Individual interactions in a multi-country implementation-focused quality of care network for maternal, newborn and child health: A social network analysis

Evaluating theory of change to improve the functioning of the network for improving quality of care for maternal, newborn and child health

In 2017, WHO and global partners launched 'The Network for Improving Quality of Care for Maternal, Newborn and Child Health' (QCN) seeking to reduce in-facility maternal and newborn deaths and stillbirth by 50% in health facilities by 2022. We explored how the QCN theory of change guided what actually happened over 2018-2022 in order to understand what worked well, what did not, and to ultimately describe the consequences of QCN activities. We applied theory of change analysis criteria to investigate how well-defined, plausible, coherent and measurable the results were, how well-defined, coherent, justifiable, realistic, sustainable and measurable the assumptions were, and how independent and sufficient the causal links were. We found that the QCN theory of change was not used in the same way across implementing countries. While the theory stipulated Leadership, Action, Learning and Accountability as the principle to guide network activity implementation other principles and varying quality improvement methods have also been used; key conditions were missing at service integration and process levels in the global theory of change for the network. Conditions such as lack of physical resources were frequently reported to be preventing adequate care, or harm patient satisfaction. Key partners and implementers were not introduced to the network theory of change early enough for them to raise critical questions about their roles and the need for, and nature of, quality of care interventions. Whilst the theory of change was created at the outset of QCN it is not clear how much it guided actual activities or any monitoring and evaluation as things progressed. Enabling countries to develop their theory of change, perhaps guided by the global framework, could improve stakeholder engagement, allow local evaluation of assumptions and addressing of challenges, and better target QCN work toward achieving its goals.

Effectiveness of a multi-country implementation-focused network on quality of care: Delivery of interventions and processes for improved maternal, newborn and child health outcomes

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) aims to work through learning, action, leadership and accountability. We aimed to evaluate the effectiveness of QCN in these four areas at the global level and in four QCN countries: Bangladesh, Ethiopia, Malawi and Uganda. This mixed method evaluation comprised 2-4 iterative rounds of data collection between 2019-2022, involving stakeholder interviews, hospital observations, QCN members survey, and document review. Qualitative data was analysed using a coding framework developed from underlying theories on network effectiveness, behaviour change, and QCN proposed theory of change. Survey data capturing respondents' perception of QCN was analysed with descriptive statistics. The QCN global level, led by the WHO secretariat, was effective in bringing together network countries' governments and global actors via providing online and in-person platforms for communication and learning. In-country, various interventions were delivered in 'learning districts', however often separately by different partners in different locations, and pandemic-disrupted. Governance structures for quality of care were set-up, some preceding QCN, and were found to be stronger and better (though often externally) resourced at national than local levels. Awareness of operational plans and network activities differed between countries, was lower at local than national levels, but increased from 2019 to 2022. Engagement with, and value of, QCN was perceived to be higher in Uganda and Bangladesh than in Malawi or Ethiopia. Capacity building efforts were implemented in all countries-yet often dependent on implementing partners and donors. QCN stakeholders agreed 15 core monitoring indicators though data collection was challenging, especially for indicators requiring new or parallel systems. Accountability initiatives remained nascent in 2022. Global and national leadership elements of QCN have been most effective to date, with action, learning and accountability more challenging, partner or donor dependent, remaining to be scaled-up, and pandemic-disrupted.