Healthcare pricing in general will remain a key challenge for the healthcare field going into 2021. The U.S. pays more for healthcare than other rich nations, but the benefit of that expensive care is debatable. While Americans visit specialists and have diagnostic exams such as MRIs performed more often than citizens in other high-income countries, life expectancy is lower in the U.S.

Resources: Healthcare Policy Around the World

World Health Organization — Explore the legal side of healthcare around the world

HowStuffWorks — An overview of healthcare systems in 10 different countries

HealthyPeople.gov — A snapshot of global health

World101 — Different models for healthcare from around the globe

In simple terms, epidemiology is the study of health-related events and states (such as disease) and the conditions that lead to them in populations. Epidemiologists do not treat or diagnose disease in individuals; rather, they look at the distribution and determinants of health.

Think of epidemiologists as detectives, following a deductive process to discover the causes of disease and other adverse health events. They might ask questions such as:

• Which individuals are sick?
• What is their symptom set?
• When did their sickness begin?
• Where might they have been exposed?
• What social groups do those individuals belong to?
• What are the social determinants of health that might impact the health of those groups?

With the answers to these questions, epidemiologists can work toward determining the origin and mechanism of an infectious outbreak or other public health threat. Epidemiologists care about social issues in healthcare because they can impact the distribution of health-related events. Many current epidemiology issues intersect with social factors.

The COVID-19 Pandemic

Epidemiologists are interested in predicting where COVID-19 outbreaks are likely to occur and in what environments. Using data from testing and contact tracing, they learn about important characteristics of the virus, such as how long it typically lasts and how contagious it is. Their findings inform guidance to states and industries regarding safe reopening procedures .

Disparities in infections and deaths from COVID-19 are of concern to epidemiologists. The fact that Black and Latino Americans are dying at much higher rates than white Americans is important because it means many members of these social groups have pervasive underlying conditions that affect their health status. An effective prevention campaign must take those conditions into account.

The Opioid Epidemic

Pharmaceutical industry sales strategies in the 1990s and early 2000s led to an explosion of opioid prescriptions into the mid-2010s. The result has been a substantial increase in the number of people addicted to legal and illegal opioids such as OxyContin and heroin. Abuse of these drugs can lead to long-term disability and death. In fact, 130 people died every day in 2018 and 2019 from an opioid overdose, and many of those people came from working-class and low-income backgrounds, according to the U.S. Department of Health and Human Services.

Epidemiologists look at the effects of government health policies on opioid overdoses and research ways to enhance monitoring of opioid morbidity and mortality. They also study whether improved access to interventions such as naloxone and drug treatment programs has a meaningful impact on outcomes, often working together with experts in other disciplines such as psychology.

Racism and Police Brutality

Police brutality is also a current epidemiological issue. When examining the cause of injuries and deaths at the hands of police officers, epidemiologists would ask the same questions they ask when investigating disease outbreaks. Who are the victims? Black Americans are nearly three times more likely to die during an encounter with a police officer than white Americans, according to a study published in the American Journal of Public Health . What are the symptoms? Are police activities motivated by bias, such as racial profiling or excessive surveillance of nonwhite communities? Racism and police reform are major challenges epidemiology must confront going into 2021.

The U.S. has some of the worst maternal mortality outcomes among high-income countries. Black and Native Americans are bearing the brunt of the crisis. According to 2018 and 2019 information compiled by The Commonwealth Fund and The New York Times. Black women die of pregnancy-related causes at 3.3 times the rate of white women, and for Native American and Alaska Native women, it’s 2.5 times. In addition, 60% of pregnancy-related deaths are preventable; one-third of all American women report delaying needed medical care due to cost, and a lack of access to prenatal care and postpartum care is cited as a reason for the high mortality rates.

The social factors affecting access to healthcare also impact access to beginning and end-of-life care. Maternal mortality rates in the U.S. are worse than in any other rich nation, and the impacts of the crisis are not distributed evenly: Black, Native American, and Alaska Native birthing parents are two to three times more likely to die from pregnancy-related complications than white birthing parents, according to the Centers for Disease Control and Prevention (CDC). A majority of all deaths related to pregnancy are preventable, and many of them result from systemic inequities in healthcare.

Hospital mortality rates in general are highly influenced by social factors. Well-funded hospitals with well-trained staff who have experience working with a variety of patients will have lower rates of death. Metropolitan areas are likely to have large surgical centers and university medical facilities with world-class specialists and state-of-the-art equipment. These areas have seen their hospital mortality rates improve over the last decade, whereas in rural areas, rates have remained flat .

For the Black community, hospital mortality rates are impacted by their experiences with the medical field over the centuries. Historical traumas such as the Tuskegee study that researched syphilis in Black men without their consent and the theft of Henrietta Lacks’ DNA have created a mistrust for the healthcare industry. Despite being more likely to live near high-quality medical facilities,

The same mistrust that keeps Black Americans from seeking care at predominantly white facilities may also lead to dissatisfactory care at the end of their lives. Black Americans are more likely than white Americans to die in the hospital , rather than at home with their families in hospice care, according to information compiled by the Center for Health Journalism. Poor communication between healthcare providers and their Black patients is cited as one potential source of this continuing disparity in end-of-life care.

For the next few years, COVID-19 will reverberate through our societies even after an effective treatment or vaccine is developed. We will need armies of trauma-informed providers to deal with its aftermath. Climate change will also continue to have harmful implications for our mental health as well as our physical health.

Remedying structural inequities is no small task, yet all evidence indicates it is one that must be taken on immediately if many of the crises facing the healthcare field are to be overcome.

Our fast-paced world will surely continue to generate challenges for the healthcare field to contend with, but our shared future must be anti-racist and equitable. As long as human societies rely on hierarchies of privilege and power, the same old social issues will shape our health and our care far into the future.

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Racial Inequities Persist in Health Care Despite Expanded Insurance

A series of studies in an influential medical journal takes a close look at longstanding gaps in medical care.

By Roni Caryn Rabin

Two decades ago, only 9 percent of white Americans rated their health as fair or poor. But 14 percent of Hispanic Americans characterized their health in those terms, as did nearly 18 percent of Black Americans.

In recent years, access to care has improved in the wake of the Affordable Care Act, which reduced the number of uninsured Americans across all racial and ethnic groups. But the racial health gap has remained , according to a series of studies published on Tuesday in the journal JAMA.

A dismal picture of persistent health disparities in America was described in an issue devoted entirely to inequities in medicine. The wide-ranging issue included research on spending and patterns of care, comparative rates of gestational diabetes and the proportion of Black physicians at medical schools.

The journal’s editors committed to a sharper focus on racism in medicine after a controversy in June, in which a staff member seemed to suggest that racism was not a problem in health care. The ensuing criticism led to the resignation of the top editor and culminated with a pledge to increase staff diversity and publish a more inclusive array of papers.

“The topics of racial and ethnic disparities and inequities in medicine and health care are of critical importance,” Dr. Phil B. Fontanarosa, interim editor in chief of JAMA, said in a statement. He noted that more than 850 articles on racial and ethnic disparities and inequities have been published in JAMA and associated journals in the past five years.

The new issue offers studies on disparities in the utilization of health care services and in overall health spending. Together, the findings paint a portrait of a nation still plagued by medical haves and have-nots whose ability to benefit from scientific advances varies by race and ethnicity, despite the fact that the A.C.A. greatly expanded insurance.

The racial health gap did not significantly narrow from 1999 to 2018, according to one study whose author said it was tantamount to “a comprehensive national report card.”

“We’re failing,” added Dr. Harlan Krumholz, the study’s senior author.

“If our national goals are to improve the population’s health and promote more health equity, then we have to admit that whatever we’re doing now is not doing the trick,” he said. “This should wake us up, and spark us to think of new and better approaches.”

Other studies in the journal teased apart factors that may be contributing to the gap, including different patterns of care-seeking. White Americans, for example, are more likely than members of minority groups to visit primary care physicians and specialists in the community, rather than a hospital or emergency room.

The disparity was seen even when Americans from various racial and ethnic backgrounds shared the same insurance, like Medicare , the government health plan for seniors.

“Access to primary care physicians and specialists in the outpatient setting is really important, because they’re managing chronic conditions like diabetes, heart failure, asthma and chronic obstructive pulmonary disease,” said Kenton J. Johnston, an associate professor of health management at Saint Louis University and the lead author of the study.

“If you don’t get in to see the specialist or primary care doctor, you’re going to have complications and problems downstream.”

Dr. Johnston’s study found that minority patients on Medicare have more limited access than white individuals to outpatient health care services.

Despite innovations like Medicare Advantage, which increased access to health care overall, Medicare beneficiaries who are minorities — defined as Black, Hispanic, Native American or Asian-Pacific Islander — still have less access than white or multiracial individuals to a physician who is a regular source of care.

They are also less likely to have influenza and pneumonia vaccinations, and they have more limited access to specialists, the study found.

In Dr. Johnston’s hometown, St. Louis, as in other cities, fewer health care providers and specialists are found in low-income and minority neighborhoods, which is a function of structural racism and a legacy of residential segregation, Dr. Johnston said.

“It’s not a question of insurance — it has more to do with the supply side,” he added. “If you want to access a good specialist, your choice of cardiologists is going to be different if you live out in the counties that are more affluent versus if you live in the poor areas in northern St. Louis.”

Another study in the journal compared health care spending by race and ethnicity, finding that at $8,141 per year, spending for white individuals is higher than for Americans of other races and ethnicities, and the portion of it spent on outpatient care is higher than the average.

Health care spending for Black individuals is $7,361 per year, and a smaller proportion of the funds are spent on outpatient care. The amounts that go to pay for care of Black people in an emergency room and hospital are 12 percent and 19 percent higher, respectively, than the nationwide averages.

“This is about poverty, geography and where people live and where primary care clinics are located, and it is about health insurance,” said Joseph Dieleman, an associate professor at the Institute for Health Metrics and Evaluation at the University of Washington in Seattle and an author of the study.

But the difference also reflects patient behavior. “It is also about people’s past experiences with the health care system and the quality of care they or their loved ones have received, which leads to hesitation or resistance to accessing health care early,” Dr. Dieleman said.

The findings may explain some of the disparities in health outcomes, though social and economic factors also play a role, among them poverty, so-called food deserts and neighborhoods that expose residents to pollution and offer few opportunities for physical exercise and recreation.

Another study compared rates of gestational diabetes, finding that it became more prevalent in pregnant women of all ages and across all races and ethnic groups from 2011 to 2019, with the highest rates reported in Asian Indian women.

Overall, Black women face a much higher risk of dying from pregnancy complications than white women, with maternal mortality rates of 41.7 per 100,000 live births for Black women, compared with 13.4 per 100,000 live births for white women.

The disparity persists even when adjusted for factors like age and income, according to an editorial elsewhere in the journal. Black infant mortality rates are also higher, with death rates of 10.62 per 1,000 live births for Black newborns, compared with 4.68 per 1,000 live births for white babies.

Black patients opt for more preventive care when their physician is Black, according to the editorial, and mortality rates for newborns drop sharply when they are cared for by Black physicians.

The proportion of faculty physicians at American medical schools who identified as Black or African American has only slightly increased over the past 30 years, from 2.6 percent of faculty in 1990 to 3.8 percent of faculty in 2020, still far less than their proportion of the general population, the editorial said.

The pandemic has highlighted longstanding inequities, taking a greater toll on Black and Hispanic communities. An editorial in the journal noted that the health care system has a long history of racism. Hospitals only desegregated when they were threatened with the loss of federal funds from the Medicaid and Medicare programs, which were enacted in 1966.

While the A.C.A. and the expansion of Medicaid in many states has improved access to medical care, the inequities persist. The editorial, written by Alexander N. Ortega and Dylan H. Roby of Drexel University in Philadelphia, called for more investment in research, training, clinical practice and community engagement.

“Ending structural racism and inequities in the U.S. health care system has proved to be a challenge,” the authors wrote.

Because of an editing error, an earlier version of this article incorrectly described the journals that Dr. Phil B. Fontanarosa, interim editor in chief of JAMA, said had published more than 850 articles related to racial disparities. They were published in a variety of journals associated with JAMA, not just JAMA itself. 

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Pregnancy, Childbirth and Postpartum Experiences

A Pill for Postpartum Depression: The F.D.A. has approved the first pill for postpartum depression , a milestone considered likely to increase recognition and treatment of the debilitating condition .

Opera Singers: All too often, women in the industry lose work when they become pregnant , even as pregnancy and childbirth are believed to have positive effects on the voice.

Pregnancy Discrimination: A new federal law that requires employers to provide “reasonable accommodations” for pregnant and postpartum workers just went into effect. Here is what that means .

The Most Dangerous Time:  Research shows that most pregnancy-related maternal deaths occur in the year after a baby is born . The discovery is changing how doctors care for new mothers .

Failing Black Families : A groundbreaking new study showed how Black mothers and babies have the worst childbirth outcomes  in the United States, regardless of their socioeconomic status .

• Research article
• Open Access
• Published: 12 January 2021

Social justice in health system; a neglected component of academic nursing education: a qualitative study

• Hosein Habibzadeh 1 ,
• Madineh Jasemi 1 &
• Fariba Hosseinzadegan   ORCID: orcid.org/0000-0002-3464-7385 1  

BMC Nursing volume  20 , Article number:  16 ( 2021 ) Cite this article

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In recent decades, increasing social and health inequalities all over the world has highlighted the importance of social justice as a core nursing value. Therefore, proper education of nursing students is necessary for preparing them to comply with social justice in health systems. This study is aimed to identify the main factors for teaching the concept of social justice in the nursing curriculum.

This is a qualitative study, in which the conventional content analysis approach was employed to analyze a sample of 13 participants selected using purposive sampling method. Semi-structured interviews were conducted to collect and analyze the data.

Analysis of the interviews indicated that insufficient education content, incompetency of educators, and inappropriate education approaches made social justice a neglected component in the academic nursing education. These factors were the main sub-categories of the study and showed the negligence of social justice in academic nursing education.

Research findings revealed the weaknesses in teaching the concept of social justice in the nursing education. Accordingly, it is necessary to modify the content of nursing curriculum and education approaches in order to convey this core value. Since nursing educators act as role models for students, especially in practical and ethical areas, more attention should be paid to competency of nursing educators, specially training in the area of ethical ideology and social justice.

Peer Review reports

Professional values include action standards that are accepted by group members and provide a framework for evaluating beliefs and notions affecting behavior [ 1 ]. Acquisition of professional nursing values is a prerequisite for resolving conflicts; it improves service quality and increases job satisfaction of nurses [ 2 ]. The core values accepted and presented by American Association of Colleges of Nursing (AACN) (1998) include human dignity, integrity, autonomy, altruism, and social justice [ 3 ], out of which social justice has attracted more attention in recent years. Disproportionate burden of diseases and deaths in parts of the society associated with environmental and socioeconomic factors has been recognized for decades; however, the number of documents on these issues has increased dramatically over the past 15 years [ 4 ]. The WHO Commission on Social Determinants of Health attributes these differences to social inequalities in the distribution of power, income, shelter, education, and healthcare as well as climate change, vulnerability, and other life conditions. It also prioritizes social justice as a mechanism for correcting and eliminating inequalities [ 5 ]. Social justice in the health system refers to providing equal healthcare services for all individuals, regardless of their personal characteristics [ 6 ]. The AACN defines social justice as fair treatment, regardless of one’s economic status, race, ethnicity, age, citizenship, disability, or sexual orientation [ 7 ].

Although social justice has been identified as a professional value in documents issued by reputable nursing associations such as International Council of Nurses (ICN), Canadian Nurses Association (CNA), American Nurses Association (ANA), and AACN [ 8 ], the discussion of social justice in nursing profession has always been accompanied by serious doubts and concerns [ 9 ]. In addition, nurses’ responses to social injustice have not always been admirable, and nursing profession’s poor performance originates from various factors such as unawareness [ 10 ].

Development of a professional value such as social justice is a continuous and long-term process that begins with professional nursing education and continues throughout years of nursing practice. Education plays a key role in acquiring professional values [ 11 ]. Students, educators, faculties, clinical and educational experiences, and individual values are among the most important components of learning and development of professional values [ 12 ]. It is very important to train highly skilled and qualified nurses to provide necessary care for heterogeneous populations in today’s ever-changing demographic prospect. Nursing students must understand their responsibility for poplulation health issues and social factors affecting health (eg, world hunger, environmental pollution, lack of access to health care, violation of human rights, and inequitable distribution of health care resources, including nursing services) and in this regard acquire the necessary knowledge and skills [ 13 ].

To institutionalize the concept of social justice in nursing students, especially in developed countries, measures have been taken in the area of education, which include modifications made to nursing curriculum and education approaches [ 14 ]. For instance, simulation is a one of new methods utilized for teaching this concept [ 15 ]. Since the mid-2000s, there has been an increase in tendency towards online learning [ 16 ], co-curricular experiences [ 17 ], and digital storytelling [ 18 ] in order to promote students’ understanding of social justice issues. Nevertheless, some studies have addressed the weaknesses of nursing curriculum in teaching social justice [ 19 , 20 ] and have attributed nurses’ inability in pursuing social justice to their poor scientific and practical competencies [ 21 ]. Although several quantitative and qualitative studies have been conducted in recent decades to institutionalize the concept of social justice among nursing graduates [ 22 , 23 , 24 , 25 ], academic nursing education has unfortunately failed to train competent nurses who seek information and training on social justice. Considering the importance of this subject, a qualitative approach [ 26 ] was adopted to provide an in-depth understanding of social justice based on the realistic results derived from the participants’ real experiences. Therefore, in this study, the experiences of nursing educators and students in identifying the main factors for teaching the concept of social justice in nursing education program were analyzed.

Study design and setting

This qualitative study was conducted using a conventional content analysis method. The participants were recruited from three nursing faculties (Urmia, Tabriz, and Tehran) and two teaching hospitals of Tehran (Motahari Hospital) and Urmia (Talegani Hospital) in Iran. These cities were selected due to their large size and forerun in educational, clinical, and social nursing activities.

Study participants

In view of the objective of the study - identify the main factors for teaching the concept of social justice in the nursing curriculum - we initially selected nursing educators by purposive sampling method. Nursing educators who had more than 5 years of service experience and among the prominent educators with activity in nursing institutions that involved in developing social justice were selected. The data from the study then led us to students and clinical nurses. Among the students, the final year undergraduate students, exemplary and active in social fields, and among the nurses, those with more than 2 years of service experience, accepted by the system professionally and actively in the field of social justice, such as voluntary activities in public health promotion, were selected for the interview.

The participants included 6 men and 9 women with the mean age of 39.07 ± 12.92 years old and mean work experience of 20.00 ± 7.22 years. Out of all the participants, 5 individuals had PhD, whereas 2 had Master’s degrees; the rest had Bachelor’s degrees in nursing. In total, 7 individuals were nursing educators, 2 individuals were clinical nurses, and 4 individuals were nursing students (Table  1 ).

Data collection

The data were collected using in-depth, semi-structured individual interviews conducted at the times and in the places selected by the participants (mainly at nursing faculties). Each interview lasted for 30–90 min; they were audio recorded upon the participants’ permission and transcribed verbatim. All the 13 interviews were conducted by the research team (FH, MJ, and HH) between February and November 2019. The participants were asked questions about their experiences of (learning/teaching) social justice issues. Considering the abstract nature of the research subject, the researchers raised more objective questions. For instance, the educators were asked to “describe their experiences of modification to the curriculum to cover social justice issues”, whereas the students were asked to “describe their experiences of social justice-based practices during internships”. In addition, to better identify factors affecting social justice education in nursing, the educators and students were asked questions such as “Considering your experiences, what factors have affected your engagement in social justice in education?” and “How do you describe education approaches adopted by educators for teaching social justice?”, respectively. (See Additional file  1 for details). The researchers continued the interviews until the data were completely saturated, i.e. when no new idea, concept, or category was derived from the final interviews.

To better relate to the environments of the study and the participants and analyze the data realistically, the researchers also used field notes. Field notes are a brief summary of the observations made while collecting data. This is not limited to a particular type of activity or behavior and assesses the non-verbal behaviors of the participants and their interactions with others. It also depicts a picture of a social position. In this study, field notes also made a detailed presentation of the situation in the right place immediately after the interview and provided the opportunity to confirm the psychological and emotional reactions of the participants. For example, attending the emergency ward of one of the teaching hospitals in Urmia city and observing nursing education in the clinical environment led to a field note focusing the training on the clinical procedures that confirm the insufficient educational content and lack of attention to social justice in nursing education.

Data analysis

After the data were collected, they were analyzed using the conventional content analysis approach. For this purpose, Grundheim and Lundman’s (2004) method was adopted [ 27 ]. In this method, an entire interview is regarded as an analysis unit involving notes that must be analyzed and coded. The researchers listened to the interviews for several times and transcribed the recorded interviews verbatim. The paragraphs, sentences, and words were considered meaning units. A meaning unit is a set of words and sentences that are related to each other in content and are categorized based on their content and context. The texts were reviewed several times to highlight words containing key concepts or meaning units and extract the initial codes. The codes were then reviewed several times in a continuous process from code extraction to labeling. Similar codes were merged, categorized, and labeled and the subcategories were determined. The extracted subcategories were finally compared and merged (if possible) to form the main categories.

Assessing data accuracy and stability

Guba and Lincoln’s (1986) criteria were used to ensure the accuracy and stability of the research data. The credibility of the data was assessed using member-checking and prolonged engagement techniques. For member-checking technique, the participants reviewed the content of the interview and the resulting codes to ensure the accurate meaning and for really reflecting their experiences. The data were also assessed by an external researcher (peer debriefing). To ensure the dependability, data collection methods, interview, taking notes, coding, and data analysis were expressed in detail in order to make judging by the external auditor (external auditing). In order to achieve confirmability, the audit trail method was used, so that all stages of the research, especially the stages of data analysis and the results, were provided to checking of two expert colleagues in the field of qualitative research. The transferability of the findings was also established by providing a rich description of the research report and the content of the interviews was represented by the selected quotations from the participants [ 28 ].

Ethical considerations

The participants were selected after the approval of Ethics Committee of Urmia University of Medical Sciences and the necessary permissions (Code: IR.UMSU.REC.1397.223) were granted. Prior to the interviews, the participants were informed about their anonymity, confidentiality of their information, the research method and objectives, and their right to leave the study at will. The participants also signed informed consent forms.

Classification of the interviews showed that three sub-categories of “insufficient educational content”, “limited competency of nursing educators”, and “inappropriate education approaches” led to the emergence of the main category called “social justice; a neglected component of academic education” (Table  2 ).

Social justice; a neglected component of academic education

Proper education plays a major role in training justice-seeking nurses. Social justice and its importance in healthcare are constituents of the nursing syllabus. Paying more attention to this issue in practical and objective areas of education by educators can influence students’ thoughts, attitudes, and behaviors to pursue justice in health systems. However, Iran’s education system has unfortunately failed to promote justice because of insufficient educational content, limited competency of nursing educators, and inappropriate education approaches.

Insufficient educational content

Development of a comprehensive nursing curriculum, especially on ethical issues such as social justice, could substantially contribute to the preparation of socially and morally conscious nurses who are able to make significant changes in the public health at local, national, and international levels. In this study, the participants highlighted some weaknesses in the content of the existing nursing curriculum such as lack of attention to social justice, discontinuity in presenting courses on ethical values, and allocating most of the nursing courses to medical issues and clinical care.

Lack of attention to social justice in nursing curriculum

Social justice is a core nursing value which plays a significant role in promoting justice by nursing students and nurses. However, according to the participants, it has unfortunately been neglected in the existing nursing curriculum. In this regard, one participant stated,

“In the fourth semester, we studied a course on nursing ethics. I think there was no discussion on social justice because I don’t remember anything about this topic” (Participant No. 7/Nursing Student).

Regarding the importance of teaching social determinants of health, another participant stated,

“I was not aware of the importance of social issues in health until I participated in a workshop called ‘Social Justice in Health’. It really changed my beliefs and broadened my perspective” (Participant No. 10/Clinical Nurse).

Discontinuity in presenting courses on ethical values

Values are major components of the nursing profession. The institutionalization and development of professional values such as social justice contribute significantly to the future of this profession. The few number of courses presented on ethical values and discontinuity in the presented courses (for instance, no course on ethical values is provided for post-graduate students) were major items mentioned by the participants. In this regard, one of the participants stated,

“When students are repeatedly reminded of the importance of a value, they will realize its importance and the value will be institutionalized in them. We partially studied professional values and social justice issues in the fourth semester of our undergraduate courses; however, no similar course was provided for us afterwards during the Master’s program” (Participant No. 5/ Faculty Member).

Or another participant stated:

“We cannot deny that the ethical issues have been institutionalized in our professional graduates to some extent. But, these issues are not worked on in a principled and scientific manner and that there is no constant focus on them. After all, the effect of the hidden curriculum has been more prominent.”(Participant No.1/Faculty Member).

Allocating most of nursing courses to medical issues and clinical care

Diseases and clinical care are among the most fundamental parts of theoretical and practical training provided for nursing students; however, due to the multi-dimensional nature of the nursing profession, special attention should be paid to other dimensions as well. According to the research results, the existing nursing curriculum focuses mainly on transferring knowledge and skills associated with physical and routine care. One participant expressed,

“Most of our courses were related to various diseases and nursing care, and educators rarely talked about ethical and legal issues during their lectures” (Participant No. 6/ Nursing Student).

Another participant stated the reasons for the focus of nursing education on the physical and caring dimensions:

“Well, when we see that our graduates have problems in providing quality clinical care, we also have to do more in the field of clinical care.”(Participant No.3/ Faculty Member).

Limited competency of nursing educators

Educators play an undeniable role in training competent nurses through institutionalizing beliefs and behaviors. Using proper teaching and behavioral approaches, educators can improve students’ critical thinking skills and prepare them to promote justice in health systems. According to the participants, insufficient competency of nursing educators in teaching social justice issues and inappropriate value perspectives of educators in developing social justice were the main properties of this category.

Insufficient capabilities of educators in teaching social justice issues

Educators must be equipped with sufficient scientific, practical, and ethical capacities in order to effectively institutionalize the concept of social justice in students. According to the participants, nursing educators’ insufficient knowledge and experience about social justice issues make it difficult for them to transfer such knowledge to their students. One participant said,

“When I was a student, I once informed my educator about the unjust patient admission procedure in the surgical department. Yet, my educator recommended me to do what the head nurses would say. I did not see the necessary authority in my educator to establish justice” (Participant No. 11/ Clinical Nurse).

Low presence of nursing educators in clinical and community settings is also one of the factors that, according to the participants, has contributed to this problem.

“Unfortunately, our professors are so involved in education and research, especially to promote themselves, that they do not have the opportunity to address social issues.” (Participant No.9/ Faculty Member).

Inappropriate value perspectives of educators in developing social justice

The participants highlighted the important role of nursing educators’ ethical perspectives in promoting the quality of education and training qualified nurses who would provide services tailored to the needs of the society. They also argued that ethical values could help educators establish and expand social justice in health systems. According to the results, most of the educators had undesirable value perspectives on establishing social justice in the area of health. In this respect, participant no. 5 stated,

“When a nurse has no right to make any decisions in a healthcare system, what can I say to the student about social justice?” (Participant No. 5/ Faculty Member).

“My main responsibility is to transfer knowledge in the field of nursing and I think ethics should be taught by educators in medical ethics.” (Participant No.2/ Faculty Member).

Inappropriate education approaches

Education approaches are considered an essential part of the educational structure and play a key role in transferring ethical values such as social justice to students. Given the abstract nature of social justice, choosing the best education approach could help educators resolve complicated problems during teaching in order to institutionalize professional values and beliefs. According to the findings, educators adopt poor education approaches to transfer ethical values such as social justice and self-awareness to students. In this regard, focusing on traditional education approaches and using insufficient affective learning approaches were cited by the participants.

Focusing on traditional education approaches

Undoubtedly, lecturing is one of the most widely used education approaches; however, this traditional method is very ineffective in teaching abstract concepts such as social justice. According to the participants, educators mostly use lecturing approach to teach social justice issues and students are rarely involved in the teaching process. One participant argued that educators mainly use teacher-centered approaches in ethical discussions, stating,

“We (the students) had no active role in the professional ethics class. The educator spoke on relevant topics based on the availed syllabus and provided some examples of clinical ethical issues. However, I think that educators must discuss social justice issues with students to help them visualize and understand cases of injustice and discuss appropriate reactions in such situations” (Participant No. 13/ Nursing Student).

Another participant stated this:

“The predominant teaching method in professional ethics classes has been lecturing. Every now and then, there was some discussions in between, but it was very rare. Other nursing educators were also using the lecture method when talking about ethics” (Participant No. 7/ Nursing Student).

Using insufficient affective learning approaches

The use of affective learning strategies such as reflective activities and simulations leading to emotional responses plays an important role in creating self-reflection and transferring professional knowledge and skills to nursing students. However, based on the participants’ experience, affective learning approaches are not used effectively and systematically in teaching ethical issues such as social justice. In this regard, one participant stated,

“Since there are too many topics on professional ethics, we (educators) can only convey basic issues to students and it is difficult for us to adopt other learning strategies such as the affective approach” (Participant No. 4/ Faculty Member).

The same participant further stated:

“Now, in the professional ethics class, I do my best to teach the content with a combination of methods. For example, we have formed a group for medical students in the cyberspace (WhatsApp) and asked students to express the issues and questions of clinical ethics. They should raise it there because there is no time in the classroom for these issues. However, we have not performed the same for nursing students yet” (Participant No. 4/ Faculty Member).

According to the research findings, social justice in a health system is a neglected component of academic nursing education due to factors including insufficient educational content, limited competency of nursing educators, and inappropriate education approaches. These factors were introduced as the main research subcategories in this study.

Some weaknesses were observed in the content of nursing curriculum, which is an main factor in promoting professional nursing values such as social justice in nursing students. Lack of attention to the issue of social justice in nursing curriculum has also been mentioned in other studies [ 13 , 20 ]. Based on the participants’ experience, most of the nursing courses are allocated to medical issues and clinical care. According to Thurman, clinical specialties have received the main focus of nursing curriculum, whereas little attention has been paid to social justice issues [ 21 ] . This problem can be attributed to the poor performance of nurses in clinical care. The participants also believed that there was discontinuity in presenting courses on ethical values because the professional ethics course was presented only to undergraduate students. This issue disrupts the proper institutionalization of ethical values such as social justice in nursing students. Frenk et al. believe that the preparation of healthcare professionals to address current healthcare inequalities and challenges has been slowed down by obsolete, fragmented, and static curriculum [ 29 ]. In addition, Rozendo et al. highlighted inconsistencies in terms of presenting social justice-related issues in nursing curricula and argued that there was little material on social justice in post-graduate nursing programs [ 14 ].

Nursing educators’ competencies also affect teaching social justice issues. In today’s rapidly-changing world facing numerous crises, experienced educators play a significant role in training qualified nurses equipped with various skills enabling them to create social development. Accordingly, Read et al. highlighted the critical role of nursing educators in institutionalizing fundamental principles of social justice and health equity in students [ 30 ]. According to Ellis, educators should shift nursing students’ learning and thinking attitudes from individualism to community-centered frameworks and from tertiary (reactionary) to primary (preventive) care approaches [ 31 ]. However, unfortunately, the research findings indicated that nursing educators are not sufficiently qualified to teach and institutionalize social justice in students. In this regard, educators’ insufficient knowledge and experience in teaching social justice issues were highlighted by the participants. Borhani et al. found that ethical knowledge of nursing educators determined their students’ professional ethics competencies [ 32 ]. Akbas et al also argued that nursing educators’ knowledge and skills were the first and most important factors affecting their success in teaching issues of professional ethics [ 33 ]. As mentioned by the participants, inappropriate value perspectives of educators in developing social justice was another weakness of nursing educators. The significant impact of educators’ perspectives on teaching ethical values such as social justice has also been emphasized by Parandeh et al. [ 12 ].

Education approaches adopted to present and convey ethical values to students are of high importance. In this regard, Einhellig discussed the ineffectiveness of traditional approaches such as lecturing in institutionalizing social justice in nursing graduates and outlined the benefits of affective learning approaches [ 19 ]. According to the findings, lecturing is the dominant approach used to teach social justice in Iran’s nursing faculties, which is an inefficient teaching approach, as suggested by the research literature. This is probably due to the large number of students and limited time allocated to each academic course. While cognitive learning approaches rely on principles and concepts, affective learning approaches support the integration of knowledge with emotions, attitudes, and personal beliefs [ 34 ]. Neumann found that affective education approaches could enhance students’ understanding and use of ethical values [ 35 ]. Einhellig highlighted that nursing faculties need to use various strategies with a focus on behavior changes in order to successfully institutionalize the concept of social justice in nursing graduates [ 24 ].

Limitations

The findings of the present study were limited to factors affecting education of social justice in the nursing curriculum in the health system in the culture of Iran. Other limitations of this study was the consideration of the three nursing faculties and two teaching hospitals in Iran. As such, it may not be a representative of the experiences of all the nursing profession members in Iran. Limitations of our study proposed the need for conducting further studies with larger and mixed groups and in different cultures.

The research findings provided researchers with an insight into the weaknesses of nursing curricula, educators, and education approaches in social justice development in Iran. It seems that more attention must be paid to professional values and social determinant of health in nursing curricula in order to train justice-seeking nurses with a sense of responsibility. Educators play a prominent role in training competent individuals who are aware of and sensitive to social issues and inequalities. It is necessary to change the education approaches adopted by nursing educators in order to institutionalize the concept of social justice in students. After changing the content of nursing curriculum and applying different education approaches, future studies can focus on the impact of such changes on social development and social justice promotion.

Availability of data and materials

The interview dataset generated and analysed during the current study are not publicly available due to promises of participant anonymity and confidentiality. However, on reasonable request the data could be available from the corresponding author. All applications should be sent to [email protected] . All requests will be answered within a maximum of 1 month by email.

Abbreviations

World Health Organization

American Association of Colleges of Nursing

International Council of Nurses

American Nurses Association

Canadian Nurses Association

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Acknowledgments

This study is a part of a PhD dissertation approved and funded by Vice Chancellor for Research, Urmia University of Medical Sciences. The researchers would like to thank the authorities of School of Nursing and Midwifery, Urmia University of Medical Sciences, as well as the participants for their kind cooperation.

This study was funded by Department of Research, Urmia University of Medical Sciences, which had no role in the design of the study, data collection, analysis, interpretation of data, or writing the manuscript.

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The study was designed by HH,MJ and FH. FH participated as the main interviewer. The initial deductive data analysis was done by FH and used as validation of the analysis carried out by HH and MJ. The final data analysis of the interviews was discussed and consented to by all authors. A first draft of the article was developed by FH and MJ. All authors then contributed to this, and finalized it together. FH was responsible for the final draft of the manuscript. All authors read and approved the final manuscript.

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Habibzadeh, H., Jasemi, M. & Hosseinzadegan, F. Social justice in health system; a neglected component of academic nursing education: a qualitative study. BMC Nurs 20 , 16 (2021). https://doi.org/10.1186/s12912-021-00534-1

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By Francesca Colombo , Head, Health Division, Organisation for Economic Co-operation and Development (OECD) and Helen E. Clark , Prime Minister of New Zealand (1999-2008), The Helen Clark Foundation

The COVID-19 crisis has affected more than 188 countries and regions worldwide, causing large-scale loss of life and severe human suffering. The crisis poses a major threat to the global economy, with drops in activity, employment, and consumption worse than those seen during the 2008 financial crisis . COVID-19 has also exposed weaknesses in our health systems that must be addressed. How?

For a start, greater investment in population health would make people, particularly vulnerable population groups, more resilient to health risks. The health and socio-economic consequences of the virus are felt more acutely among disadvantaged populations, stretching a social fabric already challenged by high levels of inequalities. The crisis demonstrates the consequences of poor investment in addressing wider social determinants of health, including poverty, low education and unhealthy lifestyles. Despite much talk of the importance of health promotion, even across the richer OECD countries barely 3% of total health spending is devoted to prevention . Building resilience for populations also requires a greater focus on solidarity and redistribution in social protection systems to address underlying structural inequalities and poverty.

Beyond creating greater resilience in populations, health systems must be strengthened.

High-quality universal health coverage (UHC) is paramount. High levels of household out-of-pocket payments for health goods and services deter people from seeking early diagnosis and treatment at the very moment they need it most. Facing the COVID-19 crisis, many countries have strengthened access to health care, including coverage for diagnostic testing. Yet others do not have strong UHC arrangements. The pandemic reinforced the importance of commitments made in international fora, such as the 2019 High-Level Meeting on Universal Health Coverage , that well-functioning health systems require a deliberate focus on high-quality UHC. Such systems protect people from health threats, impoverishing health spending, and unexpected surges in demand for care.

Second, primary and elder care must be reinforced. COVID-19 presents a double threat for people with chronic conditions. Not only are they at greater risk of severe complications and death due to COVID-19; but also the crisis creates unintended health harm if they forgo usual care, whether because of disruption in services, fear of infections, or worries about burdening the health system. Strong primary health care maintains care continuity for these groups. With some 94% of deaths caused by COVID-19 among people aged over 60 in high-income countries, the elder care sector is also particularly vulnerable, calling for efforts to enhance control of infections, support and protect care workers and better coordinate medical and social care for frail elderly.

Third, the crisis demonstrates the importance of equipping health systems with both reserve capacity and agility. There is an historic underinvestment in the health workforce, with estimated global shortages of 18 million health professionals worldwide , mostly in low- and middle-income countries. Beyond sheer numbers, rigid health labour markets make it difficult to respond rapidly to demand and supply shocks. One way to address this is by creating a “reserve army” of health professionals that can be quickly mobilised. Some countries have allowed medical students in their last year of training to start working immediately, fast-tracked licenses and provided exceptional training. Others have mobilised pharmacists and care assistants. Storing a reserve capacity of supplies such as personal protection equipment, and maintaining care beds that can be quickly transformed into critical care beds, is similarly important.

Fourth, stronger health data systems are needed. The crisis has accelerated innovative digital solutions and uses of digital data, smartphone applications to monitor quarantine, robotic devices, and artificial intelligence to track the virus and predict where it may appear next. Access to telemedicine has been made easier. Yet more can be done to leverage standardised national electronic health records to extract routine data for real-time disease surveillance, clinical trials, and health system management. Barriers to full deployment of telemedicine, the lack of real-time data, of interoperable clinical record data, of data linkage capability and sharing within health and with other sectors remain to be addressed.

Fifth, an effective vaccine and successful vaccination of populations around the globe will provide the only real exit strategy. Success is not guaranteed and there are many policy issues yet to be resolved. International cooperation is vital. Multilateral commitments to pay for successful candidates would give manufacturers certainty so that they can scale production and have vaccine doses ready as quickly as possible following marketing authorisation, but could also help ensure that vaccines go first to where they are most effective in ending the pandemic. Whilst leaders face political pressure to put the health of their citizens first, it is more effective to allocate vaccines based on need. More support is needed for multilateral access mechanisms that contain licensing commitments and ensure that intellectual property is no barrier to access, commitments to technology transfer for local production, and allocation of scarce doses based on need.

The pandemic offers huge opportunities to learn lessons for health system preparedness and resilience. Greater focus on anticipating responses, solidarity within and across countries, agility in managing responses, and renewed efforts for collaborative actions will be a better normal for the future.

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2. Improving population health and building healthy societies in times of COVID-19

By Helena Legido-Quigley , Associate Professor, London School of Hygiene and Tropical Medicine

The COVID-19 pandemic has been a stark reminder of the fragility of population health worldwide; at time of writing, more than 1 million people have died from the disease. The pandemic has already made evident that those suffering most from COVID-19 belong to disadvantaged populations and marginalised communities. Deep-rooted inequalities have contributed adversely to the health status of different populations within and between countries. Besides the direct and indirect health impacts of COVID-19 and the decimation of health systems, restrictions on population movement and lockdowns introduced to combat the pandemic are expected to have economic and social consequences on an unprecedented scale .

Population health – and addressing the consequences of COVID-19 – is about improving the physical and mental health outcomes and wellbeing of populations locally, regionally and nationally, while reducing health inequalities.¹ Moreover, there is an increasing recognition that societal and environmental factors, such as climate change and food insecurity, can also influence population health outcomes.

The experiences of Maria, David, and Ruben – as told by Spanish public broadcaster RTVE – exemplify the real challenges that people living in densely populated urban areas have faced when being exposed to COVID-19.¹

Maria is a Mexican migrant who has just returned from Connecticut to the Bronx. Her partner Jorge died in Connecticut from COVID-19. She now has no income and is looking for an apartment for herself and her three children. When Jorge became ill, she took him to the hospital, but they would not admit him and he was sent away to be cared for by Maria at home with their children. When an ambulance eventually took him to hospital, it was too late. He died that same night, alone in hospital. She thinks he had diabetes, but he was never diagnosed. They only had enough income to pay the basic bills. Maria is depressed, she is alone, but she knows she must carry on for her children. Her 10-year old child says that if he could help her, he would work. After three months, she finds an apartment.

David works as a hairdresser and takes an overcrowded train every day from Leganés to Chamberi in the centre of Madrid. He lives in a small flat in San Nicasio, one of the poorest working-class areas of Madrid with one of the largest ageing populations in Spain. The apartments are very small, making it difficult to be in confinement, and all of David’s neighbours know somebody who has been a victim of COVID-19. His father was also a hairdresser. David's father was not feeling well; he was taken to hospital by ambulance, and he died three days later. David was not able to say goodbye to his father. Unemployment has increased in that area; small local shops are losing their customers, and many more people are expecting to lose their jobs.

Ruben lives in Iztapalapa in Mexico City with three children, a daughter-in-law and five grandchildren. Their small apartment has few amenities, and no running water during the evening. At three o’clock every morning, he walks 45 minutes with his mobile stall to sell fruit juices near the hospital. His daily earnings keep the family. He goes to the central market to buy fruit, taking a packed dirty bus. He thinks the city's central market was contaminated at the beginning of the pandemic, but it could not be closed as it is the main source of food in the country. He has no health insurance, and he knows that as a diabetic he is at risk, but medication for his condition is too expensive. He has no alternative but to go to work every day: "We die of hunger or we die of COVID."

These real stories highlight the issues that must be addressed to reduce persistent health inequalities and achieve health outcomes focusing on population health. The examples of Maria, David and Ruben show the terrible outcomes COVID-19 has had for people living in poverty and social deprivation, older people, and those with co-morbidities and/or pre-existing health conditions. All three live in densely populated urban areas with poor housing, and have to travel long distances in overcrowded transport. Maria’s loss of income has had consequences for her housing security and access to healthcare and health insurance, which will most likely lead to worse health conditions for her and her children. Furthermore, all three experienced high levels of stress, which is magnified in the cases of Maria and David who were unable to be present when their loved ones died.

The COVID-19 pandemic has made it evident that to improve the health of the population and build healthy societies, there is a need to shift the focus from illness to health and wellness in order to address the social, political and commercial determinants of health; to promote healthy behaviours and lifestyles; and to foster universal health coverage.² Citizens all over the world are demanding that health systems be strengthened and for governments to protect the most vulnerable. A better future could be possible with leadership that is able to carefully consider the long-term health, economic and social policies that are needed.

In order to design and implement population health-friendly policies, there are three prerequisites. First, there is a need to improve understanding of the factors that influence health inequalities and the interconnections between the economic, social and health impacts. Second, broader policies should be considered not only within the health sector, but also in other sectors such as education, employment, transport and infrastructure, agriculture, water and sanitation. Third, the proposed policies need to be designed through involving the community, addressing the health of vulnerable groups, and fostering inter-sectoral action and partnerships.

Finally, within the UN's Agenda 2030 , Sustainable Development Goal (SDG) 3 sets out a forward-looking strategy for health whose main goal is to attain healthier lives and wellbeing. The 17 interdependent SDGs offer an opportunity to contribute to healthier, fairer and more equitable societies from which both communities and the environment can benefit.

The stories of Maria, David and Ruben are real stories featured in the Documentary: The impact of COVID19 in urban outskirts, Directed by Jose A Guardiola. Available here. Permission has been granted to narrate these stories.

Buck, D., Baylis, A., Dougall, D. and Robertson, R. (2018). A vision for population health: Towards a healthier future . [online] London: The King's Fund. [Accessed 20 Sept. 2020]

Wilton Park. (2020). Healthy societies, healthy populations (WP1734). Wiston House, Steyning. Retrieved from https://www.wiltonpark.org.uk/event/wp1734/ Cohen B. E. (2006). Population health as a framework for public health practice: a Canadian perspective. American journal of public health , 96 (9), 1574–1576.

3. Imagine a 'well-care' system that invests in keeping people healthy

By Maliha Hashmi , Executive Director, Health and Well-Being and Biotech, NEOM, and Jan Kimpen , Global Chief Medical Officer, Philips

Imagine a patient named Emily. Emily is aged 32 and I’m her doctor.

Emily was 65lb (29kg) above her ideal body weight, pre-diabetic and had high cholesterol. My initial visit with Emily was taken up with counselling on lifestyle changes, mainly diet and exercise; typical advice from one’s doctor in a time-pressured 15-minute visit. I had no other additional resources, incentives or systems to support me or Emily to help her turn her lifestyle around.

I saw Emily eight months later, not in my office, but in the hospital emergency room. Her husband accompanied her – she was vomiting, very weak and confused. She was admitted to the intensive care unit, connected to an insulin drip to lower her blood sugar, and diagnosed with type 2 diabetes. I talked to Emily then, emphasizing that the new medications for diabetes would only control the sugars, but she still had time to reverse things if she changed her lifestyle. She received further counselling from a nutritionist.

Over the years, Emily continued to gain weight, necessitating higher doses of her diabetes medication. More emergency room visits for high blood sugars ensued, she developed infections of her skin and feet, and ultimately, she developed kidney disease because of the uncontrolled diabetes. Ten years after I met Emily, she is 78lb (35kg) above her ideal body weight; she is blind and cannot feel her feet due to nerve damage from the high blood sugars; and she will soon need dialysis for her failing kidneys. Emily’s deteriorating health has carried a high financial cost both for herself and the healthcare system. We have prevented her from dying and extended her life with our interventions, but each interaction with the medical system has come at significant cost – and those costs will only rise. But we have also failed Emily by allowing her diabetes to progress. We know how to prevent this, but neither the right investments nor incentives are in place.

Emily could have been a real patient of mine. Her sad story will be familiar to all doctors caring for chronically ill patients. Unfortunately, patients like Emily are neglected by health systems across the world today. The burden of chronic disease is increasing at alarming rates. Across the OECD nearly 33% of those over 15 years live with one or more chronic condition, rising to 60% for over-65s. Approximately 50% of chronic disease deaths are attributed to cardiovascular disease (CVD). In the coming decades, obesity, will claim 92 million lives in the OECD while obesity-related diseases will cut life expectancy by three years by 2050.

These diseases can be largely prevented by primary prevention, an approach that emphasizes vaccinations, lifestyle behaviour modification and the regulation of unhealthy substances. Preventative interventions have been efficacious. For obesity, countries have effectively employed public awareness campaigns, health professionals training, and encouragement of dietary change (for example, limits on unhealthy foods, taxes and nutrition labelling).⁴,⁵ Other interventions, such as workplace health-promotion programmes, while showing some promise, still need to demonstrate their efficacy.

The COVID-19 crisis provides the ultimate incentive to double down on the prevention of chronic disease. Most people dying from COVID-19 have one or more chronic disease, including obesity, CVD, diabetes or respiratory problems – diseases that are preventable with a healthy lifestyle. COVID-19 has highlighted structural weaknesses in our health systems such as the neglect of prevention and primary care.

While the utility of primary prevention is understood and supported by a growing evidence base, its implementation has been thwarted by chronic underinvestment, indicating a lack of societal and governmental prioritization. On average, OECD countries only invest 2.8% of health spending on public health and prevention. The underlying drivers include decreased allocation to prevention research, lack of awareness in populations, the belief that long-run prevention may be more costly than treatment, and a lack of commitment by and incentives for healthcare professionals. Furthermore, public health is often viewed in a silo separate from the overall health system rather than a foundational component.

Health benefits aside, increasing investment in primary prevention presents a strong economic imperative. For example, obesity contributes to the treatment costs of many other diseases: 70% of diabetes costs, 23% for CVD and 9% for cancers. Economic losses further extend to absenteeism and decreased productivity.

Fee-for-service models that remunerate physicians based on the number of sick patients they see, regardless the quality and outcome, dominate healthcare systems worldwide. Primary prevention mandates a payment system that reimburses healthcare professionals and patients for preventive actions. Ministries of health and governmental leaders need to challenge skepticism around preventive interventions, realign incentives towards preventive actions and those that promote healthy choices by people. Primary prevention will eventually reduce the burden of chronic diseases on the healthcare system.

As I reflect back on Emily and her life, I wonder what our healthcare system could have done differently. What if our healthcare system was a well-care system instead of a sick-care system? Imagine a different scenario: Emily, a 32 year old pre-diabetic, had access to a nutritionist, an exercise coach or health coach and nurse who followed her closely at the time of her first visit with me. Imagine if Emily joined group exercise classes, learned where to find healthy foods and how to cook them, and had access to spaces in which to exercise and be active. Imagine Emily being better educated about her diabetes and empowered in her healthcare and staying healthy. In reality, it is much more complicated than this, but if our healthcare systems began to incentivize and invest in prevention and even rewarded Emily for weight loss and healthy behavioural changes, the outcome might have been different. Imagine Emily losing weight and continuing to be an active and contributing member of society. Imagine if we invested in keeping people healthy rather than waiting for people to get sick, and then treating them. Imagine a well-care system.

Anderson, G. (2011). Responding to the growing cost and prevalence of people with multiple chronic conditions . Retrieved from OECD.

Institute for Health Metrics and Evaluation. GBD Data Visualizations. Retrieved here.

OECD (2019), The Heavy Burden of Obesity: The Economics of Prevention, OECD Health Policy Studies, OECD Publishing, Paris.

OECD. (2017). Obesity Update . Retrieved here.

Malik, V. S., Willett, W. C., & Hu, F. B. (2013). Global obesity: trends, risk factors and policy implications. Nature Reviews Endocrinology , 9 (1), 13-27.

Lang, J., Cluff, L., Payne, J., Matson-Koffman, D., & Hampton, J. (2017). The centers for disease control and prevention: findings from the national healthy worksite program. Journal of occupational and environmental medicine , 59 (7), 631.

Gmeinder, M., Morgan, D., & Mueller, M. (2017). How much do OECD countries spend on prevention? Retrieved from OECD.

Jordan RE, Adab P, Cheng KK. Covid-19: risk factors for severe disease and death. BMJ. 2020;368:m1198.

Richardson, A. K. (2012). Investing in public health: barriers and possible solutions. Journal of Public Health , 34 (3), 322-327.

Yong, P. L., Saunders, R. S., & Olsen, L. (2010). Missed Prevention Opportunities The healthcare imperative: lowering costs and improving outcomes: workshop series summary (Vol. 852): National Academies Press Washington, DC.

OECD. (2019). The Heavy Burden of Obesity: The Economics of Prevention. Retrieved here .

McDaid, D., F. Sassi and S. Merkur (Eds.) (2015a), “Promoting Health, Preventing Disease: The Economic Case ”, Open University Press, New York.

OECD. (2019). The Heavy Burden of Obesity: The Economics of Prevention. Retrieved from OECD.

4. Why e arly detection and diagnosis is critical

By Paul Murray , Head of Life and Health Products, Swiss Re, and André Goy , Chairman and Executive Director & Chief of Lymphoma, John Theurer Cancer Center, Hackensack University Medical Center

Although healthcare systems around the world follow a common and simple principle and goal – that is, access to affordable high-quality healthcare – they vary significantly, and it is becoming increasingly costly to provide this access, due to ageing populations, the increasing burden of chronic diseases and the price of new innovations.

Governments are challenged by how best to provide care to their populations and make their systems sustainable. Neither universal health, single payer systems, hybrid systems, nor the variety of systems used throughout the US have yet provided a solution. However, systems that are ranked higher in numerous studies, such as a 2017 report by the Commonwealth Fund , typically include strong prevention care and early-detection programmes. This alone does not guarantee a good outcome as measured by either high or healthy life expectancy. But there should be no doubt that prevention and early detection can contribute to a more sustainable system by reducing the risk of serious diseases or disorders, and that investing in and operationalizing earlier detection and diagnosis of key conditions can lead to better patient outcomes and lower long-term costs.

To discuss early detection in a constructive manner it makes sense to describe its activities and scope. Early detection includes pre-symptomatic screening and treatment immediately or shortly after first symptoms are diagnosed. Programmes may include searching for a specific disease (for example, HIV/AIDS or breast cancer), or be more ubiquitous. Prevention, which is not the focus of this blog, can be interpreted as any activities undertaken to avoid diseases, such as information programmes, education, immunization or health monitoring.

Expenditures for prevention and early detection vary by country and typically range between 1-5% of total health expenditures.¹ During the 2008 global financial crisis, many countries reduced preventive spending. In the past few years, however, a number of countries have introduced reforms to strengthen and promote prevention and early detection. Possibly the most prominent example in recent years was the introduction of the Affordable Care Act in the US, which placed a special focus on providing a wide range of preventive and screening services. It lists 63 distinct services that must be covered without any copayment, co-insurance or having to pay a deductible.

Whilst logic dictates that investment in early detection should be encouraged, there are a few hurdles and challenges that need to be overcome and considered. We set out a few key criteria and requirements for an efficient early detection program:

1. Accessibility The healthcare system needs to provide access to a balanced distribution of physicians, both geographically (such as accessibility in rural areas), and by specialty. Patients should be able to access the system promptly without excessive waiting times for diagnoses or elective treatments. This helps mitigate conditions or diseases that are already quite advanced or have been incubating for months or even years before a clinical diagnosis. Access to physicians varies significantly across the globe from below one to more than 60 physicians per 10,000 people.² One important innovation for mitigating access deficiencies is telehealth. This should give individuals easier access to health-related services, not only in cases of sickness but also to supplement primary care.

2. Early symptoms and initial diagnosis Inaccurate or delayed initial diagnoses present a risk to the health of patients, can lead to inappropriate or unnecessary testing and treatment, and represents a significant share of total health expenditures. A medical second opinion service, especially for serious medical diagnoses, which can occur remotely, can help improve healthcare outcomes. Moreover, studies show that early and correct diagnosis opens up a greater range of curative treatment options and can reduce costs (e.g. for colon cancer, stage-four treatment costs are a multiple of stage-one treatment costs).³

3. New technology New early detection technologies can improve the ability to identify symptoms and diseases early: i. Advances in medical monitoring devices and wearable health technology, such as ECG and blood pressure monitors and biosensors, enable patients to take control of their own health and physical condition. This is an important trend that is expected to positively contribute to early detection, for example in atrial fibrillation and Alzheimers’ disease. ii. Diagnostic tools, using new biomarkers such as liquid biopsies or volatile organic compounds, together with the implementation of machine learning, can play an increasing role in areas such as oncology or infectious diseases.⁴

4. Regulation and Intervention Government regulation and intervention will be necessary to set ranges of normality, to prohibit or discourage overdiagnosis and to reduce incentives for providers to overtreat patients or to follow patients' inappropriate requests. In some countries, such as the US, there has been some success through capitation models and value-based care. Governments might also need to intervene to de-risk the innovation paradigm, such that private providers of capital feel able to invest more in the development of new detection technologies, in addition to proven business models in novel therapeutics.

OECD Health Working Papers No. 101 "How much do OECD countries spend on prevention" , 2017

World Health Organization; Global Health Observatory (GHO) data; https://www.who.int/gho/health_workforce/physicians_density/en/

Saving lives, averting costs; A report for Cancer Research UK, by Incisive Health, September 2014

Liquid Biopsy: Market Drivers And Obstacles; by Divyaa Ravishankar, Frost & Sullivan, January 21, 2019

Liquid Biopsies Become Cheap and Easy with New Microfluidic Device; February 26, 2019

How America’s 5 Top Hospitals are Using Machine Learning Today; by Kumba Sennaar, February 19, 2019

5. The business case for private investment in healthcare for all

Pascal Fröhlicher, Primary Care Innovation Scholar, Harvard Medical School, and Ian Wijaya, Managing Director in Lazard’s Global Healthcare Group

Faith, a mother of two, has just lost another customer. Some households where she is employed to clean, in a small town in South Africa, have little understanding of her medical needs. As a type 2 diabetes patient, this Zimbabwean woman visits the public clinic regularly, sometimes on short notice. At her last visit, after spending hours in a queue, she was finally told that the doctor could not see her. To avoid losing another day of work, she went to the local general practitioner to get her script, paying more than three daily wages for consultation and medication. Sadly, this fictional person reflects a reality for many people in middle-income countries.

Achieving universal health coverage by 2030, a key UN Sustainable Development Goal (SDG), is at risk. The World Bank has identified a $176 billion funding gap , increasing every year due to the growing needs of an ageing population, with the health burden shifting towards non-communicable diseases (NCDs), now the major cause of death in emerging markets . Traditional sources of healthcare funding struggle to increase budgets sufficiently to cover this gap and only about 4% of private health care investments focus on diseases that primarily affect low- and middle-income countries.

In middle-income countries, private investors often focus on extending established businesses, including developing private hospital capacity, targeting consumers already benefiting from quality healthcare. As a result, an insufficient amount of private capital is invested in strengthening healthcare systems for everyone.

Why is this the case? We discussed with senior health executives investing in Lower and Middle Income Countries (LMIC) and the following reasons emerged:

• Small market size . Scaling innovations in healthcare requires dealing with country-specific regulatory frameworks and competing interest groups, resulting in high market entry cost.
• Talent . Several LMICs are losing nurses and doctors but also business and finance professionals to European and North American markets due to the lack of local opportunities and a significant difference in salaries.
• Untested business models with relatively low gross margins. Providing healthcare requires innovative business models where consumers’ willingness to pay often needs to be demonstrated over a significant period of time. Additionally, relatively low gross margins drive the need for scale to leverage administrative costs, which increases risk.
• Government Relations. The main buyer of health-related products and services is government; yet the relationship between public and private sectors often lacks trust, creating barriers to successful collaboration. Add to that significant political risk, as contracts can be cancelled by incoming administrations after elections. Many countries also lack comprehensive technology strategies to successfully manage technological innovation.
• Complexity of donor funding. A significant portion of healthcare is funded by private donors, whose priorities might not always be congruent with the health priorities of the government.

Notwithstanding these barriers, healthcare, specifically in middle-income settings, could present an attractive value proposition for private investors:

• Economic growth rates . A growing middle class is expanding the potential market for healthcare products and services.
• Alignment of incentives . A high ratio of out-of-pocket payments for healthcare services is often associated with low quality. However, innovative business models can turn out of pocket payments into the basis for a customer-centric value proposition, as the provider is required to compete for a share of disposable income.
• Emergence of National Health Insurance Schemes . South Africa, Ghana, Nigeria and others are building national health insurance schemes, increasing a population’s ability to fund healthcare services and products .
• Increased prevalence of NCDs. Given the increasing incidence of chronic diseases and the potential of using technology to address these diseases, new business opportunities for private investment exist.

Based on the context above, several areas in healthcare delivery can present compelling opportunities for private companies.

• Aggregation of existing players.
• Leveraging primary care infrastructure. Retail companies can leverage their real estate, infrastructure and supply chains to deploy primary care services at greater scale than is currently the case.
• Telemedicine . Telecommunications providers can leverage their existing infrastructure and customer base to provide payment mechanisms and telehealth services at scale. As seen during the COVID-19 pandemic, investment in telemedicine can ensure that patients receive timely and continuous care in spite of restrictions and lockdowns.
• Cost effective diagnostics . Diagnostic tools operated by frontline workers and combined with the expertise of specialists can provide timely and efficient care.

To fully realize these opportunities, government must incentivise innovation, provide clear regulatory frameworks and, most importantly, ensure that health priorities are adequately addressed.

Venture capital and private equity firms as well as large international corporations can identify the most commercially viable solutions and scale them into new markets. The ubiquity of NCDs and the requirement to reduce costs globally provides innovators with the opportunity to scale their tested solutions from LMICs to higher income environments.

Successful investment exits in LMICs and other private sector success stories will attract more private capital. Governments that enable and support private investment in their healthcare systems would, with appropriate governance and guidance, generate benefits to their populations and economies. The economic value of healthy populations has been proven repeatedly , and in the face of COVID-19, private sector investment can promote innovation and the development of responsible, sustainable solutions.

Faith – the diabetic mother we introduced at the beginning of this article - could keep her client. As a stable patient, she could measure her glucose level at home and enter the results in an app on her phone, part of her monthly diabetes programme with the company that runs the health centre. She visits the nurse-led facility at the local taxi stand on her way to work when her app suggests it. The nurse in charge of the centre treats Faith efficiently, and, if necessary, communicates with a primary care physician or even a specialist through the telemedicine functionality of her electronic health system.

Improving LMIC health systems is not only a business opportunity, but a moral imperative for public and private leaders. With the appropriate technology and political will, this can become a reality.

6. How could COVID-19 change the way we pay for health services?

John E. Ataguba, Associate Professor and Director, University of Cape Town and Matthew Guilford, Co-Founder and Chief Executive Officer, Common Health

The emergence of the new severe acute respiratory syndrome coronavirus (SARS-Cov-2), causing the coronavirus disease 2019 (COVID-19), has challenged both developing and developed countries.

Countries have approached the management of infections differently. Many people are curious to understand their health system’s performance on COVID-19, both at the national level and compared to international peers. Alongside limited resources for health, many developing countries may have weak health systems that can make it challenging to respond adequately to the pandemic.

Even before COVID-19, high rates of out-of-pocket spending on health meant that every year, 800 million people faced catastrophic healthcare costs ,100 million families were pushed into poverty, and millions more simply avoided care for critical conditions because they could not afford to pay for it.

The pandemic and its economic fallout have caused household incomes to decline at the same time as healthcare risks are rising. In some countries with insurance schemes, and especially for private health insurance, the following questions have arisen: How large is the co-payment for a COVID-19 test? If my doctor’s office is closed, will the telemedicine consultation be covered by my insurance? Will my coronavirus care be paid for regardless of how I contracted the virus? These and other doubts can prevent people from seeking medical care in some countries.

In Nigeria, like many other countries in Africa, the government bears the costs associated with testing and treating COVID-19 irrespective of the individual’s insurance status. In the public health sector, where COVID-19 cases are treated, health workers are paid monthly salaries while budgets are allocated to health facilities for other services. Hospitals continue to receive budget allocations to finance all health services including the management and treatment of COVID-19. That implies that funds allocated to address other health needs are reduced and that in turn could affect the availability and quality of health services.

Although health workers providing care for COVID-19 patients in isolation and treatment centres in Nigeria are paid salaries that are augmented with a special incentive package, the degree of impact on the quality improvement of services remains unclear. The traditional and historical allocation of budgets does not always address the needs of the whole population and could result in poor health services and under-provision of health services for COVID-19 patients.

In some countries, the reliance on out-of-pocket funding is hardly better for private providers, who encounter brand risks, operational difficulties, and – in extreme cases – the risk of creating “debtor prisons” as they seek to collect payment from patients. Ironically, despite the huge demand for medical services to diagnose and treat COVID-19, large healthcare institutions and individual healthcare practitioners alike are facing financial distress.

Dependence on a steady stream of fee-for-service payments for outpatient consultations and elective procedures is leading to pay cuts for doctors in India , forfeited Eid bonuses for nurses in Indonesia , and hospital bankruptcies in the United States . In a recent McKinsey & Company survey, 77% of physicians reported that their business would suffer in 2020 , and 46% were concerned about their practice surviving the coronavirus pandemic.

COVID-19 is exposing how fee-for-service, historical budget allocation and out-of-pocket financing methods can hinder the performance of the health system. Some providers and health systems that deployed “value-based” models prior to the pandemic have reported that these approaches have improved financial resilience during COVID-19 and may support better results for patients. Nevertheless, these types of innovations do not represent the dominant payment model in any country.

How health service providers are paid has implications for whether service users can get needed health services in a timely fashion, and at an appropriate quality and an affordable cost. By shifting from fee-for-service reimbursements to fixed "capitation" and performance-based payments, these models incentivize providers to improve quality and coordination while also guaranteeing a baseline income level, even during times of disruption.

Health service providers could be paid either in the form of salaries, a fee for services they provide, by capitation (whether adjusted or straightforward), through global budgets, or by using a case-based payment system (for example, the diagnostics-related groups), among others. Because there are different incentives to consider when adopting any of the methods, they could be combined to achieve a specific goal. For example, in some countries, health workers are paid salaries , and some specific services are paid on a fee-for-service basis.

Ideally, health services could be purchased strategically , incorporating aspects of provider performance in transferring funds to providers and accounting for the health needs of the population they serve.

In this regard, strategic purchasing for health has been advocated and should be highlighted as crucial with the emergence of the COVID-19 pandemic. There is a need to ensure value in the way health providers are paid, inter alia to increase efficiency, ensure equity, and improve access to needed health services. Value-based payment methods, although not new in many countries, provide an avenue to encourage long-term value for money, better quality, and strategic purchasing for health, helping to build a healthier, more resilient world.

7. L essons in integrated care from the COVID-19 pandemic

Sarah Ziegler, Postdoctoral Researcher, Department of Epidemiology and Biostatistics, University of Zurich, and Ninie Wang, Founder & CEO, Pinetree Care Group.

Since the start of the COVID-19 pandemic, people suffering non-communicable diseases (NCDs) have been at higher risk of becoming severely ill or dying. In Italy, 96.2% of people who died of COVID-19 lived with two or more chronic conditions.

Beyond the pandemic, cardiovascular disease, cancer, respiratory disease and diabetes are the leading burden of disease, with 41 million annual deaths. People with multimorbidity - a number of different conditions - often experience difficulties in accessing timely and coordinated healthcare, made worse when health systems are busy fighting against the pandemic.

Here is what happened in China with Lee, aged 62, who has been living with Chronic Obstructive Pulmonary Disease (COPD) for the past five years.

Before the pandemic, Lee’s care manager coordinated a multi-disciplinary team of physicians, nurses, pulmonary rehabilitation therapists, psychologists and social workers to put together a personalized care plan for her. Following the care plan, Lee stopped smoking and paid special attention to her diet, sleep and physical exercises, as well as sticking to her medication and follow-up visits. She participated in a weekly community-based physical activity program to meet other COPD patients, including short walks and exchange experiences. A mobile care team supported her with weekly cleaning and grocery shopping.

Together with her family, Lee had follow-up visits to ensure her care plan reflected her recovery and to modify the plan if needed. These integrated care services brought pieces of care together, centered around Lee’s needs, and provided a continuum of care that helped keep Lee in the community with a good quality of life for as long as possible.

Since the COVID-19 outbreak, such NCD services have been disrupted by lockdowns, the cancellation of elective care and the fear of visiting care service . These factors particularly affected people living with NCDs like Lee. As such, Lee was not able to follow her care plan anymore. The mobile care team was unable to visit her weekly as they were deployed to provide COVID-19 relief. Lee couldn’t participate in her community-based program, follow up on her daily activities, or see her family or psychologists. This negatively affected Lee’s COPD management and led to poor management of her physical activity and healthy diet.

The pandemic highlights the need for a flexible and reliable integrated care system to enable healthcare delivery to all people no matter where they live, uzilizing approaches such as telemedicine and effective triaging to overcome care disruptions.

Lee’s care manager created short videos to assist her family through each step of her care and called daily to check in on the implementation of the plan and answer questions. Lee received tele-consultations, and was invited to the weekly webcast series that supported COPD patient communities. When her uncle passed away because of pneumonia complications from COVID-19 in early April, Lee’s care manager arranged a palliative care provider to support the family through the difficult time of bereavement and provided food and supplies during quarantine. Lee could even continue with her physical activity program with an online training coach. There were a total of 38 exercise videos for strengthening and stretching arms, legs and trunk, which she could complete at different levels of difficulty and with different numbers of repetitions.

Lee’s case demonstrates that early detection, prevention, and management of NCDs play a crucial role in a global pandemic response. It shows how we need to shift away from health systems designed around single diseases towards health systems designed for the multidimensional needs of individuals. As part of the pandemic responses, addressing and managing risks related to NCDs and prevention of their complications are critical to improve outcomes for vulnerable people like Lee.

How to design and deliver successful integrated care

The challenge for the successful transformation of healthcare is to tailor care system-wide to population needs. A 2016 WHO Framework on integrated people-centered health services developed a set of five general strategies for countries to progress towards people-centered and sustainable health systems, calling for a fundamental transformation not only in the way health services are delivered, but also in the way they are financed and managed . These strategies call for countries to:

• Engage and empower people / communities: an integrated care system must mobilize everyone to work together using all available resources, especially when continuity of essential health and community services for NCDs are at risk of being undermined.
• Strengthen governance and accountability, so that integration emphasizes rather than weakens leadership in every part of the system, and ensure that NCDs are included in national COVID-19 plans and future essential health services.
• Reorient the model of care to put the needs and perspectives of each person / family at the center of care planning and outcome measurement, rather than institutions.
• Coordinate services within and across sectors, for example, integrate inter-disciplinary medical care with social care, addressing wider socio-economic, environmental and behavioral determinants of health.
• Create an enabling environment, with clear objectives, supportive financing, regulations and insurance coverage for integrated care, including the development and use of systemic digital health care solutions.

Whether due to an unexpected pandemic or a gradual increase in the burden of NCDs, each person could face many health threats across the life-course.

Only systems that dynamically assess each person’s complex health needs and address them through a timely, well-coordinated and tailored mix of health and social care services will be able to deliver desired health outcomes over the longer term, ensuring an uninterrupted good quality of life for Lee and many others like her.

• Wang B, Li R, Lu Z, Huang Y. Does comorbidity increase the risk of patients with COVID-19: evidence from meta-analysis. Aging (Albany NY) 2020;12: 6049–57.
• WHO. Noncommunicable diseases in emergencies. Geneva: World Health Organization, 2016.
• WHO. COVID-19 significantly impacts health services for noncommunicable diseases. June 2020.
• Kluge HHP, Wickramasinghe K, Rippin HL, et al. Prevention and control of non-communicalbe diseases in the COVID-19 response. The Lancet. 2020. 395:1678-1680
• WHO. Framework on integrated people-centred health services. Geneva: World Health Organization, 2016.

8 . Why access to healthcare alone will not save lives

Donald Berwick, President Emeritus and Senior Fellow, Institute for Healthcare Improvement; Nicola Bedlington, Special Adviser, European Patient Forum; and David Duong, Director, Program in Global Primary Care and Social Change, Harvard Medical School.

Joyce lies next to 10 other women in bare single beds in the post-partum recovery room at a rural hospital in Uganda. Just an hour ago, Joyce gave birth to a healthy baby boy. She is now struggling with abdominal pain. A nurse walks by, and Joyce tries to call out, but the nurse was too busy to attend to her; she was the only nurse looking after 20 patients.

Another hour passes, and Joyce is shaking and sweating profusely. Joyce’s husband runs into the corridor to find a nurse to come and evaluate her. The nurse notices Joyce’s critical condition - a high fever and a low blood pressure - and she quickly calls the doctor. The medical team rushes Joyce to the intensive care unit. Joyce has a very severe blood stream infection. It takes another hour before antibiotics are started - too late. Joyce dies, leaving behind a newborn son and a husband. Joyce, like many before her, falls victim to a pervasive global threat: poor quality of care.

Adopted by United Nations (UN) in 2015, the Sustainable Development Goals (SDG) are a universal call to action to end poverty, protect the planet and ensure that all enjoy peace and prosperity by 2030. SDG 3 aims to ensure healthy lives and promote wellbeing for all. The 2019 UN General Assembly High Level Meeting on Universal Health Coverage (UHC) reaffirmed the need for the highest level of political commitment to health care for all.

However, progress towards UHC, often measured in terms of access, not outcomes, does not guarantee better health, as we can see from Joyce’s tragedy. This is also evident with the COVID-19 response. The rapidly evolving nature of the COVID-19 pandemic has highlighted long-term structural inefficiencies and inequities in health systems and societies trying to mitigate the contagion and loss of life.

Systems are straining under significant pressure to ensure standards of care for both COVID-19 patients and other patients that run the risk of not receiving timely and appropriate care. Although poor quality of care has been a long-standing issue, it is imperative now more than ever that systems implement high-quality services as part of their efforts toward UHC.

Poor quality healthcare remains a challenge for countries at all levels of economic development: 10% of hospitalized patients acquire an infection during their hospitalization in low-and-middle income countries (LMIC), whereas 7% do in high-income countries. Poor quality healthcare disproportionally affects the poor and those in LMICs. Of the approximately 8.6 million deaths per year in 137 LMICs, 3.6 million are people who did not access the health system, whereas 5 million are people who sought and had access to services but received poor-quality care.

Joyce’s story is all too familiar; poor quality of care results in deaths from treatable diseases and conditions. Although the causes of death are often multifactorial, deaths and increased morbidity from treatable conditions are often a reflection of defects in the quality of care.

The large number of deaths and avoidable complications are also accompanied by substantial economic costs. In 2015 alone, 130 LMICs faced US $6 trillion in economic losses. Although there is concern that implementing quality measures may be a costly endeavor, it is clear that the economic toll associated with a lack of quality of care is far more troublesome and further stunts the socio-economic development of LMICs, made apparent with the COVID-19 pandemic.

Poor-quality care not only leads to adverse outcomes in terms of high morbidity and mortality, but it also impacts patient experience and patient confidence in health systems. Less than one-quarter of people in LMICs and approximately half of people in high-income countries believe that their health systems work well.

A lack of application and availability of evidenced-based guidelines is one key driver of poor-quality care. The rapidly changing landscape of medical knowledge and guidelines requires healthcare workers to have immediate access to current clinical resources. Despite our "information age", health providers are not accessing clinical guidelines or do not have access to the latest practical, lifesaving information.

Getting information to health workers in the places where it is most needed is a delivery challenge. Indeed, adherence to clinical practice guidelines in eight LMICs was below 50%, and in OECD countries, despite being a part of national guidelines, 19-53% of women aged 50-69 years did not receive mammography screening.4 The evidence in LMICs and HICs suggest that application of evidence-based guidelines lead to reduction in mortality and improved health outcomes.

Equally, the failure to change and continually improve the processes in health systems that support the workforce takes a high toll on quality of care. During the initial wave of the COVID-19 pandemic, countries such as Taiwan, Hong Kong, Singapore and Vietnam, which adapted and improved their health systems after the SARS and H1N1 outbreaks, were able to rapidly mobilize a large-scale quarantine and contact tracing strategy, supported with effective and coordinated mass communication.

These countries not only mitigated the economic and mortality damage, but also prevented their health systems and workforce from enduring extreme burden and inability to maintain critical medical supplies. In all nations, investing in healthcare organizations to enable them to become true “learning health care systems,” aiming at continual quality improvement, would yield major population health and health system gains.

The COVID-19 pandemic underscores the importance for health systems to be learning systems. Once the dust settles, we need to focus, collectively, on learning from this experience and adapting our health systems to be more resilient for the next one. This implies a need for commitment to and investment in global health cooperation, improvement in health care leadership, and change management.

With strong political and financial commitment to UHC, and its demonstrable effect in addressing crises such as COVID-19, for the first time, the world has a viable chance of UHC becoming a reality. However, without an equally strong political, managerial, and financial commitment to continually improving, high-quality health services, UHC will remain an empty promise.

1. United Nations General Assembly. Political declaration of the high-level meeting on universal health coverage. New York, NY2019.

2. Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health equity in England: the Marmot review 10 years on. Institute of Health Equity;2020.

3. National Academies of Sciences, Engineering, and Medicine: Committee on Improving the Quality of Health Care Globally. Crossing the global quality chasm: Improving health care worldwide. Washington, DC: National Academies Press;2018.

4. World Health Organization, Organization for Economic Co-operation and Development, World Bank Group. Delivering quality health services: a global imperative for universal health coverage. World Health Organization; 2018.

5. Kruk ME, Gage AD, Arsenault C, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global Health. 2018;6(11):e1196-e1252.

6. Ricci-Cabello I, Violán C, Foguet-Boreu Q, Mounce LT, Valderas JM. Impact of multi-morbidity on quality of healthcare and its implications for health policy, research and clinical practice. A scoping review. European Journal of General Practice. 2015;21(3):192-202.

7. Valtis YK, Rosenberg J, Bhandari S, et al. Evidence-based medicine for all: what we can learn from a programme providing free access to an online clinical resource to health workers in resource-limited settings. BMJ global health. 2016;1(1).

8. Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America . Washington, DC: National Academies Press 2012.