The Political Economy of Spatial Child Health Inequalities in Ethiopia: A Public Policy Analysis

The Political Economy of Spatial Child Health Inequalities in Ethiopia: A Public Policy Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Political Economy of Spatial Child Health Inequalities in Ethiopia: A Public Policy Analysis Anteneh Gebremichael DOBAMO This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6498222/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background: Despite national progress in reducing child mortality, Ethiopia continues to exhibit significant spatial inequalities in child health outcomes. The Afar region, in particular, remains critically underserved. While technical challenges are often cited, such explanations overlook the deeper structural, political, and institutional drivers of inequality. Objectives: This study investigates how public policy processes and political economy dynamics contribute to persistent spatial inequalities in child health in Ethiopia, with a specific focus on the Afar region. Methods: A qualitative case study design was employed, drawing on 23 semi-structured interviews with federal and regional policymakers, advisors, and development partners, as well as the analysis of 53 policy and historical documents. The analysis is guided by Walt and Gilson’s Policy Triangle and Moncrieffe and Luttrell’s Political Economy Framework, examining actors, context, content, and processes. Results: Four intersecting drivers of spatial inequality were identified: (1) historical marginalisation rooted in exclusionary state formation; (2) institutional fragmentation and weak subnational capacity; (3) dominant policy narratives that prioritise efficiency over equity; and (4) donor influence that reinforces verticalism and policy uniformity. Together, these dynamics reproduce and sustain child health inequities in Afar. Conclusion: Spatial inequalities in child health in Ethiopia are not incidental; they are structurally embedded in governance, policy design, and global-local power relations. Addressing them requires systemic reform grounded in justice, regional inclusion, and responsive decentralisation. This case study contributes to broader debates on inequality, decentralisation, and health governance in low- and middle-income countries. Health inequality political economy public policy decentralization Ethiopia Afar child health equity global health governance Figures Figure 1 1. Introduction Health inequalities remain among the most enduring and ethically urgent challenges in global development. While international frameworks such as the Sustainable Development Goals (SDGs) have committed to reducing child mortality and improving health equity, low- and middle-income countries (LMICs) continue to experience deep and persistent inequalities. These inequalities are especially pronounced in regions marked by structural marginalisation, weak institutional capacity, and limited access to essential public services (CSDH, 2008; WHO, 2008; UN, 2022). In mainstream policy discourse across LMICs, health inequalities are frequently conceptualized through biomedical or technical lenses, focusing predominantly on service delivery infrastructure and accessibility challenges. Such framings often overlook the political, economic, and institutional forces that shape who benefits from policy and how equity is (or is not) operationalized. As a result, deeper questions about governance, power, and historical injustice remain underexplored in many policy analyses (Gilson & Raphaely, 2008; Reich, 1995; Bambra et al., 2019). A more comprehensive approach is needed—one that moves beyond policy content to examine the broader processes, actors, and contexts that shape public policy design and implementation. To address this gap, the study draws on two complementary frameworks: the Policy Triangle Framework developed by Walt and Gilson (1994) and a Political Economy approach as elaborated by Moncrieffe and Luttrell (2005) and Buse, Mays, and Walt (2012). The Policy Triangle offers a structured way to examine policy through four interconnected dimensions—content, context, process, and actors—providing a multidimensional understanding of policy formation and implementation. The Political Economy approach, in turn, illuminates how structural power relations, institutional legacies, and global influences shape the priorities, incentives, and constraints within policy systems. Together, these frameworks enable a more critical and layered analysis of how inequalities in health emerge, persist, and are legitimized within public policy. Ethiopia provides a compelling case to explore these dynamics. The country has achieved measurable progress in reducing national under-five mortality, with rates falling to 67 per 1,000 live births by 2016 (CSA & ICF, 2016). However, these national averages conceal stark subnational inequalities. The Afar region, for example, recorded the highest under-five mortality rate in the country—125 deaths per 1,000 live births—nearly double the national average. Despite decades of investment in health infrastructure and decentralisation reforms, Afar continues to experience some of the poorest child health outcomes in the country. These inequalities cannot be attributed solely to geographic remoteness or cultural difference. While Afar’s arid landscape, mobile pastoralist livelihoods, and dispersed rural settlements present logistical challenges, these are compounded by a long-standing legacy of political exclusion, underdevelopment, and weak institutional support. National development strategies have historically prioritised central highland regions, leaving peripheral areas like Afar structurally disadvantaged (EEA, 2021; Piguet, 2001; Tesfaye et al., 2017). Furthermore, Ethiopia’s federal structure, while formally decentralised, has often failed to devolve meaningful authority or resources to regional governments—limiting their ability to design and implement locally appropriate health policies (Kanbur & Venables, 2005; Moncrieffe & Luttrell, 2005). The influence of international development actors has also shaped Ethiopia’s health policy landscape. Donor-supported initiatives have expanded access to services and contributed to progress toward universal health coverage (UHC), yet they have often prioritised vertical programs and performance-based metrics over equity-sensitive, context-specific reform. As a result, structurally marginalised regions like Afar remain underserved, their needs obscured within aggregate national indicators (CSDH, 2008; Ruducha et al., 2017; WHO, 2008). This study critically examines how Ethiopia’s public policy processes—shaped by both domestic institutions and international influences—contribute to the persistence of spatial child health inequalities. Using Afar as a case study, it investigates how actors, institutional structures, policy narratives, and decision-making processes intersect to shape policy outcomes across space. By applying the Policy Triangle Framework (Walt & Gilson, 1994) alongside a Political Economy lens (Moncrieffe & Luttrell, 2005; Buse et al., 2012), the study moves beyond surface-level diagnoses to engage with the deeper structural, political, and institutional forces that shape child health outcomes. In doing so, this study addresses a critical gap in the literature: the lack of empirically grounded, process-sensitive, and context-aware analyses of how public policy contributes to inequality across ethno-regional settings in LMICs. As Gilson and Raphaely (2008) and Raphael (2010) have observed, health policy research in these contexts often neglects the politics of decision-making and the enduring effects of structural injustice. By integrating political economy with a comprehensive policy analysis framework, this study contributes to a more robust understanding of how inequality is produced and sustained. Its findings aim to inform more inclusive, just, and contextually responsive policy responses—both in Ethiopia and in other LMICs where spatial health inequalities reflect broader failures of governance, representation, and institutional accountability. 2. Methods 2.1 Research Paradigm and Methodological Orientation This study is grounded in a constructivist ontology and interpretivist epistemology , which assert that public policies and health inequalities are shaped by socially constructed meanings, power relations, and institutional dynamics. Rather than viewing policy as a neutral or technical process, this perspective highlights how actors interpret problems, frame solutions, and interact within historically and politically embedded contexts (Harding, 2004; Gilson et al., 2011; Bryman, 2012). This approach supports a qualitative methodological orientation aimed at unpacking the complex and dynamic processes underlying persistent health inequalities. The researcher's personal and professional background in public policy and health systems further enriched the inquiry through critical reflexivity and contextual insight. 2.2 Research Design An embedded single-case study design (Yin, 2003) was employed to enable in-depth analysis of Ethiopia’s child health policy processes at both national and subnational levels. The Afar region was selected as a critical case due to its persistently poor child health outcomes and systemic marginalisation, making it an illustrative context for examining spatial inequality. This design allowed the researcher to explore how actors , institutions , and global influences interact to shape policy content , implementation processes , and equity outcomes across different governance levels. 2.3 Data Collection a) Document Analysis A total of 53 policy documents were reviewed, including: Global governance frameworks (e.g., UN conventions, AU instruments) National policies (e.g., the Constitution, HSDPs, HSTPs, and GTPs) Sectoral strategies related to health, education, water/sanitation (WASH), and social protection Inclusion criteria focused on documents with relevance to child health equity, regional development, and policy implementation from 1991 to 2021. Documents were sourced from official government portals, ministries, and international organisations. A combination of content and discourse analysis was applied, using a structured thematic coding framework to examine policy narratives, actor positioning, institutional dynamics, and framing of equity (George, 2009; Paltridge, 2006). b) Semi-Structured Interviews A total of 23 key informant interviews were conducted with policymakers, parliamentarians, advisors, and development partners operating at both federal and regional levels. Participants were selected through purposive and snowball sampling techniques (Patton, 2002; Glaser & Strauss, 1967). The sample included six officials from the Ministry of Health (federal and subnational levels), three national parliamentarians, three representatives from the Ministries of Finance, Peace, and Water, two parliamentary advisors, and nine representatives from bilateral and multilateral development agencies. The interview guide was developed specifically for this study based on the conceptual frameworks and research objectives. It was tailored to each respondent group, piloted, and iteratively refined to ensure clarity and contextual relevance. Interviews were conducted in English or Amharic, transcribed, and analysed using NVivo 12. Data collection continued until thematic saturation was achieved. An English-language version of the final interview guide is included as Supplementary File 1 and referenced in the manuscript. 2.4 Ethical Considerations The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the University of Sunderland Ethics Committee. All participants received written information, provided informed consent, and were assured of confidentiality. Data were anonymised, securely stored, and used solely for research purposes. Ethical principles of beneficence, justice, and respect guided all stages of the research (Lincoln & Guba, 1985; Lobzhanidze et al., 2016). 2.5 Analytical Framework and Data Analysis The study employed Framework Analysis (Ritchie & Spencer, 1994), a structured and transparent method suited to applied policy research. The analysis followed five stages: 1. Familiarization with transcripts and documents 2. Identifying a thematic framework (deductive from theory, inductive from data) 3. Indexing and coding with NVivo 4. Charting themes across data sources 5. Mapping and interpretation to generate explanatory insights Two complementary theoretical frameworks guided the analysis: Policy Triangle Framework ( Walt & Gilson, 1994 ): Applied to examine policy content , actors , processes , and context , with attention to how decisions are shaped across multiple levels of governance. Political Economy Analysis Framework ( Moncrieffe & Luttrell, 2005; Buse et al., 2012 ): Used to explore historical legacies , power asymmetries , institutional structures , and donor influence in the production of inequality. The combined use of these frameworks allowed for a layered and multidimensional analysis of both what policy says and why structural inequalities persist, despite reform rhetoric. An initial set of 14 themes and 74 codes expanded to 18 themes and 114 codes as new patterns emerged. Analytical rigour was ensured through triangulation, member validation, and reflexive engagement (Miles & Huberman, 1994; Guest et al., 2014). 2.6 Trustworthiness: Reliability, Validity, and Transferability Reliability was supported by transparent procedures, standardized interview protocols, and consistent coding. Validity was enhanced through triangulation across data sources, member checking, and rich contextualization. Transferability was enabled through detailed case description and the use of generalizable conceptual frameworks that may inform similar settings. The researcher’s familiarity with Ethiopian public institutions and global policy environments further supported nuanced interpretation while maintaining a reflexive stance to ensure analytical balance. 3. Results 3.1 Historical Legacies and Spatial Disadvantage The Afar region’s underdevelopment is rooted in its incorporation into the Ethiopian state through centralized state-building in the late 19th century. This process established patterns of political exclusion and limited public investment in peripheral regions. Historical and policy documents reviewed confirm that the Afar region was long treated as a periphery, with development efforts focused primarily on the highland core. This legacy has shaped both attitudes and institutional frameworks that persist to this day​. “Historically, regions like Afar have often been seen as peripheral to the national development agenda. As a result, critical services such as education and health infrastructure were not prioritised.” — Participant 5 This is further reflected in earlier imperial policies and the central government’s allocation of land and resources, where vast areas of Afar pasture were granted to state elites and investors, undermining traditional pastoral livelihoods​. Policy efforts such as the Villagization Program and subsequent infrastructure investments continued to marginalize Afar pastoralists by framing their mobility as a developmental problem rather than adapting services to nomadic lifestyles​. 3.2 Institutional Fragmentation, Weak Regional Capacity, and Accountability Gaps Despite Ethiopia’s federal structure granting autonomy to regional states, policy interviews and documents highlight persistent top-down planning. Major strategies such as the Health Sector Development Program (HSDP) and Growth and Transformation Plans (GTP I & II) were developed at the federal level with limited consultation or adaptation to regional realities​. “Our regional strategies largely follow federal frameworks, even when they may not fully align with local needs. There’s limited flexibility for adaptation.” — Participant 13 Regional administrations—particularly in Afar—face significant technical and human resource constraints, impeding their ability to contextualize or implement policy effectively. In practice, regional planning often mirrors federal templates, despite local variations in population mobility, climate, and geography​. Moreover, ambiguities in the division of responsibilities between federal and regional actors weaken accountability. Federal ministries lack enforcement mechanisms over regional outcomes, while regional offices lack sufficient autonomy or capacity to innovate. “It’s difficult to say who is responsible when something fails. The federal government says it’s up to us, but we lack the tools to do things differently.” — Participant 2 The lack of cross-sectoral coordination at the regional level, particularly among health, education, and water bureaus, further impedes integrated responses to child health. 3.3 Ideological Framing: Efficiency Over Equity A recurrent theme across interviews and document analysis is that equity—though often cited in mission statements and strategic plans—has been subordinated to efficiency and scale. For example, the Health Sector Transformation Plan I (HSTP-I) acknowledges equity as a goal, but the implementation has disproportionately focused on population-level coverage targets rather than reaching hard-to-reach groups like pastoralists​. “Everyone talks about fairness, but in regard to funding, it’s all about numbers—how many people reached, not who is being left behind.” — Participant 10 This framing is embedded in flagship programs such as the Health Extension Program (HEP), which was developed with sedentary agrarian populations in mind. Its static model proved ineffective in Afar, where households are mobile and seasonal migration is common​. Despite longstanding recognition that “special attention shall be given to the health needs of women and children” (FMOH, 1993), neither budget allocations nor service models reflected these commitments in practice. 3.4 Donor Influence and Global Governance Norms Donors play a major role in Ethiopia’s health system, contributing substantial financial and technical support. However, the analysis reveals that donor-driven policy agendas often emphasize standardized metrics, vertical programming, and short-term impact rather than addressing deeper structural inequalities​. “Donors want numbers and quick wins. That’s understandable, but it doesn’t always help places like Afar, where progress is slow and context matters.” — Participant 3 Documents such as the Paris Declaration on Aid Effectiveness (2005) and Ethiopia’s UN Country Framework commit donors to country ownership and alignment. However, in practice, many initiatives are channeled through federal institutions, reinforcing centralized control and limiting space for regional innovation​. Equity rhetoric is common in donor frameworks—USAID, DFID, and the World Bank mention marginalized populations, including pastoralists—but these priorities are rarely operationalized in disaggregated planning or targeted investments​. Summary of Findings Taken together, these findings demonstrate that child health inequalities in Afar are not merely the result of service delivery gaps, but are rooted in deeper structural and political economic factors. Historical marginalization, weak regional institutions, technocratic policy framing, and donor-driven planning have combined to entrench spatial inequity. Despite rhetorical commitments to equity, public policy processes in Ethiopia remain insufficiently sensitive to the realities of ethnically and geographically distinct regions like Afar. Without confronting the institutional biases and power dynamics embedded in both national and global policy systems, efforts to improve child health equity are unlikely to succeed. 4. Discussion This study set out to investigate how Ethiopia’s public policy processes and broader political economy structures contribute to persistent spatial inequalities in child health, focusing on the Afar region. Using Walt and Gilson’s (1994) Policy Triangle and Moncrieffe and Luttrell’s (2005) Political Economy Framework, the analysis reveals how structural marginalisation, institutional fragmentation, ideological framing, and global donor influence intersect to entrench health inequalities across geographic space. Rather than viewing these inequalities as implementation deficits or technical inefficiencies, the findings underscore that they are deeply embedded in historical legacies, policy logics, and governance arrangements. This framing resonates with Reich’s (2019) assertion that inequities in health outcomes are frequently political in origin and sustained by policy processes that obscure power asymmetries and normative biases. 4.1 Structural Drivers and the Legacy of Marginalisation The findings affirm that spatial inequalities in child health are not accidental or residual—they are historically rooted and systematically reproduced. As Kanbur and Venables (2005) and Bambra et al. (2019) argue, such inequalities are often a consequence of spatially uneven investment, long-standing socio-political exclusion, and institutional neglect. The integration of the Afar region into the modern Ethiopian state during the late 19th and early 20th centuries was marked by hierarchical centralisation, in which peripheral regions were subordinated without adequate public investment or representation (Harbeson, 1978; Zewde, 2002). Afar was constructed more as a security frontier than a developmental priority, shaping both historical underinvestment and enduring political marginalisation. Although Ethiopia’s Constitution (FDRE, 1995, Article 89[4]) enshrines the principle of equitable development, policy frameworks such as the Growth and Transformation Plans (MoFED, 2010; 2015) and the Health Sector Development and Transformation Plans (FMOH, 2010; 2015; 2020) refer to pastoralist regions in generic terms and fail to institutionalise equity in budgeting or implementation. The framing of Afar as “hard to reach” or “lagging behind” obscures the systemic and political roots of its underdevelopment. This aligns with Bourdieu’s (1986, 1992) notion of symbolic violence—where dominant discourses define some populations as “other,” thereby justifying their neglect. Fraser’s (2005) theory of social justice—focused on redistribution, recognition, and representation—helps unpack these dynamics. The Afar region suffers from redistributive injustice (limited fiscal resources), misrecognition (framed as a burden rather than a rights-bearing constituency), and representational exclusion (limited voice in national policymaking). Marmot (2005) further asserts that such systemic inequalities should be seen not only as development failures but as avoidable injustices, requiring structural remedies rather than programmatic adjustments. 4.2 Institutional Gaps: Fragmentation and Weak Accountability Despite Ethiopia’s federalist design, the actual governance of the health sector remains heavily centralised. As Vaughan (2003) and Libman and Obydenkova (2019) note, decentralisation in hybrid or authoritarian federal systems is often more symbolic than substantive. Health policy planning and budget allocation are primarily driven by central authorities, with limited discretion left to regional bureaus—particularly in regions like Afar that lack political leverage and technical capacity. Federal policy documents—including the Health Sector Development Plan IV and Health Sector Transformation Plans I and II (FMOH, 2015; 2020)—acknowledge regional inequalities, but their design remains top-down. These frameworks prioritise centralised performance metrics and universal templates that do not account for regional diversity. Interviews with regional officials revealed that health bureaus in Afar lack the financial autonomy, technical flexibility, and institutional support to tailor services to their socio-ecological context. Instead, they are expected to adapt to pre-defined national priorities without meaningful input or resources. Bossert and Mitchell’s (2011) “decision space” framework captures this gap between formal responsibilities and actual autonomy. In Ethiopia, decentralisation has granted nominal authority to regions but withheld the political and institutional conditions required to exercise it. This mismatch is echoed in other LMICs. In Nigeria, central budget control limits local innovation (Olaniyan & Lawanson, 2010); in India, conditional funding and rigid schemes undercut the promise of responsive decentralisation (George, 2009; Rao et al., 2005). Walt and Gilson’s (1994) emphasis on the alignment of actors, processes, and contexts further explains how fragmented roles and weak accountability mechanisms hinder effective policy delivery. Without clear mandates or structured intergovernmental coordination, efforts to improve service delivery in regions like Afar are diluted. The failure to institutionalise vertical and horizontal accountability not only weakens implementation but also exacerbates distrust between levels of government. 4.3 Ideological Bias: Equity as Rhetoric, Efficiency as Practice Ethiopia’s health policy discourse frequently invokes equity as a guiding principle, but in practice, efficiency and coverage dominate the agenda. This disjuncture between rhetorical commitments and operational priorities is a recurring theme in global health systems (Reich, 2019; Gilson & Raphaely, 2008). The Health Extension Program (HEP), although successful in expanding basic services, was conceptualised around static, community-based delivery models that are ill-suited to the realities of pastoralist and mobile populations in Afar (Banteyerga, 2011; Admasu et al., 2016). This mirrors experiences elsewhere. In India, the National Rural Health Mission promised equity but operationalised it through centralised, conditional programming that stifled regional adaptation (George, 2009). In Kenya, devolution reforms promised more responsive governance, but were hampered by bureaucratic inertia and limited fiscal autonomy at the county level (Tsofa et al., 2017). From a justice perspective, Ethiopia’s prevailing policy logic fails fundamental ethical tests. Rawls’ (2009) difference principle asserts that inequalities are only just if they benefit the least advantaged—an ideal clearly unmet in Afar’s case. Daniels (2008) underscores that health policies must actively protect the vulnerable, while Sen’s (1999) capabilities approach reminds us that health equity is not merely about access but about expanding real freedoms and agency. Uniform service models constrain these freedoms rather than enabling them. Fraser’s (2005) model reinforces this point: Afar’s mischaracterisation as “difficult to serve” reflects a failure of recognition; its lack of adapted services reflects distributive injustice; and its exclusion from policy design highlights representational marginalisation. Without addressing all three dimensions, equity remains performative rather than transformative. 4.4 Global Governance: Donor Influence and Policy Translation Gaps Donor engagement has played a central role in Ethiopia’s health sector development. Programmes targeting child mortality, maternal health, and infectious diseases have improved national indicators. Yet, this donor-led architecture has also reinforced centralisation and a focus on technocratic, easily measurable outputs (Ruducha et al., 2017; Reich, 1995). The One Plan, One Budget, One Report (OPB) framework aligned donor funding with national strategies but left little space for regionally tailored innovations. Donor preferences for “quick wins” and measurable performance—such as immunisation coverage and facility construction—often sideline structurally marginalised populations like those in Afar, who require more flexible, long-term strategies. Gilson et al. (2011) and Muntaner et al. (2009) caution that such efficiency-driven approaches risk depoliticising health equity and sustaining structural exclusion under a veneer of evidence-based practice. Reich (1995) and Gilson and Raphaely (2008) further argue that donors often avoid politically sensitive reforms in favour of technocratic fixes, resulting in policies that may be effective in aggregate terms but inequitable in distribution. Comparative evidence from Tanzania, Mozambique, and Bangladesh shows similar outcomes: donor harmonisation increased central control but eroded space for subnational responsiveness (Brinkerhoff & Bossert, 2008; Pavignani & Dura, 2009). Ethiopia’s case is emblematic of this broader global governance dilemma—between rhetorical commitments to equity and performance frameworks that prioritise short-term, centrally managed success. 4.5 Advancing Health Policy Analysis Through Political Economy This study contributes to a growing body of health policy research that emphasises the importance of political economy and context-sensitive analysis in LMICs (Gilson & Raphaely, 2008; Gilson et al., 2018). By integrating Walt and Gilson’s (1994) Policy Triangle with Moncrieffe and Luttrell’s (2005) political economy approach, the study illuminates how actors, institutions, and ideologies interact to structure health policy outcomes. As Reich (2019) and Grindle and Thomas (1991) suggest, reforms in health are shaped not only by evidence and efficiency but also by elite interests, institutional constraints, and political negotiations. This perspective reveals how inequality is built into the design and governance of health systems, rather than arising from unintended consequences. Understanding “who gets what, when, and how” in policy processes is essential for disrupting these patterns of exclusion. Ultimately, the findings underscore that spatial child health inequalities in Ethiopia are not exceptions—they are structural outcomes of policy systems that privilege uniformity, centralised control, and technocratic metrics over justice, participation, and contextual relevance. 5. Conclusion This study examined why spatial child health inequalities persist in Ethiopia, focusing on the Afar region. Drawing on political economy and policy analysis frameworks, it demonstrates that these inequalities are not simply due to technical weaknesses or implementation failures. Instead, they reflect entrenched historical, institutional, and ideological structures that shape health policy formulation, resource allocation, and service delivery. Despite formal commitments to equity, Afar continues to face systemic exclusion through centralised decision-making, symbolic decentralisation, and inflexible, standardised service models that overlook the region’s distinct needs. Efficiency-driven governance—reinforced by domestic planning logics and donor frameworks—undermines the realisation of health equity on the ground. This study contributes to global health policy scholarship by showing that inequality is embedded in the very architecture of policymaking. The Ethiopian case mirrors broader global trends in countries such as India, Kenya, and Mozambique, where centralised planning and donor-driven standardisation constrain meaningful reform and subnational agency. To address these inequalities, Ethiopia must move from rhetorical commitments to structural transformation. This requires: Genuine decentralization , with operational and fiscal autonomy for regional health bureaus; Equity-sensitive service designs that reflect the lived realities of underserved populations; Robust accountability mechanisms that link funding and performance to inclusive outcomes; and Donor engagement strategies that prioritise long-term, locally driven capacity-building over short-term numerical success. Ultimately, reducing spatial health inequalities demands more than policy reforms—it requires confronting marginalisation as a political and ethical injustice. Justice-driven, power-conscious governance is essential to transforming Ethiopia’s health system into one that serves all regions equitably. Abbreviations • SDGs • Sustainable Development Goals • LMICs • Low- and Middle-Income Countries • HEP • Health Extension Program • UHC • Universal Health Coverage • WHO • World Health Organization • FDRE • Federal Democratic Republic of Ethiopia • DPs • Development Partners • DAPs • Development Assistance Partners • MoH • Ministry of Health • NGO • Non-Governmental Organisation • CSDH • Commission on Social Determinants of Health Declarations Conflict of Interest Statement The author declares no conflicts of interest. Funding Statement This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Acknowledgments The author wishes to thank the key informants, policy advisors, and Ministry of Health representatives in Ethiopia who contributed valuable insights to this study. Gratitude is also extended to the University of Sunderland for ethical oversight and academic guidance throughout the research process. Ethics approval and consent to participate This study received ethical approval from the University of Sunderland Ethics Committee. All participants received written information, provided informed consent, and were assured of confidentiality. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Consent for publication All participants were informed about the intended dissemination of findings and consented to the publication of anonymized data. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to confidentiality agreements with participants, but are available from the corresponding author on reasonable request. Competing interests The author declares no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions Anteneh Gebremichael Dobamo is the sole author of this study. He conceived the research idea, conducted data collection and analysis, and drafted and revised the manuscript. Acknowledgements The author extends sincere gratitude to the policymakers, advisors, and Ministry of Health officials who participated in the study. Appreciation is also due to the University of Sunderland for academic guidance and ethical oversight. Authors' information Anteneh Gebremichael Dobamo holds an MPH, MA, and PhD, with expertise in public health policy and political economy. He can be contacted at 📧 [email protected] . References Abbott, P., Wallace, C., & Sapsford, R. (2004). The social policy of the European Union. Palgrave Macmillan. Admasu, K., Balcha, T., & Getahun, H. (2016). 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Social stratification: Class, race, and gender in sociological perspective. Westview Press. Gudina, M. (2006). Contradictory interpretations of Ethiopian history: The need for a new paradigm. In D. Turton (Ed.), Ethnic federalism: The Ethiopian experience in comparative perspective (pp. 67–86). James Currey. Harding, S. (Ed.). (2004). The feminist standpoint theory reader: Intellectual and political controversies. Routledge. Harbeson, J. W. (1978). The Ethiopian Afar and the state. African Affairs, 77(307), 479–496. Kanbur, R., & Venables, A. J. (2005). Spatial inequalities and development. In R. Kanbur & A. J. Venables (Eds.), Spatial inequality and development (pp. 3–10). Oxford University Press. Kingdon, J. W. (1995). Agendas, alternatives, and public policies (2nd ed.). HarperCollins. Lee, K., & Walt, G. (2014). Globalisation, global health, and the politics of governance. In M. Parker & I. Harper (Eds.), The anthropology of public health (pp. 81–98). Routledge. Libman, A., & Obydenkova, A. (2019). Understanding authoritarian federalism: Comparative insights and conceptual framework. Democratization, 26(7), 1151–1169. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Sage Publications. Lobzhanidze, M., Lewis, J., & Reynolds, L. (2016). Ethical guidance for social science field research in low- and middle-income countries. ODI Working Paper. Mamdani, M. (1996). Citizen and subject: Contemporary Africa and the legacy of late colonialism. Princeton University Press. Marmot, M. (2005). Social determinants of health inequalities. The Lancet, 365(9464), 1099–1104. Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis: An expanded sourcebook (2nd ed.). Sage Publications. Ministry of Health (FMOH). (2005–2020). Health Sector Development Plans (HSDP I–IV) and Health Sector Transformation Plans I & II. Ministry of Health, Ethiopia. Moncrieffe, J., & Luttrell, C. (2005). An analytical framework for understanding the political economy of policy-making. Overseas Development Institute. Mosse, D. (2013). The anthropology of international development. Annual Review of Anthropology, 42, 227–246. Muntaner, C., Sridharan, S., & Solar, O. (2009). Canada’s global perspective on health equity. International Journal of Health Services, 39(2), 355–371. Paltridge, T. (2006). Discourse analysis. In R. Carter & D. Nunan (Eds.), The Cambridge guide to teaching English to speakers of other languages (pp. 36–43). Cambridge University Press. Patton, M. Q. (2002). Qualitative research and evaluation methods (3rd ed.). Sage Publications. Pavignani, E., & Dura, L. (2009). Health sector coordination in post-conflict settings. World Health Organization. Piguet, F. (2001). When people are made poor: The causes of poverty in Afar pastoral areas of Ethiopia. UN-Emergencies Unit for Ethiopia. Raphael, D., & Bryant, T. (2019). The politics of health in the Canadian welfare state (3rd ed.). Canadian Scholars Press. Rawls, J. (2009). A theory of justice (Rev. ed.). Harvard University Press. Reich, M. R. (1995). The politics of health sector reform in developing countries: Three cases of pharmaceutical policy. Health Policy, 32(1–3), 47–77. Reich, M. R. (2019). Political economy analysis for health. Bulletin of the World Health Organization, 97(8), 514–514A. Ritchie, J., & Spencer, L. (1994). Qualitative data analysis for applied policy research. In A. Bryman & R. G. Burgess (Eds.), Analysing qualitative data (pp. 173–194). Routledge. Rao, K. D., Ramani, S., Hazarika, I., George, S., & Mundodan, J. M. (2005). India’s health workforce: Size, composition and distribution. Human Resources for Health, 3(1), 1–5. Sabatier, P. A. (1986). Top-down and bottom-up approaches to implementation research. Journal of Public Policy, 6(1), 21–48. Sheikh, K., George, A., & Gilson, L. (2011). People-centred science: Strengthening the practice of health policy and systems research. Health Research Policy and Systems, 9, 30. Solar, O., & Irwin, A. (2010). A conceptual framework for action on the social determinants of health. World Health Organization. Sriram, V., Sheikh, K., & Bennett, S. (2018). Governing the mixed health workforce: Learning from Asian contexts. Health Policy and Planning, 33(5), 505–514. Ssengooba, F., Ekirapa-Kiracho, E., & Onama, V. (2017). Sub-national health planning and equity in Uganda. International Journal for Equity in Health, 16, 207. Stake, R. E. (1995). The art of case study research. Sage Publications. Tesfaye, F., et al. (2017). Factors affecting child mortality in Afar region. BMC Pediatrics, 17, 212. Tsofa, B., Goodman, C., Gilson, L., & Molyneux, S. (2017). Devolution and its effects on health workforce and commodities management – early implementation experiences in Kilifi County, Kenya. International Journal for Equity in Health, 16, 169. Tumusiime, P. (2018). Universal health coverage: What it means for Ethiopia. Ethiopian Journal of Health Development, 32(1), 2–4. United Nations. (2015). Transforming our world: The 2030 agenda for sustainable development. https://sdgs.un.org/2030agenda USAID. (2019). Ethiopia country development cooperation strategy: 2011–2019. Vaughan, S. (2003). Ethnicity and power in Ethiopia. University of Edinburgh. Walt, G., & Gilson, L. (1994). Reforming the health sector in developing countries: The central role of policy analysis. Health Policy and Planning, 9(4), 353–370. World Bank. (2006). World development report 2006: Equity and development. Oxford University Press. World Bank. (2017). Ethiopia country assistance evaluation. World Health Organization. (2008). World Health Report: Primary health care now more than ever. World Health Organization. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. World Health Organization. (2017). Tracking universal health coverage: 2017 global monitoring report. https://www.who.int/healthinfo/universal_health_coverage/en/ Yin, R. K. (2003). Case study research: Design and methods (3rd ed.). Sage Publications. Zewde, B. (2002). A history of modern Ethiopia, 1855–1991 (2nd ed.). Ohio University Press. Additional Declarations No competing interests reported. Supplementary Files SemiStructuredInterviewGuide.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 29 Aug, 2025 Reviewers invited by journal 29 Jul, 2025 Editor assigned by journal 07 Jul, 2025 Editor invited by journal 09 May, 2025 Submission checks completed at journal 08 May, 2025 First submitted to journal 08 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6498222","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":492631215,"identity":"071b5eda-a3a5-4589-8496-86f3a3f89342","order_by":0,"name":"Anteneh Gebremichael DOBAMO","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYDADA/YGEGlBpPIDIMU8YFKCFC0SCSAmEVr4pZufPf5QcUfOXPL51Q0/CiQY+Nu7E/BqkZxzzNzgwJlnxpazc8pu9gAdJnHm7Aa8WgxuJJhJHGw7nLjhdk7aDR6gFgOJXPxa7G+kf5M4+O9w/YabZ9Ju/iFGi4FEDtCWhsMJBjfYj90myhaJO2fKJM4cO2y44UwO220ZAwkegn7hn92+TaKi5rC8wfHjz26++WMjx9/ei18LUkTwGIBJ/MpRtbA/IKx6FIyCUTAKRiQAAEm7TWBDREFJAAAAAElFTkSuQmCC","orcid":"","institution":"Ethiopian Public Health Association","correspondingAuthor":true,"prefix":"","firstName":"Anteneh","middleName":"Gebremichael","lastName":"DOBAMO","suffix":""}],"badges":[],"createdAt":"2025-04-21 18:38:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6498222/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6498222/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88097074,"identity":"21df94bc-a3d3-47cc-9305-bd2ba845b5a4","added_by":"auto","created_at":"2025-08-01 11:02:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45363,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConceptual and Analytical Framework\u003c/strong\u003e\u003cbr\u003e\n \u003cem\u003e(Adapted from Walt \u0026amp; Gilson, 1994; Moncrieffe \u0026amp; Luttrell, 2005)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6498222/v1/2caeec8eb2dab0c1766c3d5d.png"},{"id":88101180,"identity":"ce00f8e6-f361-439d-acf1-ef1bcbd1fd77","added_by":"auto","created_at":"2025-08-01 11:26:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1198924,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6498222/v1/20e300b2-8ad0-4a92-a7e3-8a067c4b3e1a.pdf"},{"id":88097076,"identity":"60588dc1-3aed-49e1-900b-83f38fb3ae3f","added_by":"auto","created_at":"2025-08-01 11:02:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":509993,"visible":true,"origin":"","legend":"","description":"","filename":"SemiStructuredInterviewGuide.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6498222/v1/1bcc6942cb21e86ede93249f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Political Economy of Spatial Child Health Inequalities in Ethiopia: A Public Policy Analysis\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eHealth inequalities remain among the most enduring and ethically urgent challenges in global development. While international frameworks such as the Sustainable Development Goals (SDGs) have committed to reducing child mortality and improving health equity, low- and middle-income countries (LMICs) continue to experience deep and persistent inequalities. These inequalities are especially pronounced in regions marked by structural marginalisation, weak institutional capacity, and limited access to essential public services (CSDH, 2008; WHO, 2008; UN, 2022).\u003c/p\u003e\u003cp\u003eIn mainstream policy discourse across LMICs, health inequalities are frequently conceptualized through biomedical or technical lenses, focusing predominantly on service delivery infrastructure and accessibility challenges. Such framings often overlook the political, economic, and institutional forces that shape who benefits from policy and how equity is (or is not) operationalized. As a result, deeper questions about governance, power, and historical injustice remain underexplored in many policy analyses (Gilson \u0026amp; Raphaely, 2008; Reich, 1995; Bambra et al., 2019). A more comprehensive approach is needed\u0026mdash;one that moves beyond policy content to examine the broader processes, actors, and contexts that shape public policy design and implementation.\u003c/p\u003e\u003cp\u003eTo address this gap, the study draws on two complementary frameworks: the Policy Triangle Framework developed by Walt and Gilson (1994) and a Political Economy approach as elaborated by Moncrieffe and Luttrell (2005) and Buse, Mays, and Walt (2012). The Policy Triangle offers a structured way to examine policy through four interconnected dimensions\u0026mdash;content, context, process, and actors\u0026mdash;providing a multidimensional understanding of policy formation and implementation. The Political Economy approach, in turn, illuminates how structural power relations, institutional legacies, and global influences shape the priorities, incentives, and constraints within policy systems. Together, these frameworks enable a more critical and layered analysis of how inequalities in health emerge, persist, and are legitimized within public policy.\u003c/p\u003e\u003cp\u003eEthiopia provides a compelling case to explore these dynamics. The country has achieved measurable progress in reducing national under-five mortality, with rates falling to 67 per 1,000 live births by 2016 (CSA \u0026amp; ICF, 2016). However, these national averages conceal stark subnational inequalities. The Afar region, for example, recorded the highest under-five mortality rate in the country\u0026mdash;125 deaths per 1,000 live births\u0026mdash;nearly double the national average. Despite decades of investment in health infrastructure and decentralisation reforms, Afar continues to experience some of the poorest child health outcomes in the country.\u003c/p\u003e\u003cp\u003eThese inequalities cannot be attributed solely to geographic remoteness or cultural difference. While Afar\u0026rsquo;s arid landscape, mobile pastoralist livelihoods, and dispersed rural settlements present logistical challenges, these are compounded by a long-standing legacy of political exclusion, underdevelopment, and weak institutional support. National development strategies have historically prioritised central highland regions, leaving peripheral areas like Afar structurally disadvantaged (EEA, 2021; Piguet, 2001; Tesfaye et al., 2017). Furthermore, Ethiopia\u0026rsquo;s federal structure, while formally decentralised, has often failed to devolve meaningful authority or resources to regional governments\u0026mdash;limiting their ability to design and implement locally appropriate health policies (Kanbur \u0026amp; Venables, 2005; Moncrieffe \u0026amp; Luttrell, 2005).\u003c/p\u003e\u003cp\u003eThe influence of international development actors has also shaped Ethiopia\u0026rsquo;s health policy landscape. Donor-supported initiatives have expanded access to services and contributed to progress toward universal health coverage (UHC), yet they have often prioritised vertical programs and performance-based metrics over equity-sensitive, context-specific reform. As a result, structurally marginalised regions like Afar remain underserved, their needs obscured within aggregate national indicators (CSDH, 2008; Ruducha et al., 2017; WHO, 2008).\u003c/p\u003e\u003cp\u003eThis study critically examines how Ethiopia\u0026rsquo;s public policy processes\u0026mdash;shaped by both domestic institutions and international influences\u0026mdash;contribute to the persistence of spatial child health inequalities. Using Afar as a case study, it investigates how actors, institutional structures, policy narratives, and decision-making processes intersect to shape policy outcomes across space. By applying the \u003cb\u003ePolicy Triangle Framework\u003c/b\u003e (Walt \u0026amp; Gilson, 1994) alongside a \u003cb\u003ePolitical Economy lens\u003c/b\u003e (Moncrieffe \u0026amp; Luttrell, 2005; Buse et al., 2012), the study moves beyond surface-level diagnoses to engage with the deeper structural, political, and institutional forces that shape child health outcomes.\u003c/p\u003e\u003cp\u003eIn doing so, this study addresses a critical gap in the literature: the lack of empirically grounded, process-sensitive, and context-aware analyses of how public policy contributes to inequality across ethno-regional settings in LMICs. As Gilson and Raphaely (2008) and Raphael (2010) have observed, health policy research in these contexts often neglects the politics of decision-making and the enduring effects of structural injustice. By integrating political economy with a comprehensive policy analysis framework, this study contributes to a more robust understanding of how inequality is produced and sustained. Its findings aim to inform more inclusive, just, and contextually responsive policy responses\u0026mdash;both in Ethiopia and in other LMICs where spatial health inequalities reflect broader failures of governance, representation, and institutional accountability.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e2.1 Research Paradigm and Methodological Orientation\u003c/h2\u003e\n \u003cp\u003eThis study is grounded in a \u003cstrong\u003econstructivist ontology\u003c/strong\u003e and \u003cstrong\u003einterpretivist epistemology\u003c/strong\u003e, which assert that public policies and health inequalities are shaped by socially constructed meanings, power relations, and institutional dynamics. Rather than viewing policy as a neutral or technical process, this perspective highlights how actors interpret problems, frame solutions, and interact within historically and politically embedded contexts (Harding, 2004; Gilson et al., 2011; Bryman, 2012). This approach supports a qualitative methodological orientation aimed at unpacking the complex and dynamic processes underlying persistent health inequalities. The researcher\u0026apos;s personal and professional background in public policy and health systems further enriched the inquiry through critical reflexivity and contextual insight.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e2.2 Research Design\u003c/h2\u003e\n \u003cp\u003eAn \u003cstrong\u003eembedded single-case study design\u003c/strong\u003e (Yin, 2003) was employed to enable in-depth analysis of Ethiopia\u0026rsquo;s child health policy processes at both national and subnational levels. The Afar region was selected as a critical case due to its persistently poor child health outcomes and systemic marginalisation, making it an illustrative context for examining spatial inequality. This design allowed the researcher to explore how \u003cstrong\u003eactors\u003c/strong\u003e, \u003cstrong\u003einstitutions\u003c/strong\u003e, and \u003cstrong\u003eglobal influences\u003c/strong\u003e interact to shape \u003cstrong\u003epolicy content\u003c/strong\u003e, \u003cstrong\u003eimplementation processes\u003c/strong\u003e, and \u003cstrong\u003eequity outcomes\u003c/strong\u003e across different governance levels.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003e2.3 Data Collection\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003ea) Document Analysis\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eA total of \u003cstrong\u003e53 policy documents\u003c/strong\u003e were reviewed, including:\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eGlobal governance frameworks\u003c/strong\u003e (e.g., UN conventions, AU instruments)\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eNational policies\u003c/strong\u003e (e.g., the Constitution, HSDPs, HSTPs, and GTPs)\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eSectoral strategies\u003c/strong\u003e related to health, education, water/sanitation (WASH), and social protection\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eInclusion criteria focused on documents with relevance to child health equity, regional development, and policy implementation from 1991 to 2021. Documents were sourced from official government portals, ministries, and international organisations. A combination of content and discourse analysis was applied, using a structured thematic coding framework to examine policy narratives, actor positioning, institutional dynamics, and framing of equity (George, 2009; Paltridge, 2006).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eb) Semi-Structured Interviews\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eA total of 23 key informant interviews were conducted with policymakers, parliamentarians, advisors, and development partners operating at both federal and regional levels. Participants were selected through purposive and snowball sampling techniques (Patton, 2002; Glaser \u0026amp; Strauss, 1967). The sample included six officials from the Ministry of Health (federal and subnational levels), three national parliamentarians, three representatives from the Ministries of Finance, Peace, and Water, two parliamentary advisors, and nine representatives from bilateral and multilateral development agencies.\u003c/p\u003e\n \u003cp\u003eThe interview guide was developed specifically for this study based on the conceptual frameworks and research objectives. It was tailored to each respondent group, piloted, and iteratively refined to ensure clarity and contextual relevance. Interviews were conducted in English or Amharic, transcribed, and analysed using NVivo 12. Data collection continued until thematic saturation was achieved. An English-language version of the final interview guide is included as Supplementary File 1 and referenced in the manuscript.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003e2.4 Ethical Considerations\u003c/h2\u003e\n \u003cp\u003eThe study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the University of Sunderland Ethics Committee. All participants received written information, provided informed consent, and were assured of confidentiality. Data were anonymised, securely stored, and used solely for research purposes. Ethical principles of beneficence, justice, and respect guided all stages of the research (Lincoln \u0026amp; Guba, 1985; Lobzhanidze et al., 2016).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e2.5 Analytical Framework and Data Analysis\u003c/h2\u003e\n \u003cp\u003eThe study employed Framework Analysis (Ritchie \u0026amp; Spencer, 1994), a structured and transparent method suited to applied policy research. The analysis followed five stages:\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e1. Familiarization with transcripts and documents\u003c/p\u003e\n \u003c/span\u003e\u003cspan\u003e\n \u003cp\u003e2. Identifying a thematic framework (deductive from theory, inductive from data)\u003c/p\u003e\n \u003c/span\u003e\u003cspan\u003e\n \u003cp\u003e3. Indexing and coding with NVivo\u003c/p\u003e\n \u003c/span\u003e\u003cspan\u003e\n \u003cp\u003e4. Charting themes across data sources\u003c/p\u003e\n \u003c/span\u003e\u003cspan\u003e\n \u003cp\u003e5. Mapping and interpretation to generate explanatory insights\u003c/p\u003e\n \u003c/span\u003e\n \u003cp\u003eTwo complementary theoretical frameworks guided the analysis:\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003ePolicy Triangle Framework\u003c/strong\u003e (\u003cem\u003eWalt \u0026amp; Gilson, 1994\u003c/em\u003e): Applied to examine \u003cstrong\u003epolicy content\u003c/strong\u003e, \u003cstrong\u003eactors\u003c/strong\u003e, \u003cstrong\u003eprocesses\u003c/strong\u003e, and \u003cstrong\u003econtext\u003c/strong\u003e, with attention to how decisions are shaped across multiple levels of governance.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003ePolitical Economy Analysis Framework\u003c/strong\u003e (\u003cem\u003eMoncrieffe \u0026amp; Luttrell, 2005; Buse et al., 2012\u003c/em\u003e): Used to explore \u003cstrong\u003ehistorical legacies\u003c/strong\u003e, \u003cstrong\u003epower asymmetries\u003c/strong\u003e, \u003cstrong\u003einstitutional structures\u003c/strong\u003e, and \u003cstrong\u003edonor influence\u003c/strong\u003e in the production of inequality.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eThe combined use of these frameworks allowed for a layered and multidimensional analysis of both what policy says and why structural inequalities persist, despite reform rhetoric. An initial set of 14 themes and 74 codes expanded to 18 themes and 114 codes as new patterns emerged. Analytical rigour was ensured through triangulation, member validation, and reflexive engagement (Miles \u0026amp; Huberman, 1994; Guest et al., 2014).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2.6 Trustworthiness: Reliability, Validity, and Transferability\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eReliability\u003c/strong\u003e was supported by transparent procedures, standardized interview protocols, and consistent coding.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eValidity\u003c/strong\u003e was enhanced through triangulation across data sources, member checking, and rich contextualization.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eTransferability\u003c/strong\u003e was enabled through detailed case description and the use of generalizable conceptual frameworks that may inform similar settings.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eThe researcher\u0026rsquo;s familiarity with Ethiopian public institutions and global policy environments further supported nuanced interpretation while maintaining a reflexive stance to ensure analytical balance.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Historical Legacies and Spatial Disadvantage\u003c/h2\u003e\u003cp\u003eThe Afar region\u0026rsquo;s underdevelopment is rooted in its incorporation into the Ethiopian state through centralized state-building in the late 19th century. This process established patterns of political exclusion and limited public investment in peripheral regions. Historical and policy documents reviewed confirm that the Afar region was long treated as a periphery, with development efforts focused primarily on the highland core. This legacy has shaped both attitudes and institutional frameworks that persist to this day​.\u003c/p\u003e\u003cp\u003e\u0026ldquo;Historically, regions like Afar have often been seen as peripheral to the national development agenda. As a result, critical services such as education and health infrastructure were not prioritised.\u0026rdquo; \u0026mdash; \u003cem\u003eParticipant 5\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis is further reflected in earlier imperial policies and the central government\u0026rsquo;s allocation of land and resources, where vast areas of Afar pasture were granted to state elites and investors, undermining traditional pastoral livelihoods​.\u003c/p\u003e\u003cp\u003ePolicy efforts such as the Villagization Program and subsequent infrastructure investments continued to marginalize Afar pastoralists by framing their mobility as a developmental problem rather than adapting services to nomadic lifestyles​.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Institutional Fragmentation, Weak Regional Capacity, and Accountability Gaps\u003c/h2\u003e\u003cp\u003eDespite Ethiopia\u0026rsquo;s federal structure granting autonomy to regional states, policy interviews and documents highlight persistent top-down planning. Major strategies such as the Health Sector Development Program (HSDP) and Growth and Transformation Plans (GTP I \u0026amp; II) were developed at the federal level with limited consultation or adaptation to regional realities​.\u003c/p\u003e\u003cp\u003e\u0026ldquo;Our regional strategies largely follow federal frameworks, even when they may not fully align with local needs. There\u0026rsquo;s limited flexibility for adaptation.\u0026rdquo; \u0026mdash; \u003cem\u003eParticipant 13\u003c/em\u003e\u003c/p\u003e\u003cp\u003eRegional administrations\u0026mdash;particularly in Afar\u0026mdash;face significant technical and human resource constraints, impeding their ability to contextualize or implement policy effectively. In practice, regional planning often mirrors federal templates, despite local variations in population mobility, climate, and geography​.\u003c/p\u003e\u003cp\u003eMoreover, ambiguities in the division of responsibilities between federal and regional actors weaken accountability. Federal ministries lack enforcement mechanisms over regional outcomes, while regional offices lack sufficient autonomy or capacity to innovate.\u003c/p\u003e\u003cp\u003e\u0026ldquo;It\u0026rsquo;s difficult to say who is responsible when something fails. The federal government says it\u0026rsquo;s up to us, but we lack the tools to do things differently.\u0026rdquo; \u0026mdash; \u003cem\u003eParticipant 2\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe lack of cross-sectoral coordination at the regional level, particularly among health, education, and water bureaus, further impedes integrated responses to child health.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Ideological Framing: Efficiency Over Equity\u003c/h2\u003e\u003cp\u003eA recurrent theme across interviews and document analysis is that equity\u0026mdash;though often cited in mission statements and strategic plans\u0026mdash;has been subordinated to efficiency and scale.\u003c/p\u003e\u003cp\u003eFor example, the Health Sector Transformation Plan I (HSTP-I) acknowledges equity as a goal, but the implementation has disproportionately focused on population-level coverage targets rather than reaching hard-to-reach groups like pastoralists​.\u003c/p\u003e\u003cp\u003e\u0026ldquo;Everyone talks about fairness, but in regard to funding, it\u0026rsquo;s all about numbers\u0026mdash;how many people reached, not who is being left behind.\u0026rdquo; \u0026mdash; \u003cem\u003eParticipant 10\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis framing is embedded in flagship programs such as the Health Extension Program (HEP), which was developed with sedentary agrarian populations in mind. Its static model proved ineffective in Afar, where households are mobile and seasonal migration is common​.\u003c/p\u003e\u003cp\u003eDespite longstanding recognition that \u0026ldquo;special attention shall be given to the health needs of women and children\u0026rdquo; (FMOH, 1993), neither budget allocations nor service models reflected these commitments in practice.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Donor Influence and Global Governance Norms\u003c/h2\u003e\u003cp\u003eDonors play a major role in Ethiopia\u0026rsquo;s health system, contributing substantial financial and technical support. However, the analysis reveals that donor-driven policy agendas often emphasize standardized metrics, vertical programming, and short-term impact rather than addressing deeper structural inequalities​.\u003c/p\u003e\u003cp\u003e\u0026ldquo;Donors want numbers and quick wins. That\u0026rsquo;s understandable, but it doesn\u0026rsquo;t always help places like Afar, where progress is slow and context matters.\u0026rdquo; \u0026mdash; \u003cem\u003eParticipant 3\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDocuments such as the Paris Declaration on Aid Effectiveness (2005) and Ethiopia\u0026rsquo;s UN Country Framework commit donors to country ownership and alignment. However, in practice, many initiatives are channeled through federal institutions, reinforcing centralized control and limiting space for regional innovation​.\u003c/p\u003e\u003cp\u003eEquity rhetoric is common in donor frameworks\u0026mdash;USAID, DFID, and the World Bank mention marginalized populations, including pastoralists\u0026mdash;but these priorities are rarely operationalized in disaggregated planning or targeted investments​.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSummary of Findings\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTaken together, these findings demonstrate that child health inequalities in Afar are not merely the result of service delivery gaps, but are rooted in deeper structural and political economic factors. Historical marginalization, weak regional institutions, technocratic policy framing, and donor-driven planning have combined to entrench spatial inequity.\u003c/p\u003e\u003cp\u003eDespite rhetorical commitments to equity, public policy processes in Ethiopia remain insufficiently sensitive to the realities of ethnically and geographically distinct regions like Afar. Without confronting the institutional biases and power dynamics embedded in both national and global policy systems, efforts to improve child health equity are unlikely to succeed.\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study set out to investigate how Ethiopia\u0026rsquo;s public policy processes and broader political economy structures contribute to persistent spatial inequalities in child health, focusing on the Afar region. Using Walt and Gilson\u0026rsquo;s (1994) Policy Triangle and Moncrieffe and Luttrell\u0026rsquo;s (2005) Political Economy Framework, the analysis reveals how structural marginalisation, institutional fragmentation, ideological framing, and global donor influence intersect to entrench health inequalities across geographic space. Rather than viewing these inequalities as implementation deficits or technical inefficiencies, the findings underscore that they are deeply embedded in historical legacies, policy logics, and governance arrangements. This framing resonates with Reich\u0026rsquo;s (2019) assertion that inequities in health outcomes are frequently political in origin and sustained by policy processes that obscure power asymmetries and normative biases.\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Structural Drivers and the Legacy of Marginalisation\u003c/h2\u003e\u003cp\u003eThe findings affirm that spatial inequalities in child health are not accidental or residual\u0026mdash;they are historically rooted and systematically reproduced. As Kanbur and Venables (2005) and Bambra et al. (2019) argue, such inequalities are often a consequence of spatially uneven investment, long-standing socio-political exclusion, and institutional neglect. The integration of the Afar region into the modern Ethiopian state during the late 19th and early 20th centuries was marked by hierarchical centralisation, in which peripheral regions were subordinated without adequate public investment or representation (Harbeson, 1978; Zewde, 2002). Afar was constructed more as a security frontier than a developmental priority, shaping both historical underinvestment and enduring political marginalisation.\u003c/p\u003e\u003cp\u003eAlthough Ethiopia\u0026rsquo;s Constitution (FDRE, 1995, Article 89[4]) enshrines the principle of equitable development, policy frameworks such as the Growth and Transformation Plans (MoFED, 2010; 2015) and the Health Sector Development and Transformation Plans (FMOH, 2010; 2015; 2020) refer to pastoralist regions in generic terms and fail to institutionalise equity in budgeting or implementation. The framing of Afar as \u0026ldquo;hard to reach\u0026rdquo; or \u0026ldquo;lagging behind\u0026rdquo; obscures the systemic and political roots of its underdevelopment. This aligns with Bourdieu\u0026rsquo;s (1986, 1992) notion of symbolic violence\u0026mdash;where dominant discourses define some populations as \u0026ldquo;other,\u0026rdquo; thereby justifying their neglect.\u003c/p\u003e\u003cp\u003eFraser\u0026rsquo;s (2005) theory of social justice\u0026mdash;focused on redistribution, recognition, and representation\u0026mdash;helps unpack these dynamics. The Afar region suffers from redistributive injustice (limited fiscal resources), misrecognition (framed as a burden rather than a rights-bearing constituency), and representational exclusion (limited voice in national policymaking). Marmot (2005) further asserts that such systemic inequalities should be seen not only as development failures but as avoidable injustices, requiring structural remedies rather than programmatic adjustments.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Institutional Gaps: Fragmentation and Weak Accountability\u003c/h2\u003e\u003cp\u003eDespite Ethiopia\u0026rsquo;s federalist design, the actual governance of the health sector remains heavily centralised. As Vaughan (2003) and Libman and Obydenkova (2019) note, decentralisation in hybrid or authoritarian federal systems is often more symbolic than substantive. Health policy planning and budget allocation are primarily driven by central authorities, with limited discretion left to regional bureaus\u0026mdash;particularly in regions like Afar that lack political leverage and technical capacity.\u003c/p\u003e\u003cp\u003eFederal policy documents\u0026mdash;including the Health Sector Development Plan IV and Health Sector Transformation Plans I and II (FMOH, 2015; 2020)\u0026mdash;acknowledge regional inequalities, but their design remains top-down. These frameworks prioritise centralised performance metrics and universal templates that do not account for regional diversity. Interviews with regional officials revealed that health bureaus in Afar lack the financial autonomy, technical flexibility, and institutional support to tailor services to their socio-ecological context. Instead, they are expected to adapt to pre-defined national priorities without meaningful input or resources.\u003c/p\u003e\u003cp\u003eBossert and Mitchell\u0026rsquo;s (2011) \u0026ldquo;decision space\u0026rdquo; framework captures this gap between formal responsibilities and actual autonomy. In Ethiopia, decentralisation has granted nominal authority to regions but withheld the political and institutional conditions required to exercise it. This mismatch is echoed in other LMICs. In Nigeria, central budget control limits local innovation (Olaniyan \u0026amp; Lawanson, 2010); in India, conditional funding and rigid schemes undercut the promise of responsive decentralisation (George, 2009; Rao et al., 2005).\u003c/p\u003e\u003cp\u003eWalt and Gilson\u0026rsquo;s (1994) emphasis on the alignment of actors, processes, and contexts further explains how fragmented roles and weak accountability mechanisms hinder effective policy delivery. Without clear mandates or structured intergovernmental coordination, efforts to improve service delivery in regions like Afar are diluted. The failure to institutionalise vertical and horizontal accountability not only weakens implementation but also exacerbates distrust between levels of government.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Ideological Bias: Equity as Rhetoric, Efficiency as Practice\u003c/h2\u003e\u003cp\u003eEthiopia\u0026rsquo;s health policy discourse frequently invokes equity as a guiding principle, but in practice, efficiency and coverage dominate the agenda. This disjuncture between rhetorical commitments and operational priorities is a recurring theme in global health systems (Reich, 2019; Gilson \u0026amp; Raphaely, 2008). The Health Extension Program (HEP), although successful in expanding basic services, was conceptualised around static, community-based delivery models that are ill-suited to the realities of pastoralist and mobile populations in Afar (Banteyerga, 2011; Admasu et al., 2016).\u003c/p\u003e\u003cp\u003eThis mirrors experiences elsewhere. In India, the National Rural Health Mission promised equity but operationalised it through centralised, conditional programming that stifled regional adaptation (George, 2009). In Kenya, devolution reforms promised more responsive governance, but were hampered by bureaucratic inertia and limited fiscal autonomy at the county level (Tsofa et al., 2017).\u003c/p\u003e\u003cp\u003eFrom a justice perspective, Ethiopia\u0026rsquo;s prevailing policy logic fails fundamental ethical tests. Rawls\u0026rsquo; (2009) \u003cem\u003edifference principle\u003c/em\u003e asserts that inequalities are only just if they benefit the least advantaged\u0026mdash;an ideal clearly unmet in Afar\u0026rsquo;s case. Daniels (2008) underscores that health policies must actively protect the vulnerable, while Sen\u0026rsquo;s (1999) capabilities approach reminds us that health equity is not merely about access but about expanding real freedoms and agency. Uniform service models constrain these freedoms rather than enabling them.\u003c/p\u003e\u003cp\u003eFraser\u0026rsquo;s (2005) model reinforces this point: Afar\u0026rsquo;s mischaracterisation as \u0026ldquo;difficult to serve\u0026rdquo; reflects a failure of recognition; its lack of adapted services reflects distributive injustice; and its exclusion from policy design highlights representational marginalisation. Without addressing all three dimensions, equity remains performative rather than transformative.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Global Governance: Donor Influence and Policy Translation Gaps\u003c/h2\u003e\u003cp\u003eDonor engagement has played a central role in Ethiopia\u0026rsquo;s health sector development. Programmes targeting child mortality, maternal health, and infectious diseases have improved national indicators. Yet, this donor-led architecture has also reinforced centralisation and a focus on technocratic, easily measurable outputs (Ruducha et al., 2017; Reich, 1995). The One Plan, One Budget, One Report (OPB) framework aligned donor funding with national strategies but left little space for regionally tailored innovations.\u003c/p\u003e\u003cp\u003eDonor preferences for \u0026ldquo;quick wins\u0026rdquo; and measurable performance\u0026mdash;such as immunisation coverage and facility construction\u0026mdash;often sideline structurally marginalised populations like those in Afar, who require more flexible, long-term strategies. Gilson et al. (2011) and Muntaner et al. (2009) caution that such efficiency-driven approaches risk depoliticising health equity and sustaining structural exclusion under a veneer of evidence-based practice.\u003c/p\u003e\u003cp\u003eReich (1995) and Gilson and Raphaely (2008) further argue that donors often avoid politically sensitive reforms in favour of technocratic fixes, resulting in policies that may be effective in aggregate terms but inequitable in distribution. Comparative evidence from Tanzania, Mozambique, and Bangladesh shows similar outcomes: donor harmonisation increased central control but eroded space for subnational responsiveness (Brinkerhoff \u0026amp; Bossert, 2008; Pavignani \u0026amp; Dura, 2009). Ethiopia\u0026rsquo;s case is emblematic of this broader global governance dilemma\u0026mdash;between rhetorical commitments to equity and performance frameworks that prioritise short-term, centrally managed success.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e4.5 Advancing Health Policy Analysis Through Political Economy\u003c/h2\u003e\u003cp\u003eThis study contributes to a growing body of health policy research that emphasises the importance of political economy and context-sensitive analysis in LMICs (Gilson \u0026amp; Raphaely, 2008; Gilson et al., 2018). By integrating Walt and Gilson\u0026rsquo;s (1994) Policy Triangle with Moncrieffe and Luttrell\u0026rsquo;s (2005) political economy approach, the study illuminates how actors, institutions, and ideologies interact to structure health policy outcomes.\u003c/p\u003e\u003cp\u003eAs Reich (2019) and Grindle and Thomas (1991) suggest, reforms in health are shaped not only by evidence and efficiency but also by elite interests, institutional constraints, and political negotiations. This perspective reveals how inequality is built into the design and governance of health systems, rather than arising from unintended consequences. Understanding \u0026ldquo;who gets what, when, and how\u0026rdquo; in policy processes is essential for disrupting these patterns of exclusion.\u003c/p\u003e\u003cp\u003eUltimately, the findings underscore that spatial child health inequalities in Ethiopia are not exceptions\u0026mdash;they are structural outcomes of policy systems that privilege uniformity, centralised control, and technocratic metrics over justice, participation, and contextual relevance.\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study examined why spatial child health inequalities persist in Ethiopia, focusing on the Afar region. Drawing on political economy and policy analysis frameworks, it demonstrates that these inequalities are not simply due to technical weaknesses or implementation failures. Instead, they reflect entrenched historical, institutional, and ideological structures that shape health policy formulation, resource allocation, and service delivery.\u003c/p\u003e\u003cp\u003eDespite formal commitments to equity, Afar continues to face systemic exclusion through centralised decision-making, symbolic decentralisation, and inflexible, standardised service models that overlook the region\u0026rsquo;s distinct needs. Efficiency-driven governance\u0026mdash;reinforced by domestic planning logics and donor frameworks\u0026mdash;undermines the realisation of health equity on the ground.\u003c/p\u003e\u003cp\u003eThis study contributes to global health policy scholarship by showing that inequality is embedded in the very architecture of policymaking. The Ethiopian case mirrors broader global trends in countries such as India, Kenya, and Mozambique, where centralised planning and donor-driven standardisation constrain meaningful reform and subnational agency.\u003c/p\u003e\u003cp\u003eTo address these inequalities, Ethiopia must move from rhetorical commitments to structural transformation. This requires:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eGenuine decentralization\u003c/b\u003e, with operational and fiscal autonomy for regional health bureaus;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eEquity-sensitive service designs\u003c/b\u003e that reflect the lived realities of underserved populations;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eRobust accountability mechanisms\u003c/b\u003e that link funding and performance to inclusive outcomes; and\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDonor engagement strategies\u003c/b\u003e that prioritise long-term, locally driven capacity-building over short-term numerical success.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eUltimately, reducing spatial health inequalities demands more than policy reforms\u0026mdash;it requires confronting marginalisation as a political and ethical injustice. Justice-driven, power-conscious governance is essential to transforming Ethiopia\u0026rsquo;s health system into one that serves all regions equitably.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; SDGs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u0026bull; Sustainable Development Goals\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; LMICs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u0026bull; Low- and Middle-Income Countries\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; HEP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u0026bull; Health Extension Program\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; UHC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u0026bull; Universal Health Coverage\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; WHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u0026bull; World Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; FDRE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u0026bull; Federal Democratic Republic of Ethiopia\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; DPs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u0026bull; Development Partners\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; DAPs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u0026bull; Development Assistance Partners\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; MoH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u0026bull; Ministry of Health\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; NGO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u0026bull; Non-Governmental Organisation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; CSDH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u0026bull; Commission on Social Determinants of Health\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The author declares no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The author wishes to thank the key informants, policy advisors, and Ministry of Health representatives in Ethiopia who contributed valuable insights to this study. Gratitude is also extended to the University of Sunderland for ethical oversight and academic guidance throughout the research process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethical approval from the University of Sunderland Ethics Committee. All participants received written information, provided informed consent, and were assured of confidentiality. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants were informed about the intended dissemination of findings and consented to the publication of anonymized data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to confidentiality agreements with participants, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnteneh Gebremichael Dobamo is the sole author of this study. He conceived the research idea, conducted data collection and analysis, and drafted and revised the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author extends sincere gratitude to the policymakers, advisors, and Ministry of Health officials who participated in the study. Appreciation is also due to the University of Sunderland for academic guidance and ethical oversight.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnteneh Gebremichael Dobamo holds an MPH, MA, and PhD, with expertise in public health policy and political economy. He can be contacted at 📧 [email protected].\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAbbott, P., Wallace, C., \u0026amp; Sapsford, R. (2004). The social policy of the European Union. 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(2010). A conceptual framework for action on the social determinants of health. World Health Organization.\u003c/li\u003e\n \u003cli\u003eSriram, V., Sheikh, K., \u0026amp; Bennett, S. (2018). Governing the mixed health workforce: Learning from Asian contexts. Health Policy and Planning, 33(5), 505\u0026ndash;514.\u003c/li\u003e\n \u003cli\u003eSsengooba, F., Ekirapa-Kiracho, E., \u0026amp; Onama, V. (2017). Sub-national health planning and equity in Uganda. International Journal for Equity in Health, 16, 207.\u003c/li\u003e\n \u003cli\u003eStake, R. E. (1995). The art of case study research. Sage Publications.\u003c/li\u003e\n \u003cli\u003eTesfaye, F., et al. (2017). Factors affecting child mortality in Afar region. BMC Pediatrics, 17, 212.\u003c/li\u003e\n \u003cli\u003eTsofa, B., Goodman, C., Gilson, L., \u0026amp; Molyneux, S. (2017). Devolution and its effects on health workforce and commodities management \u0026ndash; early implementation experiences in Kilifi County, Kenya. 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(2017). Ethiopia country assistance evaluation.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2008). World Health Report: Primary health care now more than ever.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2017). Tracking universal health coverage: 2017 global monitoring report. https://www.who.int/healthinfo/universal_health_coverage/en/\u003c/li\u003e\n \u003cli\u003eYin, R. K. (2003). Case study research: Design and methods (3rd ed.). Sage Publications.\u003c/li\u003e\n \u003cli\u003eZewde, B. (2002). A history of modern Ethiopia, 1855\u0026ndash;1991 (2nd ed.). Ohio University Press.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health inequality, political economy, public policy, decentralization, Ethiopia, Afar, child health, equity, global health governance","lastPublishedDoi":"10.21203/rs.3.rs-6498222/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6498222/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nDespite national progress in reducing child mortality, Ethiopia continues to exhibit significant spatial inequalities in child health outcomes. The Afar region, in particular, remains critically underserved. While technical challenges are often cited, such explanations overlook the deeper structural, political, and institutional drivers of inequality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e\u003cbr\u003e\nThis study investigates how public policy processes and political economy dynamics contribute to persistent spatial inequalities in child health in Ethiopia, with a specific focus on the Afar region.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003cbr\u003e\nA qualitative case study design was employed, drawing on 23 semi-structured interviews with federal and regional policymakers, advisors, and development partners, as well as the analysis of 53 policy and historical documents. The analysis is guided by Walt and Gilson’s Policy Triangle and Moncrieffe and Luttrell’s Political Economy Framework, examining actors, context, content, and processes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nFour intersecting drivers of spatial inequality were identified: (1) historical marginalisation rooted in exclusionary state formation; (2) institutional fragmentation and weak subnational capacity; (3) dominant policy narratives that prioritise efficiency over equity; and (4) donor influence that reinforces verticalism and policy uniformity. Together, these dynamics reproduce and sustain child health inequities in Afar.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003cbr\u003e\nSpatial inequalities in child health in Ethiopia are not incidental; they are structurally embedded in governance, policy design, and global-local power relations. Addressing them requires systemic reform grounded in justice, regional inclusion, and responsive decentralisation. This case study contributes to broader debates on inequality, decentralisation, and health governance in low- and middle-income countries.\u003c/p\u003e","manuscriptTitle":"The Political Economy of Spatial Child Health Inequalities in Ethiopia: A Public Policy Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-01 11:02:49","doi":"10.21203/rs.3.rs-6498222/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"320793273671851977453245787604387330319","date":"2025-08-29T13:29:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-29T13:13:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-07T10:46:45+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-09T15:31:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-09T03:08:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-09T03:07:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7b3b36f4-9e59-4b23-ac8f-cd6c3af5a197","owner":[],"postedDate":"August 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-01T11:02:49+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-01 11:02:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6498222","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6498222","identity":"rs-6498222","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}