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 Nicole Bergen Thesis Supervisors: Dr. Ronald Labonté and Dr. Manisha Kulkarni Thesis submitted in partial fulfillment of the requirements for the PhD degree in Population Health Interdisciplinary School of Health Sciences Faculty of Health Sciences University of Ottawa 27 April 2020 © Nicole Bergen, Ottawa, Canada, 2020 Table of contents List of tables................................................................................................................................................. ix List of figures ................................................................................................................................................ x List of acronyms and abbreviations ............................................................................................................ xi Acknowledgements .................................................................................................................................... xii Co-authorship and approvals ..................................................................................................................... xv Abstract ..................................................................................................................................................... xvii Chapter 1. Introduction ................................................................................................................................ 1 1.1 What is health equity? ........................................................................................................................ 1 1.2 Research goals, questions and objectives........................................................................................... 5 1.3 Theoretical approach .......................................................................................................................... 6 1.3.1 Population health and social determinants of health ................................................................. 6 1.3.2 Philosophical, theoretical and conceptual framing ..................................................................... 7 1.4 Methods and methodological approach ............................................................................................. 8 1.4.1 Methodology ................................................................................................................................ 8 1.4.2 Study context ............................................................................................................................... 9 1.4.3 Data collection and analysis overview ....................................................................................... 10 1.4.4 Research participants ................................................................................................................. 12 1.5 Ethical considerations ....................................................................................................................... 15 1.6 Reflexivity statement ........................................................................................................................ 16 1.6.1 Journey to the PhD ..................................................................................................................... 16 1.6.2 Positionality and partnerships ................................................................................................... 17 1.6.3 Anticipated outcomes ................................................................................................................ 19 1.7 References ........................................................................................................................................ 19 Chapter 2. Literature review: health equity ............................................................................................... 24 2.1 Defining health equity and related terminology .............................................................................. 24 2.2 Three constructs of health equity ..................................................................................................... 26 2.2.1 Health ......................................................................................................................................... 26 2.2.2 Distribution of health ................................................................................................................. 28 2.2.3 Characterization of the distribution of health ........................................................................... 29 2.3 Approaches to reduce health inequity ............................................................................................. 30 ii 2.4 The UN 2030 Agenda for Sustainable Development ........................................................................ 32 2.4.1 A new global development agenda ........................................................................................... 32 2.4.2 The emergence of equity as a priority ....................................................................................... 35 2.4.3 Implementing the SDGs and advancing health equity ............................................................... 36 2.5 Conclusion ......................................................................................................................................... 38 2.6 References ........................................................................................................................................ 39 Chapter 3. Maternal, newborn and child health in Ethiopia ...................................................................... 48 3.1 Federal Democratic Republic of Ethiopia .......................................................................................... 48 3.1.1 Oromia region ............................................................................................................................ 50 3.1.2 Jimma Zone ................................................................................................................................ 51 3.2 Health sector ..................................................................................................................................... 53 3.2.1 Organization and financing ........................................................................................................ 53 3.2.2 National policies and programs ................................................................................................. 55 3.2.3 Community mobilization and ownership ................................................................................... 57 3.3 Maternal, newborn and child health ................................................................................................ 58 3.3.1 Historical context of health, with a focus on MNCH .................................................................. 58 3.3.2 MNCH during the MDG period: mixed success .......................................................................... 60 3.3.3 Inequities in MNCH .................................................................................................................... 61 3.4 Promoting equity in MNCH ............................................................................................................... 63 3.4.1 Health equity and the Health Extension Program ..................................................................... 64 3.4.2 Health equity and MWAs ........................................................................................................... 66 3.5 Moving forward an agenda for equity in MNCH? ............................................................................. 70 3.6 Conclusion ......................................................................................................................................... 71 3.7 References ........................................................................................................................................ 72 Chapter 4. Exploring health and health inequality among rural communities in Jimma Zone .................. 84 4.1 Abstract ............................................................................................................................................. 85 4.2 Keywords ........................................................................................................................................... 86 4.3 Background ....................................................................................................................................... 86 4.4 Methods ............................................................................................................................................ 87 4.4.1 Sampling and participant recruitment ....................................................................................... 87 4.4.2 Data collection ........................................................................................................................... 88 4.4.3 Data analysis .............................................................................................................................. 88 4.4.4 Ethical clearance ........................................................................................................................ 89 iii 4.5 Results ..............................................................................................................................................