Does high workload reduce the quality of healthcare? Evidence from rural Senegal

Abstract: There is a widely held perception that staff shortages in low and middle-income countries (LMICs) lead to an excessive workload, which in turn has a negative effect on the quality of healthcare delivered. Yet there is little empirical evidence supporting these claims. We use data from nearly 200 public health facilities visited by undercover standardised patients in rural Senegal to determine the causal effect of workload on the quality of care. We exploit quasi-random variation in workload created by the study design and use an instrumental variable approach. We find that despite a lack of staff, levels of workload are low, as providers spend no more than two hours a day consulting patients. Even at times when workload is high, we do not find evidence suggesting that a higher workload reduces provider effort or the quality of healthcare. Our findings are consistent with the notion that providers operate below their production possibility frontier and have ample capacity to attend more patients without compromising quality. This contradicts the prevailing discourse that staff shortages are a key reason for poor quality care in LMICs and suggests that we need to look elsewhere for an explanation.