Will health care providers be ready to provide quality care?

that health care providers have ample time to see more patients, because their time may be stretched to accommodate other activities, including providing care to inpatients (though the health facilities included in the SDI samples are mainly primary care facilities). However, they do suggest that some commonly reported problems, such as overcrowding and long wait times, may be due to factors such as poor facility management, large administrative burdens, or uneven distribution of patients throughout the day rather than a lack of sufficient staff.

A patient’s basic expectation is that health care providers will exhibit clinical competence in providing care. But competent care, where the health care provider accurately diagnoses and appropriately treats illnesses, is not a given. SDI data can shed light on facets of the patient experience that have to do with the clinical skills of health care providers. Will the providers competently assess the patient’s condition, ask relevant questions, perform appropriate tests, and recommend suitable treatment?

In recent years, quality of care has received more attention in the health research community, with increasing recognition that good health outcomes depend not just on patients’ access to care but also on the competence and skill of the health care provider. Accurate diagnosis and treatment are important for the health outcomes of patients and can also influence future patterns of health care use (Escamilla et al. 2018; Rao and Sheffel 2018). The SDI survey includes clinical vignettes that are administered to health care providers. This innovative addition measures the quality of clinical care, unlike the inputsfocused perspective taken in many earlier surveys (Das and Leonard 2006). Clinical vignettes may be less reliable for assessing quality of care than other methods, such as the use of standardized patients, but they are easier to implement, less expensive, and less disruptive to health facility operations. Overall, clinical vignettes have been shown to be “a valid and comprehensive method that directly focuses on the process of care provided in actual clinical practice” (Peabody et al. 2000).

In the SDI surveys considered in this book, health care providers are tested on five core vignettes: childhood diarrhea with dehydration, childhood pneumonia, adult tuberculosis, adult diabetes mellitus, and childhood malaria with anemia. Additionally, countries may add specific vignettes and occasionally remove vignettes (for example, the malaria with anemia vignette was not administered in Kenya). These vignettes represent common clinical cases that a health care provider would face in the low- and middle-income-country context.

These high-burden conditions make up 30 percent of all-age disability-adjusted life years in Sub-Saharan Africa.10 Each provider is scored on the percentage of vignettes for which he or she provides the correct diagnosis and treatment.11 Multivariate regressions to test the relationship between provider-level variables are described here and presented fully in a previous paper.12 Further details on the vignettes are available in appendix A, tables A.5 and A.6.

Clinical vignettes are useful for measuring the diagnostic and treatment accuracy of health care providers. They also provide valuable information on adherence to clinical protocols. The vignettes contain country-adapted information to simulate a full consultation, including recommended questions on a patient’s history, physical examination, laboratory tests, and options for care, which allows for a full measurement of provider adherence to clinical guidelines. For example, in Niger, the results of the clinical vignettes show that only 3.5 percent of health care providers accurately diagnose diarrhea with severe dehydration. To assess the severity of the case, the WHO guidelines for the integrated management of childhood illness (IMCI) recommend administering a skinfold test, checking for lethargy, checking whether the child is able to drink, and checking for agitated or irritable behavior. IMCI requires two positive danger signs to denote a case as severe, but only 24 percent of providers in the sample checked for both danger signs. Health care providers in Niger who inquire about each of these signs are significantly more likely to arrive at a correct diagnosis. The vignettes offer rich data, showing gaps in knowledge that can improve the understanding of provider performance and offer insights for policy or investment actions.

Figure 2.5 shows the estimated confidence intervals for diagnostic accuracy by type of provider and country. Overall mean diagnostic accuracy (the percentage of all vignettes administered for which health care providers give correct diagnoses) varies by country, from a high of 69 percent in Tanzania to a low of 40 percent in Nigeria. Across the sample, doctors and clinical officers have the best diagnostic accuracy (67 percent), followed by nurses (55 percent) and other medical staff (36 percent). However, the range by type of provider varies substantially by country, from a 10-percentage-point difference between doctors and other medical staff in Mozambique to a 43-percentage-point difference in Uganda. Controlling for both facility- and provider-level characteristics, doctors have the highest diagnostic accuracy, males have higher diagnostic accuracy than females, and adults ages 40–49 years have slightly higher diagnostic accuracy than younger or older colleagues. Perhaps not unexpectedly, providers with secondary and postsecondary education perform significantly better than those with only primary education. There is no significant difference between the performance of providers in urban and rural facilities or between those in public or private facilities, but providers at health posts score significantly lower than those at hospitals or health clinics. Because less specialized providers will likely continue to provide the bulk of diagnoses at