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

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with federal and regional policymakers, advisors, and development partners, as well as the analysis of 53 policy and historical documents.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.