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 models: 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.

Fig 1. Framework describing drivers of legitimacy and ownership of the work of quality of care network (QCN) from the perspective of national governments leading the work of QCN.

A) Depiction of interactions between institutions (actors) comprising the quality of care network (QCN) at global level (left) and national level (right). Interactions include political, normative and cognitive interactions between institutions as defined by Sanderink and Nasiritousi [19]. The width of the arrows indicates the strength of the interaction and is illustrative only and analyzed qualitatively. The width of the arrow depends on the variables in part B of the figure. B) We draw on work on individual, organizational and system capacities [20, 21] and models by Nasiritousi and Faber [13] (purple text) and Tallberg and Zurn [9] (orange text) on sources of institutional legitimacy to describe factors influencing the strength of interactions between institutions. These are depicted as characteristics of organizations (center of the diamond), organizational culture (next layer of the diamond) and wider culture and political stability surrounding the organization (outer diamond).

Fig 2. QCN learning and sharing methods at global, regional, national and local levels.