Table 1.

Assumptions underlying the theory of change

Assumptions
1. Key stakeholders are convinced by the available evidence about the MSI and are initially (assumption 1a) and remain (assumption 1b) willing to collaborate with the scale-up process
2. Attention of national scale-up steering group members (assumption 2a) and resource team members (assumption 2b, added in 2018) not diverted by other priorities; low staff turnover of national scale-up steering group members (assumption 2c, added in 2020)
3. New knowledge on scale-up lessons is sufficiently well documented (assumption 3a) and disseminated (assumption 3b)
4. Sufficient opportunities to apply scale-up knowledge are available
5. DHMTs are willing to participate in the intervention even though no implementation funds are provided
6. Effective facilitation skills of the country research team (assumption 6a) and resource team (assumption 6b)* during action research cycles; work plan developed by DHMTs is feasible (time-frame, decision-authority, resources) (assumption 6c) and addresses real problems (assumption 6d)
7. DHMTs remain convinced of the value of the MSI (assumption 7a); and sufficient support is available from the resource team to support the expansion of district groups (assumption 7b)
8. Resource team members develop sufficient facilitation skills from working with new district groups (assumption 8a); low turnover of resources team members (assumption 8b)
9. DHMT remains key organisational structure at sub-national level (assumption 9a); DHMT works as a team (assumption 9b); low turnover of DHMT members (assumption 9c); decision-space does not decrease (assumption 9d)
10. DHMTs' involvement in this project, with the consequent opportunity costs, does not undermine (through possible diversion in project activities) health service delivery
11. Service delivery plans remain in line with health care needs
12. New knowledge on MSI lessons is sufficiently well documented (assumption 12a, added in 2019) and disseminated to relevant stakeholders (assumption 12b, added in 2019)
13. The MSI is a scalable intervention and, if needed, further adapted to the context in which it is implemented (added in 2021)
14. There is an understanding of power relationships between key stakeholders, which could potentially hinder or facilitate scale-up
15. Windows of opportunity to integrate (parts of) the MSI in existing structures and strategies are identified and used (added in 2021)

DHMT District health management team, MSI Management strengthening intervention

^* In 2019, the assumption ‘Effective facilitation skills during action research cycles’ was specified to refer to both the country research team and the resource team