To what extent is equity entrenched in HIV/AIDS-related policy documents in Ethiopia? A policy content analysis.

introductionIt is important to assess the extent of mentions of equity in policy and strategic documents for several reasons. First, it helps us understand the root causes of inequities, revealing both failures and successes. Second, it shows the readiness of stakeholders and leaders to take actions towards equity. Third, it identifies areas of improvement to plan strategies towards equity. The objective of this study was to assess the degree to which equity is incorporated in human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS)-related policy documents in Ethiopia.

methodsA policy content analysis was conducted on the basis of Marmot's social determinants of health framework. We have included policies, strategic plans, guidelines and reports on the basis of relevance to HIV/AIDS, timeliness and availability to the public. The search for documents took place between 1 March 2023 and 1 May 2023. The included documents in the content analysis were published between 1998 and 2022. These documents were accessed from Google, the Joint United Nations Programmes for HIV/AIDS, the WHO, the World Bank, the Ethiopian Federal Ministry of Health and the International Institute for Primary Health Care-Ethiopia websites. These documents were evaluated for mentioning equity in broader view or in relation to social categories (residence, occupation/employment, religion, sex/gender, ethnicity, education, income, region, age and multiple disadvantaged groups) and structural dimensions or health systems building blocks, such as health leadership and governance, workforce, financing, medical products and technologies and information systems. A Bardache's eightfold policy analysis guided the content analysis and synthesis of findings.

resultsA total of 26 documents were reviewed and analysed. Mentions of equity in policy documents increased over time, but the level of mention varied among national plans, treatment guidelines and reports. Over time, the mentioning of equity increased in strategic plans and guidelines, while it decreased in reports. In the same documents, there seems to be a shift from equality to equity because mentions of (in)equity increased from 149 between 2011 and 2015 to 328 between 2016 and 2022, while (in)equality mentions declined from 117 to 53 during the same period. Equity was mentioned in relation to health system functions and/or social classes. Gender (in)equity was the most frequently mentioned issue, while (in)equity related to multiple disadvantaged groups, religion, employment status and social capital was less frequently mentioned. (In)equity is deeply embedded in health system governance, but it is least integrated into the health information system.

conclusionsThe mentioning and consideration of (in)equity in policy and strategic documents have increased over time, but not consistently or comprehensively. Growing emphasis has been placed on equity rather than equality. The shift from equality to equity in HIV/AIDS policy documents reflects a more nuanced understanding of the diverse needs of individuals and groups. More attention is given to gender issues and health system governance than to other dimensions of equity. It is vital that policy-makers revise their HIV/AIDS-related policy documents to promote health equity for all social strata, particularly among multiple disadvantaged groups. Health information systems should be designed in such a way that they generate and manage information to assess the extent of (in)equity and the progress towards equity in HIV/AIDS services.