Abstract
Objective
To test the success of a maternal healthcare quality improvement intervention in actually improving quality.
Design
Cluster-randomized controlled study with implementation evaluation; we randomized 12 primary care facilities to receive a quality improvement intervention, while 12 facilities served as controls.
Setting
Four districts in rural Tanzania.
Participants
Health facilities (24), providers (70 at baseline; 119 at endline) and patients (784 at baseline; 886 at endline).
Interventions
In-service training, mentorship and supportive supervision and infrastructure support.
Main outcome measures
We measured fidelity with indictors of quality and compared quality between intervention and control facilities using difference-in-differences analysis.
Results
Quality of care was low at baseline: the average provider knowledge test score was 46.1% (range: 0–75%) and only 47.9% of women were very satisfied with delivery care. The intervention was associated with an increase in newborn counseling (β: 0.74, 95% CI: 0.13, 1.35) but no evidence of change across 17 additional indicators of quality. On average, facilities reached 39% implementation. Comparing facilities with the highest implementation of the intervention to control facilities again showed improvement on only one of the 18 quality indicators.
Conclusions
A multi-faceted quality improvement intervention resulted in no meaningful improvement in quality. Evidence suggests this is due to both failure to sustain a high-level of implementation and failure in theory: quality improvement interventions targeted at the clinic-level in primary care clinics with weak starting quality, including poor infrastructure and low provider competence, may not be effective.
Effect of Patient Navigation and Financial Incentives on Smoking Cessation Among Primary Care Patients at an Urban Safety-Net Hospital
