At this year’s Frontiers Health event in Berlin, one panel cut directly into this tension, exploring a core truth about future-proofing health systems: panels can sketch the problem, but the real intrigue lies in how organisations attempt to solve it.

For panellist Chrys Herrera, Merck’s head of health equity and access realisation, health equity sits at the heart of that challenge. It isn’t a parallel ambition. It is the mechanism that determines whether transformation succeeds.

Crucially, Merck doesn’t treat health equity as a fringe operation. Instead, the company has established three interdependent pillars that guide its decisions: beginning with people and their lived realities; building through the systems that surround them; and sustaining the work through shared value. These pillars act less like slogans and more like orientation points, guiding Merck on a journey to answer a deceptively simple question: if equity is essential to sustainable health, what does it look like to build it into the everyday machinery of a global pharma organisation?

The simplicity of that old model has a certain appeal – a belief that delivering a treatment equates to delivering impact. Yet, as health systems have become more intricate, the fragility of that assumption has been bought sharply into view. A medicine can only succeed in a system capable of supporting it, and, as Herrera notes, those systems are rarely uniform.

Merck’s newer framing accepts that complexity, rather than smoothing it away. “It’s not just about access,” Herrera said. “It’s about what we do as a company to help improve health outcomes in communities.”

Herrera is quick to emphasise that Merck’s equity work remains a work in progress; more a series of deliberate small steps towards an ambitious goal, rather than a single completed transformation. The shift invites a more expansive understanding of the conditions required for a medicine to have its intended effect – diagnostic pathways that work, representation in research, digital literacy, confidence in care environments, and the social circumstances surrounding a condition.

Of course, adjusting the definition of equity inevitably reshapes how success is understood. Metrics that once offered tidy reassurance now feel insufficient without context. “We're still building this journey of what success looks like, but the intention is there to move away from just the big number of clinical outcomes,” Herrera explained. “We also have to look at the quality of our interactions with patients, stakeholders, and communities.”

The myClad clinical trial shows how this works when embedded early. Instead of consulting patients once the study design was settled, Merck involved more than 20 patient groups from the outset. They weren’t there to rubber-stamp decisions; they shaped them. As Herrera explains, the trial’s protocol, recruitment approach, packaging, and even the surrounding technologies were refined through their input. “It’s not just about the medicine,” he said, “but what technologies could complement the medicine beyond the pill.”

This approach rarely delivers neat, linear insights. It disrupts assumptions, alters plans, and often requires teams to rethink parts of the process they considered settled. That disruption, Herrera argues, is part of its value. It forces organisations to adjust while adjustments are still easy to make.

Yet, he’s clear that one compelling example doesn’t create a culture. “We’re building from a position of strength,” he said, “but the challenge now is making this standard practice, not just best practice.”

“One measure of success is when equity becomes a routine part of business planning,” he said. “When leaders automatically think about marginalised populations – without us prompting them.”

To reach that point, equity has to be woven into the organisation’s architecture – into strategy documents, incentive structures, resourcing decisions, and evaluation frameworks. Herrera describes Merck’s internal shift as something that grows through layers, rather than leaps: sustainability KPIs that incorporate equity, therapeutic franchises developing their own equity roadmaps, governance models that distribute responsibility, rather than centralise it.

“The old model was to silo health equity or access into a small CSR-style team,” he said. “If you really want this to be owned by the business, you want to see the health equity team as a business partner, so to speak, advising business leaders and telling them, ‘This is the health equity angle to your strategy’ or ‘These are populations where we should be considering health equity and we should be designing our initiatives around them’.”

His benchmark for real progress is deliberately unsentimental. “Even if I get hit by a bus,” he said, “the work should continue. It should be independent of personality.”

The line is wry, but the point is serious: equity must stick because the system holds it in place, not because individuals do.

Durability also requires long-term thinking. In several pilots, Herrera explained, building system readiness expanded access while only “minimally diluting profitability” – the sort of trade-off that takes a steadier hand to evaluate.

Merck’s storied history and family-based ownership structure helps here. “The Merck family likes to say we think in generations, not quarters,” he said. “We have to think about the next 350 years.”

With that kind of time horizon, equity becomes less an act of altruism and more a logic for long-term survival.

“What I’d like us to do is move from parallel play to cooperative play,” he said. “We’re in the same markets […] But we haven’t yet figured out how to synergise our forces for common good.”

It’s an invitation, rather than a critique, and it hints at a future where equity becomes a shared infrastructure, as opposed to a scattered set of initiatives.

“We cannot solve the world's problems alone,” he stressed. “We need partners, we need force multipliers, and this is where we need to align with local partners and to make sure that we address what the local health system priorities are in order for us to make change that sticks.”

In that sense, Herrera’s reflections move beyond the panel’s headlines. They draw attention to the machinery inside organisations – the small decisions, the evolving assumptions, the systems that slowly shift their weight. Equity becomes less about what companies say and more about what they repeatedly do.

And if the health systems of the future are to hold together under the pressures we already see coming, it may be these quieter, systemic changes that determine how resilient they truly become. Because a system that doesn’t reach everyone will eventually fail everyone.