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Multi-sectoral collaboration has been identified as a critical component in a wide variety of health and development initiatives. For India’s Integrated Child Development Services (ICDS) scheme, which serves over 100 million people annually across more than one million villages, a key point of multi-sectoral collaboration – or “convergence”, as it is often called in India – is between the three frontline worker cadres jointly responsible for delivering essential maternal and child health and nutritional services throughout the country: the Accredited Social Health Activist (ASHA), Anganwadi worker (AWW), and auxiliary nurse midwife (ANM), or “AAA” workers. Despite the long-recognized importance of collaboration within this triad, there has been relatively little documentation of what this looks like in practice and what is needed in order to improve it. Informed by a conceptual framework of collaborative governance, this study applies inductive thematic analysis of in-depth interviews with 18 AAA workers and 6 medical officers from six villages across three administrative blocks in Hardoi district of Uttar Pradesh state to identifiy key elements of collaboration. These are grouped into three broad categories: organizational (including interdependence, role clarity, guidance/support, and resource availability); relational (interpersonal, conflict resolution); and personal (flexibility, diligence, locus of control). These findings underscore the importance of personal and relational collaboration features, which are underemphasized in India’s ICDS, the largest of its kind globally, and in the multi-sectoral collaboration literature more broadly – both of which place greater emphasis on organizational aspects of collaboration. These findings are largely consistent with prior studies, but are notably different in that they highlight the importance of flexibility, locus of control, and conflict resolution in collaborative relationships, all of which relate to one’s ability to adapt to unexpected obstacles and find mutually workable solutions with colleagues. From a policy perspective, supporting these key element of collaboration may involve giving frontline workers more autonomy in how they get the work done, which may in some cases be impeded by additional training to reinforce worker role delineation, closer monitoring, or other top-down efforts to push greater convergence. Given the essential role that frontline workers play in multi-sectoral initiatives in India and around the world, there is a clear need for policymakers and managers to understand the elements affecting collaboration between these workers when designing and implementing programs.

The aim of this review was to rapidly synthesize the available evidence regarding the expected impacts of piped water chlorination, drainage, and sewerage on individuals living in low- and middle-income urban settings. A systematic search was conducted in bibliographic databases and library catalogs. Impact evaluations that included a comparator and one of the three interventions of interest, attempted to control for confounding and selection bias, and took place in urban settings in a low- or middle-income country were considered. Outcomes related to health, well-being, economic growth, and the bacterial content of water were considered. A total of 1,483 articles were identified, with 18 included after final screening. Most studies were case-control and took place in Brazil, the Pacific Islands, or south-western Asia. Fifteen studies considered sewerage, five considered chlorination, and two studies considered drainage with some studies considering multiple interventions. All primary outcomes were related to health. When implemented alone, the sewerage and chlorination interventions were largely successful. The evidence regarding the effects of chlorination, drainage, and sewerage interventions is limited and generally has a high risk of bias. When properly implemented, sewerage and chlorination are likely to have positive health impacts. However, when implemented poorly, all three interventions can have negative health impacts. HIGHLIGHTS Most studies focused on sewerage interventions.; Chlorination and sewerage interventions were successful in reducing disease burden.; Contamination sources included lack of improved WaSH, sources in the nearby environment, and household hygiene practices.; Infrastructure maintenance issues affected the interventions’ impacts.; Proper household hygiene practices should be included for effective interventions.

The current body of research into multisectoral collaborations (MSCs) for health raises more questions than it answers, both in terms of how to implement MSCs and how to study them. This article reflects on current methodological gaps and opportunities for advancing MSC research, based on a targeted review of existing literature and qualitative input from researchers and practitioners at the 2018 Health Systems Research (HSR) Symposium in Liverpool. Through framework analysis of 205 MSC research papers referenced in a separately published MSC ‘overview of reviews’ paper, this article identifies six broad MSC question domains (‘meta questions’) and applies content analysis to estimate the relative frequency with which these meta questions and the research method(s) used to answer them are present in the literature. Results highlight a preponderance of research exploring MSC implementation using case study methods, which, in aggregate, does not seem to adequately meet policymakers’ and practitioners’ needs for generalizable or transferable insights. The content analysis is complemented by qualitative insights from HSR Symposium participants and the authors’ own experience to identify six key methodological gaps in research on MSC for health. For each of these gaps, we propose areas in which we believe there are opportunities for methodological development and innovation to help advance this field of study, including: better understanding the role of power dynamics in shaping MSCs; development of a classification framework (or frameworks) of governance arrangements; exploring divergence of perspective and experience among MSC partners; identifying or generating theoretical frameworks for MSC that work across sectors and disciplines; developing intermediate indicators of collaboration; and increasing transferability of insights to other contexts. Collaboration with researchers outside of the health sector will enhance efforts in each of these areas, as will the establishment and strengthening of pluralistic MSC evidence networks also involving policymakers and practitioners.

As health systems practitioners and researchers increasingly turn towards systems thinking approaches and work on building interorganisational networks, they have demonstrated increasing interest in network analysis for investigating relationships and interactions between system actors, both at the individual and organisational levels. Despite the potential of network-based approaches to improve health system efficiency, effectiveness and responsiveness, both the theoretical and practical guidance on designing and evaluating network-building strategies is underdeveloped within the field. While there are multiple tools and resources to help users collect, manage and analyse network data, there is much less guidance on the practical applications of this information. One apparent gap is the limited application of longitudinal organisational network analysis, in which data are collected from the same organisational actors repeatedly over multiple time points. This yields insights into the dynamic nature of networks, including how the network structure and interactions change over time. Given that networks are rarely static, the addition of the time dimension has the potential to substantially enhance the analytical value of network analysis and contribute to more nuanced guidance for interested practitioners and policymakers. In this article, the authors draw on their experiences in conducting longitudinal network analysis of interorganisational relationships in the USA and India to comment on the opportunities and challenges of the methodology within the field of health systems research. We also provide suggestions as to how some of these challenges may be addressed or mitigated.

ObjectivesMultisectoral collaboration (MSC) is widely recognised as a critical aspect of policies, programmes and interventions addressing complex public health issues, yet it is undertheorised and difficult to measure. Limited understanding of the intermediate steps linking MSC formation to intended health outcomes leaves a substantial knowledge gap about the types of strategies that may be most effective in making such collaborations successful. This paper, which reports the quantitative strand of a broader mixed-methods study, takes a step toward filling in this ‘missing middle’ of MSC evaluation by developing and testing the FLW-MSC scale, an instrument to assess collaboration among the frontline workers of one of India’s largest and most widely known MSCs: the Integrated Child Development Services (ICDS) scheme.DesignThis study involved development, field-testing and psychometric testing of an 18-item, Likert-type frontline worker collaboration scale, including internal consistency, construct validity and criterion validity.SettingVillage-level primary healthcare in rural Uttar Pradesh, India.Participants281 anganwadi workers, 266 accredited social health activists and 124 auxiliary nurse midwives selected based on random sampling of anganwadi catchment areas from 346 gram panchayats (GPs), including 173 intervention GPs and 173 pair-matched control GPs from a parent evaluation study.ResultsResults support the scale’s internal consistency (ordinal α=0.92–0.95), construct validity (reasonable exploratory factor analysis model fit for five of the six dyadic relationships Tucker-Lewis Index=0.84–0.88; Root Mean Squared Error of Approximation=0.09–0.11), and criterion validity (regression of collaboration score on an information-sharing indicator β=3.528; p=0.006).ConclusionsThe scale may be useful for ICDS managers to detect and address poor collaboration as the Indian government redoubles its efforts to strengthen and monitor MSC, or ‘convergence’, with important implications for the critical priority of child development. Further, the FLW-MSC scale may be adapted for measuring frontline worker collaboration across sectors in many other scenarios and low/middle-income country contexts.

Aims: Rapidly synthesize the available evidence regarding the expected impacts of piped water chlorination, drainage, and sewerage on individuals living in low- and middle-income urban settings. Methods: A systematic search was conducted in bibliographic databases and library catalogues. Impact evaluations that included a comparator and one of the three interventions of interest, attempted to control for confounding and selection bias, and took place in urban settings in a low- or middle-income country were considered. Outcomes related to health, well-being, economic growth, and the bacterial content of water were considered.Results: 1483 articles were identified, with 18 included after final screening. Most studies were case-control and took place in Brazil, the Pacific Islands, or south-western Asia. Fifteen studies considered sewerage, five considered chlorination, and two studies considered drainage with some studies considering multiple interventions. All primary outcomes were related to health. When implemented alone, the sewerage and chlorination interventions were largely successful. Conclusions: The evidence regarding the effects of chlorination, drainage, and sewerage interventions is limited and generally has a high risk of bias. When properly implemented, sewerage and chlorination are likely to have positive health impacts. However, when implemented poorly, all three interventions can have negative health impacts.

Background Given the paradigmatic shift represented by the Sustainable Development Goals (SDGs) as compared to the Millennium Development Goals - in particular their broad and interconnected nature - a new set of health policy and systems research (HPSR) priorities are needed to inform strategies to address these interconnected goals. Objectives To identify high priority HPSR questions linked to the achievement of the Sustainable Development Goals. Methods We focused on three themes that we considered to be central to achieving the health related SDGs: (i) Protecting and promoting access to health services through systems of social protection (ii) Strengthening multisectoral collaborations for health and (iii) Developing more participatory and accountable institutions. We conducted 54 semi-structured interviews and two focus group discussions to investigate policy-maker perspectives on evidence needs. We also conducted an overview of literature reviews in each theme. Information from these sub-studies was extracted into a matrix of possible research questions and developed into three domain-specific lists of 30–36 potential priority questions. Topic experts from the global research community then refined and ranked the proposed questions through an online platform. A final webinar on each theme sought feedback on findings. Results Policy-makers continue to demand HPSR for many well-established issues such as health financing, human resources for health, and service delivery. In terms of service delivery, policy-makers wanted to know how best to strengthen primary health care and community-based systems. In the themes of social protection and multisectoral collaboration, prioritized questions had a strong emphasis on issues of practical implementation. For participatory and accountable institutions, the two priority questions focused on political factors affecting the adoption of accountability measures, as well as health worker reactions to such measures. Conclusions To achieve the SDGs, there is a continuing need for research in some already well established areas of HPSR as well as key areas highlighted by decision-makers. Identifying appropriate conceptual frameworks as well as typologies of examples may be a prerequisite for answering some of the substantive policymaker questions. In addition, implementation research engaging non-traditional stakeholders outside of the health sector will be critical.

Implementation research (IR) focuses on understanding how and why interventions produce their effects in a given context. This often requires engaging a broad array of stakeholders at multiple levels of the health system. Whereas a variety of tools and approaches exist to facilitate stakeholder engagement at the national or institutional level, there is a substantial gap in the IR literature about how best to do this at the local or community level. Similarly, although there is extensive guidance on community engagement within the context of clinical trials—for HIV/AIDS in particular—the same cannot be said for IR. We identified a total of 59 resources by using a combination of online searches of the peer-reviewed and grey literature, as well as crowd-sourcing through the Health Systems Global platform. The authors then completed two rounds of rating the resources to identify the ‘10 best’. The resources were rated based on considerations of their relevance to IR, existence of an underlying conceptual framework, comprehensiveness of guidance, ease of application, and evidence of successful application in low- or middle-income countries or relevant contexts. These 10 resources can help implementation researchers think strategically and practically about how best to engage community stakeholders to improve the quality, meaningfulness, and application of their results in order to improve health and health systems outcomes. Building on the substantial work that has already been done in the context of clinical trials, there is a need for clearer and more specific guidance on how to incorporate relevant and effective community engagement approaches into IR project planning and implementation.

BackgroundAs population health and well-being are influenced by multiple factors that cut across sectoral boundaries, an intersectoral approach that acknowledges and leverages the multiple determinants, actors and sectors at play is increasingly seen as critical for achieving meaningful and lasting improvements. In this study, we utilize social network analysis (SNA) to characterize the intersectoral collaboration between the organizations working on maternal & child health (MCH) and water & sanitation (WASH) before and immediately after the implementation of HCL Foundation (HCLF)-funded HCL Samuday Project (2015-2017) in a rural block of Uttar Pradesh state, India. While SNA has been used to examine public health issues, few have used it monitor stakeholder relationships, intervene, improve and facilitate project implementation involving intersectoral partnerships, particularly in the context of a low-and middle-income countries.MethodAn organization-level SNA was conducted with 31 key informants from 24 organizations working on MCH and/or WASH in Kachhauna, Uttar Pradesh, India. Data were collected using face-to-face, semi-structured interviews between June and September 2017. Density, centrality and homophily were calculated to describe the network and a qualitative analysis was also conducted to identify the strengths and weaknesses of collaboration between organizations working on MCH and WASH.ResultsOverall, our findings showed that the network of organizations working on MCH and WASH in Kachhauna grew in number since the implementation of Samuday. HCLF rapidly achieved centrality, thus positioning the organization to serve as a gatekeeper of information and enabling it to play a coordinator role within the network. Direct collaboration between other organizations working on MCH and WASH was low at both time points. Interviews with key informants indicated widespread interest in increasing interorganizational interactions and engagement throughout the network.ConclusionThis study demonstrates the feasibility and practical application of SNA for projects like Samuday that involve intersectoral collaboration. It also provides lessons about the use of SNA with organizations as the unit of analysis and in the context of rural India, including challenges, practical considerations, and limitations.

Multisectoral action is key to addressing many pressing global health challenges and critical for achieving the Sustainable Development Goals, but to-date, understanding about how best to promote and support multisectoral action for health is relatively limited. The challenges to multisectoral action may be more acute in low-income and middle-income countries (LMICs) where institutions are frequently weak, and fragmentation, even within the health sector, can undermine coordination. We apply the lens of governance to understand challenges to multisectoral action. This paper (1) provides a high level overview of possible disciplines, frameworks and theories that could be applied to enrich analyses in this field; (2) summarises the literature that has sought to describe governance of multisectoral action for health in LMICs using a simple political economy framework that identifies interests, institutions and ideas and (3) introduces the papers in the supplement. Our review highlights the diverse, but often political nature of factors influencing the success of multisectoral action. Key factors include the importance of high level political commitment; the incentives for competition versus collaboration between bureaucratic agencies and the extent to which there is common understanding across actors about the problem. The supplement papers seek to promote debate and understanding about research and practice approaches to the governance of multisectoral action and illustrate salient issues through case studies. The papers here are unable to cover all aspects of this topic, but in the final two papers, we seek to develop an agenda for future action. This paper introduces a supplement on the governance of multisectoral action for health. While many case studies exist in this domain, we identify a need for greater theory-based conceptualisation of multisectoral action and more sophisticated empirical investigation of such collaborations.

The focus of the health sector in most countries remains almost exclusively on health care services, and the potential of multisectoral collaboration remains untapped in many low- and middle-income countries.Different sectors have different contributions to make towards solving specific health problems. In each case, the profile, interests, incentives, and relationships of key individuals and sectors must be mapped and analysed to inform the design of approaches and systems to tackle a shared problem.Collaborative and distributed leadership is key for effective governance of multisectoral action, with a need to build leadership capacity across sectors and levels of government and cultivate champions in different sectors who can agree on common objectives.Important ways forward to support countries to take a multisectoral approach for health include ensuring that the universal health coverage agenda addresses the capacity of the health sector to work with other sectors, learning from multisectoral efforts that do not involve the health sector, improving the capacity of global institutions to support countries in undertaking multisectoral action, and developing a clear implementation research agenda for multisectoral action for health.

In Vietnam, discrimination against people living with HIV/AIDS (PLHIV) is defined within and prohibited by the 2007 national HIV/AIDS law. Despite the law, PLHIV face discrimination in health care, employment, education and other spheres. This study presents the first national estimates of the levels and types of discrimination that are defined in Vietnamese law and experienced by PLHIV in Vietnam. A nationally representative sample of 1200 PLHIV was surveyed, and 129 PLHIV participated in focus group discussions (FGDs). In the last 12 months, nearly half of the survey population experienced at least one form of discrimination and many experienced up to six different types of discrimination. The most common forms of discrimination included disclosure of HIV status without consent; denial of access to education for children; loss of employment; advice, primarily from health care providers, to abstain from sex; and physical and emotional harm. In logistic regression analysis, the experience of discrimination differed by gender, region of residence and membership status in a PLHIV support group. The logistic regression and FGD results indicate that disclosure of HIV status without consent was associated with experiencing other forms of discrimination. Key programme and policy recommendations are discussed.

BACKGROUND In light of the decline in donor HIV funding HIV programmes increasingly need to assess their available and potential resources and maximize their utilization. This article presents lessons learned related to how countries have addressed the sustainability of HIV programmes in a stakeholder-driven sustainability analysis. METHODOLOGY During HIV/AIDS Programme Sustainability Analysis Tool (HAPSAT) applications in six countries (Benin Guyana Kenya Lesotho Sierra Leone and South Sudan) stakeholders identified key sustainability challenges for their HIV responses. Possible policy approaches were prepared and those related to prioritization and resource mobilization are analysed in this article. RESULTS The need to prioritize evidence-based interventions and apply efficiency measures is being accepted by countries. Five of the six countries in this study requested that the HAPSAT team prepare prioritization strategies. Countries recognize the need to prepare for an alternative to universal access by 2015 acknowledging that their capacity might be insufficient to reach such high-coverage levels by then. There is further acceptance of the importance of reaching the most-at-risk marginalized populations as seen for example in South Sudan and Sierra Leone. However the pace at which resources are shifting towards these populations is slow. Finally only two of the six countries Kenya and Benin chose to examine options for generating additional financial resources beyond donor funding. In Kenya three non-donor sources were recommended yet even if all were to be implemented it would cover only 25% of the funding needed. CONCLUSIONS Countries are increasingly willing to address the challenges of HIV programme sustainability yet in different ways and with varying urgency. To secure achievements made to date and maximize future impact countries would benefit from strengthening their strategic plans operational plans and funding proposals with concrete timelines and responsibilities for addressing sustainability issues.

This article is contributed by a practitioner in the area of country-level health systems strengthening who also has a background in resilience research. The intent of the article is to offer constructive reflection on the disconnect between the insights of resilience research and the application of those insights through development assistance. The primary reason for the existence of this communication block is that resilience research findings are not often translated in a format that is useful to those implementing resilience promotion projects. As a result, implementers do not usually review relevant research to guide their interventions. Resilience researchers and practitioners need a common language, one that arises from effective community engagement.

Social capital is a compound and complex construct, an umbrella term under which social cohesion, social support, social integration and/or participation are often lumped together. Beyond its growing appeal to policy makers, practitioners and researchers in public health in general and mental health in particular, social capital is now also an integral part of broad-based discussions on social-ecological resilience, ecosystem sustainability, and the collective management of natural resources (see for instance, Adger et al., 2005; Hardin, 1968; Pretty, 2003). This chapter revisits and updates the analysis presented in an earlier interdisciplinary review of primary evidence linking social capital and mental health (Almedom, 2005).