SERVICE NIGER DELIVERY Service Delivery Indicators INDICATORS HEALTH | MARCH 2017 Education | Health Niger’s sharp declines in neonatal and infant mortality since 1960s has raised the nation’s life expectancy at birth from 37 years in 1960 to 58.4 years in 2010 placing the country slightly above the Sub-Saharan Africa average of 54 years. Yet, mortality rates remain high and Niger’s maternal mortality exceeded that of most West African Economic and Monetary Union states in 2010. From October to November 2015 Service Delivery Indicator (SDI) health and education surveys were conducted in Niger to assess the service delivery and the environment in which the services are delivered. In health, 256 facilities, including district hospitals, health centers, and health posts participated in the survey. Information was gathered from 1,355 health providers in public and private and rural and urban settings to give a picture of care in Niger. The objectives of the Service Delivery Indicator survey are: (i) To access the quality, effectiveness and productivity of service delivery in frontline services; and (ii) To track the flow of resources and assess the functioning of management, supervision and governance of service delivery. This Technical Brief focuses on the first objective. Highlights Service Delivery Indicators in the Health Results Chain Input availability Input Availability Health Providers Health Outcomes On average, health facilities in Niger §§ ■ Average Absence had half of the tracer drugs1 available. Rate 33% Tracer medications for children were ■ Diagnostic generally more available than those Accuracy 27% for mothers. ■ Adherence to Urban public facilities had 22 percent §§ ■ Infrastructure 13% guidelines 17% ■ Maternal Mortality 554/100k ■ Caseload 9.8 patients a day ■N greater availability than rural public ■M  inimum Equipment 36%  eonatal Mortality 27/1,000 ■ Managing maternal and ones and health posts averaged ■ Drug Availability 50% ■S  killed birth attendance 20% neonatal complications 12% lower tracer drug availability than hospitals (note: rural locations in Niger do not have hospitals). Availability of vaccines, estimated at 45 percent nationally, §§ §§On average, health providers in Niger saw 9.8 outpatients was hindered by the lack of PCV10 and tuberculosis 2 per provider-day. Public facilities had almost twice higher vaccines, which were available in 55 and 72 percent of volumes than private facilities. Hospitals had significantly facilities, respectively. less (1.0) patients per provider-day than health posts (6.1) Approximately one in two health facilities in Niger had §§ or clinics (17.2). functional basic equipment , such as with the lowest levels Provider knowledge 3 observed in health posts. Urban public facilities were 86 percent more likely to have all equipment than rural public §§On average, health providers in Niger correctly diagnosed facilities. less than two out of the five tracer conditions (32%). The Less than a quarter of the facilities had required infrastructure §§ tracers include three childhood illnesses (malaria with such as safe drinking water, functional sanitation, and anemia, pneumonia, and diarrhea with severe dehydration) power available on the day of the survey. Private providers and two adult illnesses (pulmonary tuberculosis and were twice as likely to have safe drinking water, functional diabetes mellitus). sanitation, and power simultaneously available. § Private providers did more than twice as well as public § providers at identifying diabetes mellitus, but failed entirely Provider effort to diagnose acute diarrhea with severe dehydration. Health One third of health workers were observed to be absent per §§ posts were uniformly the worst. day, with higher absence rates recorded in public facilities §§On average, only 12 percent of the necessary clinical than private ones. Staff in health centers were 1.8 times actions to manage immediate post-partum hemorrhage more likely to be absent than those in health posts. and neonatal asphyxia were taken by providers. 1 Tracer drugs are WHO 14 essential medicine comprised of oxytocin, misoprostol, sodium chloride, azithromycin, calcium gluconate, cefixime, magnesium sulfate, benzathine benzyl- penicillin powder, ampicillin powder, betamethasone or dexamethasone, gentamicin, nifedipine, metronidazole, medroxyprogesterone acetate (Depo-Provera), iron supplements, and folic acid supplements. Not sure we need this detail here if we can point to the web site? 2 Vaccine used to protect infants, young children, and adults against disease caused by the bacterium Streptococcus pneumoniae (pneumococcus). 3 The equipment expected in all facilities is a weighing scale (adult, child or infant), a stethoscope, a blood pressure cuff, and a thermometer. This brief was prepared by Raihona Atakhodjayeva, Operations Analyst with guidance from Christophe Rockmore, Senior Economist (The World Bank) When presented with a patient who was pregnant §§ (25 percent). Even without considering refrigerators or and moderately anemic, less than one percent of sterilizing equipment, there were gaps in the availability providers diagnosed the anemia, while almost all of basic items such as a scale (81 percent of facilities; 74 providers diagnosed the pregnancy. Regionally, percent of health posts), blood pressure cuffs (58 per- providers in Tahoua were 9.5 percentage points cent of facilities, 44 percent of health posts, 83 percent more likely than those in Niamey to identify only the of health centers), and stethoscopes (69 percent, 56 per- pregnancy. cent, and 92 percent, respectively). Only thermometers Presented with a patient who had clear signs of pre- §§ (92 percent, 89 percent, 97 percent, respectively) were eclampsia, 11 percent of providers diagnosed the in relatively high supply. pre-eclampsia as being severe, although 50 percent Comparisons across public and private and within diagnosed the pre-eclampsia. public suggest that there was an urban bias. The major public-private distinction was in sterilizing equipment; private facilities were nearly four times as likely to have SDI Results sterilizing equipment. When looking within public facili- ties, urban ones were twice as likely to have a scale, 1.6 Availability of Key Inputs times as likely to have a sphygmomanometer, and 1.4 In the Niger health system, multiple types of facilities times as likely to have a stethoscope. However, among exist; of these the Health posts (case de santé), clinics health centers, urban facilities were less likely to have a (centres de santé intégré) and district hospitals (hôpi- refrigerator (0.7 times) and 2.2 times more likely to have tal de district) were included in the SDI survey popula- a sterilization device. tion. These facilities account for the nearly 87 percent of the health service utilization as reported in the 2014 household survey undertaken by the Institut National On average, only 13.3 percent of de la Statistique. The survey used a two-stage sampling strategy that allowed for disaggregation by geographic facilities in Niger had all three location (rural and urban) and by provider type (public and private). As a result, these findings provide an as- infrastructure items (electricity, sessment of the quality of service delivery and the envi- ronment in which the services are delivered in rural and water, and sanitation). urban locations, in public and private health facilities. Drugs. On average, health facilities in Niger had 50 per- cent of tracer drugs available. Rural public facilities had Infrastructure. On average, only 13.3 percent of facili- 22 percent less WHO tracer drugs available than urban ties in Niger had all three infrastructure items (electric- public facilities, which was driven by the different for ity, water, and sanitation). There were disparities across health centers (17 percent). Adjusting for level, health public-private and rural-urban breakdowns. Among posts had 42% less drug availability than first-level hos- health centers, all private facilities had electricity, while pitals, but health centers and hospitals had the same 57 percent of public ones had it. Among public facili- availability. There were more drugs for mothers (20 per- ties, urban ones had far more infrastructure than rural cent) and children (19 percent) in urban public than in ones, even among health centers. Public health centers rural public facilities. However, there was no significant were approximately 82 percent more likely to have elec- difference among public and private facilities. tricity and 23 percent more likely to have clean water Equipment. Nationally, 36 percent of facilities had all than their rural comparators. equipment evaluated simultaneously. Hospitals had Communication. Almost all facilities had a functional more than health posts (66 percent) or health centers phone available (93 percent), with no significant dif- ferences across public and private facilities or public FIGURE 1. Infrastructure Availability (percent) facilities in rural and urban. There were differences in availability of functional phones by level: 94 percent 79.1 79.1 of health posts had a functional phone, 91 percent of health centers, and 100 percent of hospitals had one. 60.1 Private facilities were 13 times more likely (31 percent) 48.2 to provide phone credit to a private phone. 30.8 Computers were generally not available, with 17 per- 26.2 cent of facilities reporting a computer and 15 percent 2.5 2.5 reporting a functional computer. There were no sig- nificant differences among public and private facilities Public Private Rural public Urban public in the availability of computers in general, although Health post Health center Hospital facility-owned computers were 10 times as likely to be functional in private facilities. Across facility levels, the 2 NIGER SERVICE DELIVERY INDICATORS ■ HEALTH FIGURE 2. Breakdown of Reasons for Absence (percent) FIGURE 3. Tracer Conditions Diagnostic Accuracy (percent) 83.2 Medical Medical Leave Leave Training/Seminar Training/Seminar 61.6 O O Business cialcial Business Leave Leave 32.1 Unauthorized Unauthorized Collect Collect Salary Salary 5.4 7.3 Strike Strike Diarrhea Pneunomia Malaria Pulmonary Diabetes Other Other with severe with anemia tuberculosis mellitus dehydration (type 2) patterns were consistent for presence or functionality: absence were annual leave (41 percent) and medical 5 percent of health posts, 32 percent of health centers leave (26.5 percent). and 98 percent of hospitals, respectively, had functional Absence from facilities is correlated with remoteness, computers. facility type and total staff, workload and peers, and Internet access was generally unavailable (4 percent) managerial influence. Facilities requiring means of and non-functional when available (3 percent). There transport such as boats/animals were more associated was no significant difference in functional internet with absence. Hospitals were positively associated with across public and private facilities. Public urban facilities absence compared to health posts. Caseload-adjusted (21 percent) were 20 times as likely to have functional workload (0.2) and peer absence (0.2) had the same ef- internet as rural public facilities. Functioning internet ac- fects. Finally, when the manager provided negative or cess is correlated with facility type: 0 percent of health positive feedback, it had an impact. Interestingly, given posts, 4 percent of health centers, and 95 percent of the significant positive correlation in nearly all other cas- hospitals, respectively, had such service. es including education in Niger, the absence of the head was not significantly related to the absence of staff. Provider Ability: What providers know? The average absence-adjusted The SDI survey assessed provider ability and knowledge using two process quality indicators (the adherence caseload in the public sector was to clinical guidelines in five tracer conditions, and the management of one maternal and one neonatal com- plication), and an outcome quality indicator (diagnostic 9.8 patients per provider per day. accuracy in five tracer conditions). Provider ability and knowledge. Having health pro- fessionals present in facilities is a necessary but insuffi- Provider effort: What providers do? cient condition for delivering quality health services. For this reason, two process quality indicators (the adher- Caseload. Health centers provide the majority of care in ence to clinical guidelines in five tracer conditions and Niger at over 74 percent rate. Consistent with a rural popu- the management of maternal and newborn complica- lation, more care is provided in rural than in urban areas. tions) and an outcome quality indicator, diagnostic ac- The public sector provides the majority of its care in the curacy, in five tracer conditions were used to evaluate rural areas, consistent with the population distribution. providers. Very little care is recorded as being provided in hospitals. Provider ability to recognize conditions that repre- The average absence-adjusted caseload in the public sent a high burden of overall disease was limited. sector was 9.8 patients per provider per day. The SDI On average providers diagnose 1.5 out of the five tracer data for Niger suggests that a large share of health pro- conditions (31.5 percent), primarily pulmonary tubercu- viders, especially those in moderately sized facilities, had losis and pneumonia. Of particular concern are the very very low caseload levels. low rates of diagnosis of the severity of dehydration and Absence rate. One third of Niger’s health workers were anemia. The data suggest that providers do not ask suf- absent on a given day. The providers least likely to be ficient questions, nor the most medically-relevant ones. absent were the public providers in health posts (19 per- Management of life-threatening maternal and cent). There was little variation across rural and urban or neonatal complications. The second process quality public and private. indicator is clinicians’ ability to manage maternal and The overwhelming majority—nearly 82 percent—of neonatal complications. This indicator reflects the pro- all absences were approved. The primary reasons for portion of relevant treatment actions proposed by the NIGER SERVICE DELIVERY INDICATORS ■ HEALTH 3 Special topics: first ante-natal care visit FIGURE 4. Diagnostic and Treatment Accuracy and severe pre-eclampsia. (percent providers) At the request of the Ministry of Health in a country with the world’s highest total fertility rate (7.6 births/woman), Diagnose 31.1 two simulations related to pregnancy were designed 38.7 specifically for Niger.4 Partial treatment 11.5 First ante-natal care visit. This vignette simulated 14.6 the initial visit by a woman who was pregnant for the first time and had mild anemia. On average almost no Full treatment 1.5 providers recognized both elements, although nearly 2.4 92 percent of providers diagnosed the pregnancy. Public providers did better than private providers for Public Private danger signs, key questions, physical examinations, and care. However, public providers were more likely clinician. Except for medical officers in rural public fa- to diagnose a pregnancy without anemia than private providers. Providers in Tahoua were 9.5 percentage cilities, provider adherence to guidelines is always low- points more likely than those in Niamey to identify er than those of the tracer conditions. Midwives, who only the pregnancy. are specialized in family planning and obstetric-related care, almost always perform at the level of doctors or Severe pre-eclampsia. This vignette simulated the better. The only exception is examinations in the case visit by a woman in the final weeks of pregnancy with of neonatal asphyxia, however midwives’ diagnostic signs of hypertension. On average, 11 percent of provid- rate (91 percent) is 11 percentage points higher than ers recognized the condition. Public providers did better doctors (closest second) and generally more than 20 than private providers for physical and clinical examina- tions, and care. Among public providers, urban ones percentage points better than other provider catego- did better than their rural counterparts on physical and ries. Although adherence was generally low by facility clinical examinations, and diagnoses in general. Overall, type, it was 28 percent lower in health posts than in the recognition of the problem remains low. Providers hospitals. in other regions did worse than Niamey. For example, Process quality was also found to progressively decline the rate of correct diagnosis was 15 percent in Maradi, 6 by cadre type and by facility level. Only 2 percent of the percent in Tahoua, and 12 percent in Zinder. Overall, the providers adhered to at least 75 percent of the guide- recognition of pre-eclampsia without consideration of lines. Using a lower threshold of 50 percent adher- the severity, was still significantly different from Niamey ence, 93 percent of the providers who found all 5 cases in Maradi (42 percent), Tahoua (45 percent), and Zinder reached the threshold. For post-partum hemorrhage (46 percent). and neonatal asphyxia, only 13 percent of the providers who found both cases adhered to at least 50 percent Leadership, management and incentives of the guidelines. Regression results confirmed that Leadership and management: facility heads are the knowledge of the questions to ask and their interpreta- ministry’s first supervision agents and are most directly tion was essential: providers that indicated they would able to monitor service delivery. However, most facility perform a skin pinch are 26 percent more likely than heads did not report using incentive methods, whether average to diagnose severe dehydration. positive (34 percent used them) or negative (18 per- cent). Private facility heads were more than twice as likely to cite or use positive incentives and 4 times as likely to cite negative incentives. FIGURE 5. Use of Incentives by facility heads, by ownership in health centers (percent) Supervision: providers received a visit per quarter on average, with larger teams in urban public than in rural 62 62 public facilities (three versus two people). There was 48 50 48 greater use of supervision worksheets in private versus 45 public facilities (63 percent) and in urban relative to 40 34 rural among public facilities (40 percent more preva- 29 26 lent). Among supervision teams, disease focal points 24 22 18 20 19 were most likely to use supervision tools, to review 13 7 6 7 staff presence, and to examine medical stocks, but not 0 0 0 0 0 0 more likely to leave written comments. The focus on Niger Public Private Rural Public Urban Public quality of care decreased rapidly as the facility level decreased from all at the hospital level to 55 percent Any positive incentive cited Any positive incentive used Promotion cited in health centers and 19 percent in health posts. More Promotion used Any negative incentive cited 4 Demographic and Health Survey 2012. 4 NIGER SERVICE DELIVERY INDICATORS ■ HEALTH generally, quality of care was a greater focus for private to be done in other areas such as adherence to guide- facilities (87 percent) than public ones (38 percent). lines, diagnostics, and provider absence. Community engagement: the functioning of the fa- Regardless of the cause, the lack of basic inputs, such as cility management committee (COGES), as measured refrigerators and sterilization equipment, and the lack of by the presence of meeting minutes varied significant- electricity make it difficult for health personnel to pro- ly; nearly 40 percent of public facilities did not have vide appropriate care. minutes compared to zero percent of the private fa- cilities. Rural public facilities were more than twice as Provision of care is hindered by the overall level of likely as urban public facilities to not have minutes of ability to properly handle the various cases remains a the last meeting. concern. In addition, the gap between those formally trained and trained on the job, particularly for adult What does this mean care, is a further cause for concern. The overall level of skills in the management of maternal and neona- for Niger? tal complications is in line with the burden of mortal- The situation in Niger is generally worse than in other ity (535 deaths per 100,000 pregnancies; DHS 2012). countries that have done SDI. Niger ranks in the top Niger’s performance in diagnostic accuracy, adherence half of the table for caseload (third) and drug avail- to guidelines, and the management of maternal and ability (fourth). Niger ranks seventh for equipment and child health complications places it near the bottom of drug availability, eighth for diagnostic accuracy and the table for SDI countries. management of maternal and neonatal complications, and ninth (last) for adherence to clinical guidelines Human resource availability is a challenge, with a 33 and infrastructure availability. While there are concerns percent national absence rate. This is 2.23 times higher across the board, drug availability, which is such a than in primary education, where teachers were ab- concern for providers and communities is apparently sent from school 15 percent of the time using the same relatively well-handled in Niger. There is perhaps more methodology. At-a-Glance TABLE 1: SDI Health Indicators by Geographic Area: Ability, Efforts and Inputs Across Countries NIGER Tanzania Kenya Senegal Tanzania Uganda Togo Nigeria Mozambique 2015 2014 2013 2010 2010 2013 2013 2013 2014 What providers do (effort provider) Caseload 9.8 7.3 15.2 – – 6.0 5.2 5.2 17.4 (per provider per day) Absence from facility 33.1 14.3 27.5 20 21 46.7 37.6 31.7 23.9 (% providers) What providers know (provider ability) Diagnostic accuracy 26.9 60.2 72.2 34 57 58.1 48.5 39.6 58.3 (% clinical cases) Adherence to clinical 17.4 43.8 43.7 22 35 41.4 35.6 31.9 37.4 guidelines (% clinical cases) Management of maternal and neonatal complications 12.0 30.4 44.6 – – 19.3 26.0 19.8 29.9 (% clinical cases) What providers have to work with (availability of inputs) Drug availability 50.4 60.3 54.2 78 76 47.2 49.2 49.2 42.7 (% drugs) Equipment availability 35.9 83.5 76.4 53 78 21.9 92.6 21.7 79.5 (% facilities) Infrastructure Availability 13.3 50.0 46.8 39 19 63.5 39.2 23.8 34.0 (% facilities) NIGER SERVICE DELIVERY INDICATORS ■ HEALTH 5 TABLE 2: SDI Health Indicators by Geographic Area: Ability, Efforts, and Inputs Across Niger Indicators NIGER Public Private Rural Public Urban Public Caseload 9.8 10 4.6 10.1 8.6 (per provider per day) Absence from facility 33.1 33.3 30.7 31.1 34.0 (% providers) Diagnostic accuracy 26.9 26.5 32.8 26.0 27.5 (% clinical cases) Adherence to clinical guidelines 17.4 17.3 20.0 17.2 17.4 (% clinical cases) Management of maternal and neonatal complications 12.0 12.1 11.0 12.2 11.9 (% clinical cases) Drug availability 50.4 50.4 50.0 49.3 66.6 (% drugs) Equipment availability 35.9 35.9 35.8 33.3 74.3 (% facilities) Infrastructure availability 13.3 10.7 62.3 8.0 51.8 (% facilities) 6 NIGER SERVICE DELIVERY INDICATORS ■ HEALTH Annex. Definition of the Health Service Delivery Indicators Caseload per health provider Number of outpatient visits per The number of outpatient visits recorded in outpatient records in the three months prior to the survey, divided by the clinician per day. number of days the facility was open during the three-month period and the number of health professionals who conduct patient consultations (i.e. excluding cadre-types such as public health nurses and out-reach workers). Absence rate Share of a maximum of 10 randomly Number of health professionals that are not off duty who are absent from the facility on an unannounced visit as a selected providers absent from the share of ten randomly sampled workers. Health professionals doing fieldwork (mainly community and public health facility during an unannounced visit. professionals) were counted as present. The absence indicator was not estimated for hospitals because of the complex arrangements of off duty, shifts etc. Diagnostic accuracy Average share of correct diagnoses For each of the following five clinical cases: (i) acute diarrhea; (ii) pneumonia; (iii) diabetes mellitus; (iv) pulmonary provided in the five clinical cases. tuberculosis; (v) malaria with anemia. For each clinical case, assign a score of one as correct diagnosis for each clinical case if diagnosis is mentioned. Sum the total number of correct diagnoses identified. Divide by the total number of clinical cases. Where multiple diagnoses were provided by the clinician, the diagnosis is coded as correct as long as it is mentioned, irrespective of what other alternative diagnoses were given. Adherence to clinical guidelines Unweighted average of the share For each of the following five clinical cases: (i) acute diarrhea; (ii) pneumonia; (iii) diabetes mellitus; (iv) pulmonary of relevant history taking questions, tuberculosis; (v) malaria with anemia. History Taking Questions: Assign a score of one if a relevant history-taking the share of relevant examinations question is asked. The number of relevant history taking questions asked by the clinician during consultation is performed. expressed as a percentage of the total number of relevant history questions included in the questionnaire. Relevant Examination Questions: Assign a score of one if a relevant examination question is asked. The number of relevant examination taking questions asked by the clinician during consultation is expressed as a percentage of the total number of relevant examination questions included in the questionnaire. For each clinical case: Unweighted average of the: relevant history questions asked, and the percentage of physical examination questions asked. The history and examination questions considered are based on the Nigeria National Clinical Guidelines and the guidelines for Integrated Management of Childhood Illnesses (IMCI). Management of maternal and neonatal complications Share of relevant treatment actions For each of the following two clinical cases: (i) post-partum hemorrhage; and (ii) neonatal asphyxia. Assign a proposed by the clinician. score of one if a relevant action is proposed. The number of relevant treatment actions proposed by the clinician during consultation is expressed as a percentage of the total number of relevant treatment actions included in the questionnaire. Management of maternal and neonatal complications Share of relevant treatment actions For each of the following two clinical cases: (i) post-partum hemorrhage; and (ii) neonatal asphyxia. Assign a proposed by the clinician. score of one if a relevant action is proposed. The number of relevant treatment actions proposed by the clinician during consultation is expressed as a percentage of the total number of relevant treatment actions included in the questionnaire. Drug availability Share of basic drugs which at the Priority medicines for mothers: Assign score of one if facility reports and enumerator confirms/observes the facility time of the survey were available at has the drug available and non-expired on the day of visit. The list of priority drugs can be accessed from the the health facilities. Technical report. The aggregate is adjusted by facility type to accommodate the fact that not all drugs (injectables) are expected to be at the lowest level facility, dispensaries/health posts where health workers are not expected to offer injections. Equipment availability Share of facilities with Assign score of one if enumerator confirms the facility has one or more functioning of each of the following: thermometer, stethoscope and thermometers, stethoscopes, blood pressure cuffs, and a weighing scale (adult, child, or infant weighing scale) as weighing scale, refrigerator and defined below. Health centers and first level hospitals are expected to include two additional pieces of equipment: sterilization equipment. a refrigerator and sterilization device/equipment. Infrastructure availability Share of facilities with all three Infrastructure aggregate: Assign score of one if facility reports and enumerator confirms facility has electricity and items: electricity and water and water and sanitation as defined. Electricity: Assign score of one if facility reports having the electric power grid, a sanitation. fuel operated generator, a battery operated generator or a solar powered system as their main source of electricity. Water: Assign score of one if facility reports their main source of water is piped into the facility, piped onto facility grounds or comes from a public tap/standpipe, tube well/borehole, a protected dug well, a protected spring, bottled water or a tanker truck. Sanitation: Assign score of one if facility reports and enumerator confirms facility has one or more functioning flush toilets or VIP latrines, or covered pit latrine (with slab). NIGER SERVICE DELIVERY INDICATORS ■ HEALTH 7 About the SDI surveys The SDI survey was conducted between October and December 2015. The fieldwork involved collecting information from 256 health facilities, which included district hospitals, health centers and health posts, and 1,355 health providers. The results provide a representative snapshot of the quality of service delivery and the physical environment within which services are delivered across different settings of care, ranging from public and private facilities, and facilities located in rural and urban settings. The survey provides information on three dimensions of service delivery: measures of (i) provider effort; (ii) provider knowledge and ability; and (iii) the availability of key inputs, such as drugs, equipment and infrastructure (such as availability of sanitation, quality of lighting in classrooms, etc.). Niger is the tenth country where SDI surveys have been implemented, the other being: Tanzania, Senegal, Tanzania, Uganda, Nigeria, Togo and Madagascar. This allows for comparison across countries and benchmarking country performance. The Service Delivery Indicators (SDI) Program The SDI initiative is a partnership of the World Bank, the African Economic Research Consortium (AERC), and the African Development Bank to develop and institutionalize the collection of a set of indicators that would gauge the quality of service delivery within and across countries and over time. The ultimate goal is to sharply increase accountability for service delivery across Africa, by offering important advocacy tools for citizens, governments, and donors alike; to work toward the end goal of achieving rapid improvements in the responsiveness and effectiveness of service delivery. More information on the SDI survey instruments and data, and more generally on the SDI initiative can be found at: www.SDIndicators.org and www.worldbank.org/SDI, or by contacting SDI@worldbank.org. © 2017 International Bank for Reconstruction and Development / The World Bank Group 1818 H Street NW Washington DC 20433 Telephone: +1 202-473-1000 Internet: www.worldbankgroup.org This work is a product of the Service Delivery Indicators initiative (www.SDIndicators.org, www.worldbank.org/SDI) and the staff of the International Bank for Reconstruction and Development/The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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