title: 'The stars seem aligned': a qualitative study to understand the effects of context on scale-up of maternal and newborn health innovations in Ethiopia, India and Nigeria.
abstract: Donors commonly fund innovative interventions to improve health in the hope that governments of low and middle-income countries will scale-up those that are shown to be effective. Yet innovations can be slow to be adopted by country governments and implemented at scale. Our study explores this problem by identifying key contextual factors influencing scale-up of maternal and newborn health innovations in three low-income settings: Ethiopia, the six states of northeast Nigeria and Uttar Pradesh state in India.
  
  
  
  We conducted 150 semi-structured interviews in 2012/13 with stakeholders from government, development partner agencies, externally funded implementers including civil society organisations, academic institutions and professional associations to understand scale-up of innovations to improve the health of mothers and newborns these study settings. We analysed interview data with the aid of a common analytic framework to enable cross-country comparison, with Nvivo to code themes.
  
  
  
  We found that multiple contextual factors enabled and undermined attempts to catalyse scale-up of donor-funded maternal and newborn health innovations. Factors influencing government decisions to accept innovations at scale included: how health policy decisions are made; prioritising and funding maternal and newborn health; and development partner harmonisation. Factors influencing the implementation of innovations at scale included: health systems capacity in the three settings; and security in northeast Nigeria. Contextual factors influencing beneficiary communities' uptake of innovations at scale included: sociocultural contexts; and access to healthcare.
  
  
  
  We conclude that context is critical: externally funded implementers need to assess and adapt for contexts if they are to successfully position an innovation for scale-up.
authors.affiliation: London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, UK. neil.spicer@lshtm.ac.uk.
authors.forename: Neil
authors.identifier: 0000-0003-3451-8003
authors.initials: N
authors.lastname: Spicer
authors.affiliation: London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, UK.
authors.forename: Della
authors.initials: D
authors.lastname: Berhanu
authors.affiliation: Save the Children, 1st & 2nd Floor, Plot No. 18, Sector - 44, Gurgaon, Haryana, 122003, India.
authors.forename: Dipankar
authors.initials: D
authors.lastname: Bhattacharya
authors.affiliation: Health Hub, The Office, 4th Floor, Ropp House, Adetokunbo Ademola Crescent, Wuse II, Abuja, Nigeria.
authors.forename: Ritgak Dimka
authors.initials: RD
authors.lastname: Tilley-Gyado
authors.affiliation: London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, UK.
authors.forename: Meenakshi
authors.initials: M
authors.lastname: Gautham
authors.affiliation: London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, UK.
authors.forename: Joanna
authors.initials: J
authors.lastname: Schellenberg
authors.affiliation: Jarco Consulting, PO Box 43107, Gofa Sefer, Addis Ababa, Ethiopia.|Federal Ministry of Health of Ethiopia, PO Box 1234, Addis Ababa, Ethiopia.
authors.forename: Addis
authors.initials: A
authors.lastname: Tamire-Woldemariam
authors.affiliation: London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, UK.
authors.forename: Nasir
authors.initials: N
authors.lastname: Umar
authors.affiliation: London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, UK.
authors.forename: Deepthi
authors.initials: D
authors.lastname: Wickremasinghe
mesh_terms: D004059:Diffusion of Innovation; D005002:Ethiopia; D005260:Female; D006291:Health Policy; D006801:Humans; D007194:India; D000068104:Infant Health / Q000706:statistics & numerical data*; D007231:Infant, Newborn; D000068097:Maternal Health / Q000706:statistics & numerical data*; D008427:Maternal Health Services / Q000458:organization & administration*; D009549:Nigeria; D011247:Pregnancy; D036301:Qualitative Research
keywords: Context; Ethiopia; Health policy and systems; India; Innovations; Maternal and newborn health; Northeast Nigeria; Scale-up; Uttar Pradesh