Roles played by Locally Elected Representatives in Facilitating Multi-Sectoral Action for Health: Evidence from Kerala, India.

Multi-Sectoral Action (MSA) for health involves the collaboration of various stakeholder groups within and beyond the health sector and is seen to be critical for the attainment of the Sustainable Development Goals. In Kerala, India, decentralisation reforms have been in place for some time, and we sought to characterise the roles specifically played by locally elected representatives or Local Self-Government (LSG) members, in relation to MSA. Between July and October 2021, we conducted in-depth interviews with 80 participants from four districts in the southern Indian state of Kerala. Participants were community leaders, healthcare professionals, public health officials and elected members of LSG bodies. After obtaining written informed consent, participants were interviewed about the roles of various stakeholders in implementing primary care reforms with a particular focus on MSA at the grassroots level. The interviews were recorded, translated into English, and thematically analysed by the research team using ATLAS.ti 9.1 software. Participants ranged in age from 35 to 60 years. LSGs played a number of critical MSA roles, including being a gatekeeper for local action; coordinator of departments, sectors and actors (departments of health, revenue, labour, and education departments as well as volunteers); custodian of community, particularly those 'left behind,' crisis manager, team builder and advocate even for communities for which they did not have direct responsibility. LSGs were widely seen by implementers as central figures in coordinating MSA for health in Kerala, before and during the COVID-19 pandemic, and in relation to 'left behind' groups. The multiplicity of roles played by LSGs suggests the need for flexibility on the one hand as well as the plurality of roles on the other hand, which may be necessary to enable convergence and MSA, particularly at local levels.