Data sources/ measurement

- 8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe comparability of assessment methods if there is more than one group

_See the relevant text: “Diagnostic and treatment accuracy (knowledge) were measured using clinical vignettes focused on seven common conditions associated with the main causes of child and maternal mortality in Sub-Saharan Africa: malaria, tuberculosis, diarrhea, pneumonia, diabetes, neonatal asphyxia and post-partum hemorrhage. All seven of these are major global health challenges, with three of them – diarrhea, neonatal asphyxia, and malaria – together causing more than 180,000,000 disability-adjusted life years (Appendix Table S3). Whether providers are available to provide care at regular opening hours was assessed by verifying their presence through unannounced visits at the health facilities. Availability of drugs and functionality of equipment was assessed by visual inspections of storage facilities and consulting rooms at the health facilities._ _Clinical vignettes have been used extensively in the medical literature to assess clinical knowledge of health workers. Data from vignettes studies are directly policy relevant as they are closely linked to the quality of medical training and quality improvement programs. Validation studies show that clinical vignettes, for relatively simple scenarios such as those assessed as part of the SDI program, perform similarly to standardized patients methods. Although a health worker’s clinical vignette performance is not a measure of quality of care per se, it represents the highest level of quality care which s/he can deliver given his/her current knowledge, assuming that there are no constraints in drugs, equipment and motivations. (More details on the clinical vignettes are provided in Section S4 in the appendix.)_ _The clinical vignettes were adjusted to country-specific diagnostic and treatment protocols. All health providers assessed were asked for informed consent to participate. The enumerators presented the provider with the patient’s symptoms and prompted the provider to take the patient’s history, suggest physical examination and diagnostic tests that in principle could be conducted on site, make a diagnosis, and prescribe a course of treatment and follow-up management plan. For this study, we identified the lowest common denominators across the country-specific protocols to define comparable criteria across countries for diagnostic and treatment accuracy for each of the conditions. This methodological choice implies that knowledge is assessed at a lower standard than more stringent World Health Organization (WHO) protocols. Based on the responses to each vignette, we generated two variables: diagnostic accuracy and treatment accuracy, which are the percentage of respondents who provided an accurate diagnosis and – separately – an accurate treatment for a given condition. Both outcomes should be viewed as measuring the minimum required knowledge to prescribe correct diagnostic and treatment services. (See Table S7 for information on the coding of the two knowledge scores.)_ 38