Publication: The Realities of Primary Care: Variation in Quality of Care Across Nine Countries in Sub-Saharan Africa
Loading...
Published
2021-04
ISSN
Date
2021-04-08
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.”
Digital Object Identifier
Associated URLs
Associated content
Other publications in this report series
Publication The Economic Value of Weather Forecasts: A Quantitative Systematic Literature Review(Washington, DC: World Bank, 2025-09-10)This study systematically reviews the literature that quantifies the economic benefits of weather observations and forecasts in four weather-dependent economic sectors: agriculture, energy, transport, and disaster-risk management. The review covers 175 peer-reviewed journal articles and 15 policy reports. Findings show that the literature is concentrated in high-income countries and most studies use theoretical models, followed by observational and then experimental research designs. Forecast horizons studied, meteorological variables and services, and monetization techniques vary markedly by sector. Estimated benefits even within specific subsectors span several orders of magnitude and broad uncertainty ranges. An econometric meta-analysis suggests that theoretical studies and studies in richer countries tend to report significantly larger values. Barriers that hinder value realization are identified on both the provider and user sides, with inadequate relevance, weak dissemination, and limited ability to act recurring across sectors. Policy reports rely heavily on back-of-the-envelope or recursive benefit-transfer estimates, rather than on the methods and results of the peer-reviewed literature, revealing a science-to-policy gap. These findings suggest substantial socioeconomic potential of hydrometeorological services around the world, but also knowledge gaps that require more valuation studies focusing on low- and middle-income countries, addressing provider- and user-side barriers and employing rigorous empirical valuation methods to complement and validate theoretical models.Publication Direct and Indirect Impacts of Transport Mobility on Access to Jobs: Evidence from South Africa(Washington, DC: World Bank, 2025-11-12)Access to jobs is essential for economic growth. In Africa, unemployment rates are notably high. This paper reexamines the relationship between transport mobility and labor market outcomes, with a particular focus on the direct and indirect effects of transport connectivity. As predicted by theory, wages are influenced by the level of commuting deterrence. Generally, higher earnings are associated with longer commute times and/or higher commuting costs. Local accessibility is also important, especially for individuals with time constraints. Both direct and indirect impacts are found to be significant in South Africa, where job accessibility has been challenging since the end of apartheid. For the direct impact, the wage elasticity associated with commuting costs is significant. Returns on commute are particularly high for women. Local accessibility to socioeconomic facilities, such as shops and health services, is also found to have a significant impact, consistent with the concept of mobility of care. To enhance employment, therefore, it is crucial to connect people not only to job locations but also to various socioeconomic points of interest, such as markets and hospitals, in an integrated manner. This integration will enable individuals to spend more time working and commuting longer distances.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 From Policy to Practice: Lessons from the Implementation of the Refugee Work Rights Policy in Ethiopia(Washington, DC: World Bank, 2025-11-10)This paper examines the early implementation of Ethiopia’s refugee work rights policy, with a focus on the issuance of permits that enable refugees to engage in economic activities. Building on significant legal and institutional advances under the 2019 Refugee Proclamation and subsequent directives, the analysis explores how these reforms are being operationalized in practice. Using a mixed-methods approach, combining document review, administrative data analysis, and semi-structured interviews, the paper identifies both progress and remaining challenges. Permit issuance has increased since the adoption of detailed operational guidance in 2024, reflecting the Government of Ethiopia’s commitment to operationalizing its progressive legal framework and ensuring that refugees can exercise their right to work. However, take-up remains modest, with about 5.2 percent of the working-age population holding a permit. Preliminary evidence suggests that coordination gaps, limited subnational capacity, low awareness among refugees and employers, and disincentives to formalize in a largely informal labor market are contributing to the low take-up. The paper offers policy suggestions, grounded in the Ethiopian context and emerging evidence, to help translate legal commitments into improved labor market outcomes for refugees.Publication Monitoring Global Aid Flows: A Novel Approach Using Large Language Models(Washington, DC: World Bank, 2025-11-04)Effective monitoring of development aid is the foundation for assessing the alignment of flows with their intended development objectives. Existing reporting systems, such as the Organisation for Economic Co-operation and Development’s Creditor Reporting System, provide standardized classification of aid activities but have limitations when it comes to capturing new areas like climate change, digitalization, and other cross-cutting themes. This paper proposes a bottom-up, unsupervised machine learning framework that leverages textual descriptions of aid projects to generate highly granular activity clusters. Using the 2021 Creditor Reporting System data set of nearly 400,000 records, the model produces 841 clusters, which are then grouped into 80 subsectors. These clusters reveal 36 emerging aid areas not tracked in the current Creditor Reporting System taxonomy, allow unpacking of “multi-sectoral” and “sector not specified” classifications, and enable estimation of flows to new themes, including World Bank Global Challenge Programs, International Development Association–20 Special Themes, and Cross-Cutting Issues. Validation against both Creditor Reporting System benchmarks and International Development Association commitment data demonstrates robustness. This approach illustrates how machine learning and the new advances in large language models can enhance the monitoring of global aid flows and inform future improvements in aid classification and reporting. It offers a useful tool that can support more responsive and evidence-based decision-making, helping to better align resources with evolving development priorities.
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 Sourcebook on the Foundations of Social Protection Delivery Systems(Washington, DC: World Bank, 2020-07-30)The Sourcebook synthesizes real-world experiences and lessons learned of social protection delivery systems from around the world, with a particular focus on social and labor benefits and services. It takes a practical approach, seeking to address concrete “how-to” questions, including: How do countries deliver social protection benefits and services? How do they do so effectively and efficiently? How do they ensure dynamic inclusion, especially for the most vulnerable and needy? How do they promote better coordination and integration—not only among social protection programs but also programs in other parts of government? How can they meet the needs of their intended populations and provide a better client experience? The Sourcebook structures itself around eight key principles that can frame the delivery systems mindset: (1) delivery systems evolve over time, do so in a non-linear fashion, and are affected by the starting point(s); (2) additional efforts should be made to “do simple well”, and to do so from the start rather than trying to remedy by after-the-fact adding-on of features or aspects; (3) quality implementation matters, and weaknesses in the design or structure of any core system element will negatively impact delivery; (4) defining the “first mile” for people interface greatly affects the system and overall delivery, and is most improved when that “first mile” is understood as the weakest link in delivery systems); (5) delivery systems do not operate in a vacuum and thus should not be developed in silos; (6) delivery systems can contribute more broadly to government’s ability to intervene in other sectors, such as health insurance subsidies, scholarships, social energy tariffs, housing benefits, and legal services; (7) there is no single blueprint for delivery systems, but there are commonalities and those common elements constitute the core of the delivery systems framework; (8) inclusion and coordination are pervasive and perennial dual challenges, and they contribute to the objectives of effectiveness and efficiency.Publication Unlocking the Power of Healthy Longevity(Washington, DC: World Bank, 2024-09-12)Noncommunicable diseases (NCDs) are among the major health and development challenges of our time. Every year, about 41 million people die due to NCDs. This makes up about 74 percent of all deaths globally, the majority of which are in low- and middle-income countries (LMICs). Countless more people live with NCDs every day. Yet, NCDs are largely treatable and preventable. The risk of developing NCDs and deaths from them can both be lowered with appropriate attention to prevention and treatment. However, weak health systems and limited access to affordable care and information, especially in LMICs, contribute to lapses in seeking and receiving appropriate and timely care. This compendium is a compilation of 18 chapters, each exploring a different but related topic in the nexus of NCDs, human capital, and productivity. It is based on a series of analytical work taken up by the World Bank to support the Healthy Longevity Initiative (HLI) - a collaborative effort between the World Bank, the University of Toronto, and key academic and development partners including the Harvard University and the University of Washington. The HLI presents one of a growing set of efforts to increase the urgency of policy response to NCDs across the world.Publication The Government Analytics Handbook(Washington, DC: World Bank, 2023-09-28)The Government Analytics Handbook presents frontier evidence and practitioner insights on how to leverage data to strengthen public administration. Covering a range of microdata sources—such as administrative data and public servant surveys—as well as tools and resources for undertaking the analytics, it transforms the ability of governments to take a data-informed approach to diagnose and improve how public organizations work. The "Handbook" is a must-have for practitioners, policy makers, academics, and government agencies. It is available as a single volume in print or digital formats, and as chapters for modular use. Additional tools, data and background information are available at worldbank.org/governmentanalytics. “Governments have long been assessed using aggregate governance indicators, giving us little insight into their diversity and how they can practically be improved. This pioneering handbook shows how microdata can be used to give scholars and practitioners granular and real insights into how states work, and practical guidance on the process of state-building.” —Francis Fukuyama, Stanford University, author of State-Building: Governance and World Order in the 21st Century - "The Government Analytics Handbook is the most comprehensive work on practically building government administration I have ever seen, helping practitioners to change public administration for the better.” —Francisco Gaetani, Special Secretary for State Transformation, Government of Brazil - “The machinery of the state is central to a country’s prosperity. This handbook provides insights and methodological tools for creating a better shared understanding of the realities of a state, to support the redesign of institutions, and improve the quality of public administration.” —James Robinson, University of Chicago, coauthor of Why Nations FailPublication The Changing Wealth of Nations 2021(Washington, DC: World Bank, 2021-10-27)It is now clear that a narrow focus on the growth of gross domestic product (GDP) is insufficient to achieve humanity’s aspirations for sustainable prosperity. Wellfunctioning ecosystems and educated populations are requisites for sustainable wellbeing. These and other too-often-neglected ingredients of national wealth must be addressed if the development path is to be sustainable. The Changing Wealth of Nations 2021: Managing Assets for the Future provides the most comprehensive accounting of the wealth of nations, an in-depth analysis of the evolution of wealth, and pathways to build wealth for the future. This report—and the accompanying global database—firmly establishes comprehensive wealth as a measure of sustainability and a key component of country analytics. It expands the coverage of wealth accounts and improves our understanding of the quality of all assets, notably, natural capital. Wealth—the stock of produced, natural, and human capital—is measured as the sum of assets that yield a stream of benefits over time. Changes in the wealth of nations matter because they reflect the change in countries’ assets that underpin future income. Countries regularly track GDP as an indicator of their economic progress, but not wealth, and national wealth has a more direct and long-term impact on people’s lives. This report provides a new set of tools and analysis to help policy makers navigate risks and to guide collective action. Wealth accounts can be applied in macroeconomic analysis to areas of major policy concern such as climate change and natural resource management. This report can be used to look beyond GDP, to gauge nations’ economic well-being, and to promote sustainable prosperity.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.