This study describes and evaluates the strategies developed and implemented by the Ministry of Public Health in Ecuador to spread continuous quality improvement (CQI) and best care practices for essential obstetric and neonatal care (EONC) throughout the country. The first phase of this initiative began in 2003 with 14 health care facilities ranging from health centers to hospitals; new facilities were added over time. Drawing on these experiences, the Ministry of Health with technical support from HCI compiled and published conclusions on best care practices in 2007-2008 in preparation a spread phase to 51 facilities with no prior formal involvement beginning in 2009. The study compares the demonstration and spread phases; and presents data collected to monitor, evaluate and stimulate improvement. This study investigated three questions:

1)         What processes were implemented to introduce and spread CQI and best care practices?

2)         Did these processes lead to greater coverage, more rapid compliance (rates of spread) at lower costs (resources used) over time? 

3)         What was the effectiveness (best practices) and cost-effectiveness of spread compared with the demonstration phases?