in this paper suggests that more attention should be placed on the skills and training of the health workforce to ensure that patients receive quality care, regardless of the type of provider they see. While post-secondary education is associated with better diagnostic ability, more investigation and data are needed to understand how medical training and on-the-job training build on basic provider skills and competencies.

The analysis of a caseload indicator arises from a recognition of a global human resources shortage and an uneven distribution of health workers, both at the global and local level. Specifically, the World Health Organization (WHO) estimates that the Africa region bears more than 24% of the global burden of disease but has access to only 3% of the health workers.<sup>36</sup> Contrary to expectations, this analysis indicates relatively low caseload overall in the period before COVID-19, with 43% of health facilities seeing fewer than 5 patients per provider per day. This is in line with recent analyses in Latin America which look at efficient allocation of care and found substantial variation. In Ecuador, a World Bank report estimated that approximately one-third of primary care facilities have low case counts (fewer than 500 outpatient visits per month).<sup>37</sup> Similarly, in Peru, analysis found that around 10% of health facilities have fewer than 30 total patient visits per day.<sup>38</sup> Although it is difficult to determine the optimal theoretical caseload, in both of these cases other similarly equipped facilities are able to see three to four times the volume of patients.

Low caseload might raise some concerns about effective allocation of human resources in health care delivery, but it also points to the success of the global effort to bring health facility and health care providers closer to people, especially in rural and remote areas.<sup>39</sup> While this expanded geographical access to care is important, especially from an equity perspective, low caseload in primary care facilities across countries provides further evidence to consider reorganization of services within the existing health system to enhance efficiency without compromising on equitable access, as proposed by the Lancet Global Health Commission on High Quality Health Systems.<sup>40</sup> Such quality-focused service delivery redesign would entail providing treatment of chronic and stable conditions, preventative care, low acuity and algorithmic services, and palliative care at the primary level while more complex or rare conditions will be managed in tertiary or specialized care centers.

Our findings concerning low caseload also offer insight on the debate regarding overcrowding in facilities and its impact on quality of care. Academic literature on health facility capacity has focused on overcrowding, and its potential impact on wait times and reduced time for clinical consultation.<sup>41,42</sup> For instance, in central Mozambique, evidence indicates that the average outpatient consultation requires over 40 minutes of waiting at most clinics. Longer wait times, of up to one hour, are reported for first antenatal visits.<sup>43</sup> The patient experience of long wait times and short consultation times might not necessarily result from health care providers’ failure to cope with high demand. Caseload is only reflective of the clinical aspects of the health care providers’ job and their responsibilities may include other administrative tasks. Long wait times might be reflective of poor facility management and health care providers’ time being stretched to accommodate other activities. Overcrowding at health facilities may also result from an uneven distribution of patients throughout the day, a lack of scheduled appointments, or a concentration of patients for a specific service (e.g., antenatal care) on pre-specified days. In addition, many countries now face overcrowding due to surges in COVID-19 cases, putting an unprecedented strain on health care systems and personnel.<sup>44</sup>

> 36 WHO (2013). 37 Vermeersch & Giovagnoli (2020). 38 World Bank (2020c). 39 WHO & IBRD (2017). 40 Kruk et al. (2018). 41 WHO (2006). 42 Chen et al. (2004). 43 Wagenaar et al. (2016). 44 Odula (2020).

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