Structure of this chapter

progressing through the care-seeking process and the obstacles that she may face. For the patient to receive high-quality care, all parts of the system must be functional, and SDI surveys show the likelihood of shortfalls at each step of the process. Framing the analysis in this way emphasizes that the indicators of health system performance are not impersonal numbers. They mirror real people’s experiences in the health system and quantify whether the patients who rely on the system receive the care they need. For that reason, these indicators provide crucial evidence that can be used to make the system more effective, responsive, and fair. This information is collected through enumerator visits to a sample of health facilities in each country.1 The majority of the data collection is done through a survey administered to the facility manager as well as direct observation of the availability and functioning of infrastructure, equipment, medicines, and other physical assets.

Consistent with the spirit of the SDI surveys, this chapter follows a typical patient in her care-seeking journey through the health system. It asks whether the patient will find health professionals present at her health facility and begins to explore whether the outpatient caseload may limit the ability of these health care providers to offer appropriate care. Then it summarizes evidence on whether health workers are trained and skilled to diagnose and treat the typical patient’s condition correctly and whether they have the needed tools and medicines at hand.

The results presented suggest key opportunities for improving health care systems. Where provider absence is high, there is room for improving both monitoring and accountability, and, while some facilities have a large volume of patients, others are relatively underused, suggesting the possibility of improving care by shifting staff. Similarly, staff knowledge of basic conditions varies widely, and efforts could be made to strengthen competence among staff who form the frontline of care. Finally, some basic infrastructure, equipment, and medicines remain unavailable at many health facilities, constituting physical constraints to better care. In the wake of COVID-19, many health systems will undergo an overhaul, and this chapter concludes with recommendations for reimagining systems on the basis of findings across countries.

The findings presented in this chapter build on previously published work. A recent study using SDI health data assesses the quality of health care across Sub-Saharan Africa on the basis of providers’ clinical attendance, knowledge of seven basic medical conditions, and availability of key medicines, reporting country-level averages for key indicators and an overall estimate of readiness to provide care (Di Giorgio et al. 2020). The study’s findings emphasize the need