Objectives: This paper reports on an analysis of 11 African Union (AU) policy documents to ascertain the frequency and the extent of mention of 13 core concepts in relation to 12 vulnerable groups, with a specific focus on people with disabilities.

Method: The paper applied the EquiFrame analytical framework to the 11 AU policy documents. The 11 documents were analysed in terms of how many times a core concept was mentioned and the extent of information on how the core concept should be addressed at the implementation level. Each core concept mention was further analysed in terms of the vulnerable group in referred to.

Results: The analysis of regional AU policies highlighted the broad nature of the reference made to vulnerable groups, with a lack of detailed specifications of different needs of different groups. This is confirmed in the highest vulnerable group mention being for ‘universal’. The reading of the documents suggests that vulnerable groups are homogeneous in their needs, which is not the case. There is a lack of recognition of different needs of different vulnerable groups in accessing health care.

Conclusion: The need for more information and knowledge on the needs of all vulnerable groups is evident. The current lack of mention and of any detail on how to address needs of vulnerable groups will significantly impair the access to equitable health care for all.

Acknowledging barriers to people accessing health care has important implications for providing equitable access to health care and ensuring the best possible outcomes in relation to wellbeing and social justice. Disability is one such barrier.¹ Disability is a common human experience and, in interaction with crucial environmental barriers, can and does limit equitable access to health care. Not accessing health care further exacerbates existing health problems, and puts people with activity limitations at risk for developing new health problems that could easily have been prevented. For example, if a person in a wheelchair is unable to access the health service they will not visit the facility when having bronchitis, leading to further complications if not treated or resolved. Disability is not the only reason why people are limited in their access to equitable health care, but is the focus of this paper. Other groups that are often limited in their access to equitable health care include people living in poverty, women-headed households, orphans and other children with special needs, ethnic minorities, youth, displaced people and people with chronic illnesses (Dixon Woods et al. 2005; Goudge et al. 2009; Makwiza et al. 2009; Panter-Brick 2002; Perry et al. 2007; Reichard, Sacco & Turnbull 2004; Ridde 2008).

Equitable access to health care is more likely when issues from both health-focused and vulnerability-focused policy documents are integrated into single policy documents with integrated implementation plans. This ensures that issues of vulnerability are mainstreamed and included in all policies rather than being treated as a special case and as a separate and often ‘afterthought’ issue. We argue that mainstreaming at the level of policy documents is a step in the direction of ensuring equitable access to health care truly for all.

Buse et al. (2007:1) describe how ‘[p]olicy analysis can contribute to meeting health objectives and untangling the complex forces of power and process that underpin change’. Thus, to meet the health objectives of equitable access to health care by vulnerable groups, we need to understand the extent to which their needs are integrated into health related policies, as a step towards understanding the ‘complex forces’ that influence this integration and lead (or not) to equitable access to health care. If vulnerable groups and their specific needs are not visible or are seen as a separate issue not for inclusion in a ‘mainstream’ policy, their needs are not likely to be addressed and integrated into such ‘mainstream’ policies, and even less at the implementation and budget allocation stages. Thus, it is of interest to determine the extent to which such groups are included in policy documents in order to advocate for such inclusion if required.

The EquitAble project² has as one of its aims to determine the impact of a range of vulnerability factors in equitable access to health care with a specific focus on the impact of disability. The first stage of the EquitAble project comprised an analysis of policy documents to determine whether the identified vulnerability factors are integrated into existing policies on health care provision. The national policies of four African countries (Sudan, Namibia, Malawi and South Africa), regional policies developed by the AU for its member states, and a range of international policies were analysed. The policies considered are those related to health care service provision and managing specific health care priorities in the African region. This paper reports on the analysis of the regional policies developed by the AU for its member states. The analysis of individual country policies are presented in a separate paper (Mannan et al. 2012).

Vulnerable groups are ‘social groups who experience limited resources and consequent high relative risk for morbidity and premature mortality’ (Flaskerud & Winslow 1998:69). The focus of the EquiFrame (Mannan et al. 2011) is vulnerability, specifically in relation to accessing health care. Vulnerable groups included in the EquitAble analysis were women, children, elderly people, ethnic minorities, displaced people, people suffering from some illnesses and people with disabilities. Other groups, such as sexual minorities, can also be considered vulnerable but were not included in the analysis. The focus of the analysis was on developing and using a policy analysis tool rather than being fully exhaustive of all vulnerable groups.

Vulnerability is a complex process whereby individual characteristics of a person or group of people put that person at risk of not accessing, for example, health care. The risk factor in itself does not cause limited access, but rather the interaction of the factor with a range of other factors external to the person results in an outcome of lack of access. Thus, having an impairment does not in itself determine access to health care, but the interaction of having an impairment, such as loss of lower limb mobility, long distances to the health facility, poor or expensive transport, and inaccessible buildings all contribute to an outcome of inequitable access to health care for that person. The role of policies is to ensure that these external factors are set out and elucidated in order to ensure effective implementation. This needs to be done for the different needs of different vulnerable groups.

Mannan et al. (2011) identified the 12 key vulnerable groups from a review of the literature. An additional category ‘universal’, was included to capture information clearly referring to vulnerable groups but not sufficiently specific in its mention to allocate to one of the other 12 groups (Table 2). Two of the groups were omitted from this regional analysis – ‘increased relative risk for morbidity’ and ‘mother and child mortality’ – as these are more complex and require access to health care to be given a diagnosis of a health condition for the first, or a range of factors outside of a narrow scope of health care for the second.

The objectives of the paper are to:

1. Identify relevant health policies for the region of Africa developed by the African Union.

2. Review these policy documents in relation to the frequency and extent of mention of the identified vulnerable groups and core concepts.

The EquiFrame matrix provides a detailed analysis of which core concept is mentioned for which vulnerable groups and the nature of the mention, as set out in Appendix 1, as an example. The nature of the mention was rated according to a scale, as set out below. The higher the rating the more comprehensive and detailed the nature of the mention. Ratings of 3 and 4 would be required in order to address the different needs of different vulnerable groups:

0 = Concept not mentioned at all

1 = Concept only mentioned but not developed (incidental)

2 = Concept mentioned and explained (notable)

3 = Specific policy actions identified to address concept (central)

4 = Intention to monitor concept expressed (fundamental) N/A = Not relevant

Regional policies refer to policies developed within Africa and by the main African regional body, the AU. The AU is a body that brings together African countries and develops policies on issues related to specific African continent needs and problems.

The documents analysed for this report are recommendations from the AU Assembly to member countries, with the aim of providing guidelines for member states to develop their own national level policies. The documents reviewed include charters, protocols, declarations, policy frameworks, strategies and a plan of action. These documents deal with continent-wide issues of importance in relation to health, such as HIV and/or AIDS, Malaria, TB, and sexual and reproductive health services.

The following 11 documents were selected and analysed. All are available from the AU website (AU n.d.):

1. African charter on human and people’s rights – Banjul, Organisation for African Unity (OAU) document, 1981.

2. African charter on the rights and welfare of the child – 1990, entered into force 1999 – OAU.

3. Protocol to the African charter on human and people’s rights on the rights of women in Africa. – 1995 adopted in 2003.

4. Africa summit on roll back Malaria – 25 April 2000, Abuja – OAU document.

5. Abuja declaration on HIV and/or AIDS, TB and other related infections diseases – OAU, April 2001.

6. Pan-African forum for children – OAU document – May 2001.

7. Maputo declaration on HIV/AIDS, tuberculosis, Malaria and other related infectious diseases – July 2003 – AU document.

8. Draft continental policy framework for the promotion of sexual and reproductive health and rights in Africa. – AU, October 2005.

9. Plan of action on sexual and reproductive health and rights (Maputo Plan of Action) 2007–2010 – AU document, September 2006.

10. AU youth charter – AU, July 2006.

11. Africa health strategy: 2007–2015 – AU document, April 2007.

The analysis consisted of scanning the written text for mentions of core concepts and vulnerable groups. Terms that were contained in the definition of the concepts of groups were noted as mentions, and, in addition, different terms but that had the same meaning. The focus was on the meaning of the core concept or vulnerable groups rather than strict use of the actual term. For example, ‘limited resources’ and ‘poor’ were noted as being about the same vulnerable group.

Once the policy was analysed and the ratings set out on the matrix, the 11 policies were summarised with respect to the number of core concepts mentioned and for which vulnerable group these were mentioned, as set out in Appendix 2.

If a policy was a general one, those sections that made reference to health and health care and the preamble and guiding principles were identified within the policy and analysed in detail. For example, if a document dealt with issues ranging from health, education and employment, then only the preamble and the specific health clauses were considered for analysis. The language used in the policy was the basis for the analysis.

If there was more than one occurrence of a core concept for a particular vulnerable group, all instances were recorded under the ‘number column of the matrix’ but only the highest rating was included under the relevant vulnerable group. The analysis presented below focuses on the number of times a core concept was mentioned, followed by a separate description of the rating.

The large number of ‘universal’ mentions (relative to the other 12 specific vulnerable groups) highlights the nature of the policy content, which remains broad and lacking in specificity in relation to those sectors of the population who may struggle to access health care. For example, a policy would mention ‘all vulnerable groups’ but not specify which these would include. Whilst it is acknowledged that this is a step in the right direction, there remains a gap as to how the needs of such groups are to be met within the scope of a policy. It sounds more like a token mention of vulnerable groups than a serious consideration of the aspects to be addressed in order to meet their needs. Furthermore, the lack of specificity obscures the different needs of different groups.

Across the 11 policies, ‘capacity building’ was the most frequently mentioned core concept (42) followed by ‘coordination of services’. Apart from ‘autonomy’ and ‘privacy’, which were never mentioned, ‘cultural responsiveness’ was mentioned least. These results reflect the scope of the policies as pushing for capacity building of health care providers and ensuring that services are provided in a coordinated manner. ‘Access’ is mentioned 28 times across 6 policies. However, as shown in the more detailed analysis on ‘access’ below, the majority of these mentions are about a broad notion of ‘equitable access to health care’ in some form or another. Making services physically accessible and providing information in an accessible format are not reflected as being important components of health care provision, as they are not mentioned specifically. This trend is counteracted to some extent by the relatively frequent mention of ‘non-discrimination’ and ‘individualised services’. Both are mentioned in six policies. Mentions of these two core concepts remain general (e.g. ‘no discrimination for anyone’ and ‘services relevant for all’) rather than specifying different needs of different vulnerable groups, especially disabled people.

These results all reflect the broad nature of these regional documents and their emphasis on building strong health care services that provide equitable access for all but with little unpacking of what equitable access entails for individual vulnerable groups or what ‘for all’ really means.

Core concepts that were coded as having a specific policy action were ‘protection from harm’, ‘prevention’, ‘non-discrimination’, ‘capacity building’, ‘individualised services’, ‘accountability’, ‘quality’ and ‘access’.

There are different components to accessibility – physical, financial and information. The references to ‘access’ in the 11 documents were reviewed in relation to these three components. An additional type of mention is a more general point about ‘access to services’ which is common in the regional documents. The documents frequently make reference to the need for access to health care services but without any further specifications of what this entails.

In total there were 28 mentions of ‘access’, ranging from zero to nine mentions per document (Table 5). The more general category of ‘equitable access to services’ is the largest of the mentioned components, confirming the broad-stroke nature of the regional policies. While this category does not specifically refer to any of the three components – physical, financial and information access – they are implicit in the phrase ‘access to universal and equitable health care services’ or variations on that phrase. However, given the discussion above, it may be insufficient for these to be mentioned implicitly, and it would be preferable for these policies to make more explicit what is required in order to ensure access to universal and equitable health.

The issue of affordable drugs or access to drugs have been coded under ‘financial’ because of its overt reference to financial aspects of this reference – affordable.

The lack of further specifications in the ‘access to universal and equitable health care’ may lead to lack of implementation in a context where there are many implementation issues to be considered. This lack, furthermore, may reflect poor or no knowledge of the required specifications and/or the human rights implications of not addressing specific needs of different vulnerable groups. Given the argument that policy documents must make clear reference to the needs of vulnerable groups and ways to meet these through implementation as one of the components of ensuring universal and equitable access to health, it is worrying that the regional policy documents fail to provide more detailed specifications.

The second objective of reviewing these policies in relation to core concepts and vulnerable groups showed that there are important gaps in the way the core concepts and vulnerable groups are addressed in these policies. The very general nature of reference to vulnerable groups and the limited mention of core concepts suggests that there is limited scope for guiding countries in developing their national policies.

The analysis of regional AU policies highlighted the broad nature of the reference made to vulnerable groups, with a lack of detailed specifications of different needs of different groups. This is confirmed in the highest vulnerable group mention being for ‘universal’. The reading of the documents suggests that vulnerable groups are homogeneous in their needs, which is not the case. The needs of a people living far from a health facility are not the same as those for a deaf person attending a clinic. The first requires adequate transport while the second requires an accessible form of communication, such as sign language. This type of nuance is lost in general mentions of vulnerable groups.

The regional nature of the policies may explain some of the lack of detail concerning relevant policy actions and intention to monitor, as this would be more suitable in national level policies. However, one would like to see regional policies provide guidelines on these at least. In particular, the number of ratings of 3 and 4 should be increased. Increased numbers of 3 ratings would ensure that specific policy actions are identified to address the concept, and of 4 ratings that these policy actions are taken seriously through an intention to monitor the concept.

The recent focus on the importance of mainstreaming disability in the discussion on the millennium development goals (MDGs) reflects, firstly, the lack of consideration of disability within the MDGs generally, and secondly, should be an impetus for ensuring that the needs of disabled people and other vulnerable groups are made more explicit in policies.

One of the aims of the AU is to ‘mainstream gender in all programmes and activities of the union.’ (AU n.d.). Alongside the mainstreaming of gender, there needs to be mainstreaming of disability needs and those of other vulnerable groups in all the policies and related documentation. The focus should be on diversity management to address all needs of all people.

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