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

Assessing the determinants of out-of-pocket health expenditures among Cambodian households in informal employment using survey data

BACKGROUND

As the deadline for the Sustainable Development Goals approaches, financial protection in Cambodia remains inadequate, especially for nonpoor informal workers lacking formal social health protection coverage or access to other prepayment schemes. This exposes them to high out-of-pocket health expenditures (OOPE) and related financial hardship. To better understand the drivers behind these expenditures, our study aims to model their healthcare, health, and social determinants and to assess their relative importance.

METHODS

In 2023, we conducted a cross-sectional multistage clustered sampling survey across seven Cambodian provinces, surveying 3,254 households engaged in informal employment and not covered by any formal social health protection scheme. The survey gathered information on households' use of outpatient and inpatient care and associated OOPE. We employed generalized linear models (GLMs) to analyse the healthcare, health, and social determinants of OOPE and the OOPE budget share (the proportion of total annual household consumption expenditure spent on OOPE) and applied Shapley decomposition analysis to quantify the relative contributions of these determinants to the explained variance in our outcomes.

RESULTS

Healthcare variables were the dominant contributors to the explained variance in all outcomes (41.36-50.73%), followed by health factors. While several social variables were significant, only the wealth quintile made notable contributions to explaining variance in our outcomes. The key healthcare contributors included the sector type and level of care, and the number of outpatient medications. Important health contributors included illness severity and the presence of chronic illnesses or noncommunicable diseases.

CONCLUSIONS

Our findings emphasize the necessity of integrating nonpoor informal workers and their dependents into formal prepayment schemes to reduce OOPE and enhance financial protection on Cambodia's path toward universal health coverage. Strategically engaging with private providers and pharmacies to improve access to essential services and medicines, coupled with the implementation of an effective referral system are important policy considerations to this end. Further research is needed on how health determinants are modifiable with policy interventions. Our findings can assist the Cambodian government in advancing its universal health coverage goals and offer insights for other countries aiming to extend coverage to similar population groups.

Challenges and Opportunities of Universal Health Coverage in Africa: A Scoping Review

BACKGROUND

Universal health coverage (UHC) is a global priority, with the goal of ensuring that everyone has access to high-quality healthcare without suffering financial hardship. In Africa, most governments have prioritized UHC over the last two decades. Despite this, the transition to UHC in Africa is seen to be sluggish, with certain countries facing inertia. This study sought to examine the progress of UHC-focused health reform implementation in Africa, investigating the approaches utilized, the challenges faced, and potential solutions.

METHOD

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines, we scoped the literature to map out the evidence on UHC adoption, roll out, implementation, challenges, and opportunities in the African countries. Literature searches of the Cochrane database of systematic reviews, PUBMED, EBSCO, Eldis, SCOPUS, CINHAL, TRIP, and Google Scholar were conducted in 2023. Using predefined inclusion criteria, we focused on UHC adoption, rollout, implementation, and challenges and opportunities in African countries. Primary qualitative, quantitative, and mixed-methods evidence was included, as well as original analyses of secondary data. We employed thematic analysis to synthesize the evidence.

RESULTS

We found 9633 documents published between May 2005 and December 2023, of which 167 papers were included for analysis. A significant portion of UHC implementation in Africa has focused on establishing social health protection schemes, while others have focused on strengthening primary healthcare systems, and a few have taken integrated approaches. While progress has been made in some areas, considerable obstacles still exist. Financial constraints and supply-side challenges, such as a shortage of healthcare workers, limited infrastructure, and insufficient medical supplies, remain significant barriers to UHC implementation throughout Africa. Some of the promising solutions include boosting public funding for healthcare systems, strengthening public health systems, ensuring equity and inclusion in access to healthcare services, and strengthening governance and community engagement mechanisms.

CONCLUSION

Successful UHC implementation in Africa will require a multifaceted approach. This includes strengthening public health systems in addition to the health insurance schemes and exploring innovative financing mechanisms. Additionally, addressing the challenges of the informal sector, inequity in healthcare access, and ensuring political commitment and community engagement will be crucial in achieving sustainable and comprehensive healthcare coverage for all African citizens.

Which socio-economic groups benefit most from public health expenditure in Senegal? A dynamic benefit incidence analysis

Despite efforts to enhance public investment in Senegal's health sector, the equitable distribution of benefits between socioeconomic groups remains largely unexplored. To address this gap, our study examines the progressive (or regressive) nature of public health expenditure. Utilizing data from the latest survey on household living conditions (2018-2019) in conjunction with administrative data on health expenditure from the same period (provided by the Ministry of Health of Senegal), we performed a benefit incidence analysis. This entailed segmenting the population by poverty quintiles and subsequently estimating how each group utilized and benefitted from public health expenditure, according to level of care and geographical location. Additionally, we performed a marginal benefit analysis to discern the impact of an increase in public health expenditure on various socioeconomic groups. Our findings unveil a pro-rich distribution of benefits at both primary healthcare and hospital levels, observable both at national and regional levels. Moreover, disparities in the distribution of resource allocation between Senegal's 14 administrative regions were observed. Ultimately, our results indicate that under prevailing conditions, increasing public health expenditure would not yield a pro-poor distribution of benefits. Therefore, our research underscores the imperative of better targeting populations for greater equity between regions and social groups.

Disability in childhood and the equity of health services: a cross-sectional comparison of mass drug administration strategies for soil-transmitted helminths in southern Malawi

BACKGROUND

School-based approaches are an efficient mechanism for the delivery of basic health services, but may result in the exclusion of children with disabilities if they are less likely to participate in schooling. Community-based 'door to door' approaches may provide a more equitable strategy to ensure that children with disabilities are reached, but disability is rarely assessed rigorously in the evaluation of health interventions.

OBJECTIVES

To describe the prevalence and factors associated with disability among children aged 5-17 years and to assess the relative effectiveness of routine school-based deworming (SBD) compared with a novel intervention of community-based deworming (CBD) in treating children with disabilities for soil-transmitted helminths.

SETTING

DeWorm3 Malawi Site (DMS), Mangochi district, Malawi.

PARTICIPANTS

All 44 574 children aged 5-17 years residing within the DMS.

PRIMARY AND SECONDARY OUTCOME MEASURES

Disability was defined as a functional limitation in one or more domains of the Washington Group/UNICEF Child Functioning Module administered as part of a community-based census. Treatment of all children during SBD and CBD was independently observed and recorded. For both intervention types, we performed bivariate analyses (z-score) of the absolute proportion of children with and without disabilities treated (absolute differences (ADs) in receipt of treatment), and logistic regression to examine whether disability status was associated with the likelihood of treatment (relative differences in receipt of treatment).

RESULTS

The overall prevalence of disability was 3.3% (n=1467), and the most common domains of disability were hearing, remembering and communication. Boys were consistently more likely to have a disability compared with girls at all age groups, and disability was strongly associated with lower school attendance and worse levels of education. There was no significant difference in the proportion of children with disabilities treated during SBD when assessed by direct observation (-1% AD, p=0.41) or likelihood of treatment (adjusted risk ratio (aRR)=1.07, 95% CI 0.89 to 1.28). Treatment of all children during CBD was substantially higher than SBD, but again showed no significant difference in the proportions treated (-0.5% AD, p=0.59) or likelihood of treatment (aRR=1.04, 95% CI 0.99 to 1.10).

CONCLUSION

SBD does not appear to exclude children with disabilities, but the effect of consistently lower levels of educational participation of children with disabilities should be actively considered in the design and monitoring of school health interventions.

TRIAL REGISTRATION NUMBER

NCT03014167.

Equity in national healthcare economic evaluation guidelines: Essential or extraneous?

BACKGROUND

The focus on health maximisation in a healthcare economic evaluation (HEE) - that is health gains are of equal value regardless of the recipient- has significant implications as health systems attempt to address persistent and growing health inequities. This study aimed to systematically compare and contrast the equity principles of different health technology assessment (HTA) agencies and how equity is addressed in HEE guidelines.

METHODS

HTA agencies were identified through the ISPOR, GEAR, iDSI, HTAi, INAHTA, HTAsiaLink, and RedETSA websites in June 2021 and updated in August 2023. Agencies websites were then searched to retrieve HEE guidelines. The guidelines were grouped into two categories: well-established and newly-developed agency guidelines, based on whether or not they published their first guidelines before 2009. Data extracted summarised the methodological details in the reference cases, including specifics on how equity featured and in what role. In those agencies where equity did not feature explicitly in the HEE guidelines, an additional search of the agency website was undertaken to understand if equity featured in those agencies' decision-making frameworks.

RESULTS

The study included 46 guidelines from 51 countries. Only 30% of the guidelines were explicit about the equity assumptions. Health equity (using a broad definition) was mentioned in 29 guidelines and 14 included a specific definition while only seven recommended specific methods to incorporate inequalities. Addressing equity concerns was usually suggested as an additional analyses rather than a key part of the assessment. It was unclear how equity was incorporated into decision-making processes. In addition, equity was mentioned in other guidance - such as decision-making frameworks - provided by five agencies that did not mention it in the HEE guidelines, and 7 of 14 topic selection criteria that were identified.

CONCLUSION

Equity is given less attention than efficiency in HEE guidelines. This indicates that HTA agencies while subscribing to an extra-welfarist approach have a narrow evaluative space - focusing on maximising health and not considering the opportunity cost of the equity constraint. The omission of equity and the lack of systematic approaches in guidelines poses a threat to the international endeavours to reduce inequities. It is timely for HTA agencies to reconsider their positions on equity explicitly.

Exploring the road to public healthcare accessibility: a qualitative study to understand healthcare utilization among hard-to-reach groups in Kerala, India

BACKGROUND

Kerala, a southern state in India, is known to be atypical due to its high literacy rate and advanced social development indicators. Facing competition from a dominant private healthcare system, recent government health system reforms have focused on providing free, high-quality universal healthcare in the public sector. We carried out an analysis to ascertain the initial impacts of these measures among 'hard to reach groups' as part of a larger health policy and systems research study, with a focus on public sector health service utilisation.

METHODS

We conducted Focus Group Discussions (FGDs) among identified vulnerable groups across four districts of Kerala between March and August of 2022. The FGDs explored community perspectives on the use of public healthcare facilities including enablers and barriers to healthcare access. Transliterated English transcripts were coded using ATLAS.ti software and thematically analyzed using the AAAQ framework, supplemented with inductive code generation.

RESULTS

A total of 34 FGDs were conducted. Availability and cost-effectiveness were major reasons for choosing public healthcare, with the availability of public insurance in inpatient facilities influencing this preference. However, accessibility of public sector facilities posed challenges due to long journeys and queues. Uneven roads and the non-availability of public transport further restricted access. Gaps in acceptability were also observed: participants noted the need for the availability of special treatments available, reduced waiting times for special groups like those from tribal communities or the elderly mindful of their relatively greater travel and need for prompt care. Although quality improvements resulting from health reform measures were acknowledged, participants articulated the need for further enhancements in the availability and accessibility of services so as to make public healthcare systems truly acceptable.

CONCLUSION

The 'Kerala Model of Development' has been applauded internationally for its success in recent years. However, this has not inured the state from the typical barriers to public sector health care use articulated by participants in the study, which match global evidence. In order to deepen the impact of public sector reforms, the state must try to meet service user expectations- especially among those left behind. This requires attention to quality, timeliness, outreach and physical access. Longer term impacts of these reforms - as we move to a post-COVID scenario - should also be evaluated.

Litigation in access to universal health coverage for children and adolescents in Brazil

Background

Brazil's Unified Health System (SUS) ensures universal, equitable, and excellent quality health coverage for all. The broad right to health, supported by the Constitution, has led to excessive litigation in the public sector. This has negatively impacted the financial stability of SUS, created inequality in children and adolescents' access to healthcare, and affected communication between the healthcare system and the judiciary. The enactment of Law Number 13.655 on 25 April 2018, proposed significant changes in judicial decisions. This study aimed to investigate decision-making changes in health litigation involving children and adolescents following the implementation of the new normative model.

Methods

The study is cross-sectional, analyzing 3753 national judgment documents from all State Courts of Brazil, available on their respective websites from 2014 to 2020. It compares regional legal decisions before and after the promulgation of Law Number 13.655/2018. Data tabulation, statistical analysis, textual analysis, coding, and counting of significant units in the collected documents were performed. The results of data cross-referencing are presented in tables and diagrams.

Results

The majority (96.86%) of legal claims (3635 cases) received partial or total provision of what was prescribed by the physician. The Judiciary predominantly handled these cases individually. The analysis indicates that the decisions made did not adhere to the norms established in 2018.

Conclusion

Regional heterogeneity in health litigation was observed, and there was no significant variability in decisions during the studied period, even after the implementation of the new normative paradigm in 2018. Technical-scientific support was undervalued by the magistrates. Prioritizing litigants undermines equity in access to Universal Health Coverage for children and adolescents.

Can a private sector engagement intervention that prioritizes pro-poor strategies improve healthcare access and quality? A randomized field experiment in Kenya

Private sector engagement in health reform has been suggested to help reduce healthcare inequities in sub-Saharan Africa, where populations with the most need seek the least care. We study the effects of African Health Markets for Equity (AHME), a cluster randomized controlled trial carried out in Kenya from 2012 to 2020 at 199 private health clinics. AHME included four clinic-level interventions: social health insurance, social franchising, SafeCare quality-of-care certification programme and business support. This paper evaluates whether AHME increased the capacity of private health clinics to serve poor clients while maintaining or enhancing the quality of care provided. At endline, clinics that received AHME were 14.5 percentage points (pp) more likely to be empanelled with the National Health Insurance Fund (NHIF), served 51% more NHIF clients and served more clients from the middle three quintiles of the wealth distribution compared to control clinics. Comparing individuals living in households near AHME treatment and control clinics (N = 8241), AHME led to a 6.7-pp increase in the probability of holding any health insurance on average. We did not find any additional effect of AHME on insurance holding among poor households. We measured quality of care using a standardized patient (SP) experiment (N = 596 SP-provider interactions) where recruited and trained SPs were randomized to present as either 'not poor', and able to afford all services provided, or 'poor' by telling the provider they could only afford ∼300 Kenyan Shillings (US$3) in fees. We found that poor SPs received lower levels of both correct and unnecessary services, and AHME did not affect this. More work must be done to ensure that clients of all wealth levels receive high-quality care.

Extending universal health coverage to informal workers: A systematic review of health financing schemes in low- and middle-income countries in Southeast Asia

Achieving universal health coverage (UHC) is a priority of most low- and middle-income countries, reflecting governments' commitments to improved population health. However, high levels of informal employment in many countries create challenges to progress toward UHC, with governments struggling to extend access and financial protection to informal workers. One region characterized by a high prevalence of informal employment is Southeast Asia. Focusing on this region, we systematically reviewed and synthesized published evidence of health financing schemes implemented to extend UHC to informal workers. Following PRISMA guidelines, we systematically searched for both peer-reviewed articles and reports in the grey literature. We appraised study quality using the Joanna Briggs Institute checklists for systematic reviews. We synthesized extracted data using thematic analysis based on a common conceptual framework for analyzing health financing schemes, and we categorized the effect of these schemes on progress towards UHC along the dimensions of financial protection, population coverage, and service access. Findings suggest that countries have taken a variety of approaches to extend UHC to informal workers and implemented schemes with different revenue raising, pooling, and purchasing provisions. Population coverage rates differed across health financing schemes; those with explicit political commitments toward UHC that adopted universalist approaches reached the highest coverage of informal workers. Results for financial protection indicators were mixed, though indicated overall downward trends in out-of-pocket expenditures, catastrophic health expenditure, and impoverishment. Publications generally reported increased utilization rates through the introduced health financing schemes. Overall, this review supports the existing evidence base that predominant reliance on general revenues with full subsidies for and mandatory coverage of informal workers are promising directions for reform. Importantly, the paper extends existing research by offering countries committed to progressively realizing UHC around the world a relevant updated resource, mapping evidence-informed approaches toward accelerated progress on the UHC goals.

Mapping health service coverage inequalities in Africa: a scoping review protocol

INTRODUCTION

Addressing inequities in health service coverage is a global priority, especially with the resurgence of interest in universal health coverage. However, in Africa, which has the lowest health service coverage index, there is limited information on the progress of countries in addressing inequalities related to health services. Thus, we seek to map the evidence on inequalities in health service coverage in Africa.

METHODS AND ANALYSIS

We will conduct a scoping review following the Joanna Briggs Institute Manual for Evidence Synthesis. We preregistered this protocol with the Open Science Framework on 26 July 2022 (https://osf.io/zd5bt). We will consider any empirical research that assesses inequalities in relation to services for reproductive, maternal, newborn and child health (eg, family planning), infectious diseases (eg, tuberculosis treatment) and non-communicable diseases (eg, cervical cancer screening) in Africa. We will search MEDLINE, Embase, Web of Science, CINAHL, PsycINFO and Cochrane Library from their inception onwards. We will also hand-search Google and Global Index Medicus, and screen reference lists of relevant studies. We will evaluate studies for eligibility and extract data from included studies using pre-piloted and standardised forms. We will further extract a core set of health service coverage indicators, which are disaggregated by place of residence, race/ethnicity/culture, occupation, gender, religion, education, socioeconomic status and social capital plus equity stratifiers. We will summarise data using a narrative approach involving thematic syntheses and descriptive statistics. We will report our findings according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist.

ETHICS AND DISSEMINATION

Ethical approval is not required as primary data will not be collected. This work will contribute to identifying knowledge gaps in the evidence of inequalities in health service coverage in Africa, and propose strategies that could help overcome current challenges. We will disseminate our findings to knowledge users through a publication in a peer-reviewed journal and organisation of workshops.

HIV testing and counselling among women in Benin: a cross-sectional analysis of prevalence and predictors from demographic and health survey data

OBJECTIVE

To examine the uptake of HIV testing and counselling (HTC) and its associated factors among women in Benin.

DESIGN

We performed a cross-sectional analysis of data from the 2017-2018 Benin Demographic and Health Survey. A weighted sample of 5517 women was included in the study. We used percentages to present the results of the uptake of HTC. Multilevel binary logistic regression analysis was used to examine the predictors of HTC uptake. The results were presented using adjusted odds ratios (aORs), with 95% confidence intervals (CIs).

SETTING

Benin.

PARTICIPANTS

Women aged 15-49.

OUTCOME MEASURE

Uptake of HTC.

RESULTS

The overall uptake of HTC among women in Benin was found to be 46.4% (44.4%-48.4%). The odds of HTC uptake was higher among women covered by health insurance (aOR 3.04, 95% CI 1.44 to 6.43) and those with comprehensive HIV knowledge (aOR 1.77, 95% CI 1.43 to 2.21). The odds of HTC uptake increased with increasing level of education, with the highest odds among those in the secondary or higher level (aOR 2.06, 95% CI 1.64 to 2.61). Also, the age of the women, mass media exposure, region of residence, high community literacy level, and high community socioeconomic status were associated with higher odds of HTC uptake. Women residing in rural areas were less likely to use HTC. Religious affiliation, number of sexual partners, and place of residence were associated with lower odds of HTC uptake.

CONCLUSION

Our study has shown that the uptake of HTC among women in Benin is relatively low. There is a need to enhance efforts to empower women, as well as reduce health inequities as they all have a substantial impact on HTC uptake among women in Benin, taking into consideration the factors identified in this study.

Impact of community-based health insurance on healthcare utilisation and out-of-pocket expenditures for the poor in Senegal

OBJECTIVES

This study aims to assess the impact of the subsidised community health insurance scheme in Senegal particularly on the poor.

DESIGN AND SETTING

The study used data from a household survey conducted in 2019 in three regions, representing 29.3% of the total population. Inverse probability of treatment weighting approach was applied for the analysis.

PARTICIPANTS

1766 households with 15 584 individuals selected through a stratified random sampling with two draws.

MAIN OUTCOME MEASURES

The impact of community-based health insurance (CBHI) was evaluated on poor people's access to care and on their financial protection. For the measurement of access to care, we were interested in the use of health services and non-withdrawal from care in case of illness. To assess financial protection, we looked at out-of-pocket expenditure by type of provider and by type of service, the weight of out-of-pocket expenditure on household income, non-exposure to impoverishing health expenditure and non-exposure to catastrophic health expenditure.

RESULTS

The results indicate that the CBHI increases primary healthcare utilisation for non-poor (OR 1.36 (CI90 1.02-1.8) for the general scheme and 1.37 (CI90 1.06-1.77) for the special scheme for indigent recipients of social cash transfers), protect them against catastrophic (OR 1.63 (CI90 1.12-2.39)) or impoverishing (OR 2.4 (CI90 1.27-4.5)) health expenditures. However, CBHI has no impact on the poor's healthcare utilisation (OR 0.61 (CI90 0.4-0.94)) and do not protect them from the burden related to healthcare expenditures (OR: 0.27 (CI90 0.13-0.54)).

CONCLUSION

Our study found that CBHI has an impact on the non-poor but does not sufficiently protect the poor. This leads us to conclude that a health insurance programme designed for the general population may not be appropriate for the poor. A qualitative study should be conducted to better understand the non-financial barriers to accessing care that may disproportionately affect the poorest.

Universal health coverage and the poor: to what extent are health financing policies making a difference? Evidence from a benefit incidence analysis in Zambia

BACKGROUND

Zambia has invested in several healthcare financing reforms aimed at achieving universal access to health services. Several evaluations have investigated the effects of these reforms on the utilization of health services. However, only one study has assessed the distributional incidence of health spending across different socioeconomic groups, but without differentiating between public and overall health spending and between curative and maternal health services. Our study aims to fill this gap by undertaking a quasi-longitudinal benefit incidence analysis of public and overall health spending between 2006 and 2014.

METHODS

We conducted a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies at three time points. We combined data from household surveys and National Health Accounts.

RESULTS

Results showed that public (concentration index of - 0.003; SE 0.027 in 2006 and - 0.207; SE 0.011 in 2014) and overall (0.050; SE 0.033 in 2006 and - 0.169; SE 0.011 in 2014) health spending on curative services tended to benefit the poorer segments of the population while public (0.241; SE 0.018 in 2007 and 0.120; SE 0.007 in 2014) and overall health spending (0.051; SE 0.022 in 2007 and 0.116; SE 0.007 in 2014) on institutional delivery tended to benefit the least-poor. Higher inequalities were observed at higher care levels for both curative and institutional delivery services.

CONCLUSION

Our findings suggest that the implementation of UHC policies in Zambia led to a reduction in socioeconomic inequality in health spending, particularly at health centres and for curative care. Further action is needed to address existing barriers for the poor to benefit from health spending on curative services and at higher levels of care.

Inequity in the Access to eHealth and Its Decomposition Case of Poland

The aim of this research is to analyze the disparities in the distribution of information and communication technologies and skills across geographically determined population groups and to identify the source of the inequity. Literature showed that the nature of e-Health has the potential to resolve health inequalities. However, its successful implementation depends on such factors as the accessibility of required technologies to all people, the existence of technical infrastructure as well as people having the necessary information and communication skills. Employment of the Theil index allowed us to measure and decompose the national inequality into both: between and within macro-regions differences. Data was collected from Statistics Poland. The results showed the existence of inequity and its drivers. The novelty of this research results from application of the Theil index in the field of eHealth and identification of the barrier in access to e-Health, which can be a basis for improvement in government policy.

Noncommunicable Diseases Prevention Policies and Their Implementation in Africa: A Systematic Review

Objectives: To synthesize the existing evidence on NCD policy equity, policy practices, and policy implementation gaps to prevent NCDs in African countries.

Methods: Following the PRISMA-Extension for equity-focused review guidelines, the authors systematically searched documentary evidence from seven databases (BMC, CINHAL Plus, Cochrane, Google Scholar, PubMed, Web of Science, and Scopus) to identify studies conducted and published on African countries between April 2013 and December 31, 2020.

Results: From identified 213 records, 21 studies were included in the final synthesis. Major results showed inadequate studies on NCD policy, unsatisfactory NCD-related policy development, poor policy implementation, lack of policy equity to combat NCDs, and lack of data recorded on NCDs’ prevalence, morbidity, and mortality.

Conclusion: The rigorous WHO-endorsed NCD policies and prevention strategies on the African continent might debar African policymakers and leaders from developing and implementing indigenous NCD-combating strategies. Continent-wide innovative and indigenous NCD-prevention policies and policy equity to effectively prevent, control, and manage NCDs must be developed by African scientists and policymakers.

Equity in healthcare access and service coverage for older people: a scoping review of the conceptual literature

There is currently no global review of the conceptual literature on the equity of healthcare coverage (including access) for older people. It is important to understand the factors affecting access to health and social care for this group, so that policy and service actions can be taken to reduce potential inequities. A scoping review of published and grey literature was conducted with the aim of summarising how health and social care service access and coverage for older people has been conceptualised. PubMed, MEDLINE, PsycINFO, CINAHL, Web of Science, SciELO, LILACS, BIREME and Global Index Medicus were searched. Selection of sources and data charting were conducted independently by two reviewers. The database searches retrieved 10 517 citations; 32 relevant articles were identified for inclusion from a global evidence base. Data were summarised and a meta-framework and model produced listing concepts specific to equitable health and social care service coverage relating to older people. The meta-framework identified the following relevant factors: acceptability, affordability, appropriateness, availability and resources, awareness, capacity for decision-making, need, personal social and cultural circumstances, physical accessibility. This scoping review is relevant to the development and specification of policy for older people. It conceptualises those factors, such as acceptability and affordability, that affect an older person's ability and capacity to access integrated, person-centred health and social care services in a meaningful way. These factors should be taken into account when seeking to determine whether equity in service use or access is being achieved for older people.

Does the implementation of UHC reforms foster greater equality in health spending? Evidence from a benefit incidence analysis in Burkina Faso

Introduction

Burkina Faso is one among many countries in sub-Saharan Africa having invested in Universal Health Coverage (UHC) policies, with a number of studies have evaluated their impacts and equity impacts. Still, no evidence exists on how the distributional incidence of health spending has changed in relation to their implementation. Our study assesses changes in the distributional incidence of public and overall health spending in Burkina Faso in relation to the implementation of UHC policies.

Methods

We combined National Health Accounts data and household survey data to conduct a series of Benefit Incidence Analyses. We captured the distribution of public and overall health spending at three time points. We conducted separate analyses for maternal and curative services and estimated the distribution of health spending separately for different care levels.

Results

Inequalities in the distribution of both public and overall spending decreased significantly over time, following the implementation of UHC policies. Pooling data on curative services across all care levels, the concentration index (CI) for public spending decreased from 0.119 (SE 0.013) in 2009 to −0.024 (SE 0.014) in 2017, while the CI for overall spending decreased from 0.222 (SE 0.032) in 2009 to 0.105 (SE 0.025) in 2017. Pooling data on institutional deliveries across all care levels, the CI for public spending decreased from 0.199 (SE 0.029) in 2003 to 0.013 (SE 0.002) in 2017, while the CI for overall spending decreased from 0.242 (SE 0.032) in 2003 to 0.062 (SE 0.016) in 2017. Persistent inequalities were greater at higher care levels for both curative and institutional delivery services.

Conclusion

Our findings suggest that the implementation of UHC in Burkina Faso has favoured a more equitable distribution of health spending. Nonetheless, additional action is urgently needed to overcome remaining barriers to access, especially among the very poor, further enhancing equality.

Breaking Barriers to Healthcare Access: A Multilevel Analysis of Individual- and Community-Level Factors Affecting Women's Access to Healthcare Services in Benin

Background: In low-income countries such as Benin, most people have poor access to healthcare services. There is scarcity of evidence about barriers to accessing healthcare services in Benin. Therefore, we examined the magnitude of the problem of access to healthcare services and its associated factors. Methods: We utilized data from the 2017–2018 Benin Demographic and Health Survey (n = 15,928). We examined the associations between the demographic and socioeconomic characteristics of women using multilevel logistic regression. The outcome variable for the study was problem of access to healthcare service. Adjusted odds ratios (AORs) with 95% confidence intervals (95% CI) were estimated. Results: Overall, 60.4% of surveyed women had problems in accessing healthcare services. Partner’s education (AOR = 0.70; 95% CI; 0.55–0.89), economic status (AOR = 0.59; 95% CI; 0.47–0.73), marital status (AOR = 0.44; 95% CI; 0.39–0.51), and parity (AOR = 1.85; 95% CI; 1.45–2.35) were significant individual-level factors associated with problem of access to healthcare. Region (AOR = 5.24; 95% CI; 3.18–8.64) and community literacy level (AOR = 0.69; 95% CI; 0.51–0.94) were the main community-level risk factors. Conclusions: Enhancing husband education through adult education programs, economic empowerment of women, enhancing national education coverage, and providing priority for unmarried and multipara women need to be considered. Additionally, there is the need to ensure equity-based access to healthcare services across regions.

Exploring equity and inclusion in Malawi's National Disability Mainstreaming Strategy and Implementation Plan

Background

Equity and inclusion are important principles in policy development and implementation. The aim of this study is to explore the extent to which equity and inclusion were considered in the development of Malawi’s National Disability Mainstreaming Strategy and Implementation Plan.

Methods

We applied an analytical methodology to review the Malawi’s National Disability Mainstreaming Strategy and Implementation Plan using the EquIPP (Equity and Inclusion in Policy Processes) tool. The EquIPP tool assesses 17 Key Actions to explore the extent of equity and inclusion.

Results

The development of the Malawi National Disability Mainstreaming Strategy and Implementation Plan was informed by a desire to promote the rights, opportunities and wellbeing of persons with disability in Malawi. The majority (58%) of the Key Actions received a rating of three, indicating evidence of clear, but incomplete or only partial engagement of persons with disabilities in the policy process. Three (18%) of the Key Actions received a rating of four indicating that all reasonable steps to engage in the policy development process were observed. Four (23%) of the Key Actions received a score five indicating a reference to Key Action in the core documents in the policy development process.

Conclusions

The development of disability policies and associated implementation strategies requires equitable and inclusive processes that consider input from all stakeholders especially those whose wellbeing depend on such policies. It is pivotal for government and organisations in the process of policy or strategy development and implementation, to involve stakeholders in a virtuous process of co-production – co-implementation – co-evaluation, which may strengthen both the sense of inclusion and the effectiveness of the policy life-cycle.

The emergence of the national medical assistance scheme for the poorest in Mali

Universal health coverage is high up the international agenda. The majority of the West Africa's countries are seeking to define the content of their compulsory, contribution-based medical insurance system. However, very few countries apart from Mali have decided to develop a national policy for poorest population that is not based on contributions. This qualitative research examines the historical process that has permitted the emergence of this public policy. The research shows that the process has been very long, chaotic and suspended for long periods. One of the biggest challenges has been that of intersectoriality and the social construction of the poorest to be targeted by this public policy, as institutional tensions have evolved in accordance with the political issues linked to social protection. Eventually, the medical assistance scheme for the poorest saw the light of day in 2011, funded entirely by the government. Its emergence would appear to be attributable not so much to any new concern for the poorest in society but rather to a desire to give the social protection policy engaged in a guarantee of universality. This policy nonetheless remains an innovation within French-speaking West Africa.

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

Senegal is firmly committed to the objective of universal health coverage (UHC). Various initiatives have been launched over the past decade to protect the Senegalese population against health hazards, but these initiatives are so far fragmented. UHC cannot be achieved without health system strengthening (HSS). Here we assess the core capacities of the Senegalese health systems to deliver UHC, and identify requirements for HSS in order to implement and facilitate progress towards UHC. Based on a critical review of existing data and documents, complemented by the authors' experience in supporting UHC policy making and implementation, we evaluate the main foundational and institutional bottlenecks relative to the six health system building blocks, together with an analysis of the demand-side of the health system, which facilitate or hamper progress towards UHC. Despite the fact that many institutions are now in place to deliver UHC, important weaknesses limit progress along the two dimensions of UHC. Substantial disparities characterise resource allocation in the health sector, and health risk protection schemes are highly fragmented. This spreads down to the rest of the health system including service delivery and consequently, impacts on health outcomes. These constraints are acknowledged by the authorities, solutions have been proposed, but these necessitate strong political will. Moreover, progress towards UHC is constrained by the difficulty to act on social determinants of health and a lack of fiscal space.