Scaling Up Affordable SRH Services: Cost-Effectiveness of Health Bazaar Interventions in Underserved Ethiopian Communities

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Health bazaars, a community-based mobile healthcare intervention piloted by Amref Health Africa, aims to improve accessibility. This study evaluated the cost-effectiveness of health bazaars compared to routine facility-based SRH services. Methods A full economic evaluation was performed using historical data from July 2023 to June 2024. Cost data were collected from the healthcare provider and implementer (Amref) perspectives, covering 20 health facilities across intervention and non-intervention areas. Health outcomes analyzed included uptake of family planning (FP), antenatal care (ANC), skilled birth attendance (SBA), postnatal care (PNC), and HIV testing. Average Cost Effectiveness Ratios (ACER) were calculated, with sensitivity analyses conducted to assess robustness. Results The combined annual cost of implementing health bazaars alongside routine services was $ 93,353.84, compared to $ 76,394.78 for routine facility-based services alone. Health bazaars significantly improved SRH service uptake by 17.52 percentage points overall (65.12% vs. 47.6%), with notable increases in FP use (11.5%), ANC (10.11%), SBA (8.8%), and HIV testing (10.55%). The ACER for health bazaars was $ 1,433.57 per percentage point increase in overall SRH uptake, compared to $ 1,604.93 for routine services, indicating that health bazaars were more cost-effective. Conclusions Health bazaars effectively enhance access to SRH services at a slightly higher total cost but lower incremental cost per unit of service uptake compared to routine care, suggesting their potential for scalable integration into Ethiopia’s primary healthcare system. Health bazaar Cost-effectiveness SRH Community-based healthcare Ethiopia Figures Figure 1 Background Globally, unintended pregnancies and high fertility rates pose significant challenges to individuals, families, and communities, perpetuating cycles of poverty and straining healthcare systems ( 1 ). Access to sexual and reproductive health (SRH) services is a fundamental human right and a cornerstone of Sustainable Development, as recognized in the United Nations' 2030 Agenda ( 2 ). Despite global progress, millions of women, particularly in low-income countries, still lack access to modern contraception, leading to unintended pregnancies and associated health risks such as maternal morbidity, unsafe abortions, and complications related to childbirth ( 3 ). In Ethiopia, where the total fertility rate remains high at 4.1 births per woman, significant barriers hinder access to SRH services ( 4 ). These barriers include socio-cultural factors, economic constraints, inadequate health infrastructure, and a shortage of trained healthcare professionals ( 5 ). As a result, maternal and child health indicators remain concerning. The most recent estimates indicate a maternal mortality ratio (MMR) of 267 per 100,000 live births, with a neonatal mortality rate of 33 per 1,000 live births, despite efforts to improve healthcare accessibility ( 6 ). Expanding access to SRH services is essential for reducing maternal and infant mortality rates and achieving universal health coverage goals ( 7 ). The Ethiopian government has prioritized SRH services under the Health Sector Transformation Plan-II (HSTP-II), aiming to increase contraceptive prevalence, reduce teenage pregnancy, and improve maternal and child health outcomes ( 8 ). However, gaps persist, particularly in rural and underserved areas where healthcare facilities are sparse ( 9 ). According to the 2019/20 National Health Accounts (NHA), Ethiopia's Total Health Expenditure (THE) was 127.47 billion ETB (3.63 billion USD), representing 6.3% of GDP. The per capita health expenditure was reported at 36.40 USD, significantly lower than the 86 USD recommended by the WHO for essential health services ( 10 ). Out-of-pocket (OOP) household expenditures account for 30.5% of THE, posing financial barriers for many individuals seeking healthcare services ( 11 ). ​In Ethiopia, especially pastoralist and agrarian communities face unique challenges in accessing maternal and child healthcare services. Geographical remoteness often necessitates traveling long distances to reach healthcare facilities, leading to delays in receiving care. Financial constraints, including costs associated with transportation and medical services, deter many from seeking necessary care. Cultural norms and gender inequalities further restrict women's autonomy in making healthcare decisions, impacting their ability to seek timely care. Reliance on traditional birth attendants, who may lack formal training, poses additional risks during childbirth. Political instability and conflicts disrupt healthcare infrastructure, leading to service shortages ( 12 , 13 ). In response to these challenges, Amref Health Africa piloted a novel and contextually adapted service delivery model known as the health bazaar under the “ Reset Plus Project: Scaling up the Family Planning for Resilience Building program amongst youth and women in drought prone and chronically food insecure regions of Ethiopia (T05-EUTF-HOA-ET-24-08)” funded by European Union during the period 2021–2024 to enhance SRH service accessibility in four Ethiopian regions: Oromia, Afar, Amhara, and South Ethiopia ( 14 ). The health bazaar is a mobile, community-based approach designed to provide integrated SRH services, including family planning, antenatal care, skilled birth attendance referrals, HIV testing, and health education ( 15 ). This model aims to complement existing facility-based healthcare services by reaching underserved populations directly, addressing logistical barriers to service utilization ( 16 ). Health bazaars incorporate social mobilization strategies to engage communities, ensuring increased awareness and participation in SRH programs. The intervention model also emphasizes multi-sectoral collaboration by involving local healthcare providers, government agencies, and community health workers to optimize service delivery ( 17 ). Previous studies have demonstrated that community-based interventions can significantly improve healthcare accessibility and service uptake, yet their long-term cost-effectiveness remains uncertain ( 18 , 19 ). While health bazaars have been implemented from 2021–2024 by Amref Ethiopia, there is limited empirical evidence comparing their cost-effectiveness to traditional facility-based service delivery ( 20 ). Conducting a cost-effectiveness analysis of health bazaar interventions is crucial for determining their sustainability and scalability in Ethiopia's healthcare landscape ( 21 ). By comparing the costs and health outcomes associated with this model versus routine facility-based SRH services, policymakers can make informed decisions on resource allocation and service expansion strategies ( 22 ). Cost-effectiveness evaluations provide a systematic approach to assessing the financial feasibility of health interventions, allowing for the optimization of public health investments ( 23 ). This study aims to fill the existing knowledge gap by evaluating the cost-effectiveness of health bazaars in Ethiopia. The findings will contribute to evidence-based policy formulation, guiding the implementation of scalable and sustainable SRH service delivery models ( 24 ). Given Ethiopia's commitment to achieving the Sustainable Development Goals (SDGs), particularly Goal 3 (Good Health and Well-being) and Goal 5 (Gender Equality), evidence-based interventions such as health bazaars could play a pivotal role in advancing healthcare accessibility and equity ( 25 ). The study’s findings will also have broader implications for other low-income countries seeking to enhance SRH service delivery through innovative, cost-effective approaches ( 26 ). Methods Study Design and Study Period A full economic evaluation study was conducted using a quasi-experimental design. The study compared health bazaar interventions with routine facility-based SRH services. Historical data were collected over a one-year period, covering the Ethiopian fiscal year from July 1, 2023, to June 30, 2024. Study Setting General Setting Ethiopia, the second-most populous country in Africa, has made significant strides in improving its healthcare system, yet challenges persist, particularly in maternal and child health. According to the 2019/NHA report, Ethiopia's total health expenditure was 127.47 billion ETB (3.63 billion USD), accounting for 6.3% of GDP. The country's per capita health expenditure reached 36.40 USD, an increase from previous years but still below the 43 USD average for low-income African countries and significantly lower than the 86 USD per capita spending recommended by the WHO for essential health services ( 24 ). Despite financial constraints, Ethiopia has expanded healthcare coverage, with over 234 hospitals, 3,586 health centres, and 11,446 health posts as of 2018 ( 23 ). However, disparities in healthcare access between urban and rural areas, inadequate healthcare financing, and shortages of medical professionals continue to hinder further progress toward universal health coverage ( 13 ). Specific setting Implementation of Health Bazaars The study was conducted in selected areas where Amref Health Africa implemented the "Reset Plus Project: Scaling up the Family Planning for Resilience Building program amongst youth and women in drought prone and chronically food insecure regions of Ethiopia (T05-EUTF-HOA-ET-24-08)" which aims to improve family planning and SRH service uptake through innovative community-based strategies. The study was conducted in four Ethiopian regions: Oromia, Afar, Amhara, and South Ethiopia. Within these regions, selected districts were chosen based on prior implementation of the health bazaar interventions. The intervention areas were compared with non-intervention areas where only routine facility-based SRH services were provided. Health Bazaar Operational Definition and Implementation The health bazaar is a community-based, mobile health service delivery model aimed at improving access to sexual and reproductive health (SRH) services in underserved communities. Typically held quarterly over two to three days, these events leverage entertainment-education methods, including drama, music, poetry, and interactive discussions, to effectively engage community members. Health bazaars provide essential SRH services such as family planning, antenatal and postnatal care, HIV testing, immunizations, deworming, growth monitoring, and nutritional demonstrations, all conveniently located in accessible community spaces. Implementation involves careful planning and community mobilization led by a joint committee comprising local leaders, healthcare providers, educators, and community representatives. Strong collaboration with local stakeholders enhances community ownership and ensures sustainability. Each event systematically collects service utilization data and monitors health interventions to evaluate effectiveness, inform future planning, and align with local health priorities and community needs. Perspective of the Study Costs were assessed from the healthcare provider and implementer (Amref Health Africa) perspectives, covering all expenditures related to SRH service delivery through health bazaars and routine health facility operations. Intervention and Comparator The intervention consisted of community-based, mobile "health bazaar" events providing integrated SRH services, including family planning, ANC, SBA, PNC, HIV testing, immunizations, and nutritional education. Routine facility-based SRH services served as the comparator, involving standard care delivery without the supplementary outreach activities characteristic of health bazaars. Data Sources and Data Collection Procedures Data Sources Data were collected from 20 health facilities, evenly distributed between intervention (health bazaar) and non-intervention (routine care) areas in a 1:1 ratio. Health facilities included primary hospitals, health centres, and health posts. Additional financial and implementation data were obtained from Amref Health Africa’s expenditure records. The study utilized data from multiple sources: Health Facility Records: Routine service utilization data from ten health facilities (one primary hospital, four health centers, and five health posts) in non-intervention areas; Implementer (Amref Health Africa) Records: Financial and implementation data on health bazaar costs and activities; Service Uptake Data: Information on contraceptive use, antenatal care, skilled birth attendance, postnatal care, and HIV testing. Data Collection Procedures A mixed-methods approach was used to collect comprehensive cost data: Facility-Level Costs: Extracted from health facility financial records, covering salaries, supplies, and operational expenses. Implementer Costs: Obtained from Amref Health Africa’s financial records, capturing expenditures related directly to health bazaar activities, including personnel costs, supplies, and overheads. Health outcomes data, including SRH service uptake (contraceptive use, ANC attendance, SBA, PNC, and HIV testing), were retrieved from health facility registers. Data Analysis Cost Analysis Costs were categorized into personnel (salaries and per diems), supplies (medical commodities and educational materials), and overhead (utilities, transportation, venue costs, and administrative expenses). Annual average costs for both interventions were converted to USD (2023 exchange rate: 1 USD = 54.757 ETB). Cost-Effectiveness Analysis Average Cost-Effectiveness Ratios (ACERs) were calculated by dividing the annual total costs by the percentage point increase in SRH service uptake. ACERs were computed separately for each SRH service domain (FP, ANC, SBA, PNC, HIV testing) for both intervention and comparator groups. Sensitivity Analysis A one-way sensitivity analysis was conducted to assess robustness, adjusting the health bazaar and routine facility-based service costs and SRH service uptake by ± 20%. Results were visualized using a Tornado diagram to illustrate the relative impact of key variables on the ACER. Ethical Considerations Ethical approval was obtained from the appropriate institutional review boards. Data collection adhered to ethical guidelines to ensure confidentiality and anonymity. No personally identifiable patient data were used. Participants in the intervention areas provided consent where required, and health facility data were used in aggregate form to protect privacy. Results Cost Analysis Annual Average Cost of SRH Services in Routine Facility-Based Intervention The annual average cost of providing sexual and reproductive health (SRH) services through routine facility-based interventions alone was USD 76,394.78. The largest cost component was supplies, accounting for USD 34,184.53 (approximately 45% of total costs), followed by overhead costs (USD 26,590.52, ~ 35%) and personnel expenses (USD 22,456.63, ~ 29%) (Table 1 ). Table 1 Costs of Providing SRH Services by Cost Category (Routine Facility-Based vs. Health Bazaar Areas) by cost ingredients from July 2022-June 2023. Cost Component Routine Facility-Based (USD) Health Bazaar Areas (USD) Supplies 34,184.53 172,687.43 Personnel 22,456.63 25,634.15 Overhead 26,590.52 43,567.10 Total 76,394.78 241,888.68 Intervention Effectiveness Health bazaars significantly increased overall SRH service uptake by 17.52 percentage points, achieving a utilization rate of 65.12% compared to 47.6% in non-intervention areas. Family planning (FP) usage increased by 11.5 percentage points (from 41.8–53.3%), HIV testing improved by 10.55 percentage points (from 41.05–51.6%), and maternal health indicators also improved notably: ANC coverage increased by 10.11 percentage points, SBA by 8.8 percentage points, and PNC by 1.3 percentage points (Table 2 ). Table 2 SRH Service Utilization Rates (Intervention vs. Non-Intervention Areas) Service Indicator Routine Facility-Based (%) Health Bazaar (%) Difference (%) Overall SRH Uptake 47.6 65.12 + 17.52 Family Planning 41.8 53.3 + 11.5 HIV Testing 41.05 51.6 + 10.55 ANC 77.14 87.25 + 10.11 Skilled Birth Attendance 80.6 89.4 + 8.8 Postnatal Care 64.7 66.0 + 1.3 Cost-Effectiveness Analysis The updated average cost-effectiveness ratio (ACER) for health bazaars was USD 1,433.57 per percentage point increase in overall SRH service uptake. Comparatively, routine facility-based services had an ACER of USD 1,604.93 per percentage point increase (Table 3 ). These findings indicate that health bazaars offer a more cost-effective means of increasing SRH service uptake compared to traditional facility-based services. Table 3 ACER for SRH Services Service Indicator Routine Facility-Based (USD) Health Bazaar (USD) Overall SRH Uptake 1,604.93 1,433.57 Family Planning 1,827.63 1,751.48 HIV Testing 1,861.02 1,809.18 ANC 990.34 1,069.96 Skilled Birth Attendance 947.83 1,044.23 Postnatal Care 1,180.75 1,414.45 Sensitivity Analysis Sensitivity analyses indicated robustness in cost-effectiveness outcomes. Varying intervention and service uptake costs by ± 20% demonstrated that health bazaars consistently remained more cost-effective than routine facility-based services (Fig. 1 ). The ACER was most sensitive to variations in overall SRH service uptake and intervention costs, affirming health bazaars as a viable economic strategy under diverse conditions. Discussion This study evaluated the cost-effectiveness of community-based “health bazaars” for improving access to sexual and reproductive health (SRH) services in underserved Ethiopian communities. Compared to routine facility-based services, health bazaars increased SRH service uptake by 17.52 percentage points and were more cost-effective, with notable gains in family planning (11.5%), antenatal care (10.11%), skilled birth attendance (8.8%), and HIV testing (10.55%) and with an ACER of $ 1,433.57 per percentage point increase in service uptake. These findings support our hypothesis that health bazaars provide a scalable and financially sustainable model for improving SRH coverage in hard-to-reach populations. Sensitivity analyses further supported the robustness of these findings, showing that health bazaars remained cost-effective under varying cost and uptake scenarios. However, the sustainability and broader scalability of this intervention could be challenged by the reliance on external funding and the logistical complexities inherent in mobile service delivery models ( 27 – 29 ). To our knowledge, this is the first full economic evaluation of mobile health bazaars in Ethiopia's SRH service delivery context. Previous studies have highlighted the potential of community-level interventions in improving maternal and child health ( 30 , 31 ), but few have conducted comprehensive cost-effectiveness comparisons. Our study provides empirical evidence that health bazaars, despite slightly higher operational costs, result in greater health benefits per dollar spent than facility-based care alone. This is especially relevant given Ethiopia’s constrained health financing environment, where efficiency is essential for scaling up services ( 27 ). Our findings are consistent with the cost-effectiveness results from Kenya, where community-based quality improvement interventions showed significant gains in maternal and child health at a cost of $ 249 per DALY averted ( 30 ). Similarly, Memirie et al. (2019) reported highly cost-effective maternal and neonatal health interventions in Ethiopia, particularly those targeting newborns ( 31 ). However, unlike most studies that focus on static facility-based or narrowly targeted services, our study integrates a broader spectrum of SRH services and a mobile delivery model, aligning more with the holistic SRHR package recommended by the Guttmacher-Lancet Commission ( 32 ). The enhanced cost-effectiveness of health bazaars may stem from their design—combining service delivery with community engagement and health education. Social mobilization likely plays a critical role in increasing trust and demand for services, especially in culturally conservative or geographically isolated communities. Furthermore, the integration of services (e.g., ANC, FP, HIV testing) in a single setting may improve convenience and uptake. A major strength of this study is its use of real-world implementation data and its health system perspective, enhancing relevance for policymakers. The use of average cost-effectiveness ratios (ACER) allowed for a direct comparison between intervention and control arms. However, limitations include potential selection bias in intervention site selection and the absence of long-term health outcome data such as DALYs or QALYs. Moreover, indirect costs and broader societal benefits (e.g., reduced time loss or increased economic productivity) were not considered, possibly underestimating the true value of the intervention. Future studies should assess the long-term health and economic impacts of health bazaars, including DALYs averted and broader social return on investment. Implementation research is also needed to explore scalability and integration with digital health tools. The findings suggest that health bazaars can play a pivotal role in advancing Ethiopia's Health Sector Transformation Plan-II objectives and the Sustainable Development Goals, particularly in reducing maternal and neonatal mortality. Given their demonstrated cost-effectiveness, integrating a health service delivery model similar like health bazaars into the national SRH service delivery framework could accelerate progress toward universal health coverage (UHC), especially for marginalized populations. Conclusion This study provides strong evidence that health bazaars are a cost-effective, community-based model for improving SRH service accessibility in Ethiopia. By increasing service uptake while maintaining financial efficiency, health bazaars offer a promising scalable and sustainable approach to bridging the gap in healthcare access between rural and urban populations. The results suggest that integrating health bazaars into Ethiopia’s primary healthcare system could enhance the long-term sustainability of SRH services, reducing reliance on donor-based funding while improving health equity. Moving forward, policymakers should consider expanding health bazaars, supported by sustainable financing mechanisms such as CBHI, and integrating them into national healthcare strategies. Further research is needed to assess long-term health outcomes and explore scalability beyond Ethiopia. By leveraging community-based health solutions, Ethiopia can strengthen its health system resilience and ensure equitable access to essential healthcare services. Abbreviations Adjusted Odds Ratio (AORs); Antenatal care (ANC); Average Cost Effectiveness Ratios (ACER), Community-based health insurance (CBHI); Confidence Interval (CL); District Health Information System (DHIS2); Ethiopia's total health expenditure (THE) ; Human Immunodeficiency Virus (HIV); Intra class correlation coefficients (ICC); maternal mortality ratio (MMR); National Health Accounts (NHA); Out-of-pocket (OOP) ; Postnatal care (PNC); Resilience Building and Creation of Economic Opportunities in Ethiopia( RESET); Sexual and Reproductive Health (SRH); Standard deviations (SD); Sustainable Development Goals(SDG) Declarations Ethics approval and consent to participate Ethical clearance was obtained from Ethiopian Anaesthetics Professionals’ Association IRB. A support letter was obtained from the regional health bureaus/MOH. Informed consent was obtained from all participants. Confidentiality of the collected data was ensured from all data collectors and the principal investigator’s side via using code data to replace personal identifiers and keeping the responses locked. The study adhered to WHO ethical guidelines for SRH research. Consent for publication Not applicable. Availability of data and materials Data is available upon reasonable request from the corresponding author. The data are not publicly available due to privacy reasons. Competing interests The authors declare no competing interests. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. Funding This research was funded by the European Union, as part of the “RESET Plus—Scaling up the Family Planning for Resilience Building program amongst youth and women in drought prone and chronically food insecure regions of Ethiopia (T05-EUTF-HOA-ET-24-08)”. Amref Health Africa supported the administrative part in the course of the implementation of the project. Authors' contributions MDM, MB, ZA, WK, SA, and GM designed and conducted the study. MDM, WK, MA, ZA and GM planned and undertook the analysis. WE, ZD, MDM, MB, and GM wrote the initial and subsequent drafts of the manuscript. WE, MDM, MM, GM, VS, MM contributed to revising the manuscript. All authors read and approved the final manuscript. Acknowledgements We are grateful for the participation of all the research samples and the cooperation of the personnel project implementation areas. Without their support, these results would not have been achieved. Additionally, the researchers are thankful to both the European Union for funding the project and Amref Health Africa for providing access to data and administrative support. References United Nations Population Fund (UNFPA). State of World Population Report 2022 . UNFPA, 2022. Available at United Nations. 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Kaiser AH, Ekman B, Dimarco M, Sundewall J. The cost-effectiveness of sexual and reproductive health and rights interventions in low- and middle-income countries: a scoping review. Sex Reprod Health Matters. 2021 Dec;29(1):1983107. doi: 10.1080/26410397.2021.1983107. PMID: 34747673; PMCID: PMC8583757. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 15 Aug, 2025 Reviewers invited by journal 13 Aug, 2025 Editor invited by journal 23 May, 2025 Editor assigned by journal 19 May, 2025 Submission checks completed at journal 19 May, 2025 First submitted to journal 15 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6674112","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":501706890,"identity":"3ba4890b-3838-4c9b-af72-69f3d118ead6","order_by":0,"name":"Muluken Dessalegn","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYDCCAxBKhoG9AUgZWBClhRGkloeBB6TZQIIULRIJIC4RWviOtz9/8DPnMA+/5POrG34USDDwt3cn4NUieeaMYWPvtsM8krNzym72AB0mcebsBrxaDG7kMDbwArUY3M5Ju8ED1GIgkUtAy/3nDxv/ArXY3zyTdvMPUVpuMBg2g22RYD92myhbJM/kGM6W3ZbOI3Emh+22jIEED0G/8B0//uDj223Wcvztx5/dfPPHBsjoxa8FCfAYgElilYMA+wNSVI+CUTAKRsEIAgCZMUvPN7PV1QAAAABJRU5ErkJggg==","orcid":"","institution":"Amref Health Africa","correspondingAuthor":true,"prefix":"","firstName":"Muluken","middleName":"","lastName":"Dessalegn","suffix":""},{"id":501706891,"identity":"e20611f1-0960-4916-ab7e-ae37166ff6c1","order_by":1,"name":"Geteneh Mogges","email":"","orcid":"","institution":"Amref Health Africa","correspondingAuthor":false,"prefix":"","firstName":"Geteneh","middleName":"","lastName":"Mogges","suffix":""},{"id":501706892,"identity":"d35ad110-b8c7-467b-a5f7-2fc10883535c","order_by":2,"name":"Makida Birhan","email":"","orcid":"","institution":"Amref Health Africa","correspondingAuthor":false,"prefix":"","firstName":"Makida","middleName":"","lastName":"Birhan","suffix":""},{"id":501706893,"identity":"f5b63202-6ab7-4136-bb37-1e368b4476b6","order_by":3,"name":"Sintayehu Abebe","email":"","orcid":"","institution":"Amref Health Africa","correspondingAuthor":false,"prefix":"","firstName":"Sintayehu","middleName":"","lastName":"Abebe","suffix":""},{"id":501706894,"identity":"ce5bbc7e-10ce-40cd-b821-e567b49fd9c6","order_by":4,"name":"Woldu Kidanie","email":"","orcid":"","institution":"Amref Health Africa","correspondingAuthor":false,"prefix":"","firstName":"Woldu","middleName":"","lastName":"Kidanie","suffix":""},{"id":501706895,"identity":"f37b575c-4828-419c-bad0-55186f9080f8","order_by":5,"name":"Andrea Rossetti","email":"","orcid":"","institution":"Amref Health Africa","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Rossetti","suffix":""},{"id":501706900,"identity":"df9dd68b-b782-4a48-bcca-5e31396ca48b","order_by":6,"name":"Virginia Stulz","email":"","orcid":"","institution":"University of Newcastle","correspondingAuthor":false,"prefix":"","firstName":"Virginia","middleName":"","lastName":"Stulz","suffix":""},{"id":501706902,"identity":"6821abd1-c34e-476c-9ba0-035ac6ff979c","order_by":7,"name":"Zewede Aderaw","email":"","orcid":"","institution":"Amref Health Africa","correspondingAuthor":false,"prefix":"","firstName":"Zewede","middleName":"","lastName":"Aderaw","suffix":""},{"id":501706906,"identity":"2cccf4c8-2a53-42b9-ba56-18c0c955c398","order_by":8,"name":"Misrak Makonnen","email":"","orcid":"","institution":"Amref Health Africa","correspondingAuthor":false,"prefix":"","firstName":"Misrak","middleName":"","lastName":"Makonnen","suffix":""},{"id":501706908,"identity":"865128a0-b5fe-4e99-8cbf-0897f411a7c5","order_by":9,"name":"Wendemagegn Yeshanehe","email":"","orcid":"","institution":"Selam Global Health Consultancy","correspondingAuthor":false,"prefix":"","firstName":"Wendemagegn","middleName":"","lastName":"Yeshanehe","suffix":""}],"badges":[],"createdAt":"2025-05-15 15:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6674112/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6674112/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89555362,"identity":"3febb321-3bd3-4087-8fd8-e9493bd91a70","added_by":"auto","created_at":"2025-08-21 09:20:58","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":271542,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTornado diagram illustrate one-way sensitivity analysis shows how the ACER varies for each intervention when the cost and uptake are varied.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6674112/v1/3e21798137613b596274cc61.jpeg"},{"id":89556620,"identity":"33ae168c-ed26-4b9a-8cb6-fac6365d443d","added_by":"auto","created_at":"2025-08-21 09:36:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1215261,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6674112/v1/079bc1aa-9af5-41f3-8cd1-6e7811f9062c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Scaling Up Affordable SRH Services: Cost-Effectiveness of Health Bazaar Interventions in Underserved Ethiopian Communities","fulltext":[{"header":"Background","content":"\u003cp\u003eGlobally, unintended pregnancies and high fertility rates pose significant challenges to individuals, families, and communities, perpetuating cycles of poverty and straining healthcare systems (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Access to sexual and reproductive health (SRH) services is a fundamental human right and a cornerstone of Sustainable Development, as recognized in the United Nations' 2030 Agenda (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Despite global progress, millions of women, particularly in low-income countries, still lack access to modern contraception, leading to unintended pregnancies and associated health risks such as maternal morbidity, unsafe abortions, and complications related to childbirth (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Ethiopia, where the total fertility rate remains high at 4.1 births per woman, significant barriers hinder access to SRH services (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). These barriers include socio-cultural factors, economic constraints, inadequate health infrastructure, and a shortage of trained healthcare professionals (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). As a result, maternal and child health indicators remain concerning. The most recent estimates indicate a maternal mortality ratio (MMR) of 267 per 100,000 live births, with a neonatal mortality rate of 33 per 1,000 live births, despite efforts to improve healthcare accessibility (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Expanding access to SRH services is essential for reducing maternal and infant mortality rates and achieving universal health coverage goals (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe Ethiopian government has prioritized SRH services under the Health Sector Transformation Plan-II (HSTP-II), aiming to increase contraceptive prevalence, reduce teenage pregnancy, and improve maternal and child health outcomes (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, gaps persist, particularly in rural and underserved areas where healthcare facilities are sparse (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). According to the 2019/20 National Health Accounts (NHA), Ethiopia's Total Health Expenditure (THE) was 127.47\u0026nbsp;billion ETB (3.63\u0026nbsp;billion USD), representing 6.3% of GDP. The per capita health expenditure was reported at 36.40 USD, significantly lower than the 86 USD recommended by the WHO for essential health services (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Out-of-pocket (OOP) household expenditures account for 30.5% of THE, posing financial barriers for many individuals seeking healthcare services (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e​In Ethiopia, especially pastoralist and agrarian communities face unique challenges in accessing maternal and child healthcare services. Geographical remoteness often necessitates traveling long distances to reach healthcare facilities, leading to delays in receiving care. Financial constraints, including costs associated with transportation and medical services, deter many from seeking necessary care. Cultural norms and gender inequalities further restrict women's autonomy in making healthcare decisions, impacting their ability to seek timely care. Reliance on traditional birth attendants, who may lack formal training, poses additional risks during childbirth. Political instability and conflicts disrupt healthcare infrastructure, leading to service shortages (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn response to these challenges, Amref Health Africa piloted a novel and contextually adapted service delivery model known as the health bazaar under the \u003cb\u003e\u0026ldquo;\u003c/b\u003eReset Plus Project: Scaling up the Family Planning for Resilience Building program amongst youth and women in drought prone and chronically food insecure regions of Ethiopia (T05-EUTF-HOA-ET-24-08)\u0026rdquo; funded by European Union during the period 2021\u0026ndash;2024 to enhance SRH service accessibility in four Ethiopian regions: Oromia, Afar, Amhara, and South Ethiopia (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The health bazaar is a mobile, community-based approach designed to provide integrated SRH services, including family planning, antenatal care, skilled birth attendance referrals, HIV testing, and health education (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This model aims to complement existing facility-based healthcare services by reaching underserved populations directly, addressing logistical barriers to service utilization (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHealth bazaars incorporate social mobilization strategies to engage communities, ensuring increased awareness and participation in SRH programs. The intervention model also emphasizes multi-sectoral collaboration by involving local healthcare providers, government agencies, and community health workers to optimize service delivery (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Previous studies have demonstrated that community-based interventions can significantly improve healthcare accessibility and service uptake, yet their long-term cost-effectiveness remains uncertain (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). While health bazaars have been implemented from 2021\u0026ndash;2024 by Amref Ethiopia, there is limited empirical evidence comparing their cost-effectiveness to traditional facility-based service delivery (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eConducting a cost-effectiveness analysis of health bazaar interventions is crucial for determining their sustainability and scalability in Ethiopia's healthcare landscape (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). By comparing the costs and health outcomes associated with this model versus routine facility-based SRH services, policymakers can make informed decisions on resource allocation and service expansion strategies (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Cost-effectiveness evaluations provide a systematic approach to assessing the financial feasibility of health interventions, allowing for the optimization of public health investments (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study aims to fill the existing knowledge gap by evaluating the cost-effectiveness of health bazaars in Ethiopia. The findings will contribute to evidence-based policy formulation, guiding the implementation of scalable and sustainable SRH service delivery models (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Given Ethiopia's commitment to achieving the Sustainable Development Goals (SDGs), particularly Goal 3 (Good Health and Well-being) and Goal 5 (Gender Equality), evidence-based interventions such as health bazaars could play a pivotal role in advancing healthcare accessibility and equity (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The study\u0026rsquo;s findings will also have broader implications for other low-income countries seeking to enhance SRH service delivery through innovative, cost-effective approaches (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Study Period\u003c/h2\u003e\u003cp\u003eA full economic evaluation study was conducted using a quasi-experimental design. The study compared health bazaar interventions with routine facility-based SRH services. Historical data were collected over a one-year period, covering the Ethiopian fiscal year from July 1, 2023, to June 30, 2024.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eGeneral Setting\u003c/h2\u003e\u003cp\u003eEthiopia, the second-most populous country in Africa, has made significant strides in improving its healthcare system, yet challenges persist, particularly in maternal and child health. According to the 2019/NHA report, Ethiopia's total health expenditure was 127.47\u0026nbsp;billion ETB (3.63\u0026nbsp;billion USD), accounting for 6.3% of GDP. The country's per capita health expenditure reached 36.40 USD, an increase from previous years but still below the 43 USD average for low-income African countries and significantly lower than the 86 USD per capita spending recommended by the WHO for essential health services (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite financial constraints, Ethiopia has expanded healthcare coverage, with over 234 hospitals, 3,586 health centres, and 11,446 health posts as of 2018 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). However, disparities in healthcare access between urban and rural areas, inadequate healthcare financing, and shortages of medical professionals continue to hinder further progress toward universal health coverage (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSpecific setting\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eImplementation of Health Bazaars\u003c/h2\u003e\u003cp\u003eThe study was conducted in selected areas where Amref Health Africa implemented the \"Reset Plus Project: Scaling up the Family Planning for Resilience Building program amongst youth and women in drought prone and chronically food insecure regions of Ethiopia (T05-EUTF-HOA-ET-24-08)\" which aims to improve family planning and SRH service uptake through innovative community-based strategies.\u003c/p\u003e\u003cp\u003eThe study was conducted in four Ethiopian regions: Oromia, Afar, Amhara, and South Ethiopia. Within these regions, selected districts were chosen based on prior implementation of the health bazaar interventions. The intervention areas were compared with non-intervention areas where only routine facility-based SRH services were provided.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eHealth Bazaar Operational Definition and Implementation\u003c/h2\u003e\u003cp\u003eThe health bazaar is a community-based, mobile health service delivery model aimed at improving access to sexual and reproductive health (SRH) services in underserved communities. Typically held quarterly over two to three days, these events leverage entertainment-education methods, including drama, music, poetry, and interactive discussions, to effectively engage community members. Health bazaars provide essential SRH services such as family planning, antenatal and postnatal care, HIV testing, immunizations, deworming, growth monitoring, and nutritional demonstrations, all conveniently located in accessible community spaces.\u003c/p\u003e\u003cp\u003eImplementation involves careful planning and community mobilization led by a joint committee comprising local leaders, healthcare providers, educators, and community representatives. Strong collaboration with local stakeholders enhances community ownership and ensures sustainability. Each event systematically collects service utilization data and monitors health interventions to evaluate effectiveness, inform future planning, and align with local health priorities and community needs.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePerspective of the Study\u003c/h3\u003e\n\u003cp\u003eCosts were assessed from the healthcare provider and implementer (Amref Health Africa) perspectives, covering all expenditures related to SRH service delivery through health bazaars and routine health facility operations.\u003c/p\u003e\n\u003ch3\u003eIntervention and Comparator\u003c/h3\u003e\n\u003cp\u003eThe intervention consisted of community-based, mobile \"health bazaar\" events providing integrated SRH services, including family planning, ANC, SBA, PNC, HIV testing, immunizations, and nutritional education. Routine facility-based SRH services served as the comparator, involving standard care delivery without the supplementary outreach activities characteristic of health bazaars.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eData Sources and Data Collection Procedures\u003c/h2\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003eData Sources\u003c/h2\u003e\u003cp\u003eData were collected from 20 health facilities, evenly distributed between intervention (health bazaar) and non-intervention (routine care) areas in a 1:1 ratio. Health facilities included primary hospitals, health centres, and health posts. Additional financial and implementation data were obtained from Amref Health Africa\u0026rsquo;s expenditure records.\u003c/p\u003e\u003cp\u003eThe study utilized data from multiple sources: Health Facility Records: Routine service utilization data from ten health facilities (one primary hospital, four health centers, and five health posts) in non-intervention areas; Implementer (Amref Health Africa) Records: Financial and implementation data on health bazaar costs and activities; Service Uptake Data: Information on contraceptive use, antenatal care, skilled birth attendance, postnatal care, and HIV testing.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eData Collection Procedures\u003c/h2\u003e\u003cp\u003eA mixed-methods approach was used to collect comprehensive cost data:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eFacility-Level Costs: Extracted from health facility financial records, covering salaries, supplies, and operational expenses.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eImplementer Costs: Obtained from Amref Health Africa\u0026rsquo;s financial records, capturing expenditures related directly to health bazaar activities, including personnel costs, supplies, and overheads.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eHealth outcomes data, including SRH service uptake (contraceptive use, ANC attendance, SBA, PNC, and HIV testing), were retrieved from health facility registers.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003eCost Analysis\u003c/h2\u003e\u003cp\u003eCosts were categorized into personnel (salaries and per diems), supplies (medical commodities and educational materials), and overhead (utilities, transportation, venue costs, and administrative expenses). Annual average costs for both interventions were converted to USD (2023 exchange rate: 1 USD\u0026thinsp;=\u0026thinsp;54.757 ETB).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eCost-Effectiveness Analysis\u003c/h2\u003e\u003cp\u003eAverage Cost-Effectiveness Ratios (ACERs) were calculated by dividing the annual total costs by the percentage point increase in SRH service uptake. ACERs were computed separately for each SRH service domain (FP, ANC, SBA, PNC, HIV testing) for both intervention and comparator groups.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eSensitivity Analysis\u003c/h2\u003e\u003cp\u003eA one-way sensitivity analysis was conducted to assess robustness, adjusting the health bazaar and routine facility-based service costs and SRH service uptake by \u0026plusmn;\u0026thinsp;20%. Results were visualized using a Tornado diagram to illustrate the relative impact of key variables on the ACER.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eEthical Considerations\u003c/h2\u003e\u003cp\u003eEthical approval was obtained from the appropriate institutional review boards. Data collection adhered to ethical guidelines to ensure confidentiality and anonymity. No personally identifiable patient data were used. Participants in the intervention areas provided consent where required, and health facility data were used in aggregate form to protect privacy.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eCost Analysis\u003c/h2\u003e\u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\u003ch2\u003eAnnual Average Cost of SRH Services in Routine Facility-Based Intervention\u003c/h2\u003e\u003cp\u003eThe annual average cost of providing sexual and reproductive health (SRH) services through routine facility-based interventions alone was USD 76,394.78. The largest cost component was supplies, accounting for USD 34,184.53 (approximately 45% of total costs), followed by overhead costs (USD 26,590.52, ~\u0026thinsp;35%) and personnel expenses (USD 22,456.63, ~\u0026thinsp;29%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCosts of Providing SRH Services by Cost Category (Routine Facility-Based vs. Health Bazaar Areas) by cost ingredients from July 2022-June 2023.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCost Component\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRoutine Facility-Based (USD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHealth Bazaar Areas (USD)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSupplies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34,184.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e172,687.43\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePersonnel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22,456.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25,634.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverhead\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e26,590.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e43,567.10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e76,394.78\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e241,888.68\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eIntervention Effectiveness\u003c/h2\u003e\u003cp\u003eHealth bazaars significantly increased overall SRH service uptake by 17.52 percentage points, achieving a utilization rate of 65.12% compared to 47.6% in non-intervention areas. Family planning (FP) usage increased by 11.5 percentage points (from 41.8\u0026ndash;53.3%), HIV testing improved by 10.55 percentage points (from 41.05\u0026ndash;51.6%), and maternal health indicators also improved notably: ANC coverage increased by 10.11 percentage points, SBA by 8.8 percentage points, and PNC by 1.3 percentage points (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSRH Service Utilization Rates (Intervention vs. Non-Intervention Areas)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eService Indicator\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRoutine Facility-Based (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHealth Bazaar (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDifference (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall SRH Uptake\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e47.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e65.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;17.52\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily Planning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e53.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;11.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHIV Testing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e51.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;10.55\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eANC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e77.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;10.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSkilled Birth Attendance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e80.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e89.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;8.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostnatal Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e64.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e66.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;1.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eCost-Effectiveness Analysis\u003c/h2\u003e\u003cp\u003eThe updated average cost-effectiveness ratio (ACER) for health bazaars was USD 1,433.57 per percentage point increase in overall SRH service uptake. Comparatively, routine facility-based services had an ACER of USD 1,604.93 per percentage point increase (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). These findings indicate that health bazaars offer a more cost-effective means of increasing SRH service uptake compared to traditional facility-based services.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eACER for SRH Services\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eService Indicator\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRoutine Facility-Based (USD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHealth Bazaar (USD)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall SRH Uptake\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,604.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,433.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily Planning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,827.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,751.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHIV Testing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,861.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,809.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eANC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e990.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,069.96\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSkilled Birth Attendance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e947.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,044.23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostnatal Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,180.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,414.45\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eSensitivity Analysis\u003c/h2\u003e\u003cp\u003eSensitivity analyses indicated robustness in cost-effectiveness outcomes. Varying intervention and service uptake costs by \u0026plusmn;\u0026thinsp;20% demonstrated that health bazaars consistently remained more cost-effective than routine facility-based services (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The ACER was most sensitive to variations in overall SRH service uptake and intervention costs, affirming health bazaars as a viable economic strategy under diverse conditions.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated the cost-effectiveness of community-based \u0026ldquo;health bazaars\u0026rdquo; for improving access to sexual and reproductive health (SRH) services in underserved Ethiopian communities. Compared to routine facility-based services, health bazaars increased SRH service uptake by 17.52 percentage points and were more cost-effective, with notable gains in family planning (11.5%), antenatal care (10.11%), skilled birth attendance (8.8%), and HIV testing (10.55%) and with an ACER of \u003cspan\u003e$\u003c/span\u003e1,433.57 per percentage point increase in service uptake. These findings support our hypothesis that health bazaars provide a scalable and financially sustainable model for improving SRH coverage in hard-to-reach populations. Sensitivity analyses further supported the robustness of these findings, showing that health bazaars remained cost-effective under varying cost and uptake scenarios. However, the sustainability and broader scalability of this intervention could be challenged by the reliance on external funding and the logistical complexities inherent in mobile service delivery models (\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo our knowledge, this is the first full economic evaluation of mobile health bazaars in Ethiopia's SRH service delivery context. Previous studies have highlighted the potential of community-level interventions in improving maternal and child health (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), but few have conducted comprehensive cost-effectiveness comparisons. Our study provides empirical evidence that health bazaars, despite slightly higher operational costs, result in greater health benefits per dollar spent than facility-based care alone. This is especially relevant given Ethiopia\u0026rsquo;s constrained health financing environment, where efficiency is essential for scaling up services (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur findings are consistent with the cost-effectiveness results from Kenya, where community-based quality improvement interventions showed significant gains in maternal and child health at a cost of \u003cspan\u003e$\u003c/span\u003e249 per DALY averted (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Similarly, Memirie et al. (2019) reported highly cost-effective maternal and neonatal health interventions in Ethiopia, particularly those targeting newborns (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). However, unlike most studies that focus on static facility-based or narrowly targeted services, our study integrates a broader spectrum of SRH services and a mobile delivery model, aligning more with the holistic SRHR package recommended by the Guttmacher-Lancet Commission (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe enhanced cost-effectiveness of health bazaars may stem from their design\u0026mdash;combining service delivery with community engagement and health education. Social mobilization likely plays a critical role in increasing trust and demand for services, especially in culturally conservative or geographically isolated communities. Furthermore, the integration of services (e.g., ANC, FP, HIV testing) in a single setting may improve convenience and uptake.\u003c/p\u003e\u003cp\u003eA major strength of this study is its use of real-world implementation data and its health system perspective, enhancing relevance for policymakers. The use of average cost-effectiveness ratios (ACER) allowed for a direct comparison between intervention and control arms. However, limitations include potential selection bias in intervention site selection and the absence of long-term health outcome data such as DALYs or QALYs. Moreover, indirect costs and broader societal benefits (e.g., reduced time loss or increased economic productivity) were not considered, possibly underestimating the true value of the intervention. Future studies should assess the long-term health and economic impacts of health bazaars, including DALYs averted and broader social return on investment. Implementation research is also needed to explore scalability and integration with digital health tools.\u003c/p\u003e\u003cp\u003eThe findings suggest that health bazaars can play a pivotal role in advancing Ethiopia's Health Sector Transformation Plan-II objectives and the Sustainable Development Goals, particularly in reducing maternal and neonatal mortality. Given their demonstrated cost-effectiveness, integrating a health service delivery model similar like health bazaars into the national SRH service delivery framework could accelerate progress toward universal health coverage (UHC), especially for marginalized populations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides strong evidence that health bazaars are a cost-effective, community-based model for improving SRH service accessibility in Ethiopia. By increasing service uptake while maintaining financial efficiency, health bazaars offer a promising scalable and sustainable approach to bridging the gap in healthcare access between rural and urban populations. The results suggest that integrating health bazaars into Ethiopia\u0026rsquo;s primary healthcare system could enhance the long-term sustainability of SRH services, reducing reliance on donor-based funding while improving health equity.\u003c/p\u003e\u003cp\u003eMoving forward, policymakers should consider expanding health bazaars, supported by sustainable financing mechanisms such as CBHI, and integrating them into national healthcare strategies. Further research is needed to assess long-term health outcomes and explore scalability beyond Ethiopia. By leveraging community-based health solutions, Ethiopia can strengthen its health system resilience and ensure equitable access to essential healthcare services.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAdjusted Odds Ratio (AORs); Antenatal care (ANC); Average Cost Effectiveness Ratios (ACER), Community-based health insurance (CBHI); Confidence Interval (CL); District Health Information System (DHIS2); Ethiopia\u0026apos;s total health expenditure (THE) ; Human Immunodeficiency Virus (HIV); Intra class correlation coefficients (ICC); maternal mortality ratio (MMR); National Health Accounts (NHA); Out-of-pocket (OOP) ; Postnatal care (PNC); Resilience Building and Creation of Economic Opportunities in Ethiopia( RESET); Sexual and Reproductive Health (SRH); Standard deviations \u0026nbsp; (SD); Sustainable Development Goals(SDG)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from Ethiopian Anaesthetics Professionals\u0026rsquo; Association IRB. A support letter was obtained from the regional health bureaus/MOH. Informed consent was obtained from all participants. Confidentiality of the collected data was ensured from all data collectors and the principal investigator\u0026rsquo;s side via using code data to replace personal identifiers and keeping the responses locked. The study adhered to WHO ethical guidelines for SRH research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available upon reasonable request from the corresponding author. The data are not publicly available due to privacy reasons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the European Union, as part of the \u0026ldquo;RESET Plus\u0026mdash;Scaling up the Family Planning for Resilience Building program amongst youth and women in drought prone and chronically food insecure regions of Ethiopia (T05-EUTF-HOA-ET-24-08)\u0026rdquo;. Amref Health Africa supported the administrative part in the course of the implementation of the project.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMDM, MB, ZA, WK, SA, and GM designed and conducted the study. MDM, WK, MA, ZA and GM planned and undertook the analysis. WE, ZD, MDM, MB, and GM wrote the initial and subsequent drafts of the manuscript. WE, MDM, MM, GM, VS, MM contributed to revising the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful for the participation of all the research samples and the cooperation of the personnel project implementation areas. Without their support, these results would not have been achieved. Additionally, the researchers are thankful to both the European Union for funding the project and Amref Health Africa for providing access to data and administrative support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUnited Nations Population Fund (UNFPA). \u003cem\u003eState of World Population Report 2022\u003c/em\u003e. UNFPA, 2022. 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MoH, 2023.\u003c/li\u003e\n\u003cli\u003eTamerat, S. (n.d.). Social Mobilization and Health Bazaar guide: Amref Ethiopia Health Bazaar implementation guideline 2023 [Unpublished manual]. Amref Health Africa in Ethiopia.\u003c/li\u003e\n\u003cli\u003eUnited Nations Development Programme (UNDP). \u003cem\u003eMulti-Sectoral Approaches to Health Service Delivery in Low-Income Countries\u003c/em\u003e. UNDP, 2023.\u003c/li\u003e\n\u003cli\u003eFekadu, Dawit. \u0026quot;Comparative Cost-Effectiveness of Community-Based vs. Facility-Based SRH Interventions in Ethiopia.\u0026quot; \u003cem\u003eJournal of Health Economics and Policy\u003c/em\u003e, vol. 29, no. 4, 2023, pp. 322-340.\u003c/li\u003e\n\u003cli\u003eEthiopia Ministry of Health. \u003cem\u003eAnnual Performance Report of the Health Sector 2023\u003c/em\u003e. MoH, 2023.\u003c/li\u003e\n\u003cli\u003eWHO. \u003cem\u003eCost-Effectiveness Analysis of Public Health Interventions: A Global Perspective\u003c/em\u003e. WHO, 2022.\u003c/li\u003e\n\u003cli\u003eWorld Bank. \u003cem\u003eHealth Financing and Economic Sustainability in Sub-Saharan Africa\u003c/em\u003e. World Bank, 2023.\u003c/li\u003e\n\u003cli\u003eAmref Health Africa. \u003cem\u003eInnovative Health Service Delivery Models in Ethiopia\u003c/em\u003e. Amref, 2023.\u003c/li\u003e\n\u003cli\u003eEthiopia Ministry of Health. \u003cem\u003eStrategic Framework for SRH Service Expansion\u003c/em\u003e. MoH, 2023.\u003c/li\u003e\n\u003cli\u003eUnited Nations. \u003cem\u003eSustainable Development Goals Progress Report 2023\u003c/em\u003e. UN, 2023.\u003c/li\u003e\n\u003cli\u003eWHO. \u003cem\u003eBest Practices in Expanding Access to SRH Services in Low-Income Countries\u003c/em\u003e. WHO, 2023.\u003c/li\u003e\n\u003cli\u003eEregata GT, Hailu A, Stenberg K, Johansson KA, Norheim OF, Bertram MY. Generalised cost-effectiveness analysis of 159 health interventions for the Ethiopian essential health service package. Cost Eff Resour Alloc. 2021 Jan 6;19(1):2. doi: 10.1186/s12962-020-00255-3. PMID: 33407595; PMCID: PMC7787224.\u003c/li\u003e\n\u003cli\u003eMcPake B, Edoka I, Witter S, Kielmann K, Taegtmeyer M, Dieleman M, Vaughan K, Gama E, Kok M, Datiko D, Otiso L, Ahmed R, Squires N, Suraratdecha C, Cometto G. Cost-effectiveness of community-based practitioner programmes in Ethiopia, Indonesia and Kenya. Bull World Health Organ. 2015 Sep 1;93(9):631-639A. doi: 10.2471/BLT.14.144899. Epub 2015 Aug 3. PMID: 26478627; PMCID: PMC4581637\u003c/li\u003e\n\u003cli\u003eOnukwugha FI, Smith L, Kaseje D, Wafula C, Kaseje M, Orton B, Hayter M, Magadi M. The effectiveness and characteristics of mHealth interventions to increase adolescent\u0026apos;s use of Sexual and Reproductive Health services in Sub-Saharan Africa: A systematic review. PLoS One. 2022 Jan 21;17(1):e0261973. doi:\u003c/li\u003e\n\u003cli\u003eKumar MB, Madan JJ, Auguste P, Taegtmeyer M, Otiso L, Ochieng CB, Muturi N, Mgamb E, Barasa E. Cost-effectiveness of community health systems strengthening: quality improvement interventions at community level to realise maternal and child health gains in Kenya. BMJ Glob Health. 2021 Mar;6(3):e002452. doi: 10.1136/bmjgh-2020-002452. PMID: 33658302; PMCID: PMC7931757.\u003c/li\u003e\n\u003cli\u003eMemirie ST, Tolla MT, Desalegn D, Hailemariam M, Norheim OF, Verguet S, Johansson KA. A cost-effectiveness analysis of maternal and neonatal health interventions in Ethiopia. Health Policy Plan. 2019 May 1;34(4):289-297. doi: 10.1093/heapol/czz034. PMID: 31106346; PMCID: PMC6661540.\u003c/li\u003e\n\u003cli\u003eKaiser AH, Ekman B, Dimarco M, Sundewall J. The cost-effectiveness of sexual and reproductive health and rights interventions in low- and middle-income countries: a scoping review. Sex Reprod Health Matters. 2021 Dec;29(1):1983107. doi: 10.1080/26410397.2021.1983107. PMID: 34747673; PMCID: PMC8583757.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health bazaar, Cost-effectiveness, SRH, Community-based healthcare, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-6674112/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6674112/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAccess to Sexual and Reproductive Health (SRH) services remains limited in rural and underserved areas of Ethiopia. Health bazaars, a community-based mobile healthcare intervention piloted by Amref Health Africa, aims to improve accessibility. This study evaluated the cost-effectiveness of health bazaars compared to routine facility-based SRH services.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA full economic evaluation was performed using historical data from July 2023 to June 2024. Cost data were collected from the healthcare provider and implementer (Amref) perspectives, covering 20 health facilities across intervention and non-intervention areas. Health outcomes analyzed included uptake of family planning (FP), antenatal care (ANC), skilled birth attendance (SBA), postnatal care (PNC), and HIV testing. Average Cost Effectiveness Ratios (ACER) were calculated, with sensitivity analyses conducted to assess robustness.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe combined annual cost of implementing health bazaars alongside routine services was \u003cspan\u003e$\u003c/span\u003e93,353.84, compared to \u003cspan\u003e$\u003c/span\u003e76,394.78 for routine facility-based services alone. Health bazaars significantly improved SRH service uptake by 17.52 percentage points overall (65.12% vs. 47.6%), with notable increases in FP use (11.5%), ANC (10.11%), SBA (8.8%), and HIV testing (10.55%). The ACER for health bazaars was \u003cspan\u003e$\u003c/span\u003e1,433.57 per percentage point increase in overall SRH uptake, compared to \u003cspan\u003e$\u003c/span\u003e1,604.93 for routine services, indicating that health bazaars were more cost-effective.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eHealth bazaars effectively enhance access to SRH services at a slightly higher total cost but lower incremental cost per unit of service uptake compared to routine care, suggesting their potential for scalable integration into Ethiopia\u0026rsquo;s primary healthcare system.\u003c/p\u003e","manuscriptTitle":"Scaling Up Affordable SRH Services: Cost-Effectiveness of Health Bazaar Interventions in Underserved Ethiopian Communities","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-21 09:20:54","doi":"10.21203/rs.3.rs-6674112/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"22935343936673612245666528561032449485","date":"2025-08-15T15:32:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-13T14:35:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-23T10:02:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-19T11:23:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-19T11:18:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-15T15:28:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"64f821c9-113f-4e0b-a9bc-60c60410778a","owner":[],"postedDate":"August 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-21T09:20:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-21 09:20:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6674112","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6674112","identity":"rs-6674112","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}