Policymakers and institutional structures affecting health inequality in Ethiopia: a 1 Qualitative Study 2

21 Background : Ethiopia generally provides a story of progress in child health, but unevenly 22 distributed. The attitude, knowledge, political drives, interest groups and institutional 23 dynamics in health equity policy setting and execution has not been explored in Ethiopia. 24 Without addressing these issues, the right kind of policy choice and implementation 25 cannot be attained. 26 Methods : This study was conducted between 2015 and 2017 in Ethiopia. The study 27 utilized a qualitative framework, grounded in social determinants for health and health 28 policy. Semi-structured interviews; executed policy analysis; and reviewed the literature. 29 In-depth interviews were conducted among twenty-one policymakers and reviewed 23 30 policy documents and over 350 literatures, Transcribed data, policy extracts and articles 31 were synthesised and analysed by ATLAS.ti 7.1.4. 32 Results: Ethiopia is in an early state of recognizing and intervening against health 33 inequalities. The quality and level of knowledge is mixed and gets reduced as one goes 34 to the rural areas. Consensus is slowly developing on the major underlying causes of 35 inequality. The contents of health policy documents are neither comprehensive nor 36 strongly supported by evidence. There are multiple interest groups with varying level of 37 knowledge and power. Complex political and institutional relations affect policy making 38 process negatively. Participants demonstrated denialism; blaming of victims; 39 misconceptions; and one size fits all attitudes. 40 Conclusions : Any future work for improving health equity needs to be build more on 41 evidence and embrace more participatory processes to address all types of interest 42 groups. 43


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WHO through its Social Determinants for Health (SDH) review concluded, the situations 55 under which people are born, live, work and age can cause unfair health disparities (9-56 11). Generally, health inequalities, including inequalities in child health are considered as 57 inequity (12)(13)(14).

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Ethiopia demonstrates a very high child health inequality at impact, outcome and input   Health inequality is being increasingly seen as a political matter, resulting in political 75 consequences that affects security and stability (26,27). Unfair distribution of health and 76 violation of the right to 'the highest attainable health in a country' are interrelated (28).  Participants were purposively selected, based on their role of policy making and 106 implementation in relation to child health. Regional States and districts that displayed a            Interest groups, the motivations in the background 202 The study showed that the policy drive, directions and technical guidance for reduction of 203 inequality have come from an interest group of political leaders and technical elites.

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Recently a growing strong political interest to address the widening gap, "The Minister himself made a personal ambition to achieve this.". Three other interest groups also came out 206 as summarized in Table 3. These groups are important factors in policy making and 207 implementation process. Some participants argued, the latest push by the political elite is 208 a show-off and technical views were not very well considered in the policy making 209 process.
210 Table 3. Summary of interest groups that might affect equity policy making in Ethiopia

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The interest group which did not emerge clearly and strongly is a group that believes the

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Process and Institutional relations affecting equity policy 220 The study found that reducing inequality and introducing accountability through a 221 centralized approach has proven to be a complex exercise in the federal state of Ethiopia.

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It was also found that lack of a quantified inequality reduction vision, lack of clear division 223

Powerful political elite, spearheading
A small group comprised of ministers and a few directors, politically interested

"By the way, we are a special sector as a ministry; we have received a directive from the Federal Affairs Ministry to increase equity." a key participant
The minsters from Federal Affairs and Health have been perusing the recent agenda to

Ready technocrats
Interested in reducing inequality but thinks the elites are motivated by politics Based in regional states and mid-level central leadership   Exworthy, Blane and Marmot outlined the steps for how the use of data and its 291 dissemination helped the UK to initiate and shape its equity programmes in health (48).

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The Black Report in the UK was rejected without action (44,46).

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Participants living in regional states and development partners highlighted inequalities got 294 persisted due to inverse equities that followed in appropriate policies. The richer and more There was an extensive use of "us versus them" language, 'victim blaming' and 312 frustrations during the interviews. Some participants from the federal state tended to 313 argue peripheral regional states are the main cause of the inequality, due to lack of 314 responsiveness, accountability, lifestyles and cultural factors. Blaming the victims for 315 health inequality was observed and criticised in the 1970s and 1980s in Europe. on health equity policy agenda setting. The outcome was ineffective policy that miss to 343 considered local ethnic lifestyles in regional states (57). 344 We included various data collection and analysis approaches which made us triangulate 345 the findings. The study however should be interpreted in light of its limitations. This study 346 might have been challenged by the "policeman" or other similar effects of the tendency to   The datasets generated and/or analysed during the current study are not publicly 388 available due sensitivity of the subject matter studied but are available from the 389 corresponding author on a reasonable request.

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Competing interest 391 The authors declare that they have no competing interests.