Nambiar, BP; (2016) Investigating the effect of a quality improvement intervention on newborn care in three central districts in Malawi. Doctoral thesis , UCL (University College London).

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Abstract

Quality Improvement (QI) interventions are complex in nature and evaluation focusing solely on measuring its impact is unable to answer questions of how or why the intervention worked. Results from the impact and outcome evaluation of a large QI intervention aimed at reducing newborn mortality in 3 central districts in Malawi had been inconclusive. I use a theory based evaluation (TBE) approach in my PhD, to analyse the implementation theory and understand the program theory behind the QI intervention in Malawi. I developed a research strategy, which includes a combination of Theory of Change (ToC) and Realist evaluation approaches for program evaluation. I begin with a description of the Theory of Change and how it evolved over the course of the project. Following this I produce a summary and synthesis of all the available evidence in relation to this Theory of Change. This includes all data generated from the process evaluation as well as a range of documentary evidence generated through the course of the project. For synthesizing this evidence I use the consolidated framework for implementation research (CFIR), which helps to develop a structured understanding of the implementation theory. Next, I adapt realist evaluation principles to analyse the intervention mechanisms. I compare the mechanisms of successful QI interventions with those of the Malawi intervention to understand why we were unable to observe an impact on newborn care in our QI health facilities. Various mechanisms for successful QI interventions have been hypothesized in literature. The strategy adopted to trigger these mechanisms include collaborative learning sessions, data improvement, continuous stakeholder engagement and feedback. While all these strategies could be identified within the QI intervention implemented in Malawi the implementation process was unable to garner enough individual or organizational momentum to trigger the actual intervention mechanisms. This can be attributed to a series of implementation challenges such as the intervention complexity characterized by conceptual clarity regarding the intervention design, the evolving role of the implementing organization, stakeholder perceptions, programme planning and governance. Contextual factors such as availability of human and material resources also influenced the mechanism of the intervention. Impact evaluation of complex interventions is important, but seldom provides information to decision makers and policy advisors on ‘how’ interventions work. Using theory-based approaches to evaluating complex QI interventions provides an insight into how and why the interventions worked (or not). Such evaluation is important for theory building and needs to adopt a broader health systems research (HSR) approach to evaluation In the discussion, I critique the evaluation approaches used and provide recommendations for future evaluation of complex interventions.

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