Skip to content
Quality improvement initiatives are not one size fits all. They need to be adapted to fit local needs, priorities and the organisational culture of the implementing facility.

Access to maternal and newborn care is increasing but due to the poor quality of care provided this doesn’t necessarily lead to fewer avoidable deaths. Investments in quality improvement initiatives in health facilities are therefore seen as key interventions.

This qualitative study explored how a quality improvement initiative implemented across three facility types – primary health centres, public hospitals and private facilities – in Lagos, Nigeria was adapted to each facility type. The Nigeria Healthcare Quality Initiative (NHQI) has been implemented since 2015 and aims to improve maternal and newborn health outcomes in facilities in Lagos State.

The aim of the study was to contribute to knowledge of what worked, what was adapted and why. This better understanding of the influence of context is thought to improve the design, implementation and evaluation of quality improvement initiatives. The study was conducted using multiple-case study design, meaning one case study per facility type aiming to understand the extent to which the NHQI was adapted to fit the particular contexts and whether and how contexts were adapted to enable the NHQI.

Results from this study show that the three core activities of the NHQI had to be adapted to suit the implementation context in Lagos. The three core activities were as described in the theory of change are:

  • Establish collaboratives
  • Build capacity
  • Measurement and evaluation

The authors conclude that context plays a key role in the implementation of quality improvement initiatives. Complex interventions need to be adapted to their implementation environments which may compromise fidelity, making it difficult to replicate these in other settings. Secondly, adaptations that need to be made due to a shortage of resources, can negatively affect feasibility, meaning some interventions may be successful in high-resource settings but fail in more resource constrained settings. To achieve the best possible gains from QI, these findings underscore the importance of being explicit about the likely influence of contextual factors on implementation and transparent about the need to commit time and resources to address them.


Modupe Oludipe

Health Strategy and Delivery Foundation, Lagos, Nigeria

Adedoyin Ogunyemi

Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria

Profile picture of Dr Nasir Umar
Dr Nasir Umar

IDEAS Nigeria Country Coordinator and Assistant Professor

Kelechi Ohiri

Health Strategy and Delivery Foundation, Lagos, Nigeria

Profile picture of Professor Joanna Schellenberg
Professor Joanna Schellenberg

IDEAS Co-Principal Investigator and Professor

Profile picture of Professor Tanya Marchant
Professor Tanya Marchant

IDEAS Principal Investigator and Professor