Involving the public in decision-making about large-scale changes to health services: a scoping review

BACKGROUND: Public involvement in large-scale changes (LSC) to health services is strongly promoted - and even mandated - in several health systems. This scoping review aimed to describe the evidence about how public involvement is conceptualised and conducted in LSC, with what impact, and how different stakeholders perceived this process. METHODS: After searching eight databases, 34 publications were included. Data were extracted and charted using a standardised form. Findings from the literature were discussed with frontline stakeholders. RESULTS: Public involvement remains poorly defined and its aims lack clarity in LSC. Public meetings are most often used to gather public views but raise the issue of representativeness. However, evidence in the literature is scarce about which involvement methods - informative and deliberative - are appropriate for the different stages of the LSC and with what impact. In several cases, the involved public felt they had no influence on decision-making regarding LSC proposals, sometimes leading to an environment of mistrust. In those instances, the public understood the technical arguments for change and actively questioned them, opposed LSC plans and sought alternative routes to voice their views. CONCLUSION: More research and consideration are needed regarding who should be involved, with what purpose and how. We argue that in practice two models of involvement, invited and uninvited participation, coexist and therefore interactions between the two should be given further consideration in LSC

“We don’t trust all data coming from all facilities”: factors influencing the quality of care network data quality in Ethiopia

BACKGROUND: Good quality data are a key to quality health care. In 2017, WHO has launched the Quality of Care Network (QCN) to reduce maternal, newborn and stillbirth mortality via learning and sharing networks. Guided by the principle of equity and dignity, the network members agreed to implement the programme in 2017-2021. OBJECTIVE: This paper seeks to explore how QCN has contributed to improving data quality and to identify factors influencing quality of data in Ethiopia. METHODS: We conducted a qualitative study in selected QCN facilities in Ethiopia using key informant interview and observation methods. We interviewed 40 people at national, sub-national and facility levels. Non-participant observations were carried out in four purposively selected health facilities; we accessed monthly reports from 41 QCN learning facilities. A codebook was prepared following a deductive and inductive analytical approach, coded using Nvivo 12 and thematically analysed. RESULTS: There was a general perception that QCN had improved health data documentation and use in the learning facilities, achieved through coaching, learning and building from pre-existing initiatives. QCN also enhanced the data elements available by introducing a broader set of quality indicators. However, the perception of poor data quality persisted. Factors negatively affecting data quality included a lack of integration of QCN data within routine health system activities, the perception that QCN was a pilot, plus a lack of inclusive engagement at different levels. Both individual and system capabilities needed to be strengthened. CONCLUSION: There is evidence of QCN's contribution to improving data awareness. But a lack of inclusive engagement of actors, alignment and limited skill for data collection and analysis continued to affect data quality and use. In the absence of new resources, integration of new data activities within existing routine health information systems emerged as the most important potential action for positive change

Individual, organizational and system circumstances, and the functioning of a multi-country implementation-focused network for maternal, newborn and child health: Bangladesh, Ethiopia, Malawi, and Uganda

Better policies, investments, and programs are needed to improve the integration and quality of maternal, newborn, and child health services. Previously, partnerships and collaborations that involved multiple countries with a unified aim have been observed to yield positive results. Since 2017, the WHO and partners have hosted the Quality of Care Network [QCN], a multi-country implementation network focused on improving maternal, neonatal, and child health care. In this paper, we examine the functionality of QCN in different contexts. We focus on implementation circumstances and contexts in four network countries: Bangladesh, Ethiopia, Malawi, and Uganda. In each country, the study was conducted over several consecutive rounds between 2019-2022, employing 227 key informant interviews with major stakeholders and members of the network countries, and 42 facility observations. The collected data were coded using Nvivo-12 software and categorized thematically. The study showed that individual, organizational and system-level circumstances all played an important role in shaping implementation success in network countries, but that these levels were inter-linked. Systems that enabled leadership, motivated and trained staff, and created a positive culture of data use were critical for policy-making including addressing financing issues-to the day-to-day practice improvement at the front line. Some characteristics of QCN actively supported this, for example, shared learning forums for continuous learning, a focus on data and tracking progress, and emphasising the importance of coordinated efforts towards a common goal. However, inadequate system financing and capacity also hampered network functioning, especially in the face of external shocks

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

Factors shaping network emergence: A cross-country comparison of quality of care networks in Bangladesh, Ethiopia, Malawi, and Uganda

The Quality-of-Care Network (QCN) was conceptualized by the World Health Organization (WHO) and other global partners to facilitate learning on and improve quality of care for maternal and newborn health within and across low and middle-income countries. However, there was significant variance in the speed and extent to which QCN formed in the involved countries. This paper investigates the factors that shaped QCN’s differential emergence in Bangladesh, Ethiopia, Malawi, and Uganda. Drawing on network scholarship, we conducted a replicated case study of the four country cases and triangulated several sources of data, including a document review, observations of national-level and district level meetings, and key informant interviews in each country and at the global level. Thematic coding was performed in NVivo 12. We find that QCN emerged most quickly and robustly in Bangladesh, followed by Ethiopia, then Uganda, and slowest and with least institutionalization in Malawi. Factors connected to the policy environment and network features explained variance in network emergence. With respect to the policy environment, pre-existing resources and initiatives dedicated to maternal and newborn health and quality improvement, strong data and health system capacity, and national commitment to advancing on synergistic goals were crucial drivers to QCN’s emergence. With respect to the features of the network itself, the embedding of QCN leadership in powerful agencies with pre-existing coordination structures and trusting relationships with key stakeholders, inclusive network membership, and effective individual national and local leadership were also crucial in explaining QCN’s speed and quality of emergence across countries. Studying QCN emergence provides critical insights as to why well-intentioned top-down global health networks may not materialize in some country contexts and have relatively quick uptake in others, and has implications for a network’s perceived legitimacy and ultimate effectiveness in producing stated objectives

Individual, organizational and system circumstances, and the functioning of a multi-country implementation-focused network for maternal, newborn and child health: Bangladesh, Ethiopia, Malawi, and Uganda

Better policies, investments, and programs are needed to improve the integration and quality of maternal, newborn, and child health services. Previously, partnerships and collaborations that involved multiple countries with a unified aim have been observed to yield positive results. Since 2017, the WHO and partners have hosted the Quality of Care Network [QCN], a multi-country implementation network focused on improving maternal, neonatal, and child health care. In this paper, we examine the functionality of QCN in different contexts. We focus on implementation circumstances and contexts in four network countries: Bangladesh, Ethiopia, Malawi, and Uganda. In each country, the study was conducted over several consecutive rounds between 2019-2022, employing 227 key informant interviews with major stakeholders and members of the network countries, and 42 facility observations. The collected data were coded using Nvivo-12 software and categorized thematically. The study showed that individual, organizational and system-level circumstances all played an important role in shaping implementation success in network countries, but that these levels were inter-linked. Systems that enabled leadership, motivated and trained staff, and created a positive culture of data use were critical for policy-making including addressing financing issues-to the day-to-day practice improvement at the front line. Some characteristics of QCN actively supported this, for example, shared learning forums for continuous learning, a focus on data and tracking progress, and emphasising the importance of coordinated efforts towards a common goal. However, inadequate system financing and capacity also hampered network functioning, especially in the face of external shocks

How to evaluate a multi-country implementation-focused network: Reflections from the Quality of Care Network (QCN) evaluation

Learning about how to evaluate implementation-focused networks is important as they become more commonly used. This research evaluated the emergence, legitimacy and effectiveness of a multi-country Quality of Care Network (QCN) aiming to improve maternal, newborn and child health (MNCH) outcomes. We examined the QCN global level, national and local level interfaces in four case study countries. This paper presents the evaluation team’s reflections on this 3.5 year multi-country, multi-disciplinary project. Specifically, we examine our approach, methodological innovations, lessons learned and recommendations for conducting similar research. We used a reflective methodological approach to draw lessons on our practice while evaluating the QCN. A ‘reflections’ tool was developed to guide the process, which happened within a period of 2–4 weeks across the different countries. All country research teams held focused ‘reflection’ meetings to discuss questions in the tool before sharing responses with this paper’s lead author. Similarly, the different lead authors of all eight QCN papers convened their writing teams to reflect on the process and share key highlights. These data were thematically analysed and are presented across key themes around the implementation experience including what went well, facilitators and critical methodological adaptations, what can be done better and recommendations for undertaking similar work. Success drivers included the team’s global nature, spread across seven countries with members affiliated to nine institutions. It was multi-level in expertise and seniority and highly multidisciplinary including experts in medicine, policy and health systems, implementation research, behavioural sciences and MNCH. Country Advisory Boards provided technical oversight and support. Despite complexities, the team effectively implemented the QCN evaluation. Strong leadership, partnership, communication and coordination were key; as were balancing standardization with in-country adaptation, co-production, flattening hierarchies among study team members and the iterative nature of data collection. Methodological adaptations included leveraging technology which became essential during COVID-19, clear division of roles and responsibilities, and embedding capacity building as both an evaluation process and outcome, and optimizing technology use for team cohesion and quality outputs

Opportunities to sustain a multi-country quality of care network: Lessons on the actions of four countries Bangladesh, Ethiopia, Malawi, and Uganda

The Quality of Care Network (QCN) is a global initiative that was established in 2017 under the leadership of WHO in 11 low-and- middle income countries to improve maternal, newborn, and child health. The vision was that the Quality of Care Network would be embedded within member countries and continued beyond the initial implementation period: that the Network would be sustained. This paper investigated the experience of actions taken to sustain QCN in four Network countries (Bangladesh, Ethiopia, Malawi, and Uganda) and reports on lessons learned. Multiple iterative rounds of data collection were conducted through qualitative interviews with global and national stakeholders, and non-participatory observation of health facilities and meetings. A total of 241 interviews, 42 facility and four meeting observations were carried out. We conducted a thematic analysis of all data using a framework approach that defined six critical actions that can be taken to promote sustainability. The analysis revealed that these critical actions were present with varying degrees in each of the four countries. Although vulnerabilities were observed, there was good evidence to support that actions were taken to institutionalize the innovation within the health system, to motivate micro-level actors, plan opportunities for reflection and adaptation from the outset, and to support strong government ownership. Two actions were largely absent and weakened confidence in future sustainability: managing financial uncertainties and fostering community ownership. Evidence from four countries suggested that the QCN model would not be sustained in its original format, largely because of financial vulnerability and insufficient time to embed the innovation at the sub-national level. But especially the efforts made to institutionalize the innovation in existing systems meant that some characteristics of QCN may be carried forward within broader government quality improvement initiatives

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

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) was established to build a cross-country platform for joint-learning around quality improvement implementation approaches to reduce mortality. This paper describes and explores the structure of the QCN in four countries and at global level. Using Social Network Analysis (SNA), this cross-sectional study maps the QCN networks at global level and in four countries (Bangladesh, Ethiopia, Malawi and Uganda) and assesses the interactions among actors involved. A pre-tested closed-ended structured questionnaire was completed by 303 key actors in early 2022 following purposeful and snowballing sampling. Data were entered into an online survey tool, and exported into Microsoft Excel for data management and analysis. This study received ethical approval as part of a broader evaluation. The SNA identified 566 actors across the four countries and at global level. Bangladesh, Malawi and Uganda had multiple-hub networks signifying multiple clusters of actors reflecting facility or district networks, whereas the network in Ethiopia and at global level had more centralized networks. There were some common features across the country networks, such as low overall density of the network, engagement of actors at all levels of the system, membership of related committees identified as the primary role of actors, and interactions spanning all types (learning, action and information sharing). The most connected actors were facility level actors in all countries except Ethiopia, which had mostly national level actors. The results reveal the uniqueness and complexity of each network assessed in the evaluation. They also affirm the broader qualitative evaluation assessing the nature of these networks, including composition and leadership. Gaps in communication between members of the network and limited interactions of actors between countries and with global level actors signal opportunities to strengthen QCN