Estimated travel time and staffing constraints to accessing the Ethiopian health care system: A two-step floating catchment area analysis

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.