Publication: The Realities of Primary Care: Variation in Quality of Care Across Nine Countries in Sub-Saharan Africa
Loading...
Date
2021-04
ISSN
Published
2021-04
Author(s)
Editor(s)
Abstract
The COVID-19 pandemic has highlighted the centrality of primary care in protecting people’s health and well-being during and beyond crises. It has also provided an opportunity to strengthen and redesign primary care so that it will better serve its purpose. However, to-date there is limited evidence on the quality of service delivery in primary care. Service Delivery Indicators surveys have attempted to fill this gap. Using Service Delivery Indicators surveys of 7,810 health facilities and 66,151 health care providers in nine Sub-Saharan African countries, this paper investigates the quality of care across five domains to understand a citizen’s experience of primary care in his/her country. The results indicate substantial heterogeneity in the quality of primary care service delivery between and within countries. The availability of basic equipment, infrastructure, and essential medicines varies—public facilities, facilities in rural areas, and non-hospitals are more lacking compared with private facilities, urban facilities, and hospitals. In terms of patient care, health care providers’ ability to correctly diagnose and treat common health conditions is low and variably distributed. COVID-19 has catalyzed a long overdue health system redesign effort, and the Service Delivery Indicators surveys offer an opportunity to examine carefully the quality of service delivery, with an eye toward health system reform.
Link to Data Set
Citation
“Conner, Ruben; Andrews, Kathryn; Gatti, Roberta; Sharma, Jigyasa. 2021. The Realities of Primary Care: Variation in Quality of Care Across Nine Countries in Sub-Saharan Africa. Policy Research Working Paper;No. 9607. © World Bank. http://hdl.handle.net/10986/35402 License: CC BY 3.0 IGO.”
Associated URLs
Associated content
Other publications in this report series
Publication Geopolitics and the World Trading System(Washington, DC: World Bank, 2024-12-23)Until the beginning of this century, the GATT/WTO system worked. Economic research provided a compelling explanation. It showed that if governments maximize the well-being of their own countries broadly defined, GATT/WTO principles would facilitate mutually beneficial cooperation over their trade policy choices. Now heightened geopolitical rivalry seems to have undermined the WTO. A simple transposition of the previous rationalization suggests that geopolitics and trade cooperation are not compatible. The paper shows that this is only true if rivalry eclipses any consideration of own-country well-being. In all other circumstances, there are gains from trade cooperation even with geopolitics. Furthermore, the WTO’s relevance is in question only if it adheres too rigidly to its existing rules and norms. Through measured adaptation to the geopolitical imperative, the WTO can continue to thrive as a forum for multilateral trade cooperation in the age of geopolitics.Publication The Macroeconomic Implications of Climate Change Impacts and Adaptation Options(Washington, DC: World Bank, 2025-05-29)Estimating the macroeconomic implications of climate change impacts and adaptation options is a topic of intense research. This paper presents a framework in the World Bank's macrostructural model to assess climate-related damages. This approach has been used in many Country Climate and Development Reports, a World Bank diagnostic that identifies priorities to ensure continued development in spite of climate change and climate policy objectives. The methodology captures a set of impact channels through which climate change affects the economy by (1) connecting a set of biophysical models to the macroeconomic model and (2) exploring a set of development and climate scenarios. The paper summarizes the results for five countries, highlighting the sources and magnitudes of their vulnerability --- with estimated gross domestic product losses in 2050 exceeding 10 percent of gross domestic product in some countries and scenarios, although only a small set of impact channels is included. The paper also presents estimates of the macroeconomic gains from sector-level adaptation interventions, considering their upfront costs and avoided climate impacts and finding significant net gross domestic product gains from adaptation opportunities identified in the Country Climate and Development Reports. Finally, the paper discusses the limits of current modeling approaches, and their complementarity with empirical approaches based on historical data series. The integrated modeling approach proposed in this paper can inform policymakers as they make proactive decisions on climate change adaptation and resilience.Publication Global Poverty Revisited Using 2021 PPPs and New Data on Consumption(Washington, DC: World Bank, 2025-06-05)Recent improvements in survey methodologies have increased measured consumption in many low- and lower-middle-income countries that now collect a more comprehensive measure of household consumption. Faced with such methodological changes, countries have frequently revised upward their national poverty lines to make them appropriate for the new measures of consumption. This in turn affects the World Bank’s global poverty lines when they are periodically revised. The international poverty line, which is based on the typical poverty line in low-income countries, increases by around 40 percent to $3.00 when the more recent national poverty lines as well as the 2021 purchasing power parities are incorporated. The net impact of the changes in international prices, the poverty line, and new survey data (including new data for India) is an increase in global extreme poverty by some 125 million people in 2022, and a significant shift of poverty away from South Asia and toward Sub-Saharan Africa. The changes at higher poverty lines, which are more relevant to middle-income countries, are mixed.Publication From Patriarchy to Policy(Washington, DC: World Bank, 2025-05-29)Legal institutions play an important role in shaping gender equality in economic domains, from inheritance to labor markets. But where do gender equal laws come from? Using cross-country data on social norms and legal equality, this paper investigates the socio-cultural roots of gender inequity in the legal system and its implications for female labor force participation. To identify the impact of social norms, the analysis uses an empirical strategy that exploits pre-modern differences in ancestral patriarchal culture as an instrument for present-day gender norms. The findings show that ancestral patriarchal culture is a strong predictor of contemporary norms, and conservative social norms are associated with more gender inequality in the de jure legal framework, the de facto implementation of laws, and the labor market. The paper presents evidence for a political selection mechanism linking norms to laws: countries with more conservative norms elect political leaders who are more hostile to gender equality, who then pass less progressive legislation. The results highlight the cultural roots and political drivers of legalized gender inequality.Publication Global Socio-economic Resilience to Natural Disasters(Washington, DC: World Bank, 2025-05-22)Most disaster risk assessments use damages to physical assets as their central metric, often neglecting distributional impacts and the coping and recovery capacity of affected people. To address this shortcoming, the concepts of well-being losses and socio-economic resilience—the ability to experience asset losses without a decline in well-being—have been proposed. This paper uses microsimulations to produce a global estimate of well-being losses from, and socio-economic resilience to, natural disasters, covering 132 countries. On average, each $1 in disaster-related asset losses results in well-being losses equivalent to a $2 uniform national drop in consumption, with significant variation within and across countries. The poorest income quintile within each country incurs only 9% of national asset losses but accounts for 33% of well-being losses. Compared to high-income countries, low-income countries experience 67% greater well-being losses per dollar of asset losses and require 56% more time to recover. Socio-economic resilience is uncorrelated with exposure or vulnerability to natural hazards. However, a 10 percent increase in GDP per capita is associated with a 0.9 percentage point gain in resilience, but this benefit arises indirectly—such as through higher rate of formal employment, better financial inclusion, and broader social protection coverage—rather than from higher income itself. This paper assess ten policy options and finds that socio-economic and financial interventions (such as insurance and social protection) can effectively complement asset-focused measures (e.g., construction standards) and that interventions targeting low-income populations usually have higher returns in terms of avoided well-being losses per dollar invested.
Journal
Journal Volume
Journal Issue
Collections
Related items
Showing items related by metadata.
Publication The Quality of Health and Education Systems Across Africa(Washington, DC: World Bank, 2021-11-18)Have teachers mastered the subject matter they are teaching? Can doctors accurately diagnose and treat critical health conditions? Are schools and health facilities sufficiently stocked with needed equipment and supplies? Are they sufficiently supported and staffed to optimize learning and health care outcomes? For the past decade, the World Bank’s Service Delivery Indicators (SDI) surveys have collected nationally representative data in countries across Africa to answer these questions. The surveys aim to measure the quality of services where they meet citizens: in schools and health facilities. The Quality of Health and Education Systems Across Africa: Evidence from a Decade of Service Delivery Indicators Surveys identifies areas of achievement and constraint in service delivery, shedding light on how service delivery may foster or stunt human capital accumulation. SDI surveys show that schools and health clinics across Africa are still falling short in some critical areas. The delivery of primary care services is very heterogenous between and within countries. Many health facilities lack the basic necessities to provide proper care, such as essential medicines, basic diagnostic equipment, and adequate water and sanitation. Moreover, health care providers’ ability to diagnose and treat common health conditions correctly is low and distributed unevenly. Health personnel’s absence from health facilities remains a concern across the surveyed countries. Learning is low, and, not unlike health care, levels of student learning vary significantly across countries: less than half of grade 4 students can recite a simple sentence or perform basic mathematical operations. This deficient learning is correlated with teachers’ low levels of content knowledge and sub-par pedagogy skills. Some schools are also missing crucial inputs, such as blackboards or private and gendered toilets, and struggle with high pupil-teacher ratios. Despite these challenges, success stories in both sectors illustrate the quality of service delivery that could be achieved and showcase the dedication of teachers and medical staff across Africa. By studying data from thousands of facilities, considering the local context, and drawing insights from the literature, this book offers important insights for how countries can strengthen health and education systems and build back better in the wake of the massive disruptions brought about by the COVID-19 pandemic.Publication What Can the Service Delivery Indicator Surveys Tell Us about COVID-19 Preparedness?(World Bank, Washington, DC, 2020-07)To aid national and international efforts to support countries in enhancing their pandemic preparedness in the face of COVID-19, this paper draws from the World Bank's Service Delivery Indicator surveys to highlight key aspects of health service preparedness in Kenya, Sierra Leone, and Tanzania. The results of this analysis paint a highly variable picture. At least 10 percent of lower-level facilities in all three countries have inpatient care capacity, suggesting that these lower-level facilities could help absorb surges in patient flow. Less than half of the facilities in the three countries have a fixed or mobile phone and less than a third have internet access, suggesting a likely challenge in communication and timely sharing of essential information. Concerningly, less than half of the facilities have appropriate handwashing facilities for patients, with even lower rates in rural areas. Between 80 and 95 percent of the facilities have a thermometer to diagnose fever, but availability of a thermometer, stethoscope, and blood pressure cuff together is variable (ranging from almost 90 percent of the facilities in Tanzania to less than 65 percent in Sierra Leone). The paper concludes by highlighting key innovations for future surveys to improve measurement of pandemic preparedness.Publication Unlocking SDG 3 Success(World Bank, Washington, DC, 2023-12-05)This year holds special significance as the midpoint in implementation of the Sustainable Development Goals (SDGs). With each step closer to the end of the SDG implementation window, efforts to measure progress and achievement toward these goals will only intensify. While rhetoric often emphasizes the importance of data for development, the global community has yet to fully translate this discourse into substantial investments in high-quality data for evidence-based decision-making. Beyond just financial commitments to robust data collection, there is a pressing need for greater political and scientific dedication.Publication Unlocking SDG 3 Success(Washington, DC: World Bank, 2024-08-08)This year holds special significance as the midpoint in implementation of the Sustainable Development Goals (SDGs). With each step closer to the end of the SDG implementation window, efforts to measure progress and achievement toward these goals will only intensify. While rhetoric often emphasizes the importance of data for development, the global community has yet to fully translate this discourse into substantial investments in high-quality data for evidence-based decision-making. Beyond just financial commitments to robust data collection, there is a pressing need for greater political and scientific dedication. Measurement should serve as a catalyst for action and accountability, but in turn, there must be accountability in measurement processes. Choices regarding what to measure, how to measure it, what remains unmeasured, and to whom findings are disseminated reflect political decisions and underlying conceptualization of problems and solutions, and can profoundly impact policy directions.Publication Costa Rica Case Study : Primary Health Care Achievements and Challenges within the Framework of the Social Health Insurance(World Bank, Washington, DC, 2013-01)The objective of this paper is to assess the key interventions Costa Rica has developed to expand health coverage for the poor and other vulnerable groups, with an emphasis on its approach to primary health care. Universal health coverage in Costa Rica is provided through a single national health insurance program. This program, which protects the poor without the pitfalls of a fragmented system, and the sustained policies that have enabled the building of a solid primary health care system, is broadly recognized as a success story. At the same, time new challenges are emerging to sustaining the success of Costa Rica's universal health coverage. Social Security of Costa Rica (Caja Costarricense de Seguridad Social, CCSS) faces increased production costs and demographic and epidemiological changes in a rapidly aging population. This report is divided into three broad sections: (1) objective of the case study and health system overview; (2) primary health care and the organization of health services within CCSS; and (3) agenda of key policy decisions for a renewed primary health care approach as part of a more responsive and sustainable health insurance system.
Users also downloaded
Showing related downloaded files
Publication Media and Messages for Nutrition and Health(World Bank, Washington, DC, 2020-06)The Lao People’s Democratic Republic (Lao PDR) has experienced rapid and significant economic growth over the past decade. However, poor nutritional outcomes remain a concern. Rates of childhood undernutrition are particularly high in remote, rural, and upland areas. Media have the potential to play an important role in shaping health and nutrition–related behaviors and practices as well as in promoting sociocultural and economic development that might contribute to improved nutritional outcomes. This report presents the results of a media audit (MA) that was conducted to inform the development and production of mass media advocacy and communication strategies and materials with a focus on maternal and child health and nutrition that would reach the most people from the poorest communities in northern Lao PDR. Making more people aware of useful information, essential services and products and influencing them to use these effectively is the ultimate goal of mass media campaigns, and the MA measures the potential effectiveness of media efforts to reach this goal. The effectiveness of communication channels to deliver health and nutrition messages to target beneficiaries to ensure maximum reach and uptake can be viewed in terms of preferences, satisfaction, and trust. Overall, the four most accessed media channels for receiving information among communities in the study areas were village announcements, mobile phones, television, and out-of-home (OOH) media. Of the accessed media channels, the top three most preferred channels were village announcements (40 percent), television (26 percent), and mobile phones (19 percent). In terms of trust, village announcements were the most trusted source of information (64 percent), followed by mobile phones (14 percent) and television (11 percent). Hence of all the media channels, village announcements are the most preferred, have the most satisfied users, and are the most trusted source of information in study communities from four provinces in Lao PDR with some of the highest burden of childhood undernutrition.Publication Remarks at the United Nations Biodiversity Conference(World Bank, Washington, DC, 2021-10-12)World Bank Group President David Malpass discussed biodiversity and climate change being closely interlinked, with terrestrial and marine ecosystems serving as critically important carbon sinks. At the same time climate change acts as a direct driver of biodiversity and ecosystem services loss. The World Bank has financed biodiversity conservation around the world, including over 116 million hectares of Marine and Coastal Protected Areas, 10 million hectares of Terrestrial Protected Areas, and over 300 protected habitats, biological buffer zones and reserves. The COVID pandemic, biodiversity loss, climate change are all reminders of how connected we are. The recovery from this pandemic is an opportunity to put in place more effective policies, institutions, and resources to address biodiversity loss.Publication Economic Recovery(World Bank, Washington, DC, 2021-04-06)World Bank Group President David Malpass spoke about the world facing major challenges, including COVID, climate change, rising poverty and inequality and growing fragility and violence in many countries. He highlighted vaccines, working closely with Gavi, WHO, and UNICEF, the World Bank has conducted over one hundred capacity assessments, many even more before vaccines were available. The World Bank Group worked to achieve a debt service suspension initiative and increased transparency in debt contracts at developing countries. The World Bank Group is finalizing a new climate change action plan, which includes a big step up in financing, building on their record climate financing over the past two years. He noted big challenges to bring all together to achieve GRID: green, resilient, and inclusive development. Janet Yellen, U.S. Secretary of the Treasury, mentioned focusing on vulnerable people during the pandemic. Kristalina Georgieva, Managing Director of the International Monetary Fund, focused on giving everyone a fair shot during a sustainable recovery. All three commented on the importance of tackling climate change.Publication The Journey Ahead(Washington, DC: World Bank, 2024-10-31)The Journey Ahead: Supporting Successful Migration in Europe and Central Asia provides an in-depth analysis of international migration in Europe and Central Asia (ECA) and the implications for policy making. By identifying challenges and opportunities associated with migration in the region, it aims to inform a more nuanced, evidencebased debate on the costs and benefits of cross-border mobility. Using data-driven insights and new analysis, the report shows that migration has been an engine of prosperity and has helped address some of ECA’s demographic and socioeconomic disparities. Yet, migration’s full economic potential remains untapped. The report identifies multiple barriers keeping migration from achieving its full potential. Crucially, it argues that policies in both origin and destination countries can help maximize the development impacts of migration and effectively manage the economic, social, and political costs. Drawing from a wide range of literature, country experiences, and novel analysis, The Journey Ahead presents actionable policy options to enhance the benefits of migration for destination and origin countries and migrants themselves. Some measures can be taken unilaterally by countries, whereas others require close bilateral or regional coordination. The recommendations are tailored to different types of migration— forced displacement as well as high-skilled and low-skilled economic migration—and from the perspectives of both sending and receiving countries. This report serves as a comprehensive resource for governments, development partners, and other stakeholders throughout Europe and Central Asia, where the richness and diversity of migration experiences provide valuable insights for policy makers in other regions of the world.Publication South Asia Development Update, April 2024: Jobs for Resilience(Washington, DC: World Bank, 2024-04-02)South Asia is expected to continue to be the fastest-growing emerging market and developing economy (EMDE) region over the next two years. This is largely thanks to robust growth in India, but growth is also expected to pick up in most other South Asian economies. However, growth in the near-term is more reliant on the public sector than elsewhere, whereas private investment, in particular, continues to be weak. Efforts to rein in elevated debt, borrowing costs, and fiscal deficits may eventually weigh on growth and limit governments' ability to respond to increasingly frequent climate shocks. Yet, the provision of public goods is among the most effective strategies for climate adaptation. This is especially the case for households and farms, which tend to rely on shifting their efforts to non-agricultural jobs. These strategies are less effective forms of climate adaptation, in part because opportunities to move out of agriculture are limited by the region’s below-average employment ratios in the non-agricultural sector and for women. Because employment growth is falling short of working-age population growth, the region fails to fully capitalize on its demographic dividend. Vibrant, competitive firms are key to unlocking the demographic dividend, robust private investment, and workers’ ability to move out of agriculture. A range of policies could spur firm growth, including improved business climates and institutions, the removal of financial sector restrictions, and greater openness to trade and capital flows.