Abstract
Delivering health services to vulnerable populations is a significant challenge in many countries. Groups vulnerable to social, economic, and environmental challenges may not be considered or may be impacted adversely by the health policies that guide such services.We report on the application of EquiFrame, a novel policy analysis framework, to ten Namibian health policies, representing the top ten health conditions in Namibia identified by the World Health Organization. Health policies were assessed with respect to their commitment to 21 Core Concepts of human rights and their inclusion of 12 Vulnerable Groups. Substantial variation was identified in the extent to which Core Concepts of human rights and Vulnerable Groups are explicitly mentioned and addressed in these health policies. Four health policies received an Overall Summary Ranking of High quality; three policies were scored as having Moderate quality; while three were assessed to be of Low quality. Health service provision that is equitable, universal, and accessible is instigated by policy content of the same. EquiFrame may provide a novel and valuable tool for health policy appraisal, revision, and development.
Introduction
The delivery of healthcare to vulnerable populations is a significant challenge in many countries. Groups vulnerable to social, economic, and environmental challenges may not be considered or may be adversely impacted by the policies that guide health services. The elderly, migrants,refugees, and people with disabilities and chronic illnesses are some groups that experience social vulnerability due to the shared resource and capacity shortages generated by their common ethnic, racial, cultural and geographical position (Allotey et al. 2012). ‘Regarding access to and equity in health, these populations are still underprivileged due to their status and identity’ (Mannan n.d.).There is an urgent need to evaluate what health policies actually state and to what they commit with regard to social inclusion and human rights (Mannan, Amin, et al. 2012).
The Republic of Namibia is amongst Africa’s largest, though least populous nations (U.S. Global Health Initiative n.d.). With an estimated population of 2.2 million and a landmass equaling that of France (824,292 square kilometers), Namibia’s population is sparsely and unevenly distributed in urban centers and rural communities across vast distances, with a population density of 2.6 people per square kilometer (U.S. Global Health Initiative n.d.). On March 21, 1990, Namibia realized its independence subsequent to a century of colonial rule, first by Germany and then by South Africa, following the successful implementation of United Nations Resolution 435 (Ministry of Health and Social Services [Namibia] and Macro International Inc. 2008). Namibia’s governance under the South African apartheid regime has resulted in substantial social and economic disparities and consequential socioeconomic challenges, including high poverty, illiteracy, poor access to sanitation, and so forth, which are still evident today (World Health Organization 2009). Although Namibia’s per capita income of US$4,700 (2011, Atlas method) positions it in the World Bank’s upper-middle income classification, Namibia’s income distribution is amongst the most unequal in the world, with a Gini coefficient estimate of 0.5971 by the 2009/2010 household survey (World Bank 2012). Since independence, health has remained a priority for the Government of Namibia, substantiated by the number of health sector reforms and developments that have been realized under the Primary Health Care strategy, including a substantial increase in coverage of and access to health and social welfare services (Republic of Namibia Ministry of Health and Social Services and World Health Organization 2010). Total expenditure on health per capita (Intl $, 2010) is$436; and total expenditure on health as percentage of GDP (2010) is 6.8%(World Health Organization 2012).
Notwithstanding the number of existing health and social welfare points, access to healthcare is difficult for an extensive number of Namibians due to remoteness and long distances, challenging equitable and accessible healthcare(Republic of Namibia Ministry of Health and Social Services and World Health Organization 2010).Considerable differences in access are evident between urban and rural households: urban households are, on average,25 minutes away from the nearest government health facility, while this distance is 114 minutes for rural residents(Republic of Namibia Ministry of Health and Social Services and World Health Organization 2010). Further substantial challenges confronting the public health sector include the high burden of communicable diseasessuch as Human Immunodeficiency Virus (HIV), a high maternal mortality ratio, and child malnutrition (Republic of Namibia Ministry of Health and Social Services and World Health Organization 2010). Namibia’s Vision 2030 presents the long-term development framework for the country: to be a prosperous and industrialized nation, developed by human resources, and enjoying peace, harmony, and political stability(Namibia High Commission London n.d.; Government of the Republic of Namibia 2004).
This paper reports on the application of EquiFrame, a novel analytical and peer-reviewed framework that serves to identify the strengths and weaknesses in current health policy according to the degree to which a policy promotes and protects Core Concepts of human rights in healthcare, particularly among Vulnerable Groups. EquiFrame evaluates the degree of explicit commitment of an existing health policy to 21 Core Concepts of human rights and inclusion of 12 Vulnerable Groups, guided by the ethos of universal, equitable, and accessible health services. Health policies established on the values of equity are more likely to result in health services that are more justly distributed throughout a population. This requires that policy-makers strive to ensure the provision of health services for all, particularly for Vulnerable Groups, in response to their needs (World Health Organization 2008). If a commitment to Core Concepts of human rights and the inclusion of Vulnerable Groups underpin policy formation, it is more likely that this will be inculcated in health service delivery. EquiFrame has been applied in the analysis of 51 health policies across Namibia, Malawi, South Africa, and Sudan. This paper reports on the findings of this application to ten Namibian health policies. We sought to identify, at the policy level, the degree of commitment of these Namibian health policies to Core Concepts of human rights and their inclusion of Vulnerable Groups. Accordingly, our aim was to identify best-practice Namibian health policies, and to ascertain health policies that may require urgent revision.
Method
Development of EquiFrame
There is a scarcity of literature that outlines and utilizes analytical frameworks for the content of policies, or policy ‘on the books’(Stowe and Turnbull 2001). There is, however, a body of research on the process of health policy development (Gilson et al. 2008). While this body of research focuses on the critical importance of how policy is made, only little guidance is offered on evaluating policy ‘on the books’. Developing and applying a method for analyzing the actual content of policies was the focus of the present research. EquiFrame has been devised with the intention of developing a health policy analysis framework that would be of particular relevance in low-income countries in general, and in Africa in particular, and is guided by the ethos of universal, equitable, and accessible health services. EquiFrame has been developed as part of a work package led by Ahfad University for Women, Sudan, within a large EU FP7 funded project, EquitAble, which is led by the Centre for Global Health at Trinity College Dublin, Ireland, and which has a consortium of international partners (see www.equitableproject.org).
Selection of Policies
The World Health Report, ‘Working Together for Health’(World Health Organization 2006) , noted that Africa has the greatest disease burden of any continent but has the poorest health services. The four African countries that are the focus of this policy analysis framework each represent distinct challenges in terms of equitable access to healthcare. These four countries allow us to address how access to the healthcare systems for Vulnerable Groups can best be promoted in contexts where the population is highly dispersed (Namibia); where chronic poverty and high disease burden compete for meager resources (Malawi); where, despite relative wealth, universal and equitable access to healthcare is yet to be attained (South Africa); and where a large proportion of the population has been displaced (Sudan).
EquiFrame has been applied in the analysis of 51 health policies across Namibia, Malawi, South Africa, and Sudan. Health policies were included if they met the following criteria: (1) Health policy documents produced by the Ministry of Health; (2) Policies addressing health issues outside of the Ministry of H