compared to private facilities in all nine countries, potentially arising from differences in incentive structures and management practices between these facility types. Health care provider absences have been well documented previously and our results are approximately consistent with the 35% absence rate reported by other researchers in a cross-section of low-income countries, but suggest that the problem has persisted into more recent years.<sup>33</sup> The absence rate overall is also higher in public facilities, suggesting that providers in public facilities may have increased demands that take them outside of the facility, including attending trainings, seminars, outreach, and other authorized activities. While authorized absences might not have an adverse effect on health service delivery, especially if facility management is strong, unauthorized provider absence will disrupt services and might result in increased patient wait times and deter patients from seeking health care in the future. For example, in western Kenya, nurse absence during a patient’s first antenatal care (ANC) visit significantly reduces the probability that a woman tests for HIV over her entire pregnancy, whereas nurse attendance during first ANC visit increases the likelihood of delivering in a hospital or health center and receiving appropriate treatment and counseling.<sup>34</sup> Authorized absences, particularly in overburdened facilities, might reflect insufficient staffing or planning, speaking to the importance of better understanding staffing decisions and the role of management quality. Beyond staff management, more research is required to further corroborate existing evidence of the positive impact of strong facility management practices on primary health care processes and outcomes.<sup>35</sup> In sum, the ramifications of differences between provider absence in public as opposed to private facilities are non-negligible and have the potential to further increase health disparities between those able to afford private care versus public care.

Similarly, key medicines and supplies are more commonly available in private as opposed to public facilities. This again begins to suggest that private facilities may have more effective procurement and supply chain systems that prevent stockouts of these key inputs. The gap between public and private persists even in urban areas, suggesting that it is not driven by the inaccessibility or remoteness of facilities. Higher level public facilities have better availability, but the lack of medicines in lower level public facilities is concerning, given that medicines included in the SDI survey are geared towards primary care and would be useful and necessary even at lower levels. Private facilities that profit from medicine sales may also be further incentivized to maintain adequate stock in a way that public facilities are not. Further investigation is required to better understand the potential incentive structures, efficiencies, and management practices that may be driving better performance in private facilities, so that these practices can be emulated in public ones.

The SDI vignettes focus on core conditions that providers at all levels of the health care system should be able to successfully diagnose and treat. Diagnostic and treatment accuracy are higher at hospitals than health centers or health posts. Since the majority of initial patient presentation is likely to be at lower-level facilities, these results suggest that strengthening the capacity of workers at lower-level institutions is needed in order to enable them to act as the frontline of primary care. Results are not significantly different between public and private facilities or urban and rural facilities, suggesting an encouraging equity in the current distribution of skilled health care providers.

Nurses and lower-level medical providers comprise the majority of the health workforce and need to be relied upon for patient care. Yet, they performed significantly worse than doctors on diagnostic and treatment accuracy as measured by the SDI vignettes. With increased task shifting, lower-level staff are asked to play a larger role in patient care. Nurses are also more likely to prescribe antibiotics when they are not required (though this varies by country), which may be due to uncertainty about proper prescription or patient pressure for access to antibiotics. The implications for patient health and for contributing to antimicrobial resistance cannot be overlooked. The evidence

> 33 Chaudhury et al. (2006). 34 Goldstein (2013). 35 Macarayan et al. (2019).

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