Current realities versus theoretical optima: quantifying efficiency and sociospatial equity of travel time to hospitals in low-income and middle-income countries

Kerry L. M. Wong, Oliver J. Brady, Oona Maeve Renee Campbell, Christopher Jarvis, Andrea Pembe, Gabriela B. Gomez, Lenka Benova

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Background Having hospitals located in urban areas where people, resources and wealth concentrate is efficient, but leaves long travel times for the rural and often poorer population and goes against the equity objective. We aimed to assess the current efficiency (mean travel time in the whole population) and equity (difference in travel time between the poorest and least poor deciles) of hospital care provision in four sub-Saharan African countries, and to compare them against their theoretical optima.

Methods We overlaid the locations of 480, 115, 3787 and 256 hospitals in Kenya, Malawi, Nigeria and Tanzania, respectively, with high-resolution maps of travel time, population and wealth to estimate current efficiency and equity. To identify the potential optima, we simulated 7500 sets of hospitals locations based on various population and wealth weightings and percentage reallocations for each country.

Results The average travel time ranged from 38 to 79min across countries, and the respective optima were mildly shorter (

Interpretations Current hospital distribution in the four sub-Saharan African countries could be considered efficient. Simultaneous gains in efficiency and equity do not necessarily require a fundamental redesign of the healthcare system. Our analytical approach is readily extendible to aid decision support in adding and upgrading existing hospitals.

Original languageEnglish
Article numbere001552
JournalBMJ Global Health
Issue number4
Number of pages10
Publication statusPublished - 2019


  • physical accessibility to health services
  • health services research
  • health service provision
  • health equity
  • health inequality
  • shortest travel time
  • sub-Saharan Africa

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