The silencing of political context in health research in Ethiopia: why it should be a concern.

In 2004, the Ethiopian government launched what has been called an innovative and groundbreaking solution to the country's public health challenges; the Health Extension Programme (HEP). The positive public health outcomes that have been reported following the implementation of the HEP have led researchers and global health actors to propose it as a model for other countries to emulate. In this systematic review, we point to a potential weakness and methodological bias in the existing research. Despite being implemented within a context of an increasingly authoritarian regime, research conducted following the implementation of HEP reflects a limited discussion of the political context. Following a discussion of why political context is marginalized we provide arguments for why a focus on political context is important: first, political context has an impact on health systems and actualizes questions related to good governance and ethics. While some of the studies we reviewed acknowledge the importance of political factors we contend that the one-sided focus on the positive relationship between political will, political commitment and political leadership on the one hand, and key public health outcomes on the other, reflects a narrow engagement with health system governance frameworks. This leads to a silencing of issues actualized by the authoritarian nature of the Ethiopian regime. Secondly, the political context has methodological implications. More specifically, we contend that the current political situation increases the probability of social desirability bias. In order to balance the overarching positive literature on Ethiopia's health system, research that takes the political context into account is much needed.