Health Equity in Public Health: Structuring Disparities and Pandemic Preparedness

 Written by Eda Koselleck and Giulia Rezala

Abstract: This study discusses health equity from two complementary perspectives: geographic inequalities in healthcare access and pandemic preparedness. The objective was to analyze how structural disparities affect access to healthcare services in urban and rural contexts and how these inequalities influence responses to global health emergencies. A narrative literature review with a qualitative and interpretative approach was conducted based on scientific articles and institutional publications related to health equity, healthcare access, social determinants of health, and pandemic preparedness. The selected literature was analyzed through thematic organization and critical synthesis. The findings indicate that rural populations frequently face barriers related to healthcare infrastructure, shortage of professionals, limited access to specialized services, and socioeconomic vulnerabilities. In the context of pandemics, preexisting inequalities contributed to disproportionate impacts on vulnerable populations, especially regarding access to testing, treatment, and vaccines during the COVID-19 pandemic. The analysis also highlights the importance of community health workers, telemedicine, and international cooperation in reducing inequities in healthcare delivery and emergency response. It also demonstrates that health inequities are structurally determined and intensified during public health crises. Strengthening equitable healthcare systems and integrating equity into pandemic preparedness strategies are essential to reduce disparities and improve global public health responses.

Keywords: health equity, social determinants of health, rural health services, healthcare disparities, pandemic preparedness

1. Introduction

Health equity has become one of the central challenges in modern public health, reflecting the need to ensure that all individuals have fair and just access to healthcare services regardless of their socioeconomic status, geographic location or social identity. Despite significant medical and technological advancements, profound disparities in health outcomes persist both within and between countries. These inequalities are not random but are shaped by structural factors such as income, education, infrastructure and political priorities.

Two particularly important dimensions of health inequity are geographic disparities and crisis-related vulnerabilities. On the one hand, differences between urban and rural healthcare systems demonstrate how access to medical services, qualified professionals and infrastructure is distributed. On the other hand, global health emergencies - most notably the COVID-19 pandemic - have exposed how deeply entrenched inequalities affect the ability to respond to crises and protect vulnerable populations.

This paper examines these two dimensions of health equity. First, it analyzes disparities in healthcare access between urban and rural areas, highlighting structural limitations and their impact on health outcomes. Second, it explores health equity in pandemic preparedness, focusing on how countries can better protect vulnerable populations during future global health crises. Together, these perspectives illustrate that achieving health equity requires not only strengthening healthcare systems but also addressing broader social and structural inequalities.

2. Methodology

This study is a narrative literature review with a qualitative and interpretative design. The main objective of this methodological approach is to synthesize and critically analyze existing scientific evidence on health equity, with a particular focus on geographic disparities in healthcare access and pandemic preparedness. For information gathering, relevant publications were selected through a purposive and thematic search strategy, guided by the conceptual scope of the research. Sources were included based on their relevance to the central analytical dimensions of the study, namely structural inequalities in healthcare systems, urban–rural disparities in access to health services, and global health equity in the context of pandemics.

The literature search was conducted using major academic databases and scientific search platforms, including peer-reviewed journal repositories and institutional publications from international health organizations. Keywords such as “health equity,” “social determinants of health” “rural health services,” “healthcare disparities,” and “pandemic preparedness” were used to guide the search process.

Following identification and selection, the materials were read in full and organized thematically. The analysis was conducted through critical synthesis, allowing for the identification of recurrent patterns, structural determinants, and conceptual gaps within the literature. The findings were structured into two main analytical axes: (1) geographic inequalities in healthcare access and (2) health equity in pandemic preparedness. This methodological approach is commonly employed in public health and social science research when the aim is to develop conceptual and analytical discussions rather than to test hypotheses or generate primary data. It allows for an integrative and critical examination of the literature, contributing to a broader understanding of health equity as a structural and global issue.

3. Geographic Inequalities in Healthcare Access: Urban vs. Rural Contexts

3.1. Structural Disparities in Healthcare Systems

It is easily observable in most countries around the world that there is a structural difference in the health services available to populations in large cities and those in rural areas. It is known that financial resources and more advanced technologies are mainly concentrated in capital cities, due not only to the higher number of residents but also to the population’s level of education.. As stated by Guimarães et al. (2020, p. 4), “preventive health is hindered by limitations in understanding the health-disease process and the ways of preventing morbidities and promoting health”. The understanding that a multidisciplinary network is necessary to maintain the health of an entire population is relatively recent; it may seem obvious to those already familiar with the subject, but it still appears to be in its early stages in several regions of the world.

3.2. Barriers to Access and the Role of Community Health Workers

The notion that the physician is the only professional capable of properly handling more serious conditions remains embedded in the collective consciousness, leading many people to settle for the alternatives available in their region—often pharmacies, resorting to medications to control symptoms rather than properly treating them; or, in some cases, the mediation carried out by community health workers. . As shown by Méllo, Santos, and Albuquerque (2023, p. 503) in a narrative review,

the large concentration of community health worker (CHW) programs still occurs in low- and middle-income countries, in Africa (18) and Asia (12), Latin America (05), with only a few experiences in high-income countries in North America (02) and Oceania (01).

It is evident that CHWs are extremely important for resolving low- and medium-complexity issues, sometimes being the only health professionals available in rural areas. This also helps reduce the need for residents of inland regions to travel to capital cities in search of care, which worsens the overcrowding situation in most public hospitals, in addition to having a significant impact on these individuals’ income, as pointed out by Guimarães et al. (2020, p. 5):

It is necessary to consider the distance required to access health services (an average of 60 km), the duration of the trip (an average of 4 hours), transportation costs (small wooden boats require fuel), and, in cases of hospitalization, the costs of lodging and food for companions, since riverside populations generally do not have residences in urban areas; in addition to the impact caused by the need to interrupt activities such as agriculture and fishing, which are often the only sources of income in these communities.

3.3. Mental Health Inequalities in Rural Areas

In the field of mental health, the reality is even more precarious. Even today, the impact—or even the existence—of mental disorders is still frequently questioned, with many people delegitimizing diagnoses or not even seeking care for mental health symptoms. According to the World Health Organization’s 2022 report, “researchers from the World Economic Forum calculated that a broadly defined set of mental health conditions cost the world economy approximately US$ 2.5 trillion in 2010” (WHO, 2022, p. 50). Despite this, in many regions of the world, this money is not properly directed toward the specific needs of populations. For example, “an estimated 80%–90% of the mental health care budget in Southeast Asian countries [is] directed to hospitals, [so] many communities may miss out on the benefits of having locally accessible and affordable mental health care services” (ANDARY, 2023, p. 2). In addition, in some countries, such as Timor-Leste, “there was consensus that there were insufficient numbers of, and training opportunities for, mental health personnel” (HALL, 2019, p. 99).

3.4. Cultural and Systemic Challenges in Diagnosis and Treatment

With low governmental incentives for the specialization of professionals in this field, little progress is made in addressing the challenges related to diagnosis and treatment in mental health. A clear example is neuropsychological testing, often developed by and for Western populations, especially European ones. As a result, many of these instruments incorporate elements that are not part of the daily life of diverse cultures. This is the case of the HTP (House-Tree-Person) test, in which the patient is asked to draw a house, and the elements present in the drawing are evaluated. Among these elements is the chimney, whose relevance becomes questionable in cultural contexts where such a structure is not common, such as in tropical countries. In this sense, it becomes necessary to carry out cross-cultural adaptations for different populations in order to make the test more accessible and culturally appropriate. As mentioned by Borsa, Damásio, and Bandeira (2012, p. 430):

The process of adapting instruments should consider the relevance of original instrument concepts and domains in the new culture, in addition to considering the appropriateness of each item of the original instrument in terms of the ability to represent such concepts and domains in the new target population.

3.5. Technological Solutions and Their Limitations

Even with a diagnosis, it is difficult for residents of remote areas to access appropriate treatment, whether evaluation, medication, or therapy sessions. In many countries, “it is challenging to find competent healthcare personnel in rural regions, even when the facilities are accessible. Low motivation discourages qualified healthcare workers from working in remote areas” (Samuel, 2021, p. 6). One possible way to overcome these obstacles is telemedicine, which has been very helpful in recent years in expanding access to specialized professionals in hard-to-reach areas. Moreover, this technology proved especially useful during the pandemic context. As an example, one can cite the eSanjeevani platform, launched by the Indian government as part of the Digital India program. According to Stoltzfus et al. (2023, p.3), “with the advent of the COVID-19 pandemic, healthcare providers have leveraged video conferencing technology to diagnose and treat patients residing in remote locations, utilizing the eSanjeevani service”.

Despite its benefits, the remote modality also has its challenges. For example, the doctor-patient relationship, which ends up being affected by the lack of human contact. According to Lisboa et al. (2023, p. 6), “the technologies provided by telemedicine, in many cases, represent changes in the conventional doctor-patient relationship, requiring a process of general acceptance of a certain technological mediation promoted by them”. It should also be noted that the people most in need of care may have difficulty accessing even this type of consultation, mainly due to the lack of necessary equipment. As shown by Stoltzfus et al. (2023, p. 3):

Telemedicine programs require full-time staff to manage and troubleshoot equipment and systems. All these processes may be expensive and time-consuming. Remote medicine also relies on patients having the devices and network access necessary to successfully participate in a telehealth encounter. As with any information technology sector, telemedicine is also likely to face intermittent delays due to technological difficulties such as poor network connections, equipment failures, and more.

In summary, inequalities in access to health services between urban and rural areas highlight the need for more inclusive strategies adapted to local realities. Valuing multidisciplinary teams, strengthening the role of community health workers, and culturally adapting diagnostic instruments are fundamental steps to increase the effectiveness of care. Therefore, continuous investment in public policies that promote equity is essential, ensuring not only access but also the quality of health services, especially in the world’s most vulnerable regions.

4. Health Equity in Pandemic Preparedness

4.1. Conceptual Foundations of Health Equity in Pandemics

Health equity in pandemics refers to the principle that all individuals, regardless of socioeconomic status, geographic location or social identity, should have fair and just access to healthcare resources and protection during public health crises. It focuses on reducing avoidable and unjust differences in health outcomes across populations. Ensuring health equity is essential not only for ethical reasons but also for effective disease control and global stability.  The COVID-19 pandemic revealed profound inequalities in healthcare systems worldwide. While some countries were able to respond quickly with widespread testing, treatment and vaccination programs, others struggled due to limited resources and infrastructure. Within countries, marginalized populations, including low-income communities, migrants and the elderly, were disproportionately affected. These disparities demonstrated that pandemic preparedness must go beyond medical readiness and incorporate equity-focused strategies to protect the most vulnerable. (MUJICA, 2022)

4.2. Structural Inequalities in Access to Healthcare Resources

One of the most critical challenges in pandemic preparedness is unequal access to essential healthcare services. During the COVID-19 pandemic, access to vaccines, testing and treatment varied significantly across and within countries. High-income nations were able to secure large quantities of vaccines early, often purchasing more doses than needed. In contrast, many low- and middle-income countries faced severe shortages and delays.¹¹ Testing capacity also differed widely. Countries with advanced healthcare systems were able to implement widespread testing for its citizens, enabling early detection and containment of the virus. Meanwhile, regions with limited infrastructure struggled to identify cases, contributing to uncontrolled transmission. Similarly, access to treatment, including hospital care, intensive care units and essential medications, were uneven, leading to disparities in survival rates (MUJICA, 2022).

The World Health Organization has emphasized in its publications in 2025 that these inequalities are rooted in structural differences between healthcare systems of different countries and global economic disparities. (WHO, 2025). It is clear that without addressing these systemic issues, future pandemics are likely to reproduce similar patterns of inequality.

4.3. Vulnerable Populations and Intersectional Risks

Pandemics disproportionately affect certain groups that are already vulnerable due to social, economic or health-related factors. Elderly individuals face a higher risk of severe illnesses and death due to weaker immune systems and pre-existing health conditions. Low-income communities often experience higher exposure to infectious diseases because of crowded living conditions, limited access to healthcare and jobs that do not allow remote work (MUJICA, 2022).Migrants and refugees are particularly at risk due to barriers such as language differences, lack of legal status and limited access to healthcare services. These groups may also face discrimination, further reducing their ability to receive adequate care.

Importantly, these vulnerabilities often overlap. For example, an elderly person living in a low-income community may face compounded risks. Addressing these intersecting inequalities is essential for improving pandemic preparedness and ensuring equitable outcomes (MUJICA, 2022); (UNITED NATIONS YOUTH OFFICE, 2025)

4.4. Consequences of Health Inequalities in Pandemics

4.4.1. Health Outcomes

Health inequities during pandemics result in significantly different health outcomes across populations. As stated above, disadvantaged groups tend to experience higher infection rates due to increased exposure and limited access to preventive measures. They are also more likely to suffer severe illness and death due to delayed diagnosis and inadequate treatment (WFPHA, s.d.).

During the COVID-19 pandemic, mortality rates were consistently higher among socioeconomically disadvantaged populations. These disparities highlight how social determinants of health (such as income, education and living conditions) directly influence pandemic outcomes. (MUJICA, 2022)

4.4.2. Socioeconomic Impacts

Beyond physical health, pandemics have far-reaching economic and social impacts that disproportionately affect vulnerable populations. Many individuals in low-income communities faced job loss and financial instability due to lockdowns and economic disruptions. Unlike higher-income workers, they often lacked savings or social protection systems to cushion these effects (UNITED NATIONS YOUTH OFFICE, 2025).

Education was also significantly disrupted, particularly for students without access to digital learning tools. This has long-term implications for social mobility and inequality. Additionally, pandemics can exacerbate social tensions and inequalities, further marginalizing already disadvantaged groups (WFPHA, s.d.). These economic and social consequences create a cycle of inequality that persists even after the immediate health crisis has passed.

4.5. Case Studies: Global Inequalities in Pandemic Response

4.5.1. Vaccine Distribution Disparities

One of the clearest examples of health inequity during the COVID-19 pandemic was the unequal distribution of vaccines. High-income countries secured the majority of vaccine supplies early through advance purchase agreements, leaving limited availability for lower-income nations. According to reports from the World Health Organization, this unequal distribution not only prolonged the pandemic but also increased the risk of new variants emerging (WHO, 2025). The situation demonstrated that vaccine equity is not only a moral issue but also a global health necessity.

4.5.2. National Responses: UK vs. South Africa

Different countries’ responses to the pandemic further illustrate the role of equity in health outcomes. For example, the United Kingdom implemented one of the fastest vaccination campaigns in the world. However, disparities persisted within the country, with lower vaccination rates observed in disadvantaged communities (WFPHA, s.d.). In contrast, South Africa faced significant delays in vaccine access due to global supply inequalities and struggled in routine immunization coverage. This highlights how global systems can influence national outcomes, particularly for countries with fewer resources (WHO, 2025). These comparisons demonstrate that both domestic policies and international cooperation are critical in achieving health equity.

4.5.3. Global Initiatives (COVAX)

Global initiatives such as COVAX were established to promote equitable access to vaccines. Supported by organizations like the United Nations, COVAX aimed to distribute vaccines to low- and middle-income countries. While the initiative succeeded in delivering millions of doses, it faced challenges including limited supply, funding constraints and competition from wealthier nations. As a result, its impact was significant but insufficient to fully address global inequities (European Comission, s.d.)

4.6. Policy Responses and Future Strategies

Future pandemic preparedness must prioritize equity from the outset. To achieve this, governments should identify vulnerable populations in advance and develop targeted strategies to protect them. This includes ensuring the fair allocation of resources such as vaccines, testing, and treatment. Furthermore, incorporating equity indicators into preparedness plans can help monitor progress and ensure accountability throughout the implementation of public health measures.

Moreover, as pandemics are global challenges, they require coordinated international responses. In this context, strengthening cooperation between countries is essential for sharing resources, knowledge, and technology. Agreements led by the World Health Organization aim not only to improve global preparedness, but also to promote more equitable responses in future health emergencies (WHO, 2025). In addition, health equity cannot be achieved without well-prepared health systems around the world. Investments in healthcare infrastructure, workforce development, and universal access to healthcare can significantly improve a country’s ability to respond to crises such as pandemics (UNITED NATIONS YOUTH OFFICE, 2025). At the same time, stronger health systems help reduce disparities in access to care, particularly among underserved communities.

Finally, the use of data to identify and monitor vulnerable populations enables more effective and equitable interventions. Data-driven approaches allow governments to allocate resources where they are needed most, while also helping evaluate the impact and effectiveness of public policies (European Comission, s.d.). This approach ensures that no group is overlooked during pandemic responses.

4.7. Interim Conclusion: Strengthening Equity in Future Pandemics

The COVID-19 pandemic demonstrated that health inequities are not only ethical concerns but also critical public health challenges. Unequal access to healthcare resources, the disproportionate impact on vulnerable populations and the uneven distribution of vaccines all contributed to preventable suffering and prolonged the global crisis.

Future pandemic preparedness must prioritize fairness alongside efficiency. By integrating equity into planning, strengthening global cooperation and investing in resilient public health systems, countries can better protect vulnerable populations and reduce disparities.

Ultimately, achieving health equity in pandemics is essential for building a safer, more resilient world. Without it, future health crises will continue to disproportionately affect those who are already most at risk.

5. Conclusion: Towards a More Equitable Global Health System

The analysis of health equity from both a structural and crisis-oriented perspective demonstrated that inequalities in healthcare are deeply embedded in social, economic and political systems. The contrast between urban and rural healthcare access reveals how geographic location continues to determine the availability and quality of medical services, with rural populations often facing significant barriers such as limited infrastructure, workforce shortages and reduced access to specialized care. These disparities are further compounded by cultural, educational and economic factors, creating persistent gaps in health outcomes.

At the same time, the experience of the COVID-19 pandemic has shown that health inequities become even more pronounced during global crises. Unequal access to vaccines, testing and treatment, as well as the disproportionate impact on vulnerable populations, highlight the limitations of current pandemic preparedness strategies. The pandemic made clear that health systems cannot be considered effective if they fail to protect those most at risk.

Taken together, both parts of this paper underscore that health equity must be understood as a fundamental component of public health rather than a secondary objective. Addressing these challenges requires a comprehensive approach that includes strengthening healthcare infrastructure, investing in underserved regions, promoting global cooperation and integrating equity into all stages of policy design and implementation.

Ultimately, achieving health equity is not only a matter of justice but also a prerequisite for resilient and effective health systems. Without targeted efforts to reduce disparities, future health crises will continue to reproduce and amplify existing inequalities. Ensuring equitable access to healthcare; both in everyday context and in times of crisis - is therefore essential for building a healthier and more inclusive global society.

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