Priority setting in times of crises: an analysis of priority setting for the COVID-19 response in the Western Pacific Region.

BACKGROUND: While priority setting is recognized as critical for promoting accountability and transparency in health system planning, its role in supporting rational, equitable and fair pandemic planning and responses is less well understood. This study aims to describe how priority setting was used to support planning in the initial stage of the pandemic response in a subset of countries in the Western Pacific Region (WPR). METHODS: We purposively sampled a subset of countries from WPR and undertook a critical document review of the initial national COVID-19 pandemic response plans. A pre-specified tool guided data extraction and the analysis examined the use of quality parameters of priority setting, and equity considerations. RESULTS: Nine plans were included in this analysis, from the following countries: Papua New Guinea, Tonga, The Philippines, Fiji, China, Australia, New Zealand, Japan, and Taiwan. Most commonly the plans described strong political will to respond swiftly, resource needs, stakeholder engagement, and defined the roles of institutions that guided COVID-19 response decision-making. The initial plans did not reflect strong evidence of public engagement or considerations of equity informing the early responses to the pandemic. CONCLUSION: This study advances an understanding of how priority setting and equity considerations were integrated to support the development of the initial COVID-19 responses in nine countries in WPR and contributes to the literature on health system planning during emergencies. This baseline assessment reveals evidence of the common priority setting parameters that were deployed in the initial responses, the prioritized resources and equity considerations and reinforces the importance of strengthening health system capacity for priority setting to support future pandemic preparedness.

Stakeholder participation in the COVID-19 pandemic preparedness and response plans: A synthesis of findings from 70 countries.

Stakeholder participation is a key component of a fair and equitable priority-setting in health. The COVID-19 pandemic highlighted the need for fair and equitable priority setting, and hence, stakeholder participation. To date, there is limited literature on stakeholder participation in the development of the pandemic plans (including the priority setting plans) that were rapidly developed during the pandemic. Drawing on a global study of national COVID-19 preparedness and response plans, we present a secondary analysis of COVID-19 national plans from 70 countries from the six WHO regions, focusing on stakeholder participation. We found that most plans were prepared by the Ministry of Health and acknowledged WHO guidance, however less than half mentioned that additional stakeholders were involved. Few plans described a strategy for stakeholder participation and/or accounted for public participation in the plan preparation. However, diverse stakeholders (including multiple governmental, non-governmental, and international organizations) were proposed to participate in the implementation of the plans. Overall, there was a lack of transparency about who participated in decision-making and limited evidence of meaningful participation of the community, including marginalized groups. The critical relevance of stakeholder participation in priority setting requires that governments develop strategies for meaningful participation of diverse stakeholders during pandemics such as COVID-19, and in routine healthcare priority setting.

A global comparative analysis of the the inclusion of priority setting in national COVID-19 pandemic plans: A reflection on the methods and the accessibility of the plans.

BACKGROUND: Despite the swift governments' response to the COVID-19 pandemic, there remains a paucity of literature assessing the degree to which; priority setting (PS) was included in the pandemic plans and the pandemic plans were publicly accessible. This paper reflects on the methods employed in a global comparative analysis of the degree to which countries integrated PS into their COVID-19 pandemic plans based on Kapiriri & Martin's framework. We also assessed if the accessibility of the plans was related to the country's transparency index. METHODS: Through a three stage search strategy, we accessed and reviewed 86 national COVID-19 pandemic plans (and 11 Canadian provinces and territories). Secondary analysis assessed any alignment between the readily accessible plans and the country's transparency index. RESULTS AND CONCLUSION: 71 national plans were readily accessible while 43 were not. There were no systematic differences between the countries whose plans were readily available and those whose plans were 'missing'. However, most of the countries with 'missing' plans tended to have a low transparency index. The framework was adapted to the pandemic context by adding a parameter on the need to plan for continuity of priority routine services. While document review may be the most feasible and appropriate approach to conducting policy analysis during health emergencies, interviews and follow up document review would assess policy implementation.

How did European countries set health priorities in response to the COVID-19 threat? A comparative document analysis of 24 pandemic preparedness plans across the EURO region.

The COVID-19 pandemic has forced governments across the world to consider how to prioritise the allocation of scarce resources. There are many tools and frameworks that have been designed to assist with the challenges of priority setting in health care. The purpose of this study was to examine the extent to which formal priority setting was evident in the pandemic plans produced by countries in the World Health Organisation's EURO region, during the first wave of the COVID-19 pandemic. This compliments analysis of similar plans produced in other regions of the world. Twenty four pandemic preparedness plans were obtained that had been published between March and September 2020. For data extraction, we applied a framework for identifying and assessing the elements of good priority setting to each plan, before conducting comparative analysis across the sample. Our findings suggest that while some pre-requisites for effective priority setting were present in many cases - including political commitment and a recognition of the need for allocation decisions - many other hallmarks were less evident, such as explicit ethical criteria, decision making frameworks, and engagement processes. This study provides a unique insight into the role of priority setting in the European response to the onset of the COVID-19 pandemic.

Planning with a gender lens: A gender analysis of pandemic preparedness plans from eight countries in Africa.

Background: Health planning and priority setting with a gender lens can help to anticipate and mitigate vulnerabilities that women and girls may experience in health systems, which is especially relevant during health emergencies. This study examined how gender considerations were accounted for in COVID-19 pandemic response planning in a subset of countries in Africa. Methods: Multi-country document review of national pandemic response plans (published before July 2020 and as of March 2022) from Ethiopia, Ghana, Kenya, Nigeria, Rwanda, South Africa, Uganda, and Zambia, supplemented with secondary data on gender representation on planning committees. A gender analysis framework informed the study design and the Morgan et al. matrix guided data extraction and analysis. Results: All plans reflected implicit and explicit considerations of the impacts of the pandemic responses on women and girls. Through a gender lens, the implicit considerations focused on ensuring safety and protections (e.g., training, access to personal protective equipment) for community and facility-based health care workers and broad engagement of the community in risk communication. The explicit gender considerations, reflected in a minority of plans, focused on addressing gender-based violence and providing access to essential services (e.g., sexual and reproductive health care, psychosocial supports), products (e.g., menstrual hygiene products) and social protection measures. Women were underrepresented on the COVID-19 planning committees in all countries. Conclusions: The plans reflected varying national efforts to develop pandemic responses that anticipated and reflected unique vulnerabilities faced by women, though subsequent plans reflected further consideration of gender-relevant impacts compared to initial plans. Embedding a gender lens in emergency preparedness planning furthers equity and could support anticipation and timely mitigation of negative outcomes for women and girls who are often further marginalized during health emergencies.

A global comparative analysis of the criteria and equity considerations included in eighty-six national COVID-19 plans.

Systematic priority setting (PS), based on explicit criteria, is thought to improve the quality and consistency of the PS decisions. Among the PS criteria, there is increased focus on the importance of equity considerations and vulnerable populations. This paper discusses the PS criteria that were included in the national COVID-19 pandemic plans, with specific focus on equity and on the vulnerable populations considered. Secondary synthesis of data, from a global comparative study that examined the degree to which the COVID-19 plans included PS, was conducted. Only 32 % of the plans identified explicit criteria. Severity of the disease and/or disease burden were the commonly mentioned criteria. With regards to equity considerations and prioritizing vulnerable populations, 22 countries identified people with co-morbidities others mentioned children, women etc. Low social-economic status and internally displaced population were not identified in any of the reviewed national plans. The limited inclusion of explicit criteria and equity considerations highlight a need for policy makers, in all contexts, to consider instituting and equipping PS institutions who can engage diverse stakeholders in identifying the relevant PS criteria during the post pandemic period. While vulnerability will vary with the type of health emergency- awareness of this and having mechanisms for identifying and prioritizing the most vulnerable will support equitable pandemic responses.

"You're Not Understood, and You're Isolated": A Narrative Account of Loneliness by Black Older Adults in Ontario, Canada.

Loneliness among older adults is a leading health and social concern globally and in Canada, including racialized and minoritized groups. Although previous studies have explored loneliness among ethnic minoritized groups in Canada, little is known about the constellating factors contributing to loneliness among native-born and immigrant Black older adults (BOAs) in Canada and their unique ways of dealing with the experience. Our study explores the constellating factors shaping loneliness experiences among BOAs living in Ontario. Using a narrative approach, we purposively selected and interviewed 13 BOAs. Time as a driver of change, a sense of belonging reinforced through place identity, and challenges of making a new home were dominant themes. Our finding highlights the need for increased cultural sensitivity at the micro and macro levels, which will improve a sense of belonging and reduce loneliness among racialized immigrant older adults.

What are effective strategies to respond to the psychological impacts of working on the frontlines of a public health emergency?

Background: The COVID-19 pandemic has disrupted the healthcare and public health sectors. The impact of working on the frontlines as a healthcare or public health professional has been well documented. Healthcare organizations must support the psychological and mental health of those responding to future public health emergencies. Objective: This systematic review aims to identify effective interventions to support healthcare workers' mental health and wellbeing during and following a public health emergency. Methods: Eight scientific databases were searched from inception to 1 November 2022. Studies that described strategies to address the psychological impacts experienced by those responding to a public health emergency (i.e., a pandemic, epidemic, natural disaster, or mass casualty event) were eligible for inclusion. No limitations were placed based on study design, language, publication status, or publication date. Two reviewers independently screened studies, extracted data, and assessed methodological quality using the Joanna Briggs Institute critical appraisal tools. Discrepancies were resolved through discussion and a third reviewer when needed. Results were synthesized narratively due to the heterogeneity of populations and interventions. Outcomes were displayed graphically using harvest plots. Results: A total of 20,018 records were screened, with 36 unique studies included in the review, 15 randomized controlled trials, and 21 quasi-experimental studies. Results indicate that psychotherapy, psychoeducation, and mind-body interventions may reduce symptoms of anxiety, burnout, depression, and Post Traumatic Stress Disorder, with the lowest risk of bias found among psychotherapy interventions. Psychoeducation appears most promising to increase resilience, with mind-body interventions having the most substantial evidence for increases in quality of life. Few organizational interventions were identified, with highly heterogeneous components. Conclusion: Promoting healthcare workers' mental health is essential at an individual and health system level. This review identifies several promising practices that could be used to support healthcare workers at risk of adverse mental health outcomes as they respond to future public health emergencies.Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=203810, identifier #CRD42020203810 (PROSPERO).

Was priority setting included in the Canadian COVID-19 pandemic planning and preparedness? A comparative analysis of COVID-19 pandemic plans from eight provinces and three territories.

BACKGROUND: Variation in priorities during pandemic planning among the federal, provincial and territorial jurisdictions are thought to have impacted Canada's ability to effectively control the spread of the COVID-19 virus, and protect the most vulnerable. The potential influence of diverse and divergent political, cultural, and behavioural factors, regarding inclusion of priority setting (PS) in pandemic preparedness planning across the country is not well understood. This study aimed to examine how the Canadian federal, provincial and territorial COVID-19 pandemic preparedness planning documents integrated PS. METHODS: A documentary analysis of the federal, eight provincial, three territorial COVID-19 preparedness and response plans. We assessed the degree to which the documented PS processes fulfilled established quality requirements of effective PS using the Kapiriri & Martin framework. RESULTS: While the federal plan included most of the parameters of effective PS, the provinces and territories reflected few. The lack of obligation for the provinces and territories to emulate the federal plan is one of the possible reasons for the varying inclusion of these parameters. The parameters included did not vary systematically with the jurisdiction's context. CONCLUSION: Provinces could consider using the framework of the federal plan and the WHO guidelines to guide future pandemic planning. Regular evaluation of the instituted PS would provide a mechanism through which lessons can be harnessed and improvement strategies developed. Future studies should describe and evaluate what PS mechanisms were implemented.

"But I survived": A phenomenological study of the health and wellbeing of aging Black women in the Greater Toronto Area, Canada.

Studies that assess the association between race and health have focused intently on the cumulative impact of continuous exposure to racism over an extended period. While these studies have contributed significantly to the general understanding of the life experiences and health status of racialized people, few studies have explicitly bridged the experiences of aging with gender and the wide structural barriers and social factors that have shaped the lives of racialized older women. This study aimed to investigate the origins of health inequities to highlight factors that intersect to affect the health and wellbeing of older Black women across their life course. Descriptive phenomenology was used to describe older Black women's health and wellbeing, and factors that impact their health across their life course. Criteria-based sampling was used to recruit study participants (n = 27). To be eligible women needed to be 55 years or older, speak English, self-identify as a Black female, and live in the Greater Toronto Area. Data analysis was guided by phenomenology. Themes identified demonstrated that participants' health and wellbeing were influenced by gender bias, racism, abuse, and retirement later in life. Participants reported having poor mental health during childhood and adulthood due to anxiety and depression. Other chronic illnesses reported included hypertension, diabetes, and cancer. Qualitative methods provided details regarding events and exposures that illuminate pathways through which health inequities emerge across the life course.

Examining priority setting in the national COVID-19 pandemic plans: A case study from countries in the WHO- South-East Asia Region (WHO-SEARO).

Background: The World Health Organization- South-East Asia Region (WHO-SEARO) accounted for almost 17% of all the confirmed cases and deaths of COVID-19 worldwide. While the literature has documented a weak COVID-19 response in the WHO-SEARO, there has been no discussion of the degree to which this could have been influenced/ mitigated with the integration of priority setting (PS) in the region's COVID-19 response. The purpose of this paper is to describe the degree to which the COVID-19 plans from a sample of WHO-SEARO countries included priority setting. Methods: The study was based on an analysis of national COVID-19 pandemic response and preparedness planning documents from a sample of seven (of the eleven) countries in WHO-SEARO. We described the degree to which the documented priority setting processes adhered to twenty established quality indicators of effective PS and conducted a cross-country comparison. Results: All of the reviewed plans described the required resources during the COVID-19 pandemic. Most, but not all of the plans demonstrated political will, and described stakeholder involvement. However, none of the plans presented a clear description of the PS process including a formal PS framework, and PS criteria. Overall, most of the plans included only a limited number of quality indicators for effective PS. Discussion and conclusion: There was wide variation in the parameters of effective PS in the reviewed plans. However, there were no systematic variations between the parameters presented in the plans and the country's economic, health system and pandemic and PS context and experiences. The political nature of the pandemic, and its high resource demands could have influenced the inclusion of the parameters that were apparent in all the plans. The finding that the plans did not include most of the evidence-based parameters of effective PS highlights the need for further research on how countries operationalize priority setting in their respective contexts as well as deeper understanding of the parameters that are deemed relevant. Further research should explore and describe the experiences of implementing defined priorities and the impact of this decision-making on the pandemic outcomes in each country.

Priority setting for pandemic preparedness and response: A comparative analysis of COVID-19 pandemic plans in 12 countries in the Eastern Mediterranean Region.

Background: The COVID-19 pandemic has significantly disrupted health systems and exacerbated pre-existing resource gaps in the Eastern Mediterranean Region (WHO-EMRO). Active humanitarian and refugee crises have led to mass population displacement and increased health system fragility, which has implication for equitable priority setting (PS). We examine whether and how PS was included in national COVID-19 pandemic plans within EMRO. Methods: An analysis of COVID-19 pandemic response and preparedness planning documents from a sample of 12/22 countries in WHO-EMRO. We assessed the degree to which documented PS processes adhere to twenty established quality parameters of effective PS. Results: While all reviewed plans addressed some aspect of PS, none included all quality parameters. Yemen's plan included the highest number (9) of quality parameters, while Egypt's addressed the lowest (3). Most plans used evidence in their planning processes. While no plans explicitly identify equity as a criterion to guide PS; many identified vulnerable populations - a key component of equitable PS. Despite high concentrations of refugees, migrants, and IDPs in EMRO, only a quarter of the plans identified them as vulnerable. Conclusion: PS setting challenges are exacerbated by conflict and the resulting health system fragmentation. Systematic and quality PS is essential to tackle long-term health implications of COVID-19 for vulnerable populations in this region, and to support effective PS and equitable resource allocation.

Understanding Social and Emotional Loneliness among Black Older Adults: A Scoping Review.

Black older adults' (BOAs) experience of loneliness differs from other ethnic groups because of the disproportionate disadvantages faced across their life course. This scoping review aimed to describe the range of research on loneliness or subjective social isolation among BOAs, identifying the contributing factors to loneliness in this population, based on Weiss' Social provision Framework. Of the 15,345 initial retrieved citations from seven databases and corporate websites, we included 27 studies conducted in the USA, Nigeria, South Africa, Ghana, Canada, the United Kingdom, and Uganda. Studies reporting on BOAs' experience of loneliness focused on the influence of attachment, social integration, opportunity for nurturance, reassurance of worth, guidance, socio-economic factors, health-related factors and behaviors, and technology, media device possession and usage. There is a need for future studies to identify which social provisions (when targeted) could reduce loneliness, allowing clinicians to develop relevant interventions.

An analysis of how health systems integrated priority-setting in the pandemic planning in a sample of Latin America and the Caribbean countries.

BACKGROUND: Latin America and the Caribbean (LAC) are among those regions most affected by the COVID-19 pandemic worldwide. The COVID-19 pandemic has strained health systems in the region. In this context of severe healthcare resource constraints, there is a need for systematic priority-setting to support decision-making which ensures the best use of resources while considering the needs of the most vulnerable groups. The aim of this paper was to provide a critical description and analysis of how health systems considered priority-setting in the COVID-19 response and preparedness plans of a sample of 14 LAC countries; and to identify the associated research gaps. METHODS: A documentary analysis of COVID-19 preparedness and response plans was performed in a sample of 14 countries in the LAC region. We assessed the degree to which the documented priority-setting processes adhered to established quality indicators of effective priority-setting included in the Kapiriri and Martin framework. We conducted a descriptive analysis of the degree to which the reports addressed the quality parameters for each individual country, as well as a cross-country comparison to explore whether parameters varied according to independent variables. RESULTS: While all plans were led and supported by the national governments, most included only a limited number of quality indicators for effective priority-setting. There was no systematic pattern between the number of quality indicators and the country's health system and political contexts; however, the countries that had the least number of quality indicators tended to be economically disadvantaged. CONCLUSION: This study adds to the literature by providing the first descriptive analysis of the inclusion of priority-setting during a pandemic, using the case of COVID-19 response and preparedness plans in the LAC region. The analysis found that despite the strong evidence of political will and stakeholder participation, none of the plans presented a clear priority-setting process, or used a formal priority-setting framework, to define interventions, populations, geographical regions, healthcare setting or resources prioritized. There is need for case studies that analyse how priority-setting actually occurred during the COVID-19 pandemic and the degree to which the implementation reflected the plans and the parameters of effective priority-setting, as well as the impact of the prioritization processes on population health, with a focus on the most vulnerable groups.

Sexual and reproductive health and rights of "last mile" adolescents: a scoping review.

Globally, significant progress has been made in the realm of adolescent sexual and reproductive health. We conceptualised "last mile" adolescents as having two or more of the following factors of identity: refugee, Indigenous, 2SLGBTQIA+, out of school, rurally or remotely located, slum dwelling, incarcerated or previously incarcerated, HIV/AIDS infected, and living with a disability. We conducted a scoping review with an aim to synthesise evidence and identify research gaps in the literature pertaining to the sexual and reproductive health and rights (SRHR) of last mile adolescents. We conducted searches in three databases (Embase, Global Health, and Medline). Fifty-four publications met our inclusion criteria. Our results revealed that the state of evidence on the SRHR of last mile adolescents is poor. Very few studies used qualitative and mixed-method inquiry. The number of studies carried out in North America, Europe, and Oceania were limited. We found insufficient disaggregated data with respect to SRHR-related knowledge, behaviour, and access to services. Adopting an intersectional lens is critical to uncover the multiplicative effects of last mile adolescents' factors of identity on their SRHR. National data systems should be strengthened to enable the collection of quality disaggregated data which can play a vital role in identifying SRHR inequities affecting last mile adolescents. Research priorities should be realigned to generate data globally on the SRHR of last mile adolescents whose lives are marked by intersecting vulnerabilities.

A scoping review of strategies to support public health recovery in the transition to a "new normal" in the age of COVID-19.

BACKGROUND: During the COVID-19 pandemic, the public health workforce has experienced re-deployment from core functions such as health promotion, disease prevention, and health protection, to preventing and tracking the spread of COVID-19. With continued pandemic deployment coupled with the exacerbation of existing health disparities due to the pandemic, public health systems need to re-start the delivery of core public health programming alongside COVID-19 activities. The purpose of this scoping review was to identify strategies that support the re-integration of core public health programming alongside ongoing pandemic or emergency response. METHODS: The Joanna Briggs Institute methodology for scoping reviews was used to guide this study. A comprehensive search was conducted using: a) online databases, b) grey literature, c) content experts to identify additional references, and d) searching reference lists of pertinent studies. All references were screened by two team members. References were included that met the following criteria: a) involved public health organizations (local, regional, national, and international); b) provided descriptions of strategies to support adaptation or delivery of routine public health measures alongside disaster response; and c) quantitative, qualitative, or descriptive designs. No restrictions were placed on language, publication status, publication date, or outcomes. Data on study characteristics, intervention/strategy, and key findings were independently extracted by two team members. Emergent themes were established through independent inductive analysis by two team members. RESULTS: Of 44,087 records identified, 17 studies were included in the review. Study designs of included studies varied: descriptive (n = 8); qualitative (n = 4); mixed-methods (n = 2); cross-sectional (n = 1); case report (n = 1); single-group pretest/post-test design (n = 1). Included studies were from North America (n = 10), Africa (n = 4), and Asia (n = 3) and addressed various public health disasters including natural disasters (n = 9), infectious disease epidemics (n = 5), armed conflict (n = 2) and hazardous material disasters (n = 1). Five emergent themes were identified on strategies to support the re-integration of core public health services: a) community engagement, b) community assessment, c) collaborative partnerships and coordination, d) workforce capacity development and allocation, and e) funding/resource enhancement. CONCLUSION: Emergent themes from this study can be used by public health organizations as a beginning understanding of strategies that can support the re-introduction of essential public health services and programs in COVID-19 recovery.

Supporting the pandemic response and timely access to COVID-19 vaccines: a case for stronger priority setting and health system governance in Nigeria.

Priority setting and health system governance are critical for optimising healthcare interventions and determining how best to allocate limited resources. The COVID-19 pandemic has buttressed the need for these especially now that vaccines are available to curb the spread of the disease. In many low- and middle-income countries (LMICs), vaccine coverage remains low, due in large part to sub-optimal priority setting and health system governance which has led to inequities in access and has fuelled vaccine hesitancy. An analysis of the situation in Nigeria identified key issues that have affected the health system response to COVID-19 and impeded timely access to the vaccine. These include weak vaccine procurement strategies, limited evidence on strategies for prioritising recipients and approaches for rolling out mass vaccination programmes for the entire population, lack of a communication strategy to reduce the incidence of vaccine hesitancy and failures to proactively address vaccine hesitancy through the implementation of vaccination programmes. Nigeria and other many other LMICs are still facing the prospect of subsequent and potentially worsening waves of the COVID-19 pandemic. Without effective priority setting, there is a risk that the country will not accelerate vaccine rollout quickly enough to achieve high coverage rates that will ensure herd immunity. In the context of existing weaknesses in health system governance, there is an urgent need to strengthen priority settings in Nigeria and identify and implement context-specific solutions that can improve vaccine coverage for the population.

Equity, justice, and social values in priority setting: a qualitative study of resource allocation criteria for global donor organizations working in low-income countries.

BACKGROUND: There is increasing acceptance of the importance of social values such as equity and fairness in health care priority setting (PS). However, equity is difficult to define: the term means different things to different people, and the ways it is understood in theory often may not align with how it is operationalized. There is limited literature on how development assistance partner organizations (DAP) conceptualize and operationalize equity in their health care prioritization decisions that affect low-income countries (LIC). This paper explores whether and how equity is a consideration in DAP priority setting processes. METHODS: This was a qualitative study involving 38 in-depth interviews with DAPs involved in health-system PS for LICs and a review of their respective webpages. RESULTS: While several PS criteria were identified, direct articulation of equity as an explicit criterion was lacking. However, the criterion was implied in some of the responses in terms of prioritizing vulnerable populations. Where mentioned, respondents discussed the difficulties of operationalizing equity as a PS criterion since vulnerability is associated with several varying and competing factors including gender, age, geography, and income. Some respondents also suggested that equity could be operationalized in terms of an organization not supporting the pre-existing inequities. Although several organizations' webpages identify addressing inequities as a guiding principle, there were variations in how they spoke about its operationalization. While intersectionalities in vulnerabilities complicate its operationalization, if organizations explicitly articulate their equity focus the other organizations who also have equity as a guiding principle may, instead of focusing on the same aspect, concentrate on other dimensions of vulnerability. That way, all organizations will contribute to achieving equity in all the relevant dimensions. CONCLUSIONS: Since most development organizations support some form of equity, this paper highlights a need for an internationally recognized framework that recognizes the intersectionalities of vulnerability, for mainstreaming and operationalizing equity in DAP priority setting and resource allocation. Such a framework will support consistency in the conceptualization of and operationalization of equity in global health programs. There is a need for studies which to assess the degree to which equity is actually integrated in these programs.