The Quality of Health and Education Systems Across Africa
Explicitly or implicitly, the following questions are on a patient’s mind as she engages with the health system: • Provider’s effort. Will health care providers be present at the health facility? Will health care providers be too busy with other patients? • Provider’s knowledge. Are health care providers able to diagnose and treat common conditions correctly? • Inputs. Will the necessary infrastructure, equipment, supplies, and medicines be available? These questions and the indicators embedded in them provide a broad overview of the current state of the health system, with each indicator measuring a different aspect of quality of care.8
Will health care providers be present in the health facility? After deciding to seek care at a health facility of her choice and overcoming any barriers to reaching the facility, a patient would expect health care professionals to be available at the health facility during scheduled work hours. However, even among workers who are assigned to be on duty, it is not guaranteed that every health care professional will be present and available to provide services to patients. Health worker absence has long been recognized as a fundamental obstacle to improving the quality of care in low- and middle-income settings (Bamgboye and Adeleye 1992; Belita, Mbindyo, and English 2013; Chaudhury and Hammer 2004). Despite recent gains, the problem persists in many countries, and both a better understanding of the underlying drivers and innovative solutions are needed to address it (Tumlinson et al. 2019). The SDI surveys reveal that, on average, 6 out of 10 health care providers are present at the facilities surveyed on any given day. Across all nine countries, 43 percent of providers are absent from their facility during an unannounced visit. This high absence rate includes absence for both authorized and unauthorized reasons (further analyzed below) and is consistent with rates observed in Bangladesh, Ecuador, India, Indonesia, Peru, and Uganda, where 35 percent of health workers, on average, are absent from health clinics during an unannounced visit (Chaudhury et al. 2006). SDI surveys include two visits, of which the second is not announced, to assess staff presence, allowing for an unbiased estimate of the absence rate on a typical day of operation. Absence rates differ substantially across countries, ranging from more than 50 percent in public facilities in Kenya to less than 20 percent in private facilities in Mozambique and Tanzania, as shown in figure 2.1. Outside of
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