This study aimed to assess the effect of distance from the nearest health facility on zero-dose children in Ethiopia by using a generalised structural equation modelling.

A cross-sectional secondary analysis of longitudinal data.

Community-based study in five regions of Ethiopia (Tigray, Oromia, Amhara, Southern Nation Nationalities and Peoples (SNNP) regions, and Addis Ababa city).

The final analysis included a weighted sample of 1973 mother–child pairs.

The primary outcome was the direct effect of distance to the nearest health facility on zero-dose children. The secondary outcome was the mediating effect of maternal reproductive health service utilisation on this relationship.

The prevalence of zero-dose children was 15.7%, with significant urban (2.2%) and rural (19.7%) disparities. The median distance to the nearest health facility was 1.93 km, with median distances of 2.10 km for rural and 1.26 km for urban residents. Similarly, the mean distance to the nearest public health facility was 2.09 km (SD = ±1.72). Each additional kilometre from the nearest public health facility was associated with 14.2% higher odds of a child being zero-dose (aOR: 1.14 (95% CI 1.02 to 1.28)). This effect was predominantly direct, accounting for 89.4% of the total effect (aOR: 1.13 (95% CI 1.01 to 1.26)), while the indirect effect mediated through maternal reproductive health service utilisation was minimal and not statistically significant (aOR: 1.01 (95% CI 0.97 to 1.05)).

This study suggests that greater distance to the nearest health facility increases the likelihood of children being zero-dose. Therefore, improving physical access to health services through expanded outreach programmes and mobile vaccination services, and strengthening maternal health services, particularly antenatal care and facility delivery, is essential for reducing the burden of zero-dose children.