Stop Calling It a Health System If It Does Not Deliver on Health Equity
Dr. José M. Zuniga, President/CEO, Fast-Track Health
We have been told that health equity is something to aim for as an end goal after systems have done their work. But that thinking is backward. Health equity is not the outcome; it is the standard. If a health system is not producing equitable outcomes, then it is not functioning but is instead failing by design.
We do not need more platitudes about closing gaps. We need the courage to acknowledge that those gaps exist because our systems were never built to serve everyone equally. And we need to stop treating equity as a feature we can retrofit, rather than the foundational principle that should drive everything from funding flows to digital health innovation.
Across cities, countries, and continents, Fast-Track Health works with communities whose health outcomes are directly shaped by their geography, income, gender, race, and identity. In many urban areas, life expectancy can vary by 10 to 20 years between neighborhoods separated by a single bus route. In some nations, maternal mortality remains unacceptably high, not due to lack of knowledge, but lack of political will to allocate resources where they are needed most.
This inequity is not a natural disaster; it is a policy choice.
We cannot meaningfully talk about achieving universal health coverage (UHC), meeting the health-related Sustainable Development Goals (SDGs), or preparing for future pandemics unless we treat equity as the default, not the deluxe package. A system that delivers excellent care only to the privileged is not an excellent system. It is an exclusionary one.
There are models to draw from. The Fast-Track Cities initiative, for example, is grounded in data-driven accountability and community leadership – two pillars that cannot be faked. In cities where political will aligns with community power, we have seen progress in expanding access to HIV prevention and treatment, improving retention in care, and building trust where it had been broken. We are proving, city by city, that equity-centered responses are not only more just, but they are also more effective.
To scale this progress, we must change more than programs. We must change the paradigm. That means shifting from targeting “vulnerable populations” to dismantling the structures that produce vulnerability in the first place; disaggregated data collection to real-time accountability that informs and drives change; and top-down technical assistance to co-created solutions, where community knowledge is valued as expertise.
It also means being honest about who is missing from decision-making tables and why. Tokenism in the name of inclusion does not produce equitable policies. What it produces is performative optics. We need shared governance, shared metrics, and shared ownership. And that includes making space for community health workers, whose lived experience and proximity to care delivery position them not just as implementers, but as architects of better systems.
As the world looks beyond the 2030 horizon and debates what comes after the SDGs, we must ask: Will we repeat the cycle of aspirational goal-setting followed by uneven delivery? Or will we finally center the people, places, and practices that make health equity real? We cannot afford to lose another decade to frameworks that measure progress in averages while masking disparities. We need to normalize not “exceptionalize” equity.
A quote often misattributed to Mahatma Gandhi but no less resonant for our purpose is: “The true measure of any society can be found in how it treats its most vulnerable members.” If that is true, then health systems should be judged not by the speed of discovery or innovation or the number of clinics and hospitals built, but by how well they serve those most often left behind in a world mired in inequity. Our moral test is ultimately how we treat our children, those in the shadows of life (the needy, sick, or handicapped), and our elderly.
Fast-Track Health is committed to operationalizing equity – not just as a value, but as a requirement. We call on governments, multilateral institutions, city leaders, and private sector actors to join us in making health equity the threshold for legitimacy in global health. Because if your system is not delivering equity, it is not a health system. It is an exclusion system. And that is not something we can fix around the edges; it is something we must transform from the ground up.