Rethinking service delivery

On the health side, the surveys reveal substantial gaps in service quality. Rates of provider absence are high, particularly in public facilities, and the caseloads of staff vary dramatically, with some facilities overwhelmed and others underattended. Health care providers are correct in only about half of their diagnoses of basic medical conditions, with lower rates among nurses and lower-level health care workers, who are likely to be a patient’s first point of contact with the health system. Despite decades of efforts to strengthen the supply chain, equipment and medicines are frequently unavailable. Finally, deficiencies in infrastructure continue to be particularly pronounced in rural areas. The combination of these factors suggests that a typical patient seeking care in these systems is likely to find a facility lacking in the basic necessities for care.

SDI results suggest margins for strengthening the delivery of health services. Health leaders, system coordinators, and facility managers can do more to ensure the presence of health care providers and to balance caseloads fairly by reallocating staff to overburdened facilities. Such efforts may demand politically sensitive trade-offs between widespread geographic presence and improved quality of care. Both presence and caseload can be monitored and actively managed at low marginal cost via improved information management systems. To improve diagnosis, governments will need to reinforce competencies, especially among nonphysician providers in frontline facilities. The lack of equipment and medicine is puzzling given a decades-long focus on increasing the availability of basic inputs. Governments can look at health facilities that succeed on this metric and incentivize other units to emulate these examples. Finally, improving access to water, sanitation, and electricity can go a long way toward reducing infrastructure gaps at rural health facilities.

COVID-19 has brought new challenges to health systems. In addition to the urgency of stopping transmission—with both nonpharmaceutical interventions and vaccinations—policy makers need to protect core functions of health service delivery and ensure equitable access to care, while managing increased stress on the system, including the need for critical care (World Bank 2020a). The pandemic-related recession and growing demands on public expenditures are exerting fiscal pressure on governments. Health spending priorities should be protected in this new environment, including spending for immediate needs, such as providing COVID-19 diagnostics, surveillance, and care, and spending for longer-term objectives, such as expanding universal health coverage. Routine services disrupted by the pandemic will need to resume and, in some cases, address significant lags—for example, in routine immunization. Reckoning with existing system-level weaknesses will be an important step for policy makers and administrators as they embark on the rebuilding process.

In the education sector, SDI evidence gives a granular, frontline picture of the learning crisis so well depicted in the World Development Report 2018: Learning to Realize Education’s Promise (World Bank 2018). In the nine countries in this sample, measured learning is, on average, low among public school students, but the variance across and within countries is large. Some students in all nine SDI countries are already performing well, illustrating the potential for each country to bring its students to a high level. Results underscore the importance of specific school inputs and teacher characteristics that correlate positively with higher student learning. In particular, classrooms with functioning blackboards; clean, private, and gendered toilets; and more teachers per student are characteristics observed more frequently in schools with higher average student test scores. Equally important is having more knowledgeable teachers, with gender and age being strong predictors of teachers’ effectiveness. Finally, private schools in a subsample of SDI countries show higher average levels of learning than their public counterparts.

In already challenging contexts, governments should not take for granted basic inputs that can help to improve students’ daily experience in school. Having functioning blackboards and toilets might seem trivial, but evidence suggests that these features can make a big difference for some children. The SDI evidence suggests that policy makers should prioritize hiring, retaining, and continuously training more and better teachers to improve student learning. Content knowledge and pedagogical skills, two strong predictors of learning, should be incorporated in hiring practices and professional development systems for teachers. Additional lessons and insights may arise from studying education systems as a whole, including the private sector, which seems to be doing better, on average, in a subset of countries. Education SDI surveys can help governments to deploy investments efficiently so that more young people can reach their full potential.

Today, COVID-19 threatens educational outcomes in many countries (World Bank 2020b). The combination of school closures and economic recession is likely to increase dropout rates and affect learning significantly. Disconcertingly, it is often the most vulnerable members of the population who lose access to education. Strategies to remediate schooling losses will require designing and implementing school reopening protocols adapted to the specificities of the pandemic. At a minimum, these efforts will involve protective equipment and supplies, health screening, and social distancing. Tailored teaching and learning resources, especially for disadvantaged children, are urgently needed in many settings to make up for lost learning (World Bank 2020c). Deeper reforms will be needed to sustain access to schooling and promote children’s learning at all stages, from cognitive stimulation in the early years to nurturing relevant skills in childhood and adolescence. Building blocks for success will include