Does Provider Effort Constrain Healthcare Quality? Evidence from Antenatal Care Visits in the Democratic Republic of Congo and Nigeria

Low quality healthcare provision may arise for at least three reasons: poor infrastructure, inadequate training, and a lack of effort. Using direct observations of first antenatal care (ANC) visits in 585 primary health centers in the Democratic Republic of Congo and Nigeria, we benchmark observed care against the WHO ANC protocol. Then, we estimate the share of consultations in which the providers know they should perform an action, have all needed equipment and supplies, and yet do not perform the necessary action. Low effort explains a third of observed under-performance, including in risk screening— for example, asking about complications in prior pregnancies— which does not entail supplies or equipment. Finally, we examine the correlates of effort provision to show that knowledge and experience are imperfect predictors of effort, and that, ceteris paribus, female providers outperform males. These results show that improving health outcomes may require policies eliciting greater provider effort to bolster infrastructure investments.