Department of International Health, Johns Hopkins Bloomberg School of Public Health (JHSPH), Baltimore, USA.
Johns Hopkins India Private Limited, New Delhi, India.
BMC Health Serv Res. 2024 May 16;24(1):634. doi: 10.1186/s12913-024-11002-2.
Multisectoral collaboration is essential for advancing primary health care (PHC). In low- and middle-income countries (LMICs), limited institutional capacities, governance issues, and inadequate stakeholder engagement impede multisectoral collaboration. India faces similar challenges, especially at the meso-level (districts and subdistricts). Owing to its dependence on context, and insufficient evidence, understanding "How" to improve multisectoral collaboration remains challenging. This study aims to elicit specific recommendations to strengthen meso-level stewardship in India for multisectoral collaboration. The findings from this study may offer lessons for other LMICs.
Using purposive, maximum variation sampling, the study team conducted semi-structured interviews with 20 diverse participants, including policymakers, implementers, development agency representatives, and academics experienced in multisectoral initiatives. The interviews delved into participants' experiences, the current situation, enablers, and recommendations for enhancing stakeholder engagement and capacities at the meso-level for multisectoral collaboration.
Context and power are critical elements to consider in fostering effective collaboration. Multisectoral collaboration was particularly successful in three distinct governance contexts: the social-democratic context as in Kerala, the social governance context in Chhattisgarh, and the public health governance context in Tamil Nadu. Adequate health system input and timely guidance instil confidence among local implementers to collaborate. While power plays a role through local leadership's influence in setting agendas, convening stakeholders, and ensuring accountability. To nurture transformative local leaders for collaboration, holistic, equity-driven, community-informed approaches are essential. The study participants proposed several concrete steps: at the state level, establish "central management units" for supervising local implementers and ensuring bottom-up feedback; at the district level, rationalise committees and assign deliverables to stakeholders; and at the block level, expand convergence structures and involve local self-governments. Development partners can support data-driven priority setting, but local implementers with contextual familiarity should develop decentralised plans collaboratively, articulating rationales, activities, and resources. Finally, innovative training programs are required at all levels, fostering humility, motivation, equity awareness, leadership, problem- solving, and data use proficiency.
This study offers multiple solutions to enhance local implementers' engagement in multisectoral efforts, advocating for the development, piloting, and evaluation of innovative approaches such as the block convergence model, locally-led collaboration efforts, and novel training methods for local implementers.
多部门协作对于推进初级卫生保健（PHC）至关重要。在中低收入国家（LMICs），机构能力有限、治理问题以及利益相关者参与不足等因素阻碍了多部门协作。印度也面临着类似的挑战，尤其是在中观层面（地区和分区）。由于对背景的依赖以及证据不足，理解“如何”加强多部门协作仍然具有挑战性。本研究旨在为印度加强中观层面的多部门协作提出具体建议。这项研究的结果可能为其他 LMICs 提供经验教训。
研究团队采用有目的、最大差异抽样方法，对 20 名来自不同背景的参与者进行了半结构化访谈，包括政策制定者、执行者、发展机构代表以及在多部门倡议方面有经验的学者。访谈深入探讨了参与者在多部门协作方面的经验、现状、促进因素和建议，以增强中观层面的利益相关者参与和能力。
背景和权力是促进有效协作的关键因素。多部门协作在三个不同的治理背景下取得了特别成功：社会民主背景下的喀拉拉邦、社会治理背景下的恰蒂斯加尔邦和公共卫生治理背景下的泰米尔纳德邦。充分的卫生系统投入和及时的指导使当地执行者有信心进行协作。虽然权力通过地方领导层在设定议程、召集利益相关者和确保问责制方面的影响力发挥作用。为了培养有变革能力的协作地方领导者，需要采取整体的、以公平为导向的、以社区为基础的方法。研究参与者提出了几项具体步骤：在邦层面，设立“中央管理单位”，负责监督地方执行者并确保自下而上的反馈；在区层面，对委员会进行合理化并向利益相关者分配可交付成果；在街区层面，扩大融合结构并让地方自治政府参与进来。发展伙伴可以支持数据驱动的重点设定，但具有背景知识的当地执行者应该共同制定分散的计划，阐明理由、活动和资源。最后，需要在各个层面提供创新培训计划，培养谦逊、动力、公平意识、领导力、解决问题和数据使用能力。
本研究提出了多种方法来加强地方执行者在多部门工作中的参与度，倡导制定、试点和评估创新方法，如街区融合模式、地方主导的协作努力以及针对地方执行者的新型培训方法。
