allocation” as one in which the provider with the highest competence is matched to the posting with the largest outpatient caseload; the provider with the second-highest competence to the posting with the second-largest outpatient caseload; and so on. We restrict hypothetical reallocations to postings within the same health facility level and rural/urban setting (together, a “sector”) in each country, while holding the caseload constant at each posting.

To calculate the potential gains from provider reallocation, we first computed the share of vignette conditions that the average provider could correctly treat, weighted by the observed outpatient caseload at each posting. Then, we reallocated providers to the “optimal allocation” taking the constraints into account till all existing providers were assigned to all existing postings. This process produced the highest possible proportions of vignettes correctly treated when weighted by the observed outpatient caseloads. Following the reallocation simulations, we re-computed the predicted correct management shares for the average patient and calculated the realized gains from the reallocation. Regardless of the practicability of any such reallocation, the resulting estimate is a valid measure of the quality implication of provider misallocation. The **Supplemental Appendix** discusses the process in further detail.

# **3 Results: Provider Caseloads and Patient Crowding**

## **3.1 Caseload Patterns for PHC Providers**

The first part of our results establishes the overall patterns in daily outpatient caseloads across the countries in our sample. The top panel of **Table 1** presents summary statistics for each country as well as for all countries in our sample (as a country-level average of medians). The median facility in the average country sample saw on average 25.9 patients per day, ranging from 2.1 in Nigeria to 87.2 patients per day in Malawi (Column 4, Table 1). The median provider in the average country saw on average 10.9 patients per day, with country-level medians ranging from 1.2 (Nigeria) to 20.7 patients per day (Malawi). A provider who saw 10.9 patients per day would face a one hour and forty minute workday in addition to other duties if providers were spending nine minutes per patient, which is the _highest_ mean consultation time observed in LMIC settings.<sup>6</sup> Given that the mean consultation time across LMIC settings is usually closer to five minutes, it could well be the case that the median SSA provider spends no more than one hour a day seeing outpatients.

In the bottom panel of Table 1, we compared these estimates to WHO statistics, using the combined number of physicians, nurses, midwives, and CHWs reported per 1,000 population.<sup>19</sup> We assumed 6 visits per person per year and 250 working days for each provider. These assumptions indicated that the mean provider (physician, nurse or midwife) would be responsible for 30.6 outpatients per day, ranging from 12.4 to 96.0 across countries, as these countries had generally lower availability of PHC providers than the African Region as a whole. Across all countries, the mean provider outpatient caseload we estimated from the SDI data tracked these estimates in a range from 9% (in Niger) to 114% (in Kenya) of the WHO-based calculation, with an average 49% lower

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