Section A: participant demographics and sectoral mapping

This study drew on the insights of eleven programme implementers from diverse backgrounds within Assam’s NNM. Their expertise, spanning district and block levels, covered various programmes and management functions, including planning, execution, and monitoring. This carefully selected group provided a comprehensive understanding of ISC within the mission from multiple operational perspectives. Participants’ firsthand accounts illuminated the practicalities of implementing such collaboration, offering valuable lessons for future programme design. Additionally, their varied backgrounds and expertise added significant depth and credibility to the study’s findings, illustrating the complexities of executing a large-scale, intersectoral public health programme in Assam.

For the purpose of this study, a detailed mapping exercise was conducted with the participants to comprehensively understand the involvement of various sectors in the nutrition programme. This exercise was crucial in visualising the intricate network of sectoral collaboration required for the effective implementation of the mission within Assam. Participants, who were programme implementors from district and block levels, provided insights into the range of sectors they coordinate with on a day-to-day basis. These insights were supplemented by an extensive review of relevant guidelines and policies associated with the NNM. This approach ensured a thorough understanding of both the theoretical framework of the mission and its practical execution on the ground. The findings from this exercise were collated into a visual diagram (Fig. 1), which illustrates different sectors involved in the implementation of intersectoral nutrition interventions at different administrative levels. This representation serves to highlight the complexity and interconnectivity of the sectors, showcasing how sectors such as health, education, agriculture, women’s empowerment, public health, private sector, non-governmental organisations academic institutions and rural development come together in a concerted effort to address nutritional challenges. The mapping clearly demonstrated that the NNM is not just the purview of health or nutrition sectors but is a multifaceted initiative requiring coordinated efforts across various sectors. Each sector contributes unique expertise and resources, playing a critical role in the holistic approach needed to tackle the multifactorial issue of malnutrition. The exercise highlighted the need for effective intersectoral communication and collaboration. It emphasised the importance of each sector understanding its role and how it fits into the bigger picture of the mission. This mapping serves as a valuable tool for programme implementers and stakeholders, providing a clear visual guide to the complex network of collaborations essential for the success of the NNM.

Fig. 1

Different sectors involved in the implementation of intersectoral nutrition interventions at different administrative levels

Section B: thematic analysis of the findings

Thematic analysis of the interviews revealed three key themes and six subthemes related to ISC:

Theme 1: operationalisation of ISC in daily practice

First theme delves into the practical enactment of within the routine functioning of health programmes, particularly nutritional interventions. This theme is crucial as it bridges the gap between theoretical constructs of ISC and their tangible execution.

Participants consistently stressed the indispensability of effective ISC for the success of nutrition programmes. They illuminated the notion that programmes such as Community Management of Acute Malnourished Children (CMAM), Water and Sanitation Hygiene [55], and Weekly Iron and Folic acid Supplementation (WIFS) require a synergistic effort across various sectors to achieve their objectives. This aligns with the collaborative governance framework. For instance, participant 4 described how their understanding of the need for collaboration across sectors grew, showing how collaborative governance principles work in practice, a participant recounted:

“Nutrition interventions like CMAM (Community Management of Acute Malnourished Children), WASH (Water, Sanitation And Hygiene), and IFA (Iron and Folic Acid) consumption in schools require sectors to work in close coordination; otherwise, these programmes are not successful. When I joined first, I thought it was a data entry and compiling type of job, but I later learnt that there are several sectors involved to make nutrition intervention successful in the field.” (Participant 4)

On the other hand, a few participants reported that despite an agreement on the importance of collaboration, the operationalisation of these agreements into tangible outcomes often encounters stumbling blocks. One of the participant pointed out the challenges in navigating the differing work cultures and priorities of each sector. The sentiment expressed here is that while reaching a consensus on objectives is feasible in the structured environment of a meeting, the diverse expertise and institutional cultures present challenges in the translation of these strategies into effective programme delivery. Reflecting on their experiences, one participant recalled

“Establishing intersectoral collaboration is challenging due to different work cultures between sectors. All sectors have their own priorities. Every sector is expert in their own subject, bringing all their expertise to the table and agreeing for achieving common goals is easy in meetings, but it’s difficult while operationalising it because at every level different actors are involved.” (Participant 3)

Additionally, a participant emphasised the reliance of ISC on not just coordination, but timely action. Participants also stressed the need for a supportive network and highlighted how interpersonal relationships can accelerate or hinder progress. The quote from participant 5, suggests that when good relationships exist, work is expedited, implying that social capital is a significant currency in ISC.

“We need support in most of these activities, the entire mission itself is based on coordination, but sometimes it is difficult to get the work done timely manner. Because other sectors will have other meetings and work, our work is not important to them. They say yes to our faces, but the process gets delayed unnecessarily; if we have a good connection with these officials, work will be done immediately.” (Participant 5)

Another participant reported on a critical issue affecting the operationalisation of intersectoral nutrition interventions in schools, particularly the administration of IFA supplements, which are essential for addressing nutritional deficiencies in children. The participant’s account reveals a troubling shortage of IFA stocks in schools, which directly obstructs the programme’s execution. This shortage is compounded by a hesitancy among teachers to distribute the tablets to children—a task for which they attend training and meetings but hesitate to perform due to fears of potential health risks to the students, particularly adolescent girls. The participant also sheds light on the resistance from parents, who express their mistrust in free supplied medications by complaining to teachers and advising against the use of these supplements for their children. A participant elaborated

“There were no stock of IFAs in school that I visited last month. Teachers are not bothered to administer the IFA tablets it to children, they will attend all our meetings, but when it comes to administering the tables, they are hesitant and scared that if anything would happen to adolescent girls. There also have been instances of parents complaining to teachers not to give free medicines to their children, and they see a good doctor instead.” (Participant 7)

Theme 2: facilitators of ISC

Theme 2 explores the key elements that support and improve ISC within nutrition programmes. This theme delves into implementers’ perspectives on the dynamics and conditions necessary for effective ISC. It focuses on three subthemes: defining sectoral mandates, which involves clarifying roles and responsibilities among diverse stakeholders; leadership dynamics, which looks at how different leadership styles and strategies impact ISC effectiveness; and interpersonal relations and engagement, which highlights the importance of building and maintaining strong, collaborative relationships across sectors.

Defined sectoral mandates

Several participants stressed the importance of well-defined sectoral mandates in the operationalisation of ISC. A participant emphasised the need for a systematic approach, where sectors are not only mapped out with clearly delineated roles but also are held accountable through regular follow-ups and meetings. This participant elaborated that such a systematic approach is not just about assigning tasks; it is about cultivating a sense of ownership and responsibility towards shared goals. As an example, one participant described

“Firstly, there should be a mapping of sectors and allocating roles for each sector with achievable clear targets. And there should be strict follow up of these gaols in monthly meetings then only these sectors own these gaols, for example we have CMAM programme which states which sector looks after what task it is easier to operationalise such interventions.” (Participant 8)

The mention of the CMAM programme as an example highlights how clear, achievable targets assigned to specific sectors can streamline the process, making the operationalisation of such interventions more feasible and efficient according to the participant. The participant also points out that the effectiveness of such a system is enhanced when there are regular check-ins on progress, ideally through monthly meetings. These meetings serve as a platform for different sectors to update each other on their progress towards meeting their targets, discuss challenges, and coordinate efforts.

Interpersonal relationships

The importance of interpersonal relationships in fostering successful ISC is highlighted by many participants. Participant 11 particularly emphasises the crucial role of personal connections in ISC engagements and the significance of consistent communication across sectors. Furthermore, the participant highlighted the need to pay attention to others’ priorities, reflecting individuals’ desire for positive social identity through alignment with group norms and goals. By actively listening to and supporting the initiatives of other sectors, participant 11 highlights the establishment of reciprocity, where mutual benefit promotes ongoing collaboration. This ‘give-and-take’ policy represents a fundamental principle of effective ISC. From this perspective, interpersonal relationships and communication emerge as key mechanisms that facilitate ISC by fostering trust, resource exchange, goal alignment, and reciprocal cooperation.

“Personal relations matter a lot; if you are good, they are good. In my case I meet them constantly and update them about our progress also, sometimes I have to listen to their priorities. sometimes I end up extending my support to their sectoral programmes. It’s a kind of give-and-take policy. Effective collaboration also depends a lot on officers’ attitude and trust.” (Participant 11)

The participant also touches on the significance of attitude and trust among officers. They suggest that the disposition of the individuals involved can greatly influence the collaborative process. A positive attitude and the establishment of trust are pinpointed as key factors that can either facilitate or hinder the effectiveness of working together across different sectors.

Furthering this understanding, participant 2, underscores the vital importance of one’s approach and the cultivation of interpersonal relationships for successful intersectoral collaboration. Participant stress the impact of their own continuous and deliberate efforts to connect with other sector heads through various forms of communication. By engaging in repeated interactions and holding regular meetings, whether it be over the phone or during informal tea sessions, the participant has been able to foster stronger connections and a sense of camaraderie with their counterparts. This participant attributes the improvement in their working rapport within the block to these sustained efforts at relationship building. They highlight that these are not occasional or one-off meetings but a consistent and focused strategy to enhance mutual understanding and cooperation among the sectors.

“A lot depends on our approach and interpersonal relationships; I had repeated interactions and regular meetings with different sectors heads over the phone and over a tea. Repeated meetings and familiarisation have improved my rapport in the block. Our District Commissioner sir also very much promoted teamwork. He treats all the sector equally.” (Participant 2)

Additionally, the participant notes the positive influence of leadership in promoting a collaborative environment. They praise the District Commissioner for his role in advocating for teamwork and for treating every sector equally. According to the participant, the District Commissioner’s actions have significantly contributed to creating an atmosphere where teamwork is not only encouraged but is also a lived value.

Leadership dynamics

Effective leadership played a crucial role in guiding collective action towards shared health goals. Proactive leadership, drawing from transformational principles, fostered inclusivity and unity among stakeholders. Participant 10 highlighted this through their Block Development Officer (BDO), who organised inclusive intersectoral meetings using tools like monthly meetings and committees. The BDO ensured participation from all sector heads, promoting shared ownership and accountability. Sharing meeting minutes with those absent fostered transparency and kept everyone informed. By actively encouraging participation and resolving conflicts, the BDO promoted open communication and problem-solving. The BDO’s repeated interactions with sectors like education emphasised the importance of building relationships and trust to overcome initial barriers to collaboration. These strategies, reflecting shared and distributive leadership principles, collectively enhanced engagement, communication, and cooperation among stakeholders in ISC initiatives, aligning efforts towards common health outcomes, as supported by social identity principles.

“Our BDO sir ensures all sectorial heads participate in the meeting, even if some sector did not attend due to some other engagement, he makes sure that the minutes reach them. Sir give chance to everyone to speak and resolve any conflicts if arise during meeting. For example, in case of WIFS programme implementation in school, the education sectors presence was minimal thinking that the WIFS programme is health sectors programme, but after our BDO sir repeated interaction with them now a days they are attending regularly and participate in discussions.” (Participant 10)

The participant also highlights the BDO’s commitment to democratic principles during meetings, where every attendee is given the opportunity to speak and any conflicts that arise are addressed through dialogue. This approach has been particularly effective in the case of the WIFS programme in schools, where initially, the education sector’s involvement was limited. The participant attributes the change in the education sector’s engagement to the BDO’s persistent efforts in encouraging their regular attendance and active participation in discussions. According to the participant, these efforts by the BDO have led to a significant improvement in the education sector’s collaboration in the WIFS programme, indicating a shift in their perception of the programme being solely a concern of the health sector.

Theme 3: barriers for ISC

Three key barriers to effective ISC have emerged, each posing significant challenges to intersectoral initiatives. Firstly, having a collective vision and proper oversight is crucial for a unified approach and strong monitoring to ensure all sectors are working towards common goals. Secondly, fair resource allocation is essential for equitable distribution of resources, ensuring that all sectors are fully supported and engaged in ISC efforts. Lastly, power dynamics and hierarchical disparities create obstacles due to unequal power relations and structures, making it difficult to build trust and equitable partnerships across different organisational levels. This issue of power asymmetry highlights the disproportionate influence and control some sectors have over decision-making, hindering collaborative efforts.

Lack of shared vision

The participant 1 details specific operational issues encountered with collaboration committees, which are mandated by the ministry to facilitate intersectoral collaboration. They point out that, in practice, the regularity of these committee meetings falls short of the ministry’s directives. Instead of meeting consistently as intended, the committees convene primarily during special events or large-scale campaigns, which deviates from their original purpose of ensuring ongoing, systematic collaboration.

“We have directives from the ministry for forming collaboration committees, these committees should meet regularly, but these committees meet if there are any special events like celebration or any mass movement campaign etc. There is no clarity on the nutrition target from the other sector except the health sector.” (Participant 1)

Furthermore, the participant also expresses concern over the unclear targets related to nutrition outside the health sector. They note that while the health sector has delineated nutrition targets, there is a lack of clarity and communication regarding these goals from other sectors involved. According to the participants such absence of shared clarity on objectives undermines the potential for effective collaboration, as all sectors are not aligned in their understanding and pursuit of common targets in nutrition.

Unfair resource allocation

In addition to the lack of collective vision several participants raised the concern of equitable resource distribution which has been identified as a pivotal factor influencing the efficacy and sustainability of collaborative efforts. Participant 6, particularly noting the lack of financial support for collaboration meetings and training activities. This participant pointed out that while the health sector benefits from a robust funding stream, other sectors struggle with insufficient financial resources, hampering their ability to contribute to and participate in ISC activities. The participant elaborated,

“No, we don’t get much funding for convergent meetings and training activities, but the health sector has a lot of funding. If they club some of their meeting and capacity-building session jointly with us, that would be beneficial. If this change happens at higher level and gets a joint letter for such collaborative events, it is easier to push the collaboration further down at the field level.” (Participant 6)

From the participants perspective a joint letter or directive from higher authorities endorsing shared resource use for ISC-related activities could serve as a catalyst for this change. This would enable a more equitable distribution of resources, ensuring that all sectors can engage meaningly in ISC and that the collective impact on health programmes is not compromised by financial constraints.

Power dynamics

Power dynamics emerged as a recurring theme in discussions on ISC. Participants identified power dynamics as a major barrier to fair collaboration. They highlighted how the health sector often wields disproportionate power in collaborative efforts. This observation aligns with the concept of power asymmetry, where some actors or sectors have more control over decision-making and resource allocation in collaborative settings. One participant expressed.

“I feel that the health sector is the most powerful compared to all other sectors. Because it has so many professional doctors, nurses and ANMs who work to cure the disease and save lives, our work in in front of them is insignificant. In some instances, the final call on referring malnourished children to NRC was taken only by health sector, because they are more qualified than us. Joint training with the health sector would boost our confidence in identifying malnourished children more accurately. This would also help the health sector trust our data.” (Participant 9)

The participant expresses a perspective that the health sector holds a position of greater power and influence within the context of intersectoral collaboration, primarily due to the critical nature of its work and the professional qualifications of its personnel. They highlight that the sector employs numerous professionals such as doctors, nurses, and Auxiliary Nurse Midwives (ANMs), whose roles are directly associated with life-saving interventions and treating diseases. Participants also expressed that the prominence of the health sector overshadows the work done by professionals from other sectors to the point where their contributions can seem less significant. They note that in certain situations, such as when decisions are made about referring malnourished children to Nutrition Rehabilitation Centers (NRCs), it is the health sector that predominantly makes these decisions, given their higher qualifications and expertise in health matters. Additionally, participants also reported that joint training programmes could also help in building trust between the health sector and other sectors, by demonstrating the reliability and validity of the data provided by non-health sectors.