2. Policy Makers Need to Focus on the Quality and Not Just the Quantity of Services Delivered _<mark>Deon Filmer and Adam Wagstaff</mark>_ Education and health policymakers often focus on indicators of the _quantity_ of services provided: Are children enrolled in school? Are women delivering their babies in a health facility? Are newborn babies receiving postnatal care? This assumes that children in school will automatically learn, and that health outcomes such as maternal and child mortality will automatically improve as service coverage increases.

This assumption often is wrong. Even in countries on track to hit enrollment targets, children often have low levels of mastery of reading, writing and mathematics. Indonesia and Mexico, for example, had both almost reached the universal primary completion MDG target by the mid‐2000s, but at the time 68 percent of Indonesian youth and 50 percent of Mexican youth lacked even minimally adequate competence in mathematics.<sup>15</sup> In health, evidence shows a similar tenuous link between service coverage and outcomes. For example, having women deliver their babies in a health facility (an MDG and SDG target) has been found _not_ to lead to lower maternal or neonatal mortality rates.<sup>16</sup> In both education and health, poor _quality_ of service delivery is the key reason why service coverage does not necessarily translate into better outcomes. We know this because research – much of it done at the World Bank – has zeroed in on the quality of service delivery.

Early research focused on a very basic aspect of quality: are teachers and health workers actually teaching and delivering health services? Random unannounced visits to schools and health centers in six developing countries uncovered high absenteeism rates – 19% in the case of teachers and as much as 35% in the case of health workers.<sup>17</sup> Averaging across seven African countries, more recent research found that 23% of teachers were absent from school, and 44% were absent from the classroom.<sup>18</sup> Absenteeism – coupled with teachers spending time in class but not teaching – resulted in, on average, just 23⁄4 hours of teaching time per day instead of the scheduled 51⁄2 hours.

Later research looked at another aspect of the quality of education and health services – provider knowledge. The study of seven African countries also tested primary school teachers’ knowledge of their subject by asking them to grade mock student tests in language and mathematics. Teachers did well enough on spelling and simple grammar, with two‐thirds grading at least 80% of the questions correctly. But they did much worse in other areas, averaging 44% on vocabulary and comprehension, and just 25% on composition. In mathematics, the results also were worse the more complex the task. On average, 91%

> 15 Filmer D, Hasan A, Pritchett L. A Millennium Learning Goal: Measuring Real Progress in Education: Center for Global Development, 2006.

> 16 Gabrysch S, Nesbitt RC, Schoeps A, Hurt L, Soremekun S, Edmond K, Manu A, Lohela TJ, Danso S, Tomlin K, Kirkwood B, and Campbell OMR. Does Facility Birth Reduce Maternal and Perinatal Mortality in Brong Ahafo, Ghana? A Secondary Analysis Using Data on 119,244 Pregnancies from Two Cluster‐Randomised Controlled Trials. The Lancet Global Health 2019; 7(8): e1074‐e87.

> 17 Chaudhury N, Hammer J, Kremer M, Muralidharan K, Rogers FH. Missing in Action: Teacher and Health Worker Absence in Developing Countries. _Journal of Economic Perspectives_ 2006; 20(1): 91‐116.

> 18 Bold T, Filmer D, Martin G, Molina E, Stacy B, Rockmore C, Svensson J, and Wane W. Enrollment without Learning: Teacher Effort, Knowledge, and Skill in Primary Schools in Africa. _Journal of Economic Perspectives_ 2017; 31(4): 185‐204.

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