Table 4.

Foundational factors in the MERI motivational framework.

Factor	Description
Self-reliance	Districts, health facilities, and communities are encouraged to create change by themselves for themselves. Autonomy is promoted at all levels, cultivating innovation, local solutions for local needs, and resourcefulness through a “use what you have” philosophy. Participatory facilitation methods grounded in community development theory encourage skill development, meaningful dialogue, and critical thinking while discouraging dependency.
Collective action	Broad, informed, and action-oriented engagement cultivates constructive relationships and cooperation. A culture of “everyoneness”, investment in champions, and a clear and unified goal enhances connectivity and momentum within and between levels. Resolve for change is affirmed and drives collaborative implementation and action.
Embeddedness	Maximizing compatibility with district and community priorities, structures, and processes is integral to change implementation. Existing resources and people are leveraged; activities align with district and national programs and policies. Investment in district leadership as key implementation team members reinforces use of established structures and reporting relationships. A “cascade approach” sees initial activities amongst district stakeholders, who, in turn, support health facility capacity development, whose representatives then engage communities.
Transparency	Clear and consistent communication and practices from implementation outset proactively address common expectation gaps. Well-documented implementer, participant, and beneficiary roles and responsibilities are shared early and widely; problems are addressed quickly and openly.
Comprehensiveness	A “whole system” approach ensures intervention compatibility with all structures (health and non-health) throughout an entire district. District-wide and broad coverage, reach, and comprehensive engagement seek to leave none out, consistent with district health system priorities.