Pan American Health Organization · 2020
Equity-focused recommendations to adapt COVID-19 social and physical distancing measures for vulnerable populations including informal workers, migrants, and indigenous peoples.
- Issuer
- Pan American Health Organization
- Edition
- 2020
- Audience
- Decisionmakers, technical teams, and policy implementers in national and local governments in Latin America, the Caribbean, and globally
- Evidence
- Expert panel analysis, systematic review of PAHO/WHO guidelines, UN agency reports, observational studies, country reports, and 1,304+ bibliographic references (48% PAHO/WHO, 40% other UN agencies, 7% published articles, 3% country reports)
- Reviewed
- 19 Oct 2026 · GMJ
What this guideline says
GMJ summary
This PAHO guidance addresses the critical challenge of implementing non-pharmacological public health measures (NPIs) during the COVID-19 pandemic in populations facing structural inequities in Latin America and the Caribbean. The document recognizes that measures such as home confinement, quarantine, school and workplace closures, and physical distancing cannot be implemented equally across all population groups due to barriers related to housing conditions, employment precarity, lack of social protection, and limited access to basic services like water.
The guidance presents a comprehensive framework identifying 12 structural factors that create barriers and adverse effects when implementing NPIs: material living conditions, income and employment, social protection, education, cultural relevance, psychosocial risk, gender inequity and burden of care, delivery of basic services, health care continuity, human rights, social participation, and communication. For each measure, the document provides concrete recommendations to eliminate barriers and mitigate adverse effects, emphasizing that groups such as informal workers (54% of the economically active population in the region), residents of overcrowded informal settlements (20% of the urban population), migrants, indigenous peoples, persons with disabilities, and incarcerated individuals face disproportionate challenges.
The core message is that effective pandemic response requires not treating socioeconomic consequences as ‘collateral damage’ but integrating health, social, and economic policies guided by equity, human rights, gender equality, cultural relevance, community participation, and intersectorality. Structural recommendations include guaranteeing universal health coverage with at least 6% of GDP invested in health, extending social protection to the entire population including informal workers, establishing emergency basic income equivalent to the poverty line for six months, and ensuring universal access to water for handwashing.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Establish emergency basic income equivalent to the poverty line for six months for the entire population living in poverty (additional cost: 2.0% of GDP) to enable compliance with confinement and quarantine measures
- Provide free health care to informal workers (54% of the economically active population, ~325 million people) and their families who lose employment-linked health insurance
- Guarantee a minimum daily volume of clean water for all households not connected to water supply systems through distribution, tankers, or kiosks, with free basic consumption to facilitate handwashing
- Create alternative residential facilities for quarantine/isolation when home conditions are unsuitable, providing food, water, hygiene products, and basic articles for the required 14-day period
- Reduce prison populations through alternatives for minor offenses and those near sentence completion, given 200% occupancy rates in Latin American prisons and documented outbreaks affecting 93,000+ incarcerated persons globally
- Establish paid occupational sick leave for COVID-19 contracted in the workplace and preventive quarantine, with unemployment benefits extended to informal workers
- Facilitate internet and computer access for teleworking and distance learning (currently only 15% of poor workers and 25% of vulnerable workers have home computers with internet in the region)
- Provide food support replacing 85 million school meals lost due to closures, through delivery, vouchers, or cash transfers for six months to populations in extreme poverty
Matrix of barriers and adverse effects associated with non-pharmacological public health measures by structural factor
Table extracted from the guideline
| Structural factor | Intermediate factors (ways manifested) | Individual quarantine | Home confinement | Workplace closure | School closure | Enclosed facilities | Gathering restrictions | Transit restrictions | Handwashing |
|---|---|---|---|---|---|---|---|---|---|
| Material living conditions | Lack of housing; overcrowded housing; collective community practices; absent/irregular water supply; limited public areas | ● | ● | ● | ● | ● | |||
| Income and employment | Lack of income; lack of unemployment benefits; inability to get to work | ● | ● | ● | ● | ||||
| Social protection | Absence of social, labor rights; weak welfare state | ● | ● | ● | |||||
| Education and learning | Changes in school operations; lack of distance learning means/experience | ● | |||||||
| Cultural relevance | Clash with ancestral community values, traditions, beliefs, practices | ● | ● | ● | ● | ||||
| Psychosocial risk | Social isolation; deterioration in community relations; adverse conditions for healthy behaviors; uncertainty | ● | ● | ● | ● | ● | ● | ||
| Gender inequity & burden of care | Caregiver overload; housework overload; loss of women's autonomy | ● | ● | ● | |||||
| Basic services delivery | Difficulty accessing food vendors, medicines, essential protection services | ● | ● | ● | ● | ||||
| Health care access & continuity | Lack of continuity in follow-ups, exams; postponement of consultations | ● | ● | ● | |||||
| Human rights | Rights violations; greater discrimination; gender-based violence; violence against children | ● | ● | ||||||
| Social participation | Lack of participation in adaptation/implementation; lack of intersectoral coordination | ||||||||
| Communication | Lack of information for persons with disabilities; inability to understand official language; lack of media access |
Source: Pan American Health Organization, Guidance for implementing non-pharmacological public health measures in populations in situations of vulnerability in the context of COVID-19. Reproduced in summary form.
From the guideline
Verbatim
“The balance between the implementation of measures and the 'new normalcy,' with the reopening of businesses, workplaces, and schools, once again introduces a false dichotomy between health and the economy.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Chair of Georgia's Public Health Institute and having worked extensively on health systems in conflict-affected and displaced populations, I recognize this guidance addresses vulnerabilities we observe daily in the South Caucasus. Georgia's rapid adoption of lockdown measures in March 2020 was epidemiologically sound but exposed profound gaps: our informal sector workers—market vendors, construction laborers, seasonal agricultural workers—had no safety net when mobility restrictions were imposed, and in Tbilisi's older districts, multi-generational households in 40-square-meter apartments could not meaningfully isolate. The recommendation I would emphasize most to Georgian colleagues is establishing alternative isolation facilities with full support services; we saw in Adjara and Imereti that when cases had no option but to return to crowded homes, entire families became infected. The implementation caveat for our context is that while the guidance recommends emergency basic income at 2% of GDP, Georgia's fiscal space and donor dependency make this challenging without external support—we must realistically sequence interventions, perhaps starting with targeted support for identifiable vulnerable groups (registered IDP families, recipients of the existing subsistence allowance, rural municipalities with documented water access problems) rather than attempting universal coverage immediately. The intersectoral coordination called for in this document is particularly difficult in Georgia's fragmented governance structure where health, social protection, and municipal services operate in separate silos with limited joint planning mechanisms.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 19 Oct 2026
Applicability
Georgia and the South Caucasus
This guidance is highly relevant for Georgia and the South Caucasus region, where informal employment comprises a significant portion of the workforce, internal displacement affects hundreds of thousands, and rural-urban disparities in access to water and health services persist. Georgia’s experience with universal health coverage since 2013 provides a foundation, but the pandemic has exposed gaps in social protection for informal workers, seasonal agricultural laborers, and populations in high-altitude or remote settlements where physical distancing and handwashing infrastructure may be limited. National programmes would need to consider specific vulnerabilities: internally displaced persons from Abkhazia and South Ossetia living in collective centers; labor migrants returning from Russia, Turkey, and EU countries; ethnic minority populations (Azeri, Armenian) in regions with language barriers to health communication; and overcrowded conditions in Tbilisi’s older housing stock. Armenia and Azerbaijan face similar challenges with remittance-dependent households, large informal sectors, and need for culturally adapted messaging for ethnic and religious minorities. Implementation would require coordination between ministries of health, labor, internally displaced persons, and regional administrations, with particular attention to ensuring water access in drought-affected areas and maintaining continuity of care for the region’s high burden of cardiovascular disease and diabetes during lockdowns.
Questions this guideline answers
Quick answers
What populations are considered most vulnerable to barriers in implementing COVID-19 measures?
Informal workers and their families (54% of the economically active population, ~325 million people in Latin America), residents of informal settlements with overcrowding and limited water access (20% of urban population), migrants and refugees, indigenous populations, persons with disabilities, older persons in institutional care, incarcerated persons (1.7 million in the region with 200% prison occupancy), essential workers in low-paid jobs, women heads of household with children, homeless populations, and those with noncommunicable disease comorbidities in poverty.
What are the key structural interventions recommended to enable compliance with measures?
Invest at least 6% of national GDP in health to guarantee universal health coverage; extend social protection to all informal workers; provide unemployment insurance covering the majority of the working population; establish emergency basic income equivalent to the poverty line for six months (cost: 2.0% of GDP); provide food support for six months to those in extreme poverty; expand water distribution networks with free water for those unable to pay; guarantee minimum daily volume of clean water through tankers or kiosks where networks don't exist; waive or subsidize payments for water, electricity, and heating; and suspend evictions with rent support.
How should quarantine and isolation be implemented for people in overcrowded housing?
Create alternative residential facilities (shelters, hotels, designated centers) for COVID-19 cases and contacts when home conditions are unsuitable or when living with high-risk family members. These facilities must provide food, water, hygiene products, and basic articles for the entire isolation/quarantine period. In-home isolation requires ensuring at least 1-meter distance between cases and contacts, good ventilation, mask use, separate beds, and provision of supplies. For indigenous communities, establish community facilities for isolation consistent with local culture. Provide health checks through home visits or remote consultations during the quarantine period.
What support is needed for workers who lose income due to business closures or quarantine?
Guarantee income during sick leave or preventive quarantine through existing protection systems and emergency mechanisms; provide free health care for informal workers and their families who lose employment-linked insurance; establish paid occupational sick leave if COVID-19 is contracted in the workplace; introduce cash subsidies and basic goods for workers losing jobs, especially informal workers; expand unemployment benefits to be inclusive and adequate in duration; adopt measures to maintain employment and limit mass layoffs; facilitate internet and computer access for teleworking where job type permits; waive or subsidize utility payments (water, electricity, heating); and provide rent support with installment options while suspending evictions.
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Quality & accreditation
- ASF PHC — Standard 4 — Acute & Same-Day Care · Primary Health Clinic
- ASF PHC — Standard 7 — Governance & Staffing · Primary Health Clinic
- ASF Hospital — Standard 9 — Refugee & Migrant Health
- ASF Laboratory — Standard 9 — Refugee & Migrant Health
- ASF Medical Transport — Standard 8 — Refugee & Migrant Health
Other guidelines on this topic
- Recommendations to expand access to hand washing and its proper use
- Guidance for Tuberculosis Prevention and Control in Indigenous Populations in the Region of the Americas
- Proposal for Increasing Health Care Coverage for Venezuelan Refugees and Migrants Living with HIV. Update in Response to the COVID-19 Pandemic
- Microplanning manual to guide implementation of preventive chemotherapy to control and eliminate neglected tropical diseases
- Infection Prevention and Control for the Management of Mpox in People in Situations of Vulnerability such as Prisons and Other Custodial Facilities
- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- 2020
- Status
- Current
- Published
- 2020-01-01
- Languages
- English, Spanish
- Scope
- Non-pharmacological public health measures (quarantine, confinement, closures, distancing, handwashing) in populations facing structural inequities during COVID-19
- Audience
- Decisionmakers, technical teams, and policy implementers in national and local governments in Latin America, the Caribbean, and globally
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- Expert panel analysis, systematic review of PAHO/WHO guidelines, UN agency reports, observational studies, country reports, and 1,304+ bibliographic references (48% PAHO/WHO, 40% other UN agencies, 7% published articles, 3% country reports)
- Record history
- Created 19 Oct 2026 · updated 19 Oct 2026 · next check Apr 2027
Pan American Health Organization. Guidance for implementing non pharmacological public health measures in populations in situations of vulnerability in the context of COVID-19. Washington, D.C.: PAHO; 2020. Available from: https://iris.paho.org/handle/10665.2/53078GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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