Efficiency, quality, and management practices in health facilities providing outpatient HIV services in Kenya, Nigeria, Rwanda, South Africa and Zambia


Few studies have assessed the efficiency and quality of HIV services in low-resource settings or considered the factors that determine both performance dimensions. To provide insights on the performance of outpatient HIV prevention units, we used benchmarking methods to identify best-practices in terms of technical efficiency and process quality and uncover management practices with the potential to improve efficiency and quality. We used data collected in 338 facilities in Kenya, Nigeria, Rwanda, South Africa, and Zambia. Data envelopment analysis (DEA) was used to estimate technical efficiency. Process quality was estimated using data from medical vignettes. We mapped the relationship between efficiency and quality scores and studied the managerial determinants of best performance in terms of both efficiency and quality. We also explored the relationship between management factors and efficiency and quality independently. We found levels of both technical efficiency and process quality to be low, though there was substantial variation across countries. One third of facilities were mapped in the best-performing group with above-median efficiency and above-median quality. Several management practices were associated with best performance in terms of both efficiency and quality. When considering efficiency and quality independently, the patterns of associations between management practices and the two performance dimensions were not necessarily the same. One management characteristic was associated with best performance in terms of efficiency and quality and also positively associated with efficiency and quality independently: number of supervision visits to HIV units.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.



Antiretroviral therapy


Data envelopment analysis


Decision making unit


HIV testing and counseling


Optimizing the Response in Prevention HIV Efficiency in Africa


Optimizing the Response in Prevention and Treatment HIV Efficiency in Nigeria


Principal components analysis


Prevention of mother-to-child transmission


Seemingly unrelated regression


Variable returns to scale


  1. 1.

    Joint United Nations Programme on HIV/AIDS (2020) Global AIDS Update 2020. UNAIDS, Geneva

    Google Scholar 

  2. 2.

    Global Burden of Disease Health Financing Collaborator N (2020) Health sector spending and spending on HIV/AIDS, tuberculosis, and malaria, and development assistance for health: progress towards Sustainable Development Goal 3. Lancet. 396:693–724. https://doi.org/10.1016/S0140-6736(20)30608-5

    Article  Google Scholar 

  3. 3.

    Anderson SJ, Cherutich P, Kilonzo N, Cremin I, Fecht D, Kimanga D, Harper M, Masha RL, Ngongo PB, Maina W, Dybul M, Hallett TB (2014) Maximising the effect of combination HIV prevention through prioritisation of the people and places in greatest need: a modelling study. Lancet 384(9939):249–256. https://doi.org/10.1016/S0140-6736(14)61053-9

    Article  Google Scholar 

  4. 4.

    Bautista-Arredondo S, Gadsden P, Harris JE, Bertozzi SM (2008) Optimizing resource allocation for HIV/AIDS prevention programmes: an analytical framework. AIDS 22(Suppl 1):S67–S74. https://doi.org/10.1097/01.aids.0000327625.69974.08

    Article  Google Scholar 

  5. 5.

    Bertozzi SM, Laga M, Bautista-Arredondo S, Coutinho A (2008) Making HIV prevention programmes work. Lancet 372(9641):831–844. https://doi.org/10.1016/S0140-6736(08)60889-2

    Article  Google Scholar 

  6. 6.

    Joint United Nations Programme on HIV/AIDS (2014) Fast track: ending the AIDS epidemic by 2030. UNAIDS, Geneva

    Google Scholar 

  7. 7.

    Jones A, Cremin I, Abdullah F, Idoko J, Cherutich P, Kilonzo N, Rees H, Hallett T, O'Reilly K, Koechlin F, Schwartlander B, de Zalduondo B, Kim S, Jay J, Huh J, Piot P, Dybul M (2014) Transformation of HIV from pandemic to low-endemic levels: a public health approach to combination prevention. Lancet 384(9939):272–279. https://doi.org/10.1016/S0140-6736(13)62230-8

    Article  Google Scholar 

  8. 8.

    McGillen JB, Anderson SJ, Dybul MR, Hallett TB (2016) Optimum resource allocation to reduce HIV incidence across sub-Saharan Africa: a mathematical modelling study. Lancet HIV 3(9):e441–e448. https://doi.org/10.1016/S2352-3018(16)30051-0

    Article  Google Scholar 

  9. 9.

    Schwartlander B, Stover J, Hallett T, Atun R, Avila C, Gouws E, Bartos M, Ghys PD, Opuni M, Barr D, Alsallaq R, Bollinger L, de Freitas M, Garnett G, Holmes C, Legins K, Pillay Y, Stanciole AE, McClure C, Hirnschall G, Laga M, Padian N, Investment Framework Study G (2011) Towards an improved investment approach for an effective response to HIV/AIDS. Lancet 377(9782):2031–2041. https://doi.org/10.1016/S0140-6736(11)60702-2

    Article  Google Scholar 

  10. 10.

    The United States President’s Emergency Plan for AIDS Relief (2012) PEPFAR blueprint: creating an AIDS-free generation. The Office of the Global AIDS Coordinator. Washington, DC

    Google Scholar 

  11. 11.

    The United States President’s Emergency Plan for AIDS Relief (2014) PEPFAR 3.0 - Controlling the epidemic: delivering on the promise of an AIDS-free generation. The Office of the Global AIDS Coordinator, Washington, DC

    Google Scholar 

  12. 12.

    Joint United Nations Programme on HIV/AIDS (2015) On the Fast-Track to end AIDS by 2030: Focus on location and population. UNAIDS, Geneva

    Google Scholar 

  13. 13.

    Vassall A, Remme M, Watts C, Hallett T, Siapka M, Vickerman P, Terris-Prestholt F, Haacker M, Heise L, Haines A, Atun R, Piot P (2013) Financing essential HIV services: a new economic agenda. PLoS Med 10(12):e1001567. https://doi.org/10.1371/journal.pmed.1001567

    Article  Google Scholar 

  14. 14.

    World Health Organization (2019) Maintaining and improving quality of care within HIV clinical services. World Health Organization, Geneva

    Google Scholar 

  15. 15.

    Murray CJ (2015) Maximizing antiretroviral therapy in developing countries: the dual challenge of efficiency and quality. JAMA 313(4):359–360. https://doi.org/10.1001/jama.2014.16376

    Article  Google Scholar 

  16. 16.

    Hussey PS, Wertheimer S, Mehrotra A (2013) The association between health care quality and cost: a systematic review. Ann Intern Med 158(1):27–34. https://doi.org/10.7326/0003-4819-158-1-201301010-00006

    Article  Google Scholar 

  17. 17.

    Gertler PJ, Waldman DM (1992) Quality-adjusted cost functions and policy evaluation in the nursing home industry. J Polit Econ 100(6):1232–1256

    Article  Google Scholar 

  18. 18.

    Sherman HD, Zhu J (2006) Service productivity management: Improving Service Performance using Data Envelopment Analysis (DEA). Springer US, Boston, MA

    Google Scholar 

  19. 19.

    Masiye F, Mphuka C, Emrouznejad A (2014) Estimating the efficiency of healthcare facilities providing HIV/AIDS treatment in Zambia: a Data Envelopment Approach. In: Emrouznejad A, Cabanda E (eds) Managing service productivity: using frontier efficiency methodologies and multicriteria decision making for improving service performance. Springer, Berlin

    Google Scholar 

  20. 20.

    Lepine A, Vassall A, Chandrashekar S (2015) The determinants of technical efficiency of a large scale HIV prevention project: application of the DEA double bootstrap using panel data from the Indian Avahan. Cost Eff Resour Alloc 13:5. https://doi.org/10.1186/s12962-015-0031-2

    Article  Google Scholar 

  21. 21.

    Di Giorgio L, Moses MW, Fullman N, Wollum A, Conner RO, Achan J, Achoki T, Bannon KA, Burstein R, Dansereau E, DeCenso B, Delwiche K, Duber HC, Gakidou E, Gasasira A, Haakenstad A, Hanlon M, Ikilezi G, Kisia C, Levine AJ, Maboshe M, Masiye F, Masters SH, Mphuka C, Njuguna P, Odeny TA, Okiro EA, Roberts DA, Murray CJ, Flaxman AD (2016) The potential to expand antiretroviral therapy by improving health facility efficiency: evidence from Kenya, Uganda, and Zambia. BMC Med 14(1):108. https://doi.org/10.1186/s12916-016-0653-z

    Article  Google Scholar 

  22. 22.

    Obure CD, Jacobs R, Guinness L, Mayhew S, Integra I, Vassall A (2016) Does integration of HIV and sexual and reproductive health services improve technical efficiency in Kenya and Swaziland? An application of a two-stage semi parametric approach incorporating quality measures. Soc Sci Med 151:147–156. https://doi.org/10.1016/j.socscimed.2016.01.013

    Article  Google Scholar 

  23. 23.

    Salas-Ortiz A, La Hera-Fuentes G, Nance N, Sosa-Rubi SG, Bautista-Arredondo S (2019) The relationship between management practices and the efficiency and quality of voluntary medical male circumcision services in four African countries. PLoS One 14(10):e0222180. https://doi.org/10.1371/journal.pone.0222180

    Article  Google Scholar 

  24. 24.

    Bloom N, Sadun R, Van Reenen J (2013) Does Management Matter in Healthcare? NBER book chapter series. National Bureau of Economic Research, Cambridge, Mass

  25. 25.

    Dorgan S, Layton D, Bloom N, Homkes R, Sadun R, Van Reenen J (2010) Management in healthcare: why good practice really matters. McKinsey & Company, London

    Google Scholar 

  26. 26.

    McConnell KJ, Chang AM, Maddox TM, Wholey DR, Lindrooth RC (2014) An exploration of management practices in hospitals. Healthc (Amst) 2(2):121–129. https://doi.org/10.1016/j.hjdsi.2013.12.014

    Article  Google Scholar 

  27. 27.

    McConnell KJ, Lindrooth RC, Wholey DR, Maddox TM, Bloom N (2013) Management practices and the quality of care in cardiac units. JAMA Intern Med 173(8):684–692. https://doi.org/10.1001/jamainternmed.2013.3577

    Article  Google Scholar 

  28. 28.

    McConnell KJ, Lindrooth RC, Wholey DR, Maddox TM, Bloom N (2016) Modern Management Practices and Hospital Admissions. Health Econ 25(4):470–485. https://doi.org/10.1002/hec.3171

    Article  Google Scholar 

  29. 29.

    Tsai TC, Jha AK, Gawande AA, Huckman RS, Bloom N, Sadun R (2015) Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. Health Aff (Millwood) 34(8):1304–1311. https://doi.org/10.1377/hlthaff.2014.1282

    Article  Google Scholar 

  30. 30.

    Dunsch F, Evans DK, Eze-Aioku E, Macis M (2017) Management, Supervision, and Health Care: A Field Experiment, NBER working paper series. National Bureau of Economic Research, Cambridge, Mass

  31. 31.

    Debreu G (1951) The coefficient of resource utilization. Econometrica 19(3):273–292

    Article  Google Scholar 

  32. 32.

    Diewert WE (1980) Capital and the theory of productivity measurement. Am Econ Rev 70(2):260–267

    Google Scholar 

  33. 33.

    Farrell MJ (1957) The measurement of productive efficiency. J Royal Stat Soc Ser A (General) 120(3):253–290

    Article  Google Scholar 

  34. 34.

    Donabedian A (1978) The quality of medical care. Science 200(4344):856–864. https://doi.org/10.1126/science.417400

    Article  Google Scholar 

  35. 35.

    Charnes A, Cooper WW, Lewin AY, Seiford LM (eds) (1994) Data envelopment analysis: theory, methodology, and applications. Kluwer Academic Publishers, Boston

    Google Scholar 

  36. 36.

    Sherman HD, Zhu J (2006) Benchmarking with quality-adjusted DEA (Q-DEA) to seek lower-cost high-quality service: evidence from a U.S.bank application. Ann Oper Res 145(1):301–319

    Article  Google Scholar 

  37. 37.

    Nyman JA, Bricker DL, Link D (1990) Technical efficiency in nursing homes. Med Care 28(6):541–551

    Article  Google Scholar 

  38. 38.

    Cordero Ferrera JM, Crespo Cebada E, Murillo Zamorano LR (2014) The effect of quality and socio-demographic variables on efficiency measures in primary health care. Eur J Health Econ 15(3):289–302. https://doi.org/10.1007/s10198-013-0476-1

    Article  Google Scholar 

  39. 39.

    Garcia F, Marcuello C, Serrano D, Urbina O (1999) Evaluation of efficiency in primary health care centres: an application of data envelopment analysis. Fin Account Manag 15:67–83

    Article  Google Scholar 

  40. 40.

    Nedelea IC, Fannin JM (2013) Technical efficiency of Critical Access Hospitals: an application of the two-stage approach with double bootstrap. Health Care Manag Sci 16(1):27–36. https://doi.org/10.1007/s10729-012-9209-8

    Article  Google Scholar 

  41. 41.

    Rosenman R, Friesner D (2004) Scope and scale inefficiencies in physician practices. Health Econ 13(11):1091–1116. https://doi.org/10.1002/hec.882

    Article  Google Scholar 

  42. 42.

    Salinas-Jimenez J, Smith P (1996) Data envelopment analysis applied to quality in primary health care. Ann Oper Res 67(1):141–161

    Article  Google Scholar 

  43. 43.

    Wagner JM, Shimshak DG, Novak MA (2003) Advances in physician profiling: the use of DEA. Socio Econ Plan Sci 37:141–163

    Article  Google Scholar 

  44. 44.

    Bautista-Arredondo S, Colchero MA, Amanze OO, La Hera-Fuentes G, Silverman-Retana O, Contreras-Loya D, Ashefor GA, Ogungbemi KM (2018) Explaining the heterogeneity in average costs per HIV/AIDS patient in Nigeria: The role of supply-side and service delivery characteristics. PLoS One 13(5):e0194305. https://doi.org/10.1371/journal.pone.0194305

    Article  Google Scholar 

  45. 45.

    Bautista-Arredondo S, La Hera-Fuentes G, Contreras-Loya D, Kwan A, Van Buren SJ, Amanze OO, Atobatele A, Adeyemi A, Abatta E, Ogungbemi KM, Sosa-Rubi SG (2018) Efficiency of HIV services in Nigeria: Determinants of unit cost variation of HIV counseling and testing and prevention of mother-to-child transmission interventions. PLoS One 13(9):e0201706. https://doi.org/10.1371/journal.pone.0201706

    Article  Google Scholar 

  46. 46.

    Bautista-Arredondo S, Sosa-Rubi SG, Opuni M, Contreras-Loya D, Kwan A, Chaumont C, Chompolola A, Condo J, Galarraga O, Martinson N, Masiye F, Nsanzimana S, Ochoa-Moreno I, Wamai R, Wang'ombe J, team Os (2016) Costs along the service cascades for HIV testing and counselling and prevention of mother-to-child transmission. AIDS 30(16):2495–2504. https://doi.org/10.1097/QAD.0000000000001208

    Article  Google Scholar 

  47. 47.

    Bautista-Arredondo S, Sosa-Rubi SG, Opuni M, Kwan A, Chaumont C, Coetzee J, Condo J, Dzekedzeke K, Galarraga O, Martinson N, Masiye F, Nsanzimana S, Wamai R, Wang'ombe J, team Os (2014) Assessing cost and technical efficiency of HIV prevention interventions in sub-Saharan Africa: the ORPHEA study design and methods. BMC Health Serv Res 14:599. https://doi.org/10.1186/s12913-014-0599-9

    Article  Google Scholar 

  48. 48.

    Charnes A, Cooper WW, Rhodes E (1978) Measuring the efficiency of decision making units. Eur J Oper Res 2:429–444

    Article  Google Scholar 

  49. 49.

    Hollingsworth B (2003) Non-parametric and parametric applications measuring efficiency in health care. Health Care Manag Sci 6(4):203–218

    Article  Google Scholar 

  50. 50.

    Jacobs R, Smith PC, Street A (2006) Measuring efficiency in health care. Cambridge University Press, Cambridge

    Google Scholar 

  51. 51.

    Simar L, Wilson P (2007) Estimation and inference in two-stage, semi-parametric models of production processes. J Econ 136(1):31–64

    Article  Google Scholar 

  52. 52.

    Wagstaff A, Wang LC (2011) A hybrid approach to efficiency measurement with empirical illustrations from education and health. World Bank, Washington, DC

    Google Scholar 

  53. 53.

    Donabedian A (1966) Evaluating the Quality of Medical Care. The Milbank Memorial Fund Quarterly 44:166–206. https://doi.org/10.2307/3348969

  54. 54.

    Mainz J (2003) Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care 15(6):523–530

    Article  Google Scholar 

  55. 55.

    Das J, Gertler PJ (2007) Variations in practice quality in five low-income countries: a conceptual overview. Health Aff (Millwood) 26 (3):w296-w309. https://doi.org/10.1377/hlthaff.26.3.w296

  56. 56.

    Das J, Hammer J (2005) Which doctor? Combining vignettes and item response to measure clinical competence. J Dev Econ 78(2):348–383

    Article  Google Scholar 

  57. 57.

    Jolliffe I (2002) Principal component analysis, 2nd edn. Springer-Verlag, New York

    Google Scholar 

  58. 58.

    Bradley EH, Curry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM (2009) Research in action: using positive deviance to improve quality of health care. Implement Sci 4:25. https://doi.org/10.1186/1748-5908-4-25

    Article  Google Scholar 

  59. 59.

    Edgerton DL, Assarsson B, Hummelmose A, Laurila IP, Rickertsen K, Halvor Vale P (1996) The econometrics of demand systems. With applications to food demand in the Nordic countries. Kluwer Academic Publishers, Dordrecht

    Google Scholar 

  60. 60.

    Bloom N, Van Reenen J (2007) Measuring and explaining management practices across firms and countries. Q J Econ 122(4):1351–1408

    Article  Google Scholar 

  61. 61.

    Barber SL, Gertler PJ, Harimurti P (2007) Differences in access to high-quality outpatient care in Indonesia. Health Aff (Millwood) 26(3):w352–w366. https://doi.org/10.1377/hlthaff.26.3.w352

    Article  Google Scholar 

  62. 62.

    Leonard KL, Masatu MC (2007) Variations in the quality of care accessible to rural communities in Tanzania. Health Aff (Millwood) 26(3):w380–w392. https://doi.org/10.1377/hlthaff.26.3.w380

    Article  Google Scholar 

  63. 63.

    Mohanan M, Goldhaber-Fiebert JD, Giardili S, Vera-Hernandez M (2016) Providers' knowledge of diagnosis and treatment of tuberculosis using vignettes: evidence from rural Bihar, India. BMJ Glob Health 1(4):e000155. https://doi.org/10.1136/bmjgh-2016-000155

    Article  Google Scholar 

  64. 64.

    Mohanan M, Vera-Hernandez M, Das V, Giardili S, Goldhaber-Fiebert JD, Rabin TL, Raj SS, Schwartz JI, Seth A (2015) The know-do gap in quality of health care for childhood diarrhea and pneumonia in rural India. JAMA Pediatr 169(4):349–357. https://doi.org/10.1001/jamapediatrics.2014.3445

    Article  Google Scholar 

  65. 65.

    Peabody JW, DeMaria L, Smith O, Hoth A, Dragoti E, Luck J (2017) Large-Scale Evaluation of Quality of Care in 6 Countries of Eastern Europe and Central Asia Using Clinical Performance and Value Vignettes. Glob Health Sci Pract 5(3):412–429. https://doi.org/10.9745/GHSP-D-17-00044

    Article  Google Scholar 

  66. 66.

    Peabody JW, Liu A (2007) A cross-national comparison of the quality of clinical care using vignettes. Health Policy Plan 22(5):294–302. https://doi.org/10.1093/heapol/czm020

    Article  Google Scholar 

  67. 67.

    Chowdhury MM, Dagash H, Pierro A (2007) A systematic review of the impact of volume of surgery and specialization on patient outcome. Br J Surg 94(2):145–161. https://doi.org/10.1002/bjs.5714

    Article  Google Scholar 

  68. 68.

    Holmboe ES, Wang Y, Tate JP, Meehan TP (2006) The effects of patient volume on the quality of diabetic care for Medicare beneficiaries. Med Care 44(12):1073–1077. https://doi.org/10.1097/01.mlr.0000233685.22497.cf

    Article  Google Scholar 

  69. 69.

    Landon BE, Wilson IB, Wenger NS, Cohn SE, Fichtenbaum CJ, Bozzette SA, Shapiro MF, Cleary PD (2002) Specialty training and specialization among physicians who treat HIV/AIDS in the United States. J Gen Intern Med 17(1):12–22. https://doi.org/10.1046/j.1525-1497.2002.10401.x

    Article  Google Scholar 

  70. 70.

    Kruk ME, Prescott MR (2012) The role of health systems and policies in promoting safe delivery in low- and middle-income countries: a multilevel analysis. Am J Public Health 102(4):645–650. https://doi.org/10.2105/AJPH.2011.300462

    Article  Google Scholar 

  71. 71.

    Kruk ME, Chukwuma A, Mbaruku G, Leslie HH (2017) Variation in quality of primary-care services in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania. Bull World Health Organ 95(6):408–418. https://doi.org/10.2471/BLT.16.175869

    Article  Google Scholar 

Download references


We thank all of the members of the ORPHEA study team. Mexico: Martin Romero-Martínez and Andrea Salas-Ortiz of the National Institute of Public Health, Mexico; Claire Chaumont of Harvard University; Amilcar Azamar-Alonso of McMaster University; Ivan Ochoa-Moreno of University of York; Ada Kwan, Raluca Buzdugan, and Rita Cuckovich of University of California, Berkeley; Alvaro Canales and Victor Canales of Sistemas Integrales, Santiago, Chile. Kenya: Mercy Mugo, Hellen Nyakundi, and Joseph Wang’ombe of University of Nairobi; Omar Galárraga of Brown University;Richard Wamai of Northeastern University. Rwanda: Sabin Nsanzimana, Jean Pierre Ayingoma, Placidie Mugwaneza, and Eric Remera of Rwanda Biomedical Center, Institute of HIV/AIDS, Disease Prevention & Control; Jeanine Condo, Collins Kamanzi, Nathalie Mulindahabi, Angele Musabyimana, and Sabine Musange of National University of Rwanda School of Public Health. South Africa: Neil Martinson, Jenny Coetzee, Charity Dire, Limakatso Lebina, and Sabelo Sekhukuni of the Perinatal HIV Research Unit, University of the Witwatersrand. Zambia: Felix Masiye, Abson Chompolola, Sydney Chauwa, and Bona Chitah of University of Zambia; Kumbutso Dzekedzeke of Dzekdzeke Research & Consultancy.


This study was conducted with funding from the Bill and Melinda Gates Foundation, Seattle, WA, USA. The funder played no role in the design of the study and collection, analysis, and interpretation of data and in the writing of the manuscript.

Author information




SGSR and SBA conceptualized the study. SGSR, MO, DCL, and SBA provided guidance on data analysis and interpretation of results. CCM and GHF contributed to all parts of the analysis and produced the tables and figures. SGSR, MO, and DCL wrote the initial and final drafts of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to David Contreras-Loya.

Ethics declarations

Ethics approval and consent to participate

The ethical review boards of the following institutions approved the study in Kenya, Rwanda, South Africa, and Zambia: National Institute of Public Health, Mexico; Kenyatta National Hospital and University of Nairobi; Northeastern University; Rwanda Biomedical Center; University of the Witwatersrand; and University of Zambia. The National Institute of Public Health, Mexico, and the Nigerian Institute for Medical Research approved the study in Nigeria.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information


(DOCX 77 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Sosa-Rubí, S.G., Bautista-Arredondo, S., Chivardi-Moreno, C. et al. Efficiency, quality, and management practices in health facilities providing outpatient HIV services in Kenya, Nigeria, Rwanda, South Africa and Zambia. Health Care Manag Sci (2021). https://doi.org/10.1007/s10729-020-09541-1

Download citation


  • data envelopment analysis
  • HIV testing and counseling
  • prevention of mother-to-child transmission
  • process quality
  • technical efficiency
  • sub-Saharan Africa