<p>General demographics of interview subjects.</p>

Surgical outcomes in low- and middle-income countries are significantly worse than in their high-income country counter parts. Registries are an important tool in quality improvement as they facilitate collection and analysis of comprehensive patient data to be used for benchmarking outcomes. Despite the known efficacy of such registries, they are sparse in low- and middle-income countries. Ethiopia, however has had success implementing perioperative data collection systems at a national as well as local level. This qualitative study seeks to understand the experience of creating and managing such registries in the low-income setting from the perspective of individuals who work in this space. We performed 14 semi-structured interviews with individuals from Ethiopia who work with data systems. Interviews were performed with 3 data collectors, 3 surgeons, 3 administrators, 2 hospital focal people, and 3 ministry of health officials. Thematic analysis was employed through a grounded theory approach. Primary themes were identified: the resource ecosystem, the budget checkpoint, digitalization, the mindset highway, and universal personal commitments. From these themes, we developed an interdependent systems theory, which states that complex data systems in LMICs are driven by the dynamic interaction of three pillars: infrastructure, people, and budget prioritization. This study provides rare insight into the management of peri-operative data collection systems in LMICs from the perspective of professionals who work in this space. Findings from this study can be utilized as a reference and blueprint for other countries and groups who aim to create data collection systems in challenging environments.