Substantial quality improvements were only possible from reallocation in systems where sufficiently high-competence providers were available _and_ sufficiently busy postings existed.

In a benchmarking exercise ( **Supplemental Appendix Figure 6** ), we contextualize the size of the potential quality improvements from reallocation by using the SDI data to simulate instead the impact of training existing nurses and para-professionals in each country to the same level of medical knowledge as doctors in the same country. Specifically, we replaced the competence of those providers with a random draw from the competence distribution of doctors, again without changing any caseloads or postings, and then calculated the potential improvement in quality of care.

In countries where reallocation offered substantial improvements, we estimated that “upskilling” would typically be about half as effective as reallocation – either because doctors already made up a substantial share of observed providers, or because doctors were not reliably more competent than other provider cadres.<sup>9</sup> In other countries, reallocation was relatively ineffective because the availability of high-competence providers was very low. In these countries – namely, Madagascar, Mozambique, Niger, Sierra Leone, and Togo – increasing workforce training to the level of local doctors was equally ineffective, because even the most competent providers still had low rates of correct management in the vignettes. In such contexts, where systems of medical education and retention have failed to produce a minimally competent workforce, there appear to be few options within the existing system that would offer viable avenues to quality improvement.

# **5 Discussion: Unequal Burdens, Unequal Outcomes**

Organizations such as the World Health Organization have repeatedly argued that SubSaharan African countries face severe health worker shortages and that, as a consequence, health facilities are overcrowded and providers are routinely overburdened. A new literature on quality and availability suggests that the picture is more complicated. Studies that count the number of actual patients and medical staff at health care facilities show that health care providers, on average, are not overloaded and in fact have substantial excess capacity.<sup>20, 21</sup> Consistent with these summary measures, three recent studies that estimated the causal impact of additional patient load on the quality of medical care all found near-zero relationships between caseload and quality outcomes.<sup>10–12</sup> Our study represents a fundamental reassessment of the human resources situation in SSA. First, across a nationally representative sample of health facilities in 10 countries, we confirm that most health care providers operate under conditions of substantial excess capacity; the median _provider_ likely spends at most one hour and forty minutes each day seeing patients. Using facility-level survey data, we provide a new perspective on this fact. In these data, aggregate excess capacity across the provider population masks the fact that a minority of facilities and providers provide the majority of care in each system. The number of patients reported at busy facilities was such that the median _patient_ experience was indeed consistent with long wait times and queues, especially if most patients arrive at specific times of the day.

**12/30**