PT - JOURNAL ARTICLE AU - Wong, Kerry LM AU - Brady, Oliver J AU - Campbell, Oona Maeve Renee AU - Jarvis, Christopher I AU - Pembe, Andrea AU - Gomez, Gabriela B AU - Benova, Lenka TI - Current realities versus theoretical optima: quantifying efficiency and sociospatial equity of travel time to hospitals in low-income and middle-income countries AID - 10.1136/bmjgh-2019-001552 DP - 2019 Aug 01 TA - BMJ Global Health PG - e001552 VI - 4 IP - 4 4099 - http://gh.bmj.com/content/4/4/e001552.short 4100 - http://gh.bmj.com/content/4/4/e001552.full SO - BMJ Global Health2019 Aug 01; 4 AB - 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 79 min across countries, and the respective optima were mildly shorter (<15%). The observed equity gaps were wider than their optima. Compared with the best case scenarios, differences in the equity gaps varied from 7% in Tanzania to 77% in Nigeria. In Kenya, Malawi and Tanzania, narrower equity gaps without increasing average travel time were seen from simulations that held 75%–90% of hospitals at their current locations.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.