countries

Irrelevant or inappropriate treatment and antenatal care While much of the analysis and indeed the data are geared toward picking up underperformance, poor quality of care can also manifest in the form of irrelevant or inappropriate treatment, also called overtreatment. These terms refer to the provision of care that is at best unnecessary and at worst harmful to the patient. Such overtreatment has been shown to be significant in settings with poor quality of care (Das et al. 2016). Since the available data capture what was performed relative to the WHO protocol for necessary care, all such overtreatment cannot be captured. For instance, if health workers provided antibiotics that were not part of the WHO protocol, the questionnaires underlying the data would not have captured that action.

Nonetheless, from the data available, two indicators can be defined (presented in figure 4.5) that capture overtreatment. The first is the provision of a tetanus shot in the second or later ANC visit within the first trimester—considerably earlier than the WHO recommended period between 27 and 36 weeks of pregnancy—and without checking the records to see if the woman had received a shot in her previous visit. The fact that the assessment can rule out the provider even checking the patient’s

Figure 4.5 Overuse in antenatal care provision in five Sub-Saharan African countries

Overuse of tetanus shot

Rate of IPT in rst ANC and rst trimester

Rate of IPT in rst trimester

Share of those who never received IPT

0 10 20 30 40 50 60 70 80 Cameroon Central African Republic Nigeria Republic of Congo Democratic Republic of Congo

Source: World Bank.

Note: IPT refers to intermittent preventive treatment, which is the initiation of prophylactic malaria treatment using prescription sulfadoxine/pyrimethamine. ANC = antenatal care.

vaccination record card to see if she had already received a tetanus shot in this pregnancy mitigates some concerns about health workers providing care that is not strictly necessary in case the patient does not return for another antenatal visit. The data show that in the Central African Republic, Cameroon, and Nigeria, such overuse is generally not observed. However, in the Democratic Republic of Congo and the Republic of Congo, such overprescription is observed 10 and 26 percent of the time, respectively.

The second indicator is the provision of prophylactic malaria treatment, using prescription sulfadoxine/pyrimethamine, in the first trimester. When correctly timed, such preventive malaria treatment can improve neonatal birth outcomes (Carroli, Rooney, and Villar 2001), and evidence suggests that too-early initiation of such treatment may be harmful to fetal development (Peters et al. 2007; Hernández-Díaz et al. 2000). A caveat about this indicator may be that health workers may not know if the woman will return for a future visit and thus provide the treatment even at the risk of harming the developing fetus, particularly if they are not aware of the potential for harm. While the assessment cannot fully address this concern, as shown in figure 4.5, between 20 and 71 percent of all women in the data never receive preventive malaria care, suggesting that health workers often fail to provide the treatment even when given the correct opportunity for treatment. Taken together, these two indicators suggest that overtreatment exists even in the context of preventive care. Indeed, the fact that overtreatment can be captured despite the data not being geared toward picking it up may be indicative of substantial such overtreatment.

Correlates of the know-can-do gap The previous subsection documented the presence of a sizable know-cando gap in all the contexts studied. Effectively, this means that providers are not providing the highest level of care they can. Often that shortfall—the idle capacity—is substantial. This raises the question of why providers may not be exerting sufficient effort. The literature has identified several reasons: for instance, the providers may be busy, not paid sufficiently well, or lack motivation. They may exert greater effort for wealthier or better educated patients. This subsection exploits the richness of the data to examine the correlates of the measured know-can-do gaps using all the available data on patient, provider, and facility characteristics.

Table 4A.3 in annex 4A presents this exploratory analysis. It provides the mean know-can-do gap and the 95 percent confidence interval for each action, by country and correlate. Since the know-can-do gap represents a