European health systems are universal systems that must ensure the right to equitable physical and mental health. Health services are viewed as a basic right that should not be infringed. In a world with increased diversity every resident, irrespective of age, religion, ethnicity, or socio-economic status, is entitled to the same basket of health services. Inequalities, however, still exist and mostly relate to religious minorities. Inequalities are a major concern of policymakers and health authorities and in fact fall within the second group of the basic framework for One Health research which is captured in The World 2050 Initiative (TWI).Inclusiveness, as a concept, resonates with a rights-based approach to health including political, social, economic, scientific, and cultural actions that are geared toward advancing good health and well-being for all.
Is there a linkage between health policies, inclusiveness, and inequities?
The COVID-19 pandemic enables us to explore this question. During the COVID-19 public health emergency, Measures to contain the virus impacted communal traditions and human rights (self-isolation, quarantine, physical distancing, closures), leading to higher stress, distress, family conflicts, and loneliness. Although collective religious practices foster connectedness and resilience, there were no platforms to foster spirituality throughout the adversity faced by minorities. Furthermore, minority members claimed that activities in their spiritual places of worship, which are critical for spirituality, social support of bereaved, were banned under the guidelines. No discussion took place with spiritual leaders about safe alternatives that had been applied in previous pandemics. Other public places (i.e., parks, bars) were allowed to open whereas places of worship remained closed.
This discrepancy led to disappointment and anger at health authorities. The disempowerment of spiritual leaders of religious minorities who are responsible for the sustainability of their communities, caused a breach of trust between these communities and the health authorities, inhibiting the support of religious leaders for public health measures and their engagement in the fight against COVID-19. COVID-19 guidelines inhibited the practice of death rituals and created multi-level clashes between values and beliefs and guidelines, inhibiting effective processing of grief and effective functioning following loss. Figure 1 demonstrates the eminent clashes between declared health policies and experiences of minority members.
Throughout COVID-19 religious communities experienced disenfranchised grief, jeopardizing their wellbeing. Minorities and their leaders perceived health authorities as failing to recognize their communal loss; as devaluing their spiritual leaders ; as unaware of potential adaptations to religious values and beliefs; as failing to provide post-loss resources for practical needs; as failing to improve wellbeing and resilience through grief counseling and self-care for elders; as failing to create and make accessible communication platforms to alleviate anxiety and process collective losses to restore their social identity.
These experiences resulted in distrust, disappointment, and anger at health authorities, rejection of the vaccine, poor compliance with guidelines, ineffective grief, deeper polarization from the majority population, poor utilization of health services, poor mental health, worsening chronic illnesses, and higher expenditures of health systems. The pandemic revealed weaknesses and blind spots in responses. Although reducing inequities by community engagement has been promoted as a key element, a collaborative approach with minority leaders was lacking. Responses to the pandemic exacerbated inequalities that already existed; marginalized underrepresented groups were reported to be left behind and discriminated against partly due to policy responses.
Highlighting the system's blind spots, the pandemic demonstrated the importance of ensuring an inclusive health approach to health emergencies, which is a tenet of public universal health systems. The lack of inclusion was detrimental to achieving a commitment from minority populations to respect the control measures that health authorities advocated. The voices of minorities were excluded from social discourse and thereby from policy making. Although a public universal system is expected to attend and serve all citizens.
Health authorities underestimated the capacity of the leadership and of community members to become active in designing the response to the pandemic. Responses failed to empower and enhance wellbeing. Failing to recognize and address the needs of every marginalized group in the population, based on the right to health, led to distrust and was translated into lower compliance. Since leaders of marginalized groups were excluded from decision making on policy and guidelines, the efficacy of the responses to the pandemic were severely undermined.
Exclusionary policies may have a long-term effect on the utilization of health services long after the pandemic by neglecting alternative understandings and weakening the capacity of participatory action to promote transformative change through dialogical orientation. Moreover, Exclusionary policies may produce or exacerbate health inequities, as policies and services become increasingly adapted to the demands of vocal majorities.
Based on the COVID-19 pandemic case study, I argue for the need to form differential, inclusive, health responses to promote public health. Policymakers should shape culturally sensitive policies for planning and delivery of care. Participation of leaders of marginalized groups in decision-making is crucial to fostering culturally adapted responsive policies, and, consequently, healthier populations. Several recommendations are proposed to promote inclusiveness in responses of universal systems to a health crisis.
Practice Implications for Policymakers and health authorities
Be strategic and proactive in reaching out to specific groups, to identify and address their needs, to disseminate transparent and accurate public health information, and shape actionable options to enhance public trust in health authorities and policymakers.
Promote the substantive inclusion of marginalized groups in healthcare decision-making.
Actively listen to leaders of religious minorities to facilitate collaborations with the communities which will reduce tensions through the process of reclaiming trust in authorities and policy makers.
Apply a collaborative approach of open conversations that elucidate the challenges that religious minorities experience and the effects on equity and public health principles, especially in universal health systems.
Implications for policy makers and authorities at three levels: Leadership, community levels, and collaborators.
Leadership level: Establish trust of leaders and their communities, in authorities, health authorities must validate the leadership of minorities by approaching it, initiating dialogues, providing transparent empirical data, and understanding disparities in approach and objections. Authorities and policymakers should avoid top-down imposition of solutions using a one-size-fits-all model.
Community level: Authorities are called upon to understand the sources of objection and distrust and use culturally appropriate channels to communicate.
Collaborators: Engage clinicians from religious minorities and collaborate with them to initiate community-based efforts to understand their needs, concerns, and possible solutions.
To succeed in promoting inclusiveness, authorities, and policy makers should apply the VOICE model in several steps. Figure 2 presents the VOICE model.
Explore Values regarding inclusiveness in universal health systems.
Be Open: the knowledge does not lie only with policymakers. Reflect and ask what we learned during COVID-19. Although there is a universal health system that aspires to eliminate inequities, state policies in practice reduced inclusiveness and enhanced perceived and actual inequities between the majority population and religious minorities.
Inquire about needs, concerns, objections of minorities.
Communicate and collaborate to develop possible culturally adapted alternatives to the policies to preserve public health on the one hand and to respond in a way that includes religious minorities, on the other.
Explore alternatives over time.
Health authorities may intervene to ensure inclusiveness in health services for all members of society. Ensuring inclusive health responses is important in addressing health inequities in the short and long term.
Six interventions can foster inclusiveness:
Create future inclusiveness through leadership education making sure that the health authority boards that make policy decisions reflect the diversity of the population.
Train the next generations of leaders by inclusive communication, public engagement, involved networks, as well as recruiting agents from each minority and setting up advisory groups. With time these measures will help the leaders of religious minorities to gain influence to shape policies and help reclaim trust in policymakers health authorities.
Employ measures to prevent the infringement of civil rights of minorities and assess it as an important measure for health quality.
Reward practices of inclusiveness to direct conduct toward this goal.
Critically appraise practice by evaluating and measuring trust, polarization, and utilization of health services.
Conclusions
Inclusive, dynamic, multi-stakeholder, responses of health systems remain critical in the context of healthcare. Responses of public health authorities are to be more strategic, proactive, and inclusive, reaching out to all minorities and addressing their specific needs, values, and beliefs to foster solidarity and health equity. Shaping strategies to target diverse multi-stakeholders is a first step to engage everyone in society, reduce discrimination, health inequity, and health deterioration. A commitment to an inclusive system implies that activities and responses will be sensitive to all. Inclusiveness in public health universal systems, cannot only exist in declarations and cannot be overlooked.
Dr. Gillie Gabay
Additional Reading
Gabay G. Is it the “public” health system? The VOICE model for inclusiveness in universal (national) health systems-lessons from COVID-19. Frontiers in Public Health. 2023 Dec 13;11:1243943.
Gabay G, Tarabeih M. Death from COVID-19, Muslim death rituals and disenfranchised grief–a patient-centered care perspective. OMEGA-Journal of Death and Dying. 2022 Apr 29:00302228221095717.
Gabay G, Tarabieh M. Science and behavioral intentions among Israeli Jewish ultra-Orthodox males: death from COVID-19 or from the COVID-19 vaccine? A thematic study. Public Understanding of Science. 2022 May;31(4):410-27.
Gabay G, Tarabeih M. Underground COVID-19 home hospitals for haredim: Non-compliance or a culturally adapted alternative to public hospitalization? Journal of religion and health. 2021 Oct;60(5):3434-53.
Gabay G, Gere A, Naamati-Schneider L, Moskowitz H, Tarabieh M. Improving compliance with physical distancing across religious cultures in Israel. Israel Journal of Health Policy Research. 2021 Dec;10:1-2.
Gabay G. Health Policies and the Play out of the COVID-Vaccine in Israel. MECOSAN. 2022(2022/121).