Background: Equity seems inherent to the pursuance of universal health coverage (UHC), but it is not a natural consequence of it. We explore how the multidimensional concept of equity has been approached in key global UHC policy documents, as well as in country-level UHC policies. Methods: We analysed a purposeful sample of UHC reports and policy documents both at global level and in two Western African countries (Benin and Senegal). We manually searched each document for its use and discussion of equity and related terms. The content was summarised and thematically analysed, in order to comprehend how these concepts were understood in the documents. We distinguished between the level at which inequity takes place and the origin or types of inequities. Results: Most of the documents analysed do not define equity in the first place, and speak about "health inequities" in the broad sense, without mentioning the dimension or type of inequity considered. Some dimensions of equity are ambiguousespecially coverage and financing. Many documents assimilate equity to an overall objective or guiding principle closely associated to UHC. The concept of equity is also often linked to other concepts and values (social justice, inclusion, solidarity, human rightsbut also to efficiency and sustainability). Regarding the levels of equity most often considered, access (availability, coverage, provision) is the most often quoted dimension, followed by financial protection. Regarding the types of equity considered, those most referred to are socioeconomic , geographic, and gender-based disparities. In Benin and Senegal, geographic inequities are mostly pinpointed by UHC policy documents, but concrete interventions mostly target the poor. Overall, the UHC policy of both countries are quite similar in terms of their approach to equity. Conclusions: While equity is widely referred to in global and country-specific UHC policy documents, its multiple dimensions results in a rather rhetorical utilisation of the concept. Whereas equity covers various levels and types, many global UHC documents fail to define it properly and to comprehend the breadth of the concept. Consequently, perhaps, country-specific policy documents also use equity as a rhetoric principle, without sufficient consideration for concrete ways for implementation.

Cet article, basé sur une enquête socio-anthropologique de terrain, étudie le processus d’élaboration du projet d’Assurance pour le renforcement du capital humain (ARCH) au Bénin et les défis, risques et enjeux de mise en œuvre de cette politique de protection sociale, particulièrement en santé. Dans un premier temps, nous analysons le processus d’élaboration du projet qui se caractérise jusqu’ici par une mainmise des experts nationaux sur ses grandes orientations et une absence de débat et d’implication des parties prenantes. L’ARCH reposant sur une identification a priori de catégories de population pauvres et extrêmement pauvres, le processus de ciblage est ensuite discuté. Nous épinglons enfin divers risques et de potentielles tensions qui doivent être pris en compte dans la mise en œuvre du projet, en ce qui concerne le financement, la qualité et la gouvernance de l’offre de santé, mais également les facteurs d’adhésion de la population et la persistance de barrières à l’accès aux soins.

The numerous stakeholders involved in the development of universal health coverage (UHC) policies are likely to have diverging interests about which dimensions to prioritize, hence the importance of ensuring an effective and transparent policy dialogue. This paper aims to investigate whether or not UHC policy dialogue processes are functioning well in Benin and Senegal. Based on a literature review, we have identified a number of characteristics guaranteeing the quality of policy dialogue processes, which we have integrated into an analytical grid. The quality criteria identified were classified along four dimensions: stakeholder participation, dialogue/negotiation process, quality of situation analysis and decision criteria, and results from the negotiation process. Based on data collected through documentary review, interviews, an electronic survey and the authors’ own experience, we applied that analytical grid to the cases of Benin and Senegal. In both countries, the policy dialogue processes are largely imperfect in terms of many of the quality criteria identified. Decisions were made under strong political leadership, ensuring government coordination and ownership, and strong emphasis has been put on expanding financial risk protection. Yet, both countries perform poorly in a number of dimensions, especially with regards to conflicts of interest, transparency and accountability. None of them has really institutionalized a UHC policy dialogue process, and the UHC policymaking processes have actually bypassed existing health sector coordination mechanisms. The two countries perform well regarding the quality of situation analysis. A small (in the case of Benin) or broader (in the case of Senegal) governmental coalition managed to impose its views, given insufficient stakeholder participation. Policy networks were particularly influential in Senegal. Overall, there are important gaps that reduce the quality of UHC policy dialogue processes, hence explaining the weaknesses in their results in terms of transparency and accountability. Our analytical framework enables usto identify rooms for improvement with regard to country-led negotiation processes relating to UHC.