Missing the vulnerable – Inequalities in social protection among the general population, people living with HIV, and adolescent girls and young women in 13 sub-Saharan African countries: Analysis of population-based surveys

Inequality in access to services is a global problem mainly impacting the poorest populations. The role of social protection in reducing inequalities is recognized, but few studies have investigated whether social protection benefits people facing considerable socioeconomic inequalities. We assessed inequalities in receiving social protection among the public, men and women living with human immunodeficiency virus (PLHIV), and adolescent girls and young women (AGYW), using population-based data from 13 African countries. We constructed concentration curves and computed concentration indices (CIX) for each country and population group. We also conducted a desk review of social protection in the studied countries where information was available on the characteristics of social protection programs and their access by the general population, PLHIV, and AGYW. The sample size ranged from 10,197 in Eswatini to 29,577 in Tanzania. Women comprised 60% or more of PLHIV in the surveyed countries. 50%–70% of the respondents were unemployed, except in Cameroon, Kenya, and Uganda, where less than 50% were unemployed. Generally, the proportion of respondents from wealth quintile one (Q1), the poorest 20% of households, was like that from Q2–Q5. The proportion of the general population receiving social protection varied from 5.2% (95% Confidence Interval 4.5%–6.0%) in Ethiopia to 39.9% (37.0%–42.8%) in Eswatini. Among PLHIV, the proportion receiving social protection varied from 6.9% (5.7%–8.4%) among men living with HIV in Zambia to 45.0% (41.2–49.0) among women living with HIV in Namibia. Among AGYW, the proportion varied from 4.4% (3.6–5.3) in Ethiopia to 44.6% (40.8–48.5) in Eswatini. In general, 15% or less of the respondents from Q1 reported receiving social protection in eight countries (i.e., Cameroon, Côte d'Ivoire, Ethiopia, Kenya, Malawi, Tanzania, Uganda, and Zambia), with 10% or less in three countries (Cameroon, Côte d'Ivoire, and Ethiopia); 15%–20% in Rwanda, 30% in Zimbabwe, 40% in Lesotho, and more than 50% in Eswatini and Namibia. Among the wealthiest quintiles (Q5), the proportion receiving social protection ranged from 3.6% (2.6%–5.0%) in Ethiopia to 19.7% (16.25–23.8%) in Namibia. Only in countries with higher social protection coverage did the proportion of the poorest wealth quintile households reached also high. Socioeconomic inequalities in receiving social protection favored the poor in 11 out of 13 countries and the rich in Cameroon and were undefined in Côte d'Ivoire. The CIX values for socioeconomic inequalities in receiving social protection in these 11 countries ranged from −0.080 (p=0.002) among the general population in Malawi to −0.372 (p< 0.001) among WLHIV in Zimbabwe. However, in 8 countries (Cameroon, Côte d'Ivoire, Ethiopia, Kenya, Malawi, Tanzania, Uganda, and Zambia) of these 11 countries, 15% or less of the population from the poorest wealth quintile received social protection. In the countries surveyed, access to social protection for the general population, MLHIV and WLHIV, and AGYW was generally low but favored people from poor households. However, pro-poor social protection, although necessary, is not sufficient to ensure that people from the poorest households receive social protection. Further research is required to identify and reach people from the poorest households with social protection in sub-Saharan Africa. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The Swiss National Science Foundation (SNSF) grant number 202660 funded Olivier Keiser. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study did not require ethical clearance because the data were de-identified and can be accessed upon request at the PHIA Project website at https://phia-data.icap.columbia.edu/files. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data is publicly available and can be accessed upon request at the PHIA Project website at https://phia-data.icap.columbia.edu/