Developing an understanding of networks in LMIC health systems: how and why networks change practices to improve service delivery and quality of care

Health systems are complex and plagued with challenges leading to poor quality of care, outcomes, and health systems functioning. Often approaches to health systems strengthening focus on tangible parts of the system. However, health systems are based on people and so are, by nature, relational. Many of the challenges are, at the root, also relational. Networks are increasingly employed to tackle health system challenges by either explicitly or implicitly targeting the relational aspects of health systems. In my DPhil, I define networks as groups of facilities and/or healthcare stakeholders that are linked with an aim to change practices to improve care and health system functioning. There is limited theory-based scholarship understanding how and why networks form, function, perform, and evolve in low- and middle-income country health systems. My DPhil addresses this knowledge gap, progressing through three linked phases. In an extensive Scoping Review, I mapped the network literature (129 manuscripts) and developed a framework of key network components. Building on this, I conducted a Realist Review developing an initial programme theory explaining how and why networks form and function to change practices. I tested this programme theory through a Realist Evaluation on the Newborn Essential Solutions and Technologies programme network in Kenya using a multiple-methods case study comprising 33 in-depth interviews, informal meetng observations, and document review. My findings are captured in a refined programme theory that explains how a network evolves through three phases: Initiation & Formation, Functioning & Performing, and Sustaining Change & Impact through interrelated: - processes (identify a problem; collective vision; taking action to solve a problem; identity and culture) - activities (knowledge and skills dissemination; cross-learning; resourcing; leadership; champions; adaptability) - foundations (teamwork; psychological safe space; commitment; engaged, motivated, empowered, and confident network members; purposeful relationships, linkages, and partnerships) - cross-cutting factors (communication; trust; energy, effort, passion). The final programme theory provides a roadmap for the relational work those employing networks should perform to promote success.