Institutionalising community participation in decision making for quality maternal and newborn health services: What works, how, for whom and under what conditions?

In 2024, 194 countries endorsed World Health Assembly Resolution 77.2 recognising community participation in health decision-making is essential to improve quality, accountability, and system performance. Building the evidence base is one aim of the Resolution, yet little has been documented about how community participation has been institutionalised within health systems in low-and middle-income countries. This PhD thesis examines the institutionalisation of community participation in decision-making as a strategy to improve the quality of maternal and newborn health services. It explores how to institutionalise community participation in decision-making in health facilities by asking what works, how, for whom, and under what conditions. The multi-method PhD design included: (1) a scoping review to map the available evidence; (2) a survey of 102 low-and middle-income countries to assess the institutionalisation of community participation in maternal and newborn health services and identify potential exemplars of practice; and (3) a realist evaluation regarding how to institutionalise community participation for quality maternal and newborn health services, embedded within the Network for Improving Quality Care for Maternal, Newborn and Child Health. Initial programme theories were developed through a novel, four-phase, multi-method, and iterative process involving literature review and global workshops, and these were tested in Malawi using document review and realist interviews with national, district, facility, and community stakeholders. A limited policy-cycle perspective of community participation is documented in the reproductive, maternal, newborn, and child health literature. The survey revealed gaps between planning, and implementation and monitoring, while also identifying potential exemplars for further study. Seven programme theories emerged from testing in Malawi highlighting that institutionalisation requires protected spaces for joint planning, effective feedback loops, and leadership that embeds participation into everyday quality improvement practice. Sustained participation depends on role clarity, continuous capacity building, and equitable volunteer support, all situated within a health facility culture of learning. This PhD makes several contributions to the knowledge base; conceptual, methodological and theoretical. The scoping review clarified confusion regarding terminology in the literature and highlighted the lack of studies applying a policy cycle lens to community participation. The analysis of national progress provides original insights and established a baseline of the gaps that countries must close to achieve World Health Assembly Resolution 77.2. Methodologically, the thesis advances realist methods by contributing a novel approach towards addressing the gap in guidance on involving stakeholders in developing initial programme theories. This approach foreground stakeholders’ perspectives in theory-building. The resulting programme theories, refined through testing in Malawi, offer lessons for scalability in Malawi and similar contexts, and can be further tested across diverse contexts to develop middle-range theories to yield transferable insights for policy, programming, and the measurement of institutionalisation.