The joint BASICS/Quality Assurance Project tested several research-based interventions in three districts in Niger, West Africa to improve case management of sick children. The research design was a non-concurrent, prospective case control design. Quality of care was determined as the degree of compliance of health care workers with the Integrated Management of Childhood Illness (IMCI) standards of assessment, treatment and counselling of sick children and their caretakers. The interventions tested were (1) structured feedback of health worker performance data and (2) formal IMCI training and (3) team-based quality improvement. Performance feedback had a significant effect on compliance. Performance feedback alone created a significant short-term impact on health care worker compliance, which improved between 34% and 85% in areas of assessment of sick children (p < 0.05). In addition, performance feedback was significantly cheaper than formal training ($108 per health worker versus $430 per worker for IMCI training). However, this impact was not universal over all areas of compliance following each feedback. Instead, performance feedback had the greatest effect in areas in which health care workers performed poorly, while areas in which compliance was high eventually saw declines. In settings such as Niger, which has the highest child mortality in the world according to UNICEF figures, low-cost techniques for supporting health workers once they have been trained in clinical standards are sorely needed. Performance feedback shows promise as a technique for improving quality of care with clinical algorithms such as IMCI.

Background: WHO and UNICEF have recently developed the "Integrated Management of Childhood Illness" (IMCI) as an efficient strategy to assist developing countries reduce childhood mortality. Early experience with IMCI implementation suggests that clinical training is essential but not sufficient for the success of the strategy. Attention needs to be given to strengthening health systems, such as supervision and drug supply.