Structural Barriers and Health System Determinants of Healthcare Access among Transgender Populations in a Multi-Country Public Health Systems Analysis

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Arunkumar, M Ahajeeth, V. Arulmozhi, P. Narendran This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8516735/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Transgender people all over the world continue to have to face discrimination related to the public healthcare they receive. This is in part due to the structural weaknesses in the national public health systems. Although the need for health services specific for transgender people is increasingly acknowledged, there is still little access to the needed basic health services in many countries. Objectives This study looks at the impact of the five main components of public health systems (governance, financing, service delivery, health workforce, and health information systems) on the availability of healthcare for transgender people in different countries. Methods Quantitative and qualitative analyses were conducted using a convergent parallel mixed methods design. Quantitative data were derived from the World Health Organization’s Global Health Expenditure Database and the World Bank’s World Development Indicators for the years 2010–2024 for 32 countries. Qualitative data were collected from peer-reviewed journals, national documents, and global health reports. The WHO Health System Building Blocks Framework was used for the analyses of descriptive data, the Pearson correlation, and the multivariable linear regression. Results Compared to non-inclusive policies, countries with transgender-inclusive health policies had higher UHC service coverage, greater government health expenditure, lower out-of-pocket spending, and higher density of health workers. Transgender-inclusive policies and increased public financing for health were both separately important for greater access to health care, while the COVID-19 related disruptions to the health system caused less access to care. Conclusion Incorporating financing policy will be necessary for improving access to healthcare in a socially equitable manner. In order for health policies to reinforce the financing of health systems in an equitable manner, they need to address, equity, Universal Health Coverage and the third Sustainable Development Goal. transgender health health equity public health systems healthcare access structural barriers Universal Health Coverage and SDG 3 1. INTRODUCTION Transgender populations, in this case, are defined closely to mean persons whose gender identity differ from the assigned sex at birth. Transgender individuals represent a wide demographic globally, yet, the inequities in health they experience, are widespread geo-spatially, as well as across the social and economic spectrums. Evidence from all over the world show the alarming rates of mental health disorders, that is, depression, anxiety, and suicidal ideation they face. In addition to this, health needs remain unmet, and this population suffers from the HIV/AIDS and STIs, and that, coupled with substance use disorders and violence, is a multifaceted health issue. The above health inequities are not a phenomena within single countries, as they have been documented in high, middle, and low countries. It is evidenced that the health inequities of transgender individuals are a public health concern, and not a problem that is privy to a particular set of circumstances. It is important to note that public health individuals and researchers are attempting to understand the phenomenon with the “risk” of individual behaviours. It rather appears that the public health systems and other systems that are part of the structural determinants of health systems have the worst inequities. It is the undocumented, unrecognized, and ignored gender identity, the exclusion from the coverage of health insurance and government funded services that are aligned with the provision of gender-affirming, poorly skilled and trained health service providers, as well as the discriminatory and bias in the provision of health services that collectively form the barriers to care. These obstacles function at every point along the spectrum of health services, from preventive care, primary health care, and mental health services, to sexual and reproductive health, and the management of long-term chronic diseases. Health systems in low- and middle-income countries (LMICs) are characterized by constrained public financing, weak governance, and fragmented service delivery systems. This adversely affects access to basic health services for vulnerable and marginalized populations, including transgender individuals. In such contexts, due to financial and health service accessibility challenges, transgender persons often resort to paying out-of-pocket for health services, utilizing informal service delivery routes, or accessing health services through non-governmental organizations, which further exacerbates financial hardship. However, this issue is not exclusive to LMICs. Despite having seemingly advanced health systems, many high-income countries also face these challenges. Transgender persons experience similar issues, such as lengthy wait times, unavailability and shortage of specialized health services, geographic inequity in service distribution, and shortage of affirmative and culturally appropriate health services, particularly in primary care and mental health services. From a broad health systems perspective, the unavailability of effective responses to transgender persons’ health needs reflects significant shortcomings in the governance, financing, and delivery of health services, health workforce training, and health information systems. In many countries, transgender health issues are considered peripheral to the overall health priorities of the country, which leads to insufficient country funding for transgender health, the absence of strategies and clinical guidelines, and weak accountability. In addition, the absence of systematic gender-disaggregated data collection in health information systems renders transgender persons invisible in the health statistics, making health service planning and policy evaluation difficult. The healthcare systems deficiencies of the previous years were further revealed by the COVID-19 pandemic. The reallocating of healthcare resources, the disruption of multiple routine services, the establishment of new mobility restrictions, and the development of new forms of economic precarity disproportionately impacted marginalized social and economic communities, and the transgender population. The pandemic services interruptions negatively affected the availability of, access and support to; HIV prevention and treatment; psychotherapeutic services, and other essential services and care; as well as hormone therapy. These experiences illustrated the lack of resilience of the health systems in safeguarding access to healthcare for marginalized communities during health emergencies, reinforcing the need for equity to be a priority in the planning and response of health systems to emergencies. The global public health discourse has increasingly recognized the importance of transgender health, although most of the literature remains descriptive epidemiological studies and qualitative studies of experiences, focused on stigma and psychosocial factors, and the consequences of the individual. This scholarship has documented critical health disparities, yet there is still a notable absence of comparative and systemic analyses examining the relations between national health system structures and policies and the access to care for transgender people in different countries. There is a shortage of non-discriminatory policy environments that transcend measurable changes in performance indicators of health systems like Universal Health Coverage (UHC), overall government spending on health, and financial protection. Closing this gap is critical for informing policy and advancing global commitments to health equity, including affordable healthcare of any kind without financial distress, and to the Sustainable Development Goal 3 (SDG 3). Out of the various approaches that can be deployed to achieve this, a health systems approach is applicable, as it builds the analysis from the individual level to the institutional and systemic level that either enable or hinder equitable access to care. Therefore, the analysis in this regard is systemic and structural. In this light, the study undertakes a multi-country analysis of public health systems to identify structural health systems and barriers to the transgender healthcare system. Using the WHO Health System Building Blocks Framework, and a mix of quantitative and qualitative policy approaches, this study seeks to analyze and assess the extent to which governance, financing, service delivery, health workforce, and health information systems, in all their disparate forms impact access to transgender healthcare in different settings. In this regard, the study aspires to generate evidence that is of high policy relevance to the global public health system and to the inclusion, equity, and resilience of that system. 2. METHODS 2.1 Study Design A convergent parallel mixed methods approach was utilized to facilitate the separate yet concurrent assessment of the qualitative and quantitative dimensions of the health system indicators and policy evidence. This approach is particularly effective in health systems research as it provides a unique form of strengthening validity through triangulation. 2.2 Data sources This study utilized internationally accepted publicly available datasets, which allows the study to be transparent and replicable, and comply with the Springer Nature research data policy. The study used the World Health Organization (WHO) and the World Bank Health System databases to collect quantitative indicators for the global health system. The databases are widely relied upon for health system research. Data for each country’s health financing comes from the World Health Organization Global Health Expenditure Database (GHED). The GHED database offers balanced and comparable data for national health expenditures by country and year per the System of Health Accounts (SHA) methodology. From GHED we obtained the indicators for government health expenditure (GH) and out-of-pocket (OOP) health expenditure, which represent the public financing and financial protection and are the measures of the health system. The indicators for health service coverage and system capacity were derived from the World Bank World Development Indicators (WDI) database. These included the Universal Health Coverage (UHC) service coverage index and health workforce density, which is the ratio of physicians and nurses to a population of 1,000. Moreover, specific proxy indicators were utilized to quantify the disruption to health systems caused by COVID-19, as well as the effects on the accessibility of health services and the continuity of care. The disruption to health systems caused by COVID-19 and effects on the accessibility of health services and the continuity of care were analyzed. The last year of data available for each indicator between the years 2010 and 2024 was applied for the analyses. To address the gaps in the quantitative analysis and to understand the specific structures within the health systems, a qualitative evidence synthesis was also carried out. This involved searching for peer-reviewed journal articles published in PubMed, Scopus, and Web of Science, as well as national health policies and law documents pertaining to the health of transgender individuals. Additionally, the global and regional policy documents of the World Health Organization, the United Nations Development Programme, and the Joint United Nations Programme on HIV/AIDS were analyzed. The authors examined all qualitative documents published in the years 2010 to 2024 in order to track the presence of policies relating to transgender individuals and to describe the systems of governance and the frameworks of service provision in various countries. The authors did not collect any personal information or data that could be used to identify individuals, as all the data were aggregated at the country level; thus, there was no need to seek ethical approval for this study. In accordance with the data availability policy of Springer Nature, the data used for this analysis can be accessed without restrictions and can be found in the World Health Organization and World Bank databases. 2.3. Selection of Countries The authors selectively chose countries based on the existence of comprehensive and consistent data for all the study variables, including indicators on health financing, service coverage, workforce, and documents pertaining to policies on transgender individuals. After the application of the inclusion criteria, the final analysis consisted of 32 countries. 2.4 Analytical Framework Analysis was conducted using the WHO Health System Building Block Framework, focusing on the following domains: 1. Governance and leadership 2. Health Financing 3. Service Delivery 4. Health Workforce 5. Health Information Systems 2.5 Statistical Analysis Health system indicator data were summarized using descriptive statistics. A Pearson correlation analysis was conducted to evaluate the relationship between inclusion of policy and system performance. Linear regression analysis was used to evaluate access to care. A p-value of less than 0.05 was considered to be statistically significant. 3. RESULTS 3.1. Transgender Policy Inclusion by Countries The analysis included 32 countries at different income levels. Countries were separated by the presence or absence of policy frameworks that are inclusive of transgender persons. The analysis used legal recognition of gender and the inclusion of transgender persons in the health policy at the national level. 3.2. Policy Inclusion and Health System Indicators Table 1 shows health system indicators for countries with and without policies that are inclusive of transgender persons. Comparison of the indicators between the two groups is presented. Table 1 Health system indicators by transgender policy inclusion Indicator Inclusive policy (Mean ± SD) Non-inclusive policy (Mean ± SD) p -value UHC service coverage index 71.4 ± 8.2 56.9 ± 9.1 0.003 Government health expenditure (% GDP) 5.9 ± 1.2 3.8 ± 1.4 0.001 Out-of-pocket expenditure (%) 34.6 ± 10.5 54.2 ± 12.8 0.002 Countries with transgender-inclusive policies reported Universal Health Coverage (UHC) service coverage which translates into broad access to vital health service. Furthermore, such countries invested more health-related government expenditure in comparison to the others, and the population experienced lower out-of-pocket health expenses. All the presented differences in the results were substantial and reflect the influence of more inclusive policies and funding frameworks on the health system overall. 3.3 Health workforce capacity and service availability Excluding the coverage and financing, the capacity of the health workforce turned out to be a crucial distinguishing factor between inclusive and non-inclusive policy settings. Countries with transgender-inclusive policies recorded a better physician and nursing density, which signifies better service delivery and access to care. Table 2 Health workforce density by transgender policy inclusion Indicator Inclusive policy (Mean ± SD) Non-inclusive policy (Mean ± SD) p -value Physicians per 1,000 population 2.8 ± 0.9 1.6 ± 0.8 0.005 Nurses and midwives per 1,000 population 6.4 ± 1.8 3.9 ± 1.6 0.002 Policies that are more inclusive indicate a higher density of health care workers. This implies that health care workers are more accessible and can retain patients for primary care, mental health, and chronic disease management. These findings alludes to the theory that more inclusive policies, tend to have a higher degree of both financing and service delivery improvements. 3.4 The Inclusion of Policies and the Performance of Health Systems The inclusion of transgender policies has a degree of positive correlation to UHC service coverage, (r = 0.61, p < 0.001) as well as government health spending (r = 0.57, p = 0.002) and a negative correlation to out-of-pocket spending (r = − 0.59, p = 0.001) as per the Pearson correlation.The graphical patterns show that countries that focus on inclusivity have higher levels of health service coverage and spending on public health, while non-inclusive countries show a higher reliance on out-of-pocket spending. These relations show us the structural connection of inclusivity policies and the functioning of an equitable health system. 3.5. Access to Healthcare and its Multivariable Regression Analysis A multivariable linear regression model was used on the variables: transgender policy inclusion, government health expenditure, and the COVID-19 disruption index, to determine the predictors of accessible healthcare. Table 3 Multivariable regression predicting healthcare access Predictor β 95% CI p -value Transgender-inclusive policy 0.42 0.18–0.66 0.001 Government health expenditure 0.29 0.11–0.47 0.004 COVID-19 disruption index −0.31 −0.55 to − 0.09 0.007 In the case of neutral adjustments, inclusive policies for transgender people remained a strong independent predictor of increased health care accessibility. Increased government spending on health also increased accessibility and reinforced the importance of public investment. The COVID-19 crisis increased disruption and negatively affected accessibility, illustrating the fragility of the health systems of marginalized people during public health crises. There was no evidence of multicollinearity (variance inflation factor < 2.5) and the regression model fit appropriately 3.6 Effects of COVID-19 Disruptions on Access to Healthcare Services Countries where the pandemic caused the greatest disruptions to health systems also experienced the greatest declines in service accessibility, especially in the case of restrictive policy frameworks. The disruptions primarily limited access to routine care, mental health services, and long-term care continuity. The relationship between disruptions caused by COVID-19 and access to healthcare services across various policy contexts. Countries with health systems characterized by inclusive governance and greater public financing had a uniquely robust impact when it came to access; in contrast, systems characterized by a lack of inclusivity suffered significantly greater declines in access. 4. DISCUSSION The analysis of public health systems in multiple countries shows that the inequities in the health systems of countries in which transgender people live and access health services are mostly the result of structural functions of the health systems in these countries and not the result of individual factors. Countries where inclusive policies regarding transgender people have been implemented demonstrate improved health system outcomes with greater levels of UHC service coverage, increased health sector spending, and less reliance on out of pocket expenditure. These results further validate that positive health outcomes are achieved when health system policies are inclusive of marginalized groups. The results also suggest that the positive health outcomes associated with the system’s policies and governance structures are also positive when systems policies are inclusive. While policies such as legal gender recognition and the inclusion of transgender health in national health policies seem to have enabled health systems in performing these functions, it may be that these policies have also created the need for reallocation of resources, greater emphasis on the provision of services, and increased accountability from health system administrators. These policies improve the stewardship and leadership of the health system, attributes central to the health system building blocks of the World Health Organization, in the process demonstrating a commitment to the values of equity and human rights. Most importantly, the positive health outcomes that arise from these policies and the governance systems that support them are not limited to the transgender population. The role of public financing as a fundamental determinant of the accessibility of healthcare services became apparent. The positive impact on the accessibility of healthcare services as government health spending increased proves the importance of fiscal capacity and spending priority as facilitators for translating policy intentions into services. In contrast, countries with low public investment experienced high levels of out-of-pocket spending, a spending pattern that increases inequities and discourages people from seeking care, particularly the disadvantaged, including transgender people. These results confirm the importance of financial protection for universal health coverage (UHC) and that high out-of-pocket expenditures adversely impact the most vulnerable, who are often victims of social stigma, discrimination, and economic exclusion. However, these results also illustrate that the mere presence of policies to advance equity in health is not effective in closing the health equity gap. Despite the presence of inclusive policies, many countries still face the challenges of gaps in the training of health care providers, the integration of services, and health information systems. The gaps in effective service delivery are also a result of a lack of training in culturally and gender-sensitive care, which contributes to distrust in health systems, delays in care seeking, and poor health outcomes. The lack of service delivery models also inhibits the health system’s responsiveness and monitoring, along with the insufficient availability of gender-disaggregated health data. Such gaps point to the necessity for changes on a broader scale, encompassing the entire system to go beyond mere statements of policy to effect coordinated interventions in all building blocks of the health system.The negative correlation between disruptions in healthcare access and the COVID-19 related barriers demonstrates the escalated marginalization of transgender populations during health crises. The Covid-19 pandemic highlighted the fragility of health systems and the absence of equity-focused emergency preparedness and continuity-of-care measures for the disadvantaged. The temporary suspension of services, resource reallocation, and social protection deficits affected the transgender population most acutely. Many transgender individuals need ongoing access to hormone therapy, mental health services, and community support. The findings indicate that enduring health crises are evidence of the need for inclusive and resilient health systems that can maintain essential services. Traditionally, scholarship in Transgender health has focused on individual behaviors and individual health impacts of the crisis. This scholarship also attempts to document disparities in health outcomes. This study attempts to reverse and clarify the governance, financing, and systemic capacity pathways that define access and equity in health in different countries. This systems thinking approach, which prioritizes the population over the individual, resonates with the aim of the Journal of Public Health and the Health systems strengthening framework. The findings demonstrate that to advance transgender health equity, there is a need for more than ornate policy commitments and/or symbolic participation.The critical first step to achieving sustainable development is placing transgender health within the public health systems’ core structural components. These are inclusive governance, appropriate and equitable financing, effective delivery of services, strong health workforce development, and robust health information systems. This is vital, not only for advancing the health of transgender individuals, but also for improving the ability of health systems to offer equitable care for all, especially during impending global health emergencies. These findings are consistent with the health systems and social determinants frameworks, where governance, financing, and arrangement of institutions are the primary determinants of equitable healthcare access for marginalized groups. 5. Implications for Policy There are five policy ramifications of this study, namely (i) integration of transgender health services into the national Universal Health Coverage (UHC) benefit packages, (ii) increased culturally competent and gender-affirming care training for providers, (iii) decreased out-of-pocket costs for essential mental health and gender-affirming services, (iv) regular gender-identity-disaggregated health data collection, and (v) inclusion of equity within the health emergency preparedness frameworks. 6. Strengths and limitations Perhaps the biggest strength of this study comes from the mixed-methods, multi-country design. This allowed for the study to cover the breadth of issues of the transgender healthcare system by accessing both the quantitative indicators of the health systems, and the qualitative indicators of the policies. The study describes the structural factors of the health systems and how they serve or hinder the access of transgender healthcare in different countries by merging data from a global, standardized dataset with policy and literature reviews. The study is policy driven, and the use of the WHO Health System Building Blocks Framework to describe the other (non policy) parts adds to the depth of analysis. The study should also be of interest to global and national health policymakers with a focus on health equity. More than a few limitations apply to this study. First, the use of aggregated, secondary data from countries overlooks domestic disaggregation, and limits the extent of subnational or community-level analysis. Second, because of the ecological study design, there is no scope for individual-level, direct causal inference, and the system-level phenomenon should not be viewed as a reflection of the individual variations in access to the individual components of the healthcare. Third, lack of consistency and quality in the availability of country-specific policies relating to transgender persons may have resulted in bias in the classification of coding policies in/ out. However, the study still offers important system-level insights to support structural changes and to direct future research at the individual level, despite the shortcomings. Conclusion The examination of 32 countries shows that the structural barriers within the public health system remain a pivotal factor in the inequitable distribution of healthcare accessibility, especially for transgender individuals, across the globe. When public financing and inclusive service delivery models are also present, governance frameworks that systemically acknowledge transgender health tend to result in stronger health system outcomes, greater achievement of Universal Health Coverage, and improved availability of essential health services. This also means that policy recognition is ineffective in closing the health equity gap. Regardless of the existence of inclusive policies, the adequate provision of transgender affirming care is hindered by the insufficient integration of health services, the inadequate training of health personnel, and the deficiencies in health information systems. These obstacles speak to the need for more comprehensive, system-wide, and coordinated reforms that address the full range of health policy instruments and components. The adverse effects of the COVID-19 pandemic on the provision of health services to transgender populations also demonstrate the insufficiencies of the health systems and the vulnerability of transgender individuals to crises. During health crisis periods, the public health systems that are underfunded, lack inclusive governance, and insufficient public health investments are those that were unable to prioritize the care of marginalized populations. Integration of transgender health into national health policies, budgets, and Universal Health Coverage frameworks will be critical for the systematic achievement of the Sustainable Development Goal (SDG) 3 target of ensuring healthy lives and promoting well-being for all. Therefore, the strengthening of inclusive, resilient, and people-centered health systems as a social justice imperative is equally important for global health equity and the protection of access to care for transgender people in all settings, including routine and emergency. Declarations Acknowledgements The authors want to say thank you to the World Health Organization and the World Bank for letting them use the datasets they have. The authors also want to thank their colleagues for helping them with their study and for talking about the ideas, in this manuscript. Funding The authors received no specific funding for this study. Ethics approval and consent to participate This study is not applicable because it only used information that's already out there. The information came from sources and was already put together. This study did not involve people. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. References Reisner SL, Poteat T, Keatley J, et al. Global health burden and needs of transgender populations: a review. Lancet. 2016;388(10042):412–36. https://doi.org/10.1016/S0140-6736(16)00684-X . White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Am J Public Health. 2015;105(3):e1–15. https://doi.org/10.2105/AJPH.2014.302106 . World Health Organization. Transgender health and human rights. Geneva: WHO; 2022. Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. 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Arunkumar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYLACxgZmBgb2BiDLwIIULTwHQFokSNEikQBiEqGFf/YZs8eFO6zlDW4+v7rhR4EEA397dwJeLRLncsyNZ55JN9xwO6fsZg/QYRJnzm7Ab80ZHjNp3rbDjEAtaTd4gFoMJHLxa5GHarHfcPNM2s0/xGgxgGpJ3HCD/dhtomwxPMNWJj2zLT155pkcttsyBhI8BP0id4Z5m3Rhm7Vt3/Hjz26++WMjx9/eS8D7QMAMoXgMwCRB5Uha2B8QpXoUjIJRMApGHgAAM4JGr7SG4pkAAAAASUVORK5CYII=","orcid":"","institution":"Sri Venkateshwaraa Medical College Hospital and Research Centre","correspondingAuthor":true,"prefix":"","firstName":"S.","middleName":"","lastName":"Arunkumar","suffix":""},{"id":575818857,"identity":"13f4ad44-b800-45e9-838e-4ca348a8a767","order_by":1,"name":"M Ahajeeth","email":"","orcid":"","institution":"Madha Medical College and Research Institute","correspondingAuthor":false,"prefix":"","firstName":"M","middleName":"","lastName":"Ahajeeth","suffix":""},{"id":575818858,"identity":"2c95a097-f712-4c57-8c14-86f72de4cc22","order_by":2,"name":"V. Arulmozhi","email":"","orcid":"","institution":"Sree Balaji Medical College and Hospital","correspondingAuthor":false,"prefix":"","firstName":"V.","middleName":"","lastName":"Arulmozhi","suffix":""},{"id":575818859,"identity":"7b92fa68-490c-45ff-94b5-8613ae48531b","order_by":3,"name":"P. Narendran","email":"","orcid":"","institution":"Hindustan College of Arts \u0026 Science","correspondingAuthor":false,"prefix":"","firstName":"P.","middleName":"","lastName":"Narendran","suffix":""}],"badges":[],"createdAt":"2026-01-05 04:08:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8516735/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8516735/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100697838,"identity":"de18044b-fe6d-44c4-b255-b391163133ce","added_by":"auto","created_at":"2026-01-20 15:18:29","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":34826,"visible":true,"origin":"","legend":"","description":"","filename":"StructuralBarriersandHealthSystemDeterminantsofTransgenderHealthcareAccessAMultiCountryPublicHealthSystemsAnalysis.docx","url":"https://assets-eu.researchsquare.com/files/rs-8516735/v1/dbe4e812026d4838506e226d.docx"},{"id":100697966,"identity":"9a1af29f-d519-48c0-b274-1191e03ce254","added_by":"auto","created_at":"2026-01-20 15:19:08","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7135,"visible":true,"origin":"","legend":"","description":"","filename":"15c8bd5540364ed58a09a693bf6a674e.json","url":"https://assets-eu.researchsquare.com/files/rs-8516735/v1/b421b64230a57fd81f2cf39e.json"},{"id":100698271,"identity":"238dacdb-7fff-447b-9eff-fdc14f9d70f9","added_by":"auto","created_at":"2026-01-20 15:23:00","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":70834,"visible":true,"origin":"","legend":"","description":"","filename":"15c8bd5540364ed58a09a693bf6a674e1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8516735/v1/85b4b7d3ef5bba660f4cf3c5.xml"},{"id":100697967,"identity":"481a9222-3c75-4a94-9e87-11e39c29626e","added_by":"auto","created_at":"2026-01-20 15:19:08","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":66199,"visible":true,"origin":"","legend":"","description":"","filename":"15c8bd5540364ed58a09a693bf6a674e1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8516735/v1/46ca33180fdacf8f38ebbda3.xml"},{"id":100698062,"identity":"290eec6d-717c-4609-98b0-2f68e12b1e46","added_by":"auto","created_at":"2026-01-20 15:20:17","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":78325,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8516735/v1/03dd9f82b4de69a487d45bb1.html"},{"id":105564697,"identity":"5060dd18-b098-4d80-85ba-6dca3738f0ec","added_by":"auto","created_at":"2026-03-27 12:50:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":725771,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8516735/v1/11812852-5035-4fbd-9bce-c3fab98abd32.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Structural Barriers and Health System Determinants of Healthcare Access among Transgender Populations in a Multi-Country Public Health Systems Analysis","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eTransgender populations, in this case, are defined closely to mean persons whose gender identity differ from the assigned sex at birth. Transgender individuals represent a wide demographic globally, yet, the inequities in health they experience, are widespread geo-spatially, as well as across the social and economic spectrums. Evidence from all over the world show the alarming rates of mental health disorders, that is, depression, anxiety, and suicidal ideation they face. In addition to this, health needs remain unmet, and this population suffers from the HIV/AIDS and STIs, and that, coupled with substance use disorders and violence, is a multifaceted health issue. The above health inequities are not a phenomena within single countries, as they have been documented in high, middle, and low countries. It is evidenced that the health inequities of transgender individuals are a public health concern, and not a problem that is privy to a particular set of circumstances. It is important to note that public health individuals and researchers are attempting to understand the phenomenon with the \u0026ldquo;risk\u0026rdquo; of individual behaviours. It rather appears that the public health systems and other systems that are part of the structural determinants of health systems have the worst inequities. It is the undocumented, unrecognized, and ignored gender identity, the exclusion from the coverage of health insurance and government funded services that are aligned with the provision of gender-affirming, poorly skilled and trained health service providers, as well as the discriminatory and bias in the provision of health services that collectively form the barriers to care. These obstacles function at every point along the spectrum of health services, from preventive care, primary health care, and mental health services, to sexual and reproductive health, and the management of long-term chronic diseases.\u003c/p\u003e \u003cp\u003eHealth systems in low- and middle-income countries (LMICs) are characterized by constrained public financing, weak governance, and fragmented service delivery systems. This adversely affects access to basic health services for vulnerable and marginalized populations, including transgender individuals. In such contexts, due to financial and health service accessibility challenges, transgender persons often resort to paying out-of-pocket for health services, utilizing informal service delivery routes, or accessing health services through non-governmental organizations, which further exacerbates financial hardship. However, this issue is not exclusive to LMICs. Despite having seemingly advanced health systems, many high-income countries also face these challenges. Transgender persons experience similar issues, such as lengthy wait times, unavailability and shortage of specialized health services, geographic inequity in service distribution, and shortage of affirmative and culturally appropriate health services, particularly in primary care and mental health services. From a broad health systems perspective, the unavailability of effective responses to transgender persons\u0026rsquo; health needs reflects significant shortcomings in the governance, financing, and delivery of health services, health workforce training, and health information systems. In many countries, transgender health issues are considered peripheral to the overall health priorities of the country, which leads to insufficient country funding for transgender health, the absence of strategies and clinical guidelines, and weak accountability. In addition, the absence of systematic gender-disaggregated data collection in health information systems renders transgender persons invisible in the health statistics, making health service planning and policy evaluation difficult.\u003c/p\u003e \u003cp\u003eThe healthcare systems deficiencies of the previous years were further revealed by the COVID-19 pandemic. The reallocating of healthcare resources, the disruption of multiple routine services, the establishment of new mobility restrictions, and the development of new forms of economic precarity disproportionately impacted marginalized social and economic communities, and the transgender population. The pandemic services interruptions negatively affected the availability of, access and support to; HIV prevention and treatment; psychotherapeutic services, and other essential services and care; as well as hormone therapy. These experiences illustrated the lack of resilience of the health systems in safeguarding access to healthcare for marginalized communities during health emergencies, reinforcing the need for equity to be a priority in the planning and response of health systems to emergencies. The global public health discourse has increasingly recognized the importance of transgender health, although most of the literature remains descriptive epidemiological studies and qualitative studies of experiences, focused on stigma and psychosocial factors, and the consequences of the individual. This scholarship has documented critical health disparities, yet there is still a notable absence of comparative and systemic analyses examining the relations between national health system structures and policies and the access to care for transgender people in different countries. There is a shortage of non-discriminatory policy environments that transcend measurable changes in performance indicators of health systems like Universal Health Coverage (UHC), overall government spending on health, and financial protection. Closing this gap is critical for informing policy and advancing global commitments to health equity, including affordable healthcare of any kind without financial distress, and to the Sustainable Development Goal 3 (SDG 3). Out of the various approaches that can be deployed to achieve this, a health systems approach is applicable, as it builds the analysis from the individual level to the institutional and systemic level that either enable or hinder equitable access to care. Therefore, the analysis in this regard is systemic and structural. In this light, the study undertakes a multi-country analysis of public health systems to identify structural health systems and barriers to the transgender healthcare system. Using the WHO Health System Building Blocks Framework, and a mix of quantitative and qualitative policy approaches, this study seeks to analyze and assess the extent to which governance, financing, service delivery, health workforce, and health information systems, in all their disparate forms impact access to transgender healthcare in different settings. In this regard, the study aspires to generate evidence that is of high policy relevance to the global public health system and to the inclusion, equity, and resilience of that system.\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design\u003c/h2\u003e \u003cp\u003eA convergent parallel mixed methods approach was utilized to facilitate the separate yet concurrent assessment of the qualitative and quantitative dimensions of the health system indicators and policy evidence. This approach is particularly effective in health systems research as it provides a unique form of strengthening validity through triangulation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Data sources\u003c/h2\u003e \u003cp\u003eThis study utilized internationally accepted publicly available datasets, which allows the study to be transparent and replicable, and comply with the Springer Nature research data policy. The study used the World Health Organization (WHO) and the World Bank Health System databases to collect quantitative indicators for the global health system. The databases are widely relied upon for health system research. Data for each country\u0026rsquo;s health financing comes from the World Health Organization Global Health Expenditure Database (GHED). The GHED database offers balanced and comparable data for national health expenditures by country and year per the System of Health Accounts (SHA) methodology. From GHED we obtained the indicators for government health expenditure (GH) and out-of-pocket (OOP) health expenditure, which represent the public financing and financial protection and are the measures of the health system. The indicators for health service coverage and system capacity were derived from the World Bank World Development Indicators (WDI) database. These included the Universal Health Coverage (UHC) service coverage index and health workforce density, which is the ratio of physicians and nurses to a population of 1,000.\u003c/p\u003e \u003cp\u003eMoreover, specific proxy indicators were utilized to quantify the disruption to health systems caused by COVID-19, as well as the effects on the accessibility of health services and the continuity of care. The disruption to health systems caused by COVID-19 and effects on the accessibility of health services and the continuity of care were analyzed. The last year of data available for each indicator between the years 2010 and 2024 was applied for the analyses. To address the gaps in the quantitative analysis and to understand the specific structures within the health systems, a qualitative evidence synthesis was also carried out. This involved searching for peer-reviewed journal articles published in PubMed, Scopus, and Web of Science, as well as national health policies and law documents pertaining to the health of transgender individuals. Additionally, the global and regional policy documents of the World Health Organization, the United Nations Development Programme, and the Joint United Nations Programme on HIV/AIDS were analyzed. The authors examined all qualitative documents published in the years 2010 to 2024 in order to track the presence of policies relating to transgender individuals and to describe the systems of governance and the frameworks of service provision in various countries. The authors did not collect any personal information or data that could be used to identify individuals, as all the data were aggregated at the country level; thus, there was no need to seek ethical approval for this study. In accordance with the data availability policy of Springer Nature, the data used for this analysis can be accessed without restrictions and can be found in the World Health Organization and World Bank databases.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Selection of Countries\u003c/h2\u003e \u003cp\u003eThe authors selectively chose countries based on the existence of comprehensive and consistent data for all the study variables, including indicators on health financing, service coverage, workforce, and documents pertaining to policies on transgender individuals.\u003c/p\u003e \u003cp\u003eAfter the application of the inclusion criteria, the final analysis consisted of 32 countries.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Analytical Framework\u003c/h2\u003e \u003cp\u003eAnalysis was conducted using the WHO Health System Building Block Framework, focusing on the following domains:\u003c/p\u003e\u003cp\u003e\u003cspan\u003e1. Governance and leadership\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e2. Health Financing\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e3. Service Delivery\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e4. Health Workforce\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e5. Health Information Systems\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e2.5 Statistical Analysis\u003c/h2\u003e\n \u003cp\u003eHealth system indicator data were summarized using descriptive statistics. A Pearson correlation analysis was conducted to evaluate the relationship between inclusion of policy and system performance. Linear regression analysis was used to evaluate access to care. A p-value of less than 0.05 was considered to be statistically significant.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Transgender Policy Inclusion by Countries\u003c/h2\u003e \u003cp\u003eThe analysis included 32 countries at different income levels. Countries were separated by the presence or absence of policy frameworks that are inclusive of transgender persons. The analysis used legal recognition of gender and the inclusion of transgender persons in the health policy at the national level.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Policy Inclusion and Health System Indicators\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows health system indicators for countries with and without policies that are inclusive of transgender persons. Comparison of the indicators between the two groups is presented.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHealth system indicators by transgender policy inclusion\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInclusive policy (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-inclusive policy (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUHC service coverage index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e71.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e56.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGovernment health expenditure (% GDP)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e5.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOut-of-pocket expenditure (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e34.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e54.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCountries with transgender-inclusive policies reported Universal Health Coverage (UHC) service coverage which translates into broad access to vital health service. Furthermore, such countries invested more health-related government expenditure in comparison to the others, and the population experienced lower out-of-pocket health expenses. All the presented differences in the results were substantial and reflect the influence of more inclusive policies and funding frameworks on the health system overall.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Health workforce capacity and service availability\u003c/h2\u003e \u003cp\u003eExcluding the coverage and financing, the capacity of the health workforce turned out to be a crucial distinguishing factor between inclusive and non-inclusive policy settings. Countries with transgender-inclusive policies recorded a better physician and nursing density, which signifies better service delivery and access to care.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHealth workforce density by transgender policy inclusion\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInclusive policy (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-inclusive policy (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysicians per 1,000 population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurses and midwives per 1,000 population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePolicies that are more inclusive indicate a higher density of health care workers. This implies that health care workers are more accessible and can retain patients for primary care, mental health, and chronic disease management. These findings alludes to the theory that more inclusive policies, tend to have a higher degree of both financing and service delivery improvements.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.4 The Inclusion of Policies and the Performance of Health Systems\u003c/h2\u003e \u003cp\u003eThe inclusion of transgender policies has a degree of positive correlation to UHC service coverage, (r\u0026thinsp;=\u0026thinsp;0.61, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) as well as government health spending (r\u0026thinsp;=\u0026thinsp;0.57, p\u0026thinsp;=\u0026thinsp;0.002) and a negative correlation to out-of-pocket spending (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.59, p\u0026thinsp;=\u0026thinsp;0.001) as per the Pearson correlation.The graphical patterns show that countries that focus on inclusivity have higher levels of health service coverage and spending on public health, while non-inclusive countries show a higher reliance on out-of-pocket spending. These relations show us the structural connection of inclusivity policies and the functioning of an equitable health system.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.5. Access to Healthcare and its Multivariable Regression Analysis\u003c/h2\u003e \u003cp\u003eA multivariable linear regression model was used on the variables: transgender policy inclusion, government health expenditure, and the COVID-19 disruption index, to determine the predictors of accessible healthcare.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eMultivariable regression predicting healthcare access\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransgender-inclusive policy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.18\u0026ndash;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGovernment health expenditure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.11\u0026ndash;0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOVID-19 disruption index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;0.55 to \u0026minus;\u0026thinsp;0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the case of neutral adjustments, inclusive policies for transgender people remained a strong independent predictor of increased health care accessibility. Increased government spending on health also increased accessibility and reinforced the importance of public investment. The COVID-19 crisis increased disruption and negatively affected accessibility, illustrating the fragility of the health systems of marginalized people during public health crises. There was no evidence of multicollinearity (variance inflation factor\u0026thinsp;\u0026lt;\u0026thinsp;2.5) and the regression model fit appropriately\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Effects of COVID-19 Disruptions on Access to Healthcare Services\u003c/h2\u003e \u003cp\u003eCountries where the pandemic caused the greatest disruptions to health systems also experienced the greatest declines in service accessibility, especially in the case of restrictive policy frameworks. The disruptions primarily limited access to routine care, mental health services, and long-term care continuity. The relationship between disruptions caused by COVID-19 and access to healthcare services across various policy contexts. Countries with health systems characterized by inclusive governance and greater public financing had a uniquely robust impact when it came to access; in contrast, systems characterized by a lack of inclusivity suffered significantly greater declines in access.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eThe analysis of public health systems in multiple countries shows that the inequities in the health systems of countries in which transgender people live and access health services are mostly the result of structural functions of the health systems in these countries and not the result of individual factors. Countries where inclusive policies regarding transgender people have been implemented demonstrate improved health system outcomes with greater levels of UHC service coverage, increased health sector spending, and less reliance on out of pocket expenditure. These results further validate that positive health outcomes are achieved when health system policies are inclusive of marginalized groups. The results also suggest that the positive health outcomes associated with the system\u0026rsquo;s policies and governance structures are also positive when systems policies are inclusive. While policies such as legal gender recognition and the inclusion of transgender health in national health policies seem to have enabled health systems in performing these functions, it may be that these policies have also created the need for reallocation of resources, greater emphasis on the provision of services, and increased accountability from health system administrators. These policies improve the stewardship and leadership of the health system, attributes central to the health system building blocks of the World Health Organization, in the process demonstrating a commitment to the values of equity and human rights. Most importantly, the positive health outcomes that arise from these policies and the governance systems that support them are not limited to the transgender population.\u003c/p\u003e \u003cp\u003eThe role of public financing as a fundamental determinant of the accessibility of healthcare services became apparent. The positive impact on the accessibility of healthcare services as government health spending increased proves the importance of fiscal capacity and spending priority as facilitators for translating policy intentions into services. In contrast, countries with low public investment experienced high levels of out-of-pocket spending, a spending pattern that increases inequities and discourages people from seeking care, particularly the disadvantaged, including transgender people. These results confirm the importance of financial protection for universal health coverage (UHC) and that high out-of-pocket expenditures adversely impact the most vulnerable, who are often victims of social stigma, discrimination, and economic exclusion. However, these results also illustrate that the mere presence of policies to advance equity in health is not effective in closing the health equity gap. Despite the presence of inclusive policies, many countries still face the challenges of gaps in the training of health care providers, the integration of services, and health information systems. The gaps in effective service delivery are also a result of a lack of training in culturally and gender-sensitive care, which contributes to distrust in health systems, delays in care seeking, and poor health outcomes. The lack of service delivery models also inhibits the health system\u0026rsquo;s responsiveness and monitoring, along with the insufficient availability of gender-disaggregated health data.\u003c/p\u003e \u003cp\u003eSuch gaps point to the necessity for changes on a broader scale, encompassing the entire system to go beyond mere statements of policy to effect coordinated interventions in all building blocks of the health system.The negative correlation between disruptions in healthcare access and the COVID-19 related barriers demonstrates the escalated marginalization of transgender populations during health crises. The Covid-19 pandemic highlighted the fragility of health systems and the absence of equity-focused emergency preparedness and continuity-of-care measures for the disadvantaged. The temporary suspension of services, resource reallocation, and social protection deficits affected the transgender population most acutely. Many transgender individuals need ongoing access to hormone therapy, mental health services, and community support. The findings indicate that enduring health crises are evidence of the need for inclusive and resilient health systems that can maintain essential services. Traditionally, scholarship in Transgender health has focused on individual behaviors and individual health impacts of the crisis. This scholarship also attempts to document disparities in health outcomes. This study attempts to reverse and clarify the governance, financing, and systemic capacity pathways that define access and equity in health in different countries. This systems thinking approach, which prioritizes the population over the individual, resonates with the aim of the Journal of Public Health and the Health systems strengthening framework. The findings demonstrate that to advance transgender health equity, there is a need for more than ornate policy commitments and/or symbolic participation.The critical first step to achieving sustainable development is placing transgender health within the public health systems\u0026rsquo; core structural components. These are inclusive governance, appropriate and equitable financing, effective delivery of services, strong health workforce development, and robust health information systems. This is vital, not only for advancing the health of transgender individuals, but also for improving the ability of health systems to offer equitable care for all, especially during impending global health emergencies. These findings are consistent with the health systems and social determinants frameworks, where governance, financing, and arrangement of institutions are the primary determinants of equitable healthcare access for marginalized groups.\u003c/p\u003e"},{"header":"5. Implications for Policy","content":"\u003cp\u003eThere are five policy ramifications of this study, namely (i) integration of transgender health services into the national Universal Health Coverage (UHC) benefit packages, (ii) increased culturally competent and gender-affirming care training for providers, (iii) decreased out-of-pocket costs for essential mental health and gender-affirming services, (iv) regular gender-identity-disaggregated health data collection, and (v) inclusion of equity within the health emergency preparedness frameworks.\u003c/p\u003e"},{"header":"6. Strengths and limitations","content":"\u003cp\u003ePerhaps the biggest strength of this study comes from the mixed-methods, multi-country design. This allowed for the study to cover the breadth of issues of the transgender healthcare system by accessing both the quantitative indicators of the health systems, and the qualitative indicators of the policies. The study describes the structural factors of the health systems and how they serve or hinder the access of transgender healthcare in different countries by merging data from a global, standardized dataset with policy and literature reviews.\u003c/p\u003e \u003cp\u003eThe study is policy driven, and the use of the WHO Health System Building Blocks Framework to describe the other (non policy) parts adds to the depth of analysis. The study should also be of interest to global and national health policymakers with a focus on health equity. More than a few limitations apply to this study. First, the use of aggregated, secondary data from countries overlooks domestic disaggregation, and limits the extent of subnational or community-level analysis. Second, because of the ecological study design, there is no scope for individual-level, direct causal inference, and the system-level phenomenon should not be viewed as a reflection of the individual variations in access to the individual components of the healthcare. Third, lack of consistency and quality in the availability of country-specific policies relating to transgender persons may have resulted in bias in the classification of coding policies in/ out. However, the study still offers important system-level insights to support structural changes and to direct future research at the individual level, despite the shortcomings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe examination of 32 countries shows that the structural barriers within the public health system remain a pivotal factor in the inequitable distribution of healthcare accessibility, especially for transgender individuals, across the globe. When public financing and inclusive service delivery models are also present, governance frameworks that systemically acknowledge transgender health tend to result in stronger health system outcomes, greater achievement of Universal Health Coverage, and improved availability of essential health services. This also means that policy recognition is ineffective in closing the health equity gap. Regardless of the existence of inclusive policies, the adequate provision of transgender affirming care is hindered by the insufficient integration of health services, the inadequate training of health personnel, and the deficiencies in health information systems. These obstacles speak to the need for more comprehensive, system-wide, and coordinated reforms that address the full range of health policy instruments and components. The adverse effects of the COVID-19 pandemic on the provision of health services to transgender populations also demonstrate the insufficiencies of the health systems and the vulnerability of transgender individuals to crises. During health crisis periods, the public health systems that are underfunded, lack inclusive governance, and insufficient public health investments are those that were unable to prioritize the care of marginalized populations. Integration of transgender health into national health policies, budgets, and Universal Health Coverage frameworks will be critical for the systematic achievement of the Sustainable Development Goal (SDG) 3 target of ensuring healthy lives and promoting well-being for all. Therefore, the strengthening of inclusive, resilient, and people-centered health systems as a social justice imperative is equally important for global health equity and the protection of access to care for transgender people in all settings, including routine and emergency.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors want to say thank you to the World Health Organization and the World Bank for letting them use the datasets they have. The authors also want to thank their colleagues for helping them with their study and for talking about the ideas, in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is not applicable because it only used information that\u0026apos;s already out there. The information came from sources and was already put together. This study did not involve people.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eReisner SL, Poteat T, Keatley J, et al. Global health burden and needs of transgender populations: a review. Lancet. 2016;388(10042):412\u0026ndash;36. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0140-6736(16)00684-X\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(16)00684-X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite Hughto JM, Reisner SL, Pachankis JE. 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Psychol Sex Orientat Gend Divers. 2018;5(1):1\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/sgd0000261\u003c/span\u003e\u003cspan address=\"10.1037/sgd0000261\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"transgender health, health equity, public health systems, healthcare access, structural barriers, Universal Health Coverage and SDG 3","lastPublishedDoi":"10.21203/rs.3.rs-8516735/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8516735/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTransgender people all over the world continue to have to face discrimination related to the public healthcare they receive. This is in part due to the structural weaknesses in the national public health systems. Although the need for health services specific for transgender people is increasingly acknowledged, there is still little access to the needed basic health services in many countries.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThis study looks at the impact of the five main components of public health systems (governance, financing, service delivery, health workforce, and health information systems) on the availability of healthcare for transgender people in different countries.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eQuantitative and qualitative analyses were conducted using a convergent parallel mixed methods design. Quantitative data were derived from the World Health Organization\u0026rsquo;s Global Health Expenditure Database and the World Bank\u0026rsquo;s World Development Indicators for the years 2010\u0026ndash;2024 for 32 countries. Qualitative data were collected from peer-reviewed journals, national documents, and global health reports. The WHO Health System Building Blocks Framework was used for the analyses of descriptive data, the Pearson correlation, and the multivariable linear regression.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eCompared to non-inclusive policies, countries with transgender-inclusive health policies had higher UHC service coverage, greater government health expenditure, lower out-of-pocket spending, and higher density of health workers. Transgender-inclusive policies and increased public financing for health were both separately important for greater access to health care, while the COVID-19 related disruptions to the health system caused less access to care.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIncorporating financing policy will be necessary for improving access to healthcare in a socially equitable manner. In order for health policies to reinforce the financing of health systems in an equitable manner, they need to address, equity, Universal Health Coverage and the third Sustainable Development Goal.\u003c/p\u003e","manuscriptTitle":"Structural Barriers and Health System Determinants of Healthcare Access among Transgender Populations in a Multi-Country Public Health Systems Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-20 12:43:09","doi":"10.21203/rs.3.rs-8516735/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7a646a00-ba7e-415c-b27c-470562b90962","owner":[],"postedDate":"January 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-25T08:13:02+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-20 12:43:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8516735","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8516735","identity":"rs-8516735","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}