Health Equity as a Priority in the 2030 Agenda for Sustainable Development: A Nested Qualitative Case Study of Maternal, Newborn and Child Health in Ethiopia

Abstract

The 2015 global adoption of the United Nations 2030 Agenda for Sustainable Development places the achievement of health equity as a global priority for health and development. Due to the normative nature of the concept of health equity and the multi-level, multi-sectoral approaches required to advance it, interdisciplinary investigations are warranted to demonstrate how health equity as a policy objective is understood and operationalized. This dissertation is a case study of health equity in maternal, newborn and child health (MNCH) in Ethiopia, using qualitative methods to explore how health equity is conceptualized and pursued by stakeholders across levels of the health system. Ethiopia, a low-income country in East Africa, reported improvements in MNCH during the Millennium Development Goal period (1990-2015), largely attributed to the expansion of health services into rural areas; however, achievements were not realized across all geographies and population groups. Health equity is a stated policy objective for the country. Through a series of four articles, this dissertation addresses: community members’ perceptions and experiences related to health inequity and MNCH; barriers and enablers encountered by community-level health workers in implementing an equity-oriented MNCH intervention; subnational health managers’ understandings of health equity, and their roles in promoting it; and the characterization of health equity as a policy problem in national-level health discourses. This work deconstructs health equity into three components (health, distribution of health and characterization of the distribution of health) and compares how stakeholders across levels of the health system attribute meaning to each component and imply responsibility and accountability for health equity. The findings detail how diverse experiences related to health equity in MNCH across community, subnational and national contexts are driven by high-level technocratic framings of health equity, which tend to emphasize the delivery of a narrow package of health services to under-served geographical areas. Providing support and recognition for the role of subnational stakeholders in mediating the adaption of national health equity policies to local contexts, and making prominent the social justice underpinnings of health equity in the implementation of national policies are opportunities to strengthen the advancement of health equity in Ethiopia.