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Background: Despite large investments in the public health care system, disparities in health outcomes persist between lower- and upper-income individuals, as well as rural vs urban dwellers in Ethiopia. Evidence from Ethiopia and other low- and middle-income countries suggests that challenges in health care access may contribute to poverty in these settings., Methods: We employed a two-step floating catchment area to estimate variations in spatial access to health care and in staffing levels at health care facilities. We estimated the average travel time from the population centers of administrative areas and adjusted them with provider-to-population ratios. To test hypotheses about the role of travel time vs staffing, we applied Spearman's rank tests to these two variables against the access score to assess the significance of observed variations., Results: Among Ethiopia's 11 first-level administrative units, Addis Ababa, Dire Dawa, and Harari had the best access scores. Regions with the lowest access scores were generally poorer and more rural/pastoral. Approximately 18% of the country did not have access to a public health care facility within a two-hour walk. Our results suggest that spatial access and staffing issues both contribute to access challenges., Conclusion: Investments both in new health facilities and staffing in existing facilities will be necessary to improve health care access within Ethiopia. Because rural and low-income areas are more likely to have poor access, future strategies for expanding and strengthening the health care system should strongly emphasize equity and the role of improved access in reducing poverty., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2023 by the Journal of Global Health. All rights reserved.)

Objective: Worldwide unmet need for contraception remains high at 21.6%. As access to health facilities is one of the potential barriers to contraceptive uptake, the aim of our study was to evaluate the effect of distance to a health facility, according to its service availability, on contraceptive uptake among married Turkish women., Methods: To calculate respondents' distance to a health facility, we used data from a household survey conducted among married women, as well as data from a health facility survey conducted among the facilities that were visited for contraceptive services by the respondents. The data were collected from the Istanbul area of Turkey under the Willows Impact Evaluation project in 2018. Health facilities were categorised according to contraceptive availability and the accurate distance from respondents' homes to each type of health facility was calculated. Logistic regression was used to estimate the effect of distance to each type of health facility on uptake of each type of contraception., Results: The prevalence of overall contraceptive use among urban Turkish women was 71.9%. The most common method was withdrawal (32.5%), followed by the intrauterine device (IUD) (14.9%) and male condoms (12.4%). Distance to a health facility that did not provide long-acting contraception was not associated with any type of contraceptive use. On the other hand, distance to a health facility that provided long-acting contraception was negatively associated with the use of long-acting methods such as the IUD but was positively associated with the use of short-acting contraception such as condoms., Conclusion: The effect of distance to a health facility on contraceptive use significantly differed according to contraceptive availability at the facility. Further distance to a health facility that provided long-acting contraception decreased the use of long-acting contraception but had a substitute effect on the use of short-acting contraception. We conclude that when women face an accessibility barrier to the provision of long-acting contraception, they modify their behaviour by shifting from long- to short-acting contraception, which is less effective.

The Nigeria State Health Investment Project (NSHIP) was implemented in three Nigerian states between 2013 and 2018. Under the NSHIP, some local government areas were randomly assigned to Performance-Based Financing (PBF) intervention while others received decentralized facility financing (DFF) for comparison. This article evaluates the effect of PBF compared with DFF on health service delivery indicators in Adamawa state, under this quasi-experimental design, using the difference-in-differences technique. The analysis used health facility monthly data collected by the Health Management Information System through the District Health Information Software 2 (DHIS2). The PBF intervention group significantly increased the quantity of most of its service delivery indicators, such as antenatal care visits and deliveries by skilled personnel compared with the comparison group (DFF) after the introduction of NSHIP, although the baseline level of service delivery between PBF and DFF health facilities was statistically identical prior to the introduction of the intervention. We also conducted robustness check analysis to confirm the effect of PBF. Overall, we found a significant positive effect of PBF on most service delivery outcomes, except full vaccinations and post-natal care. One important policy implication is that we should carefully use PBF for targeted indicators., (© The Author(s) 2020. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Background: Antenatal care (ANC) is essential for ensuring the well-being of pregnant women and their fetuses. This study models the association between achieving adequate ANC and various health and health-seeking indicators across wealth quintiles in low- and middle-income countries (LMICs). Methods and findings: We analyzed data from 638,265 women across 47 LMICs using available Demographic and Health Surveys from 2010 to 2022. Via multilevel logistic regression analyses adjusted for a series of confounding variables and country and wealth quintile fixed effects, we estimated the projected impact of achieving adequate ANC utilization and quality on a series of health and health care indicators: facility birth, postnatal care, childhood immunizations, and childhood stunting and wasting. Achieving adequate levels of ANC utilization and quality (defined as at least 4 visits, blood pressure monitoring, and blood and urine testing) was positively associated with health-seeking behavior across the majority of countries. The strongest association was observed for facility birth, followed by postnatal care and child immunization. The strength of the associations varied across countries and wealth quintiles, with more significant ones observed in countries with lower baseline ANC utilization levels and among the lower wealth quintiles. The associations of ANC with childhood stunting and wasting were notably less statistically significant compared to other indicators. Despite rigorous adjustments for potential confounders, a limitation to the methodology is that it is possible that unobserved variables may still impact outcomes. Conclusions: Strengthening ANC is associated with improved use of other health care in LMICs. ANC could serve as a critical platform for improving health outcomes for mothers and their children, emphasizing its importance beyond direct impact on maternal and neonatal mortality. Leveraging data from demographic health surveys across the globe, Boshen Jiao and co-authors explore how adequate antenatal care influences health-seeking behaviors more generally. Author summary: Why was this study done?: Antenatal care is essential to the well-being of pregnant women and their fetuses. Previous research shows that the frequency of antenatal care visits can significantly influence health behaviors of both mothers and their children. Existing studies center on a limited set of countries, leading to a notable gap in our understanding of the potential broader health system impact that antenatal care can have. What did the researchers do and find?: We modeled the association between achieving adequate antenatal care and various health indicators across wealth quintiles in 47 low- and middle-income countries using data from Demographic and Health Surveys collected between 2010 and 2022. The model estimated the projected impact of achieving adequate antenatal care utilization and quality on facility birth, postnatal care, childhood immunizations, and childhood stunting and wasting. We found that achieving adequate levels of antenatal care utilization and quality was positively associated with health-seeking behavior of mothers across most countries. The stronger associations were observed in countries with lower baseline antenatal care utilization levels and among lower wealth quintiles. What do these findings mean?: Strengthening antenatal care could potentially improve the use of other health care in low- and middle- income countries. Antenatal care could serve as a critical platform for improving broader health outcomes for mothers and their children, emphasizing its importance beyond the direct impact on maternal and neonatal health. Despite rigorous adjustments for potential confounders, a limitation of the methodology is the possibility that unobserved variables may still impact the outcomes. [ABSTRACT FROM AUTHOR]

Background: Vaccine-preventable diseases (VPDs) remain major causes of morbidity and mortality in low- and middle-income countries (LMICs). Universal access to vaccination, besides improved health outcomes, would substantially reduce VPD-related out-of-pocket (OOP) expenditures and associated financial risks. This paper aims to estimate the extent of OOP expenditures and the magnitude of the associated catastrophic health expenditures (CHEs) for selected VPDs in Ethiopia. Methods and findings: We conducted a cross-sectional costing analysis, from the household (patient) perspective, of care-seeking for VPDs in children aged under 5 years for pneumonia, diarrhea, measles, and pertussis, and in children aged under 15 years for meningitis. Data on OOP direct medical and nonmedical expenditures (2021 USD) and household consumption expenditures were collected from 995 households (1 child per household) in 54 health facilities nationwide between May 1 and July 31, 2021. We used descriptive statistics to measure the main outcomes: magnitude of OOP expenditures, along with the associated CHE within households. Drivers of CHE were assessed using a logistic regression model. The mean OOP expenditures per disease episode for outpatient care for diarrhea, pneumonia, pertussis, and measles were $5·6 (95% confidence interval (CI): $4·3, 6·8), $7·8 ($5·3, 10·3), $9·0 ($6·4, 11·6), and $7·4 ($3·0, 11·9), respectively. The mean OOP expenditures were higher for inpatient care, ranging from $40·6 (95% CI: $12·9, 68·3) for severe measles to $101·7 ($88·5, 114·8) for meningitis. Direct medical expenditures, particularly drug and supply expenses, were the major cost drivers. Among those who sought inpatient care (345 households), about 13·3% suffered CHE, at a 10% threshold of annual consumption expenditures. The type of facility visited, receiving inpatient care, and wealth were significant predictors of CHE (p-value < 0·001) while adjusting for area of residence (urban/rural), diagnosis, age of respondent, and household family size. Limitations include inadequate number of measles and pertussis cases. Conclusions: The OOP expenditures induced by VPDs are substantial in Ethiopia and disproportionately impact those with low income and those requiring inpatient care. Expanding equitable access to vaccines cannot be overemphasized, for both health and economic reasons. Such realization requires the government's commitment toward increasing and sustaining vaccine financing in Ethiopia. In a cross-sectional costing analysis, Solomon Tessema Memirie and colleagues explore out-of-pocket expenditures and financial risks associated with treatment of vaccine-preventable diseases in Ethiopia. Author summary: Why was this study done?: Despite a rapid expansion in access to vaccines in the past 2 decades, vaccine-preventable diseases (VPDs) remain major causes of morbidity and mortality in low- and middle-income countries. Out-of-pocket (OOP) medical expenditures can lead to catastrophic health expenditures and impoverishment. Studies on household healthcare expenditures and associated financial risks for VPDs among children in sub-Saharan African countries are scarce. What did the researchers do and find?: We collected OOP expenditures data from 995 households to estimate medical impoverishment associated with the following vaccine-preventable childhood diseases: measles, pertussis, pneumonia, diarrhea, and meningitis. Households incur substantial OOP expenditures for the treatment of VPDs in Ethiopia. Poor families and those with sick children requiring inpatient care are likely to be impoverished. What do these findings mean?: Expanding access to vaccination has the potential to protect families from OOP expenditures related to the treatment of VPDs and its associated catastrophic and impoverishing financial consequences. The financial risk benefits primarily accrue among the poorest. Universal access to vaccines requires the government's commitment toward increasing and sustaining vaccine financing. [ABSTRACT FROM AUTHOR]

Vaccine stockouts are prevalent in Africa. Despite the importance of this as a barrier to universal vaccination coverage, rigorous studies looking at ways to reduce vaccine stockouts have been limited. We causally evaluated the effect of Vaccine Direct Delivery (VDD), an intervention to ensure the vaccine stock availability at health facilities, on the reduction of stockouts in Bauchi state, Nigeria. Employing the interrupted time-series method, we evaluated the change in the occurrence of vaccine stockouts before and after the introduction of VDD in July 2015. We used health facility level data from January 2013 to December 2018 among 175 facilities in Bauchi state, collected through the District Health Information Software 2 (DHIS2) for monthly information on stockouts and stock balances in all the health facilities in Nigeria. Data were analyzed using Stata 15 SE. To validate the causal relationship between VDD and vaccine stockouts, we conducted two sets of robustness checks. First, we evaluated the effect of VDD on the stockouts of other commodities. Second, we compared the trend of the prevalence of vaccine stockouts among health facilities between Bauchi state where VDD was introduced and another state (Adamawa state) where VDD was never introduced. After the introduction of VDD, vaccine stockouts in Bauchi state decreased by 9 percentage points on average, and they have been decreasing monthly by 0.4 percentage points more than pre-VDD. In Adamawa state, where VDD was never introduced, the prevalence of vaccine stockouts did not change over time. In Bauchi state after VDD introduction, the stock balances of target vaccines all increased, and the number of vaccinations carried out increased in neighboring health facilities. VDD intervention resulted in a significant reduction of vaccine stockouts as well as in an increase in the number of vaccinations performed. However, we should consider how to improve the system to provide vaccination service to the population in a sustainable way. [ABSTRACT FROM AUTHOR]

• We evaluate the effect of Performance-Based Financing (PBF). • The main outcome is the quantity of vaccinations carried out in northern Nigeria. • Difference-in-Differences (DiD) and ANCOVA are used to evaluate the effect of PBF. • PBF intervention increased the quantity of full vaccination cases. • Providing unconditional financial & technical assistance might be more cost-effective strategy. Vaccination is known to be one of the most cost-effective ways to avert child deaths. However, in Nigeria, the vaccination completion rate among children is extremely low and the child mortality rate is one of the highest in the world. National immunization coverage survey shows that the low vaccination rate in Nigeria is partly attributed to service delivery issues. This paper evaluates the effect of Performance-Based Financing (PBF), an incentive scheme where health facilities are funded based on their performance, on the quantity of vaccinations carried out in Adamawa state. Under the Nigeria State Health Investment Project (NSHIP), half of the Local Government Areas (LGAs) in Adamawa State were randomly assigned to receive PBF intervention between 2015 and 2018. The Difference-in-Differences (DiD) technique as well as ANCOVA analysis are used to evaluate the effect of PBF on vaccination service delivery indicators. We find that the PBF intervention significantly increased the quantity of full vaccination cases as compared to the comparison group, although the effect size was small. On the other hand, if health facilities receive intensified PEI (Polio Eradication Initiative) concurrently, the effectiveness of PBF in increasing the number of full vaccination cases do not differ significantly from health facilities that are not under PBF. Rather than providing conditional financial incentives such as PBF to health facilities, simply providing unconditional financial and technical assistance to strengthen routine immunization programs might be sufficient to increase the quantity of vaccination service provision. The positive effect of PBF on vaccination provision was not sustainable, either. Future work should explore how we can strengthen the health system in a cost-effective and sustainable way. [ABSTRACT FROM AUTHOR]