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Background: Universal Health Coverage (UHC) remains a critical public health goal that continues to elude many countries of the global south. As countries strive for its attainment, it is important to track progress in various subregions of the world to understand current levels and mechanisms of progress for shared learning. Our aim was to compare multidimensional equity gaps in access to skilled attendant at birth (SAB) and coverage of the third dose of Diphtheria-Tetanus-Pertussis (DTP3) across 14 West African countries. Methods: The study was a cross sectional comparative analysis that used publicly available, nationally representative health surveys. We extracted data from Demographic and Health Surveys, and Multiple Indicator Cluster Surveys conducted between 2010 and 2017 in Benin, Burkina Faso, Cote d’ Ivoire, The Gambia, Ghana, Guinea, Guinea Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone and Togo. The World Health Organization’s Health Equity Assessment Toolkit (HEAT Plus) software was used to evaluate current levels of intra-country equity in access to SAB and DTP3 coverage across four equity dimensions (maternal education, location of residence, region within a country and family wealth status). Results: There was a general trend of higher levels of coverage for DTP3 compared to access to SAB in the subregion. Across the various dimensions of equity, more gaps appear to have been closed in the subregion for DTP3 compared to SAB. The analysis revealed that countries such as Sierra Leone, Liberia and Ghana have made substantial progress towards equitable access for the two outcomes compared to others such as Nigeria, Niger and Guinea. Conclusion: In the race towards UHC, equity should remain a priority and comparative progress should be consistently tracked to enable the sharing of lessons. The West African subregion requires adequate government financing and continued commitment to move toward UHC and close health equity gaps.
We included 14 West African countries (Benin, Burkina Faso, Cote d’ Ivoire, The Gambia, Ghana, Guinea, Guinea Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone and Togo) that had recent (2010 or beyond) disaggregated national health survey data in this analysis. Carbo Verde, although a West African country was not included in the analysis because the latest available data point was for 2005 (which did not meet our definition of ‘recent’). The countries included in our analysis have cultural and geopolitical ties, and shared economic interests and are part of the subregional alliance, the Economic Community of West African States (ECOWAS) [13]. ECOWAS is aimed at promoting subregional integration across several fields, including cross-national health systems collaboration among member states [13]. In 2017, the combined estimated population of the 14 countries was about 372 million, with an estimated 81 million women of reproductive age (15–49 years), and an estimated total surviving infant population of 13 million [14]. Côte d’Ivoire, Ghana, Nigeria, and Senegal were classified as lower-middle income countries based on the 2017 World Bank fiscal year classification, while the others were classified as low income countries. This was a descriptive cross-sectional comparative analysis of current progress in access to SAB and DTP3 coverage, unpacked across four equity dimensions per country in the West Africa subregion. DTP3 coverage is a child health indicator and is one of the sixteen recommended UHC tracer indicators for tracking country level progress towards UHC [15]. The other indicator used in this study, SAB, although not currently a recommended UHC tracer indicator is considered a key indicator of maternal health. We used SAB instead of the current UHC maternal health indicator; antenatal care visits (ANC) because most countries in West Africa did not disaggregate ANC by number of visits or by the four dimensions of equity which was the focus of this study. Furthermore, comparable and disaggregated data for SAB for the period under review was available for all countries. We searched the UNICEF-supported Multiple Indicator Cluster Survey (MICS) and the USAID-supported Demographic and Health Survey (DHS) databases for the most current final report of either household survey for each included country as of June 31, 2019 [16, 17]. The DHS and MICS are large-scale, nationally representative, standardised household surveys. The surveys collect and report health data including access to SAB and DTP3 coverage disaggregated by socioeconomic determinants of inequality including; wealth status, maternal level of education, location of residence, and administrative regions within a country [18]. Their methodologies are considered similar, which may allow for direct comparisons of their data. The methodologies of DHS and MICS are described in detail elsewhere [18]. According to these surveys, SAB is any health professional (including doctor, nurse or midwife) able to provide basic and emergency care to mothers and their newborns during delivery and the postpartum period [16, 17]. To evaluate equity gaps in women’s access to SAB and childhood DTP3 immunisation coverage across the 14 West African countries, we stratified both tracer indicators by socioeconomic and geographic determinants of inequality. These include: maternal educational attainment, family wealth status (quintile), location of residence (urban or rural), and regions within a country. The WHO and World Bank 2017 global monitoring report on progress towards UHC recommends these as key dimensions of inequality and should be included in any equity analysis because national averages can mask unequal access to essential services in the most disadvantaged sub-populations [15]. The data generated after abstraction from the various data sources were entered into Microsoft Excel® ((Microsoft, Seattle, USA). The Microsoft Excel workbook was formatted according to the WHO Health Equity Assessment Toolkit Plus (HEAT plus) template and imported into the HEAT Plus programme for descriptive analysis and generation of ‘equiplots’ (a plot of equity analysis). HEAT Plus is a software application developed by the WHO to facilitate the assessment of within-country health equity gaps [19]. In addition, HEAT Plus provides a platform for multi-country equity comparison of health outcomes. It uses data to compare health outcomes or coverage of essential services across the different equity dimensions and it is a useful tool for measuring and monitoring inequality [19]. Using this toolkit, the most recent situation (based on the latest available national survey data) of intra-country equity gaps in access to SAB and DTP3 coverage was estimated. We compared coverage between the extremes within each dimension of inequality as a proxy for absolute inequality (i.e. between the most advantaged and the most disadvantaged). Specifically, for family wealth status, we compared coverage in the richest and poorest quintile; for maternal educational attainment, we compared those with at least secondary education and those with no formal education; for region of residence, we compared coverage in the best performing versus that in the worst region within a country; and for place of residence we compared urban versus rural. These within-country analyses were performed for access to SAB and DTP3 immunisation coverage. Finally, to compare progress across the 14 countries, the analyses included inter-country equity comparisons, i.e. equity gaps per country were ranked across the two indicators (access to SAB and DTP3 coverage) and across the four dimensions of equity assessed.
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