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Africa, Sub Saharan

  • Health facility factors associated with improvements in the quality of HIV/AIDS care at health facilities in Uganda | Publications

    Several factors are associated with HIV patient enrollment, retention in ART care and treatment outcomes. These factors can broadly be categorized into patient and health facility factors. To improve the quality of HIV care services at health units, there is need to account for the modifiable and fixed characteristics of the health units. This study investigated the relationship between characteristics of the facility and the changes in quality of care indicators in the context of an intervention to improve services delivered in the facilities.

    This was a quantitative pre/post intervention study to identify facility factors associated with improvements achieved at health facilities participating in quality improvement activities. Improvements in service delivery were measured by comparing performance on some indicators collected at the start of the intervention to the endline measures (six month later) on the same indicators. Data on health facility characteristics were collected using a standard questionnaire administered to health unit in-charges and heads of HIV clinics. Simple descriptive statistics were used to define characteristics of the health facilities while health facility factors associated with the quality of HIV/AIDS care were obtained through univariate linear and logistic regressions.
    A total of 45 health facilities were involved in improvement activities for at least six months and these were predominantly rural. Most facilities had separate HIV clinics but only a third had a dedicated HIV clinical team. At the outpatient department, the patient to staff ratio was 576:1 with an average 6.7 clinical staff members working on an HIV clinic day. There were no statistically significant associations between the region a facility was located in or the type of facility and any measure of performance in indicators. Health facilities located in rural areas perform slightly better than those in urban areas and clinics with more medical officers were worse at having patients adhere to clinic appointments (OR 0.38: P= 0.042). Other significant findings were that facilities with higher clinic staff members per clinic day did worse on indicator 1 (OR 0.79; P = 0.041) as did facilities with CD4 testing facilities (OR 0.32; P = 0.084).
    Conclusions and Recommendations

    The study found very few significant associations between characteristics of the participating facilities examined in this study and their performance in the improvement intervention. The variation in improvements seen in clinics may be due more to other characteristics of the facilities not measured, such as the types of patients they serve. Based on our findings, we recommend that facilities working to improve performance in service delivery focus on changing factors identified as causes of deficits in quality independent of considerations of the immutable characteristics of their facility. Any future study on this topic should take into account patient factors because patients with certain characteristics associated with HIV treatment indicators might be unevenly distributed among the facilities.

    A final version of this study will be avaible soon.


  • Cross-sectional examination of service delivery and costs of community- and home-based care in Tanzania | Publications

    This baseline evaluation in the Tanga District of Tanzania will evaluate the current scope of Home-Based Care (HBC) services and associated roles and responsibilities across stakeholders to inform the development of a framework and standard operating procedures for the HBC program.

    This baseline evaluation will address six questions:
    1.      How has the widespread provision of ARVs changed the scope and mandate of HBC in Tanzania?
    2.      What is the current scope of HBC services that are being provided?
    3.      How have changes brought by the provision of ARVs affected the relationships and roles of NGOs in providing services to PLWA?
    4.      What are the expectations of patients, health workers and the MOH of the HBC standards of practice? (What are the essential services that should be provided?)
    5.      What are the deficiencies in the current HBC practices?
    Answering these questions will inform the development of a framework and standard operating procedures (SOP) for HBC in Tanzania. SOPs are written procedures, based on national HBC guidelines, which will provide a detailed description of processes or steps to be followed in performing specific tasks (both clinical and non-clinical) related to delivery of particular healthcare interventions. The goal for developing SOPs for HBC is to provide guidance to providers and managers in the field on procedures for effective and efficient implementation of quality HBC services in line with the National HIV and AIDS Quality Improvement Guidelines and current best practices in the National HBC Guidelines.
    This will be a prospective cross-sectional study that examines HBC from the perspective of the three principle components of the health system: the providers, patients, and implementing partners. Both quantitative and qualitative data collection methods will be used. In-depth interviews will be the primary source of information. Quantitative data will be collected on the demographic and health characteristics of patients and HBC workers and details of the home visit (frequency, time taken, services provided, support needed, etc). Qualitative data sought include expectation and perceptions of HBC services from all perspectives, the important components of HBC, and the main perceived problems facing the delivery of HBC service as identified by HBC workers, implementing partners and patients. Furthermore, through discussions with all stakeholders suggestions on how to practically improve quality and optimize the functioning of the HBC system will be collected.


  • Comparative Study to Assess the Impact of Collaborative Improvement on Customer Satisfaction, Provider Satisfaction, and Services for PLWHA | Cote d'Ivoire | Publications


    The National Program for Medical Management of People Living with HIV (PNPEC), the Ministry of Health and Public Hygiene, the USAID Health Care Improvement Project (HCI), and several other partners have been implementing a collaborative approach to improve the quality of HIV services in Cote d'Ivoire since 2009. This collaborative approach was conducted in two phases: a demonstration from January 2009 to March 2010 in 41 sites and an expansion phase which added and additional 80 sites and began in May 2010. Before the introduction of HCI project, a baseline assessment was conducted in pilot sites in 2008, which revealed significant opportunities to improve different components of HIV care, including in the areas of ​​customer and provider satisfaction.

    The overall objective of this cross-sectional study is to measure the effect of the HCI-supported collaborative to improve the quality of services for PLWHA on client satisfaction, provider satisfaction, and HIV services. The study will include an exposed group and an unexposed group. Pilot sites that participated in the collaborative improvement effort will be included in the exposed group and sites that received no quality program will be counted among the non-exposed group.


  • Adaptability of better care practices to improve HIV/AIDS care as they spread across sites in Uganda | Publications

    26 facilities in the Northern Region of Uganda are participating in the collaborative improvement effort implementing the ART Framework. This study aims to understand how best practices to improve HIV/AIDS care are modified and adapted as they are spread across and implemented at these various sites, which are free to choose which changes they wish to apply and to modify those changes to suit their needs. This study will identify best practices that are being spread throughout the facilities and gather details of the implementation of specific changes. Tentatively, the following three practices will be studied: 1) giving 2-3 months supply of ARVs to adherent patients to improve retention, 2) pre-packaging medicines to reduce waiting time and ultimately improve coverage and clinic efficiency, and 3) using a screening tool for detecting tuberculosis in HIV/AIDS patients to improve clinical outcomes. The study will look at best practices that are implemented by five or more of the 26 participating facilities in order to understand how that change is modified across different sites.


  • Spread of better care practices to improve coverage, retention and outcomes of patients receiving ART care in resource-limited settings | Uganda | Publications

    The collaborative model of quality improvement (QI) aims at testing and implementing QI interventions on a small scale, synthesizing the most robust and effective changes, and spreading them at scale. An improvement collaborative not only generates improvements in the quality of care delivered in these initial sites, but also develops organizational learning. However, there still exist knowledge gaps on how to successfully spread evidence practices and ensure up-take and continuous application of these practices in resource-limited settings.

    The objective of this descriptive, prospective study is to gain a better understanding of how better care practices identified from demonstration collaboratives can be spread to and embraced by new sites at scale. By studying spread, future improvement collaboratives will have a better understanding of factors affecting uptake and continuous application of better care practices identified in demonstration collaboratives, and how to introduce such practices to spread sites.
    This study will focus on four research questions:
    ·         What processes need to be implemented to introduce and ensure spread of better care practices to the new sites? And how can these be improved?
    ·         Which best practices spread to new sites?
    ·         What factors (including resources) facilitated or hindered the uptake of the better care practices?
    ·         Did these practices lead to better coverage, better retention and better outcomes for ART patients in the new sites?
    Data for this study will be collected from the 19 facilities in the Eastern region.



  • Patient involvement in quality improvement activities at HIV/AIDS clinics in Uganda | Publications

    Quality improvement is becoming an important component of health care world over and there is growing recognition in the literature of the contribution patients can make to improving health outcomes (Coulter 2007, Groene 2005). Given the increasing prevalence of chronic illnesses, there is a need to have patients play an active role in their health care. This study will examine the extent to which selected interventions successfully engaged clients and providers together in quality improvement activities (problem identification, problem analysis, solution identification, and testing and implementing changes) in HIV/AIDS care clinics (in comparison to control clinics) in Uganda, and what health care providers’ and clients perceptions are on clients’ active participation in the process.

    Since 2007 the USAID Health Care Improvement (HCI) project and the Ministry of Health-Uganda have been implementing collaborative quality improvement activities in Uganda to improve the quality of service offered to clients attending HIV care clinics. Findings from a preliminary assessment revealed that clients are minimally involved in quality improvement activities at the facility-level. To address this, HCI is supporting an intervention to promote client involvement.

    This pre/post qualitative evaluation will include six intervention and six control sites. HCI coaches will provide feedback to the intervention sites and present to them a selection of interventions to increase client involvement. Sites will be invited to select the interventions that best suit their facility’s needs and resources.


  • Improving enrolment of HIV+ pregnant women in chronic HIV care/ART units at health facilities in Uganda | Publications

    HCI is working on improving the linkage of HIV+ pregnant women to chronic HIV/PMTCT services in 19 health facilities in the Eastern region of Uganda. Quality improvement teams at these sites will test changes aiming to improve these linkages. The effectiveness of these changes will be monitored by selected indicators. Changes that are found to be successful based on monitoring the indicators will then be shared across all 19 facilities. It is expected that by the end of the demonstration period there will be a list of effective changes that can then be spread to more facilities across Uganda.

    Research Questions
    This cross-sectional pre/post evaluation seeks to evaluate the scale of linkage problems, identify their causes, and inform health facility interventions to improve the linkages between ANC and chronic care for HIV+ mothers. The specific study questions are:
    1.      What proportion of HIV+ pregnant women registered in ANC units at health facilities are enrolled into chronic HIV care units?
    2.      What mechanisms do the health facilities use to ensure successful linkage of HIV+ pregnant women to HIV care clinic?
    3.      What factors do pregnant or recently (6 months) delivered women report that promoted their successful enrollment into chronic care from ANC units?


  • Evaluation of a Community Health Worker Improvement Collaborative in Ethiopia | Publications

    Ethiopia’s Health Extension Program (HEP) works to improve access to and utilization of care, recognizing that a major factor underlying the poor health status of the country’s population is the lack of physical access to health services. The program has deployed more than 30,000 frontline community health workers in health posts in rural communities across Ethiopia where they deliver services in four major areas. Health posts are expected to be staffed by two female Health Extension Workers (HEWs), women nominated by their communities and receive one year of training in public health, hygiene, health promotion, and certain interventions. Oversight, training, and support of HEWs are provided by Health Centers. HEWs train and supervise at least one volunteer Community Health Worker (vCHW) to provide health education and promotion services as well as make referrals.

    To date, the HEP has resulted in encouraging achievements such as access to sanitation, increased immunization, family planning, malaria services, and cost-effective DOTS programs (Datiko and Lindtjorn, 2010). The success of the program can be linked to key factors including political commitment of both health and political stakeholders and local ownership by communities and local political bodies. However, studies have shown that the HEP requires improvement in certain areas of management and health services such as supportive supervision from the Woreda level (Negusse et al., 2007), supplies of drugs and equipment, a well established referral and follow-up system, good transportation and communication systems, and in-service refresher training (Haines et al., 2007). The absence of these factors has placed limitations on the effectiveness of HEP and the performance of HEWs and vCHWs.

    HCI is supporting a community health system strengthening approach to address these issues.
    The objectives of the HCI Community Health Worker Improvement Collaborative are to: improve the competence and performance of HEWs; strengthen the linkage between the community and the health system; and improve the capacity of community groups to take ownership of health programs in their catchment areas and establish a community health system.
    With these program objectives in mind, this mixed-methods study aims to document and evaluate the process of strengthening a community health system and the impact this has on HEW activities. This study will be conducted in the southwest Shoa region of Ethiopia and will focus on HIV/AIDS, specifically referring pregnant women to the health center for HIV counseling and testing.
    The specific study questions are:
    1.      How have quality improvement methods impacted the competence and performance of the HEWs in referring pregnant women for HIV counseling and testing?
    2.      Has the linkage between the community and the health system been strengthened? If so, how?
    3.      Has a community health system been established and/or strengthened? If so, how does it function?
    4.      How do improvement methods impact the function of the components and management of the community health system?
    A complementary, but separate, study on the cost-effectiveness of the Community Health Worker Improvement Collaborative will also be conducted.


  • Comparison of Coaching Strategies for Improvement Collaboratives in Ugandan HIV/AIDS Health Centres | Publications


    HCI has been implementing centrally organized collaborative improvement, with coaching provided by technical experts outside the MOH hierarchy, in 113 sites in Uganda to improve health care for patients with HIV/AIDS since 2006. In 2008, HCI introduced a district-based coaching strategy using MOH district management structures, as an alternative to centrally organized coaching, to facilitate sustainability of the approach and encourage its institutionalization and greater country ownership in the Ugandan health system.This study’s goal was to measure the relative efficiency and effectiveness of the two strategies in achieving improvements in process indicators.
    The study found that there were mostly very small improvements in quality indicators for both district and central strategy sites but these were generally not associated quality improvement team performance (QITP). There were some differences in QITP in four of 13 team indicators but no difference in improvements between district and central strategy sites. The district strategy was about 1/5th the cost of the Central strategy cost and therefore significantly more efficient. We therefore recommend the MOH use the district rather than the central strategy for more widespread interventions.
    HCI is preparing a manuscript for journal submission.


  • Tanzania | Tanga Region ART/PMTCT Improvement Collaborative | Collaborative Profile
  • Implementation of standards of service delivery for orphans and vulnerable children in Kenya: A prospective evaluation of performance, costs and equity | Publications

    Due to an increase in the number of children affected by HIV and AIDS in Kenya, efforts to provide services for orphans and vulnerable children have expanded quickly in recent years. Lately, stakeholders have realized more attention should be given to outcomes and service quality. To address this, seven implementing organizations were identified to participate in the piloting of standards for services to vulnerable children in four districts. This study evaluates the effectiveness, efficiency and equity of implementation of standards of service to vulnerable children, which are of particular interest to USAID and the government of Kenya.

    For this prospective cohort study, quantitative data were collected on changes to children’s status as measured by the Child Status Index (CSI) from the baseline period immediately prior to initiation of the intervention to the end line following six months of application of the new standards. This part included an examination of whether there were differences between the performance of boys and girls and between younger and older children. Qualitative data were gathered from interviews with key implementing partners on the effects of using the new standards on performance of vulnerable children service delivery. Cost data from the perspective of the funders, USAID and the implementing partners, were collected from the accounting records of the USAID HCI Project and its partners.
    The main study questions were:
    1. 1) Was there a difference in the welfare of children receiving services from participating community-based organizations as measured by the difference between baseline and end line CSI scores?
    2. 2) What was the incremental cost to the implementing partners and USAID / HCI of implementing the new standards?
    3. 3) What was the proportion of girls and boys enrolled in vulnerable children care in the participating sites?
    4. 4) Were there differences in the effectiveness of the service delivery in improving child welfare between boys and girls and between younger and older children?
    5. 5) As reported by coaches and QI team members, what were key activities, the progress seen, the challenges and the role of stakeholders in implementing the new standards of vulnerable children care?
    There were 381 children from five service providers who had baseline and end line CSI scores (59.3% boys, 40.7% girls). The average CSI scores at baseline for all children for the twelve individual sub-domains of the CSI were between 2.8 for food security and 3.3 for emotional health. Girls tended to have slightly higher baseline CSI scores than boys in all sub-domains except for abuse / neglect however, none of the differences were statistically significant. The only statistically significant difference in improvement was in improvements in abuse / neglect in which girls where one and a half times as likely to improve by a score of 1 than boys (P=0.007). End line CSI scores all increased from the baseline by a range of an average 0.55 for care to 0.19 for wellness. Improvements seen in younger children were statistically significantly higher is shelter, care, wellness, health care services, emotional health, social behavior and education.
    Written reports from the four implementing partners showed substantive changes in activities of delivering vulnerable children’s services which they attributed to their participation in the new standards piloting. Chief among these were improved communication with and participation by children and their caregivers, improved coordination among the implementers and other governmental and NGO service delivery partners and more active problem solving to meet the specific needs of the children. Challenges to achieving better performance included a drought which increased food insecurity and decreased income in many regions, and the high expectations from service recipients.
    The cost to the implementing partners for the nine months attributable to the piloting program was 14.47 KSh per child receiving services (US$ 0.16 per child). The total cost to the USAID / Health Care Improvement Project was 4,180,000 KSh ($ 46,470).      
    Conclusions and Recommendations
    The qualitative data showed that significant positive changes were seen by the implementers in the overall quality of the services delivered to children affected by HIV/AIDS and their caregivers. By this measure, the standards piloting was a success. The improvement seen in the CSI scores was positive and encouraging, particularly given the fact that a drought was significantly affecting the welfare of the populations in the area where implementation took place. However, in the absence of a control group for a valid comparison, it is unknown how much of the improvement was due to the new standards.
    On the strength of the qualitative evaluation of the program and the low additional cost to the implementing partners, expansion of the program is recommended. If done on a regional basis so that travel expenses for the new standards workshop, learning sessions and coaching visits could be minimized, the overall efficiency of the program would be substantially enhanced. Further research is necessary to determine exactly what proportion of the CSI improvements were due to the new standards and such an evaluation should be part of any scaling up of the program.


  • Feasibility of Proposed Quality Criteria for Monitoring and Improving HIV Services | Publications

    At the request of the Office of the Global AIDS Coordinator (OGAC), the United States Agency for International Development (USAID) and the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria (Global Fund), the USAID Health Care Improvement Project (HCI) developed an approach to yield meaningful information about the quality of HIV services for users at multiple levels of the health system. The approach proposes 16 quality criteria (QC) that were assessed through 25 existing indicators. The indicators were based on measures previously required or recommended by funders and other stakeholders, such as the Global Fund, PEPFAR, and the World Health Organization. This report presents the findings from a field test of the approach in five countries in three world regions: Africa, Eurasia, and Southeast Asia.

    As a result of its findings, the report offers three recommendations:
    1.) Increase facilities’ ability to use indicator data by requiring denominators that reflect the number of patients who visit a facility;
    2.) Encourage monthly monitoring and the use of data to make decisions to manage and improve care processes; and
    3.) Improve the use and reporting of quality criteria data by: (a) supporting countries in using up-to date, centralized record systems to record patient status, (b) establishing systems to track and ensure attendance, (c) linking different service areas, and (d) supporting countries in building capacity to use their data to make decisions and improve the quality of their services.
  • Community-directed interventions for major health problems in Africa | Community Resource

    In 2005, a three-year multi-country study was launched to examine how the Community Directed Intervention (CDI) approach, which had been remarkably successful in distributing ivermectin for treatment of onchocerciasis, could be used alongside ivermectin for integrated delivery (or co-implementation) of four other health interventions: Vitamin A supplementation, distribution of insecticide-treated nets, directly observed treatment, short course (DOTS) for tuberculosis and home-management of malaria. The study covered a total of 2.35 million people.

  • Lessons on national and international use of metrics to improve health systems | Publications

    This presentation was given by Amy Stern, Senior QI Advisor on HCI, at the 28th International Conference of the International Society for Quality in Health Care, Ltd. (ISQua), which took place in Hong Kong, China from September 14-17, 2011. The conference theme was, “Patient Safety: Sustaining the Global Momentum.”

  • Feasibility of Using Quality Criteria to Monitor and Improve the Quality of HIV Services | Publications

    This short report describes assistance that the USAID Health Care Improvement Project (HCI) is providing to the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and to the Office of the Global AIDS Coordinator (OGAC) to develop an approach that can be used to harmonize global reporting and improve the quality of HIV services and health outcomes. This study details HCI’s approach that employs 16 quality criteria for 5 HIV service delivery areas: testing and counseling, care and treatment, PMTCT, TB/HIV, and harm reduction. Field tests were conducted in five selected countries: 3 in Africa, 1 in Eurasia and 1 in Southeast Asia.  

  • People first: African solutions to the health worker crisis | Community Resource

    This brief draws on AMREF's experience, looking at three key issues: appropriate training, task-shifting to lower cadres of worker, and training and supporting CHWs to bring health care closer to communities. It emphasizes both the need for global commitment to scale up proven models at the national level and leadership and ownership by African governments.

  • Lessons from Community-based Distribution of Family Planning in Africa | Community Resource

    This paper reviews several initiatives in sub-Saharan Africa to implement community-based distribution (CBD) of family planning services. Although research suggests that community-based service delivery can contribute to contraceptive use, the magnitude of impact is often in doubt. This report reviews reasons for the limited impact of CBD in Africa, compared with similar projects in Asia in previous decades, and discusses the efficacy and mechanisms of CBD.

  • Evaluation of the Spread from Niger to Mali of better care practices for essential obstetric and neonatal care and the implementation of collaborative improvement | Publications

    The USAID Health Care Improvement has demonstrated the efficiency of the dissemination of improved care practices to new regions within a country or health care system. However, while the spread within a country has been studied, there is little or no research on transferring quality improvement processes and improved health practices from one country to another. This study aims to analyze how a list of changes was transferred from the Niger in Mali, the methods used to reproduce the improved care and costs associated with its implementation.

    Research questions/objectives:
    The objective of this study is to evaluate how a package of changes developed in one country may be transferred to another. Specifically, is the package of changes developed in Niger is appropriate to the context of Mali? The null hypothesis is that the package of changes from Niger had no significant effect on indicators in Mali. This study will also examine the cost-effectiveness of the implementation of Niger’s package of changes in Mali compared to maternal and newborn health care in Mali before the improvement collaborative. The specific research questions are:

    1. What changes are appropriate to Mali? What are the perceptions of improvement teams and coaches about the package of changes? How have the changes been adapted by sites in Mali to their local context? What has helped or hindered the ownership of changes by the sites?
    2. What improvements have there been in the indicators at sites where the package of changes was introduced?
    3. Have the indicators evolved the same way in Mali and Niger?
    4. What is the cost of implementing the package of changes in Mali through the collaborative?
    5. What is the cost of implementing the package of changes in Mali in terms of quality indicators and clinical outcomes (incidence of bleeding avoided)?

    The retrospective study will include quantitative assessment of results and qualitative assessment to better understand the process of implementation and adaptation of best practices. Key information will be obtained through in-depth interviews of improvement teams at 19 sites in Mali. Two focus group discussions with coaches from Mali will be conducted to determine their perceptions and how they were affected by the collaborative. Costs related to collaborative implementation will be extracted from HCI accounting records.


  • Evaluation and cost-effectiveness analysis of a quality improvement collaborative approach for the testing and management of eclampsia /pre-eclampsia cases in Mali | Publications

    An evaluation of the USAID Healthcare Improvement (HCI) Project summarizing the results of collaborative improvement in 12 countries by over 1300 teams during 1998-2008 has shown that teams were able to achieve large increases in compliance with health care standards and in some cases, in health outcomes, across all care areas addressed, regardless of the baseline level of quality (Franco 2009). Several other reports also demonstrate the cost-effectiveness of collaborative quality improvement in achieving high compliance to standards of care and in improving outcomes. However, due to operational restrictions, most assessments of quality improvement collaboratives (QICs) have been uncontrolled pretest–post-test designs that cannot rule out other plausible causes for observed improvements, such as secular trends (Mittman 2004).

    This study will address this issue by comparing costs and outcomes for clinical management of eclampsia and pre-eclampsia in quality improvement collaborative facilities to facilities with no collaborative improvement intervention in the first six months. Following the initial six months, the collaborative improvement methodology will be introduced to the control sites and changes in quality performance will be monitored over that time.
    Implementation by the HCI Project of interventions to improve maternal and newborn health services including AMSTL and essential newborn care has been ongoing in 41 facilities in two health districts (Diema and Kayes) in the Kayes region since early 2010. Most facilities are above 80% compliance in active management of the third stage labor (AMSTL) and essential and newborn care (ENC) quality indicators and are currently working on maintaining or improving performance.
    The HCI Mali / Niger team started implementing a second QIC phase aimed at improving clinical practice with regard to pre-eclampsia and eclampsia care at the end of February, 2011. This study will determine the costs and effects of this QIC intervention and compare them to the costs and effects of a basic clinical training (BCT) in the same type of health facilities in Mali that are not part of the collaborative.
    Research questions/objectives:
    This study will determine whether a QIC intervention has an added value in improving pre-eclampsia and eclampsia care quality above basic clinical training (BCT) alone. It will also measure the relative efficiency of the two interventions. The specific research questions are:
    1. 1. Do pregnant and delivering women in QIC intervention facilities receive better care (screening/diagnostic and treatment of pre-eclampsia/eclampsia) than those in BCT-only facilities?
    2. 2. Do pregnant and delivering women in QIC intervention facilities have better clinical outcomes, in terms of eclampsia incidence than those in BCT-only facilities?
    3. 3. What is the incremental cost-effectiveness of the QIC intervention compared to the BCT-only intervention in terms of process and outcome indicators for mothers?
    4. 4. Does adherence to eclampsia/pre-eclampsia norms become higher in BCT-only sites when clinicians are trained on the QIC methodology?
    5. 5. Does adherence to eclampsia/pre-eclampsia norms in the QIC intervention facilities change in the six months following the active intervention period?
    This longitudinal study uses a controlled pre- and post-intervention design. The QIC sites will be those participating in the QIC intervention and the control sites will receive BCT only. BCT is also part of the QIC intervention.