Conclusions: What will it take to improve service delivery in health?

each condition, and correct diagnosis and treatment refer to having at least one health care provider in the facility who is able to give correct answers on the related vignette. Each bar is conditional on the availability of inputs in the prior step, with the final bar representing the overall likelihood of a patient receiving all of the necessary steps in the care process for that specific ailment. For example, to treat a case of malaria, the required tools for diagnosis are a thermometer and a malaria rapid diagnostic test, the facility needs to have at least one provider who can accurately diagnose and treat malaria in the clinical vignette, and the required medicine for treatment is artemisinin combination therapy. Although most facilities have some of these individual components, only a little over half of facilities have all of the necessary components in combination and can therefore be considered prepared to treat a case of malaria.

Readiness to provide care differs across conditions, with a high of 57.6 percent of facilities prepared to provide care for a malaria patient and a low of 10.8 percent of facilities prepared to provide care for a diabetes patient. For diabetes and tuberculosis, a limiting factor is the lack of necessary tools and medicines. Lack of timely screening and diagnosis has been identified as a pressing issue for both of these diseases, and the results of this analysis suggest that primary care facilities still do not have the tools to address this problem or to provide appropriate medicines (Manne-Goehler et al. 2019; Raviglione et al. 2012). For the other conditions, no single factor emerges as dominant; rather, a combination of deficiencies results in facilities often being unprepared to offer full care.

The SDI health surveys give insight into ordinary people’s experience of PHC in nine Sub-Saharan African countries. SDI data shed light on the obstacles people encounter in seeking quality care for common medical conditions within these health systems and identify entry points for policy to improve PHC delivery and results.

Despite decades of global efforts to promote robust PHC, SDI evidence suggests that the quality of PHC delivery in these nine countries remains suboptimal. Upon arriving at a typical health facility, patients in these countries are likely to find a substantial number of clinical personnel absent. Despite the absences, many providers’ outpatient caseloads are not especially elevated. This raises questions about how health systems organize and distribute their human resources. When health care providers are available, patients have a high likelihood of receiving an incorrect diagnosis and insufficient treatment. These risks

are especially pronounced at lower-level facilities where people typically make first contact with the health system.

Even if health care providers prescribe appropriate therapies, recommended essential medicines may not be available. The SDI surveys show that large numbers of health facilities still lack the basic infrastructure (electricity, water, sanitation), medical equipment, and sterilization facilities needed to provide quality PHC that respects patient safety. Importantly, SDI survey findings suggest substantial heterogeneity in the quality of PHC delivery between and especially within countries. An average citizen’s experience with PHC, across these nine countries, depends to a large extent on where she is accessing care— whether in a rural or urban setting, at a public or private health facility, and at which level of facility.

What can be done to improve the average person’s PHC experience in these health systems? In the aftermath of the COVID-19 pandemic, a burgeoning body of literature has noted the importance of strengthening the delivery of primary care services. The service delivery agenda moving forward should entail both an expansion and a reorganization of care to manage immediate risk and address long-term challenges simultaneously (World Bank 2020a). The results from the analysis presented in this chapter support the following directions for action.

• Apply planning and management tools to reduce provider absence rates in the public sector. Both unauthorized absences and total absence rates are higher in public facilities than in private ones, suggesting that practitioners in public facilities may have demands that take them outside of the facility, including attending trainings, providing outreach, and engaging in other authorized activities. Authorized absences, particularly in overburdened facilities, might reflect insufficient staffing or planning, speaking to the importance of better understanding staffing decisions and constraints and the role of management quality. Addressing absence rates is an important entry point for policy, because differences in provider absence rates between public and private facilities have the potential to widen health disparities further. • Rebalance caseloads and resources systemwide. As noted, low outpatient caseloads might raise concerns about the effective allocation of human resources in health care delivery, but they also point to the success of global efforts to bring health facilities and health care providers closer to people, especially in rural and remote areas (WHO and World Bank 2017).

Although expanded geographic access to care is important, especially from an equity perspective, low caseloads in primary care facilities across countries provide further evidence that services within the existing health system could be reorganized to enhance efficiency without compromising on equitable access, as proposed by the Lancet Global Health Commission on High Quality Health Systems (Kruk, Gage, Arsenault et al. 2018).

Quality-focused redesign of service delivery would entail treating chronic and stable conditions, preventive care, low acuity services, and palliative care at the primary level, while managing more complex or rare conditions in tertiary or specialized care centers. • Reinforce competencies among nurses and other less specialized cadres of health care providers in frontline facilities. In terms of providers’ diagnostic accuracy and therapeutic decisions, the SDI vignettes focus on common conditions that practitioners at all levels of the health care system should be able to diagnose and treat successfully. Diagnostic and treatment accuracy is higher at hospitals than at health centers or health posts. Because the majority of patients are likely to initially visit lower-level facilities, strengthening the capacity of of frontline workers is particularly crucial to ensure that they deliver quality primary care. Nurses and less specialized health providers make up the majority of the health workforce and need to be relied on for patient care. Yet they perform significantly worse than doctors on diagnostic and treatment accuracy as measured by the SDI vignettes. Improving these competencies likely requires improving both the quality of clinical education and the existing curriculum, beyond the current standards for in-service training. On the positive side, results from the vignette evaluations are not significantly different between health care providers at public versus private facilities or urban versus rural facilities, suggesting an encouraging equity in the current distribution of skilled health care providers. • Continue to improve supply chain management practices in the public system. Key medicines and supplies are more commonly available in private as opposed to public facilities. The gap between public and private facilities persists even in urban areas, suggesting that it is not driven by the inaccessibility or remoteness of facilities. Further investigation is required to understand better the potential incentive structures, efficiencies, and management practices that may be driving better supply chain management in private facilities, so that these practices might be emulated in public ones. • Tackle infrastructure gaps at rural health facilities. Shortfalls in medical equipment and basic infrastructure at many facilities pose urgent challenges for quality in PHC. Although the availability of basic infrastructure (improved water and sanitation facilities and electricity) is variable across countries in the sample, the starkest within-country contrasts are between urban and rural facilities. The implications of poor infrastructure at health facilities are dire: without safe water and sanitation, health care staff and patients are at increased risk of infection and associated illness (Sharma et al. 2020; WHO and UNICEF 2019). Facilities without access to electricity cannot operate crucial medical devices for