Sample, methods, and framework

to strengthen the knowledge of health care providers, identifying this weakness as the major factor impeding further improvement in the provision of care. The results show how SDI tools and data can be used to diagnose key challenges in the health system. In related work, Andrews et al. (2021) examine the correlates of these key indicators to assess differences in the performance of health facilities within and between countries. Their paper analyzes levels and trends in the provision of primary care services and offers a comprehensive assessment of both the heterogeneity of care and the systems-level factors that may be driving inequities.

The analysis presented in this chapter extends these investigations, presenting results parallel to those in chapter 3 on education and allowing for synthesis of findings across sectors.

The SDI health surveys have been implemented for more than 10 years across 13 countries in Sub-Saharan Africa, and this chapter presents data from across this period.2 In countries with multiple SDI surveys, only the most recent survey is included, because data from the same country over time are not fully comparable due to differences in sampling and measurement strategies.3 The resulting data set encompasses information on nine countries, covering 7,810 health facilities. It includes results from the following country surveys: Kenya (2018), Madagascar (2016), Mozambique (2014), Niger (2015), Nigeria4 (2013), Sierra Leone (2018), Tanzania (2016), Togo (2013), and Uganda (2013).

In each country, the sample of surveyed facilities is drawn from the ministry of health list of all health facilities offering primary care services. This list includes public facilities and facilities operated and administered by private entities or nongovernmental organizations (NGOs). Given the surveys’ focus on primary care, facilities at all levels of care, such as hospitals, health clinics, and health posts (or the national equivalent), are included if they provide primary care services. Sample selection is stratified by urban-rural location and by type of facility. The proportion of health posts varies, from none in Mozambique to 74 percent of all facilities in Sierra Leone, and the proportion of rural facilities also varies, from 49 percent of the sample in Madagascar to 88 percent in Mozambique. All surveys were designed to be nationally representative, except for the survey in Nigeria, where data were collected in 12 of 36 states because of logistical constraints. In Kenya, data are representative not only at the national level but also at the county level.5 Details of the sample are presented in table 2.1.

The SDI surveys purposefully include facilities operated by nongovernmental entities, in line with the goal of providing an inclusive assessment of citizens’ access to care. Because the private sector is responsible for a substantial portion