Characterizing ‘health equity’ as a national health sector priority for maternal, newborn, and child health in Ethiopia

ABSTRACT

Background: The pursuit of health equity is a priority in Ethiopia, especially with regards to maternal, newborn, and child health (MNCH). To date, there has been little characterization of the ‘problem’ of health inequity, and the normative assumptions implicit in the representation of the problem. Yet, such insights have implications for shaping the framing, incentivization, and implementation of health policies and their wider impact.

Objective: In this article, we characterize how health (in)equity is represented as a policy issue, how this representation came about, and the underlying assumptions.

Methods: We draw from Bacchi’s ‘what is the problem represented to be’ approach to explore how national-level actors in the health sector constitute the problem. The data for our analysis encompass 23 key informant interviews with national health sector actors working in leadership positions on MNCH in Ethiopia, and six policy documents. Findings were derived from thematic and content analysis.

Results: Health inequity is a normalized and inevitable concern that is regarded as actionable (can be altered) but not fully resolvable (can never be fully achieved). Operationally, health equity is viewed as a technocratic matter, reflected in the widespread use of metrics to motivate and measure progress. These representations are shaped by Ethiopia’s rapid expansion of health services into rural areas during the 2000s leading to the positive international attention and funding the country received for improved MNCH indicators. Expanding the coverage and efficiency of health service provision, especially in rural areas, is associated with economic productivity.

Conclusion: The metrication of health equity may detract from the fairness, justice, and morality underpinnings of the concept. The findings of this study point to the implications of global pressures in terms of maximizing health investments, and call into question how social, political, and economic determinants of health are addressed through broader development agendas.

KEYWORDS:

• Ethiopia
• health equity
• health inequity
• maternal
• newborn and child health
• policy analysis

Responsible Editor

Stig Wall, Ume University, Sweden

Responsible Editor

Stig Wall, Ume University, Sweden

Acknowledgments

We gratefully acknowledge Jimma Zonal Health Department (especially Gebeyehu Bulcha Duguma and Kunuz Haji Bedru), and Safe Motherhood Project researchers and coordinators (especially Muluemebet Abera, Yisalemush Asefa, Gemechu Beyene, Endale Erko, Jaameeta Kurji and Corinne Packer). A special thanks to Gail Webber, Sanni Yaya and David Zakus for constructive feedback about the content of the paper.

Author contributions

NB, RL, and MAK conceptualized the study in consultation with LA, SA, GK, AM, and SM. NB conducted the interviews, led the analysis, and prepared the first draft of the manuscript, with inputs and guidance from RL, AR, and MAK. LA, SA, GK, AM, and SM read the manuscript draft and provided critical comments. All authors declare their consent for the manuscript to be considered for publication.

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics and consent

We obtained ethical clearance for this research from the University of Ottawa Health Sciences and Science Research Ethics Board and an Ethiopian University Institutional Review Board in the region where the research was conducted. All participants provided written informed consent to participate in the study.

Paper context

While equity in maternal, newborn, and child health is widely accepted as a key health policy priority in Ethiopia, deeper contextualization of how the issue is understood and characterized is lacking. This paper uses Bacchi’s ‘what’s the problem represented to be’ approach as a heuristic tool to explore the normative assumptions embedded in the characterization of health equity in the Ethiopian health sector. The findings yield insight into national and global influences that shape how health equity is addressed.

Supplementary material

Supplemental data for this article can be accessed here.

Notes

¹ Understandings of social determinants of health – the factors that shape the conditions in which people grow, live, work, and age – help to clarify contextual representations of health equity, as actions on the social determinants of health are recommended to tackle situations of health inequity (29).

² Intersectoral collaborations between actors in health and non-health sectors contribute to the improvement of health equity (29), and questioning about these collaborations revealed how health equity was represented in these interactions.

³ Participants tended to speak about the concept of health equity holistically, without specifying between equity in health services versus equity in health outcomes, though cases where this distinction was made are indicated.

⁴ In the area of MNCH, the country has implemented a set of high-impact services to address maternal mortality, namely, family planning, skilled birth attendance, antenatal care, and postnatal care. Efforts to monitor and promote equity in MNCH center on expanding the coverage of these services.

Additional information

Funding

This work was carried out with grants #108028-001 (Jimma University) and #108028-002 (University of Ottawa) from the Innovating for Maternal and Child Health in Africa initiative (co-funded by Global Affairs Canada (GAC), the Canadian Institutes of Health Research (CIHR) and Canada’s International Development Research Centre (IDRC)); it does not necessarily reflect the opinions of these organizations.