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. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was funded by the Medical Research Council (MRC) Health Systems Research Initiative 5th call via grant MR/S013466/1 to TC at UCL Institute for Global Health, United Kingdom, YS and JS at Johns Hopkins University, United States of America, KA and AK at Diabetic Association of Bangladesh Perinatal Care Project, Bangladesh, CM at Parent and Child Health Initiative, Malawi, GS at Makerere University School of Public Health, Uganda, and ME at University of Oxford, United Kingdom; and by the Bill & Melinda Gates foundation via grant INV-007644 to TM at LSHTM, United Kingdom. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval was obtained from the Research Ethics Committee at University College London (3433/003); institutional review boards in Bangladesh, BADAS Ethical Review Committee (ref: BADAS-ERC/EC/19/00274), Ethiopian Public Health Institute Institutional Review Board (ref: EPHI-IRB-240-2020), National Health Sciences Research Committee in Malawi (ref: 19/03/2264) and Uganda Makerere University School of Public Health- Higher degrees Research Ethics Committee in Uganda (ref: Protocol 869) I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data is derived from qualitative interviews, most with stakeholders where only one individual holds a position, either within federal or state government, facilities, orNGOs. Every care has been taken to ensure anonymity of the data in the submitted manuscript but the authors from all 4 countries feel strongly that making data freely available would jeopardise the conditions of informed consent. We therefore request to be exempt from the requirement to make data available but have uploaded a detailed methods document. Thank you for your consideration