Uncovering and Understanding Success: A Qualitative Study of High-Performing Hospitals for Small and Sick Newborn Care in Four countries in Africa

BackgroundDespite evidence-based interventions to reduce neonatal mortality, implementation gaps continue in low-resource settings. The Newborn Essential Solutions and Technologies (NEST360) alliance supports neonatal units in Kenya, Malawi, Nigeria, and Tanzania with a package of technologies, training, data systems, and quality improvement (QI). However, wide variation in care coverage remains. This study examines the facility-level strategies used by high-performing "positive coverage outlier" hospitals to achieve and sustain high coverage of priority neonatal interventions. MethodsWe performed 74 key informant interviews and 21 focus groups across 16 hospitals in four countries. Hospitals were selected based on their coverage rates (percentage of eligible newborns receiving an intervention) for at least one of four neonatal interventions (kangaroo mother care, continuous positive airway pressure, phototherapy, hypothermia prevention). Transcripts were coded using deductive and inductive approaches to identify strategies, barriers, and facilitators of implementation. ResultsA total of 114 distinct strategies were identified. Common strategies across countries included peer-to-peer mentorship, routine data review meetings, and family education. Country-specific adaptations were also observed. For example, Malawi emphasized data-driven decision-making and Tanzania focused on infection control. Many strategies were low-cost and addressed organizational and behavioral mechanisms such as motivation, accountability, and teamwork. ConclusionsThis study highlights the importance of context-sensitive implementation strategies in achieving and sustaining high coverage for neonatal interventions. Beyond program interventions, like trainings and providing medical devices, strategies fostering staff engagement, leadership support, and cultural alignment are critical. Findings offer actionable insights for scaling up neonatal care improvements within and beyond the NEST360 network. Clinical trial numberNot applicable Contributions to the literatureO_LIThis study demonstrates how implementation science principles can be applied to facility-level quality improvement efforts to generate generalizable knowledge and identify common strategies and themes that underpin successful implementation across diverse facilities and countries. C_LIO_LIThese findings highlight the variability in program implementation across facilities and countries, demonstrating that even when facilities receive the same package, success depends on context-specific adaption. This contributes to the growing evidence that effective scale-up requires flexible, locally tailored solutions in additional to a standardized implementation package. C_LIO_LIThe use of a positive outlier approach within a multi-country implementation program demonstrates a feasible and replicable method for identifying and disseminating actionable implementation strategies, and the cross-country comparative design of this study enables the identification of convergent and context-specific strategies used to improve small and sick newborn care. C_LI