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Background: Health equity is a cross-cutting theme in the United Nations 2030 Agenda for Sustainable Development, and a priority in health sector planning in countries including Ethiopia. Subnational health managers in Ethiopia are uniquely positioned to advance health equity, given the coordination, planning, budgetary, and administration tasks that they are assigned. Yet, the nature of efforts to advance health equity by subnational levels of the health sector is poorly understood and rarely researched. This study assesses how subnational health managers in Ethiopia understand health equity issues and their role in promoting health equity and offers insight into how these roles can be harnessed to advance health equity. Methods: A descriptive case study assessed perspectives and experiences of health equity among subnational health managers at regional, zonal, district and Primary Health Care Unit administrative levels. Twelve in-depth interviews were conducted with directors, vice-directors, coordinators and technical experts. Data were analyzed using thematic analysis. Results: Subnational managers perceived geographical factors as a predominant concern in health service delivery inequities, especially when they intersected with poor infrastructure, patriarchal gender norms, unequal support from non-governmental organizations or challenging topography. Participants used ad hoc, context-specific strategies (such as resource-pooling with other sectors or groups and shaming-as-motivation) to improve health service delivery to remote populations and strengthen health system operations. Collaboration with other groups facilitated cost sharing and access to resources; however, the opportunities afforded by these collaborations, were not realized equally in all areas. Subnational health managers’ efforts in promoting health equity are affected by inadequate resource availability, which restricts their ability to enact long-term and sustainable solutions. Conclusions: Advancing health equity in Ethiopia requires: extra support to communities in hard-to-reach areas; addressing patriarchal norms; and strategic aligning of the subnational health system with non-health government sectors, community groups, and non-governmental organizations. The findings call attention to the unrealized potential of effectively coordinating governance actors and processes to better align national priorities and resources with subnational governance actions to achieve health equity, and offer potentially useful knowledge for subnational health system administrators working in conditions similar to those in our Ethiopian case study.
We drew from case study methodology to examine the perspectives and experiences of subnational health managers within one zone of Ethiopia, located in the southwest of the country, and corresponding higher levels of the health system. A descriptive case study design was selected to allow for the holistic exploration of a complex social phenomenon (the advancement of health equity) where the context and phenomenon are not clearly distinct [29]. The findings reported here are part of a larger randomized implementation study across several districts within Ethiopia. Ethics approval for this research was obtained in 2017 (in advance of commencement of data collection) from the University of Ottawa Health Sciences and Science Research Ethics Board and from an Ethiopian University Institutional Review Board. The study was undertaken in compliance with the protocols stated in the ethics approval. Participants were recruited from purposefully selected government health offices within the region and invited to participate in key informant interviews. At each selected office, we invited one senior-level manager and one MNCH manager to participate in the study (except at PHCUs, where in the absence of MNCH managers, only senior-level managers participated). The interviews were semi-structured, allowing participants to respond in an uninhibited manner, while retaining a central focus on the topic of interest. In total, we conducted semi-structured interviews with 12 participants (1 female and 11 male) that held senior leadership, managerial or coordination positions at subnational levels of the health system in Ethiopia. These included directors, vice-directors, coordinators or MNCH focal points across regional (n = 2), zonal (n = 2), woreda (n = 5) and PHCU (n = 3) levels of administration. Interviews lasted 30–90 min and focused on 5 domains of questioning (Fig. 2). Five domains of investigation in semi-structured key informant interviews with subnational health managers in Ethiopia The creation of interview guides was loosely informed by themes presented in two theoretical frameworks (an ecological framework of the social determinants of maternal and child health [30] and the framework for addressing equity through determinants of health [31]). The interview guide was pilot tested prior to data collection and revised for clarity and length. Investigation within the first domain (perceptions of relevant determinants of health) involved the use of a photo card showing a pregnant woman being carried on a traditional stretcher; participants were asked to comment on the acceptability and commonness of the scene, and underlying factors and conditions. To introduce the topic of health equity (domains 2–5), participants were read a description adapted from the World Health Organization (WHO) Commission on Social Determinants of Health [5]: “Health equity exists when everyone has a fair chance to achieve their full health potential. The opportunity to be healthy is available to everyone, regardless of their social, economic, demographic, or geographic characteristics.” The interviews were conducted in November and December 2017 by one member of the research team, who had prior experience conducting semi-structured interviews, and doing research in the Ethiopian context. All interviews were conducted at a time and place that was convenient for the participant (typically the participant’s place of work). Participants were offered the option of doing the interview in English or in the local language of their choice with the assistance of an interpreter. Nine participants chose to do the interview in English, and three requested an interpreter for all or part of the interview. The interpreter, who has an ongoing relationship with the researchers, was briefed extensively about the study beforehand, and did verbatim, real-time translation [32]. All participants gave written informed consent to participate in the study and gave permission for their interview to be audio-recorded. The recordings were subsequently transcribed in written form. For interviews where an interpreter was present, the interpreter listened to the recording and reviewed the English transcript, making minor revisions where necessary. Data were analysed through thematic analysis methods, using Atlas.ti software. Following multiple readings of the transcripts, a code guide was developed deductively based on the interview questions and expanded inductively to accommodate emergent concepts. Transcripts were coded, and cross-cutting themes were identified to illustrate understandings of health equity and perceived roles and responsibilities in addressing health inequities. Several researchers were involved in writing up the analysis. The findings of the study were discussed with experienced researchers working on related topics within the same zonal area, as well as national experts in the topic area. Researchers remained reflexive in identifying potential sources of bias and taking measures to limit them [33]. To ensure anonymity, the participants were assigned pseudonyms and are not identified by their job title or geographical location in the country; identifying details in participant quotes have been removed or altered.
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