the total number of randomly selected staff. Reasons for absence are also collected and are categorized as either authorized or unauthorized, to better understand the nature of health care provider absence from health facilities.

3.2.5 Diagnosis and treatment accuracy In recent years, quality of care has received more attention in the health research community, with an increasing recognition that good health outcomes depend not just on patient access to care but on the competence and skill of the health care provider. Accurate diagnosis and treatment are important for the health outcomes of patients and can also influence future patterns of health care utilization.<sup>15,16</sup> The SDI survey includes clinical vignettes which are administered to health care providers. This is an innovative addition which measures the quality of clinical care, rather than the inputs-focused perspective that earlier surveys had taken.<sup>17</sup> Clinical vignettes may be less reliable for assessing quality of care than other methods, such as the use of standardized patients, but are easier to implement, less expensive and less disruptive to health facility operations. Overall, clinical vignettes have been shown to be “a valid and comprehensive method that directly focuses on the process of care provided in actual clinical practice.”<sup>18</sup> The standardized clinical vignettes assess health care providers’ ability to diagnose and treat common outpatient conditions.<sup>19</sup> Vignettes are administered by two enumerators, who conduct the simulations privately with a clinician after walking the provider through an example case. The first enumerator imitates a patient presenting with an initial complaint and a basic description of the associated symptoms. The health care provider is encouraged to ask follow-up questions around symptoms and presentation of illness, and to request the results of various medical and laboratory tests. The first enumerator offers pre-specified responses to those questions and the second enumerator records how well the physician adheres to clinical guidelines in the questions asked and clinical actions undertaken. By the end of the vignette, the health care provider must provide a diagnosis and proposed treatment for the clinical case.

In the SDI surveys considered in this paper, health care providers are tested on five core vignettes: childhood diarrhea with dehydration, childhood pneumonia, adult tuberculosis (TB), adult diabetes mellitus, and childhood malaria with anemia. Additionally, countries may choose to add specific vignettes and occasionally remove vignettes (such as in Kenya where the malaria with anemia vignette was not administered). These vignettes represent common clinical cases that a health care provider would face in the low- and middle-income country (LMIC) context. These diseases also reflect some of the highest burden conditions, making up 30% of all-age disability-adjusted life years (DALYs) in Sub-Saharan Africa.<sup>20</sup> Each provider is scored on the percent of vignettes for which they provide the correct diagnosis and treatment. Correct treatment is not made conditional on correct diagnosis, so providers may occasionally recommend the correct treatment without a correct diagnosis.

To shed further light on clinical capacity to address maternal and child health issues, the SDI includes two additional vignettes designed to assess providers’ responses to more urgent medical conditions: neonatal asphyxia and post-partum hemorrhage. Both of these conditions have a clear set of guidelines and recommended actions that the providers should undertake. For the purposes of scoring, providers are assessed on seven actions for neonatal asphyxia (calling for help, placing the baby in a neutral position, checking the baby’s heartrate, checking

> 15 Rao & Sheffel (2018). 16 Escamilla et al. (2018). 17 Das & Leonard (2006). 18 Peabody et al. (2000). 19 Das et al. (2008).

20 Diarrhea at 7.6% of DALYs, Malaria at 7.9%, Diabetes at 1.3%, lower respiratory infections at 8.7%, tuberculosis at 3.3% and anemia at 1.4%, based on IHME (2020).

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