BackgroundDonors often fund projects that develop innovative practices in low and middle-income countries, hoping recipient governments will adopt and scale them within existing systems and programmes. Such innovations frequently end when project funding ends, limiting longer term potential in countries with weak health systems and pressing health needs. This paper aims to identify critical actions for externally funded project implementers to enable scale-up of maternal and newborn child health innovations originally funded by the Bill & Melinda Gates Foundation (‘the foundation’), or influenced by innovations that were originally funded by the foundation in three low-income settings: Ethiopia, the state of Uttar Pradesh in India and northeast Nigeria. We define scale-up as the adoption of donor-funded innovations beyond their original project settings and time periods.MethodsWe conducted 71 in-depth, semi-structured interviews with representatives from government, donors and other development partner agencies, donor-funded implementers including frontline providers, research organisations and professional associations. We explored three case study maternal and newborn innovations. Selection criteria were: a) innovations originally funded by the Bill & Melinda Gates Foundation (‘the foundation’), or influenced by innovations that were originally funded by the foundation; b) innovations for which a decision to scale-up had been made, allowing us to reflect on the factors influencing those decisions; c) innovations with increased geographical reach, benefitting a greater number of people, beyond districts where foundation-funded implementers were active. Our data were analysed based on a common analytic framework to aid cross-country comparisons.ResultsBased on study respondents’ accounts, we identified six critical steps that donor-funded implementers had taken to enable the adoption of maternal and newborn health innovations at scale: designing innovations for scale; generating evidence to influence and inform scale-up; harnessing the support of powerful individuals; being prepared for scale-up and responsive to change; ensuring continuity by being part of the transition to scale; and embracing the aid effectiveness principles of country ownership, alignment and harmonisation.ConclusionsSix critical actions identified in this study were associated with adopting and scaling maternal and newborn health innovations. However, scale-up is unpredictable and depends on factors outside implementers’ control.

Background The quality of data obtained through Focus Group Discussions (FGDs) is highly dependent on appropriate design and facilitation. In low-income settings steep power gradients between researcher and participants, as well as conversational norms, could reduce the ability of participants to voice personal opinions. Activity-oriented exercises have been suggested as a way overcoming these challenges, however little evidence exists - to date - on their use in low-income settings. We selected six exercises for use in Ethiopia and Nigeria and report our experiences. Methods The six exercises (picture sorting, associative pictures, picture ranking, decision trees, predictive story-telling and provocative statements) were used in 32 maternal and new-born care themed FGDs conducted in Amhara and Southern Nations Nationalities and People’s Regions (Ethiopia) and Gombe State (Nigeria). Six facilitators and two supervisors who used these exercises were interviewed about their experiences. FGD verbatim transcripts and interview notes were analysed to explore methodological effectiveness and respondents’ experience. All data were coded in NVIVO using a deductive coding frame. Results Facilitators and participants described the methods as ‘fun’ and ‘enjoyable’. The exercises yielded more in-depth and complete information than ‘normal’ FGDs, but facilitator’s probing skills and overall FGD group dynamics proved crucial in this success. Explaining and conducting the exercises increased FGD length. Data richness, participant reaction and understanding, and ease of facilitation varied by study site, exercise, and participant group. Overall, the exercises worked better in Nigeria than in Ethiopia. The provocative statement exercise was most difficult for participants to understand, the decision-tree most difficult to facilitate and the picture exercises most enjoyable. The story telling exercise took relatively little time, was well understood, yielded rich data and reduced social desirability bias. Discussion The majority of the exercises proved successful tools in yielding richer and less biased information from FGDs and were experienced as fun and engaging. Tailoring of the exercises, as well as thorough training and selection of the facilitators, were pivotal in this success. The difference in the two countries shows that adequate piloting and adaptation is crucial, and that some exercises may not be adaptable to all settings.

Health interventions introduced as part of donor-funded projects need careful planning if they are to survive when donor funding ends. In northeast Nigeria, the Gombe State Primary Health Care Development Agency and implementing partners recognized this when introducing a Village Health Worker (VHW) Scheme in 2016. VHWs are a new cadre of community health worker, providing maternal, newborn and child health-related messages, basic healthcare and making referrals to health facilities. This paper presents a qualitative study focussing on the VHW Scheme’s sustainability and, hence, contributes to the body of literature on sustaining donor-funded interventions as well as presenting lessons aimed at decision-makers seeking to introduce similar schemes in other Nigerian states and in other low- and middle-income settings. In 2017 and 2018, we conducted 37 semi-structured interviews and 23 focus group discussions with intervention stakeholders and community members. Based on respondents’ accounts, six key actions emerged as essential in promoting the VHW Scheme’s sustainability: government ownership and transition of responsibilities, adapting the scheme for sustainability, motivating VHWs, institutionalizing the scheme within the health system, managing financial uncertainties and fostering community ownership and acceptance. Our study suggests that for a community health worker intervention to be sustainable, reflection and adaption, government and community ownership and a phased transition of responsibilities are crucial.

Background: Nigeria has one of the highest maternal mortality rates in the world, but facility delivery levels are relatively low and stagnant. Few qualitative studies have explored this issue and most have focused on barriers to utilization, much can be learnt from women who already deliver in facilities. Objectives: We aimed to identify facilitators and barriers to facility delivery in Gombe State in North East Nigeria with a focus on women who have had a facility delivery. Methods: We conducted 24 narrative and in-depth interviews with mothers, and 16 focusgroup-discussions with mothers, fathers, grandmothers and community health workers. Data were collected in Hausa, and transcribed and translated into English. Preliminary data analysis was conducted through team workshops, followed by systematic coding of the transcripts. Initial themes were identified a priori from the research questions and others emerged during coding. Results: A safe delivery was the main motivator for facility delivery, with facilities considered safe because of the presence of a trained health worker, the detection and management of problems, the availability of medicines and good hygiene. Those who delivered in a facility had a desire to be modern and rejected traditional practices. Decision-making power, social norms, accessibility, cost and perceived poor quality of care were reported as barriers. Community health workers, when they reached households, provided information on the benefits of facility delivery, stressed that times were changing, provided practical help such as arranging transport and, by accompanying families to the facility, brokered better quality of care and provided social support. Conclusion: This study highlights both the facilitators and barriers to facility delivery, and demonstrates the need for interventions to address a wide range of issues at multiple levels.

In Ethiopia, high community-level exposure to consistent messages and the perceptions of community health workers (CHWs) drove behavior change. n In Nigeria, exposure to messages was limited, CHW were less trusted, and behavior change was reported less frequently.