From permission to pride: a realist synthesis of how to improve emergency care for children in low-income and lower-middle-income countries.

Improving the quality of hospital-based emergency care for children is central to reducing preventable deaths. Yet, little is known about how to prioritise and adapt interventions to context, especially in low-income and lower-middle-income countries. In this Review, we conducted a realist synthesis to develop a mid-range theory of how and why hospital-level emergency care interventions improve (or fail to improve) outcomes. Three interdependent mechanisms recur across published literature: legitimacy (permission, expectation, and identity), capability (knowledge, skills, confidence, and individual action), and connectedness (coming together, collective purpose, and coordinated team action). Legitimacy creates the conditions for action, capability enables individual action, and connectedness enables coordinated team responses. The same emergency care intervention can strengthen one or multiple mechanisms depending on context and implementation. This theory provides a basis for practical frameworks to help policy makers and hospital leaders diagnose constraints, prioritise interventions, and design more coherent implementation strategies.