Policy responses to COVID-19 present a window of opportunity for a paradigm shift in global health policy: An application of the Multiple Streams Framework as a heuristic

ABSTRACT

Drawing on Kingdon’s Multiple Streams Framework as a heuristic, this article reviews the three streams – problems, policies, and politics – as applied to the adoption of economic policies in response to the socioeconomic impacts of COVID-19. In doing so, we argue that we are currently presented with a window of opportunity to better address the social determinants of health. First, through assessing the problem stream, an understanding of inequity as a problem gained wider recognition through the disproportionate impacts of COVID-19. Second, in the policy stream, we demonstrate that appropriate and unprecedented policies can be enacted even in the face of changing evidence or evidentiary uncertainty, which are needed to address upstream factors that influence health. Lastly, in the politics stream, we demonstrate that addressing a public health ‘problem’ can be well-received by the public, making it politically viable. However, it is important to ensure the ‘problem’ is clearly relayed to the public and that this information is not perceived to change, as this can undermine trust. The social, political, and behavioural lessons presented by the COVID-19 pandemic should be drawn on in this pivotal moment for global public health.

KEYWORDS:

• Public policy
• healthy public policy
• public health
• Multiple Streams Framework
• COVID-19

The COVID-19 pandemic generated unprecedented government mobilisation in 2020. The mobilisation was warranted, as global case counts of the virus exceeded the 122 million mark as of 19 March 2021, resulting in more than 2.69 million deaths (Johns Hopkins University, 2021). Understandably, attempts to contain the pandemic led to unprecedented actions by federal, state/provincial/territorial, and municipal governments, and intergovernmental organisations. In response to the pandemic, arguably atypical policies were enacted in favour of public health. For example, many nonessential businesses have been shut down, movement across borders is greatly restricted, and widespread orders promoting physical and social distancing measures are in place. When examining the policy responses, governments around the world took policy action that was seemingly at the short-term expense of the economy, such as lockdowns, and implemented generous fiscal policies, such as stimulus cheques, in a rapid and widespread manner. When viewing the economic policies that were enacted in response to the socioeconomic impacts of the COVID-19 pandemic through the lens of Kingdon’s Multiple Streams Framework (MSF) of policymaking, insights into how policy change can happen are gleaned and suggest that a window of opportunity may be found elsewhere with COVID-19. Specifically, a paradigm shift to reshape global public health policy by enabling deeper considerations of health equity¹ and mitigating the impacts of the social determinants of health (SDH).² Thus, this article reviews the three streams of the MSF to analyze the potential of COVID-19-induced policy for sparking a global paradigm shift towards better addressing the SDH to improve health equity.

Specifically, we analyze examples from Canada and the United States for four reasons. First, while both countries are democratic, federal countries with cultural similarities, they differ in governing structures and policies (Parliament of Canada, 2012). Furthermore, while Canada and the United States are often grouped together as liberal welfare societies, the two countries had disparate approaches to social policymaking in the face of the COVID-19 pandemic (D. Béland, Dinan, Rocco, & Waddan, 2020). Therefore, drawing on both can illustrate the potential for a paradigm shift across differing political systems. Second, different levels and sectors of government acted (or rather, reacted) during the COVID-19 pandemic in both countries, further demonstrating the engagement of various entities. These entities indicated a willingness to address the socioeconomic impacts of COVID-19, which may translate to readiness to develop healthy public policy to promote health equity. Third, because Kingdon’s MSF was first applied exclusively to the United States, and subsequentially questioned on its applicability to other political contexts (D. Béland & Howlett, 2016), we hope to highlight its utility for other contexts and comparative investigation. Lastly, as residents of both countries, the authors have a strong shared understanding of the policy changes that occurred during the pandemic.

Multiple streams framework

Since John Kingdon established the MSF in 1984 , it has served as a powerful heuristic device to consider the development of policy agendas and long-term strategies for change by merging society’s problems, policy solutions, and politics (McLendon, 2003). In the MSF, problems are seen as conditions that digress from an ideal state of affairs, and are perceived by the public to require government intervention (D. Béland & Howlett, 2016). Within the policy stream, a plethora of plausible solutions are identified, assessed and narrowed down based upon feasibility (D. Béland & Howlett, 2016). The politics stream assesses influences on the body politic, including advocacy campaigns, legislative changes, and shifts in political mood (D. Béland & Howlett, 2016). When the aforementioned streams converge, they form a ‘policy window’, allowing for policy entrepreneurs and receptive policymakers to form potentially valuable connections between a problem and a solution (Herweg, 2016).

The MSF was originally developed to explain policymaking in the United States but has been applied to many other countries (Frankel, 2020; Henstra, 2010). For example, in Canada, the MSF has been presented to advocate for universal basic income (Frankel, 2020). Canada has had a history of implementing stratified basic income programmes such as the Canada Child Benefit for dependents under the age of 18, and Old Age Security for senior citizens. However, it has never enacted a universal programme that provides all Canadian citizens with continuous universal basic income, despite pilot projects/experiments such as MINCOME in Manitoba in the 1970s (Forget, 2013). In this article, we have elected to apply the MSF to demonstrate an emerging window of opportunity to address the SDH stemming from the adoption of policies in response to the socioeconomic impacts of COVID-19. With the magnitude of attention garnered by COVID-19, policy entrepreneurs, or

“advocates who are willing to invest their resources—time, energy, reputation, money—to promote a [policy] position in return for anticipated future gain in the form of material, purposive, or solitary benefits” (Kingdon, 1984, p. 179),

are faced with a window of opportunity, otherwise known as a policy window, to gain support in better address the SDH. In other words, we believe COVID-19 provides an opportunity to influence long-term global public health policies in non-traditional ways.

Problems stream

The World Health Organization (WHO) was alerted to ‘viral pneumonia’ in Wuhan, China on 31 December 2019 (World Health Organization, 2020a), which was later determined to be COVID-19. By 30 January 2020, the WHO declared it to be a Public Health Emergency of International Concern (World Health Organization, 2020b), similar to declarations made for other recent and deadly outbreaks of viral diseases such as Ebola and Zika (Chappell, 2020). However, less than two months later, on 11 March 2020, the WHO officially classified it as a pandemic (World Health Organization, 2020c), setting the course for unprecedented government mobilisation across countries (Chappell, 2020).

Within the MSF, policy change is thought to begin with identifying the problem and agenda-setting. COVID-19 has been on the radar of countries around the world since the beginning of 2020. However, the ways in which the problem has evolved has been unexpected, as limited information on COVID-19 was available in early January 2020. It took months for some countries to realize the severity of person-to-person spread of the virus and its fatal effects, particularly on the elderly and immunocompromised. In response, many countries then enacted social/physical distancing mandates. These measures were taken to minimise the infection rate and flatten the infection curve, in an effort to decrease case count saturation and minimise strain on underequipped healthcare systems.

However, as prolonged isolation became the norm, many individuals and businesses faced economic ruin. Beyond the direct impacts of morbidity and mortality, the virus’s impacts quickly became apparent within the strongly connected, highly globalised, and integrated world we presently live in (McKibbin & Fernando, 2020). Initially, when the impact was most strongly felt in China, there were interruptions to production and thus, the global supply chain, which heavily affected Western businesses (McKibbin & Fernando, 2020). However, as the virus progressed, many local economies ceased to function as they once did. Businesses and services were mandated to shut down for extended periods of time, curfews and distancing parameters were enforced, and consumers and firms changed their usual consumption patterns, causing widespread market anomalies (McKibbin & Fernando, 2020). In response, global stock indices plunged and layoffs, furloughs, and economic hardships became prevalent and wide-reaching (McKibbin & Fernando, 2020). By May 2020, the unemployment rate in the United States had shot up to 20% with more than 20.5 million people unemployed (Kochhar, 2020). Many businesses were forced to shutter either temporarily or permanently in response to pandemic regulations, with 28% of 10,969 small businesses surveyed in Canada during the week of 10–15 April 2020 reporting being fully closed due to COVID-19 (Canadian Federation of Independent Business, 2020). In addition, households cut back on spending due to uncertainties regarding finances and job retention, and companies paused planned investments given the uncertainty of the present situation (Miller, 2020). The combination of these actions led to a simultaneous recession, further exacerbating existing problems (Miller, 2020).

Nevertheless, the ‘problem’ of COVID-19 did not impact all equally. A Canadian study of COVID-19’s economic consequences on occupational tasks and mental health found that the pandemic’s economic impacts were significantly more severe for workers who were exposed to the disease and those who worked in close proximity to co-workers, than essential workers and those who worked remotely (L. P. Béland, Brodeur, Mikola, & Wright, 2020). In addition, immigrant workers also reported feeling conceded in their ability to meet financial obligations (L. P. Béland et al., 2020). While there is a well-established relationship between socioeconomic status and health that is external to COVID-19, L. P. Béland et al. (2020) also suggest a link between COVID-19 and income inequality. Further, the World Bank predicted under a baseline scenario that the pandemic could push an additional 71 million people into extreme poverty in 2020, representing the first increase in extreme poverty since 1998, and effectively wiping out world gains since 2017 (World Bank, 2020). The projected impacts of the regression are expected to be long-lasting, even if poverty declined in 2021 (World Bank, 2020).

One of the primary issues with COVID-19, is that it enabled pre-existing inequities in the SDH to become more pronounced; consequently, this led to the further exacerbation of disproportionate impacts on certain groups. While COVID-19 signalled a myriad of physical, economic, and mental health problems for all people, marginalised groups including people living in poverty, older adults, migrants, women and girls, among others, often bore the most severe impacts (Ladd & Bortolotti, 2020). The susceptibility of certain populations to the virus, because of societal and economic inequities relating to the SDH, ultimately resulted in a greater spread of disease and subsequent economic and social impacts. Therefore, it is apparent that COVID-19 is not a sole problem. Rather, the economic and societal factors at play, or the SDH, allow the virus to impact certain populations more negatively. This understanding of inequity as a problem gained wider recognition and signals the opportunity to act on the SDH as a ‘problem’, as discussed under the MSF. In other words, COVID-19 in January of 2020, when it was concerning but not largely regarded as a major problem, is analogous to the SDH gaining wider recognition. Indeed, research demonstrates that the SDH are more influential on one’s health than lifestyle and healthcare (Mikkonen & Raphael, 2010). We have established evidence of the SDH, such as the WHO’s Commission on SDH which comprehensively presented a robust evidence base in their final report, Closing the gap in a generation: health equity through action on the social determinants of health (CSDH, 2008). However, with COVID-19, some of these inequities are becoming more apparent to the wider public, demonstrating an opportunity for the framing of inequity and imbalanced SDH as a ‘problem’ that needs to be addressed.

Policy stream

The policy stream of the MSF focuses on assessing policy solutions for existing problems, bringing them to the forefront of agenda-setting frameworks. For this stream, we analyze the strict and unprecedented national and provincial lockdowns in response to COVID-19, and economic responses by the government to the consequences of the lockdowns. We seek to demonstrate that the non-traditional policies that were drawn on to address the impacts of COVID-19 can be similarly employed to better address the SDH leading to improved equity.

Practices such as physical and social distancing, mask-wearing, and handwashing were rapidly recommended and amended in response to emerging scientific evidence, such as mathematical models of the various case scenarios of the virus’ spread. However, not only was evidence considered – it was utilised in arguably extreme ways. Beyond just shutting down businesses and enforcing practices and policies to ensure that citizens stayed at home, COVID-19 also led to border closures. In a news interview, Canada’s Chief Public Health Officer, Dr. Theresa Tam noted that shutting down the world was not something that she or other health experts had ever envisaged (Zimonjic, Barton, & Ling, 2020). The COVID-19 policy response illustrates that, despite changing evidence and conditions of evidentiary uncertainty, drastic policy action can be taken to address a threat to public health, or a ‘problem’.

While the use of evidence to stimulate lockdowns and border closures was one outcome of the pandemic, the rapid economic response to a public health crisis was another development with numerous downstream public health implications. Policies put forth addressed the SDH and economic disadvantages in a rapid way that is not regularly seen. Realizing the need for economic support, both Canada and the United States implemented economic supplements to assist those who were in financial need as a result of COVID-19 and its attendant consequences. These financial supplements were released almost immediately after passage of legislation, with many people receiving their benefits in a matter of weeks (Bernard & Lieber, 2020; Hussain, 2020).

In March 2020, the United States passed a $2 trillion stimulus relief package to help American families and businesses, which was the largest economic rescue package in modern American history (Smith, 2020; U.S. Department of the Treasury, n.d.). The package included one-time stimulus payments of $1,200 USD to individual taxpayers making below $75,000, with additional funds for those with a partner and/or dependents (Smith, 2020; U.S. Department of the Treasury, n.d.). Moreover, the package provided drastically expanded unemployment benefits. Individuals became eligible to receive an additional $600 per week in addition to their standard state benefits for up to four months (Smith, 2020; U.S. Department of the Treasury, n.d.). The monumental bill was followed by a slimmer $900 billion package in December 2020 and another expansive $1.9 trillion stimulus package in March 2021, which provided similar monetary relief through one-time stimulus payments, weekly federal unemployment top-ups, an expansion of healthcare subsidies, childcare benefits, and supplementary supports (‘The Heroes Act,’ 2020; Kaplan, 2021; Lobosco & Luhby, 2020).

In Canada, the Canada Emergency Response Benefit (CERB) was established for workers who were at least 15 years old and had stopped working due to reasons related to COVID-19, and had not voluntarily quit their jobs (Government of Canada, 2020). Eligible individuals received up to $8,000 CAD for a 16-week period ($500 per week), which was later extended up to 24 weeks in July 2020 (Government of Canada, 2020). CERB was developed to help the government handle the high influx of people filing for Employment Insurance (EI) at the onset of the pandemic restrictions (Aiello, 2020). It was unique in including entire groups that are usually left out of traditional EI benefits, and eventually helped create a revised EI system with expanded flexibility around eligibility criteria, such as relaxing the amount of hours required to qualify (Aiello, 2020).

While the enactment of the stimulus and emergency packages were monumental for both American and Canadian policy responses, they were the subject of significant political debate and intense public scrutiny as time passed. In the U.S., both the House of Representatives and the Senate engaged in heated debates over the course of many weeks and months over the mounting deficit (Gale & Enda, 2020). However, ultimately both sides of the aisle were able to coalesce their members to pass bipartisan packages (Gale & Enda, 2020). Thus, demonstrating that policy solutions can overcome opposition for the greater good. Ultimately, by improving individual well-being, safety, and security, more people are able to come back to participate in the economy, ultimately strengthening long-term economic and budget prospects and allowing for long-term reconciliation (Gale & Enda, 2020).

Perhaps one of the biggest policy lessons afforded by COVID-19 is that while long-term fiscal shortfalls must be heeded, the ability to pay off the federal debt are dwarfed in comparison to the urgency of mounting health and economic problems (Gale & Enda, 2020). Despite the perceived costs, the long-term gains demonstrate the merit in our argument around the need for policy to better address the SDH and improve health equity. We also saw with the economic policies enacted during COVID-19 that such policies could be implemented even in the face of evidentiary uncertainty, given that science is always evolving, and that these could be employed in a rapid and drastic manner. However, it is noteworthy that policy solutions for the existing problems around the SDH do exist, and an opportunity is present to take policy action in this domain. As indicated above, foundational evidence from reputable bodies such as the WHO Commission on SDH already exists to inform targeted policy actions in response to the SDH (CSDH, 2008). If policymakers acted proactively and drew on science when it comes to causes of ill health, ranging from pandemics to the SDH, actions could be more impactful. As such, there is a need for proactive action drawing on research to inform policy (i.e. evidence-informed policy) for various global public health issues. In fact, it has already been acknowledged that policy reforms emerging post-COVID-19 must be durable and far-sighted, which includes being proactive and focusing on upstream factors that influence health, like the SDH (M. M. Amri & Drummond, 2021).

Politics stream

The politics stream of the MSF is comprised of factors that influence the body politic (D. Béland & Howlett, 2016). These factors include: swings in national mood, governing party turnover, and advocacy campaigns of special interest groups (D. Béland & Howlett, 2016). In the case of COVID-19, Western societies were initially largely willing to accept such drastic actions if it benefits the greater good, as common trending hashtags such as #flattenthecurve indicated. Early in the pandemic, the public generally followed these recommendations for physical and social distancing and mask-wearing with limited resistance, with the exception of individuals who believed that mask-wearing infringed on their personal freedoms. Nevertheless, not only was a large portion of society willing to accept stringent government actions and policies, but was also willingly acquiescent in doing so.

In fact, public polling demonstrated that 64% of Canadians believed that the federal government was doing a good job handling the pandemic during a time-period where the government implemented a number of initiatives to limit the health and economic impacts of COVID-19, including the CERB (M. M. Amri & Drummond, 2021; Department of Justice, 2020). In addition to the public’s general acceptance of government intervention, many leaders’ approval ratings increased during the pandemic. For instance, despite presiding over an economy with one of the largest unemployment rates in American history, President Donald Trump saw his ratings at an all-time high in early April 2020 (Edelman, 2020). Around the same time, approval ratings similarly surged for Prime Minister Justin Trudeau and the premiers of hard-hit provinces (Grenier, 2020). In a March 2020 poll, Francois Legault of the Canadian province of Quebec received an astounding 93% approval rating – making him one of the most popular leaders in the world at the time (Angus Reid Institute, 2020; Grenier, 2020).

The aforementioned statistics illustrate how government reactions to public health threats or ‘problems’ have the potential to be well-received by the public if also perceived to be simultaneously beneficial, making it a politically viable decision. However, as time progressed, reactions to policies and recommendations around the virus became increasingly politicised, as demonstrated by anti-mask protestors in Toronto fighting the city’s mandatory mask bylaw (Yuen, 2020). According to a Pew Research poll, while most Americans seem to favour wearing masks in public, considerable resistance to face coverings ascended as President Trump disseminated contradictory messages against the advice of public health officials and some political leaders (Syal, 2020). While initial ratings surged for many, leaders in North America have also faced diminished approval ratings as the pandemic progressed. In the U.S., reactions worsened. For instance, by early June 2020, President Trump’s approval rating fell to 41.1% – the lowest approval rating since the House of Representatives was in the midst of conducting its impeachment inquiry of the President in November 2019 (Skelley, 2020). While the response was not solely attributed to the President’s reaction to the virus, the shift largely worsened as the United States’ virus outcomes worsened (Skelley, 2020). The shift in public acceptance may be attributable to misunderstanding the ‘problem’, which perhaps results from contradictory information. This presents an opportunity for politicians and public health practitioners to ensure the ‘problem’ is clearly relayed to the general public, for which their support can be gleaned, aiding politicians in their pursuit for re-election.

Predictably, many substantial changes in political action have arisen from the need to react. In Canada, under the pressure to act, the government announced several measures including the introduction of CERB, extended benefits to students, increased pandemic pay for healthcare workers on the frontline, and a seniors’ pay to support that demographic. Moreover, both the United States and Canada sought to ease financial burdens associated with the government by ceasing to collect student loan payments and halting interest rates for extended periods to help citizens allocate funds towards necessities at a trying time. In further considering the case of Canada, Prime Minister Trudeau unveiled social assistance at the rate of $2,000 CAD per month for four months initially to aid those who lost or had their employment impacted due to COVID-19, while the US initially added a $600 USD weekly top-up to state unemployment benefits (Smith, 2020; The Canadian Press, 2020; U.S. Department of the Treasury, n.d.). Considering the average minimum wage across all provinces and territories in Canada was $12.63 CAD per hour as of 4 April 2020, at a rate of seven hours per day ($88.41 CAD), for 20 working days per month ($1768.20), the relief fund is about 11.6% more than the minimum wage, without factoring in tax deductions (Government of Canada, n.d.). Comparatively, the weekly top-up in the US at a monthly total of $2400 USD also pales in comparison to the federal minimum wage of $7.25 USD per hour for covered non-exempt employees (U.S. Department of Labor, n.d.). The acceptability of a benefit at a rate higher than the average minimum wage demonstrates that the public may be more understanding of precarity and not placing blame on the individual. This understanding may even extend beyond the situation around COVID-19 to demonstrate that addressing the SDH may not be out of reach if the public understands the ‘unnecessary’, ‘avoidable’, ‘unfair’, and ‘unjust’ nature of inequities (drawn from the Whitehead, 1990 definition of inequities).

Arguably, since the onset of the pandemic, there has been a shift in national moods towards overcoming inequalities. At this moment, there is a greater understanding, and perhaps even a shift towards empathy, in the national mood for alleviating substantial financial and health burdens as we prepare to rebuild in a post-COVID-19 era. There is potential for sustainability in these solutions to extend beyond the pandemic and address SDH and health inequity. However, it is imperative that there is strong definition of the problem, messaging consistency and alignment, and understanding of the benefits of alleviating inequity and associated potential positive impacts of proposed solutions.

The policy window

Bringing together an enhanced understanding of the three streams of the MSF and how they can converge to create a policy window, yields insights and considerations for paving a path forward to better address the SDH and improve health equity. As demonstrated through action on COVID-19, the problem was clearly presented, as a pandemic that threatens human life. Drawing from this understanding of the ‘problem’ stream, we suggest that there is an opportunity to elevate other major threats on health, such as poverty. This may be accomplished by raising awareness, both publicly and politically, of the large role that SDH play. In response, evidence-influenced policies can be tested even in the face of some evidentiary uncertainty. For example, lockdowns and physical distancing were deemed to be less effective in poorer countries, whereas border and school closures were deemed easier to implement across all countries (Ladd & Bortolotti, 2020). For issues that impact health, there is a wealth of research espousing practical solutions, such as universal basic income (Ruckert, Huynh, & Labonté, 2018). What is now needed is for this evidence to be drawn upon to inform the development of policy solutions to address upstream factors (i.e. SDH). With greater awareness and understanding of the SDH, we argue that we are at a juncture to create a window of opportunity for policy action, one that builds on the momentum afforded through COVID-19 and shifts in national mood.

Next steps

While many governments realize the importance of the SDH, they do not seem to grasp the importance of making the necessary financial and political investments. This is perhaps most clearly illustrated by the almost 3.2 million Canadians, including over 560,000 children, who live in poverty (Statistics Canada, 2020). The financial crisis of 2008 demonstrated that the recovery process will take years and require further increases in social and health needs, which will be presumably similar for recovering from the COVID-19 pandemic (Jani, 2020). These increases in social and health needs will only serve to further exacerbate inequalities and social fragmentation (Jani, 2020). Given that the pandemic has been more all-encompassing than the global financial crisis, we hope that the public may learn from their lived experiences and advocate for governments to have a role in improving the health and well-being of the public, even if it requires financial investments.

Perhaps, government action taken during COVID-19 can help mould public perceptions on what the role of government is and should be: prioritising the health and well-being of the public, not only in times of common hardship but in less pressing circumstances as well. As such, this platform should be capitalised on as the window can be fleeting. We should draw on this moment to readjust public thinking around various SDHs, including social supports, working conditions, and improving access to food and nutrition for those who are most resource-poor. From reassessing social safety nets to the redistribution of wealth, the place and scope of government intervention should be reconsidered and possibly expanded upon.

Globally, action is being taken to ‘build back better’, but we need to move beyond resilience, where the focus is on sustaining service provision during shocks, and embrace ‘antifragility’, to learn from shocks and build stronger and more consequential services that seek to promote health even among those who are healthy (Tumusiime et al., 2020). It is through engaging in discussions around the need for building something ‘different’, which accounts for evolutions over time, that this paradigm shift can occur. Within our ever-globalised world, health threats will continue to have widespread disruptions and impacts on the integrated world economy, necessitating a need to focus on public health and economic development policies. Because health is influenced by political decisions, global public health needs to focus on better addressing policy and governance (M. Amri, 2021). While we hope that societies, the government, and the public will take the lessons learned from this situation to improve actions for the future, there is additional gravity in this moment, and it is pivotal. We should build on the momentum afforded through wide-sweeping change in temperament to expand policy and practice towards other public health issues, while public attention remains high.

Conclusion

At its core, COVID-19 realigns the underlying message that governments can and should prioritise the health and well-being of the public, not only in times of common hardship but in less-pressing circumstances as well. COVID-19 has arguably brought about a greater understanding of the importance of ensuring sufficient support for individuals and households to meet their basic needs. Rapid government responses to provide economic supports and the associated public acceptance is indicative of both the ability of governments to quickly enact such initiatives and positive public reception to such measures. Through considering the problems, policies, and politics, under the lens of the MSF, insights for a potential window of opportunity for addressing inequity in Canada and the United States are provided. The informal recognition of SDH, knowledge of policies that can address inequities, and the political acceptance of such policy action amidst the pandemic response ushers a pivotal policy window to advance SDH-supportive policies. It is imperative that global public health actors and advocates act on this moment to initiate long-lasting, substantial, and meaningful future change.

Acknowledgments

The authors would like to sincerely thank the reviewers for their invaluable, thoughtful, and constructive comments. We would also like to thank our colleague, Sharath Voleti, for generously reviewing and providing feedback for our work.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1 In the context of health, inequity is understood as a political concept with a moral commitment to social justice, while inequality entails systematic measured differences (Kawachi, Subramanian, & Almeida-Filho, 2002). In other words, while inequalities are believed to be unnecessary and avoidable, inequities are understood as also being unfair and unjust (M. M. Amri et al., 2021; Whitehead, 1990).

2 The SDHs are defined as the economic and social conditions which affect an individual’s health status and include: peace, shelter, education, food, income, a stable eco-system, sustainable resources, and social justice and equity, as recognised by the Ottawa Charter for Health Promotion (World Health Organization, Health and Welfare Canada, & Canadian Public Health Association, 1986).