Number |
Key Language |
Key Question |
Core Concept |
Supporting Literature |
1 |
Vulnerable groups are not discriminated against on the basis of their distinguishing characteristics (for example, disability, age, ethnicity, proximity to services). |
Does the policy support the rights of vulnerable groups with equal opportunity in receiving health care? |
Non-Discrimination |
8 13 39 49 51 52 |
2 |
Vulnerable groups receive appropriate, effective, and understandable services. |
Does the policy support the rights of vulnerable groups with individually tailored services to meet their needs and choices? |
Individualized Services |
9 46 49 |
3 |
People with limited resources are entitled to some services free of charge or persons with disabilities may be entitled to respite grant. |
Does the policy indicate how vulnerable groups may qualify for specific benefits relevant to them? |
Entitlement |
8 11 49 53 54 |
4 |
For instance, peer-to-peer support among female-headed households or shared cultural values among ethnic minorities. |
Does the policy recognize the capabilities existing within vulnerable groups? |
Capability-Based Services |
48 55 56 |
5 |
Vulnerable groups can exercise choices and influence decisions affecting their life. Such consultation may include planning, development, implementation, and evaluation. |
Does the policy support the right of vulnerable groups to participate in the decisions that affect their lives and enhance their empowerment? |
Participation |
8 23 49 57 58 59 |
6 |
Vulnerable groups know how services should interact where inter-agency, intra-agency, and intersectoral collaboration is required. |
Does the policy support assistance of vulnerable groups in accessing services from within a single provider system (intra-agency) or more than one provider system (inter-agency) or more than one sector (intersectoral)? |
Coordination of Services |
7 11 49 57 60 61 |
7 |
Vulnerable groups are protected from harm during their interaction with health and related systems. |
Are vulnerable groups protected from harm during their interaction with health and related systems? |
Protection from Harm |
8 |
8 |
Vulnerable groups are protected from unwarranted physical or other confinement while in the custody of the service system/provider |
Does the policy support the right of vulnerable groups to be free from unwarranted physical or other confinement? |
Liberty |
48 49 62 |
9 |
Vulnerable groups can express “independence” or “self-determination.” For instance, a person with an intellectual disability will have recourse to an independent third party regarding issues of consent and choice. |
Does the policy support the right of vulnerable groups to consent, refuse to consent, withdraw consent, or otherwise control or exercise choice or control over what happens to him or her? |
Autonomy |
4 8 49 59 |
10 |
Information regarding vulnerable groups need not be shared among others. |
Does the policy address the need for information regarding vulnerable groups to be kept private and confidential? |
Privacy |
8 13 52 |
11 |
Vulnerable groups are not barred from participation in services that are provided for general population. |
Does the policy promote the use of mainstream services by vulnerable groups? |
Integration |
49 57 |
12 |
Vulnerable groups make a meaningful contribution to society. |
Does the policy recognize that vulnerable groups can be productive contributors to society? |
Contribution |
12 |
13 |
The policy recognizes the value of family members of vulnerable groups as a resource for addressing health needs. |
Does the policy recognize the value of the family members of vulnerable groups in addressing health needs? |
Family Resource |
13 |
14 |
Persons with chronic illness may have mental health effects on other family members, such that these family members themselves require support. |
Does the policy recognize that individual members of vulnerable groups may have an impact on the family members, requiring additional support from health services? |
Family Support |
49 57 62 |
15 |
i) Vulnerable groups are consulted on the acceptability of the service provided. ii) Health facilities, goods, and services must be respectful of ethical principles and culturally appropriate, that is, respectful of the culture of vulnerable groups. |
Does the policy ensure that services respond to the beliefs, values, gender, interpersonal styles, attitudes, cultural, ethnic, or linguistic aspects of the person? |
Cultural Responsiveness |
11 13 54 57 |
16 |
Vulnerable groups have access to internal and independent professional evaluation or procedural safeguard. |
Does the policy specify to whom, and for what, services providers are accountable? |
Accountability |
8 24 49 52 61 |
17 |
Does the policy support vulnerable groups in seeking primary, secondary, and tertiary prevention of health conditions? |
Prevention |
8 11 13 57 64 |
|
18 |
Does the policy support the capacity building of health workers and of the system that they work in addressing health needs of vulnerable groups? |
Capacity Building |
7 8 49 57 59 |
|
19 |
Vulnerable groups have accessible health facilities (that is, transportation; physical structure of the facilities; affordability and understandable information in appropriate format). |
Does the policy support vulnerable groups –physical, economic, and information access to health services? |
Access |
8 13 58 60 65 |
20 |
Vulnerable groups are assured of the quality of the clinically appropriate services. |
Quality |
8 11 13 54 57 |
|
21 |
Does the policy support efficiency by providing a structured way of matching health system resources with service demands in addressing health needs of vulnerable groups? |
Efficiency |
60 66 67 |
Vulnerable groups
While the term “vulnerability” is one of the most frequently used terms in social science research, difficulties arise when it comes to applying this concept as a tool for measurement and analysis. Vulnerable groups may be defined as social groups who experience limited resources and consequent high relative risk for morbidity and premature mortality.12
This definition squares with the idea that vulnerability should be related to claims for special protection (for instance, in health policies), where there is a) a greater likelihood of people experiencing “wrongs,” and b) a duty to avoid identifiable “wrongs.”68 The inclusion of vulnerable groups is an ethical imperative for health policy, and requires the development of appropriate indicators.69 Furthermore, the social determinants approach to public health sees the identification of vulnerable population groups and the causes of differential vulnerability as being of critical importance, allowing us to sensitize vulnerable populations to the health benefits of programs, extend service coverage, and reduce barriers to access—all key components of inclusive health.70,71 However, quantifying vulnerability is challenging, as is identifying just who is to be considered “vulnerable.” This concept needed to be clarified in order to reinforce its heuristic capacity and political and practical relevance. To draw up a comprehensive list of appropriate social groups, we conducted a literature review spanning the international and national literatures. The resulting list was then refined and integrated to produce a categorization that would be credible across the four project countries, as well as regional and international health policies. However, it was evident that there was also a need for flexibility for the purpose of accommodating any additional country-specific groups, where integration of them into another theme might miss the opportunity to provide valuable information. The vulnerable groups outlined by EquiFrame are provided in Table 2, and resonate with the “Social Determinants Approaches to Public Health” report.70
Table 2. EquiFrame vulnerable groups definitions
Number |
Vulnerable Group |
Attributes or Definitions |
1 |
Limited Resources |
Poor people or people living in poverty |
2 |
Increased Relative Risk for Morbidity |
People with one of the top ten illnesses identified by WHO as occurring within the relevant country |
3 |
Mother-Child Mortality |
Factors affecting maternal and child health (0-5 years) |
4 |
Female-Headed Household |
Households headed by a woman |
5 |
Children with Special Needs |
Children marginalized by special contexts, such as orphans or street children |
6 |
Aged |
Referring to older age |
7 |
Youth |
Referring to younger age without identifying gender |
8 |
Ethnic Minorities |
Non-majority groups in terms of culture, race, or ethnic identity |
9 |
Displaced Populations |
People who, because of civil unrest or unsustainable livelihoods, have been displaced from their previous residence |
10 |
Living Away from Services |
People living far from health services, either in travel time or distance |
11 |
Suffering from Chronic Illness |
People who have an illness requiring continuous care |
12 |
Disabled |
Persons with disabilities, including physical, sensory, intellectual, or mental health conditions, and including synonyms of disability |
Scoring
A data extraction matrix (checklist) was developed to measure the quality of the analyzed policy documents. The EquiFrame Matrix was constructed with the vertical axis listing the 21 core concepts and the horizontal axis listing the 12 or more vulnerable groups.
Each core concept (CC) received a score from 1 to 4. This was a rating of the quality of commitment to the core concept within the policy document:
1 = Concept only mentioned
2 = Concept mentioned and explained
3 = Specific policy actions identified to address the concept
4 = Intention to monitor concept was expressed
If a core concept was not relevant to the document context, it was stated as not applicable.
In each document, the presence of core concepts was assessed for each vulnerable group that was identified in the policy. If no vulnerable group was mentioned but a core concept addressed the total population (for example, “all people”), the core concept was scored as “universal.” The total number and scores for mentioned core concepts and vulnerable groups was calculated for each document across the four countries. A consensus was reached through discussion with other team members in instances where the two researchers formulated incongruent appraisals regarding references to core concepts.
Summary indices
The four summary indices of EquiFrame are as follows:
Core concept coverage: A policy was examined with respect to the number of core concepts mentioned out of the 21 core concepts identified; and this ratio was expressed as a rounded up percentage. In addition, the actual terminologies used to explain the core concepts within each document were extracted to allow for future qualitative analysis and cross-checking between raters (see Mannan et al).50
Vulnerable group coverage: A policy was examined with respect to the number of vulnerable groups mentioned out of the 12 vulnerable groups identified, and this ratio was expressed as a rounded-up percentage. In addition, the actual terminologies used to describe the vulnerable groups were extracted to allow for qualitative analysis and cross-checking between raters.
Core concept quality: A policy was examined with respect to the number of core concepts within it that were rated 3 or 4 out of the 21 core concepts identified; that is, as either stating a specific policy action or intention to monitor that action. When several references to a core concept were found to be present, the top quality score received was recorded as the final quality scoring for the respective concept.
Each document was given an overall summary ranking in terms of it being of low, moderate, or high standing according to the following criteria:
(i) High = if the policy achieved ≥50% on all of the three scores above.
(ii) Moderate = if the policy achieved ≥50% on two of the three scores above.
(iii) Low = if the policy achieved <50% on two or three of the three scores above.
Analysis of the national health policy of Sudan and drug policy of Sudan
Based on these indices, more than 70 health policies from the four African country partners were assessed with regards to core concept coverage, vulnerable group coverage, and core concept quality and were given an overall summary ranking in relation to core concepts and vulnerable groups. In this paper, we present the analyses of only two policies to illustrate the application of EquiFrame to disparate types of policies. These two policies are the National Health Policy of Sudan and the Drug Policy of Sudan, and they have been chosen because the Sudanese team, based at Ahfad University for Women, led the policy analysis work package that produced the EquiFrame policy analysis framework. For the analysis of all policies, two members of the research team independently applied EquiFrame to analyze each of the policies. Where difference of interpretation occurred these were addressed by subsequent discussion, until a consensus position was agreed between the raters.
The National Health Policy of Sudan (2007) has been formulated within the context of a comprehensive peace agreement which puts an end to the many years of conflict that disrupted the country’s social service institutions, including its health institutions and services. The policy is framed within the remits of the relevant provisions of the interim Constitution of Sudan, from 2005, the Local Government Act from 2003, and the resolute state laws and decrees which have introduced and institutionalized decentralized federalism in the country. Furthermore, the policy draws from and builds on the 25-year health strategy and existing policies relating to reproductive health, child health, HIV/AIDS, the national drugs policy, the essential primary health care package, and the 10-year human resources strategy. It also reiterates national and international commitments, such as the Alma-Ata Declaration and the Health for All strategy, the Millennium Summit Declaration, and other global strategies such as Roll Back Malaria (RBM), Stop TB, and the Global Strategy for the Prevention and Control of Sexually Transmitted Infections, including HIV/AIDS. The General Directorate of Health Planning and Development (FMOH) took the lead in drafting this document, supported by a drafting committee comprised of national consultants, representatives of UN agencies (WHO and UNICEF), representatives of the General Directorates in the Federal Ministry of Health, and many other individuals who assisted in the work to accomplish this task. A consensus-building workshop was held on May 12 and 13, 2007, in Khartoum to enrich this document. The process began in 2001 and has passed through many phases, essentially iterative, of assessing the situation, reviewing a host of background documents, and at times, collecting empirical data.
The National Health Policy of Sudan addressed 14 of the 21 core concepts outlined by EquiFrame (67%) (see Graph 1). The most frequently occurring concepts included prevention, non-discrimination, coordination of services, capacity-building, and access. A number of concepts were not mentioned in the policy: autonomy, liberty, family resource, family support, integration, entitlement, and capability-based services. Eleven concepts were rated as having a level 3 or 4 quality of commitment, that is, specific policy actions were identified that addressed the concept, or an intent to monitor the concept was expressed. These concepts are protection from harm, prevention, privacy, participation, non-discrimination, cultural responsiveness, coordination of services, capacity-building, individualized services, quality, and efficiency.
Graph 1. EquiFrame core concept coverage
All vulnerable groups were mentioned in this document with the exception of two: female-headed households and aged (see Graph 2). The most frequently mentioned vulnerable groups comprised limited resources, increased relative risk for morbidity, ethnic minorities, and disabled. However, most of the concepts were mentioned in a universal way, defined in terminologies such as the whole population, citizens, or people of Sudan, vulnerable and professional, and health institutions. Four vulnerable groups: mother child mortality, children (with special needs), youth, and living away from services, were mentioned only once. The policy scored 83% with respect to vulnerable group coverage; 67% on core concept coverage and 52% on core concept quality. The overall summary ranking of the policy was rated to be high (Table 3).
Graph 2. EquiFrame vulnerable group coverage
The National Drug Policy document is based on the 1981 action program on essential drugs (DAP) and the policy aims to provide drugs in a safe, effective, and quality manner; enhance judicious usage of drugs; and provide advanced pharmacological service. The document addressed eight of the 21 core concepts, namely, protection from harm, prevention, cultural responsiveness, coordination of services, capacity-building, quality, access, and efficiency (Graph 1). All concepts that were mentioned were rated at a level 3 or 4 quality of commitment to the concept, that is, specific policy actions were identified that addressed the concept or an intention to monitor the concept was expressed. In terms of quality of commitment to core concepts, the concepts protection from harm and efficiency received the highest score of 4, that is, an intention to monitor these concepts was expressed. The remaining concepts were mentioned with reference to specific policy actions that addressed the concepts, and were therefore given a quality rating score of 3.
Only two vulnerable groups, namely individuals with limited resources and mother-child mortality, were explicitly mentioned in the document (Graph 2). The Drugs Policy for Sudan scored 17% on vulnerable group coverage; 38% on core concepts coverage; and 100% on core concept quality. The overall summary ranking of the policy was rated to be low (Table 3).
Table 3. EquiFrame Summary Indices: National Health Policy of (Northern) Sudan and National Drugs Policy of (Northern) Sudan
Policies |
VG% |
CC% |
% of CC Quality Between 3 to 4 |
Quality of Policy |
National Health Policy |
83 |
67 |
52 |
High |
Drugs Policy |
17 |
38 |
100 |
Low |
Discussion
The above results are intended to illustrate how EquiFrame can be used to illuminate aspects of human rights and social inclusion in two policies that have quite different foci. While these policies address very broad and quite specific remits, respectively, the application of the EquiFrame methodology has revealed important results relevant to social inclusion and human rights. For instance, the National Health Policy included 83% of vulnerable groups and 67% of core concepts, 52% of which were mentioned at a quality rating of 3 or 4. In contrast, the Drugs Policy of Sudan included only 17% of vulnerable groups, and 38% of core concepts, although all of these concepts received a quality rating of 3 or 4. Accordingly, the National Health Policy and National Drug Policy received an overall quality rating of high and low, respectively. These findings are illustrative of the manner in which EquiFrame can be applied to reveal the disparate quality of health policies, both across and within countries, in terms of commitment to core concepts of human rights and inclusion of vulnerable groups.
Ultimately, EquiFrame allows one to evaluate – to measure – the extent of inclusion and prominence of rights accorded to persons with disabilities and other vulnerable groups in policy and planning documents. This is important as, according to the old adage, “What gets measured gets done.” The framework was developed with regard to health policy documents with the motivation to contribute to enhancing equity in service delivery and access to health care. It is hoped that health policies instituted on the values and importance of equity are more likely to result in health services that are more fairly distributed within the population. This paper has sought to give an introductory overview of the framework and provide some comparative analysis.
Both through the process of undertaking this research and feeding the results back to stakeholder workshops in each of the four countries, we have noted several factors that are important to consider when interpreting the results of EquiFrame, either within or across countries. While the inclusion criteria sought the relevant policy documents in each country, not all of the documents analyzed were official “policies”; some were described as “guidelines,” “strategic plans,” or “programs.” Clearly, these instruments may not have been designed with an equivalent purpose and so in some cases it may be misleading to deem them as being policy-related or to compare them, even in the absence of a policy document in that area. To the extent that such documents are not policy-related, one could simply highlight the lack of a policy.
The indices we have used—scores of over 50% for each of our ratings—are essentially arbitrary, but at least intuitively appealing as we are determining if half or more of a particular attribute is present in a document. However, such indices could be changed to reflect different weighting or sensitivity with regard to human rights, vulnerability, or specific actions to address a concept or intention to monitor a concept being expressed. Indeed, these latter two categories could be treated separately, rather than combined as we did here. Ultimately, EquiFrame is a methodology for descriptive analysis that can provide quantitative indices that can be fine-tuned for the required purpose.
Even when there may be strong comparability between the structure and function of policy instruments, it may be less reasonable to expect some documents to address human rights and vulnerable groups than others. For instance, is it reasonable for the Sudanese Voluntary Sector Policy (0%) and the Mental Health Policy (92%) to each mention vulnerable groups? It could be argued that one is about how a sector operates while the other is about provision of specific services. Even if one accepts this argument, we feel that it can still be illuminating to know the extent to which they focus on social inclusion. In the case of Sudan, more comparable sector policies (National Health Policy, 83%) and service provision policies (Malaria Policy, 58%) also differ considerably with regard to social inclusion.
In our country feedback workshops, some stakeholders argued that some documents use the term “all,” as in “all people” to be fully inclusive, making it unnecessary to reference specific vulnerable groups. Indeed, subsidiary analysis of the use of “all,” or its synonyms, indicates that documents using such catch-all terms also specify certain vulnerable groups but not others. Accordingly, we feel it is important to establish which vulnerable groups are included, and which are not, since the use of inclusive terminology does not necessarily address the concerns of specific vulnerable groups.
While EquiFrame has been developed for the purposes of policy analysis, we do believe that its form of analysis can also be usefully applied to other types of planning and guiding documents, and that the coverage of core concepts of human rights and the inclusion of vulnerable groups is pertinent to these documents too. Fuller understanding of the content of any such documents can always be and should always be strengthened by understanding of the context in which the document was developed, as well as the process of its development. However, describing “policy on the books” is not only a legitimate practice but a vital one if we are to recognize and develop documents that are most likely to support human rights and promote greater inclusion in health service provision.
Health policy analysis may be beneficial both retrospectively and prospectively, in the understanding of past policy failures and successes and the development of future policy implementation.32 Accordingly, it is hoped that the utility of EquiFrame, as a policy analysis tool, will extend beyond its application as a framework for evaluation to the development of new policy documents and to the revision of existing documents. By highlighting some high quality documents, EquiFrame can point those developing countries towards some supreme examples of human rights coverage and vulnerable group inclusion. It can also provide a checklist of factors for consideration, as well as indicating specific terms and phrasing for use in a policy.
In order to realize the hope that better polices will be associated with better health care, empowerment and social inclusion of vulnerable and marginalized groups must occur in the process of policy development and efforts to implement such polices, as well as in policy documents. The practice of privilege, power, and dominance, in local and national policy contexts, and also in the context of programs supported through international aid, will continue to undermine aspirations for equity.28,72 Without inclusive and effective means of policy development and implementation, “policy on the books” will be inert. Perfectly equitable health policies will only contribute to social inclusion if cognate policies in other sectors embrace similar principles, and if they are translated in measurable actions. While this has not been the target of this paper, it is necessary for the potential benefits of better written policy to become a reality.
The universality of human rights is contested and it may be argued that interpretations are subject to cultural values and contextual realities.51 As such, any analysis of human rights or social inclusion in health policies is in itself necessarily going to reflect certain cultural and contextual factors. The reflexivity of the analyst – that is, their awareness of their positioning and how this affects their understanding of a policy -is therefore of critical importance. Interpretations do not arise in isolation from who the analysis is done by, for whom and in what context. Although these complex issues are very important, it is equally important to recognize that in many instances the pragmatic reality of lived exclusion is hurtful, often resulting in needless mortality, and frequently all too easy to recognize by the failure to address it in health policies. The number of persons with disabilities is increasing globally, but this is not reflected by the coverage of this group in relevant policies.16,17,18 By and large, the extensive gap in access to health between disparate groups in low, middle, and high-income countries is well established.11 In the context of low-income countries, where resources are scarce, marginalized or vulnerable people may experience greater social exclusion with the result that their right to health is undermined to an even greater extent than in wealthier countries. The health achievements that have been realized in Europe have by now been initiated in south Asia and other regions however, and could ensue in sub-Saharan Africa, so that no country is forced to withstand levels of ill-health that are preventable.73 Equity in health is an astute and feasible political aspiration and our concerns with human rights and vulnerability complement progressive views pertaining to the need for health policies to be placed within a broader ethics framework.74 If human rights and social inclusion do not underpin policy formation, however, it is unlikely that equity will be inculcated in service delivery. Through its discernment of policy commitment to core concepts of human rights and vulnerable groups, underpinned by the principle of health care that is universal and equitable, EquiFrame stands to promote the United Nations’ directive of health for all, with its implicit assumption of universal and equitable access to health care.
Acknowledgements
This research was funded by the European Commission Framework Programme 7, Project Title: Enabling Universal and Equitable Access to Healthcare for Vulnerable People in Resource Poor Settings in Africa, Grant Agreement No.: 223501.
Mutamad Amin, PhD, is Professor and Director of Research at Ahfad University for Women, Omdurman, Sudan.
Malcolm MacLachlan, PhD, is Professor at the Centre for Global Health & School of Psychology, Trinity College Dublin, Ireland and Extraordinary Professor at the Centre for Rehabilitation Studies, Stellenbosch University, South Africa.
Hasheem Mannan, PhD, is Senior Research Fellow at the Centre for Global Health.
Shahla El Tayeb, PhD, is Assistant Professor at School of Psychology at Ahfad University for Women, Omdurman, Sudan.
Amani El Khatim, MD, is Assistant Professor at School of Physiotherapy at Ahfad University for Women.
Leslie Swartz, PhD, is Professor in the Department of Psychology, University of Stellenbosch, South Africa.
Alister Munthali, PhD, is Associate Professor at the Centre for Social Research, University of Malawi.
Gert Van Rooy, MA, is Research Fellow at the Multidisciplinary Research Centre, University of Namibia.
Joanne McVeigh, HDip Psych, is Research Assistant at the Centre for Global Health & School of Psychology.
Arne H. Eide, PhD, is Chief Scientist at SINTEF Health Research, Norway.
Marguerite Schneider, MA, is Research Officer in the Department of Psychology, University of Stellenbosch, South Africa.
Please address correspondence to Malcolm MacLachlan, Centre for Global Health and School of Psychology, Trinity College Dublin, Ireland, email: malcolm.maclachlan@tcd.ie.
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