How is equity approached in universal health coverage? An analysis of global and country policy documents in Benin and Senegal

Abstract

Background: Equity seems inherent to the pursuance of universal health coverage (UHC), but it is not a natural consequence of it. We explore how the multidimensional concept of equity has been approached in key global UHC policy documents, as well as in country-level UHC policies. Methods: We analysed a purposeful sample of UHC reports and policy documents both at global level and in two Western African countries (Benin and Senegal). We manually searched each document for its use and discussion of equity and related terms. The content was summarised and thematically analysed, in order to comprehend how these concepts were understood in the documents. We distinguished between the level at which inequity takes place and the origin or types of inequities. Results: Most of the documents analysed do not define equity in the first place, and speak about "health inequities" in the broad sense, without mentioning the dimension or type of inequity considered. Some dimensions of equity are ambiguousespecially coverage and financing. Many documents assimilate equity to an overall objective or guiding principle closely associated to UHC. The concept of equity is also often linked to other concepts and values (social justice, inclusion, solidarity, human rightsbut also to efficiency and sustainability). Regarding the levels of equity most often considered, access (availability, coverage, provision) is the most often quoted dimension, followed by financial protection. Regarding the types of equity considered, those most referred to are socioeconomic , geographic, and gender-based disparities. In Benin and Senegal, geographic inequities are mostly pinpointed by UHC policy documents, but concrete interventions mostly target the poor. Overall, the UHC policy of both countries are quite similar in terms of their approach to equity. Conclusions: While equity is widely referred to in global and country-specific UHC policy documents, its multiple dimensions results in a rather rhetorical utilisation of the concept. Whereas equity covers various levels and types, many global UHC documents fail to define it properly and to comprehend the breadth of the concept. Consequently, perhaps, country-specific policy documents also use equity as a rhetoric principle, without sufficient consideration for concrete ways for implementation.

An assessment of the core capacities of the Senegalese health system to deliver Universal Health Coverage

“…However, this is a major challenge which necessitates strong political will, and is constrained by lack of fiscal space, continued disparities in resource allocation and resistance to merging existing fragmented schemes. For instance, while health sector policy documents in Senegal often intend to reduce disparities, equity is often referred to a rhetoric principle, without sufficient consideration for concrete ways for implementation [ 69 ]. In addition, other constraints to UHC are found on the demand side: the predominant influence of social determinants of health are difficult to tackle because they need inter-sectoral action [ 70 ] This can only be achieved if accountability is also envisioned in a multi-sectoral way – for instance, if all the departments contributing to the UHC policy receive a clear mission statement with well-defined roles and responsibilities, and are held accountable for their results in these respects.…”

Exploring Equity and Inclusion in Malawi’s National Disability Mainstreaming Strategy and Implementation Plan

“…Despite the listing of many government ministries and their diverse roles in the implementation of the NDMS&IP, it is not apparent how these important stakeholders would help ful l anticipated objectives. Studies indicate that effective stakeholder engagement helps in achieving desired goals and objectives [4,14] It is the justi cation for recommendations for transdisciplinary research approaches in identifying pathways to change regarding persistent societal problems [14]. In order to ensure equity, inclusion and effectiveness in programmes for persons with disabilities, we cannot continue doing things for persons with disabilities, but with them.…”

“…Equity and inclusion are important principles in policy development and implementation [1,2]. Equity refers to ensuring the absence of systemic and structural disparities between individuals or groups whereas inclusion entails the extent to which individuals or groups feel a part of an organization or process [2][3][4]. The UN Convention on the Rights of Persons with Disabilities (CRPD) highlights the importance of equity and inclusion for participation of persons with disabilities [5] Inclusive laws and policies are very important in safeguarding equity and inclusion of persons with disabilities and vulnerable populations in society [3].…”

Exploring Equity and Inclusion in Malawi’s National Disability Mainstreaming Strategy and Implementation Plan

“…Despite the listing of many government ministries and their diverse roles in the implementation of the NDMS&IP, it is not apparent how these important stakeholders would help ful l anticipated objectives. Studies indicate that effective stakeholder engagement helps in achieving desired goals and objectives [4,15] It is the justi cation for recommendations for transdisciplinary research approaches in identifying pathways to change regarding persistent societal problems [15]. In order to ensure equity, inclusion and effectiveness in programmes for persons with disabilities, we cannot continue doing things for persons with disabilities, but with them.…”