Structural Determinants of Child Health Inequalities in Nigeria’s South East Geopolitical Zone: A Critical Realist Theoretical Analysis

Child health inequalities in Nigeria's South East geopolitical zone persist despite economic development, relatively high literacy rates, and healthcare infrastructure investment, suggesting that proximal determinants fail to adequately explain the gradient. This study employs a critical realist theoretical framework to investigate the structural mechanisms generating and sustaining child health inequalities across Anambra, Ebonyi, Enugu, Imo, and Abia states. A realist synthesis approach was used to integrate quantitative data from the 2021 NDHS and MICS with qualitative findings from 80 in-depth interviews with caregivers, paediatricians, community leaders, and health policymakers conducted across all five states. Retroductive reasoning was applied to identify generative mechanisms beneath observed inequality patterns. Quantitative analysis confirmed significant within-zone inequality in full immunisation coverage (range 38.4% to 74.6%), child stunting (range 21.3% to 42.8%), and skilled birth attendance (range 51.2% to 89.3%). Qualitative synthesis identified commodification of healthcare, patriarchal household decision-making authority over child health expenditure, and the structural legacy of post-conflict marginalisation as deep mechanisms generating inequality. Health system responsiveness and community trust emerged as critical context-mechanism-outcome configurations mediating intervention effectiveness. The study makes an original theoretical contribution by extending critical realism to paediatric health equity research in Nigeria, producing a contextualised middle-range theory of child health inequality generation applicable to similar post-conflict African settings. Keywords: child health inequalities, critical realism, South East Nigeria, structural determinants, health equity.