<p>The design of the EHCQI built upon existing assets and initiatives in Ethiopia to create robust national and regional quality planning that guides district-level system improvement and strengthens quality control. A critical factor in the successful implementation of the prototype phase has been the FMoH’s leadership of the design and implementation at all levels. The impetus for program design came from the FMoH in alignment with the Quality and Equity transformation agenda laid out in Ethiopia’s HSTP. Such high-level investment provides the ideal environment for program implementation as has been advocated since the early days of large-scale QI efforts .</p><p>We have also found that aligning collaborative design with the district-wide system from the start, as was done in a similar large scale improvement initiative in Ghana (24), has been instrumental to the integration of the learning system into existing administrative structures. This not only brings facilities within a referral system but also enhance adaptations of innovations scaled up in all levels of the health facilities.&nbsp;</p>