The deployment of health equity across regional and subregional governance systems: a scoping review of the extent, range and nature
About the project
This scoping review project examines how equity has been articulated, institutionalized and operationalized within regional and subregional health governance arrangements globally between 2005 and 2025. Against the backdrop of the COVID-19 pandemic—which exposed profound failures in global solidarity, inequitable access to vaccines and health products, and the limitations of the WHO-led global health governance system—the project responds to growing recognition that regional systems may offer more context-responsive and equity-driven approaches to managing transnational health threats. The project is grounded in concerns that, despite repeated invocations of equity in global health discourse, there has been little systematic assessment of whether equity principles have meaningfully shaped regional health governance practices during this period.
The study employs a PRISMA-guided scoping review to answer two core research questions: whether equity has been deployed in regional and subregional health governance, and the extent, range and nature of that deployment. Through a synthesis of academic literature and policy documents, the scoping review systematically maps how equity has been defined, institutionalized, and operationalized within governance instruments, mandates and practices across regions.
A third research question, to be addressed through a focus-group workshop, examines Canada’s role in advancing equitable access to vaccines and health products domestically, regionally, and internationally, with particular attention to the Inter-American system. The focus-group workshop explores how Canada contributes to norm formation, regional cooperation, and equitable pandemic management, positioning regional governance as a critical intermediary between global health responses and national health actions.
Key findings
Across regions, the findings reveal marked variation in the institutionalization, operationalization and transformative ambition of equity in health governance. Europe demonstrates the most robust extent, range and nature of equity deployment. Equity is formally embedded through legal and strategic mandates, most notably via initiatives such as the Joint Action Health Equity Europe and WHO European frameworks. The region shows broad multilevel engagement—spanning the European Commission, the Council of Europe, national ministries and civil society—and employs robust policy instruments including health-equity impact assessments, monitoring frameworks and treaty-based obligations. Equity is addressed across multiple social determinants of health (SDoH), and governance reforms exhibit recognitional, distributive and transformative characteristics.
In Africa, equity deployment is moderately strong but more sector specific. Equity is embedded primarily through access-oriented and redistributive mechanisms, particularly in pharmaceutical governance and public health financing. Continental initiatives such as the African Medicines Agency and commitments under the Abuja Declaration demonstrate legal and diplomatic alignment, with an emphasis on reducing inequities in access to medicines and strengthening regulatory capacity. While transformative in scope at the continental level, equity remains unevenly operationalized across subregions (East, West, South and Central Africa).
The Americas show sustained and historically rooted engagement with equity, particularly through the Pan American Health Organization. Equity is framed as a core normative value and operationalized through intersectoral policy tools such as Urban HEART, health impact assessments and pooled procurement mechanisms like the Revolving Fund for Vaccines. The range of equity groups and SDoH addressed is broad, though formalization varies across subregional and national contexts.
By contrast, the Middle East and North Africa, the Caribbean and the Pacific Islands exhibit weak formal embedding of equity. In the Middle East and North Africa, equity appears indirectly through discussions of system capacity and financing rather than explicit mandates. The Caribbean shows minimal institutionalization, with limited policy instruments and an absence of monitoring or sustainability mechanisms. The Pacific Islands demonstrate more targeted distributive interventions—particularly in cancer screening and workforce development—but equity remains weakly codified and reliant on partnerships rather than governance frameworks.
Overall, the project highlights a persistent gap between equity rhetoric and governance practice, underscoring the need for stronger legal mandates, accountability mechanisms, and regionally grounded equity frameworks beyond Europe.
Policy implications
- Equity should be formally institutionalized within regional health-governance mandates, not merely referenced rhetorically. Regions with stronger equity outcomes (e.g., Europe and Africa) have embedded equity through legal instruments, treaties, monitoring frameworks and dedicated institutions, while regions with weaker outcomes rely on ad-hoc or indirect references to equity. Future regional reforms should therefore require explicit equity mandates, accountability mechanisms and reporting structures to ensure sustained and enforceable commitments rather than discretionary application.
- Regional governance systems should move beyond recognitional approaches toward distributive and transformative equity mechanisms. Initial findings indicate that many regions acknowledge inequities but lack policy tools to redistribute resources or structurally reform governance arrangements. Policymakers should prioritize mechanisms such as joint procurement, pooled financing, regulatory harmonization and equity impact assessments to translate equity principles into material access to medicines, vaccines and health services, particularly during public health emergencies.
- Stronger alignment between regional institutions and social determinants of health is needed to guide equitable preparedness and response. The uneven integration of SDoH across regions highlights the need for policies that systematically identify priority populations, embed equity indicators into surveillance and preparedness frameworks, and coordinate multisectoral action across health, trade, and social policy domains to reduce structural vulnerabilities before crises occur.
Contact the researchers
Uchechukwu Ngwaba, Associate Professor, Lincoln Alexander School of Law, Toronto Metropolitan University: uche.ngwaba@torontomu.ca
Aeda R. Salim, Project Manager and Research Assistant, Lincoln Alexander School of Law, Toronto Metropolitan University: aedarsalim@torontomu.ca
Jasmeen Bassi, Research Assistant, Lincoln Alexander School of Law, Toronto Metropolitan University: jasmeen.bassi@torontomu.ca
Further information
Read full report (Coming soon)