caseload using the SDI data than the WHO data at the country level. The comparison confirms that our computations based on crude averages are likely an overestimate of the true caseload in primary care. The most plausible reason for this overestimate is that the number of PHC visits per person per year is likely much lower than the OECD average of 6, but we cannot rule out that there are other systematic differences in the way that health care workers are counted in WHO statistics versus the on-the-ground surveys used here.

We also investigated if patient loads could be much higher for doctors under the assumption that in facilities where they were present, all patients would be allocated to that doctor rather than the nurse. The estimated outpatient caseload per doctor increased from 9.5 to 19.3 patients per day ( **Supplemental Appendix Figure 4** ). However, 63% of clinics were exclusively staffed by health care professionals who were _not_ doctors; as a result, average caseloads per provider remained low for the majority of providers. Overall, the facility-level surveys supported the conclusion that PHC providers across these 10 countries experienced substantial excess capacity and underutilization during the workday.

# **3.2 Variation in Caseloads across Facilities**

A key feature of these data is that even though the mean and median caseloads are low, there is enormous variation across providers, as shown in **Figure 1** . At the 75th percentile of the caseload distribution, for example, providers see on average 2.5 times as many patients as the median provider does; and 5 times as many at the 90th percentile of the caseload distribution. One question is whether this variation largely reflects differences in facility levels and/or differences across urban and rural areas.

We therefore examined the variation in caseloads and providers across facilities using multiple regression analysis in a specification with country-level fixed effects ( **Table 2** ). Column 1 shows that at the facility level, indeed urban hospitals carried the largest caseload, followed by rural hospitals followed by urban and rural clinics, all compared to rural health posts. These results remain similar, but attenuated once we include the number of providers at the facility. Note however, that the estimated coefficient on the number of providers implies that facilities with one additional provider see 6.98 additional patients. Since this is below the mean in our sample, facilities with more providers should see fewer providers per patient, and this is what we show next. In Column 3, we use as the dependent variable the caseload _per provider_ , accounting for the number of providers at the facility, and as expected, facilities with more providers are also those that have fewer patients per provider.

We then investigated these patterns at the provider level, as opposed to the facility level. Column 4 confirms that the association between staffing levels and caseloads is sufficiently strong that urban hospitals do not have significantly more patients per provider than health posts. In fact, providers at hospitals are less busy than providers at urban and rural clinics, which have the highest per-provider caseloads. Rural hospitals, by contrast, have even lower per-provider caseloads than rural and urban health posts. There are no significant differences in caseloads between urban and rural hospitals; nor between

**8/30**