The Tools for Integrated Management of Childhood Illness (TIMCI) study protocol: a multi-country mixed-method evaluation of pulse oximetry and clinical decision support algorithms.

Effective and sustainable strategies are needed to address the burden of preventable deaths among children under-five in resource-constrained settings. The Tools for Integrated Management of Childhood Illness (TIMCI) project aims to support healthcare providers to identify and manage severe illness, whilst promoting resource stewardship, by introducing pulse oximetry and clinical decision support algorithms (CDSAs) to primary care facilities in India, Kenya, Senegal and Tanzania. Health impact is assessed through: a pragmatic parallel group, superiority cluster randomised controlled trial (RCT), with primary care facilities randomly allocated (1:1) in India to pulse oximetry or control, and (1:1:1) in Tanzania to pulse oximetry plus CDSA, pulse oximetry, or control; and through a quasi-experimental pre-post study in Kenya and Senegal. Devices are implemented with guidance and training, mentorship, and community engagement. Sociodemographic and clinical data are collected from caregivers and records of enrolled sick children aged 0-59 months at study facilities, with phone follow-up on Day 7 (and Day 28 in the RCT). The primary outcomes assessed for the RCT are severe complications (mortality and secondary hospitalisations) by Day 7 and primary hospitalisations (within 24 hours and with referral); and, for the pre-post study, referrals and antibiotic. Secondary outcomes on other aspects of health status, hypoxaemia, referral, follow-up and antimicrobial prescription are also evaluated. In all countries, embedded mixed-method studies further evaluate the effects of the intervention on care and care processes, implementation, cost and cost-effectiveness. Pilot and baseline studies started mid-2021, RCT and post-intervention mid-2022, with anticipated completion mid-2023 and first results late-2023. Study approval has been granted by all relevant institutional review boards, national and WHO ethical review committees. Findings will be shared with communities, healthcare providers, Ministries of Health and other local, national and international stakeholders to facilitate evidence-based decision-making on scale-up.Study registration: NCT04910750 and NCT05065320.

Pulse oximetry and clinical decision support algorithms show potential for supporting healthcare providers to identify and manage severe illness among children under-five attending primary care in resource-constrained settings, whilst promoting resource stewardship but scale-up has been hampered by evidence gaps.This study design article describes the largest scale evaluation of these interventions to date, the results of which will inform country- and global-level policy and planning .

Association between the use of Accredited Social Health Activist (ASHA) services and uptake of institutional deliveries in India.

This study examines the impact of accredited social health activists (ASHAs), on increasing rates of institution-based deliveries among Indian women with a specific focus on the nine low-performing, empowered action group states and Assam (EAGA) in India. Using the latest round of the National Family Health Survey-V (2019-21), we first investigate the association between the use of ASHA services and socio-demographic attributes of women using a multivariate logistic regression. We then use propensity-score matching (PSM) to address observable selection bias in the data and assess the impact of ASHA services on the likelihood of institution-based deliveries using a generalized estimating equations model. Of the 232,920 women in our sample, 55.5% lived in EAGA states. Overall, 63.3% of women (70.6% in EAGA states) reported utilizing ASHA services, and 88.6% had an institution-based delivery (84.0% in EAGA states). Younger women from the poorest wealth index were more likely to use ASHA services and women in rural areas had a two-fold likelihood. Conversely, women with health insurance were less likely to use ASHA services compared to those without. Using PSM, the average treatment effect of using ASHA services on institution-based deliveries was 5.1% for all India (EAGA = 7.4%). The generalized estimating equations model indicated that the use of ASHA services significantly increased the likelihood of institution-based delivery by 1.6 times (95%CI = 1.5-1.7) for all India (EAGA = 1.8; 95%CI = 1.7-1.9). Our study finds that ASHAs are effective in enhancing the uptake of maternal services particularly institution-based deliveries. These findings underscore the necessity for continual, systematic investments to strengthen the ASHA program and to optimize the program's effectiveness in varied settings that rely on the community health worker model, thereby advancing child and maternal health outcomes.

An Exploratory Analysis of the Cost-Effectiveness of a Multi-cancer Early Detection Blood Test Compared with Standard of Care Screening in Ontario, Canada.

BACKGROUND: Determining whether multi-cancer early detection (MCED) tests are cost effective is important in deciding whether they should be included in the clinical path of cancer care, especially for cancers where screening tools do not exist. RESEARCH OBJECTIVE: The main objective of this study is to determine the cost effectiveness of including a MCED screening regimen together with existing provincial screening protocols for selected cancers that are prevalent in Ontario, Canada, among average risk persons aged 50-75 years. The selected cancers include breast, colorectal, lung, esophageal, liver, pancreatic, stomach, and ovarian. METHODS: Cost effectiveness was estimated from a provincial Ministry of Health perspective. A state-transition Markov model representing the decision path of both the proposed and existing screening strategies along the natural history of the selected types of cancers was implemented. The incremental cost-effectiveness ratio (ICER) was calculated using data from available literature and the guidelines published by the Canadian Agency for Drugs and Technologies in Health (CADTH) for conducting a cost-effectiveness analysis, which included a discount rate of 1.5% applied to all costs and outcomes. Costs were also converted to 2022 Canadian dollars. To test the robustness of the model, both univariate and probabilistic sensitivity analyses were conducted. RESULTS: MCED screening resulted in more diagnosed cases of each type of cancer, even at an earlier stage of disease. This was also associated with fewer related deaths compared with standard of care. Notwithstanding, the analysis revealed that the MCED intervention was not cost effective [ICER: CAD$143,369 per quality-adjusted life year (QALY)], given a willingness to pay (WTP) threshold of $100,000 per QALY. The probabilistic sensitivity analyses revealed that the MCED intervention strategy was preferred to standard of care no more than 2% of the time at this WTP for both males and females. The model was most sensitive to the cost of MCED screening, and the levels of specificity of the MCED and colorectal cancer screening tests. CONCLUSION: The main contribution of the study is to present and execute a methodological approach that can be adopted to test the cost effectiveness of an MCED tool in the Canadian setting. The model is also sufficiently generic that it could be adapted to other jurisdictions, and with consideration for increasing the WTP threshold beyond the common $100,000 per QALY limit, given the life-threatening nature of cancer, to ensure that MCED interventions are cost-effective.

Assessing the hidden burden and costs of COVID-19 pandemic in South Asia: Implications for health and well-being of women, children and adolescents.

The COVID-19 pandemic has disproportionately affected vulnerable populations. With its intensity expected to be cyclical over the foreseeable future, and much of the impact estimates still modeled, it is imperative that we accurately assess the impact to date, to help with the process of targeted rebuilding of services. We collected data from administrative health information systems in six South Asian countries (Afghanistan, Bangladesh, Nepal, India, Pakistan and Sri Lanka), to determine essential health services coverage disruptions between January-December 2020, and January-June 2021, compared to the same calendar months in 2019, and estimated the impact of this disruption on maternal and child mortality using the Lives Saved Tool. We also modelled impact of prolonged school closures on continued enrollment, as well as potential sequelae for the cohort of girls who have likely dropped out. Coverage of key maternal and child health interventions, including antenatal care and immunizations, decreased by up to 60%, with the largest disruptions observed between April and June 2020. This was followed by a period of recovery from July 2020 to March 2021, but a reversal of most of these gains in April/May 2021, likely due to the delta variant-fueled surge in South Asia at the same time. We estimated that disruption of essential health services between January 2020 and June 2021 potentially resulted in an additional 19,000 maternal and 317,000 child deaths, an increase of 19% and 13% respectively, compared to 2019. Extended school closures likely resulted in 9 million adolescents dropping out permanently, with 40% likely being from poorest households, resulting in decreased lifetime earnings. A projected increase in early marriages for girls who dropped out could result in an additional 500,000 adolescent pregnancies, 153,000 low birthweight births, and 27,000 additional children becoming stunted by age two years. To date, the increase in maternal and child mortality due to health services disruption has likely exceeded the overall number of COVID-19 deaths in South Asia. The indirect effects of the pandemic were disproportionately borne by the most vulnerable populations, and effects are likely to be long-lasting, permanent and in some cases inter-generational, unless policies aimed at alleviating these impacts are instituted at scale and targeted to reach the poorest of the poor. There are also implications for future pandemic preparedness.

Could a Shigella vaccine impact long-term health outcomes?: Summary report of an expert meeting to inform a Shigella vaccine public health value proposition, March 24 and 29, 2021.

Shigellosis is a leading cause of diarrhea and dysentery in young children from low to middle-income countries and adults experiencing traveler's diarrhea worldwide. In addition to acute illness, infection by Shigella bacteria is associated with stunted growth among children, which has been linked to detrimental long-term health, developmental, and economic outcomes. On March 24 and 29, 2021, PATH convened an expert panel to discuss the potential impact of Shigella vaccines on these long-term outcomes. Based on current empirical evidence, this discussion focused on whether Shigella vaccines could potentially alleviate the long-term burden associated with Shigella infections. Also, the experts provided recommendations about how to best model the burden, health and vaccine impact, and economic consequences of Shigella infections. This international multidisciplinary panel included 13 scientists, physicians, and economists from multiple relevant specialties. According to the panel, while the relationship between Shigella infections and childhood growth deficits is complex, this relationship likely exists. Vaccine probe studies are the crucial next step to determine whether vaccination could ameliorate Shigella infection-related long-term impacts. Infants should be vaccinated during their first year of life to maximize their protection from severe acute health outcomes and ideally reduce stunting risk and subsequent negative long-term developmental and health impacts. With vaccine schedule crowding, targeted or combination vaccination approaches would likely increase vaccine uptake in high-burden areas. Shigella impact and economic assessment models should include a wider range of linear growth outcomes. Also, these models should produce a spectrum of results-ones addressing immediate benefits for usual health care decision-makers and others that include broader health impacts, providing a more comprehensive picture of vaccination benefits. While many of the underlying mechanisms of this relationship need better characterization, the remaining gaps can be best addressed by collecting data post-vaccine introduction or through large trials.

Rational design of an essential diagnostics network to support Universal Health Coverage: a modeling analysis.

BACKGROUND: Diagnostic investigations, including pathology and laboratory medicine (PALM) and radiology, have been largely absent from international strategies such as the Sustainable Development Goals. Further, there is little international guidance on which health system tiers different diagnostics should be placed, a critical step in developing a country-level diagnostics network. We describe a modeling strategy to produce tier-specific diagnostic recommendations based on disease burden, current treatment pathways, and existing infrastructure in a country. METHODS: The relational model assumes that diagnostics should be available at the lowest tier where patients might receive medical management. Using Ghana as an exemplar, the 20 diseases forecasted by 2030 and 2040 to cause the greatest burden in low- and middle-income countries were mapped to three generalized tiers in the Ghanaian health system (Primary, Secondary, and Tertiary care) for three levels of each disease (triage, uncomplicated, and complicated). The lowest tier at which a diagnostic could potentially be placed was restricted by existing infrastructure, though placement still required there be a medical justification for the diagnostic at that tier. RESULTS: The model recommended 111 unique diagnostic investigations with 17 at Primary tier, an additional 45 at Secondary tier and a further 49 at Tertiary tier. Estimated capital costs were $8,330 at Primary tier and between $571,000 to $777,000 at Secondary tier. Twenty-eight different laboratory tests were recommended as send-outs from Primary to Secondary tier, and twelve as send-outs to Tertiary tier. CONCLUSIONS: This model provides a transparent framework within which countries can customize diagnostic planning to local disease priorities, health system patient treatment pathways, and infrastructural limitations to best support Universal Health Coverage.

Systematic literature review of SARS-CoV-2 seroprevalence surveys in Canada through April 2021.

Objectives: To estimate the proportion of the population infected by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Canada through April 2021, 16 months into the coronavirus disease 2019 (COVID-19) pandemic and 4 months after COVID-19 vaccines became available. Methods: Publication databases, preprint servers, public health databases and the grey literature were searched for seroprevalence surveys conducted in Canada from 1 November 2019 to 10 July 2021. Studies were assessed for bias using the Joanna Briggs Checklist. Numbers of infections derived from seroprevalence estimates were compared with reported cases to estimate under-ascertainment ratios. Results: In total, 12 serosurveys with 210,321 participants were identified. Three (25%) serosurveys were conducted at national level, one (8.3%) was conducted at provincial level, and eight (66.7%) were conducted at local level. All 12 serosurveys had moderate or high risk of bias. The proportion of the population infected by April 2021 was low (2.6%). The proportion of the population infected was higher in surveys of residents of long-term care facilities (43.0-86%), workers at long-term care facilities (22.4-32.4%), and workers in healthcare institutions (1.4-14%). Conclusions: As of April 2021, the proportion of the population infected by SARS-CoV-2 was low in the overall population of Canada, but was high in healthcare facilities, particularly long-term care facilities, supporting the need for vaccines.

Evaluating the impact of multicancer early detection testing on health and economic outcomes: Toward a decision modeling strategy.

Emerging data provide initial support for the concept that a single, minimally invasive liquid biopsy test, performed in conjunction with confirmatory radiologic or other diagnostic testing, when indicated, could be deployed on a broad scale to screen individuals for multiple types of cancer. Ideally, such a test could do this in a way that yields a clinically important percentage of true-positive indications of cancer while minimizing false-positive signals. Modern decision modeling approaches can and should be deployed to investigate the health and economic consequences of such multicancer early detection (MCED) testing within defined at-risk populations. In this paper, through small-scale analyses involving 3 hypothetical MCED-detectible cancers, the authors illustrate the potential for MCED testing to be cost-effective, along with the pivotal role of test-induced stage shift on results. The time is ripe for additional, prospective investigations of the clinical value of MCED testing, the benefits versus the risks for screened populations, and the overall projected impact on health outcomes and costs over time.

Qualitative exploration of the dynamics of women's dietary diversity. How much does economic empowerment matter?

OBJECTIVE: This study qualitatively examined dietary diversity among married women of reproductive age who engaged in two socio-economic activities to explore the dynamics of food availability, access, costs and consumption. DESIGN: Qualitative in-depth interviews. The food groups in the Minimum Dietary Diversity for women were used to explore women's dietary diversity. IDI were used to develop a roster of daily food consumption over a week. We explored food items that were considered expensive and frequency of consumption, food items that women require permission to consume and frequency of permission sought and the role of economic empowerment. Data analysis followed an inductive-deductive approach to thematic analysis. SETTING: Rural and peri-urban setting in Enugu State, Nigeria. PARTICIPANTS: Thirty-eight married women of reproductive age across two socio-economic groupings (women who work only at home and those who worked outside their homes) were recruited in April 2019. RESULTS: Economic empowerment improved women's autonomy in food purchase and consumption. However, limited income restricted women from full autonomy in consumption decisions and access. Consumption of non-staple food items, especially flesh proteins, would benefit from women's economic empowerment, whereas staple food items would not benefit so much. Dietary diversity is influenced by food production and purchase where factors including seasonal variation in food availability, prices, contextual factors that influence women's autonomy and income are important determinants. CONCLUSION: With limited income, agency and access to household financial resources coupled with norms that restrict women's income earning, women continue to be at risk for not achieving adequate dietary diversity.

Can African-Americans Be Encouraged to Become Active Participants in Advanced Care Planning?

The purpose of this study was to encourage African-Americans to become active participants in advanced care planning through increased education and awareness. A quasi-experimental design was used in two local churches in Leon County. Thirty participants (N = 30) were African-Americans, 18 years of age and older, English speaking, from all socioeconomical levels, and from all educational backgrounds. The annotated 2003 Minnesota Survey was used to develop pre-survey and post-survey questions regarding advanced care planning. A paired t test was used to analyze the pre-survey and post-survey responses. The significant value was < 0.05, thus demonstrating a statistically significant difference in pre- and post-survey responses. The educational intervention on advanced directives indicated that all 30 participants would consider completing some form of advanced directive or discussing end-of-life care planning with either another person, a healthcare provider, or they would seek legal advice. African-Americans are more prone to chronic diseases. However, a systemic literature review describes how African-Americans were less likely to participate in advanced care planning and were less likely to receive end-of-life care than other ethnic groups. The 30-minute educational intervention encouraged African-Americans to participate in advanced care planning. Because the sample size was small, results cannot be generalized to all African-Americans. With increased educational opportunities, African-Americans may be encouraged to become active participants in advanced care planning. Advanced practice registered nurse providers should provide advanced care planning information to all patients, but especially to African-Americans. This study should be replicated in a wide variety of settings with larger numbers of participants. Further research is needed to discover additional methods of providing advanced care planning education to African-Americans.

Availability of essential diagnostics in ten low-income and middle-income countries: results from national health facility surveys.

BACKGROUND: Pathology and laboratory medicine diagnostics and diagnostic imaging are crucial to achieving universal health coverage. We analysed Service Provision Assessments (SPAs) from ten low-income and middle-income countries to benchmark diagnostic availability. METHODS: Diagnostic availabilities were determined for Bangladesh, Haiti, Malawi, Namibia, Nepal, Kenya, Rwanda, Senegal, Tanzania, and Uganda, with multiple timepoints for Haiti, Kenya, Senegal, and Tanzania. A smaller set of diagnostics were included in the analysis for primary care facilities compared with those expected at hospitals, with 16 evaluated in total. Surveys spanned 2004-18, including 8512 surveyed facilities. Country-specific facility types were mapped to basic primary care, advanced primary care, or hospital tiers. We calculated percentages of facilities offering each diagnostic, accounting for facility weights, stratifying by tier, and for some analyses, region. The tier-level estimate of diagnostic availability was defined as the median of all diagnostic-specific availabilities at each tier, and country-level estimates were the median of all diagnostic-specific availabilities of each of the tiers. Associations of country-level diagnostic availability with country income as well as (within-country) region-level availability with region-specific population densities were determined by multivariable linear regression, controlling for appropriate covariates including tier. FINDINGS: Median availability of diagnostics was 19·1% in basic primary care facilities, 49·2% in advanced primary care facilities, and 68·4% in hospitals. Availability varied considerably between diagnostics, ranging from 1·2% (ultrasound) to 76·7% (malaria) in primary care (basic and advanced) and from 6·1% (CT scan) to 91·6% (malaria) in hospitals. Availability also varied between countries, from 14·9% (Bangladesh) to 89·6% (Namibia). Availability correlated positively with log(income) at both primary care tiers but not the hospital tier, and positively with region-specific population density at the basic primary care tier only. INTERPRETATION: Major gaps in diagnostic availability exist in many low-income and middle-income countries, particularly in primary care facilities. These results can serve as a benchmark to gauge progress towards implementing guidelines such as the WHO Essential Diagnostics List and Priority Medical Devices initiatives. FUNDING: Bill & Melinda Gates Foundation.

Information asymmetry in the Kenyan medical laboratory sector.

BACKGROUND: Important information about medical laboratory providers is not readily available to all patients, clinicians nor regulators in Kenya. This study was conducted as part of a wider project aiming to improve access to high quality diagnostics by addressing information asymmetries in the Kenyan market for laboratory services. OBJECTIVES: The purpose of this study was to: 1) Gather pricing information for 49 common laboratory tests from medical laboratories in Nairobi, Kenya, noting where these prices were publicly available or withheld. 2) Assess patients' knowledge of testing information including: turnaround time, price, and test availability. METHOD: This was a cross-sectional study where a mystery caller approach was used to survey 49 tests for turnaround time, price, and availability across 13 laboratories selected purposively. The mystery shopper survey was complemented by 251 patient exit interviews at two Kenyan hospitals to understand whether patients seeking laboratory tests in Nairobi had access to such information. All 251 patients were selected by convenience sampling. RESULTS: We noted that 85% of the private laboratories did not disclose test prices and turnaround times to their patients. There was a wide range of prices on several key tests, with private in-facility laboratories charging an average test price of 468% of the average test price in public laboratories across all the 49 tests. We also found that many patients lacked key information regarding the tests they needed: 65% did not know the purpose of the test while 41% did not know the test price at all. CONCLUSION: Under the current system, patients have limited access to information regarding the key criteria required to make a rational decision. This has a significant impact on the quality, price, and turnaround time (TAT) offered by the medical laboratories that operate in this dysfunctional market.

Cost-Effectiveness Analysis of Afatinib, Erlotinib, and Gefitinib as First-Line Treatments for EGFR Mutation-Positive Non-Small-Cell Lung Cancer in Ontario, Canada.

OBJECTIVE: The objective of this study was to compare the cost effectiveness of first-line epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) for the treatment of non-small-cell lung cancer. METHODS: This study used Ontario Cancer Registry-linked administrative data to identify patients with a primary diagnosis of lung cancer who received EGFR-TKIs as first-line treatment between 1 January, 2014 and 31 August, 2019. A net benefit regression approach accounting for baseline covariates and propensity scores was used to estimate incremental net benefits and incremental cost-effectiveness ratios. Outcome measures were calculated over a 68-month period and were discounted with an annual rate of 1.5%. Sensitivity analyses were conducted to assess and characterize the uncertainties. RESULTS: A total of 547 patients were included in the study, of whom 20.1%, 23.6%, and 56.3% received afatinib, erlotinib, and gefitinib, respectively. Erlotinib was dominated by afatinib and gefitinib. Compared to gefitinib, afatinib was associated with higher effectiveness (adjusted incremental quality-adjusted life-year: 0.21), higher total costs (adjusted incremental costs: $9745), and an incremental cost-effectiveness ratio of $46,506 per quality-adjusted life-year gained. Results from the sensitivity analyses indicated the findings of the base-case analysis were robust. CONCLUSIONS: Contrary to previously published studies, our study established head-to-head comparisons of effectiveness and treatment-related costs of first-line EGFR-TKIs. Our findings suggest afatinib was the most cost-effective option among the three EGFR-TKIs.

Factors affecting treatment selection and overall survival for first-line EGFR-tyrosine kinase inhibitor therapy in non-small-cell lung cancer.

Aim: To investigate the factors associated with treatment selection and overall survival for first-line EGFR-tyrosine kinase inhibitors (EGFR-TKIs) therapy among patients with non-small-cell lung cancer. Materials & methods: We conducted a retrospective cohort study of linked administrative health databases in Ontario, Canada. Results: A total of 1011 patients received an EGFR-TKI as first-line therapy. Treatment selection and overall survival associated with these treatments were affected by age, sex, geographical residency, comorbidities and different sites of metastasis. Conclusion: Though recent approval of osimertinib offers a potential new standard of care in the first-line setting, earlier generation TKIs remain pillars in treatment of non-small-cell lung cancer therapeutic armamentarium. Our findings may contribute to optimizing treatment sequencing of EGFR-TKIs to maximize clinical benefits.

Characteristics Contributing to a Pharmacy Services Excellence Model in a Large Health System.

Objective: To identify characteristics that contribute to and promote a pharmacy services center of excellence model in a large health system. Methods: In 2019, a survey was conducted of 161 acute care pharmacy departments of health system-affiliated hospitals. Information captured included pharmacy practice models, pharmacist resource allocation, training of pharmacy residents, postgraduate training and pharmacist certifications. Results were combined with clinical pharmacy metric performance and centralized electronic data to identify features of top performing pharmacy departments. Results: Survey results were received from 141 of 161 affiliated hospitals (88%). Hospitals with 100 to 299 beds comprised 54% (n = 16 of 30) of the hospitals "at goal" and 66% (n = 26 of 40) of hospitals with "opportunity". Hospitals with top performing pharmacy services had greater participation in interdisciplinary rounds, reporting "always" participating in Adult Critical Care (67% versus 43%) and Medical/Surgical (30% vs. 8%) rounds. Hospitals that trained pharmacy residents had a greater number of clinical pharmacy metrics at goal (5.89 ± 1.59 versus 4.16 ± 1.86, p < 0.001), employed more board-certified pharmacists (2.32 ± 1.49 versus 1.57 ± 1.62, p = 0.019), more postgraduate year 1 (PGY1) trained pharmacists (2.06 ± 1.33 versus 1.19 ± 1.19, p < 0.001) and more PGY2 trained pharmacists (0.58 ± 0.64 versus 0.19 ± 0.44, p = 0.002). When including several key hospital characteristics into a single model, hospitals that trained pharmacy residents were significantly associated with achieving "at goal" status (p = 0.011). Conclusion: Defining characteristics of a pharmacy services center of excellence model included "at goal" clinical pharmacy metrics performance, clinical pharmacist time dedicated to patient care activities, accredited pharmacy residency training programs, presence of pharmacists with advanced training or board certification and optimal operations and scheduling.

Geospatial evaluation of trade-offs between equity in physical access to healthcare and health systems efficiency.

INTRODUCTION: Decisions regarding the geographical placement of healthcare services require consideration of trade-offs between equity and efficiency, but few empirical assessments are available. We applied a novel geospatial framework to study these trade-offs in four African countries. METHODS: Geolocation data on population density (a surrogate for efficiency), health centres and cancer referral centres in Kenya, Malawi, Tanzania and Rwanda were obtained from online databases. Travel time to the closest facility (a surrogate for equity) was estimated with 1 km resolution using the Access Mod 5 least cost distance algorithm. We studied associations between district-level average population density and travel time to closest facility for each country using Pearson's correlation, and spatial autocorrelation using the Global Moran's I statistic. Geographical clusters of districts with inefficient resource allocation were identified using the bivariate local indicator of spatial autocorrelation. RESULTS: Population density was inversely associated with travel time for all countries and levels of the health system (Pearson's correlation range, health centres: -0.89 to -0.71; cancer referral centres: -0.92 to -0.43), favouring efficiency. For health centres, negative spatial autocorrelation (geographical clustering of dissimilar values of population density and travel time) was weaker in Rwanda (-0.310) and Tanzania (-0.292), countries with explicit policies supporting equitable access to rural healthcare, relative to Kenya (-0.579) and Malawi (-0.543). Stronger spatial autocorrelation was observed for cancer referral centres (Rwanda: -0.341; Tanzania: -0.259; Kenya: -0.595; Malawi: -0.666). Significant geographical clusters of sparsely populated districts with long travel times to care were identified across countries. CONCLUSION: Negative spatial correlations suggested that the geographical distribution of health services favoured efficiency over equity, but spatial autocorrelation measures revealed more equitable geographical distribution of facilities in certain countries. These findings suggest that even when prioritising efficiency, thoughtful decisions regarding geographical allocation could increase equitable physical access to services.