Finally, the PCA metric is intended as an overall assessment of facility performance, combining results across the variables and allowing for identification of high and low performing facilities. These differences follow some predictable patterns, such as private facilities scoring better than public facilities on average, but there remains wide variation within each country unexplained by our analysis. There may be facility factors that increase performance which our survey has not measured, such as the adeptness of management or the job satisfaction of health workers, and these results suggest a continued need for research into determinants of facility performance. Continued efforts to identify high-performing facilities, both in terms of outputs and health outcomes, can open opportunities for country governments to identify these positive deviants and to learn lessons on what enables their success.

# 5.2 Enhancing health system measurement

In 2018, the World Bank, in collaboration with the WHO and the Organisation for Economic Co-operation and Development (OECD), released a joint report, “Delivering quality health services”, highlighting the importance of delivering high quality health services as a global imperative within the context of achieving Universal Health Coverage by 2030.<sup>45</sup> This report acknowledges the dearth of actionable evidence on quality of service delivery, despite its critical role in initiating, sustaining and monitoring quality improvement processes. As the Service Delivery Indicators surveys are specifically developed with the aim of improving quality and accountability in public service delivery, these data can provide useful guidance to this end.

These lessons have already informed project design and supported reform in a number of countries. Along with the policy lessons learned, the 10-year experience of data collection efforts across a variety of settings offers valuable lessons on further enhancing the goals and methods employed for health system measurement, including future SDI surveys. Quality of service delivery is a multifaceted, complex process and no single survey can comprehensively measure all relevant aspects. By employing a novel methodology to measure provider ability and effort, SDI surveys go beyond most existing large-scale efforts that focus primarily on measuring inputs to care. However, the SDI survey, in contradiction to the guidance from the recent body of literature on measuring quality of care, lacks a usercentered approach, partly attributable to its emphasis on measuring the supply-side correlates of service delivery.

The analysis presented in this paper is limited by the characteristics of the underlying data and of the survey methodology. For example, our indicator for measuring caseload assumes equal distribution of cases across all types of providers (including nutritionists, surgeons and other health care staff), which may introduce downward bias in measurement of caseload. Other reasons for a downward bias include the fact that our indicator does not account for inpatient care, which may be significant despite the facility designation as a primary care facility. Likewise, the current indicator does not account for the possibility of a single patient seeing multiple providers during a visit. Additionally, as we interpret the findings on caseload, we must consider that caseload does not equate to workload of the provider who may be contributing to other aspects of facility functioning, including, but not limited to, administrative duties and community outreach. To address these limitations, the future iteration of SDI surveys aims to triangulate between facility report and provider self-report to better capture the true volume of patients served, hours spent on different tasks on a typical day, and the differential distribution of caseload across different administrative units (departments) within a facility and across different provider cadres.

The methodological innovations introduced by the SDI survey in measuring provider ability and effort can be further strengthened for generating readily actionable evidence. Apart from the limitations of the vignettes that have been discussed elsewhere, our results have indicated a few opportunities for methodological improvements in the design and implementation of the vignettes.<sup>46</sup> For instance, in our current analysis, while we can assess when a provider

> 45 OECD/WHO/World Bank Group (2018).

> 46 Peabody et al (2000).

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