Sustaining Quality of Care program in maternal and neonatal health: Key enablers and barriers in Malawi's primary health facilities- A qualitative study

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While substantial investments have been made in quality improvement initiatives, their long-term sustainability remains uncertain, particularly in low- and middle-income countries. Despite significant efforts, challenges persist in maintaining the effectiveness of these programs over time. This study aimed to explore the key enablers and barriers to the sustainability of quality of care programs in maternal and neonatal healthcare in Malawian primary health facilities, particularly Mdeka and Chilomoni in the Blantyre District. Study design: This study employed a qualitative research approach with a cross-sectional descriptive design. Data were collected via in-depth interviews and focus group discussions from a purposive sample of 27 participants, including five policymakers, twelve health workers, and ten clients at the Mdeka and Chilomoni health facilities. The data were analysed via thematic analysis to identify key patterns and themes. Results The analysis of the data revealed four major themes influencing the sustainability of quality of care program at Mdeka and Chilomoni health facilities. These were shaped by the availability of resources, leadership practices, human capacity, motivation, and community engagement. The themes reflected both enabling and constraining factors, as perceived by the participants. Conclusion The sustainability of quality of care programs in primary health facilities in Malawi is influenced by multiple interrelated factors. Addressing gaps in these domains is essential for embedding quality improvement into routine service delivery and safeguarding long-term maternal and neonatal health gains. Strengthening leadership accountability, embedding capacity building, and institutionalising community participation is critical to sustaining quality improvement initiatives and improving maternal and neonatal outcomes. Sexual & Reproductive Medicine Health Policy Quality of care Sustainability Maternal and neonatal health Primary health facilities Background Quality improvement (QI) is a vital component of healthcare systems globally, particularly in reproductive health settings, where high maternal and neonatal mortality rates remain a major challenge ( 1 ). In 2020, approximately 287,000 women died from pregnancy and childbirth-related causes, whereas 2.4 million newborns died within the first 28 days of life, mostly from preventable causes ( 2 ). These deaths are disproportionately concentrated in low- and middle-income countries (LMICs), highlighting the persistent gaps in healthcare quality and delivery. Quality of care (QoC) interventions aim to continuously improve healthcare processes through structured, iterative approaches that involve personnel in implementing changes to enhance service quality ( 3 ). Such interventions have demonstrated the potential to reduce maternal and neonatal mortality and improve overall reproductive health outcomes ( 4 ). In sub-Saharan Africa, countries such as Malawi have made notable strides in implementing QoC initiatives, particularly in terms of maternal and neonatal health ( 5 ). Despite significant progress in QoC program interventions in LMICs, persistent challenges in maintaining high standards of care continue to undermine long-term gains ( 6 ). Evidence indicates that sustaining improvements requires more than short-term interventions; it demands systems, practices, and resources that can be embedded within routine health service delivery ( 1 ). Evidence from Malawi’s Blantyre district shows that only a minority (30%) of QoC interventions have been sustained from 2020 to 2023, according to reports from the District Health Information Systems 2 of 2023. Therefore, understanding the factors that either facilitate or hinder sustained QoC interventions is important for strengthening Malawi’s primary health facilities, which are the first point of care for most women and newborns ( 5 ). Identifying these enablers and barriers provides insights for policy and program implementation and contributes to global discussions on building resilient health systems capable of delivering high-quality care over time ( 6 ). This study explored the key enablers and barriers to sustaining quality of care in Malawi’s primary health facilities, with a focus on maternal and neonatal health (MNH). Methods Study Design A cross-sectional design was employed using descriptive qualitative data collection and analysis approaches. The design acknowledged the subjective nature of the problem and the diverse experiences of the participants, presenting the findings in a manner that directly reflected or closely resembled the terminology used in the research questions ( 7 ). This approach allowed for an in-depth exploration of how participants perceived, interpreted, and experienced sustainable practices within the QoC programme, providing rich insights into their views and motivations. The study was guided by the NHS Quality Improvement Sustainability Model ( 8 ), which informed data collection tool development. Study Setting The study was conducted at the Mdeka and Chilomoni health facilities in Blantyre, Malawi. These facilities were purposively selected from the ten facilities in Blantyre where the QoC program was initiated on the basis of their performance challenges in sustaining the program. Mdeka and Chilomoni health facilities have been implementing maternal and neonatal healthcare programs for a considerable period, providing a rich context for exploring the specific challenges and successes related to the sustainability of these interventions in Malawi. Study population The study population comprised a diverse range of stakeholders involved in the QoC program, including healthcare providers who were doctors, nurses, midwives, data clerks, hospital attendants, and other clinical staff directly involved in implementing QoC interventions at the Mdeka and Chilomoni health facilities; policymakers, who were individuals involved in strategic planning and resource allocation for the QoC program, including the District QI manager and members of the National Coordination Committee for the QoC program; and clients, who were patients or guardians who experienced QoC program interventions at the Mdeka and Chilomoni health facilities. The inclusion criteria included stakeholders who were directly engaged in and benefited from the QoC program at the Mdeka and Chilomoni health facilities. The exclusion criteria included those who were unwell and unable to communicate, those who were unwilling to participate or provide informed consent, and those with less than one year of experience in the program, as they were considered to have limited exposure to and understanding of the QoC program. Sampling and participant recruitment process Purposive sampling was used to select participants with in-depth knowledge of and experience with the QoC programme interventions. This method ensured that the participants could provide rich, relevant, and diverse insights into the research questions ( 9 ). A total of twenty-seven participants were interviewed, including ten individual interviews and two focus group discussions (each comprising six participants). The sample size was consistent with guidance indicating that descriptive qualitative studies typically range between five and forty participants ( 10 ). However, the final number was determined by data saturation (( 11 ), ensuring that all important elements of stakeholders’ perceptions of the sustainability of the QoC program were fully captured. The National Coordination Committee for the QoC Program and the Blantyre District Health Office identified policymakers. They were contacted through formal emails and phone calls to explain the purpose of the study and to seek consent. Healthcare workers at the Mdeka and Chilomoni health facilities were approached in person during facility visits to ensure representation across different professional roles. Patients/guardians (clients) who had used maternal and neonatal services at the facilities were recruited with the assistance of facility management and staff, whose support facilitated the process. Data collection methods Multiple methods were employed to triangulate the findings and enhance their credibility. Semi structured in-depth interviews: Fifteen interviews were conducted, five with policymakers and ten with clients (five from each facility). The interview guide ensured consistency while allowing flexibility for the participants to express their views. Focus group discussions (FGDs): Two FGDs of health workers were conducted (one from each facility, with six participants in each group) to capture group dynamics and shared perceptions of the QoC Program. This method elicited a range of views and generated discussions among program implementers. Data collection tools Policymakers used an interview guide focused on their perceptions of enablers and barriers to sustainability, knowledge of the sustainability of program interventions, and best practices for enhancing sustainability. For clients, the guide explored experiences with QoC interventions, perceived impact on health and well-being, and suggestions for improving sustainability. A focus group discussion guide was used with health workers, focusing on enablers and barriers to sustainability, their knowledge and capacity as implementers, and the contextual factors influencing the likelihood of sustaining QoC interventions. The questions were adapted from the NHS model assessment tool and tailored to fit the study context. The guides were initially developed in English and translated into Chichewa by language expert to ensure the accuracy of their meaning ( 12 ). The interview and focus group discussion guides are provided in Supplementary file 1 . A pretest was conducted to assess the clarity, content coverage, and alignment with the study objectives ( 13 ). The final versions of the tools were refined on the basis of expert discussions and the pretest results. Data collection was supported by audio recorders and field notes, ensuring the accuracy and completeness of the information ( 12 ). This contributed to the reliability and integrity of the findings. Data management Data from the focus groups and semi structured in-depth interviews were audiotaped, transcribed, and translated into English. Every transcript had participants’ descriptions labelled with an identification number different from any participant’s personal identifiable information. To ensure consistency of the translated transcripts, the researcher listened to the audio to check for the accuracy of the transcripts and variability in transcription and translation. The audio, transcripts, and translations were kept on the researcher’s computer with a password known only to the researcher. Trustworthiness Trustworthiness refers to the degree of confidence in the data, interpretation, and methods used to ensure the quality of a study ( 14 ). Key terms found in the literature that address the trustworthiness of results include credibility, dependability, transferability, and confirmability ( 15 ). First, to show credibility in this study, triangulation was employed using multiple data sources and methods such as interviews and focus groups. Additionally, credibility was increased by an external check of the research process by the research supervisors who reviewed the transcripts to check the preliminary findings and interpretations made. This helped ensure that emergent themes and patterns were substantiated in the data. Second, to ensure dependability for this study, an audit trail was maintained, documenting all steps from data collection to analysis. The code-recode strategy was used to ensure coding consistency, and the supervisor scrutinized the research tools to minimize inconsistencies and achieve clear and logical documentation. Furthermore, in this study, transferability was addressed through detailed descriptions of the research context, participants, and findings, enabling others to determine the applicability of the study to other settings. Purposive sampling was used to select a diverse range of participants, thereby enhancing their potential for transferability. Additionally, the first author carefully analysed the data and discussed the findings of the study by comparing them with other similar studies from different contexts. Lastly, Confirmability in this study was achieved with the first author maintaining a reflexive journal to document biases and assumptions. The first author’s professional background in healthcare quality improvement informed familiarity with QI processes however, this positionality was continually examined through reflexive practice to minimize undue influence on data collection, analysis, and interpretation. A confirmability audit was conducted, and triangulation was used to cross-check the data and interpretations, ensuring that the findings were shaped by participants' experiences and not researcher bias. Ethical considerations The study was approved by the Kamuzu University of Health Sciences Research and Ethics Committee (reference number: P. 12/24-1318). Further ethical approval was obtained from the Blantyre Research Ethics Committee of the two health facilities where the study was conducted. Before participation, verbal and written informed consent was obtained from the participants, ensuring that they were aware of the study’s purpose and procedures and their right to withdraw at any time without penalty. To ensure anonymity, participants were assigned numbers, and their names were not used in the study. After data analysis, the transcripts were maintained according to the university’s data management procedures. Data analysis The raw data from the in-depth interviews were transcribed and analysed manually. Each recorded interview was transcribed verbatim by the first author, who also verified and corrected errors in the transcription by rereading the transcribed data while listening to the recorded data. Data analysis followed the six phases of thematic analysis: becoming familiar with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report ( 15 ). First, the first author read the transcribed data from the in-depth interviews multiple times to familiarise with the data and recorded preliminary ideas of analytical interest that helped organise the data. Thereafter, a line-by-line analysis of the transcribed data was conducted to make sense of the collected data. Colours were assigned to sentences in the transcripts to indicate potential patterns. The investigator identified and extracted phrases and/or direct participant quotes from the data. Then, codes were derived from the dataset and grouped into small and meaningful chunks of data. Codes with similar meanings were grouped to form subthemes, which were further categorised into themes. The co-authors held several meetings to discuss and review the identified themes for a consensus and validated the themes to ensure that they were a true reflection of the collected data. Results Demographic characteristics of participants . This study included 27 participants across three categories. Two focus group discussions (FGDs), one from each facility, were held with six health workers from the QI support teams, representing diverse cadres (nurses, clinical officers, hospital attendants, health surveillance attendants, and data clerks), with equal sex distributions (three males and three females per group) and ages between 27 and 34 years. Ten individual interviews were conducted with female clients (aged 21–40 years) who had experienced QoC interventions, most of whom were married (70%) and had education levels ranging from standard one to form two. Five policymakers (three females, two males; aged 37–45 years) were interviewed, including QoC coordinators, a district QI manager, national assessors, and quality management officers. A detailed summary of participant demographics is presented in Table 1 . Table 1 Summary of the demographic characteristics of the study participants (n = 27) Variable Frequency (n) Percentage (%) Type of Participant Health Workers (FGDs) 12 44.4 Clients (Interviews) 10 37.0 Policy Makers (Interviews) 5 18.6 Gender Male 8 29.6 Female 19 70.4 Health Workers (n = 12) Male 6 50.0 Female 6 50.0 Age Range 27–34 years Cadres Represented Nurses Clinicians Hospital Attendants Data Clerks Health Surveillance Assistants 4 2 2 2 2 33.3 16.7 16.7 16.7 16.7 Clients (n = 10) Female 10 100.0 Age Range 21–25 26–30 31–35 36–40 4 3 1 2 40.0 30.0 10.0 20.0 Married 7 70.0 Single 3 30.0 Education Level Std 1–4 Std 5–8 Form 1–2 5 3 2 50.0 30.0 20.0 Policy Makers (n = 5) Male 2 40.0 Female 3 60.0 Age Range 37–45 years Positions Held QoC Coordinator, District QI Manager, National Assessor, Quality Management Officer [Table 1 here] Themes The analysis of the data revealed four major themes that influenced the sustainability of quality of care programs in the Mdeka and Chilomoni health facilities: resource availability, leadership, human capacity and motivation, and community engagement. These themes reflected both enabling and constraining factors as perceived by the participants. Each theme elucidates specific findings within that domain, supported by verbatim excerpts to provide additional context and insight. Table 2 presents the themes and their corresponding codes derived from the analysis. Table 2 Themes and codes Themes Codes Resource availability -Equipment and supplies -Infrastructure availability -Funding sources Leadership -Championing the program -Engaging stakeholders -Vision and Strategic Direction -Responsiveness to challenges Human Capacity and Motivation -Staff Training and Development -Recognition and rewards Community Engagement -Involvement in program planning -Community outreach programs -Feedback mechanisms Resource availability Resource availability emerged as an important enabler of QoC initiatives both at the Mdeka and Chilomoni health facilities, as described by participants. Stakeholders consistently highlighted that having adequate supplies, equipment, and functional infrastructure supported the implementation and sustainability of QI interventions in the health facilities. Health workers explained that the availability of basic medical supplies and tools, such as blood pressure machines, stationery, and other vital materials enabled them to conduct patient assessments effectively, accurately document data, and monitor progress on QI indicators. The participants highlighted that in some cases, where district-level supply chains fell short, community-driven solutions were described as playing an important role in addressing resource gaps. Health workers at Mdeka health facility described how local fundraising efforts helped procure the essential materials needed to keep QI interventions running. One participant explained, “Community fundraising is the initiative that was initiated by the community health committee in collaboration with the health facility committee; it has helped us to buy some materials such as stationery and blood pressure machine batteries when there are no supplies from the district, and in this way, we are able to have the supply of these resources and assist our clients accordingly” (FGD 2, Participant 5). Stakeholders at Mdeka health facility further acknowledged that investments in facility-level infrastructure improvements, such as enhanced hygiene, access to clean water, and upgraded cooking areas, positively influenced client perceptions and confidence in health facilities. One participant stated: “The hospital has water now where we can access it easily, rather than before, when we were going into the village to draw water at the borehole, and we would wait for long hours to access water because there were always many people since the whole village depended on it, and all that time we would leave our patients alone without guardians. In addition, the hospital had no cooking area, and we were having difficulties, especially for those of us who came from afar, and our patients would eat cold meals. However, now all this is history, and we can eat hot meals now because of the cooking area….” (Client, Participant 5). The participants in both facilities highlighted that despite these positive strides, resource constraints remained one of the most significant barriers to sustaining QI interventions. Health workers frequently reported shortages of essential drugs, including ferrous sulphate and Fansidar, stationery, and inadequate supplies of basic equipment, such as blood pressure machines. Health workers have highlighted that such shortages disrupted service delivery and, in some cases, led to negative patient experiences and poor health outcomes. One client voiced this frustration: “Sometimes you come for antenatal care with the hope that you are going to be assisted, and they tell you that they are out of drugs; so, you have to buy it outside, and if you don’t have money, then you won’t be able to get the drugs, and here at the village, most of us cannot manage to buy them…” (Client, Participant 3). Policymakers also acknowledged the fragility of resource sustainability, noting that a significant proportion of QI interventions were heavily donor driven. One policymaker highlighted this challenge: “Most of the activities are donor driven, and when donors pull out, we struggle to keep them running. Therefore, this overreliance on external funding creates uncertainty regarding the continuity of critical interventions, particularly collaborative learning sessions, outreach programs, and mentorship activities. Therefore, these constraints often affect the sustainability of QI initiatives” (Policy maker, Participant 4). Leadership The participants in both facilities reported that strong leadership and a clear policy direction played an important role in sustaining QoC interventions by setting clear goals and upholding accountability. They stated that leaders not only provide resources but also inspire and engage staff, making everyone feel like part of the improvement process. Health workers highlighted the value of active, problem-solving leadership at the facility level, especially during quality improvement review meetings and mentorship activities. They expressed that active leadership fosters a supportive environment, with one participant stating, “ When leaders are involved, they are at the forefront of QI interventions, and they can keep the team together despite facing challenges. For instance, people have attitudes, and they resist change, but when the leader can address all these challenges and recognise everyone’s potential, it inspires the team to strive for better outcomes….” (FGD 1, Participant 2). However, barriers, including variable engagement of leadership at some levels, were reported by the participants in both facilities. One participant stated: “ Most leaders are not active; they are supposed to monitor how QI working improvement teams are progressing and even provide mentorships, but most of them do not, so people relax because they are not monitored. Even those who are doing well are discouraged and stop implementing their QI interventions” (FGD 2, Participant 6). The participants also highlighted the inconsistent dissemination of policies and delays in finalising the national QoC guidelines. One policymaker acknowledged the following: “ The engagement is sometimes weak with the facilities due to transportation issues and lack of resources, and facilities end up working in isolation, hence affecting the sustainability of these QoC interventions, but the policies are disseminated in the facilities, and the problem is that people don’t read these policies; they just compile in their working stations” (Policymaker, Participant 3). Human Capacity and Motivation Training and mentorship are important for sustaining the QoC interventions. Health workers in both facilities reported that onsite mentorship, refresher training, and peer-to-peer learning helped them effectively apply QoC principles. They stated that training and mentorship built their skills and confidence in implementing QoC interventions. This support motivated them to recognise their efforts and strengthened their commitment to delivering quality care. Policymaker have highlighted the following: “Mentorships have been key because they build confidence and ensure that everyone knows and understands what is expected, which improves ownership and accountability in the facilities….” (Policy maker, Participant 4). However, inconsistent refresher training, mentorship, and low motivation were major barriers reported in the study from both facilities. New staff members often lack QI knowledge, disrupting continuity and slowing implementation. One health worker reported: “ We had QI training only once a long time ago; I cannot even remember which year it was. Since then, more new staff have joined and not trained, even if the current QI focal person has not trained, so how is he supposedly leading the team without sufficient knowledge? Even when mentorships are conducted, they are not effective enough. When they come, they are always in a hurry, they will be here for maybe 30 minutes then off, so we do not capture much….” (FG1, Participant 5). Another participant stated: “In terms of motivation honestly speaking, we don’t get any form of motivation here, yes even nonmonetary one, and that is why most people don’t participate in these initiatives, they say it’s another extra work, so the ones that we are involved we do it out of our passion and for the benefit of the patients ” (FG1, Participant 6). The recognition of staff contributions was considered motivating. Health workers suggested institutionalising reward systems to increase staff commitment and increase morale. Community Engagement Community engagement emerged as a significant factor influencing the sustainability of QoC interventions. The participants mentioned that community engagement is important in QoC interventions because it helps align services with the needs and expectations of the people. They also noted that it builds trust, accountability, and shared responsibility, which support the sustainability of interventions. They stated that involving local leaders, youth champions, health surveillance attendants (HSAs), and health advisory committees (HACs ) fostered trust and increased the uptake of services within the two facilities. One health worker highlighted the following statement: “Youth champions and HSAs have helped us reach clients who were not attending antiretroviral therapy (ART) clinics before seeking services. Additionally, the HSAs have helped us to spread some new interventions in the communities, for instance, the new WHO guidelines for antenatal contacts, because many people were not aware of this development, but now there is an improvement in antenatal contacts than before” (FG2, Participant 1). However, clients reported limited outreach and information sharing, with most health education delivered only at facilities, with one stating: “We only hear about some of the programmes when we come to the hospital, especially those of us that come from long distances; at first, there were some organisations that would come in the community with a mega phone and spread health information such as how we can prevent cholera, family planning and many more but now we only hear health information when we come here, which is when we are sick…” (Client, Participant 2). One policymaker highlighted this: “ The challenge of limited outreach and information sharing arises from funding constraints. Community-based activities require significant resources, and since they are often dependent on donor support, once donors withdraw, programs struggle to continue, leaving the system back at square one ” (Policy maker, Participant 1). The participants suggested expanding outreach, utilising community health workers to work in the community rather than at the facility, securing funding for community activities, and institutionalising community representation in planning to ensure long-term sustainability. Discussion This study demonstrated that sustaining QoC interventions in maternal and neonatal healthcare requires more than initial implementation success. Rather, sustainability emerges from the interaction between material resources, organisational leadership, workforce motivation, and community trust. While enabling factors supported continuity, persistent systemic weaknesses constrained the long-term sustainability of QoC practices in maternal and neonatal healthcare at both the Mdeka and Chilomoni health facilities. The key enablers include resource availability, strong leadership, enhanced human capacity through training, and effective community engagement. Conversely, substantial barriers, such as persistent resource shortages, inconsistent leadership engagement, inadequate staff training and motivation, and limited community outreach, were noted. Resource availability emerged as both an enabler and a vulnerability. This study revealed that resource availability emerged as a critical enabler of QoC initiatives across the health facilities studied. The participants consistently highlighted that adequate supplies, equipment, and functional infrastructure directly supported the smooth implementation and sustainability of the QI interventions. This aligns with the National Health Service Quality Improvement Sustainability Model (NHS QISM), which identifies resources (staff, infrastructure, and materials) as a core construct influencing sustainability by enabling the continuous delivery of interventions ( 8 ). These findings are consistent with several contemporary studies that suggest adequate resources positively influence sustainability by supporting the continuity of quality services. For example, an integrative review of healthcare programme sustainability identified funding and resource availability as among the most frequently reported outer-setting factors influencing programme continuation ( 16 ). Robust resourcing has also been described as a key enabler of sustained QI initiatives, ensuring that improvements are maintained beyond the period of initial project funding or when external oversight wanes ( 17 ). However, participants from both facilities reported inconsistent availability of essential medical supplies, such as blood pressure machines, stationery, and other vital materials, which prevented them from conducting patient assessments effectively and monitoring progress on QI indicators. In Malawi, primary healthcare facilities do not receive direct funding from the district or central levels but rather receive resources in kind through district orders ( 18 ). The current system limits the autonomy of facilities in planning, budgeting, and monitoring expenditures effectively. Critics argue that resource allocation is insufficient without systemic management reforms; resources often fail to translate into sustained quality because of poor coordination, misalignment, or wastage ( 19 ). The evidence suggests that even well-resourced health systems can produce suboptimal outcomes when foundational governance structures, service delivery platforms, and workforce systems are weak ( 6 ). Similarly, health system reform efforts must address financing mechanisms, delivery architecture, and incentive structures if resources are to meaningfully improve health outcomes ( 15 ). This dual perspective aligns with sustainability frameworks that recognise that while resources are essential, they must be embedded in adaptive processes, supportive culture, and organisational capacity for true sustainability ( 8 ). The study further revealed that active leadership plays an important role in sustaining the QoC by promoting accountability, staff engagement and collaborative problem solving. Health worker participants in both facilities reported that many facility leaders remained inactive in driving improvement initiatives in their organisations. This perceived lack of leadership engagement was reported to have a demotivating effect on some health workers, which may undermine collective efforts to sustain QoC initiatives.These results are consistent with the NHS QISM’s emphasis on strategic leadership and organisational support as a dynamic process vital for institutionalising QI practices and sustaining change through relational and motivational mechanisms ( 8 ). Similar challenges have been documented in the literature, where inconsistent leadership has been shown to weaken team cohesion and disrupt the continuation of improvement activities ( 20 ). A systematic review of leadership styles in healthcare programmes further demonstrated that limited or inconsistent engagement by formal leaders and managers was associated with declining improvement efforts over time( 21 ) . Human capacity and motivation were other factors that emerged from the study as vital for sustaining QoC interventions. Health workers reported that onsite mentorship, refresher training, and peer learning enhanced their knowledge, confidence, and ownership of QI activities. Consistent with the NHS QISM, which identifies staff capability and engagement as central to sustaining change, mentorship in this study strengthened understanding, accountability, and commitment among health workers in both facilities. However, sustainability was undermined by irregular refresher training and ineffective mentoring. The participants noted that rushed mentorship visits and a lack of QI induction for new employees hindered continuity, whereas limited motivation, particularly the absence of both financial and nonfinancial rewards, further reduced participation in the QI project. These results align with existing global evidence on factors associated with QI sustainability ( 22 , 23 ). Supportive onsite supervision has also been found to be more effective in improving quality outcomes than one-off training interventions ( 22 ). Sustained improvements have been associated with structured and continuous QI education in several settings ( 23 ). The challenges identified in this study, including hurried mentorship and inadequate follow-up, reflect operational weaknesses reported elsewhere, suggesting that the quality and consistency of mentorship are more important than its mere presence ( 23 ). Motivation has also emerged as a key determinant of sustainability in this study. Health workers indicated that recognition, even in nonmonetary forms, could improve morale and engagement. This finding is consistent with evidence showing that recognition, supportive leadership, and opportunities for professional development play critical roles in sustaining motivation in resource-constrained settings ( 24 ). Collectively, these findings suggest that formalising reward systems and embedding recognition within organisational culture may strengthen long-term participation in QI initiatives. This study also revealed that community engagement is essential for sustaining the quality of care. The participants highlighted that community engagement builds trust and accountability in the community. However, they reported that community engagement was hindered by poor outreach, weak feedback systems, and funding shortages. The participants attributed these issues to donor dependence, which threatens continuity after the end of external support. These findings align closely with the NHS QISM, which emphasises that sustainable quality improvement depends on stakeholder buy-in, integration into organisational systems, and stable resources ( 15 ). In this context, community involvement contributes to shared accountability and service alignment, reflecting sustainability principles. Despite this, limited outreach, weak feedback loops, and reliance on donor funding point to gaps in the institutionalisation of community engagement processes, suggesting that participation may remain project-based rather than fully system-driven ( 25 ). Similar findings have been reported across sub-Saharan Africa, where community health committees have been shown to strengthen accountability and resource mobilisation but often lack legitimacy and structured involvement in decision-making processes ( 28 ). In Zambia, structured platforms for community voice improved responsiveness and citizen empowerment but struggled to address systemic constraints without institutional backing ( 26 ). Comparable challenges have been observed in Nepal, where the absence of formal feedback channels weakens trust and participation ( 30 ). The participants’ recommendations to strengthen the role of community health workers align with evidence showing that CHWs serve as effective intermediaries between health facilities and communities, enhancing communication, health-seeking behaviour, and programme sustainability (31,32). While the findings of this study are broadly consistent with the literature, contextual differences remain evident. In settings such as Rwanda, where community engagement and health insurance mechanisms are domestically financed, sustained community participation has been successfully institutionalised ( 29 ). In contrast, the reliance on donor-funded outreach observed in this study reflects weaker integration of community engagement into core health system functions. Strengths and limitations of the study This study addresses an underserved research area by providing much-needed evidence on the sustainability of QoC interventions in maternal and neonatal care in Malawi, a topic that remains underexplored despite being central to improving health outcomes in LMICs. The inclusion of multiple stakeholder groups, including policymakers, health workers, and patients or guardians, also strengthens this study by capturing diverse experiences across different levels of the health system. This triangulation deepens our understanding of the complex factors that influence sustainability. Additionally, the study’s focus on reproductive health further contributes novel and practical strategies that frontline workers and policymakers can adopt to maintain improvements in maternal and neonatal outcomes. Despite several strengths, our study also has some limitations. There was limited generalisability due to the small number of study sites, and the findings may not reflect the experiences of other settings. The study focused on only two health facilities within one district, which may limit the transferability of results to other geographic or organisational settings. However, a detailed description of the research context and processes allows readers to judge the applicability of the findings to similar settings. Social desirability bias is also a potential limitation of this study given that data were collected through interviews and focus group discussions on QI practices. Participants may have provided responses they perceived as favourable or acceptable rather than reflecting their true experiences. To mitigate this, confidentiality was emphasized, neutral probing was used, and participants were encouraged to share both positive and negative experiences. Lastly, the study relied on qualitative data to examine perceptions of sustainability, which, while providing rich contextual insights, limits objective measurement and comparability across settings. Future research should adopt mixed methods approaches incorporating validated quantitative sustainability tools to enhance the robustness and generalizability of the findings. Implications for policy and practice Frontline system strengthening is critical for the effective facility-level implementation of QoC initiatives. In this study, inconsistent training was a critical sustainability barrier, a finding that aligns with previous evidence indicating that sustained staff competence requires continuous professional development supported by mentorship and supervision ( 30 ). Facilities should institutionalise regular mentorship schedules and integrate QI orientation into the induction of new staff. In addition, facilities should implement non-monetary motivation strategies to address the low morale reported by participants. Research has shown that recognition, supportive supervision, and opportunities for career development significantly influence motivation in low-resource settings ( 24 ). Strategies such as certificates of appreciation, peer-recognition systems, and leadership acknowledgements can enhance staff engagement in QI activities. Moreover, further research should explore the dynamics of donor transition and partner alignment within Malawi’s health system. The participants highlighted concerns about dependence on external funding, and there was value in conducting comparative studies on donor withdrawal plans, transition readiness assessments, and models of collaborative planning. Such studies can identify the factors that enable sustained performance once donor support wanes. Conclusion The findings of this study indicate that the sustainability of QoC interventions in maternal and neonatal health at Mdeka and Chilomoni is shaped by both enabling and constraining factors. While adequate resources, engaged leadership, staff training, and community involvement supported continuity, persistent resource shortages, inconsistent leadership engagement, irregular mentorship, low staff motivation, and donor-dependent outreach limited long-term sustainability. The enablers and barriers were similar regardless of the facilities contextual differences (urban and rural). We recommend that facility and district managers strengthen coordination with district supply systems to reduce recurrent shortages of essential drugs, equipment, and stationery. Leadership accountability should be reinforced through regular supervisory visits and structured follow-up on QI action plans. Continuous capacity building should be institutionalised through regular refresher training, structured mentorship, and QI orientation for newly deployed staff to mitigate the effects of staff turnover. In addition, community engagement should be embedded within routine facility planning by strengthening the role of community health workers and community representatives and by planning for reduced reliance on donor-funded outreach activities. These strategies may support the integration of QoC practices into routine service delivery and strengthen the sustainability of maternal and neonatal health improvements. Abbreviations CHW Community Health Workers DHIS District Health Information System FGD Focus group discussions HAC Health Advisory Committees KUHeS Kamuzu University of Health Sciences LMICs Low- and Middle-Income Countries MNH Maternal Neonatal Health NHS National Health Service NHS QISM National Health Service Quality Improvement Sustainability Model QI Quality Improvement QoC Quality of Care WHO World Health Organisation Declarations Ethics approval and consent to participate. The study was conducted in accordance with the Declaration of Helsinki (1964) and the local ethical guidelines set by Kamuzu University of Health Sciences. Ethics approval to conduct the study was granted by the Kamuzu University Research and Ethics Committee of Kamuzu University of Health Sciences (KUHeS) (reference number: P. 12/24-1318). In addition, permission was obtained from both hospitals where the study was conducted, and letter of approval was issued by the Blantyre Research Ethics. Verbal and written informed consent were obtained from all participants. To ensure anonymity, participants were assigned codes, and their names were not used in the study. Consent for publication Not applicable. Availability of data and materials The data that informed the conclusions of this study are presented in this manuscript. The interview transcripts are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study did not receive any funding. Authors' contributions BML conceptualised the study under the supervision of the EC. BML prepared the original draft, while BL and EC reviewed the manuscript, and it was further edited by BL. All the authors contributed to the completion of this manuscript and have read and approved it. Acknowledgements We gratefully acknowledge the cooperation of all the stakeholders who participated in this study. 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J Public Policy Gov 3(2):12–22 Schaaf M, Topp SM, Ngulube M (2017) From favours to entitlements: community voice and action and health service quality in Zambia. Health Policy Plann 32(6):847–859 Sharma BB, Jones L, Loxton DJ, Booth D, Smith R (2018) Systematic review of community participation interventions to improve maternal health outcomes in rural South Asia. BMC Pregnancy and Childbirth [Internet]. ;18(1):327. Available from: https://doi.org/10.1186/s12884-018-1964-1 Agarwal S, Sripad P, Johnson C, Kirk K, Bellows B, Ana J et al (2019) A conceptual framework for measuring community health workforce performance within primary health care systems. Hum Resour health 17(1):86 Ndayishimiye C, Nduwayezu R, Sowada C, Dubas-Jakóbczyk K (2025) Performance-based financing in Rwanda: a qualitative analysis of healthcare provider perspectives. BMC Health Services Research [Internet]. ;25(1):418. Available from: https://doi.org/10.1186/s12913-025-12605-z O’Neill A, Hooker L, Edvardsson K (2023) What is it we are trying to achieve here’? Community maternal and child health nurses and clinical supervision: A qualitative descriptive study. J Adv Nurs 79(10):3837–3847 Additional Declarations The authors declare no competing interests. Supplementary Files FocusGroupGuideforHealthWorkers060126.docx Focus group duscussion guide InterviewGuideforpatientsandguardians060126.docx Interview guide for patients and guardians InterviewGuideforPolicymakers060126.docx Interview guide for policy makers Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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13:10:39","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20882,"visible":true,"origin":"","legend":"\u003cp\u003eFocus group duscussion guide\u003c/p\u003e","description":"","filename":"FocusGroupGuideforHealthWorkers060126.docx","url":"https://assets-eu.researchsquare.com/files/rs-8558939/v1/c2d33606f22799870be06b76.docx"},{"id":100150049,"identity":"75aaf686-632f-4b1d-a545-903975f11946","added_by":"auto","created_at":"2026-01-13 13:10:39","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":19729,"visible":true,"origin":"","legend":"\u003cp\u003eInterview guide for patients and guardians\u003c/p\u003e","description":"","filename":"InterviewGuideforpatientsandguardians060126.docx","url":"https://assets-eu.researchsquare.com/files/rs-8558939/v1/5e40991e57c68ad6310d0412.docx"},{"id":100150051,"identity":"fc608348-cce1-46b1-8d19-2c3131914420","added_by":"auto","created_at":"2026-01-13 13:10:39","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":20860,"visible":true,"origin":"","legend":"\u003cp\u003eInterview guide for policy makers\u003c/p\u003e","description":"","filename":"InterviewGuideforPolicymakers060126.docx","url":"https://assets-eu.researchsquare.com/files/rs-8558939/v1/765bb130b9a09bcd78d9f768.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eSustaining Quality of Care program in maternal and neonatal health: Key enablers and barriers in Malawi's primary health facilities- A qualitative study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eQuality improvement (QI) is a vital component of healthcare systems globally, particularly in reproductive health settings, where high maternal and neonatal mortality rates remain a major challenge (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In 2020, approximately 287,000 women died from pregnancy and childbirth-related causes, whereas 2.4\u0026nbsp;million newborns died within the first 28 days of life, mostly from preventable causes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These deaths are disproportionately concentrated in low- and middle-income countries (LMICs), highlighting the persistent gaps in healthcare quality and delivery. Quality of care (QoC) interventions aim to continuously improve healthcare processes through structured, iterative approaches that involve personnel in implementing changes to enhance service quality (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Such interventions have demonstrated the potential to reduce maternal and neonatal mortality and improve overall reproductive health outcomes (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn sub-Saharan Africa, countries such as Malawi have made notable strides in implementing QoC initiatives, particularly in terms of maternal and neonatal health (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Despite significant progress in QoC program interventions in LMICs, persistent challenges in maintaining high standards of care continue to undermine long-term gains (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Evidence indicates that sustaining improvements requires more than short-term interventions; it demands systems, practices, and resources that can be embedded within routine health service delivery (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Evidence from Malawi\u0026rsquo;s Blantyre district shows that only a minority (30%) of QoC interventions have been sustained from 2020 to 2023, according to reports from the District Health Information Systems 2 of 2023.\u003c/p\u003e \u003cp\u003eTherefore, understanding the factors that either facilitate or hinder sustained QoC interventions is important for strengthening Malawi\u0026rsquo;s primary health facilities, which are the first point of care for most women and newborns (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Identifying these enablers and barriers provides insights for policy and program implementation and contributes to global discussions on building resilient health systems capable of delivering high-quality care over time (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This study explored the key enablers and barriers to sustaining quality of care in Malawi\u0026rsquo;s primary health facilities, with a focus on maternal and neonatal health (MNH).\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eA cross-sectional design was employed using descriptive qualitative data collection and analysis approaches. The design acknowledged the subjective nature of the problem and the diverse experiences of the participants, presenting the findings in a manner that directly reflected or closely resembled the terminology used in the research questions (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This approach allowed for an in-depth exploration of how participants perceived, interpreted, and experienced sustainable practices within the QoC programme, providing rich insights into their views and motivations. The study was guided by the NHS Quality Improvement Sustainability Model (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), which informed data collection tool development.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted at the Mdeka and Chilomoni health facilities in Blantyre, Malawi. These facilities were purposively selected from the ten facilities in Blantyre where the QoC program was initiated on the basis of their performance challenges in sustaining the program. Mdeka and Chilomoni health facilities have been implementing maternal and neonatal healthcare programs for a considerable period, providing a rich context for exploring the specific challenges and successes related to the sustainability of these interventions in Malawi.\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThe study population comprised a diverse range of stakeholders involved in the QoC program, including healthcare providers who were doctors, nurses, midwives, data clerks, hospital attendants, and other clinical staff directly involved in implementing QoC interventions at the Mdeka and Chilomoni health facilities; policymakers, who were individuals involved in strategic planning and resource allocation for the QoC program, including the District QI manager and members of the National Coordination Committee for the QoC program; and clients, who were patients or guardians who experienced QoC program interventions at the Mdeka and Chilomoni health facilities. The inclusion criteria included stakeholders who were directly engaged in and benefited from the QoC program at the Mdeka and Chilomoni health facilities. The exclusion criteria included those who were unwell and unable to communicate, those who were unwilling to participate or provide informed consent, and those with less than one year of experience in the program, as they were considered to have limited exposure to and understanding of the QoC program.\u003c/p\u003e\n\u003ch3\u003eSampling and participant recruitment process\u003c/h3\u003e\n\u003cp\u003ePurposive sampling was used to select participants with in-depth knowledge of and experience with the QoC programme interventions. This method ensured that the participants could provide rich, relevant, and diverse insights into the research questions (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A total of twenty-seven participants were interviewed, including ten individual interviews and two focus group discussions (each comprising six participants). The sample size was consistent with guidance indicating that descriptive qualitative studies typically range between five and forty participants (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, the final number was determined by data saturation ((\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), ensuring that all important elements of stakeholders\u0026rsquo; perceptions of the sustainability of the QoC program were fully captured.\u003c/p\u003e \u003cp\u003e The National Coordination Committee for the QoC Program and the Blantyre District Health Office identified policymakers. They were contacted through formal emails and phone calls to explain the purpose of the study and to seek consent. Healthcare workers at the Mdeka and Chilomoni health facilities were approached in person during facility visits to ensure representation across different professional roles. Patients/guardians (clients) who had used maternal and neonatal services at the facilities were recruited with the assistance of facility management and staff, whose support facilitated the process.\u003c/p\u003e\n\u003ch3\u003eData collection methods\u003c/h3\u003e\n\u003cp\u003eMultiple methods were employed to triangulate the findings and enhance their credibility. Semi structured in-depth interviews: Fifteen interviews were conducted, five with policymakers and ten with clients (five from each facility). The interview guide ensured consistency while allowing flexibility for the participants to express their views.\u003c/p\u003e \u003cp\u003eFocus group discussions (FGDs): Two FGDs of health workers were conducted (one from each facility, with six participants in each group) to capture group dynamics and shared perceptions of the QoC Program. This method elicited a range of views and generated discussions among program implementers.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData collection tools\u003c/h2\u003e \u003cp\u003ePolicymakers used an interview guide focused on their perceptions of enablers and barriers to sustainability, knowledge of the sustainability of program interventions, and best practices for enhancing sustainability. For clients, the guide explored experiences with QoC interventions, perceived impact on health and well-being, and suggestions for improving sustainability. A focus group discussion guide was used with health workers, focusing on enablers and barriers to sustainability, their knowledge and capacity as implementers, and the contextual factors influencing the likelihood of sustaining QoC interventions.\u003c/p\u003e \u003cp\u003eThe questions were adapted from the NHS model assessment tool and tailored to fit the study context. The guides were initially developed in English and translated into Chichewa by language expert to ensure the accuracy of their meaning (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The interview and focus group discussion guides are provided in \u003cb\u003eSupplementary file 1\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eA pretest was conducted to assess the clarity, content coverage, and alignment with the study objectives (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The final versions of the tools were refined on the basis of expert discussions and the pretest results. Data collection was supported by audio recorders and field notes, ensuring the accuracy and completeness of the information (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This contributed to the reliability and integrity of the findings.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData management\u003c/h3\u003e\n\u003cp\u003eData from the focus groups and semi structured in-depth interviews were audiotaped, transcribed, and translated into English. Every transcript had participants\u0026rsquo; descriptions labelled with an identification number different from any participant\u0026rsquo;s personal identifiable information. To ensure consistency of the translated transcripts, the researcher listened to the audio to check for the accuracy of the transcripts and variability in transcription and translation. The audio, transcripts, and translations were kept on the researcher\u0026rsquo;s computer with a password known only to the researcher.\u003c/p\u003e\n\u003ch3\u003eTrustworthiness\u003c/h3\u003e\n\u003cp\u003eTrustworthiness refers to the degree of confidence in the data, interpretation, and methods used to ensure the quality of a study (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Key terms found in the literature that address the trustworthiness of results include credibility, dependability, transferability, and confirmability (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). First, to show credibility in this study, triangulation was employed using multiple data sources and methods such as interviews and focus groups. Additionally, credibility was increased by an external check of the research process by the research supervisors who reviewed the transcripts to check the preliminary findings and interpretations made. This helped ensure that emergent themes and patterns were substantiated in the data. Second, to ensure dependability for this study, an audit trail was maintained, documenting all steps from data collection to analysis. The code-recode strategy was used to ensure coding consistency, and the supervisor scrutinized the research tools to minimize inconsistencies and achieve clear and logical documentation. Furthermore, in this study, transferability was addressed through detailed descriptions of the research context, participants, and findings, enabling others to determine the applicability of the study to other settings. Purposive sampling was used to select a diverse range of participants, thereby enhancing their potential for transferability. Additionally, the first author carefully analysed the data and discussed the findings of the study by comparing them with other similar studies from different contexts. Lastly, Confirmability in this study was achieved with the first author maintaining a reflexive journal to document biases and assumptions. The first author\u0026rsquo;s professional background in healthcare quality improvement informed familiarity with QI processes however, this positionality was continually examined through reflexive practice to minimize undue influence on data collection, analysis, and interpretation. A confirmability audit was conducted, and triangulation was used to cross-check the data and interpretations, ensuring that the findings were shaped by participants' experiences and not researcher bias.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e The study was approved by the Kamuzu University of Health Sciences Research and Ethics Committee (reference number: P. 12/24-1318). Further ethical approval was obtained from the Blantyre Research Ethics Committee of the two health facilities where the study was conducted. Before participation, verbal and written informed consent was obtained from the participants, ensuring that they were aware of the study\u0026rsquo;s purpose and procedures and their right to withdraw at any time without penalty. To ensure anonymity, participants were assigned numbers, and their names were not used in the study. After data analysis, the transcripts were maintained according to the university\u0026rsquo;s data management procedures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe raw data from the in-depth interviews were transcribed and analysed manually. Each recorded interview was transcribed verbatim by the first author, who also verified and corrected errors in the transcription by rereading the transcribed data while listening to the recorded data. Data analysis followed the six phases of thematic analysis: becoming familiar with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFirst, the first author read the transcribed data from the in-depth interviews multiple times to familiarise with the data and recorded preliminary ideas of analytical interest that helped organise the data. Thereafter, a line-by-line analysis of the transcribed data was conducted to make sense of the collected data. Colours were assigned to sentences in the transcripts to indicate potential patterns. The investigator identified and extracted phrases and/or direct participant quotes from the data. Then, codes were derived from the dataset and grouped into small and meaningful chunks of data. Codes with similar meanings were grouped to form subthemes, which were further categorised into themes. The co-authors held several meetings to discuss and review the identified themes for a consensus and validated the themes to ensure that they were a true reflection of the collected data.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cb\u003eDemographic characteristics of participants\u003c/b\u003e. This study included 27 participants across three categories. Two focus group discussions (FGDs), one from each facility, were held with six health workers from the QI support teams, representing diverse cadres (nurses, clinical officers, hospital attendants, health surveillance attendants, and data clerks), with equal sex distributions (three males and three females per group) and ages between 27 and 34 years.\u003c/p\u003e \u003cp\u003eTen individual interviews were conducted with female clients (aged 21\u0026ndash;40 years) who had experienced QoC interventions, most of whom were married (70%) and had education levels ranging from standard one to form two. Five policymakers (three females, two males; aged 37\u0026ndash;45 years) were interviewed, including QoC coordinators, a district QI manager, national assessors, and quality management officers. A detailed summary of participant demographics is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of the demographic characteristics of the study participants (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Participant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Workers (FGDs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClients (Interviews)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolicy Makers (Interviews)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth Workers (n\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge Range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u0026ndash;34 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCadres Represented\u003c/p\u003e \u003cp\u003eNurses\u003c/p\u003e \u003cp\u003eClinicians\u003c/p\u003e \u003cp\u003eHospital Attendants\u003c/p\u003e \u003cp\u003eData Clerks\u003c/p\u003e \u003cp\u003eHealth Surveillance Assistants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003cp\u003e16.7\u003c/p\u003e \u003cp\u003e16.7\u003c/p\u003e \u003cp\u003e16.7\u003c/p\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClients (n\u0026thinsp;=\u0026thinsp;10)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge Range\u003c/p\u003e \u003cp\u003e21\u0026ndash;25\u003c/p\u003e \u003cp\u003e26\u0026ndash;30\u003c/p\u003e \u003cp\u003e31\u0026ndash;35\u003c/p\u003e \u003cp\u003e36\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003cp\u003e30.0\u003c/p\u003e \u003cp\u003e10.0\u003c/p\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation Level\u003c/p\u003e \u003cp\u003eStd 1\u0026ndash;4\u003c/p\u003e \u003cp\u003eStd 5\u0026ndash;8\u003c/p\u003e \u003cp\u003eForm 1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003cp\u003e30.0\u003c/p\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePolicy Makers (n\u0026thinsp;=\u0026thinsp;5)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge Range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u0026ndash;45 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositions Held\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQoC Coordinator, District QI Manager, National Assessor, Quality Management Officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eThemes\u003c/h2\u003e \u003cp\u003eThe analysis of the data revealed four major themes that influenced the sustainability of quality of care programs in the Mdeka and Chilomoni health facilities: resource availability, leadership, human capacity and motivation, and community engagement. These themes reflected both enabling and constraining factors as perceived by the participants. Each theme elucidates specific findings within that domain, supported by verbatim excerpts to provide additional context and insight. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the themes and their corresponding codes derived from the analysis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and codes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCodes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResource availability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Equipment and supplies\u003c/p\u003e \u003cp\u003e-Infrastructure availability\u003c/p\u003e \u003cp\u003e-Funding sources\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Championing the program\u003c/p\u003e \u003cp\u003e-Engaging stakeholders\u003c/p\u003e \u003cp\u003e-Vision and Strategic Direction\u003c/p\u003e \u003cp\u003e-Responsiveness to challenges\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHuman Capacity and Motivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Staff Training and Development\u003c/p\u003e \u003cp\u003e-Recognition and rewards\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity Engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Involvement in program planning\u003c/p\u003e \u003cp\u003e-Community outreach programs\u003c/p\u003e \u003cp\u003e-Feedback mechanisms\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eResource availability\u003c/h2\u003e \u003cp\u003eResource availability emerged as an important enabler of QoC initiatives both at the Mdeka and Chilomoni health facilities, as described by participants. Stakeholders consistently highlighted that having adequate supplies, equipment, and functional infrastructure supported the implementation and sustainability of QI interventions in the health facilities. Health workers explained that the availability of basic medical supplies and tools, such as blood pressure machines, stationery, and other vital materials enabled them to conduct patient assessments effectively, accurately document data, and monitor progress on QI indicators.\u003c/p\u003e \u003cp\u003eThe participants highlighted that in some cases, where district-level supply chains fell short, community-driven solutions were described as playing an important role in addressing resource gaps. Health workers at Mdeka health facility described how local fundraising efforts helped procure the essential materials needed to keep QI interventions running. One participant explained,\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Community fundraising is the initiative that was initiated by the community health committee in collaboration with the health facility committee; it has helped us to buy some materials such as stationery and blood pressure machine batteries when there are no supplies from the district, and in this way, we are able to have the supply of these resources and assist our clients accordingly\u0026rdquo;\u003c/em\u003e (FGD 2, Participant 5).\u003c/p\u003e \u003cp\u003eStakeholders at Mdeka health facility further acknowledged that investments in facility-level infrastructure improvements, such as enhanced hygiene, access to clean water, and upgraded cooking areas, positively influenced client perceptions and confidence in health facilities. One participant stated:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The hospital has water now where we can access it easily, rather than before, when we were going into the village to draw water at the borehole, and we would wait for long hours to access water because there were always many people since the whole village depended on it, and all that time we would leave our patients alone without guardians. In addition, the hospital had no cooking area, and we were having difficulties, especially for those of us who came from afar, and our patients would eat cold meals. However, now all this is history, and we can eat hot meals now because of the cooking area\u0026hellip;.\u0026rdquo;\u003c/em\u003e (Client, Participant 5).\u003c/p\u003e \u003cp\u003eThe participants in both facilities highlighted that despite these positive strides, resource constraints remained one of the most significant barriers to sustaining QI interventions. Health workers frequently reported shortages of essential drugs, including ferrous sulphate and Fansidar, stationery, and inadequate supplies of basic equipment, such as blood pressure machines. Health workers have highlighted that such shortages disrupted service delivery and, in some cases, led to negative patient experiences and poor health outcomes. One client voiced this frustration:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes you come for antenatal care with the hope that you are going to be assisted, and they tell you that they are out of drugs; so, you have to buy it outside, and if you don\u0026rsquo;t have money, then you won\u0026rsquo;t be able to get the drugs, and here at the village, most of us cannot manage to buy them\u0026hellip;\u0026rdquo;\u003c/em\u003e (Client, Participant 3).\u003c/p\u003e \u003cp\u003ePolicymakers also acknowledged the fragility of resource sustainability, noting that a significant proportion of QI interventions were heavily donor driven. One policymaker highlighted this challenge:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Most of the activities are donor driven, and when donors pull out, we struggle to keep them running. Therefore, this overreliance on external funding creates uncertainty regarding the continuity of critical interventions, particularly collaborative learning sessions, outreach programs, and mentorship activities. Therefore, these constraints often affect the sustainability of QI initiatives\u0026rdquo;\u003c/em\u003e (Policy maker, Participant 4).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLeadership\u003c/h2\u003e \u003cp\u003eThe participants in both facilities reported that strong leadership and a clear policy direction played an important role in sustaining QoC interventions by setting clear goals and upholding accountability. They stated that leaders not only provide resources but also inspire and engage staff, making everyone feel like part of the improvement process. Health workers highlighted the value of active, problem-solving leadership at the facility level, especially during quality improvement review meetings and mentorship activities. They expressed that active leadership fosters a supportive environment, with one participant stating,\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWhen leaders are involved, they are at the forefront of QI interventions, and they can keep the team together despite facing challenges. For instance, people have attitudes, and they resist change, but when the leader can address all these challenges and recognise everyone\u0026rsquo;s potential, it inspires the team to strive for better outcomes\u0026hellip;.\u0026rdquo;\u003c/em\u003e (FGD 1, Participant 2).\u003c/p\u003e \u003cp\u003e However, barriers, including variable engagement of leadership at some levels, were reported by the participants in both facilities. One participant stated:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eMost leaders are not active; they are supposed to monitor how QI working improvement teams are progressing and even provide mentorships, but most of them do not, so people relax because they are not monitored. Even those who are doing well are discouraged and stop implementing their QI interventions\u0026rdquo;\u003c/em\u003e (FGD 2, Participant 6).\u003c/p\u003e \u003cp\u003e The participants also highlighted the inconsistent dissemination of policies and delays in finalising the national QoC guidelines. One policymaker acknowledged the following:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eThe engagement is sometimes weak with the facilities due to transportation issues and lack of resources, and facilities end up working in isolation, hence affecting the sustainability of these QoC interventions, but the policies are disseminated in the facilities, and the problem is that people don\u0026rsquo;t read these policies; they just compile in their working stations\u0026rdquo;\u003c/em\u003e (Policymaker, Participant 3).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eHuman Capacity and Motivation\u003c/h2\u003e \u003cp\u003eTraining and mentorship are important for sustaining the QoC interventions. Health workers in both facilities reported that onsite mentorship, refresher training, and peer-to-peer learning helped them effectively apply QoC principles. They stated that training and mentorship built their skills and confidence in implementing QoC interventions. This support motivated them to recognise their efforts and strengthened their commitment to delivering quality care. Policymaker have highlighted the following:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Mentorships have been key because they build confidence and ensure that everyone knows and understands what is expected, which improves ownership and accountability in the facilities\u0026hellip;.\u0026rdquo;\u003c/em\u003e (Policy maker, Participant 4).\u003c/p\u003e \u003cp\u003eHowever, inconsistent refresher training, mentorship, and low motivation were major barriers reported in the study from both facilities. New staff members often lack QI knowledge, disrupting continuity and slowing implementation. One health worker reported:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWe had QI training only once a long time ago; I cannot even remember which year it was. Since then, more new staff have joined and not trained, even if the current QI focal person has not trained, so how is he supposedly leading the team without sufficient knowledge? Even when mentorships are conducted, they are not effective enough. When they come, they are always in a hurry, they will be here for maybe 30 minutes then off, so we do not capture much\u0026hellip;.\u0026rdquo;\u003c/em\u003e (FG1, Participant 5).\u003c/p\u003e \u003cp\u003eAnother participant stated:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In terms of motivation honestly speaking, we don\u0026rsquo;t get any form of motivation here, yes even nonmonetary one, and that is why most people don\u0026rsquo;t participate in these initiatives, they say it\u0026rsquo;s another extra work, so the ones that we are involved we do it out of our passion\u003c/em\u003e and for the \u003cem\u003ebenefit of the patients\u003c/em\u003e\u0026rdquo; (FG1, Participant 6).\u003c/p\u003e \u003cp\u003eThe recognition of staff contributions was considered motivating. Health workers suggested institutionalising reward systems to increase staff commitment and increase morale.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eCommunity Engagement\u003c/h2\u003e \u003cp\u003eCommunity engagement emerged as a significant factor influencing the sustainability of QoC interventions. The participants mentioned that community engagement is important in QoC interventions because it helps align services with the needs and expectations of the people. They also noted that it builds trust, accountability, and shared responsibility, which support the sustainability of interventions. They stated that involving local leaders, youth champions, health surveillance attendants (HSAs), and health advisory committees (HACs\u003cb\u003e)\u003c/b\u003e fostered trust and increased the uptake of services within the two facilities. One health worker highlighted the following statement:\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Youth champions and HSAs have helped us reach clients who were not attending antiretroviral therapy (ART) clinics before seeking services. Additionally, the HSAs have helped us to spread some new interventions in the communities, for instance, the new WHO guidelines for antenatal contacts, because many people were not aware of this development, but now there is an improvement in antenatal contacts than before\u0026rdquo;\u003c/em\u003e (FG2, Participant 1).\u003c/p\u003e \u003cp\u003eHowever, clients reported limited outreach and information sharing, with most health education delivered only at facilities, with one stating:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We only hear about some of the programmes when we come to the hospital, especially those of us that come from long distances; at first, there were some organisations that would come in the community with a mega phone and spread health information such as how we can prevent cholera, family planning and many more but now we only hear health information when we come here, which is when we are sick\u0026hellip;\u0026rdquo;\u003c/em\u003e (Client, Participant 2).\u003c/p\u003e \u003cp\u003eOne policymaker highlighted this:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eThe challenge of limited outreach and information sharing arises from funding constraints. Community-based activities require significant resources, and since they are often dependent on donor support, once donors withdraw, programs struggle to continue, leaving the system back at square one\u003c/em\u003e\u0026rdquo; (Policy maker, Participant 1).\u003c/p\u003e \u003cp\u003eThe participants suggested expanding outreach, utilising community health workers to work in the community rather than at the facility, securing funding for community activities, and institutionalising community representation in planning to ensure long-term sustainability.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrated that sustaining QoC interventions in maternal and neonatal healthcare requires more than initial implementation success. Rather, sustainability emerges from the interaction between material resources, organisational leadership, workforce motivation, and community trust. While enabling factors supported continuity, persistent systemic weaknesses constrained the long-term sustainability of QoC practices in maternal and neonatal healthcare at both the Mdeka and Chilomoni health facilities. The key enablers include resource availability, strong leadership, enhanced human capacity through training, and effective community engagement. Conversely, substantial barriers, such as persistent resource shortages, inconsistent leadership engagement, inadequate staff training and motivation, and limited community outreach, were noted.\u003c/p\u003e \u003cp\u003eResource availability emerged as both an enabler and a vulnerability. This study revealed that resource availability emerged as a critical enabler of QoC initiatives across the health facilities studied. The participants consistently highlighted that adequate supplies, equipment, and functional infrastructure directly supported the smooth implementation and sustainability of the QI interventions. This aligns with the National Health Service Quality Improvement Sustainability Model (NHS QISM), which identifies resources (staff, infrastructure, and materials) as a core construct influencing sustainability by enabling the continuous delivery of interventions (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). These findings are consistent with several contemporary studies that suggest adequate resources positively influence sustainability by supporting the continuity of quality services. For example, an integrative review of healthcare programme sustainability identified funding and resource availability as among the most frequently reported outer-setting factors influencing programme continuation (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Robust resourcing has also been described as a key enabler of sustained QI initiatives, ensuring that improvements are maintained beyond the period of initial project funding or when external oversight wanes (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, participants from both facilities reported inconsistent availability of essential medical supplies, such as blood pressure machines, stationery, and other vital materials, which prevented them from conducting patient assessments effectively and monitoring progress on QI indicators. In Malawi, primary healthcare facilities do not receive direct funding from the district or central levels but rather receive resources in kind through district orders (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The current system limits the autonomy of facilities in planning, budgeting, and monitoring expenditures effectively. Critics argue that resource allocation is insufficient without systemic management reforms; resources often fail to translate into sustained quality because of poor coordination, misalignment, or wastage (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The evidence suggests that even well-resourced health systems can produce suboptimal outcomes when foundational governance structures, service delivery platforms, and workforce systems are weak (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Similarly, health system reform efforts must address financing mechanisms, delivery architecture, and incentive structures if resources are to meaningfully improve health outcomes (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This dual perspective aligns with sustainability frameworks that recognise that while resources are essential, they must be embedded in adaptive processes, supportive culture, and organisational capacity for true sustainability (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study further revealed that active leadership plays an important role in sustaining the QoC by promoting accountability, staff engagement and collaborative problem solving. Health worker participants in both facilities reported that many facility leaders remained inactive in driving improvement initiatives in their organisations. This perceived lack of leadership engagement was reported to have a demotivating effect on some health workers, which may undermine collective efforts to sustain QoC initiatives.These results are consistent with the NHS QISM\u0026rsquo;s emphasis on strategic leadership and organisational support as a dynamic process vital for institutionalising QI practices and sustaining change through relational and motivational mechanisms (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Similar challenges have been documented in the literature, where inconsistent leadership has been shown to weaken team cohesion and disrupt the continuation of improvement activities (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). A systematic review of leadership styles in healthcare programmes further demonstrated that limited or inconsistent engagement by formal leaders and managers was associated with declining improvement efforts over time(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003eHuman capacity and motivation were other factors that emerged from the study as vital for sustaining QoC interventions. Health workers reported that onsite mentorship, refresher training, and peer learning enhanced their knowledge, confidence, and ownership of QI activities. Consistent with the NHS QISM, which identifies staff capability and engagement as central to sustaining change, mentorship in this study strengthened understanding, accountability, and commitment among health workers in both facilities.\u003c/p\u003e \u003cp\u003eHowever, sustainability was undermined by irregular refresher training and ineffective mentoring. The participants noted that rushed mentorship visits and a lack of QI induction for new employees hindered continuity, whereas limited motivation, particularly the absence of both financial and nonfinancial rewards, further reduced participation in the QI project. These results align with existing global evidence on factors associated with QI sustainability (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Supportive onsite supervision has also been found to be more effective in improving quality outcomes than one-off training interventions (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Sustained improvements have been associated with structured and continuous QI education in several settings (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The challenges identified in this study, including hurried mentorship and inadequate follow-up, reflect operational weaknesses reported elsewhere, suggesting that the quality and consistency of mentorship are more important than its mere presence (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMotivation has also emerged as a key determinant of sustainability in this study. Health workers indicated that recognition, even in nonmonetary forms, could improve morale and engagement. This finding is consistent with evidence showing that recognition, supportive leadership, and opportunities for professional development play critical roles in sustaining motivation in resource-constrained settings (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Collectively, these findings suggest that formalising reward systems and embedding recognition within organisational culture may strengthen long-term participation in QI initiatives.\u003c/p\u003e \u003cp\u003eThis study also revealed that community engagement is essential for sustaining the quality of care. The participants highlighted that community engagement builds trust and accountability in the community. However, they reported that community engagement was hindered by poor outreach, weak feedback systems, and funding shortages. The participants attributed these issues to donor dependence, which threatens continuity after the end of external support. These findings align closely with the NHS QISM, which emphasises that sustainable quality improvement depends on stakeholder buy-in, integration into organisational systems, and stable resources (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In this context, community involvement contributes to shared accountability and service alignment, reflecting sustainability principles.\u003c/p\u003e \u003cp\u003eDespite this, limited outreach, weak feedback loops, and reliance on donor funding point to gaps in the institutionalisation of community engagement processes, suggesting that participation may remain project-based rather than fully system-driven (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Similar findings have been reported across sub-Saharan Africa, where community health committees have been shown to strengthen accountability and resource mobilisation but often lack legitimacy and structured involvement in decision-making processes (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In Zambia, structured platforms for community voice improved responsiveness and citizen empowerment but struggled to address systemic constraints without institutional backing (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Comparable challenges have been observed in Nepal, where the absence of formal feedback channels weakens trust and participation (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe participants\u0026rsquo; recommendations to strengthen the role of community health workers align with evidence showing that CHWs serve as effective intermediaries between health facilities and communities, enhancing communication, health-seeking behaviour, and programme sustainability (31,32). While the findings of this study are broadly consistent with the literature, contextual differences remain evident. In settings such as Rwanda, where community engagement and health insurance mechanisms are domestically financed, sustained community participation has been successfully institutionalised (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In contrast, the reliance on donor-funded outreach observed in this study reflects weaker integration of community engagement into core health system functions.\u003c/p\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations of the study\u003c/h2\u003e \u003cp\u003e This study addresses an underserved research area by providing much-needed evidence on the sustainability of QoC interventions in maternal and neonatal care in Malawi, a topic that remains underexplored despite being central to improving health outcomes in LMICs. The inclusion of multiple stakeholder groups, including policymakers, health workers, and patients or guardians, also strengthens this study by capturing diverse experiences across different levels of the health system. This triangulation deepens our understanding of the complex factors that influence sustainability. Additionally, the study\u0026rsquo;s focus on reproductive health further contributes novel and practical strategies that frontline workers and policymakers can adopt to maintain improvements in maternal and neonatal outcomes.\u003c/p\u003e \u003cp\u003eDespite several strengths, our study also has some limitations. There was limited generalisability due to the small number of study sites, and the findings may not reflect the experiences of other settings. The study focused on only two health facilities within one district, which may limit the transferability of results to other geographic or organisational settings. However, a detailed description of the research context and processes allows readers to judge the applicability of the findings to similar settings. Social desirability bias is also a potential limitation of this study given that data were collected through interviews and focus group discussions on QI practices. Participants may have provided responses they perceived as favourable or acceptable rather than reflecting their true experiences. To mitigate this, confidentiality was emphasized, neutral probing was used, and participants were encouraged to share both positive and negative experiences. Lastly, the study relied on qualitative data to examine perceptions of sustainability, which, while providing rich contextual insights, limits objective measurement and comparability across settings. Future research should adopt mixed methods approaches incorporating validated quantitative sustainability tools to enhance the robustness and generalizability of the findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eImplications for policy and practice\u003c/h2\u003e \u003cp\u003eFrontline system strengthening is critical for the effective facility-level implementation of QoC initiatives. In this study, inconsistent training was a critical sustainability barrier, a finding that aligns with previous evidence indicating that sustained staff competence requires continuous professional development supported by mentorship and supervision (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Facilities should institutionalise regular mentorship schedules and integrate QI orientation into the induction of new staff. In addition, facilities should implement non-monetary motivation strategies to address the low morale reported by participants. Research has shown that recognition, supportive supervision, and opportunities for career development significantly influence motivation in low-resource settings (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Strategies such as certificates of appreciation, peer-recognition systems, and leadership acknowledgements can enhance staff engagement in QI activities. Moreover, further research should explore the dynamics of donor transition and partner alignment within Malawi\u0026rsquo;s health system. The participants highlighted concerns about dependence on external funding, and there was value in conducting comparative studies on donor withdrawal plans, transition readiness assessments, and models of collaborative planning. Such studies can identify the factors that enable sustained performance once donor support wanes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study indicate that the sustainability of QoC interventions in maternal and neonatal health at Mdeka and Chilomoni is shaped by both enabling and constraining factors. While adequate resources, engaged leadership, staff training, and community involvement supported continuity, persistent resource shortages, inconsistent leadership engagement, irregular mentorship, low staff motivation, and donor-dependent outreach limited long-term sustainability. The enablers and barriers were similar regardless of the facilities contextual differences (urban and rural). We recommend that facility and district managers strengthen coordination with district supply systems to reduce recurrent shortages of essential drugs, equipment, and stationery. Leadership accountability should be reinforced through regular supervisory visits and structured follow-up on QI action plans. Continuous capacity building should be institutionalised through regular refresher training, structured mentorship, and QI orientation for newly deployed staff to mitigate the effects of staff turnover. In addition, community engagement should be embedded within routine facility planning by strengthening the role of community health workers and community representatives and by planning for reduced reliance on donor-funded outreach activities. These strategies may support the integration of QoC practices into routine service delivery and strengthen the sustainability of maternal and neonatal health improvements.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCHW Community Health Workers\u003c/p\u003e \u003cp\u003eDHIS District Health Information System\u003c/p\u003e \u003cp\u003eFGD Focus group discussions\u003c/p\u003e \u003cp\u003eHAC Health Advisory Committees\u003c/p\u003e \u003cp\u003eKUHeS Kamuzu University of Health Sciences\u003c/p\u003e \u003cp\u003eLMICs Low- and Middle-Income Countries\u003c/p\u003e \u003cp\u003eMNH Maternal Neonatal Health\u003c/p\u003e \u003cp\u003eNHS National Health Service\u003c/p\u003e \u003cp\u003eNHS QISM National Health Service Quality Improvement Sustainability Model\u003c/p\u003e \u003cp\u003eQI Quality Improvement\u003c/p\u003e \u003cp\u003eQoC Quality of Care\u003c/p\u003e \u003cp\u003eWHO World Health Organisation\u003c/p\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki (1964) and the local ethical guidelines set by Kamuzu University of Health Sciences. Ethics approval to conduct the study was granted by the Kamuzu University Research and Ethics Committee of Kamuzu University of Health Sciences (KUHeS) (reference number: P. 12/24-1318). In addition, permission was obtained from both hospitals where the study was conducted, and letter of approval was issued by the Blantyre Research Ethics. Verbal and written informed consent were obtained from all participants. To ensure anonymity, participants were assigned codes, and their names were not used in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that informed the conclusions of this study are presented in this manuscript. The interview transcripts are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBML conceptualised the study under the supervision of the EC. BML prepared the original draft, while BL and EC reviewed the manuscript, and it was further edited by BL. All the authors contributed to the completion of this manuscript and have read and approved it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe gratefully acknowledge the cooperation of all the stakeholders who participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2020) WHO recommendations on intrapartum care for a positive childbirth experience. World Health Organization\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization (2022) The WHO application of ICD-10 to deaths during pregnancy, childbirth, and puerperium. ICD-MM. World Health Organization\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson JK, Sollecito WA (2018) McLaughlin \u0026amp; Kaluzny\u0026rsquo;s continuous quality improvement in health care. 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J Adv Nurs 79(10):3837\u0026ndash;3847\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Kamuzu University of Health Sciences","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Quality of care, Sustainability, Maternal and neonatal health, Primary health facilities","lastPublishedDoi":"10.21203/rs.3.rs-8558939/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8558939/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eImproving the quality of care in primary health facilities is a central concern in global health. While substantial investments have been made in quality improvement initiatives, their long-term sustainability remains uncertain, particularly in low- and middle-income countries. Despite significant efforts, challenges persist in maintaining the effectiveness of these programs over time. This study aimed to explore the key enablers and barriers to the sustainability of quality of care programs in maternal and neonatal healthcare in Malawian primary health facilities, particularly Mdeka and Chilomoni in the Blantyre District.\u003c/p\u003e\u003ch2\u003eStudy design:\u003c/h2\u003e \u003cp\u003eThis study employed a qualitative research approach with a cross-sectional descriptive design. Data were collected via in-depth interviews and focus group discussions from a purposive sample of 27 participants, including five policymakers, twelve health workers, and ten clients at the Mdeka and Chilomoni health facilities. The data were analysed via thematic analysis to identify key patterns and themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe analysis of the data revealed four major themes influencing the sustainability of quality of care program at Mdeka and Chilomoni health facilities. These were shaped by the availability of resources, leadership practices, human capacity, motivation, and community engagement. The themes reflected both enabling and constraining factors, as perceived by the participants.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe sustainability of quality of care programs in primary health facilities in Malawi is influenced by multiple interrelated factors. Addressing gaps in these domains is essential for embedding quality improvement into routine service delivery and safeguarding long-term maternal and neonatal health gains. Strengthening leadership accountability, embedding capacity building, and institutionalising community participation is critical to sustaining quality improvement initiatives and improving maternal and neonatal outcomes.\u003c/p\u003e","manuscriptTitle":"Sustaining Quality of Care program in maternal and neonatal health: Key enablers and barriers in Malawi's primary health facilities- A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-13 13:10:35","doi":"10.21203/rs.3.rs-8558939/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bcc96fe0-b35b-44b1-9dc5-289f27038462","owner":[],"postedDate":"January 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":61068534,"name":"Sexual \u0026 Reproductive Medicine"},{"id":61068535,"name":"Health Policy"}],"tags":[],"updatedAt":"2026-01-13T13:10:35+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-13 13:10:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8558939","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8558939","identity":"rs-8558939","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}