investment for long-term benefits in this region, what actionable lessons can be learned from an analysis of the variation in citizen experiences within the health care system?

# 2. The Service Delivery Indicators initiative

The SDI surveys were developed to directly respond to the need for accountability in social sector service delivery. The SDI initiative began in 2008 when researchers and practitioners at the World Bank Group, in partnership with the African Economic Research Consortium (AERC), the William and Flora Hewlett Foundation and the African Development Bank, developed novel survey tools and methodology to comprehensively measure primary health care and primary education service delivery.

The SDI initiative is premised on the concept of making services work for the poor, as outlined in the World Development Report 2004.<sup>10</sup> The report emphasizes the idea of accountability and of enabling clients to give feedback directly to providers of services. By creating measures of service provision through the SDI, health care providers can be held accountable for providing quality services and individuals in the community can use the results to demand improvements. Through this “short route to accountability”, health systems can be improved not just through government decisions but by an active process involving citizen engagement. This focus is echoed in the recent Lancet Commission on High Quality Health Systems, which noted that “governments and civil society should ignite demand for quality in the population to empower people to hold systems accountable and actively seek high-quality care.”<sup>11</sup> The SDI health facility survey offers a set of indicators for benchmarking of health system performance. These indicators focus on potential determinants of the quality of services provided: the knowledge of medical providers; their effort towards patient care; and the availability of necessary equipment, supplies, and medicines. The survey adopts the perspective of an average patient, meaning that the focus is on indicators of provider knowledge of common conditions, and physical inputs required for commonly-used services. This information is collected through enumerator visits to a representative sample of health facilities in each country undertaking an SDI survey. The majority of the data collection is based on a survey administered to the facility manager, and also includes direct observation of the availability and functioning of infrastructure, equipment, medicines and other physical assets.

# 3. Data description and methodology

## 3.1 Sample

The SDI health surveys have been implemented for over 10 years across 13 countries in Sub-Saharan Africa and this paper presents data combined from across this period. Four surveys were excluded, either because they were pilots (Senegal 2010) or because they were not yet complete and data were not publicly available (Guinea Bissau 2018, Cameroon 2019, Malawi 2019). In countries with multiple SDI surveys, we include only the most recent survey, excluding Kenya 2012 and Tanzania 2010/2014. The resulting data set includes information on nine countries, covering 7,810 health facilities. The data include results from the following country surveys: Kenya (2018), Madagascar (2016), Mozambique (2014), Niger (2015), Nigeria (2013), Sierra Leone (2018), Tanzania (2016), Togo (2013) and Uganda (2013).

In each country, the sample of facilities is selected based on a complete listing of health facilities provided by the Ministry of Health. This includes facilities operated by private entities or non-governmental organizations (NGOs), and facilities at all levels of care, including hospitals, health clinics and health posts (or the national

> 11 Kruk et al. (2018).

10 World Bank (2004).

2