confidential: for review only - bmj

Confidential: For Review OnlyScaling up primary health services for improving

reproductive, maternal and child health: a multi-sectoral collaboration in the conflict setting of Afghanistan

Journal: BMJ

Manuscript ID BMJ-2018-047401

Article Type: Analysis

BMJ Journal: BMJ

Date Submitted by the Author: 08-Oct-2018

Complete List of Authors: Das, Jai; Aga Khan UniversityAkseer, Nadia; Hospital for Sick Children, Centre for Global Child HealthMirzazada, Shafiq; Aga Khan University Kabul AfghanistanPeera, Zahra; Aga Khan UniversityNoorzada, Omarwalid; Hospital for Sick Children, Centre for Global Child HealthArmstrong, Corinne; Independent consultant , Mukhtar, Kashif; Aga Khan UniversityNaeem, Ahmed Jan; Islamic Republic of Afghanistan Ministry of Public HealthBhutta, Zulfiqar; Aga Khan University, Division of Women and Child Health

Keywords: Afghanistan, Health services, Maternal, Child, Multisectoral

https://mc.manuscriptcentral.com/bmj

BMJ

Confidential: For Review Only

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Scaling up primary health services for improving reproductive, maternal and child health: a multi-3

sectoral collaboration in a conflict setting of Afghanistan 4

Jai K Das1, Nadia Akseer2,3, Shafiq Mirzazada4, Zahra Peera1, Omarwalid Noorzada2, Corinne E 5

Armstrong5, Kashif Mukhtar1, Ahmed Jan Naeem6, Zulfiqar A Bhutta1,2,3 6

7 1. Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan 8 2. Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada 9 3. Dalla Lana School of Public Health, University of Toronto, Canada 10 4. Aga Khan University, Kabul, Afghanistan 11 5. Indepdendent, London, United Kingdom 12 6. Ministry of Health, Government of Afghanistan 13

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Jai K Das – [email protected] 15

Nadia Akseer - [email protected] 16

Shafiq Mirzazada - [email protected] 17

Zahra Peera - [email protected] 18

Omarwalid Noorzada - [email protected] 19

Corinne E Armstrong - [email protected] 20

Kashif Mukhtar - [email protected] 21

Ahmed Jan Naeem - [email protected] 22

Zulfiqar A Bhutta - [email protected] 23

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Word Count: 25

Corresponding author 26

Zulfiqar A Bhutta 27

Centre for Global Child Health, The Hospital for Sick Children 28

686 Bay Street, Toronto, ON M5G 0A4, Canada. 29

Tel: +1 416 813 7654x328532 30

e-mail: [email protected] 31

32

33

Standfirst 34

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An innovative and evolutionary model of multi-stakeholder and –sector collaboration in scaling up health 36

service coverage in Afghanistan. 37

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Word count: 3275 40

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Introduction 44

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After a long standing civil war following the Soviet invasion of 1979 and subsequent political instability, 46

Afghanistan in 2001 faced economic collapse, compromised infrastructure and extremely weak capacity 47

for delivering health services to its populace.1 Compounded by complex geography and frequent 48

environmental shocks, Afghanistan’s health and survival indicators at that time were among the worst 49

globally. The average life expectancy was only 44.5 years, and based on local surveys,2 the estimated 50

maternal mortality ratio (MMR) (1600 per 100 000 live births) and infant mortality rate (165 per 1000 51

live births) were at alarming levels.2 Disability and diseases contribute to 60% of childhood deaths in 52

Afghanistan. 3 Access to essential reproductive, maternal newborn and child health (RMNCH) 53

interventions was very low, with only 14% of births in the hands of a skilled attendant, and safe drinking 54

water available to less than 40% of the population.4 Geographical access to health services was also 55

poor as only 10 % of the population lived within one hour’s walking distance of a health facility.5 56

Economic and social indicators also waned – about 30% of Afghans were literate (only 5.7% of females) 57

and annual gross domestic product (GDP) per capita was about 199 USD (supplement 1).4, 6 58

59

With grim circumstances and an immense redevelopment agenda, one of Afghanistan’s immediate post-60

conflict priorities was to increase access to primary healthcare and prioritize key interventions, 61

particularly for rural and underserved populations. It is therefore hardly surprising that rapid scale of 62

interventions within respective sectors e.g. restoration or basic civic services, education, food security 63

and immunizations received prioritization above long-term multi-sectoral or cross-sectoral planning. 64

Afghanistan’s Basic Package of Health Services (BPHS) was introduced in the year 2003 at the primary 65

care level which is an example of an innovative multi-sectoral collaboration that encompassed devising, 66

implementing, scaling, and iteratively refining health service delivery in a poor, post-conflict crises 67

setting. Afghanistan’s distinctive BPHS is one of the first and longest-running primary healthcare models 68

in such contexts, and has been cited as a success, despite reported limitations and ongoing challenges.7-9 69

70

BPHS is one of 12 case studies selected from more than 300 responses to a global call for proposals on 71

success factors for multisectoral collaboration issued by the Partnership for Maternal, Newborn & Child 72

Health (PMNCH). 10 This paper examines the multi-sectoral approach that was successful in scaling the 73

BPHS in Afghanistan and the methodology is sescribed in Box 1. We define multi-sectoral as deliberate 74

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collaboration between various stakeholders (e.g. government, donors, NGOs, academia) and across 75

sectors (e.g. health, economic, environmental) to ensure rapid improvements in health service coverage 76

and outcomes. 11 77

78

Box 1: Methodology 79

To meet the objectives of the case study, a country working group comprising of various stakeholders 80

was formed (Supplement 2). The stakeholders included representatives from government, donors, UN 81

agencies, major NGOs and academia. Following the formation of a country working group, a systematic 82

review to identify exisiting literature was conducted. A search strategy with relevant key words was 83

developed and articles were searched on EMBASE, Medline, Scopus, CINAHL, PubMed and Google 84

Scholar. Gray literature was also searched on Google web and other relevant websites. Two reviewers 85

conducted the search and data from identified studies was abstracted on an extraction sheet and 86

conflicts were resolved by mutual consensus (Supplement 2). We reviewed the genesis and 87

implementation of the BPHS using the seven component conceptual framework comprising of Context, 88

challenge and stakeholders; Programme Description; Framing and planning; Implementation 89

architecture and mechanisms; Monitoring, accountability and learning; Results; and Evolution, scale and 90

sustainability which is detailed in the methods guide. 12 A themetaic analysis was conducted on the 91

information gathered from the identified papers/reports based on the components of the conceptual 92

framework. We also conducted a search to identify large national level household surveys including 93

Demographic Health Survey and Multiple Indicaticator Cluster Surveys (MICS), National Risk and 94

Vulnerability Assessment (NRVA), Afghanistan Living Conditions Survey (ALCS), National Nutritional 95

Survey (NNS) and Afghanistan Health Survey (AHS) and extracted data on relevant indicators including 96

for poverty, Gross Domestic Product (GDP), water, sanitation and Hygiene (WASH) and RMNCH for 97

which a trend analysis was performed over the years for which data was available. A preliminary report 98

was prepared and shared with BPHS key stakeholders and the coutry working group and a 99

multistakeholder review meeting was held in July 2018 in Kabul to appraise and refine the report’s 100

content, suggest additional sources of data, and provide feedback on the process of developing the case 101

study. The multistakeholder review process drew on both the methods used in the first Success Factors 102

study series13 and the PMNCH guide for multistakeholder dialogues. 14 103

104

Context, challenge and stakeholders 105

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106

Afghanistan’s devastating social, political, economic, environmental and health context in 2001 required 107

immediate and innovative action. Faced with poorly distributed health facilities, insufficient funding, and 108

extreme shortages of health professionals, the conception of BPHS and its subsequent implementation 109

in 2003 was the first step to tackling Afghanistan’s complex health challenges (Supplement 1).7 In 2002, 110

a diverse group of stakeholders from government (line ministries), United Nations (UN) agencies, donors 111

(including World Bank (WB), European Union (EU), United States Agency for International Development 112

(USAID)), UN agencies, international and national NGOs, and academia agreed on a collaborative model 113

to deliver essential health services through the BPHS (fig 1).15 114

115

Fig 1: Multi-sectoral model of engagement for Afghanistan’s BPHS 116

117

Programme Description - What did the BPHS encompass? 118

119

Afghanistan’s BPHS was designed and implemented in 2003, to provide a standardized package of basic 120

health services at population level prioritising women’s and children’s health, and equitable access 121

through targeted services to underserved areas. 2, 4, 6, 15 The BPHS has seven primary elements of 122

healthcare: maternal and newborn health; child health and immunization; public nutrition; 123

communicable disease treatment and control; mental health; disability and physical rehabilitation 124

services; and regular supply of essential drugs (supplement 3).15 The first version of BPHS launched in 125

2003, was first revised in 2005 and again in 2010, expanding the package to respond to newly identified 126

health priorities.4, 15 In the 2005 revision of BPHS, mental health and disability services were scaled, 127

while eye care services, community based therapeutic centers and family health action groups, and 128

revision of the national salary policy were the major changes in 2010 (table 1). 7, 15 A third revision is 129

currently ongoing in 2018 with a focus on non-communicable diseases such as mental health and 130

trauma care. In 2005, the essential package of hospital services (EPHS) was modeled to complement the 131

BPHS and delineate the hospital referral system necessary to support the BPHS. 132

133

Table 1: Major elements and revsisions of BPHS 134

Healthcare services 2003 2005 2010

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Healthcare services 2003 2005 2010

Maternal and newborn health Antenatal care

Delivery care

Postpartum care

Family planning

Care of the newborn

Same as 2003 Same as 2003

Child health and immunization Expanded Program on

Immunization (EPI) services

(routine and outreach)

Integrated Management of

Childhood Illness

Same as 2003 Same as 2003

Public nutrition Micronutrient supplementation

Treatment of clinical malnutrition

Prevention of malnutrition

Assessment of malnutrition

Treatment of malnutrition

Prevention of malnutrition

Assessment of malnutrition

Communicable disease treatment

and control

Control of Tuberculosis

Control of Malaria

Control of HIV


Control of Malaria

Prevention of HIV and AIDS


Control of Malaria

Mental health* Community management of mental

health problems

Health facility based treatment of

outpatients and inpatients

Mental health education and

awareness

Case detection

Identification and treatment of

mental illness

Mental health education and

awareness

Case identification, diagnosis and

treatment

Disability and physical

rehabilitation services*

Physiotherapy integrated into

primary health care services

Orthopedic services expanded to

hospital level

Disability awareness,

prevention, and

education

Assessment

Referrals

Disability awareness, prevention,

and education

Provision of physical rehabilitation

services

Case identification, referral and

follow-up

Regular supply of essential drugs All essential drugs required for

basic services

Listing of all essential drugs

needed

Same as 2005

Source: 15-17

*though included in 2003, were not priority domains until 2005 onward 135

136

Framing/planning, implementation architecture and mechanisms 137

138

The developers of the BPHS relied on available data from household surveys, global experience from 139

comparable circumstances as well as the resource and capacity of the Afghan government to devise a 140

strategy for BPHS. It was unanimously determined that NGOs working in the country have the required 141

experience and capacity, and thus would be best positioned as lead implementers. 142

143

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The program was rolled out nationwide and the delivery of BPHS services in 31 of Afghanistan’s 34 144

provinces was the responsibility of the NGOs – through a ‘contracting-out mechanism’. In three of the 145

provinces (Panjshir, Kapisa and Parwan), MoPH directly delivered BPHS through contracting-in 146

mechanism called the Strengthening Mechanism (MoPH-SM).18 MoPH provided overall stewardship and 147

responsibility for the delivery of quality services throughout the country. A Grants and Services Contract 148

Management Unit (GCMU) was set up at MoPH, to manage the wide range of implementers, monitor 149

grants compliance and service delivery, and coordinate with other MoPH departments (including 150

Expanded Program of Immunization (EPI), nutrition, reproductive health etc). A PPHD was set up for 151

each province, for the MoPH to coordinate and monitor the NGOs. Consultative mechanisms were 152

established at national, ministerial, provincial and community levels to keep stakeholders engaged and 153

informed, as detailed in Supplement 4. 154

155

The findings from the systematic review and consultations during the stakeholder meeting suggested 156

that MoPH and NGOs were the major drivers of the BPHS, with important influence from the donors 157

(table 2). The Ministry of Finance (MoF) and Provincial Public Health Directorates (PPHD) also had 158

notable involvement and influence in executing the BPHS. Other sectors (education, development, 159

agriculture) had complementary roles that facilitated the human resource and structural capacity for the 160

BPHS. Communities in general were the primary beneficiaries, and were also involved in the 161

development process. 162

Table 2: BPHS Stakeholder Consultations 163

Name

Organization/

group

Role Phases in which engaged Involvement

High, medium, low in

terms of time,

resources

Influence

High,

medium, or

low

Additional notes

Ministry of

Public Health

Stewardship/

oversight

All phases High High Stewardship/

oversight

Ministry of

Finance

Fund Holder Finance Report Medium Medium

Ministry of

Higher Education

Training doctors Implementation Low Medium Trainings

Ministry of

Agriculture,

Irrigation and

Livestock

Lead

development in

agriculture and

livestock

Implementation Low Medium Support food

security and

nutrition related

activities

Ministry of Rural

Rehabilitation

and

Development

Lead

infrastructure

and road

development

Implementation Low Medium

Provincial Public

Health

Coordinator Implementation Medium Medium

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Directorate

Donors Provide funds Design and Reporting Medium Medium Influencing

Policy

NGO Implementation Planning/ Reporting High High Technical

Support

UN Support/Technic

al assistance

All phases Low Low Oversight

Political Lobby Implementation Low Low Lobby

Community Support services Implementation, Planning Low Medium Voluntary Work

164

165

Multi-donor trust funds (MDTFs) were set up at the MoF to mobilize human and capital resources for 166

the rebuilding of socio-economic institutions. One MDTF - the Afghanistan Reconstruction Trust Fund 167

(ARTF) - is the largest and longest-running in the world, established in 2002. 20 Donors, who were averse 168

to funding directly to the government of Afghanistan, often found ARTF as a safer option because of its 169

high accountability and transparency (box 2).21 170

171

Box 2. Funding mechanisms 172

The figure below shows the funds received in ARTF over the years. Among the 34 donors that have 173

contributed to the ARTF since its inception, 17 donors continue to contribute on a regular basis. 21 174

Funding to all sectors happens through ARTF, although mechanisms evolved over time, including 175

improved monitoring and evaluation, and various performance-based approaches. BPHS’s three major 176

donors are the EU, USAID and WB, investing considerable sums of money in total to rehabilitate 177

Afghanistan’s health system. USAID provided support in 13 provinces, WB in 11, and EU in 10 provinces. 178

22 Together with MoPH, donors funded NGOs to deliver BPHS through various mechanisms. The majority 179

of the BPHS major donor funding was disbursed through MoF for general BPHS budget spend, while 180

donors also pledged money for specific activities e.g. vertical programs and innovations, which was 181

channelized directly to the service providers (MoPH or NGOs). By the end of 2008, donors were fully 182

funding BPHS service delivery through NGOs. 183

Figure: Donors contribution to ARTF since the year 2002 184

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185

186

Staff training, recruitment and deployment strategies were central to the BPHS’s success. The Ministry 187

of Higher Education provided trainings to doctors, and MoPH separately provided pre-service trainings 188

to midwives and paramedics. A national standard salary policy (NSP) was announced in the year 2006 189

which encouraged incentives for employment in challenging locations.23 190

191

The BPHS had a specific vision for encouraging service reach to the poorest, underserved and isolated 192

regions, thus community-based outreach modalities were critical. Voluntary community health workers 193

(CHWs) and community groups (including family health action group and health shura) were the major 194

health workforce in BPHS as they attend to about two-thirds of all family planning clients and manage 195

nearly half of all sick children. 24 The various tiers of community engagement and demand creation 196

strategies are detailed in supplement 5. 197

198

Multi-sectoral planning and actions 199

Although direct multi-sectoral planning had started in earnest to support investments in key areas of 200

education, promotion of food security, built environment, water and sanitation and hygiene (WASH) 201

services, these efforts were uncoordinated. However, several of these parallel cross-sectoral initiatives 202

led to or enabled gains in health. 203

204

0

200

400

600

800

1000

1200U

SD

Mill

ion

Net Donor Contributors

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In 2003, the country’s first Public Nutrition Policy and Strategy was developed with The Ministry of 205

Agriculture, Irrigation and Livestock working closely with Public Nutrition Department in the MoPH for 206

coordinating all BPHS nutrition services. A multi-sectoral stakeholder platform is available through the 207

Afghanistan Food Security and Nutrition Agenda to coordinate efforts to reduce stunting in children. The 208

Health and Nutrition Policy and Strategy 2012–2020 and Food Security and Nutrition Strategy (2015–209

2019), further articulate a commitment to the right to nutrition. 210

211

In the education sector, various approaches have been implemented to expand access to education in 212

remote and rural communities including community-based education as well as accelerated learning 213

centers. 25 The 2004 Education Quality Improvement Program is the government’s main education 214

program aiming to increase access to quality basic education, especially for girls, through school grants, 215

teacher training, and strengthened institutional capacity with the support of communities and private 216

providers. 217

218

The National Solidarity Programme, established in mid-2003, conceived and championed by the Minister 219

of Finance and Minister of Rural Rehabilitation and Development in 2003, is a flagship program to 220

reduce poverty through establishing and strengthening a national network of self-governing community 221

institutions and empowering rural communities to make decisions on their own lives and livelihoods. 222

The projects included construction of irrigation facilities, health facilities, roads, bridges, schools, water 223

supply facilities, clinics, income generation and vocational training projects. 26 224

225

Monitoring, accountability and learning 226

227

Despite data gaps, particularly in severe conflict areas, the BPHS’s unique, comprehensive and rigorous 228

evaluation mechanisms have been fundamental to evidence based decision-making and policy 229

formulation.22 The role of various stakeholders involved in the monitoring and evaluation (M&E) of BPHS 230

is detailed in table 3. 231

232

The specialized Evaluation and Health Information System department was established within MoPH to 233

manage, monitor and provide timely progress data to all stakeholders,27 specifically on national health 234

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priority indicators, and coordinate across MoPH departments 27 (see supplement 6). Various tools were 235

developed to collect, monitor and evaluate the performance of BPHS, such as the routine facility-based 236

health management information system, Balanced Score Card, household and facility surveys, field 237

supervision, monitoring checklists, periodic reports submitted by NGOs and surveillance data. Finally, 238

third party academic institutes, including the Johns Hopkins University, the Indian Institute of Health 239

Management Research, and KIT Royal Tropical Institute, conducted regular independent evaluations of 240

the BPHS annually from 2004 onwards. 28, 29 Although even with these stringent mechanisms there have 241

been challenges with regards to data collection in severe conflict areas and ensuring accountability of 242

the implementors with NGOs often being reluctant to run operations in the most insecure areas. The 243

‘least-cost’ approach by the MoPH to award contracts has also been associated directly with the quality 244

of care.30 245

246

Table 3: Stakeholders’ roles in monitoring and evaluation 247

Partners Expected input

Evaluation and health information system - Leads and coordinates all the activities

Grants and services contract management unit - Coordination to apply national monitoring and evaluation tools

- Demand data on performance required for contract and grant

management

MoPH technical departments - Assist in prioritization, development and revision of performance

indicator

- Provide technical input to design assessment tools and for verification

of values of performance indicators

- Coordination to apply national monitoring and evaluation tools

Donors (EU, WB, USAID) - Provide financial support for monitoring and evaluation process

- Promote integrated monitoring and evaluation system

Other partners ( eg UNICEF, WHO and Global

Fund)

- Promote integrated monitoring and evaluation system

- Provide technical input in designing of monitoring and evaluation tools

- Provide logistic and financial support for monitoring and evaluation

process

Academic partners (Johns Hopkins University,

the Indian Institute of Health Management

Research and KIT Royal Tropical Institute)

- Perform third party evaluations of health service activities and reach

248

Results - Trends in outcomes across collaborating sectors 249

250

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The multi-sectoral collaboration of BPHS implementation in Afghanistan has generally been seen as 251

positive.7, 8, 31 To our knowledge, the process of coming together of diverse stakeholders and sectors to 252

devise, implement and scale the BPHS has not, in and of itself, been evaluated or measured for impact. 253

Success of the collaborative model can be inferred from gains in survival, health service coverage, 254

nutrition, WASH and other important sectors in Afghanistan Below we highlight several major gains or 255

lack thereof in Afghanistan post-BPHS implementation based on findings from the literature review and 256

large national level household surveys. 257

258

Trends in health 259

According to UN best modeled estimates, under-5 child mortality rates improved from 130 to 70 deaths 260

per 1000 live births from 2000 to 2016 32 and MMR improved from 1100 in the year 2000 to 396 deaths 261

by 2015.33 But there are serious reservations over the actual MMR as estimates from other data sources 262

show higher rates than expected, as well as expert knowledge of the relationship of maternal mortality 263

suggest that MMR appear to be overestimated. Nonetheless, progress and trends in many maternal and 264

child health interventions corroborate that MMR has improved in Afghanistan over the past decade and 265

a half;34 Further analyses should be conducted to better understand these estimates.35 Since 2003, 266

coverage of many essential maternal interventions including antenatal care, skilled birth attendance, 267

facility births for pregnant women improved gradually from around 15% to over 55% in the year 2015, 268

while coverage of tetanus toxoid vaccination among pregnant women has remained stagnant since 2003 269

and contraceptive use among women has been stagnant since 2012. (fig 2). Among childhood 270

interventions; coverage of fully immunized child in children under the age of two years improved from 271

30% in the year 2010 to around 59% in 2015, while coverage of oral rehydration therapy for childhood 272

diarrhea and and care seeking for childhood acute respiratory tract infection has plateaued since 2012, 273

after some initial gains (fig 2).36 274

275

Fig 2: National trends in maternal newborn and child health interventions from 2003 to 2015 276

277

Health care infrastructure and workforce have correspondingly improved. The total number of active 278

healthcare facilities has increased from 1075 in 2004 to 2493 in 2017, and the absolute number of visits 279

for healthcare increased from 2 to 84 million.37 Improvement in several other health worker cadres are 280

also documented,38 specifically of female CHWs which have increased from 729 to 14 016. Two 281

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midwifery schools were established in 2002, and by 2014, there were 34 institutions (one per province) 282

which trained several thousand midwives.8 283

Trends in other sectors 284

285

In 2001, only 1 million children were in school and almost all of those were boys; by 2015, 8.8 million 286

children were enrolled in schools with nearly 38% female. 25 There was a concurrent increase in school 287

educators which grew from 21 000 to 187 000.25 While adult literacy rates improved overall, the 288

proportion of primary school age children attending school is still low at 57% (64% for boys and 48% for 289

girls); the gender parity index (ratio of girls to boys in primary education) also improved from 0.69 to 290

0.74 between 2007 and 2012.25 291

292

In the WASH sector, rural water supply activities have accelerated and reached about 365 000 people, 293

and community-led total sanitation has also scaled up. Between 2000 and 2017, population access to 294

improved drinking water sources increased from 42% to 64% and to improved sanitation facilities 295

increased from 5% to 41%, but the progress in both of these indicators has plateaued since 2013. 296

Handwashing with soap and water has simproved to 36% in 2015, while data on open defecation rates 297

does not show any overall change since 2003 and there is no data after the year 2011 (fig 3).39 298

299

Fig 3: National trends in water and sanitation from 2003 to 2017 300

301

There have been concurrent gains in economic development (fig 4) and in promising regional 302

partnerships formed for trade, as well as significant efforts by the Government to increase domestic 303

revenue.40 The GDP per capita increased from US$ 199 in the year 2002 to US$ 669 in 2012 but 304

thereafter declined steadily to US$ 586 in 2017. Poverty rates have increased from 36% in 2007 to 55% 305

in 2017 and prevalence of food insecurity has increased from 28% in 2008 to 45% in 2017. Poverty and 306

food security are the underlying determinants of childhood undernutrition, and lack of improvement in 307

these indicators suggests marginal gains in nutrition. Despite fluctuations in data, stunting prevalence 308

has decreased from about 61% in 2004 to 41% in 2013, prevalence of underweight children has declined 309

from 41% in 2003 to 25% in 2013 and wasting prevalence has remained constant since the year 2003; 310

311

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Fig 4: National trends in poverty, nutrition and food security from 2003 to 2017 312

313

Inequities in health 314

315

It should however be underscored, that interventions coverage for all health and non-health related 316

indicators varies subnationally with stark inequalities, particularly in underprivileged rural and conflict 317

areas.36, 38The regional and socioeconomic inequities pose a threat to Afghanistan in meeting goals of 318

universal coverage of health services and interventions. 38 An analysis of the data from MICS 2010/11 319

suggests vast disparities in coverage of essential RMNCH interventions with the poorest being the most 320

deprived. The most inequitable interventions were antenatal care by skilled birth attendants (SBAs) and 321

four or more antenatal care visits, where rich had higher coverage between 3.0 and 5.6 times more than 322

the poor. While breastfeeding interventions and treatment of sick kids were found to be more equitably 323

distributed among poor and rich. 38 Inequities also existed across regions, with the highest in urban East, 324

West and Central regions of Afghanistan and lowest in South and South-east regions of the country. 38 325

326

Evolution, scale and sustainability 327

328

The BPHS and stakeholder roles evolved from its inception in 2002 to present day. The funding 329

mechanism was modified after 2010 to reflect donor transitions and streamlining of funds (supplement 330

7). The contracts awarded to various NGOs for BPHS implementation became performance based with 331

20% of total payment linked to proportional achievement of key indicators stipulated in the contract, to 332

enhance monitoring and accountability of the BPHS. The Community Midwifery Education (CME) 333

program was added to address the shortage of midwives to provide reproductive health services in rural 334

and hard-to-reach areas.41 The CME program engaged the community in all stages, including designing, 335

priority setting, planning, and implementation. The Community Health Nursing Education program 336

builds on the successful experiences and lessons learned from the CME Program. Various innovations 337

have been pilot tested and implemented to improve the coverage of essential interventions (box 3). 338

339

Box 3. Innovations in health 340

BPHS has been an evolving structure with modification in its core elements and delivery over time, 341

responsive to evidence it generated. Several innovations have been tested within the BPHS to improve 342

reach and coverage of interventions especially for the underprivileged rural and conflict areas areas. 343

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These range from innovations targeted to improve the reach of health services (mobile health teams), 344

increase access (family health houses, maternity waiting homes), improve quality of services (results-345

based financing, conditional cash transfers), and increase the use of technology (e-health innovations). 346

See supplement 8 for more details on the innovations. The current contracts of the NGOs also have a 347

separate budget for innovations which is equivalent to around 10% of the total budget. 348

349

Afghanistan’s BPHS continues to evolve and many have questioned its sustainability.7, 31 MoPH’s 350

stewardship and management and oversight of funds is a strong foundation for the future. Continued 351

prospective planning with diverse sectors in Afghanistan, particularly education, agricultural, rural 352

development will help to ensure sustainability. For example, the recent Citizens Charter (2016) is a joint 353

effort between Ministry of Rural Rehabilitation and Development, MoPH and other ministries that 354

entrusts accountability of the health system to communities themselves. Such prospectively planned 355

cross-sectoral initiatives are the next steps in healthcare sustainability in Afghanistan. 356

357

Discussion 358

359

Afghanistan’s progress in health and social sectors is an example of resilience and gains in the wake of 360

conflict and insecurity. The entire development of the BPHS reflected the multisectoral collaboration in 361

its design, execution and oversight, however, the program was stewarded and implemented by the 362

MoPH with contributions from the Ministry of Finance, Agriculture, irrigation and Livestock, Ministry of 363

Education and Ministry of Rural Rehabilitation and Development. Afghanistan’s BPHS is an example of 364

how various stakeholders and sectors collaborated to implement a basic health structure and achieved 365

gains to an extent in the health and development of the population in a conflict-affected region. The 366

gains were largely due to the defined role of the stakeholders, structured program governance and 367

implementation, committed external funding, monitoring and evaluation systems, and political will. 368

There was a formal process of multi-stakeholder planning and but a few formal processes of multi-369

sectoral execution and one example was the nutrition policy and strategy which had a formal 370

collaboration between the ministry of agriculture, irrigation and livestock with MoPH. 371

372

There is mixed evidence of how multi-sectoral planning or action has led to improvements in the 373

coverage of essential health interventions and health outcomes. There has been improvements in ANC, 374

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SBA and facility births but use of contraceptives has been fairly stagnant. The lack of improvement in 375

contraceptive use has been linked to low education amongst women, insecurity and lack of access, poor 376

socio-economic status of the population.42 Among child interventions, there has been improvement in 377

vaccination and care-seeking and management of childhood illnesses. The lack of progress on childhood 378

undernutrition although being a long-term priority of BPHS shows that preventing malnutrition has been 379

challenging because improvement in nutritional status requires efforts from sectors other than health 380

including poverty alleviation, food security, agricultural and economic growth, education and social 381

safety43 - the progress on these factors has been sub-optimal in Afghanistan apart from low access to 382

healthcare in rural and conflict areas. 383

384

BPHS has been an adaptive model responding to changing needs as evident in the evolving modalities of 385

funding, contracting process, interventions provided, and mechanisms for monitoring and evaluation. 386

Community-based approaches have helped increase access, generate demand and improve equity. 387

There have been several innovations tested within BPHS, of these, involving and empowering 388

community to be the key decision-makers. The CME program has been a major success in delivery of 389

services and also provided marginalized women with opportunities to work which aided the economic 390

uplift. Mobile health teams and community shura has helped in increasing demand. 391

392

There are several limitations and unaddressed challenges, including limitations in data collection albeit 393

stringent mechanisms and these could be attributed to the inherent difficulties in obtaining robust 394

information in chronically fragile states and inaccess to severe conflict areas. There are cultural barriers 395

to women seeking care and the female health workforce is below the required level and especially low 396

in rural and conflict areas and together with low education levels amongst women further complicates a 397

way to find a solution. Although CME programme has trained and proided an impetus to the female 398

workforce but the high attrition rate of female health professionals proves to be an obstacle still to be 399

addressed.35 One of the major reasons for inaccess to healthcare in rural areas is the lack of effective 400

infrastructure and transport. There are still high percentage of out-of-pocket expenditures and these are 401

largely due to lack of access to health facilities, inconsistent quality of the BPHS services and 402

unregulated private sector.41, 44 These factors together with challenges around monitoring and 403

accountability pose as stumbling blocks to achievement of full impact of BPHS 404

405

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Although Afghanistan has improved certain health indicators and service delivery, and has vastly 406

increased the number of health facilities and workforce, the health system remains far weaker than 407

required to ensure universal coverage, equitable access and uniform benefit. Population living within an 408

hour’s walking distance of a health facility, has increased from 10% in 2002 to 57 % of the population in 409

2014.44 Much of the gains achieved through the contracting-out model need to be supplemented with 410

robust public sector programs focusing on reducing inequities and reaching marginalized populations as 411

majority of the population lives in rural areas (75.5 %).38, 45, 46 There must be enhanced focus on reducing 412

gender disparities, promoting education and reducing school dropout rates among girls in rural 413

populations. This requires strategies and progress in other sectors especially economic growth, poverty 414

reduction strategies, investments in education and emphasis on improved transport and communication 415

networks. Gains in these sectors must be measured with a focus on reducing disparities and deliberate 416

investments in underprivileged rural and conflict areasareas.22 (Supplement 9). 417

418

Afghanistan has been in the throes of a debilitating conflict and civic unrest for almost four decades. An 419

entire generation has experienced conflict and adversity, with consequences that may run across 420

generations.34, 47 With escalating conflict since 2010, limited capacity of the health system and the heavy 421

dependence on donors, as much of the development support has come from the coalition countries and 422

therefore it is imperative that strategies are developed to develop sustainable and indigenous plans 423

which are contextually relevant. We believe that with the development of sustainable development 424

goals (SDGs) and the focus on interlinkages between various goals,48 this ought to be a national priority. 425

As a signatory for the SDGs, Afghanistan should explore a national dialogue on developing an integrated 426

strategy for health and related determinants. Creation of a national think tank to oversee this process 427

and to develop formal multi-sectoral plans for action is an important next step. The Ministry of Economy 428

was designated as the lead ministry and focal point in this effort in 2015 under the guidance of UNDP,49 429

and in moving forward it is imperative that additional ministries, notably those involved in public health 430

and nutrition are closely engaged in this effort. Afghanistan has been an example of a resilient health 431

system and people, and there is no reason why the next decade should not see accelerated progress in 432

human development. 433

434

Key messages 435

1. Afghanistan’s BPHS program has successfully scaled up health services in a poor, low capacity 436

setting due to effective multi-sectoral (stakeholders, sector) collaboration 437

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438

2. The interest and commitment of donors, coupled with coordination and stewardship from 439

MoPH and implementation contracted out to NGOs have been key factors in its success 440

441

3. Community-based outreach programs - primed through involvement of local communities in the 442

design, implementation and advocacy of service utilization - has been critical and will be the 443

platform for future programs to achieve universal health coverage, particularly for remote and 444

isolated populations 445

446

4. In moving forward, multi-sectoral planning using the interconnectedness of the SDGs and 447

deliberate engagement of other sectors (nutrition, WASH, education, development) will be 448

critical to achieve Afghanistan’s development goals. 449

450

451

Acknowledgement: We would like to acknowledge the country working group who participated in the 452

multi-stakeholder meeting and provided valuable feedback. This comprised of Alim Atarud, Abdullah 453

Fahim, Sayed Attaullah Sayedzai, Aziz Baig, Habibullah Ahmadzai, Khalil Mohmand, Khwaja Mir Islam 454

Saeed, Mohammad Fareed Asmand, Nasir Hamid, Bahara Rasooly, Muzhgan Habibi 455

456

Author Contributions 457

NA, JKD, SM and ZAB conceived the idea for this study and wrote the study proposal. JKD guided and 458

worked with a technical team on the systematic review (ZP, KM) at AKU Karachi. NA guided and worked 459

with ON the systematic review at SickKids Toronto. JD and SM conducted the multi-stakeholder meeting 460

with guidance from ZAB and AJN. CEA provided overall project coordination and oversight. All authors 461

contributed to the synthesis and writing of the manuscript. ZAB is responsible and overall guarantor of 462

the content. 463

464

Funding 465

Aga Khan University, Karachi received funding from World Health Organization 466

467

Competing Interests 468

The authorship team has read and under BMJ policy on declaration of interests. JKD, NA, ZP. ON, CEA, 469

KM, ZAB declare no competing interests. SM was associated with the Aga Khan Health Service, 470

Afghanistan from 2003-2005 and 2008-2018 and involved in implementing BPHS in three provinces of 471

Afghanistan: Badakhshan, Baghlan, and Bamyan. AJN is the current Deputy Minister of Health, 472

Afghanistan. The funders had no role in the design, conduct, analyses or write-up of the manuscript. 473

They were also not involved in decision to submit for publication. 474

Licence 475

The Corresponding Author has the right to grant on behalf of all authors, and does grant on behalf of all 476

authors, an exclusive licence (or non-exclusive for government employees) on a worldwide basis to the 477

BMJ Publishing Group Ltd (“BMJ”), and its Licensees to permit this article (if accepted) to be published in 478

The BMJ’s editions and any other BMJ products and to exploit all subsidiary rights, as set out in our 479

licence. 480

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481

Ethical Approval 482

Ethical exemption was sought and approved by the Ethical Review Committee (ERC) AKU, Karachi and 483

Institutional Review Board (IRB), Kabul. 484

485

Transparency declaration 486

The senior author (ZAB) affirms that this manuscript is an honest, accurate, and transparent account of 487

the study being reported; that no important aspects of the study have been omitted. 488

489

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Fig 1: Multi-sectoral model of engagement for Afghanistan’s BPHS

206x225mm (120 x 120 DPI)

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Fig 2: National trends in maternal newborn and child health interventions from 2003 to 2015

174x101mm (96 x 96 DPI)

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Fig 3: National trends in water, sanitation and hygiene from 2003 to 2017

168x91mm (96 x 96 DPI)

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Fig 4: National trends in poverty, food security and undernutrition from 2003 to 2017

166x103mm (96 x 96 DPI)

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1

SUPPLEMENT 1. METHODS USED TO DEVELOP THE COUNTRY CASE STUDY SERIES

This supplement is in two parts. The first part describes the methods used to develop the country case

studies; the second describes the methods used to develop the synthesis paper. A separate paper

analysing the application of the country case study methods, including the challenges encountered and

the necessary adaptations made, will follow at the conclusion of the project.

PART 1: METHODS TO DEVELOP THE COUNTRY CASE STUDIES

The country case studies built on methods that were developed and tested for the study series “Success

factors for women’s and children’s health”.1

The case study approach was adopted because it draws on

multiple sources of both qualitative and quantitative evidence to tell the story of how and why an action

across sectors unfolded over time in a given context, illuminating key moments, people, and processes

to enable the extraction of broader lessons applicable to multiple cases.2 The case studies were

developed in four phases.

• Phase 1 – Evidence review, conceptual framework, and methods development

• Phase 2 – Call for proposals and selection of country case studies

• Phase 3 – Country data collection and convening of multistakeholder dialogues

• Phase 4 – Synthesis and dissemination

In Phase 1 a structured review was undertaken of the evidence about factors influencing successful

collaboration across sectors, including review of other publications concerning the quality of the

evidence, results chain, scale and sustainability, and theory of change.3 4

This review informed the

development of the conceptual framework shown in figure 1. The conceptual framework formed the

basis for the case study methods guide.

Fig 1. Conceptual framework

The methods guide was developed to support participating countries’ use of a standard approach in

developing the case studies, which included key processes, deliverables, and anticipated timelines.4 An

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2

accompanying semi-structured questionnaire supported the organization, analysis, and synthesis of

documentation for the case study. The questions were framed around the key components of the

conceptual framework, and structured according to programme reporting standards.5 This aided the

assessment of the available data and documentation as well the identification of additional information

that would be required, e.g. through key informant interviews. The guide explicitly noted that country

teams could select and adapt questions according to the specifics of each case study.

Phase 2 was concurrent with Phase 1. An open call and selection process was used to identify the case

studies: PMNCH issued a global call for proposals, which included selection criteria (table 1) and a peer

review selection process as described in figure 2 below.

Table 1. Selection criteria for eligible proposals

Criteria Description Score

Effectiveness/impact

of the collaboration

Evidence of success – either process or impact success across multiple

dimensions: e.g. relating to the collaboration process, operational

improvements, policy and service coverage outputs, or societal, health, and

sustainable development outcomes.

30

Implementation across

sectors at scale or

ready to be scaled

Collaboration across sectors is well established, with related processes and

institutional mechanisms, and has been or is about to be taken to scale to reach

the target population in the country, province, or state.

20

Data and

documentation

Availability of data sources and documentation on the collaboration, including

evaluations, surveys, reports, and other information on which to build the

country case studies. Data are available from 2010 onwards.

20

Innovation Clearly demonstrates what is new or different about this collaboration. 10

Human rights, gender

equality, equity

Integrates human rights, gender equality, equity considerations, including

participation and voice of the target populations.

10

Agreement in principle

from collaborators

In principle, the main stakeholders of this collaboration, including government,

have approved the proposal and agreed to participate in the case study process.

10

Total score Summed review score based on the criteria.

/ 100

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3

Fig 2. Process for selection of country case studies

During Phase 3, each of the 12 successful country teams established a working group which conducted

an analysis of the main factors leading to successful collaboration in their context. Each country team

had a lead organization that submitted the original proposal. The composition of the country teams

varied depending on considerations such as the nature of the programme, stakeholders involved, policy

and programme context, and technical and other resources available. Country teams were supported by

both a national and an international consultant.

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A Global Steering Committee of partners was established to provide strategic direction and editorial

oversight over the case study methods and development, and to synthesize the cross-case findings. The

country teams and Global Steering Committee were supported by the PMNCH secretariat in overall

project management. The BMJ coordinated the journal peer review and publication of the papers.

Indicative key tasks for developing the country case studies are set out in table 2. The semi-structured

questionnaire was used to develop a working paper on the collaborative process. Relevant programme

data, reports and evaluations, and other peer-reviewed and grey literature were used as data sources,

and key informant interviews were conducted to fill identified data gaps.

Table 2. Key tasks for developing the country case studies

ESTABLISH COUNTRY-LEVEL COORDINATION TEAM AND PLAN

• Lead organization brings together a country working group to review the case study process and

timelines (and agree dates for key deliverables and events), develop the plan and budget, and secure

national consultancy support if required

• Coordination with the international consultant to set up and support the process, including organizing

the multistakeholder review meeting

• Collation of relevant programme data, reports and evaluations, and other peer-reviewed and grey

literature, as well as identification of further information and key informant interviews required

DEVELOP THE WORKING REPORT USING THE GUIDING QUESTIONS TO COLLATE DATA

• Development of the working report using the questions from the methods guide and a synthesis of

relevant programme data, reports and evaluations, and other peer-reviewed and grey literature

• Country visit by international consultant

CONDUCT MULTISTAKEHOLDER REVIEW MEETING

• Organization of a multistakeholder review meeting, following the methods guide, including preparation,

planning and inviting participants,

• Holding the multistakeholder review meeting to review and update the working report and resolve any

remaining issues

• Country visit by international consultant for the multistakeholder review

DEVELOP JOURNAL ARTICLE BASED ON THE WORKING REPORT AND MULTISTAKEHOLDER REVIEW

• Drafting of 3000-word journal article, based on the working report developed for internal editing

• Submission of the article to The BMJ

• Revision and completion of the article in response to comments from peer reviewers and The BMJ’s

Editorial Committee

• Working with The BMJ’s technical editors on copy-edited manuscript and checking pdf proofs

ACTIVITIES LEADING UP TO THE PARTNERS’ FORUM

• Publication of journal articles, contingent on approval by The BMJ’s peer review, editorial, and

publication process

• Contributing to the Partners’ Forum programme, especially the communications materials and learning

sessions that will be agreed between the lead organization and the Forum Organizing Committee as the

agenda develops

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Country teams conducted a multistakeholder review of the working paper and the factors leading to

successful collaboration. The multistakeholder review processes drew on both the methods used in the

first Success Factors study series1 6

and the PMNCH guide for multistakeholder dialogues.7

Multistakeholder reviews were used together with the semi-structured questionnaire in Phase 1 to

ensure that the case studies were evidence-based, with triangulation of information and perspectives,

and were representative of a collaborative exercise. The multistakeholder dialogues commonly involved

face-to-face meetings of health and development stakeholders engaged in, benefiting from, or

influencing the specific collaboration, including from civil society or community/target population

groups.

In Phase 4 the working paper and the outputs from the multistakeholder dialogue informed the drafting

of the 3000-word journal articles on the factors leading to successful collaboration across sectors.

Detailed outlines and/or drafts of the journal articles were reviewed by PMNCH and at least one

member of the Steering Group. Phase 3 also included a synthesis of all the case studies to identify

common factors, with the findings published in this paper. The methods for that process are described

in the next section.

PART 2. METHODS FOR DEVELOPING THE SYNTHESIS PAPER

Selection and quality of the synthesis methods

The selection of the synthesis methods for this study series was informed by a review of methods for

analysing qualitative and quantitative research for management and policy.2 8

It also drew on the

methods tested in the first Success Factors study series.1

The choice of synthesis methods was contingent on the research question and methods used, and the

nature of the available evidence. The research question (i.e. what works in collaboration across sectors)

and the methods (i.e. case studies across countries) were best matched with a cross-case analysis. The

synthesis began by organizing the findings from the different case studies in a standard format using a

matrix or text-table.2 Most of the evidence in the case studies was qualitative and descriptive. The

quantitative data used were context-specific and derived from varying sources and methods, and so

were not readily comparable between countries. The method deemed most suitable was therefore a

thematic analysis, identifying and bringing together the main, recurrent, or most important issues or

themes across the case studies.2 The aim of the synthesis was to recognize and make sense of patterns

across the case studies in order to build up a meaningful picture without compromising their richness

and diversity. A multi-grounded theory approach was then used to synthesize the emerging patterns

using a theoretical model that could be applied and tested in other contexts.9 All these methods are

detailed below.

Quality considerations

Recognizing that many in the study and synthesis teams were less familiar with qualitative methods than

with quantitative methods, it was necessary to explicate the differences between quality criteria in

qualitative and quantitative methods (see table 3). Using some of the key strategies outlined in table 3,

we aimed for rigour in the methods used, credibility in the interpretation of results, and generalizability

based on theoretical transferability.

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Table 3. Quality criteria – illustrative differences between quantitative and qualitative methods2 10-13

Quality criteria Quantitative Qualitative

Generalizability Statistical generalizability Analytical/ theoretical generalizability;

transferability within and across contexts

Validity Accuracy of measurement

Validity: face; construct; and criterion

Appropriateness of methods and expertise

and experience of researchers

Validity: democratic (all perspectives

accurately represented); dialogic (review

and deliberation of findings); process

(cogent and dependable); outcome

(resolution of research question)

Reliability Precision

Replicability: inter-observer, test-retest,

triangulation

Auditability and documentation of

research methods

Consistency in applying methods

Achieving theoretical saturation

Credibility Triangulation of data sources

Counterfactual analysis and causal

inference

Triangulation of data sources

Expertise and experience of researchers

Diverse perspectives to test and refine the

findings, including consideration of

alternative interpretations

Context for

application of

quality criteria

Embedded in a broader understanding of

and expertise in quantitative research

design, data analysis, application, and

limitations

Embedded in a broader understanding of

and expertise in qualitative research

design, data analysis, application, and

limitations

In-depth understanding of context of

analysis from different perspectives

Methods for synthesizing the findings

A multidisciplinary team conducted the evidence synthesis, led by the co-chairs of the Global Steering

Committee, who are experienced in research and synthesis methods and multi-country studies.

Together the synthesis team members brought a wide range of expertise and perspectives to the

synthesis process: from policy science, public health and epidemiology, multisectoral collaboration,

political philosophy, anthropology, health economics, and narrative analysis. The Global Steering

Committee members contributed to the synthesis, based on their reviews of the country case studies,

and reviewed the synthesis findings. Country case study leads and international consultants also

reviewed the synthesis findings. These diverse perspectives enabled the robust testing, corroboration,

and/or refining of findings. Country case study leads and international consultants also reviewed the

synthesis findings.

As described below, the evidence synthesis involved both induction and deduction, the former from the

country case studies, the latter from the themes identified in the case studies and then integrated into a

higher-order theoretical model. However, the analysis was primarily based on the data reported in the

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country case studies. The dependability of the findings was confirmed when the main themes were

discussed by the synthesis team and shared with the country teams, who agreed that they reasonably

reflected their experience. Further confirmation will be achieved if peer reviews and other readers find

the conclusions and interpretations to be valid and useful for guiding action and analysis. An audit trail

of analytical decisions further strengthens the credibility and reliability of the findings and the

triangulation.

To synthesize the findings across the case studies, the synthesis team used a multi-grounded theory

approach9 (fig 3).

Fig 3. Multi-grounded theory approach used to synthesize the studies’ findings

Adapted from Goldkuhl & Cronholm (2010)

9

The deductive analysis required an underpinning theoretical framework. The evidence review preceding

this study highlighted the paucity of strong evidence, best practices, and theoretical frameworks on

effective collaboration across sectors.3,4

The lead author on the synthesis paper had previously co-

authored peer-reviewed publications with a theoretical model, based on policy science and philosophy,

on best practices in decision-making and achieving transformative change, including through

collaboration.14 15

The synthesis team discussed how this theoretical model, having informed the

methods guide,4

could also be used for the deductive analysis. Other theoretical models could have

been used, but no alternatives were identified in the evidence review for this study3,4

or in the synthesis

team’s discussion. One of the country case studies referred to the Kindgon model; this had been

considered in the policy science and philosophy theoretical model but it did not cover the full range of

issues under consideration. A transformative change model,14

based on policy science and political

philosophy theory, was selected for use as a deductive/ theoretical framework for the evidence

synthesis. To facilitate analysis and practical application by a wide range of stakeholders, some of the

more technical policy science and political philosophy terms were adapted, including the title of the

model.

The data extraction matrix was tested on two case studies by members of the synthesis team to check

the reliability of data extraction and resolve any issues or ambiguities. The data extraction for each case

Multi-grounded theory synthesis

• Synthesis of findings across the case studies based on

deductive and inductive analyses

• Testing of the transformative change model to accommodate

the synthesis findings

• Generation of key principles of success for collaboration

across sectors

Deductive analysis/ theoretical framework

• Transformative change model used to

categorize and analyse study findings on

effective collaboration across sectors

Inductive analysis

• Cross-case analysis of findings

• Thematic analysis with theoretical

saturation

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8

study was then conducted by one team member and reviewed and discussed with the other team

members. Each case study also was reviewed by a Global Steering Committee member who highlighted

key issues for the synthesis.

The inductive analysis was based on the empirical findings from the 12 country case studies and 65

eligible proposals. It was based on a triangulation of the following methods.

Cross-case analysis.2 The main findings and related examples from each country case study were

presented in a matrix format, structured by the guiding questions in the methods guide. These findings

were then categorized by the transformative change model14

that informed the development of the

conceptual framework for the case study methods guide.

Thematic analysis. Within each category of the transformative change model, the synthesis team

conducted a thematic analysis of the cross-case matrix of findings to identify the main, recurrent, or

most important issues or themes (based on whether the findings addressed the specific study questions

and were highlighted by the country teams as a key finding contributing to, or hindering, success) across

the country case studies. The themes were then refined iteratively through discussions by the synthesis

team to reach a shared understanding of and agreement on the emerging themes. The synthesis team

also ran through a number of ways of interrogating the data by displaying it graphically in charts. The

synthesis and thematic refinement continued until there was theoretical saturation:2 that is, when

existing themes could accommodate new findings and no adjustments or new themes were required to

categorize the data.

Multi-grounded theory synthesis. Through the deductive and inductive analyses, the transformative

change model was tested based on whether its categories could accommodate the case study findings,

or if there were findings that fell outside the model (a qualitative process analogous to hypothesis

testing). The transformative change model was found to be a robust theoretical framework to

synthesize and accommodate the findings from the case studies on effective collaboration across

sectors to achieve transformative change. A higher-order synthesis to identify overarching principles of

success was developed against the main synthesis findings across different thematic categories. Future

programmes and research could apply, test, and further develop these principles on successful

collaboration across sectors to achieve health and sustainable development goals.

To ensure the quality of the findings, a triangulation of qualitative synthesis methods and reviews from

multidisciplinary perspectives was used—with the synthesis team, steering committee, and external

reviews. Synthesis findings were validated by the country teams. The theoretical validity and reliability

of the analytical framework were assessed as described above, and an audit trail of synthesis steps and

working documents was maintained. The synthesis paper was reviewed by all the authors from the

global synthesis and country case study teams and by external experts and journal peer reviewers.

References

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