<p>National healthcare quality strategy</p><p>The NHQS was developed by the FMoH with support from IHI at the beginning of the initiative, in March 2016. The NHQS identified four strategic focus areas: (i) developing an integrated approach</p><p>to quality management, (ii) igniting consumer demand for quality, (iii) linking UHC strategy with the quality agenda and (iv) strengthening data systems and feedback (22). Implementation of the NHQS is underway with the leadership of the FMOH, including creating quality governance structures at all levels, building QI capability and convening annual QI summits to support a QI ‘movement’.</p><p>Building Health Care Services Delivery capability</p><p>The capability is being built through targeted training in essential quality services standards and methods and leadership for different cadres of healthcare providers and administrators across the multiple levels of the health system.To date, two intensive 10-month Improvement Advisor professional development programs have been held to provide high-level theoretical and practical training in QI for 33 FMoH and regional-level staff who will be leading QI management in Ethiopia after the project. In addition, the IHI QI Leadership and Management program was used more broadly to train 212 woreda, regional and national managers to lead and manage the QI work that was unfolding in the woredas. As champions—individuals who showed</p><p>leadership and commitment to continuous QI—were developed, IHI worked together with the FMoH and partners to develop context- relevant and nationally owned QI trainer and participant manuals for Trainer-of-Trainers (TOT) and basic-level QI courses. IHI supported the first TOT with the FMoH in January 2018, which produced 24 federal- and RHB-level trainers. These trainers subsequently led the launch of the TOS collaboratives and provided basic quality services training to 848 participants from TOS collaborative health facilities has brought novel changes in the landscape of health care services innovations to impact.</p><p>Models of collaboration</p><p>Fidelity to implementation design. Between October 2020 and September 2023, four prototype collaboratives were completed in</p><p>Oromia, Tigray, South Ethiopia Region and Amhara. A fifth has been underway in Afar region since March 2018. Overall, the program was implemented as designed, with a few adaptations. First, woreda selection for prototype collaboratives was initially intended to include three geographically distinct woredas (urban, agrarian and pastoralist) in one region. However, a recognition of contextual differences across regions caused us to change the approach to include one prototype collaborative per region across five regions. Second, we expected to find a primary hospital and its referring facilities within one woreda. However, in two regions, the selected catchment area had a semi-urban woreda with its referral hospital situated within a separately administered woreda. We remained consistent with the design principle of structuring collaboratives along the referral system and worked with two woreda health offices in these cases.</p><p>Third, activities in Amhara region had to be delayed for 8 months due to regional security concerns. The prototype collaborative in the pastoralist Afar region was deliberately delayed until enough project experience had been gained in the agrarian communities. Adoption and effectiveness. Participating facilities have been actively engaged in the collaboratives, with all facilities represented in every learning session. Thirty-five QI teams have, on average, met once per month and received 1.6 coaching visits each month, leading to the generation of 102 change ideas that were refined over the action periods using 826 PDSA cycles; 83 of these ideas were included in the final change package (supplemental file).</p><p>Acceptability. The FMoH’s leadership of the health care quality design and implementation process, the leadership of the FMoH in developing QI training materials and the high levels of adoption of the quality planning approach and health care quality assurance activities noted to demonstrate acceptability of the approach. Also, acceptability was demonstrated through the willingness of the FMoH to dedicate full-time employees to the improvement initiative. Acceptability will be more deeply assessed during the TOS, as the entirety of the execution of the QI activities is dependent upon the approach being acceptable to health system actors to further improve the health policy performance of the country.&nbsp;</p>