Influences on policy-formulation, decision-making, organisation and management for maternal, newborn and child health in Bangladesh, Ethiopia, Malawi and Uganda: the roles and legitimacy of a multi-country network

Abstract

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) is intended to facilitate learning, action, leadership and accountability for improving quality of care in member countries. This requires legitimacy—a network’s right to exert power within national contexts. This is reflected, for example, in a government’s buy-in and perceived ownership of the work of the network. During 2019– 2022 we conducted iterative rounds of stakeholder interviews, observations of meetings, document review, and hospital observations in Bangladesh, Ethiopia, Malawi, Uganda and at the global level. We developed a framework drawing on three frameworks: Tallberg and Zurn which conceptualizes legitimacy of international organisations dependent on their features, the legitimation process and beliefs of audiences; Nasiritousi and Faber, which looks at legitimacy in terms of problem, purpose, procedure, and performance of institutions; Sanderink and Nasiritousi, to characterize networks in terms of political, normative and cognitive interactions. We used thematic analysis to characterize, compare and contrast institutional interactions in a cross-case synthesis to determine salient features. Political and normative interactions were favourable within and between countries and at global level since collective decisions, collaborative efforts, and commitment to QCN goals were observed at all levels. Sharing resources and common principles were not common between network countries, indicating limits of the network. Cognitive interactions—those related to information sharing and transfer of ideas— were more challenging, with the bi-directional transfer, synthesis and harmonization of concepts and methods, being largely absent among and within countries. These may be required for increasing government ownership of QCN work, the embeddedness of the network, and its legitimacy. While we find evidence supporting the legitimacy of QCN from the perspective of country governments, further work and time are required for governments to own and embed the work of QCN in routine care.

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

“…In other papers from this collection, we analysed the complexity of the network's composition and functioning at global, national, sub-national and local levels. [7,10,[19][20][21] In this paper, our analysis focuses on the effectiveness of the QCN through its various outputs and policy consequences as well as through the impact of such activities. We begin our analysis at the global level and then move to a cross-country analysis of QCN effectiveness at national and local levels in relation to the four LALA strategic aims -Leadership, Action, Learning, Accountability -envisioned by the QCN network as a whole.…”

“…The COVID- country. [10] This was also compounded by a lack of organisational and policy capacity, especially in Malawi, and external shocks such as the COVID-19 pandemic in all countries, and the conflict in Ethiopia. [21] We found the emergence of QCN to be greatest in Bangladesh [7] and this is reflected in Bangladesh being closest to national scale-up in this paper.…”

Factors Shaping Network Emergence: A Cross-Country Comparison of Quality of Care Networks in Bangladesh, Ethiopia, Malawi, and Uganda

“…Furthermore, the presence of charismatic and respected in-country champions is especially crucial in bringing actors together and giving the network legitimacy. [29] In Bangladesh, the buy-in and involvement of several nationally-recognized quality improvement champions gave QCN immediate credibility within the country, contributing to the relatively fast uptake of network activities.…”

“…The factors identified-both relating to the policy environment and the nature of the network-not only shape the speed and way networks are established, but also have implications for the network's perceived legitimacy [29] and the trajectory of the network's later development and effectiveness. [31] By understanding a network's emergence, practitioners may be in a better position to predict future outcomes, and also more effectively strategize accordingly to minimize or resolve less than favorable developments at the inception phase, in order to achieve long-term success.…”

“…Studying QCN emergence-as opposed to the network's ultimate effectiveness in producing outcomes related to quality improvement-provides critical insights as to why some well-intentioned top-down global health networks don't materialize in some country contexts and have relatively quick uptake in others. The pattern, speed, and extent of a network's initial emergence is likely to reflect and have implications on a network's legitimacy, configurations and interactions among involved actors, and ultimate effectiveness in producing stated objectives-each of which are discussed respectively by Akter et al, [29] Mukinda et al, [30] and Djellouli et al [31] in this paper series. An understanding of the key factors shaping variable network emergence across these countries is critical to WHO and global partners, as they seek to establish QCN activities in other countries, but also more broadly for policymakers seeking to initiate global health networks and partnerships across various contexts.…”