# 5. Discussion and conclusion

In this paper, we provide a comprehensive overview of primary health care delivery across nine Sub-Saharan African countries and across a variety of medical conditions. Overall, the results indicate that despite global efforts to strengthen primary care delivery and the focused investments made towards expanding the reach and quality of primary care since the Alma Ata declaration, the quality of primary care delivery in these nine Sub-Saharan African countries remains suboptimal. These results complement other analysis of the SDI, which looked at the results related to child and maternal health and the constraints in care readiness.<sup>25</sup> Our findings suggest substantial heterogeneity in the quality of primary care service delivery between and, especially, within countries. Our investigation of the distribution of quality service delivery indicates that an average citizen’s experience with primary health care, across these nine countries, depends to a large extent on where the individual is accessing care.

Collectively, these findings emphasize the need for evidence-based and context-driven policies to strengthen health systems and to improve health service delivery in the nine Sub-Saharan African countries. Realizing the vision of the Sustainable Development Goals and Universal Health Coverage relies extensively on effective and responsive health systems that are built on the foundation of strong primary care.<sup>26</sup> Our findings indicate that without judicious and targeted investments in improving the quality of primary care delivery, these global goals will fail to have the desired impact of improved health and well-being of all people. The lessons learned from over a decade of data collection efforts to understand health service delivery can provide instructive insight on two fronts: (1) strengthening health system performance and (2) enhancing health system measurement.

## 5.1 Strengthening health system performance

This analysis documents important disparities between a citizen’s experience of care at facilities in rural as opposed to urban areas. Specifically, while availability of basic infrastructure (improved water and sanitation facilities, and electricity) is variable across countries in the sample, the starkest within-country contrasts are between urban facilities and rural facilities. This reflects well-known disparities between infrastructure availability/functionality in urban and rural areas both within and well beyond the health sector.<sup>27</sup> The implications of poor infrastructure at health facilities are dire: without safe water and sanitation, health care facility staff and patients are at increased risk of infection and associated illness (including COVID-19 transmission).<sup>28,29</sup> Facilities without access to electricity cannot operate crucial medical devices for essential services (such as mammograms and electrocardiograms) and cannot reliably maintain a cold chain for storage of vaccines or other medicines.<sup>30</sup> This capacity for cold chain maintenance takes on added importance now, as the global community begins provision of COVID-19 vaccines and navigates the requirements for ultra-cold freezers.<sup>31</sup> Given that rural health facilities may also be more likely to provide care to lower-income members of the population, poorer quality facility infrastructure may also contribute to increased health disparities by income. The findings of this analysis indicate that despite decades of investments in infrastructure, not least from the World Bank, rural health facilities in particular are still lacking.

While global evidence on relative accountability, efficiency, and availability of key inputs in public versus private health facilities remains mixed,<sup>32</sup> this analysis highlights notable differences between facilities under these two different types of ownership. In particular, unauthorized health care provider absences are more prevalent in public

> 25 Di Giorgio et al. (2020). 26 Pettigrew et al. (2015). 27 Leslie et al. (2017). 28 UNICEF (2019). 29 Sharma et al. (2020). 30 Adair-Rohani et al. (2013). 31 Fischetti (2020). 32 Basu et al. (2012).