Our search retrieved 2623 unique records for screening of title and abstracts, 243 records with full texts; we excluded 165 of these and included 77 records in our review (see Supplementary Material Part 2). The 77 records (Supplementary Table S1) included 66 commentaries; 3 letters, 2 case reports, 2 policy reviews, an ethical analysis, a modelling study, a description of a framework, and an editorial. Most records focussed on single countries, especially the United States (US) (n = 48); 17 had a global focus and 2 regional (Africa and Americas). Many articles (n = 50) addressed systematic causes of inequity at the population level, including a focus on racially minoritised groups. Seven articles each focussed on inequities for older people and for people with disabilities; only two focussed on children, and one on pregnant people. In total, 18 of the included studies addressed risk of infection and of morbidity and mortality from COVID-19 (Table S2), 13 addressed access to COVID-19 tests and vaccines (Table S3), 15 addressed access to treatment for COVID-19 (Table S4), 8 addressed non-COVID-19 morbidity and mortality (Table S5), and 23 addressed multiple inequities (Table S6).

Inequity in risk of infection, morbidity, and mortality from COVID-19Proposals

Authors suggested ways to address inequity in risk of infection including increased provision of personal protective equipment (PPE) and increased capacity for social distancing in underserved communities and settings (Supplementary Material Table S2 and Box S1). Henry et al. recommended implementing rapid release of suitable individuals from incarceration to help ensure US prisons were capable of adhering to social distancing guidelines [28]. Other commentaries discussed prison reform and emphasised preventing incarceration. Recommendations to reduce the inequitable risk of infection for older people, and to strengthen the aged care workforce, include improved pay and paid sick leave to obviate need for carers to work multiple jobs (increasing their own risks of infection). Adebisi et al. recommended decriminalisation of sex work in Africa [29]. Bonn et al. advocated for moratoria on enforcement of laws criminalising illicit drug use [30]. Several authors recommended moratoria on housing evictions to reduce community transmission of COVID-19 in racially minoritised groups at increased risk of eviction. To improve transparency of reporting, some suggested collection and release of COVID-19 data by (self-reported) race, ethnicity, and age so that resources could be targeted to populations in need.

INEP commentary

Approaches need to address inequities for risk of adverse outcomes from infection, as well as inequities in risk of infection. Proposals primarily targeted individuals and neglected structural systems of disadvantage which place entire communities at increased risk. Communities may have intergenerational households without space to physically distance or may lack access to clean water for hand hygiene. Historical considerations contribute to inequities such as ‘red-lining’ in the US—a government practice that placed Black communities in undesirable areas close to toxic industries, major thoroughfares (with increased air pollution), or without proper infrastructure (including access to adequate food, water, and healthcare). Many still live in those same areas and have experienced generations of public health disadvantages that increased their susceptibility to harmful pathogens.

Inequity in access to testing and to vaccines for COVID-19Proposals

To increase equitable access to testing and vaccines against COVID-19 researchers suggested mobile COVID-19 testing and vaccination centres in popular community spaces such as pharmacies, physician offices, churches, and schools in communities (Table S3 and Box S2). These were proposed to benefit Aboriginal and Torres Strait Islander communities in Australia and Black American communities in the US. Other suggestions included developing equity-based allocation frameworks and including underrepresented groups in vaccine clinical trials.

Some researchers discussed the impact of economic inequity between high- and low-income countries on vaccine allocation. They discussed models for equity-based global vaccine allocation including the Covax proportional allocation model and the Fair Priority model [31]. Abbas proposed tiered pricing of vaccines according to the purchasing power of countries. After negotiation with the government of Brazil, GlaxoSmithKline (GSK) agreed to sell its 10-valent vaccine for $7 per dose although the firm was selling at $56 and $71 per dose in Europe and the US, respectively. Herzog acknowledged that a system of allocating vaccines according to the population of different countries would provide a fairer and more efficient system compared to an open market [31]. Herzog contended, however, that this could be improved on by adopting the Fair Priority model, a 3-phase system, that also factors in metrics such as standard expected years of life lost averted per dose and loss of gross national income. Herzog argued that this model more closely aligns with the World Health Organization (WHO) values of beneficence, equal moral concern, and prioritising the underserved.

A key feature of several models was early allocation of vaccines to older people to minimise mortality. Additional recommendations included the use of population-based randomised trials for roll-out of population vaccination programs, and countering vaccine hesitancy due to misinformation and mistrust of the healthcare system. For improving communication, researchers emphasised the importance of culturally and linguistically diverse, evidence-based public health messages and engaging with social influencers and leaders of cultural and faith-based groups to send them.

INEP commentary

Most of the included papers focussed on equitable vaccine allocation within countries, likely reflecting immediate priorities and available policy levers. COVID-19 vaccine access and equity, however, is a global problem, with refugees and undocumented migrants among the most vulnerable [32]. Although some records (highlighted above) discussed inequity between higher and lower income countries, this was not their primary focus and none mentioned potential ways to address to this urgent problem. These include (1) patent waivers to permit local vaccine production, (2) use of the World Trade Organisation Trade-Related Aspects of Intellectual Property Right (TRIPS) agreement to allow production of vaccines outside patent protection, and (3) sales of vaccines at cost price (to the pharmaceutical company) to eligible countries (such as the United Nations–backed Medicines Patent Pool) [33].

Within countries, use of age-based prioritisation for vaccine distribution may have been overly simplistic and missed the intersectional nature of morbidity and mortality from COVID-19. Vaccine roll-out programs run in partnership with communities tended to be more successful. In the US, Indigenous American groups given responsibility to vaccinate in their communities had higher rates than the rest of the US [34]. Local ownership of testing and vaccination messaging and facilities could also be helpful in historically disadvantaged communities, such as those noted.

Although most solutions aimed to increase vaccine uptake by improving the clarity and relevance of messaging to communities, we need research to identify other potential barriers to COVID-19 vaccination that may be redressed. Messaging may need to acknowledge mistrust from systemic racism and historical injustice before providing information about the vaccines [35]. Another key barrier noted is out-of-pocket costs associated with vaccination, particularly in countries without universal healthcare coverage.

Inequity in access to treatment for COVID-19Proposals

Several records discussed the importance of providing linguistically and culturally tailored medical care to individuals infected with COVID-19 (Table S4, Box S3). One recommendation is to deploy clinicians fluent in the preferred community language. A hospital in Massachusetts, US, implemented this initiative with 51 bilingual physicians representing 14 countries of origin who provided 14-h coverage in support to the medical team [36]. Some, including Gill et al. [37], suggested including underrepresented racially minoritised groups and people with sociodemographic disadvantages in phase 3 clinical trials as a way to increase access to, and the evidence base for treatments for these population groups.

Essien et al. [38] suggested increasing diversity among hospital triage committees and revising critical care triage guidelines to prevent underserved groups from experiencing discriminatory medical care. White and Lo [39] suggested existing triage guideline could use correction factors to reduce the impact of structural inequities, prioritise high-risk essential workers, and reject longer-term survival as an allocation criterion. Schmidt et al. [40] criticised the Sequential Organ Failure Assessment algorithm’s use of a single ‘colour-blind’ serum creatinine threshold to estimate a patient’s probability of dying in the Intensive Care Unit. This practice systematically discriminates against Black Americans who tend to have higher serum creatinine levels [40]. Erasmus [41] recommended aligning South African Intensive Care Unit triage guidelines with the South African Constitution to formally protect older people and persons with disabilities from discrimination. Brown and Goodwin [42] raised the importance of limiting consideration of disabilities and chronic illnesses that do not affect prognosis in COVID-19 infection in Intensive Care Unit triage criteria.

INEP commentary

Despite a suggestion of increasing representation in trials, no author explored ways to achieve this. Partnership with communities for the co-creation, co-design, and co-production of research projects and interventions may ensure the trial is fit for purpose and enhance the translation of findings into equitable practice changes [43]. Culturally safe recruitment strategies are also likely to be important. Some of the proposals could worsen inequities faced by older people already disproportionately affected by COVID-19 [44]. Proposals for addressing access to treatment for those with severe disease did not consider that many COVID-19 treatment algorithms inherently discriminate against older people due to in-built utilitarian biases favouring individuals with greater ‘future productivity’. This bias may be amplified in people from minoritised groups, where “weathering” from the effects of sustained cultural oppression means these individuals have become biologically older than their chronological age [45]. Policy makers and practitioners need to examine algorithms for potential discrimination from in-built biases in the data or decisions made in their development.

Non-COVID-19 morbidity and mortalityProposals

Several records promoted the uptake of telemedicine and patient care options that limit face-to-face interactions to assist in reducing inequities relating to non-COVID-19 morbidity and mortality (Table S5, Box S4). Proposals in the US included Congressional allocation of funding from the COVID-19 telehealth program to community clinics and action by the Federal Communication Commission to incentivise making broadband internet access more equitably available. Valdez et al. [46] emphasised the importance of developing accessible telemedicine approaches to optimise the participation of persons with disabilities. This is particularly important in rural communities where remoteness and disability can be intersectional and thereby compound difficulty of accessing internet-based services. Valdez et al. [46] recommended developing accessible telemedicine software to ensure compatibility with external assistive technology devices, incorporating plug-ins that allow for sign language or closed captioning, making user-friendly interfaces that use both icons and text, and enabling multiple users of the same account to incorporate others in consultations by proxy. Only two records [47, 48] mentioned disruption to children’s education and subsequent impacts on their social, economic, and health needs due to school closures. Armitage et al. [48] advocated replacing school closures with strategies to reduce COVID-19 transmission among students (smaller class sizes, physical distancing in classrooms and promotion of good hygiene practices.)

INEP commentary

Although telemedicine has the potential to facilitate physically distanced healthcare interactions, it may exclude people without reliable access to internet or electronic devices who may experience worsening of non-COVID-19 morbidity and mortality. Some authors briefly mentioned the impact of mandated school closures on child wellbeing, however, none acknowledged the unequal consequences on educational inequities and children vulnerable to experience abuse at home. This includes the effects on meeting children’s basic needs such as nutrition; studies in the UK suggested that only half of children eligible for free school meals received them during school closures in 2020 [44]. None of the papers offered detailed solutions for alternatives to school closures, or evidence to support their effectiveness. Examples could include improving classroom ventilation and use of regular testing (‘test-to-stay’) protocols. Public health policy must prioritise the most at-risk groups to protect the population as a whole [49]. Despite previous research having noted increased risk of domestic violence within unequal power relationships during the pandemic, some governments failed to enact real protection for at-risk individuals and instead simply commissioned additional research into the problem.

Multiple inequities in COVID-19Proposals

Records describing approaches to reduce multiple inequities emphasised the importance of addressing the structural causes of inequity such as racism and other social determinants of health using whole of society approaches that extend beyond the health sector (Table S6, Box S5). In Aotearoa New Zealand, a partnership among nine Iwi (Māori kin-ship groups) surveyed 18,000 constituents to identify their needs during national lockdowns [50]. In response, the partnership provided 1734 kai (food) packs, 1371 grants for home heating, 25,000 hygiene packs, and Iwi checkpoints to stop the spread of COVID-19 into Māori communities. The University College London Institute of Health Equity [51] recommended that approaches to improving the social determinants of health should be strategies that appreciate and respond to the uniqueness of communities and called for greater investment from the national government as well as the health and business sectors in cross-sector partnerships.

INEP commentary

There are other relevant groups not mentioned for any of the types of inequity. One prominent group is women, usually the primary carers for children and older parents. There was exacerbation of gender inequities due to lack of childcare, inability to work from home or to take time off if sick, and pressure to send children to school or day-care if sick due to the need to work. Analysis of global publicly available datasets found that between March 2020 and September 2021 women were more likely than men to report employment loss, forgoing work to care for others, and dropping out of school for reasons other than school closures [52]. Women were also more likely than men to report that gender-based violence had increased during the pandemic. Although some authors mentioned lower socio-economic groups, they did not focus specifically on workers in low-paid service industries, where the businesses either closed or the people were required go to work and be exposed (or go to work sick and expose others). Those working in higher-paid jobs had more job flexibility and the technology and internet assets to work from home. Intersectionality between gender, race, and employment in low-paid service jobs compounded inequities.

The COVID-19 pandemic has demonstrated that creating equity-based public health policy during a crisis is extremely difficult. Before the next pandemic, as well as for non-pandemic times, we need robust, evidence-based interventions to combat systemic health and social inequities to allow everyone in our communities can thrive. The Social Sector Trials, introduced in two localities in Aotearoa New Zealand, reveal how place-based initiatives have the potential to impact multiple inequities (including housing, drug and alcohol addiction, education, and training), with the objective of enhancing individual and collective self-determination [53]. These initiatives have highlighted the potential to re-orient existing program delivery to better understand the cumulative impact of services and increase shared responsibility for results [54].