3.1 Summarizing the three gaps

Three-gap framework Clinical quality influences health outcomes through at least three channels. First, despite investments in physical infrastructure, structural constraints may limit provider performance, particularly in primary health care in developing countries. Second, inadequate knowledge of protocols may mean that doctors do not know what they should do. Third, doctors may simply not put their knowledge to use; this may happen because they are shirking or not exerting sufficient effort. Ibnat et al. (2019) cast these three constraints into a three-gap framework, where poor health outcomes can be the consequence of a structural gap, a knowledge gap, or an effort gap. This framework thus decomposes the notion of “process quality” into its determinants—or conversely, its constraints. This framework also permits a discussion of the different methods of accurately measuring clinical quality in addition to describing how patient characteristics interact with the quality of care they receive.

The three-gap model benchmarks actual or observed performance against target performance. For the resultant shortfall, the model distinguishes between items that the health worker has the structural capacity to perform and the knowledge to perform. This in turn allows for the definitions of the three gaps, which are summarized in table 3.1, for each instance of observed care: the gap between target performance and what the worker has the knowledge to perform (called the “know gap”); the gap between knowledge and the structural capacity, that is, the equipment, supplies, and drugs (the “can-do gap”); and the gap between capacity and knowledge and what is actually done (the “know-can-do gap”). This last gap is referred to as “idle capacity” because the health worker has all the knowledge and structural capacity to perform the relevant action but does not use that available capacity.

Table 3.1 Summarizing the three gaps

Gap Definition

Knowledge gap or “know gap” The share of the protocol that the health worker lacks the knowledge to perform Structural gap or “can-do gap” The share of the protocol that the health worker lacks the structural capacity (equipment and supplies) to perform

Idle capacity, “effort gap,” or “know-can-do gap”

Target performance minus observed performance minus the know gap minus the can-do gap Source: World Bank, based on Ibnat et al. 2019.