of teachers could add double digits, but only 68% could multiply double digits. Less than one‐third could understand a Venn diagram, and only 11% could interpret data on a graph.

Results of studies testing health provider knowledge are similarly sobering. The approach is similar to that used with teachers – health providers are asked to “treat” a hypothetical patient. These “vignette” exercises have been done for a variety of medical conditions including child pneumonia, diabetes and tuberculosis. A study of nine African countries painted a rather bleak picture. On the tuberculosis vignette, 83% of health providers got the correct diagnosis, but only 54% prescribed the correct treatment. On the pneumonia vignette, 70% prescribed the correct treatment, but on the diabetes vignette, only 52% did. Having providers at their workplace and having them know their subject are necessary conditions for high‐ quality service delivery, but recent research shows that even this is not sufficient. This research shows that there is often a gap – sometimes a large one – between what service providers know in terms of their mastery of their subject and how well they perform on the job.

In the case of education, teacher performance has been assessed by looking at teachers’ pedagogical knowledge (e.g., comprehension of factual text and formulating aims and learning outcomes), their ability to assess students (e.g., formulating questions to check understanding), and their success in applying their knowledge in the classroom (e.g., introducing and summarizing the topic of a lesson). On these criteria, primary school teachers across the same seven African countries performed poorly. They scored on average just 23% on an exercise gauging their ability to formulate aims and learning outcomes and just 23% on an exercise gauging their ability to formulate questions to check students’ understanding. And when observed in their class, only 41% of teachers introduced and summarized the topic of the lesson. In health, too, there have been studies employing the direct observation approach – observing real‐life interactions between patients and health workers. But these have their drawbacks. Providers may perform differently when observed. And while in education interactions between teacher and students are limited to just a few age groups and just a few subjects, a health provider in a clinic could be dealing with any number of medical conditions. An alternative approach is to have actors pretend to be a real patient. The provider consents beforehand to participating in the study, knowing that at some stage during the study period an actor may show up pretending to be a patient, but not when. To get around the fact actors can’t be subjected to invasive exams, in some studies the actor pretends to be the parent of a sick child who is at home, with, for example, diarrhea or symptoms of pneumonia.<sup>19</sup> Providers mostly did better in the vignettes than they did when confronted with an actor, suggesting a “know‐do gap”: in the case of diarrhea, 74% got the right diagnosis in the vignette but only 3% did in the real‐life interaction with the actor; 3% recommended the correct treatment in the vignette but none recommended the correct treatment in the real‐life interaction.

What to do to improve service delivery quality? One rather sobering finding from one health study<sup>20</sup> is that while providers in better‐equipped facilities asked more questions and did more tests, they were not more likely to recommend the correct treatment. Another health study<sup>21</sup> found that providers with dual public‐private practices performed better in their private practice than in their public practice, suggesting financial incentives may play a role – a theme explored in a separate note in this series.

The above assumes that poor service quality is indeed the reason why getting children into school does not automatically ensure learning and why getting patients in to health facilities does not automatically

> 19 Mohanan M, Vera‐Hernández M, Das V, Giardili S, Goldhaber‐Fiebert JD, Rabin TL, Raj SS, Schwartz JI, and Seth A. The Know‐Do Gap in Quality of Health Care for Childhood Diarrhea and Pneumonia in Rural India. _JAMA Pediatrics_ 2015; 169(4): 349‐57.

> 20 Das J, Holla A, Das V, Mohanan M, Tabak D, and Chan B. In Urban and Rural India, A Standardized Patient Study Showed Low Levels of Provider Training and Huge Quality Gaps. _Health Affairs_ 2012; 31(12): 2774‐84.

> 21 Das J, Holla A, Mohpal A, and Muralidharan K. Quality and Accountability in Health Care Delivery: Audit‐Study Evidence from Primary Care in India. _American Economic Review_ 2016; 106(12): 3765‐99.

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