Underlying Equity Discourses of the World Health Organization: A Scoping Review Protocol

Background: Globally, increasing attention has been paid to the concept of equity in the context of health, largely stemming from the work of the World Health Organization (WHO) beginning in the late 1970s with the Declaration of Alma-Ata (WHO, 1978) and more recently following the Commission on the Social Determinants of Health (CSDH, 2008) and their final report in 2008. Despite increasing attention to this issue, there is global ambiguity on the true definition of “health inequity”, “health inequalities”, or “health disparities” (Braveman, 2006, p. 167; Braveman & Gruskin, 2003). Methods/Design: This original scoping review clarifies how the WHO conceptualizes equity. It also identifies the theoretical underpinnings guiding the WHO’s approach to equity and its broader implications. This protocol followed the PRISMA guidelines for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018), with details discussed in the full protocol. Discussion: To date, much of the research on health equity globally has been restricted to chronological discussions over time or specific research fields (Borde & Hernández, 2018, p. 3). Therefore, researching the WHO’s approach to equity in terms of alignment with theory and broader normative standpoint(s) becomes increasingly important in addressing a gap in the literature. In addition, because the definition of equity in the context of health has practical implications for its operationalization (Guerra, Borde, & Salgado De Snyder, 2016), this work seeks to clarify in the concept of equity used by the WHO in hopes of moving towards a shared understanding to bridge action [e.g. in measurement and accountability (Braveman & Gruskin, 2003)].


Background
This is one of the key messages from the Commission on the Social Determinants of Health (CSDH), a commission convened by the WHO from 2005 to 2008. Understandably, achieving equity in the context of health has become a central objective for the World Health Organization (WHO) since the World Health Assembly in 1977 (Reid, 1982) and through the start of their "health for all" agenda, famously proclaimed in the 1978 Declaration of Alma-Ata (WHO, 1978). This led to the WHO commissioning a foundational definition of inequity in health in 1990, as "differences which are unnecessary and avoidable, but in addition are considered unfair and unjust" (Whitehead, 1990).
It is widely accepted that inequalities affect many aspects of life, as social and economic inequality reduces social cohesion, unfairly distributes life chances, and results in inequalities in health outcomes (Marmot, 2018). While this Whitehead definition has been widely accepted and used internationally, there is global ambiguity on the true definition of "health inequity," "health inequalities," or "health disparities" (Braveman, 2006, p. 167;Braveman & Gruskin, 2003). Cultural differences in approaching equity, with various traditions of social justice drawn on in different countries (Pappas & Moss, 2001, p. 651), may also contribute to this ambiguity.
As a result of the CSDH, the understanding of inequitable and avoidable health differences was understood to be a result of socioeconomic, political, and historical causes (Plamondon, Bottorff, Caxaj, & Graham, 2018). The CSDH highlighted the need to tackle the structural drivers of the conditions of daily life, which is the "inequitable distribution of power, money, and resources"-explaining that "social justice is a matter of life and death" (CSDH, 2008). Despite the work of the CSDH, substantial differences in how health equity is defined and operationalized remain in the SDH literature (Lucyk & McLaren, 2017). For example, while 'equity' is a political concept with a moral commitment to social justice, 'inequality' is a measured difference (Kawachi, Subramanian, & Almeida-Filho, 2002). Yet, in international policy discourse and implementation, inequity and inequality are used interchangeably (Oickle & Clement, 2019). Such variations are problematic both for how policy is understood as well as for the execution of subsequent action [e.g. implications for measurement and accountability (Braveman & Gruskin, 2003)]. This is demonstrated by Raphael's observation that Canadian policy documents and reports possess various underlying discourses which yield different public policy implications for action (Raphael, 2011). Therefore, it is important to clarify discourses in order to better understand and be able to eliminate misunderstandings.
Clarity in terminology is crucial, as overlooked nuances in the WHO's definitions can shape global understanding through their standards, policy, and guidelines, and subsequent implementation of funding and strategies. In the past, the need for a clear definition of health equity that the WHO follows has been raised (Braveman & Gruskin, 2003). Today, the WHO provides the following definitions of equity and health inequities on their website: Equity is the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically. Health inequities therefore involve more than inequality with respect to health determinants, access to the resources needed to improve and maintain health or Social Science Protocols, June 2020, 1-6. http://dx.doi.org/10.7565/ssp.2020.2812 3 health outcomes. They also entail a failure to avoid or overcome inequalities that infringe on fairness and human rights norms (World Health Organization, n.d.).
Despite these definitions, there is minimal research investigating how the WHO conceptualizes equity in the context of health (e.g. the theoretical underpinnings guiding the WHO's approach to equity and its broader implications). While clarity in the WHO's approach to equity is important, uniformity in its approach may not be necessary. Therefore, this scoping review aims to map scholarly literature that examine the WHO's interpretation of "equity" in the context of health. This scoping review, to the best of our knowledge, is the first to review and examine the literature on how the organization conceptualizes equity.

Methods/Design
The following sections detail the approach to the scoping review, which was developed following the PRISMA guidelines for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018).

Aim and review question
The aim of this review is to identify how the WHO conceptualizes equity, with particular attention to alignment with theories of justice and approaches (e.g. egalitarianism, Rawl's Difference Principle, and Sen's Capabilities Approach). In order to achieve this aim, this review asks three interrelated questions: (1) what is the status of the scholarly literature which investigates the WHO's concept of equity, and (2) how has the WHO conceptualized equity, and (3) does and how does their conceptualization align with any theories of justice?

Inclusion criteria
Articles will be included if they meet inclusion criteria -chiefly the explicit discussion of the WHO's concept of health equity, for example in terms of conceptualization and/or definitions. Articles which mention health equity in the context of WHO's programs, policies, and so on, but do not discuss its conceptualization or definition will be excluded.

Exclusion criteria
Papers will be excluded if they: (1) State the definition of equity without any further analysis or discussion. This includes those where the WHO's definition of equity is drawn on as a side-point or casually referred to without additional interrogation, and those that discuss equity broadly and are not specific to the WHO. For example, papers that highlight the need for action to tackle health inequalities (but no critique or discussion around the meaning of equity). Or, those which reiterate what the WHO is already doing about equity (without discussing the underlying discourses).
(2) Solely focus on specific inequities (e.g. inequity of genetic testing) instead of a discussion on equity, equity in health, or health equity more broadly. This also includes articles that discuss a specific health issue/disease/condition and conclude that there are implications for equity (e.g. inequitable distribution of health care professionals, asthma, tuberculosis).
(3) Solely focus on the measurement of inequity or inequality, some of which include: epidemiological/statistical, case-control, cross-sectional studies, study of one Social Science Protocols, June 2020, 1-6. http://dx.doi.org/10.7565/ssp.2020.2812 4 country/population group, etc. However, papers that draw on a discussion of measurement to delve into discourse, theory, normative positions, etc. will be included.
(4) Are unavailable in English -due to resource restrictions.

Types of sources
This study intentionally does not restrict the selection of articles by type of paper (commentaries, editorials, literature reviews, analysis papers, etc.) nor by year (including articles from database inception), to aid in understanding if and how work in this field and broader understanding change over time, particularly with the development of the CSDH. Only papers available in English will be included.

Search Strategy Data sources
Given the WHO's disciplinary grounding in public health and medicine, Ovid MEDLINE, a medical science database will be used. Given the interdisciplinary scope of the research question and basis in social justice and social science more broadly, SCOPUS, an interdisciplinary database will be used to conduct the search. In addition to the two databases searched, two influential papers were searched in Google Scholar to include papers that cited these two papers and contained "equity" in their title. Table 1 details where all the citations were retrieved from. Further, hand-searching of relevant references from papers read during the review will complement this review strategy.

739
"What does equity in health mean?" (Mooney, 1987) From the 108 papers that cited this paper on Google Scholar, those which contained "equity" in the title.

33
"The concepts and principles of equity and health" (Whitehead, 1991) [please note: this is the same text as Whitehead (1990)] From the 3,176 papers that cited this paper (which contained 16 versions on Google Scholar), those which contained "equity" in the title.

500
Hand-searching Searching the texts of those papers which were read in their entirety for relevant references.

Elimination of duplicates
After removing duplicates from the identified papers (using both EndNote X9 and manual elimination), this resulted in 2,538 non-duplicate citations.

Approach to data extraction
Citations from EndNote X9 will be exported to an excel file, where article titles and abstracts will first be reviewed for relevance using a priori inclusion and exclusion criteria and all potentially relevant articles were read in full to determine and ensure alignment with these criteria. This will be conducted independently by two reviewers. Any potential differences will be discussed between the two reviewers and the final list of papers approved by two additional authors on the authorship team.

Data presentation
First, data on key study descriptors will be extracted from articles [e.g. author(s) and year of publication, author's/s' institution(s), title, type of publication, place published, reflections on the WHO's approach to equity, and conclusion(s)].
Because this review is designed to yield insights on the depth of interrogation of the WHO's discussion of equity, deeper information through reading and interpreting, such as comparing, analyzing, and synthesizing critiques of the WHO's approach(es), will be focused on.

Discussion
To date, much of the research on health equity globally has been restricted to chronological discussions over time or specific research fields (Borde & Hernández, 2018, p. 3). Therefore, researching the WHO's approach to equity in terms of alignment with theory and broader normative standpoint(s) becomes increasingly important in addressing a gap in the literature. In addition, because the definition of equity in the context of health has practical implications for its operationalization (Guerra, Borde, & Salgado De Snyder, 2016), this work seeks to clarify in the concept of equity used by the WHO in hopes of moving towards a shared understanding to bridge action [e.g. in measurement and accountability (Braveman & Gruskin, 2003)].