4.2 In Focus: Does discrimination contribute to poor effort?

Otherwise, the assessment finds no significant differences in idle capacity by the provider’s gender or experience.

The patient characteristics include wealth, education, and pregnancy and care-seeking history. Even these have somewhat limited explanatory power for the observed effort gap. However, in three of the five countries, there is a U-shape in how quality correlates with patient education, with the least educated and most educated patients receiving the most complete level of care. Women in their first pregnancies also appear to receive care with less idle capacity associated with it in four of the five countries. However, there is no evidence of a correlation with late versus timely ANC, which is noteworthy because often wealthier women are more likely to receive timely care, meaning that utilization itself can be a proxy for patient socioeconomic status (Das et al. 2016; Fink, Kandpal, and Shapira 2022). Box 4.2 discusses the literature on whether discrimination by the provider can lead to greater know-can-do gaps. However, a direct examination of patient wealth does not reveal a significant association with the know-can-do gap.

In addition, despite the exceptional level of detail in the data, and including everything from facility to patient characteristics, all these

Box 4.2 In Focus: Does discrimination contribute to poor effort?

This chapter shows that there is limited evidence on what drives idle capacity in health care provision but nevertheless finds that in some contexts, wealthier patients receive better care. Such differences may arise for several reasons. For one, women of different socioeconomic backgrounds might sort into different facilities. Wealthier women may live in the catchment areas of better facilities (Fink, Kandpal, and Shapira 2022), be more aware of facility quality, or be more able to pay to travel to better facilities (Akin and Hutchinson 1999; Leonard, Mliga, and Haile Mariam 2002; Kruk, Goldmann, and Galea 2009; Cohen, Lofgren, and McConnell 2017; Cronin, Guilkey, and Speizer 2019). However, recent evidence from Kenya (McCollum et al. 2018) as well as the World Bank report on Social Delivery Indicators (Gatti et al. 2021) suggest that at least in terms of infrastructure, wealthier and poorer areas have facilities of similar quality.

Yet, a recent study by Fink, Kandpal, and Shapira (2022) highlights inequality in the provision of high-quality care, with inequality in effective antenatal care (ANC) being three times as high as inequality in simple ANC coverage, as shown figure B4.2.1. The figure presents concentration curves plotting the cumulative proportion of coverage and effective coverage against the cumulative proportion of recently pregnant women ranked by household wealth. An equal distribution of care would lie along the 45-degree line. Both concentration curves—the one for simple ANC coverage and that for effective coverage—deviate from the line of equality. However, the concentration curve for simple coverage is noticeably closer to the line of equality than the concentration curve for effective

(Continued)