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Table 2 Analysis of the way equity is approached in global UHC documents

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

Document no.SourceTitleExplicit definition of equity?How equity is approached in the document
C1WHO 2008World Health Report 2008: Primary health care: Now more than ever [2]No- Chapter 1 “The challenges of a changing world” devotes a section to the “Changing values and rising expectations” which comprises a subsection on “Health equity”
- Equity is a central concern of Chapter 2 “Advancing and sustaining universal coverage”, especially in the following sections: 
“The central place of health equity in primary health care (PHC)” and “Mobilizing for health equity”
- Among the four reforms advocated for in the report, universal coverage reforms are viewed as those that “ensure that health systems contribute to health equity, social justice and the end of exclusion, primarily by moving towards universal access and social health protection” (page ix, message of the Director General -- bold ours)
- The report points to the multiple dimensions of health inequality
- Associations of equity with UHC and other concepts:
  o The report explains the links between UHC and equity – mostly through social health protection, increasing financial access to healthcare (by contrast, out-of-pocket payments (OOPs) are denounced as inequitable)
  o Equity is viewed as a value driving the primary healthcare movement, together with solidarity and social justice
C2WHO 2010World Health Report 2010: Health Systems Financing: The path to universal coverage [30]No- The report argues in chapter 3 that compulsory prepaid funds, if possible pooled into a single pool, enables to achieve equity goals – sometimes called equity funds
- It makes the case for decisions that contribute to equity in contributions, in pooling, and in use of resources
- Associations of equity with UHC and other concepts:
  o Equity is associated repeatedly with efficiency
  o It is mentioned once with fairness and basic decency
C3WHO 2013World Health Report 2013: Research for Universal Health Coverage [31]No- The report has a section dedicated to “Equity and universal health coverage
- It points to the “inequitable access to the products of research” (p. 45)
- Associations of equity with UHC and other concepts:
  o Equity is associated with cultural values, right to health and social justice as well as with discrimination
  o It is also associated with quantity and quality of services, and with efficiency
C4WHO 2013Arguing for Universal Health Coverage [32]Yes: “Equitable: does the mechanism raise funds according to people’s ability to pay and are the benefits distributed according to people’s health needs?” (p. 25)- The document focuses on the equity of the health financing system, and provides the case for “health funding policies that promote equity, efficiency and effectiveness, and ensure that the rights of the most vulnerable are not forgotten”
- It singles out out-of-pocket financing as failing badly in terms of equity and financial risk protection
- Associations of equity with UHC and other concepts:
  o Equity is associated with efficiency and effectiveness, and (human) rights (to health)
  o The document considers that equity is part of UHC: “equity and financial risk protection, which are integral to achieving progress towards UHC “(p. 25); “the equity criterion fundamental to attaining UHC” (p. 27); “the equity principles that should be the foundation of any UHC strategy” (p. 32)
C5WHO 2013Universal Health Coverage: Supporting Country Needs [33]Yes: “Equity: If all people obtain the health services they need without suffering financial hardship, equity in access has been achieved” (p. 9)- Associations of equity with UHC and other concepts:
The document considers equity is part of UHC: “This vision of UHC embodies principles of equity in access to and use of services, quality of the services people obtain, and financial protection for people needing health services” (p. 5); UHC is not only about health but also “moving closer to UHC is also about equity, development priorities, social inclusion and cohesion” (p. 10); UHC “is a concept that is fundamentally about equity” (p. 12)
C6WHO & WB 2013Background document Towards UHC: concepts, lessons and public policy challenges [34]No- The document makes the case for health financing reforms: “the objectives of universal financial protection and equity in the use of needed services are best served when health systems rely predominantly on compulsory prepaid funds”
- It also makes the case for strengthening the primary level of care
C7WB 2013The Impact of Universal Coverage Schemes in the Developing World [35]No- Associations of equity with UHC and other concepts:
  o UHC viewed as a means to increase equity
  o Equity associated with efficiency (and quality)
C8Rockefeller Foundation, Save the Children, UNICEF and WHO 2013Universal Health Coverage: A Commitment to Close the Gap [36]Yes: “inequity – unfair and avoidable inequalities” (p. 4 and later)- Equity is a central concern of this report: “This report focuses on how and why inequity – unfair and avoidable inequalities – should be prioritised as countries progress on the path towards UHC” (p. 4):
  o The report refers to all types and levels of equity identified in Table 1
  o Section 2 explains why equity is important for UHC
  o Section 3 provides a conceptual framework for assessing equity in pathways to UHC, and then lessons for equitable pathways towards UHC
  o Section 4 makes the economic case for equitable pathways towards UHC
- The report specifies that “Within health systems, equity applies to the goals of improved health outcomes, equity in finance, financial risk protection and responsiveness, as well as the objectives of good quality and utilisation based on need” (p. 15)
- Associations of equity with UHC and other concepts:
  o UHC viewed as a means to achieve greater equity, or “the response to” inequities (p. 6); and as necessitating consideration for equity throughout reform processes
  o Equity related to fairness; calls to “a moral and ethical perspective” (p. 4)
C9WHO & WB 2014Monitoring progress towards universal health coverage at country and global levels – Framework, measures and targets [25]No, but definition of equity indicators of coverage and financial protection- The framework for monitoring progress towards UHC monitoring of UHC puts a focus on equity regarding the two discrete components of health system performance (coverage of health services and financial protection), and recommends that “Measures should be disaggregated by socioeconomic and demographic strata” (p. 5)
- The global framework proposes three primary elements for disaggregation that can be measured comparably in all settings: household income, expenditure or wealth (coverage of the poorest segment of the population as compared with richer segments); place of residence (rural or urban); and gender (p. 6)
- Each country is expected to add further measures of service coverage and further equity stratifiers in order to tailor UHC monitoring to its context (p. 10)
- Recommended indicators comprise an aggregate and an equity measures
- Associations of equity with UHC and other concepts:
  o Reckons that “At the heart of UHC is a commitment to equity” (p. 6)
C10ILO 2014Universal Health Protection: Progress to date and the way forward [29]No- Mentions that OOPs are the most inequitable source of health financing (p. 2); their removal can help progress in terms of “effective and equitable access to health care, affordability and financial protection in addition to availability of quality services” (p. 6)
- Refers to “inequities in legal health coverage due to political, legislative and administrative failures” (p. 2)
- Has a section on “Moving towards Equity: National Social Protection Floors as a key strategy for achieving universal coverage in health”
- Associations of equity with UHC and other concepts:
  o UHC and equity viewed as two distinct aims (p. iii)
  o Equity associated with human rights to social security and health and the rights-based approaches underpinning the need for equity and poverty alleviation (p. iii); with social change, poverty alleviation the elimination of deprivation (pp. 4, 47); with social justice (pp. 9, 77); with vulnerability and social exclusion (p. 37); with universality (p. 39); with solidarity (p. 66); with social fairness (p. 72); with inclusion (p. 111)
  o Mentions the trade-off between equity and quality of essential health services (p. 45)
C11WB 2015Going Universal – How 24 Developing Countries Are Implementing Universal Health Coverage Reforms from the Bottom Up [37]No- Points repeatedly to the trade-off between equity in the benefit package and (fiscal) sustainability
- Associations of equity with UHC and other concepts:
  o Equity repeatedly associated with “better results for the money spent” (p. xiv) / with efficiency and effectiveness
  o Also associated with sustainability, accessibility, quality, integration; implementability
C12WHO/ regional office for Africa 2015The African Health Monitor Special issue: Universal Health Coverage [38]Not in general, but vertical equity is defined as “cross-subsidization from wealthy to poor” (p. 24)- Several chapters are focused on the equity aspects of community-based health insurance
- A case study in Senegal focuses on vertical equity – and mentions that it “is likely to overlap with the “health risk” dimension of solidarity” (p. 24)
- Another case study in Senegal reckons that the equity paradigm has been developed at the international level, as a consequence of financial barriers that have reduced utilisation of healthcare by the poorest (p. 63)
- Associations of equity with UHC and other concepts:
  o Equity repeatedly associated with efficiency
  o Also associates equity with adequacy (of coverage) and sustainability (p. 51); with universality and solidarity (p. 59–60)
  o The Regional Director mentioned the “shared values of equity, dignity, transparency, integrity, professionalism and openness”; inequities also compared to injustices (p. 67)
C13WHO & WB 2015Tracking universal health coverage: first global monitoring report [1]No- The first global monitoring report of UHC regret that “Because of the lack of data, it is not yet possible to compare the UHC service coverage index across key dimensions of inequality” (p. viii)
- A key challenge is to monitor equity in access to quality health services (p. 4)
- Associations of equity with UHC and other concepts:
  o The report states that “Equity is key to the SDGs in general and to UHC specifically” (p. xii) – and recalls SDG 3: Equitable health outcomes and well-being; global public health security and resilient societies (p. xiii)
C14WHO 2016Health financing country diagnostic: a foundation for national strategy development [39]Yes, partly: makes the distinction between different utilisations of the concept of equity (see next column)- Specifies that “equity in the use of services refers to reducing the gap that exists between the need for a health service and the actual use of that service” (p. 3)
- Defines equity in finance, which “is strongly related to the goal of financial protection, but is conceptually distinct. Equity in finance refers to the distribution of the burden of financing the health system across different socio-economic groups. To be considered equitable, the burden of health financing should be distributed according to individuals’ ability-to-pay” (p. 3)
- It is distinct from equity in financing which “has to do with how revenues are raised, not with how the money is spent” (p. 23)
- The report has a subsection on “Financial protection and equity in finance” (pp. 21–25) and another one on “Equity in service use and in the distribution of resources” (pp. 26–27)
- It makes a distinction between equity in health finance and equity in financing: “Equity in financing has to do with how revenues are raised, not with how the money is spent . This latter issue – also highly relevant to the performance of health financing arrangements – is addressed below in the section on equity in health service use and the distribution of system resources.”
- Box B2 shows a summary of key findings from previous studies on equity in financing (pp. 44–45)
- Associations of equity with UHC and other concepts:
  o Equity is approached through the links between health financing, UHC goals and intermediate  objectives – indeed, equity in service use is a UHC goal, and the distribution of resources is a UHC intermediate objective
  o Thus association of equity with other UHC objectives/goals: efficiency, transparency and accountability, quality, financial protection
C15WHO 2016Public Financing for Health in Africa: from Abuja to the SDGs [40]No- Associations of equity with UHC and other concepts:
  o Equity is associated with sustainability (pp. 8, 33), quality (p. 22), efficiency (pp. 30, 33)
C16WHO 2017Global Report: New Perspectives on Global Health Spending for Universal Health Coverage [41]No- Associations of equity with UHC and other concepts:
  o Equity is associated with social cohesion (p. 4), sustainability (p. 8)
  o Intends to promote “equitable progress towards UHC” (p. 29), thus differentiating the two concepts
C17WHO 2017Together on the road to universal health coverage – a call to action [42]No- Associations of equity with UHC and other concepts:
  o Equity is associated with efficiency (p. 14), human rights (pp. 18, 20), gender equality (p. 20)
C18WHO 2017Developing a national health financing strategy: a reference guide [43]No- Associations of equity with UHC and other concepts:
  o Considers equity in utilisation or service use relative to need as part of a normative set of goals embedded in the concept of UHC, together with financial protection and quality; equity in the distribution of health system resources as part of a set of intermediate objectives, together with efficiency, transparency and accountability (p. 1)
  o Equity also associated with effectiveness and the management of expenditure growth (p. 12)
C19WHO & WB 2017Tracking universal health coverage: 2017 global monitoring report [43]No- Has a lot in common with the first global monitoring report on UHC as for its approach of equity (lack of data preventing comparing the UHC service coverage index across key dimensions of inequality, link with SDGs and UHC, etc.)
- Associations of equity with UHC and other concepts:
  o The report reckons that “Unless health interventions are designed to promote equity, efforts to attain UHC may lead to improvements in the national average of service coverage while inequalities worsen at the same time” (p. viii) – therefore making a clear distinction between UHC and equity
C20WHO/Regional Office for Africa 2017The state of health in the WHO African Region: an analysis of the status of health, health services and health systems in the context of the SDGs [44]No- The report highlights the inequities between the countries of the WHO African region, and also within countries
- It originally mentions the inequities in the countries health security status (p. 33)
- It notices the interconnection between the different levels of inequity: “These inequities in health are a result of inequities in investments in and outcomes from these investment” (p. 83)
- Associations of equity with UHC and other concepts:
  o Equity is associated repeatedly with sustainability, efficiency and effectiveness; and once with resource adequacy (p. 71) and human rights (p. 84)
  o The report notices that the 2030 Agenda for Sustainable Development has “a strong focus on equity” (p. 1)
  o It also states that “progress towards UHC and the SDGs, particularly from the equity perspective” (p. 83), suggesting that equity is a dimension of UHC & SDGs