Understanding effective approaches to addressing the common challenges faced by global health networks: Mobilising multi-stakeholder networks to address the upstream determinants of maternal health in five low- and middle-income countries.

Background: Past case studies on global initiatives to address maternal health and survival have focused on global health networks, identifying four essential tasks that define their ability to successfully enact change. We applied the conceptual framework of global health networks at the country level to organisations sharing concerns on how to address national maternal health and the upstream determinants of maternal survival in five countries and explored how they addressed these four essential tasks. Methods: We conducted focus group discussions and key informant interviews with 20 members of national maternal health multi-stakeholder networks in Bangladesh, India, Mexico, Nigeria, and Pakistan. We drew on the principles and essential components of appreciative inquiry, an assets-based action research methodology that emerged from positivist theories of organisational development to understand how the networks addressed the four tasks. We used a deductive content analysis approach, developing initial themes based on pre-designed codes corresponding to the four tasks faced by global health networks and later identifying emergent themes in the four areas of the framework. Results: We identified themes related to each of the four tasks. Participants emphasised the need for structure and focus in defining the problem, strengths associated with network diversity, and the network's ability to pivot and redefine the problem to align with other sweeping priorities, such as COVID-19 pandemic. Themes related to inspiring action centred on aligning the issue with ongoing local and global initiatives, cultivating a sense of group ownership, and defining success incrementally. Themes related to forging alliances emphasised needing to engage high-level leadership, being opportunistic about timing, reducing barriers to participation by external players, and identifying rewards for participants. Themes related to establishing a governance structure centred on needing strong structure and organisation, cultivating individual commitment, sustaining advocacy efforts, and obtaining funding. Conclusions: Our results demonstrate that challenges commonly faced by global health networks are also relevant to networks operating on a national scale and may offer them strategies for future national networks to consider adopting to address these challenges.

Measuring maternal improvement through multi-stakeholder engagement: Documenting developments in the dynamic programmatic context of the global COVID-19 pandemic through outcome harvesting.

Background: To bolster country efforts towards meeting the targets and strategies laid out in WHO's report "Strategies toward ending preventable maternal mortality" (EPMM), a series of seven consultations, known as National Dialogues, were conducted to better understand national priority areas for the improvement of maternal health and to support the adoption and use of EPMM indicators at the national level. The last Dialogue was conducted in March 2020, as the COVID-19 pandemic was beginning to have global impacts. We aimed to explore the circumstantial challenges and opportunities that countries have encountered in meeting the specific stakeholder commitments made in each country by National Dialogue participants during the COVID-19 pandemic. Methods: We based our study methodology on outcome harvesting, a qualitative approach that examines how incremental change contributes towards achieving a specified outcome. It collects evidence on what has changed and then works backwards to determine whether and how a programme or intervention led to the observed changes. We collected data from 20 participants in five countries (Bangladesh, India, Mexico, Nigeria, and Pakistan) through key informant interviews and focus group discussions. We analysed the data through inductive coding focused on emergent themes. Results: The onset of the global COVID pandemic overturned plans and upended health systems, bringing new opportunities in some countries and halting progress towards the agenda outlined in the National Dialogue elsewhere. Participants identified adaptations that facilitated continued progress, such as shifting the locus of advocacy and activity from national to sub-national focal areas, catalytic changes in response to the crisis (including the development and improvement of digital communication and data technology), and increased awareness of the importance of identified priorities (including a human rights approach to maternal health). Conclusions: Our data suggest that the priorities for maternal health system performance to drive improvement toward ending preventable maternal deaths and the advocacy commitments designed to increase the relevance of upstream policy and health system-level determinants of maternal health and survival have retained their urgency during the COVID-19 pandemic.