Table 3. Factors that shaped emergence of QCN in four pathfinding countries.

	Bangladesh	Ethiopia	Uganda	Malawi
Policy Environment
Resources and initiatives dedicated to the issue	Strong • Quality improvement initiatives predate QCN by several decades • Several ongoing, nationwide QI activities	Strong/Moderate • Successful national network initiatives • Several nationwide quality improvement activities • However, quality units at lower levels newly established	Moderate • Prior quality improvement initiatives not specifically focused on maternal and newborn health	Weak • Actors not aware of specifics of past QI initiatives • Lack of national strategy to guide quality improvement efforts
Data and health system capacity	Strong • Many health system capacity challenges concerning human resources and infrastructure • Morale and motivation relatively high among health workforce • Foundational work on national data system	Weak • Many health system capacity challenges concerning human resources and infrastructure • Morale and motivation relatively low among health workforce • Foundational work on national data system; however new QCN indicators do not align	Weak • Many health system capacity challenges concerning human resources and infrastructure • Morale and motivation relatively low among health workforce • Lack of national monitoring and evaluation framework	Weak • Many health system capacity challenges concerning human resources and infrastructure • Morale and motivation relatively low among health workforce • Foundational work on national data system; however new QCN indicators do not align
Political developments and legacies/country leadership priorities	Strong • Strong commitments (i.e., SDGs, universal health coverage, and national health sector plan)	Weak • Strong commitments, but: • Low healthcare funding and high out-of-pocket expenditure • Political transition and unrest	Moderate • Strong commitments, but: • Low healthcare funding	Moderate • Strong commitments, but: • Low healthcare funding and frequent budget cuts
Nature of Network
Governance	Strong • Integration in strong government agency: Quality Improvement Secretariat (QIS)—responsible for setting quality standards and introducing QI improvement procedures within medical facilities since 2015 • Long history and high level of interaction and trust between many QCN implementing agencies and government actors	Moderate • Integration in strong government agency: Federal Ministry of Health of Ethiopia, which had strong QI infrastructure prior to 2015 • Some history and level of previous interaction and trust between QCN implementing agencies and government actors • Facility selection lacks adequate representation	Weak • Initially, led largely by WHO and partners, with support from Ministry of Health (embedded in relatively newer and weaker government unit) • Implementing partners lack trust and working independently of one another • Lack of community engagement in network	Weak • Integration in relatively smaller and weaker unit in Ministry of Health: Quality Management Directorate • Relatively smaller previous history of interactions between QCN implementing partners and government • Majority of involved partners requested to be in QCN vs. being invited or sought out
Leadership	Strong • Long-standing, well-respected and charismatic leaders concerned with quality improvement	Moderate • Initially, no focal point for QCN	Moderate • Initially, no focal point for QCN and leadership capacity varying across districts	Weak • Poor leadership, especially at lower levels