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Background: Quality improvement collaboratives are widely used to improve health care in both high-income and low and middle-income settings. Teams from multiple health facilities share learning on a given topic and apply a structured cycle of change testing. Previous systematic reviews reported positive effects on target outcomes, but the role of context and mechanism of change is underexplored. This realist-inspired systematic review aims to analyse contextual factors influencing intended outcomes and to identify how quality improvement collaboratives may result in improved adherence to evidence-based practices. Methods: We built an initial conceptual framework to drive our enquiry, focusing on three context domains: health facility setting; project-specific factors; wider organisational and external factors; and two further domains pertaining to mechanisms: intra-organisational and inter-organisational changes. We systematically searched five databases and grey literature for publications relating to quality improvement collaboratives in a healthcare setting and containing data on context or mechanisms. We analysed and reported findings thematically and refined the programme theory. Results: We screened 962 abstracts of which 88 met the inclusion criteria, and we retained 32 for analysis. Adequacy and appropriateness of external support, functionality of quality improvement teams, leadership characteristics and alignment with national systems and priorities may influence outcomes of quality improvement collaboratives, but the strength and quality of the evidence is weak. Participation in quality improvement collaborative activities may improve health professionals' knowledge, problem-solving skills and attitude; teamwork; shared leadership and habits for improvement. Interaction across quality improvement teams may generate normative pressure and opportunities for capacity building and peer recognition. Conclusion: Our review offers a novel programme theory to unpack the complexity of quality improvement collaboratives by exploring the relationship between context, mechanisms and outcomes. There remains a need for greater use of behaviour change and organisational psychology theory to improve design, adaptation and evaluation of the collaborative quality improvement approach and to test its effectiveness. Further research is needed to determine whether certain contextual factors related to capacity should be a precondition to the quality improvement collaborative approach and to test the emerging programme theory using rigorous research designs.

Bill & Melinda Gates Foundation.

BackgroundThe poor maintenance of equipment and inadequate supplies of drugs and other items contribute to the low quality of maternity services often found in rural settings in low- and middle-income countries, and raise the risk of adverse patient outcomes through delaying care provision. We aim to describe staff experiences of providing maternal and neonatal care in rural health facilities in Southern Tanzania, focusing on issues related to equipment, drugs and supplies.MethodsFocus group discussions and in-depth interviews were conducted with different staff cadres from all facility levels in order to explore experiences and views of providing maternity care in the context of poorly maintained equipment, and insufficient drugs and other supplies. A facility survey quantified the availability of relevant items.ResultsThe facility survey, which found many missing or broken items and frequent stock outs, corroborated staff reports of providing care in the context of missing or broken care items. Staff reported increased workloads, reduced morale, difficulties in providing optimal maternity care, and carrying out procedures with potential health risks to themselves as a result.ConclusionsInadequately stocked and equipped facilities compromise the health system’s ability to reduce maternal and neonatal mortality and morbidity by affecting staff personally and professionally, which hinders the provision of timely and appropriate interventions. Improving stock control and maintaining equipment could benefit mothers and babies, not only through removing restrictions to the availability of care, but also through improving staff working conditions.

Public health interventions should be designed with scale in mind, and researchers and implementers must plan for scale-up at an early stage. Yet, there is limited awareness among researchers of the critical value of considering scalability and relatively limited empirical evidence on assessing scalability, despite emerging methodological guidance. We aimed to integrate scalability considerations in the design of a study to evaluate a multi-component intervention to reduce unnecessary caesarean sections in low- and middle-income countries. First, we reviewed and synthesized existing scale up frameworks to identify relevant dimensions and available scalability assessment tools. Based on these, we defined our scalability assessment process and adapted existing tools for our study. Here, we document our experience and the methodological challenges we encountered in integrating a scalability assessment in our study protocol. These include: achieving consensus on the purpose of a scalability assessment; and identifying the optimal timing of such an assessment, moving away from the concept of a one-off assessment at the start of a project. We also encountered tensions between the need to establish the proof of principle, and the need to design an innovation that would be fit-for-scale. Particularly for complex interventions, scaling up may warrant rigorous research to determine an efficient and effective scaling-up strategy. We call for researchers to better incorporate scalability considerations in pragmatic trials through greater integration of impact and process evaluation, more stringent definition and measurement of scale-up objectives and outcome evaluation plans that allow for comparison of effects at different stages of scale-up.

SARS-CoV-2=severe acute respiratory syndrome coronavirus 2. Further details are available in the appendix.

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BackgroundProgress towards reaching Millennium Development Goals four (child health) and five (maternal health) is lagging behind, particularly in sub-Saharan Africa, despite increasing efforts to scale up high impact interventions. Increasing the proportion of birth attended by a skilled attendant is a main indicator of progress, but not much is known about the quality of childbirth care delivered by these skilled attendants. With a view to reducing maternal mortality through health systems improvement we describe the care routinely offered in childbirth at dispensaries, health centres and hospitals in five districts in rural Southern Tanzania. We use data from a health facility census assessing 159 facilities in five districts in early 2009. A structural and operational assessment was undertaken based on staff reports using a modular questionnaire assessing staffing, work load, equipment and supplies as well as interventions routinely implemented during childbirth.ResultsHealth centres and dispensaries attended a median of eight and four deliveries every month respectively. Dispensaries had a median of 2.5 (IQR 2–3) health workers including auxiliary staff instead of the recommended four clinical officer and certified nurses. Only 28% of first-line facilities (dispensaries and health centres) reported offering active management in the third stage of labour (AMTSL). Essential childbirth care comprising eight interventions including AMTSL, infection prevention, partograph use including foetal monitoring and newborn care including early breastfeeding, thermal care at birth and prevention of ophthalmia neonatorum was offered by 5% of dispensaries, 38% of health centres and 50% of hospitals consistently. No first-line facility had provided all signal functions for emergency obstetric complications in the previous six months.ConclusionsEssential interventions for childbirth care are not routinely implemented in first-line facilities or hospitals. Dispensaries have both low staffing and low caseload which constrains the ability to provide high-quality childbirth care. Improvements in quality of care are essential so that women delivering in facility receive “skilled attendance” and adequate care for common obstetric complications such as post-partum haemorrhage.