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

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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.