A systems approach to health equity: Lessons from five countries (YEL 2025)

Authors: Abel George (India), Abrar Barshaid (Saudi Arabia), Jason Pangelinan (Northern Mariana Islands), Sadia Murray (South Africa), Simon Radmore (Australia) and Turki Alotaibi (Saudi Arabia)

Reviewers: Abdur Rauf (YEL 2024) and Natalia Allué (YEL 2022)

Healthcare equity and access remain among the most pressing global challenges of our time serving not only as moral imperative, but a defining performance indicator of a resilient and inclusive health system. Despite advances in medicine and technology, as many as 5 billion people, up to 70% of the world’s population, still face barriers to quality care. These barriers are not simply the result of resource constraints but are deeply rooted in the ways health systems respond (or fail to respond) to the complex realities of vulnerable populations.  

This article draws on a series of presentations from the Northern Mariana Islands, India, South Africa, Saudi Arabia, and Australia, each offering a unique perspective shaped by local demographics, geography, and systemic realities. From island nations to emerging economies, the underlying challenge remains constant: how to operationalize equity at every level of the health system.  

While the contexts differ, the presentations reveal strikingly similar themes: persistent inequities in access, systemic barriers that disproportionately affect vulnerable groups, and a shared recognition that good intentions and commitment alone are not enough. 

A systems approach 

The group adopted a holistic, systems-based approach to address healthcare equity and access. This approach recognises that equity must be ‘hardwired’ into strategies, policies, and governance structures across sectors and systems. It means moving beyond aspirational statements to embedding measurable equity goals in health plans, funding models, and accountability frameworks, and partnering with other agencies to work towards shared goals.  

Universal challenges, local realities 

The presentations illustrate that while equity and access barriers are universal, their manifestations are deeply contextual. Local manifestations identified as examples from the 5 countries include: 

• In Australia, Indigenous communities experience a nine-year gap in life expectancy compared to non-Indigenous Australians. 

• In rural India, pregnant women face disproportionate mortality. 

• In South Africa, adolescent health services are fragmented and poorly aligned. 

• In Saudi Arabia, rural populations struggle with mental health and ageing. 

• In the Northern Mariana Islands, geography and workforce shortages significantly impact maternal health.  

Despite these differences, the group found that common approaches can be adapted to address local needs. 

Four pillars for change 

The group’s approach is anchored in four pillars: 

1. Strategy: Embedding equity into the core of health system strategy, policy, and governance, with clear, measurable goals. 

1. Self-determination: Shifting power to communities through consumer-centred, co-designed services that reflect cultural identity and lived experience. 

1. Novel models of care: Moving beyond one-size-fits-all solutions to embrace community-based, culturally safe, flexible, and responsive care—including virtual and face-to-face models. 

1. Inclusive leadership: Committing to authentic, visible, and accountable leadership that models inclusive behaviours and challenges systemic barriers.  

These pillars reinforce that a system based response demands coherence between national priorities and community realities. There presentations revealed not isolated stories, but interconnected lessons on how systems thinking transforms equity from principle to practice.  

A global call to action 

The World Health Organization’s Sustainable Development Goals make clear that equity and access are global priorities. The group’s work underscores that achieving these goals requires more than funding or policy, it demands sustained, coordinated, and collective effort. Stories that provide proof that even small systems can model large scale change through inclusive, system based leadership. The call to action is clear: share knowledge across borders, hold ourselves accountable, and work collectively so that no one’s health is determined by where they live, their culture, or their circumstances. 

Equity must become our shared global standard. Only by embracing a systems approach rooted in strategy, self-determination, novel care models, and inclusive leadership can we hope to deliver on the promise of health for all.