<p>We designed a three-pronged, multi-level approach for the health quality that, anchored in the Juran Trilogy of quality planning, quality assurance and quality control, was intended to ensure large-scale implementation and sustainability of effective quality improvement efforts. The components of the initiative were as follows:. Development of a National Healthcare Quality Strategy (NHQS)to establish the vision and governance structures required to achieve a quality health system;. Building of QI capability at all levels of the health system (federal,regional, zonal, woreda/district, and health facility levels) to&nbsp; &nbsp;activate the newly developed quality governance structures and help institutionalize a culture of continuous QI in Ethiopia and3. Design and implementation of maternal and newborn health(MNH) collaborative to demonstrate the translation of th equality governance structures and capability-building efforts into improvements in quality in a priority focus area of the FMoH. The MNH collaborations were designed to improve the quality of routine antenatal, delivery and postnatal care; improve management of leading causes of maternal and neonatal mortality and improve service utilization through stronger community engagement and referral networks. The collaborative design an adaptation of IHI’s Breakthrough Series model&nbsp; and the Model for Improvement framework helps to generate ideas during collaborative learning sessions (intermittent face-to-face meeting of facility teams and leaders to learn QI methods, share resultsand experiences and plan implementation), some of which are subsequently tested and ultimately implemented in health facilities.We hypothesized that these improvements would reduce facility-based maternal and neonatal mortality by at least 30% over the3-year implementation period.With full national scale in mind from the outset, the woreda (district) is chosen as the ‘scalable unit’ (a representative sub-unit of the health system targeted for full scale-up)for the collaborative innovation. This unit includes a primary hospital, linked to referring nurse-led health centers and linked to Health Extension Worker (HEW)-staffed health posts, which serve as the front lines with communities.Phased design for scale. The approach was implemented in two phases—a ‘prototype’ phase and a ‘test-of-scale (TOS)’ phase—aligned with the Ethiopian health-care tier system and grounded in IHI’s framework for large- scale. A third phase (full scale) is being planned by the FMoH. The objectives of the prototype phase were to understand the most successful implementation ideas for change and the health system attributes that influence the performance of the system. The out put of the prototype phase was the development of a change package—a set of locally developed change ideas with measurable impact for improvement of MNH. There were five prototype collaboratives,selected in consultation with the FMoH and Regional Health Bureaus(RHBs), with one in each of four agrarian regions (Amhara; Oromia;Southern Ethiopia Region, and Tigray) and one in the pastoralist region of Afar. During the prototype phase, IHI Senior Project Officers, in partnership with the woreda health office, led the learning sessions and facility coaching visits.These officers were nurses or nurse midwives trained in health service quality and coaching techniques as part of their on boarding. After refining the intervention approach during prototype and building will across the region, the project transitioned to the TOSphase, which aims to assess the effectiveness of the change package developed during the prototype phase in a much larger and more diverse set of woredas and to test the feasibility of the approach within the existing system. In this phase, learning sessions are integrated into woreda review meetings, facilitation and coaching are led by woreda-based coaching teams and QI capability building is led byRHB quality unit trainers. Learnings from the prototype and TOS phases will inform the planned national scale-up, which will be entirely country-led to ensure the sustainability of the health care service in Ethiopia.</p>