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.