How does a multi-country, multilateral network focused on specific health care improvements evolve and what shapes its ability to achieve its goals?

Maternal and newborn mortality remain high in low-resource settings, including Malawi, Bangladesh and Uganda, the focus countries of this proposal, and the other six countries involved in the quality of care network we seek to evaluate. With increasing rates of births in hospitals across low-income settings including Malawi, Bangladesh and Uganda, there is a need for health system interventions that optimise quality of care so that further reductions in mortality can be achieved despite resource constraints. To tackle a shared low- and middle-income country (LMIC) need for improved labour, childbirth and newborn care the World Health Organisation (WHO) and global partners are pursuing a 'global network' approach called The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN). Their aim is for countries to learn from each other about which approaches to improving quality of care may work best in which circumstances to achieve shared health outcome goals. The QCN, which initially involves nine countries, aims to promote coordination between partners while emphasising country ownership and leadership, and shared learning. Though there is an emerging body of work on health networks this is mostly from high-income countries or on networks focused on drawing attention to global health issues rather than those implementing change. Research on whether and how purposefully created networks might leverage global, national and local change is however, sparse.

We intend therefore to take advantage of the launch of the QCN by WHO and partners and examine how it is constructed, its operations and their effects. The network was launched in February 2017 though, to date, no external evaluation has been commissioned. Given the scale and ambition of this new QCN, the investments it involves and the possibility it could influence the way international health organisations and donors operate in the future, it needs to be studied. We propose to retrospectively (2016-2018) and prospectively (2018-2022) evaluate what aspects of the QCN work best, how it influences efforts at global, national, and local levels and how it bridges the interfaces between each of these levels (see research questions in summary of objectives).

Our work will draw on theories concerning network organisation and structure, emergence and effectiveness of networks, the policy process (agenda-setting, formulation, decision-making, implementation and evaluation), the nature of power and agency in relation to structure, and diffusion of innovation. Given available resources for this funding call we have chosen to focus our evaluation at the global level and in three of the nine countries. We have chosen Malawi, Bangladesh and Uganda as case study countries based on the range of settings and starting points they represent, their initial engagement in the network (so that we have material to evaluate), existing research links and collaborations, and enthusiasm to participate in this research. We will answer our research questions via a multi-disciplinary mixed methods programme of work that aims to achieve our objectives (see summary of objectives) by targeting the global level of the QCN, and Malawi and Bangladesh's programmes as case studies for the national and local levels, to develop theory on how the QCN operates. We will then test this emerging theory in Uganda to assess its external validity and refine aspects of it in relation to country and health systems context as appropriate.

We aim to develop generalizable theory to improve the operation of the QCN and future networks, as indicated in our impact and objectives summaries.

Our research seeks to evaluate, via three research questions (see objectives above) the emergence, legitimacy and effectiveness of a multi-lateral multi-country purposefully created implementation-focused network to improve the quality of care for maternal, newborn and child health (QCN). We will study the QCN global level, and national and local levels in three case study countries. We will examine the global-national and national-local level interfaces. We will develop theory relating to how QCN functions utilising and advancing underlying theories relating to the policy process, the interplay of structure, agency and power and its relation to policy capacity determinants including individual, organisational and systemic level capacities, and pertinent contextual and cultural factors. We will also explore network implementation in relation to the theory of change proposed by QCN and seek to develop this further in relation to the role of network actors and stakeholders. Here we will utilise framing theories related to diffusion of innovation, network organisation and effectiveness, knowledge management, and behaviour change.

To answer our research questions we will collect a mixture of qualitative and quantitative data over five iterative prospective rounds. We will interview key QCN actors and stakeholders at global, national, and local levels, conduct observations at best and worst performing hospitals in our case study countries, review key QCN documents, and conduct surveys of QCN members, and triangulate across these data. We will also access, and critique, the monitoring and evaluation data of QCN (including retrospective data) to track key processes, outputs and outcomes and assess the plausibility of QCN effects on health outcomes. We will conduct within-case, cross-case and case synthesis analyses using process-tracing, stakeholder network analysis, and thematic analyses framed by the aforementioned theories.

Our work will allow 'The Network for Improving Quality of Care for Maternal, Newborn and Child Health' (QCN) to improve its activities, as well as providing a much-needed rigorous evaluation of its work. We expect results of this study to enable improvement of key QCN mechanisms and processes to help it achieve its goal of halving maternal, newborn and stillbirth case fatality rates in participating hospitals by 2022. Via their engagement in the research key QCN stakeholders at global and national levels including policy-makers, Ministry of Health implementers and managers, and technical partners and donors, could effect the necessary operational changes deemed appropriate by the revised empirically-based theory of change for the QCN resulting from our work. The results of this work could also inform the design of future healthcare and development focused networks in low-resource settings with the associated benefit of such networks being more likely to achieve their goals.

The overall impact of our work, and it's knock-on effects could therefore be very large - leading to improvements in a variety of health and related outcomes for many different groups of people across low- and middle-income countries. Many countries are way off needed trajectories to achieve Sustainable Development Goal 3 health targets and this work should help lead to effective coverage of maternal and newborn health services as part of efforts to achieve universal health coverage.

This research is likely to be extremely cost-effective as it concerns the evaluation of as yet unevaluated activities across nine countries that we understand to represent direct investment in excess of $18 million and very large opportunity costs at global, national and local levels. Two-thirds of the funding we are seeking will also be spent directly on research in low-and-middle income countries (Malawi, Bangladesh, Uganda) and will strengthen research capacity in these countries too.