BMJ · 2017-08-18 · launched Mission Indradhanush (MI) in 2014, a strategy targeting underserved,...
Transcript of BMJ · 2017-08-18 · launched Mission Indradhanush (MI) in 2014, a strategy targeting underserved,...
Confidential: For Review Only
Improving vaccination coverage in low performing districts
of India: lessons from IMI (intensive mission indradhanush) a cross-sectoral systems strengthening strategy
Journal: BMJ
Manuscript ID BMJ.2018.046558
Article Type: Analysis
BMJ Journal: BMJ
Date Submitted by the Author: 17-Aug-2018
Complete List of Authors: Gurnani, Vandana; India Ministry of Health and Family Welfare, Joint Secretary, Reproductive and Child Health Jhalani, Manoj; India Ministry of Health and Family Welfare, Additional Secretary and Mission Director, National Health Mission Haldar, Pradeep; India Ministry of Health and Family Welfare, Deputy Commissioner (Immunization) Das, Manoj; The INCLEN Trust International Dasgupta, Rajib; Jawaharlal Nehru University, Centre of Social Medicine & Community Health Dubey, Anand; ESI-Postgraduate Institute of Medical Sciences and Research, Professor, Department of Pediatrics Massodi, Muneer; Government Medical College Srinagar, Professor,
Department of Community Medicine Rai, Sanjay; All India Institute of Medical Sciences, Professor, Department of Community Medicine Khan, Muhammad; Government Medical College Srinagar, Professor, Department of Community Medicine PEMDE, Harish; Lady Hardinge Medical College, Pediatrics; Kalawati Saran Children's Hospital, Pediatrics Jain, Pankaj; Uttar Pradesh Rural Institute of Medical Science and Research, Professor, Department of Community Medicine Angolkar, Mubashir; Jawaharlal Nehru Medical College, Professor, Department of Public Health Sharma, Pragya; Maulana Azad Medical College, Professor, Department of
Community Medicine Singh, Raghavendra ; Maulana Azad Medical College, Assistant Professor, Department of Pediatrics Chauhan, Ashish; India Ministry of Health and Family Welfare, Senior Consultant, Immunization Murray, John; Independent consultant, Arora, Narendra; The INCLEN Trust International, Research; The INCLEN Trust International, Research Sudan, Preeti; India Ministry of Health and Family Welfare
Keywords: India, Childhood vaccinations, Vaccines, Vaccination campaigns, Child
https://mc.manuscriptcentral.com/bmj
BMJ
Confidential: For Review Onlyhealth
Page 1 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
1
IMPROVING VACCINATION COVERAGE IN LOW PERFORMING DISTRICTS OF INDIA: LESSONS
FROM IMI (INTENSIVE MISSION INDRADHANUSH) A CROSS-SECTORAL SYSTEMS
STRENGTHENING STRATEGY
Vandana Gurnani1, Manoj Jhalani2, Pradeep Haldar3, Manoja Kumar Das4, Rajib Dasgupta5, Anand
Prakash Dubey6, Muneer Masssodi7, Sanjay Rai8, S. Muhammad Salim Khan9, Harish Pemde10, Pankaj
Jain11, Mubashir Angolkar12, Pragya Sharma13, Raghavendra Singh14, Ashish Chauhan15, John Murray16,
Narendra Kumar Arora17, Preeti Sudan18
1 Joint Secretary (RCH), Ministry of Health and Family Welfare, Government of India, New Delhi, India 2 Additional Secretary and Mission Director, National Health Mission, Ministry of Health and Family
Welfare, Government of India, New Delhi, India 3 Deputy Commissioner (Immunization), Ministry of Health and Family Welfare, Government of India,
New Delhi, India 4 Director Projects, The INCLEN Trust International, New Delhi, India 5 Professor, Department of Community Health, Jawaharlal Nehru University, New Delhi, India 6 Professor, Department of Paediatrics, ESI-Postgraduate Institute of Medical Sciences and Research,
New Delhi, India 7 Professor, Department of Community Medicine, Government Medical College, Srinagar, Jammu and
Kashmir, India 8 Professor, Department of Community Medicine, All India Institute of Medical Sciences, New Delhi,
India 9 Professor, Department of Community Medicine, Government Medical College, Srinagar, Jammu and
Kashmir, India 10 Professor, Department of Pediatrics, Lady Hardinge Medical College, New Delhi, India 11 Professor, Department of Community Medicine, U.P. Rural Institute of Medical Sciences & Research,
Etawah, Uttar Pradesh, India 12 Associate Professor, Department of Public Health, Jawaharlal Nehru Medical College, Belagavi,
Karnataka, India 13 Professor, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India 14 Assistant Professor, Department of Paediatrics, Maulana Azad Medical College, New Delhi, India 15Senior Consultant (Immunization), Ministry of Health & Family Welfare, Government of India, New
Delhi, India 16International Health Consultant, Iowa City, Iowa, USA. 17 Executive Director, The INCLEN Trust International, New Delhi, India 18 Principal Secretary, Ministry of Health and Family Welfare, Government of India, New Delhi, India
Corresponding Author and guarantor*
Dr Narendra Kumar Arora
Executive Director, The INCLEN Trust International Address: F-1/5, Okhla Industrial Area Phase - 1, New Delhi, Delhi 110020, India
Phone number: 91 11 47730000-99
Email: [email protected]
*Submitted by John Murray on behalf of the corresponding author; all subsequent correspondence with
Dr. Narendra Kumar Arora
Page 2 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
2
Word Count: 1 983
Key words: India, childhood vaccinations, vaccines, vaccination campaigns, child health, cross-sectoral
programming
Page 3 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
3
Stand first
The Intensified Mission Indradhanush (IMI) strategy in India demonstrated that cross-sectoral
participation is a powerful mechanism for vaccinating more high-risk children, but that a number of
systems changes are needed to incorporate this approach into routine practice and allow expansion to
the hardest to reach populations.
Introduction
India’s immunization programme is the largest in the world with annual cohorts of around 26.7 million
infants and 30 million pregnant women.1 Despite steady progress, routine childhood vaccination
coverage has been slow to rise, with an estimated 38% of children failing to receive all basic vaccines in
the first year of life in 2016.2-4 A number of factors limit vaccination coverage including mobile and
isolated populations that are difficult to reach and low demand from under-informed populations
influenced by fear of side effects and anti-vaccination messages.5-7
In response to low childhood vaccination coverage, India’s Ministry of Health and Family Welfare
launched Mission Indradhanush (MI) in 2014, a strategy targeting underserved, vulnerable, resistant and
inaccessible populations.8,9 MI ran between April 2015 and July 2017, contributing to an increase in full
immunization coverage of 6.7% (7.9% in rural areas and 3.1% in urban areas) after the first two
rounds.10 In October 2017, the Prime Minister of India spearheaded an ambitious plan to accelerate
progress further, launching Intensified Mission Indradhanush (IMI), in districts and urban cities with
persistently low immunization coverage, with the aim of reaching 90% full immunization coverage by
the end of 2018.11
This case study was developed to document the lessons learned from IMI, with an emphasis on
understanding how cross-sectoral and multi-stakeholder engagement worked to strengthen access to
and quality of vaccine services (box 1). The study hoped to identify the impact of IMI and whether the
approach can be used to build sustainable vaccination programming.
Page 4 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
4
Box 1: Approach to conducting the IMI case-study in India
The case-study was led and coordinated by the Ministry of Health and Family Welfare (MOHFW). A
steering committee under leadership of the Joint Secretary, Reproductive and Child Health was
formed and a country working group under leadership of the Deputy Commissioner for Immunization.
A team comprised of technical experts in immunization, public health and research was responsible
developing the protocol for the case-study, data collection and analysis. A modified multistakeholder
approach was used including: 12
1. Desk review of available data, including: national health coverage surveys, implementation
guidelines, standard operating procedures, performance reports from states and districts,
monitoring reports and other programmatic documents.
2. In-depth and informal interviews with key stakeholders from the national and state levels and
from five randomly selected districts.13 Sampled districts represented a cross-section of
different socio-cultural and geographic regions of the country. In each district, high performing,
low performing and vulnerable population areas were selected. Two hundred stakeholders
involved in planning, implementation and monitoring of IMI were interviewed using qualitative
interview guides organized by thematic area and summarized using a standard format (table
1).14
3. Analysis of stakeholder interviews using a modified Framework Method for comparing and
contrasting large-scale textual data across cases.15 Similarities and differences in the data were
identified and relationships drawn across different parts of the analysis, resulting in descriptive
or explanatory conclusions by theme. A health systems framework was developed populated
by main policy and programme inputs across all interviews.
4. A multi-stakeholder meeting to review and discuss of findings with key health and development
partners and stakeholders to review and agree on the main findings.
Description of Intensified Mission Indradhanush (IMI)
Programme focus
IMI targeted areas with higher rates of unimmunized children and immunization drop-outs. Updated
coverage data were used to select districts and urban cities in which: 1) At least 13,000 children were
estimated to have missed DPT3/Pentavalent 3 the previous year or; 2) DPT3/ Pentavalent 3 coverage
was estimated to be less than 70%.16 Using these criteria, the weakest 121 districts, 17 urban cities and
an additional 52 districts in North Eastern states were selected (fig 1). All children up to 5 years of age
and pregnant women were targeted, with a focus on ensuring full vaccination for children under 2 years
of age. A chain of support was established from the national level through states to districts, with senior
staff providing regular reviews of progress and receiving updates on progress.11
Page 5 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
5
Figure 1: Map of the 121 districts, 17 urban cities and 52 north-eastern districts identified for
Intensified Mission Indradhanush
Implementation
A seven-step process was developed to support district and sub-district planning and implementation of
IMI, with staff at all levels receiving training on their role in implementation (fig 2).11 Door-to-door head
count surveys and due-listing of beneficiaries were conducted by community workers and validated by
supervisors for completeness and quality. Session-planning identified new sites for conducting
vaccination sessions if needed, organised mobile teams for remote areas and ensured that supplies
were available. If inadequate numbers of staff were available at health sub-centres, resources were
provided to hire Auxillary Nurse Midwives (ANMs) or staff from other areas. Vaccine supplies were
tracked using the Electronic Vaccine Intelligence Network (e-VIN) and cold chain tracking programme
and distributed using the alternate vaccine delivery mechanism.17 Districts developed a communication
plan and materials, with stakeholders organized and coordinated to provide support matching their
roles and expertise, including household listing, supervision, identification of new vaccination sites,
community mobilisation for vaccination sessions and counselling on barriers to use such as a fear of
adverse events (table 1). Four monthly cycles of immunization were conducted between October 2017
and January 2018, each lasting 7 days.
Figure 2: Strategy for Intensified Mission Indradhanush
Monitoring and evaluating progress
Vaccination session monitoring included the collection of administrative data by ANMs and transmitted
through the routine health information system, external monitoring of sessions and small-sample
assessments of households after sessions to validate childhood vaccination coverage. E-dashboards on
mobile phones were used to collect vaccination session and household validation data which facilitated
real-time aggregation of each vaccination round. Local monitoring was conducted by ANM supervisors,
district supervisors and zonal medical officers; with support from World Health Organization (WHO) and
United Nations Children’s Fund (UNICEF) monitors. During vaccination rounds, daily supervisor
meetings were conducted to review available data and discuss problems and solutions. External
oversight was provided by national and state monitors, with meetings during each round to review
progress and structured feedback to all levels. Population-based household vaccination coverage
surveys were conducted in April and June 2018 in IMI districts.
Page 6 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
6
Table 1: Stakeholders involved in IMI implementation
Staff categories Roles
Government – Health (Ministry of Health and Family Welfare)
• Secretary & Additional Secretary, Ministry of
Health
• Joint Secretary, Deputy Commissioner, Consultant
• Secretary/Mission Director-National Health
Mission, State Expanded Programme of
Immunization Officer, Reproductive and Child
Health Officer
• State and district vaccine store managers
• District Magistrates
• Immunisation Officers
• Chief Medical Officers
Policy development, administration,
management, planning,
implementation, supervision
• Primary Health Care Centre Medical Officers
• Auxillary Nurse Midwives (ANMs)
• Accredited Social Health Activists (ASHAs),
• Nursing and medical students
Service delivery, planning, supervision
Household listing, communication,
social mobilization
Government – 12 Non-health ministries (including Women’s and Child Development, Sports and
Youth, Panchayati Raj, Urban development, Labour, Education, Minority Affairs, Information and
Broadcasting)
• Integrated Child Development Services –
Anganwadi (courtyard) centres; Anganwadi
Workers (AWW)
• Panchayati Raj members (a system of community
governance)
• Programme management staff
• School teachers
• Youth organisations (National Cadet Corps, Nehru
Yuka Kendra Sangathan, National Service Scheme)
• Child development programme officers
Health education
Mass media and print communication
Social mobilization
Household visits
Community education
Multilateral and bilateral organisations: World Health Organisation (WHO), United Nations
Children’s Fund (UNICEF), United Nations Development Programme (UNDP), Immunization
Technical Support Unit, Global Health Strategies
• National managers
• Regional WHO team leaders and surveillance
medical officers
• UNICEF health officers, consultants and social
mobilisation network coordinator
National task force
Programme implementation
Policy development
Communication
Monitoring, supervision, data analysis
Civil society individuals and groups: Non-governmental organisations, Rotary International,
religious leaders, community officials
• Community political leaders
• Community volunteers
• Thought leaders
• Educators
Social mobilization, education, celebrity
endorsements
Page 7 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
7
Summary of progress
Between October 2017 and January 2018, 97 628 vaccination sessions were conducted in IMI areas,
delivering over 15 million antigens.18 During this period, administrative data estimate that 5.95 million
children were vaccinated, with around 850 000 children vaccinated for the first time and 1.4 million
children 12 months of age or older fully vaccinated. An estimated 1.18 million pregnant women were
also vaccinated, with over 660 000 estimated to have been fully vaccinated. Vaccine and cold-chain
stock-outs were uncommon during the IMI period, with 98% of monitored sites having adequate
supplies available for sessions.19 Eleven states distributed additional funding for IMI rounds, with the
total additional funds dispersed estimated to be US$7.8 million.20
Preliminary population-based household coverage surveys conducted in IMI areas 3-5 months following
the last vaccination cycle, estimate the proportion of children 12-23 with full immunization coverage
(FIC) to be 69% in IMI districts, representing a 18.5% increase from 2016 estimates (fig 3).4,21 Percentage
Improvement in FIC ranged from 12% in Rajasthan IMI districts to 31% in Assam. Of the 190 districts
surveyed, the FIC increased by more than 30% in 56 districts, 10-30% in 83 districts (43.7%) and <10% in
51 district (26.8%).
Routine process monitoring was conducted for 98% of sessions, with head counts available in 92%, and
updated due lists in 82% (table 2).18 Of those children on due lists, 56% received needed vaccinations
during sessions. This varied considerably between states, ranging from 13% and 95%. Reasons for non-
vaccination of children on due lists from household monitoring of 24,324 cases included lack of
awareness (35%), apprehension about adverse events (26%), vaccine hesitancy (8%), child travelling
(12%), and programme related gaps (14%).18
Figure 3: Proportion of children 12-23 months fully immunized in 190 IMI districts, by state, 2016 and
2018
Page 8 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
8
Table 2: Process indicators of service delivery from routine monitoring of IMI, October 2017 – January
2018
1 Based on monitoring visits to a total of 95675 (98%) IMI vaccination sessions18
2 Due lists include unimmunized children and vaccination drop-outs requiring additional antigens 3 Monitoring data for 18 districts not available: (Arunachal Pradesh- 6, Meghalaya 3, Mizoram-1,
Nagaland-7, and Sikkim-1)
State Total number Percentage 1
Districts
in IMI
Sessions
held
Sessions
with head-
count done
Sessions
with due list
available2
Sessions
Supervised
Children on due
lists vaccinated3
Andhra
Pradesh 2 249 90 85 55 62
Arunachal
Pradesh 13 67 91 62 69 60
Assam 7 341 94 93 76 76
Bihar 16 11292 97 78 71 67
Delhi 3 1392 96 79 14 68
Gujarat 3 400 99 84 70 63
Haryana 4 942 81 81 40 48
Jammu &
Kashmir 1 114 52 81 69 70
Jharkhand 2 1198 87 84 41 53
Karnataka 3 1060 99 95 55 72
Kerala 1 91 100 100 97 25
Madhya
Pradesh 14 5015 86 93 65 78
Maharashtra 11 4127 100 89 71 52
Manipur 4 178 97 85 30 17
Meghalaya 7 135 100 100 47 53
Mizoram 3 33 67 82 58 20
Nagaland 11 50 100 64 32 37
Odisha 2 363 100 99 47 60
Rajasthan 12 3826 98 94 40 73
Sikkim 2 14 100 43 100 95
Tripura 5 75 93 77 61 13
Uttar Pradesh 60 63796 99 88 90 69
Uttrakhand 1 393 100 77 44 59
West Bengal 1 524 88 44 45 53
India 187 95675 92 82 58 56
Rural 118 80320 92 84 58
Urban 17 14462 96 91 66
North East 52 893 93 76 59
Page 9 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
9
Factors contributing to effectiveness of implementation
Introduction and acceptance
Introduction of IMI was facilitated by Prime Minister Modi who launched the initiative on 8th October
2017. The Prime Minister sent letters to Chief Ministers explicitly stating the goal of 90% full
implementation coverage in their states; and participated in regular IMI review meetings. Regular video
conferences were conducted with states by the central health minister and senior officials to monitor
progress. Twelve non-health ministries were officially contacted, informed of IMI objectives and their
roles. They committed to providing support at all levels and facilitated engagement of youth
organisations.11,22 Thus IMI saw high-level political commitment and early engagement of multiple
sectors (table 1). Adoption was driven by several factors. Close engagement and oversight by the Prime
Minister of India was very important to generating and sustaining political will and for ensuring the
commitment of government staff at all levels. IMI used programme experience built from polio
elimination, including the Reaching Every District strategy, and the development of criteria for
identifying high-risk areas.23 These methods had a track record of success in different parts of the
country, and were understood by all stakeholders. Use of existing systems and mechanisms allowed
rapid uptake, while the focus on increased accountability at the state and district level helped better
tailor activities to local needs.
Shifting responsibility to the district and sub-district levels
At district level, planning, implementation, engagement of partners, and assignment of responsibilities
was organized by District Magistrates through IMI district task forces. To streamline the participation of
non-health sectors and development partners, a lead partner was identified in every district. This
administrative model shifted responsibility for managing IMI to the district and sub-district levels who
developed plans tailored to local circumstances. To facilitate local implementation, routine vaccination
funds were used for human resource costs, incentives for staff, transportation, social mobilization and
production of information, education and communication materials. Guidelines for how additional
resources could be requested from central government and allocated for specific activities were
developed; additional funds were provided on demand to the states through supplementary plans.24 To
be effective, district magistrates and district immunization officers took responsibility for mobilising
government and non-government resources to fill staffing gaps, improve communication and
community mobilisation for vaccinations. Cross-sectoral coordination therefore required local staff
who were familiar with existing roles and areas of responsibility of partners and could provide them
with specific roles. Key informants in two areas reported delays in staff payments due to administrative
and procedural weaknesses at district level and this may have also slowed deployment of staff and other
activities. In addition, the intensity of staff time commitments (sometimes requiring temporary transfer
to under-served areas) took staff away from routine duties. There were voices of concern regarding the
long-term sustainability of this approach at both state and district level.
Household listing to improve reach
Detailed microplanning and listing of beneficiaries (creating due lists) is the heart of the IMI approach,
essential for reaching high-risk populations, and conducted for the majority of sessions (table 2).
Achieving household listing is central to the roles of ANMs, ASHAs and AWWs and where all three staff
were available and motivated this was feasible. However, household listing was difficult, particularly in
districts with staff shortages and in urban areas. In these cases, staff from outside the district and
Page 10 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
10
locally available nursing students were hired to support door-to-door household listing and other IMI
activities using IMI funds. In addition to additional staffing needs, household listing in more remote
areas required significant investments in time, innovation and transportation. Field staff found that
household beneficiary listing needed monthly updating because of frequent population shifts. Coupled
with improved listing, the creation of new vaccination session sites, the use of flexible vaccination
session times and use of mobile teams were important for improving reach.
Social mobilisation to improve access and equity
In sub-districts local stakeholders were central to mobilising families and communities for vaccination
sessions (table 3). Process monitoring data showed that even when eligible children had been placed on
due lists, not all of them were brought to vaccination sessions. In some areas communication plans
were inadequate, with no effective materials or strategies in place. Field interviews showed that
engagement of local stakeholders across sectors worked best when all were included in planning,
assigned specific tasks and communities, and provided with communication materials and strategies
that could be used to overcome vaccine hesitancy. A number of different mechanisms were used by
partners across sectors to engage families (table 3). Community health workers in several areas,
reported that inadequate time, skills and materials limited their ability to provide effective counselling
to address barriers to accepting immunizations. In some cases sites chosen for additional IMI vaccination
sessions (which included private homes, businesses and schools) had inadequate toilets, seating and
running water which may have discouraged attendance.
Page 11 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
11
Table 3: Cross-sectoral stakeholder collaboration and coordination for IMI – summary of effective
strategies and challenges
Strategies identified as important Challenges
Improve linkages with the health system
� Joint meetings between ASHAs, Angawadi Workers and
ANMs to plan strategies for reaching communities
� Household reminder slips about IMI sessions and sites
� Mobile immunization teams
� Providing prompt medical care for adverse events
� Team home visits– ANMs and community stakeholders
to improve acceptance and reduce hostility
• Inadequate infrastructure for session sites in
some communities
• Household listing made difficult by
inadequate manpower and lack of
engagement of community stakeholders to
do household listing in their own areas
Engage influencers
� Involvement of religious leaders to dispel fears and
instil confidence in vaccination
� Youth groups: awareness generation and mobilization
� Community political leaders: public endorsement
� Prabhat feri rallies: school children and youth cadets
� School promotion: teachers and students to mothers
and families
• Partner participation and cooperation
became sub-optimal when they were not
involved in planning, consulted on their roles
and availability
• Circulation of vaccine related misinformation
and rumours about adverse events;
conspiracy theories including vaccines
causing sterilization
Better use of local community stakeholders
• Peer counselling: mothers of fully immunized children
interact with and counsel mothers and grandmothers
of non-immunised
• Vikas Mitras and Tola Mitras - community level link
workers of the Bihar Mahadalit Vikas Mission -
mobilized marginalized communities and helped
frontline health workers set up (additional) IMI sessions
within Mahadalit (marginalized and extremely weak
caste groups among the Scheduled Castes) clusters.
• Ration dealers used for mobilization and to provide
information
• Requests by some community workers and
groups for incentives/payment for time spent
• Limited recognition for non-health
collaborators
• Financial shortfalls for social mobilization and
IEC activities in some areas
• Youth groups and Rotary participation limited
to urban areas
• Limited competency of CHWs in
communication and mobilization (soft skills)
so that concerns are not always identified
and addressed
Improve messaging
• Distribution of brochures, stickers, buttons, umbrellas,
public announcements
• Involvement of print and electronic media: joint media
briefing by government and partner agencies, including
development partners, NGOs and non-health sectors
• Use of social media
• Productions by the song and drama division (Ministry of
Information & Broadcasting)
• Street plays
• Baby shows with prizes for healthy fully and immunized
children
• No specific messages on adverse events
following immunisation and on debunking
myths in some social mobilization campaigns
• Grievances against the food ration system
(public distribution system) led some families
to resist vaccinations, seen as another
government programme
Page 12 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
12
Conclusions: building a sustainable routine system using experience from IMI
IMI has contributed to significant increases in fully immunized children (from 50.5% to 69%) in 190 of
the lowest performing districts, a 37% increase in coverage. IMI demonstrated that cross-sectoral
participation is a powerful mechanism for vaccinating more high-risk children, but that a number of
systems changes are needed to incorporate this approach into routine practice and allow expansion to
the hardest to reach populations. First, sustained high-level political support, advocacy and oversight
across sectors and levels and re-allocation of financial resources where needed is essential. Second, all
districts must strengthen staff capacity for household beneficiary listing, add additional vaccination sites
and invest in the transportation required to do both. Third, better communication and counselling skills
and materials are needed by community providers in health and partner sectors to be more effective at
addressing vaccine hesitancy and reluctance. Finally, districts with managerial capacity to effectively
engage with non-health stakeholders across sectors perform better; this capacity must be built in all
districts. There is willingness among all sectors to participate and support immunization programming in
the future, provided roles and commitments are clearly defined, predictable and feasible with partner
resources.
Key Messages
• The Intensified Mission Indradhanush (IMI) strategy demonstrated that cross-sectoral
participation is a powerful mechanism for vaccinating more high-risk children, but that a
number of systems changes are needed for this approach to be incorporated into routine
practice and expand to the hardest to reach populations
• Sustained high-level political support, advocacy and oversight across sectors and levels and
re-allocation of financial resources where needed is essential
• All districts must strengthen staff capacity for household beneficiary listing, add additional
vaccination sites where needed and invest in the transportation required to do both
• Better communication and counselling skills and materials are needed by community
providers in health and partner sectors to be more effective at addressing vaccine hesitancy
and reluctance – and mobilise families to attend vaccination sessions
• District managers with managerial capacity to effectively engage with non-health
stakeholders across sectors perform better; this capacity must be built in all districts.
Page 13 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
13
Acknowledgements
The authors gratefully acknowledge: contributions of technical experts from development partners
(WHO, UNICEF, UNDP) and the Immunization Technical Support Unit; the commitment and hard work of
leadership and staff in health and partner ministries and departments at district and state levels; and
the field work and technical inputs provided by state experts including: Dr Satinder Aneja, School of
Medical Sciences & Research, Sharda University, Greater Noida, Uttar Pradesh; Dr Kiran Goswami, All
India Institute of Medical Sciences, New Delhi; Dr Sanjay Chaturvedi, University College of Medical
Sciences, New Delhi; Dr Muzammil Khurshid and Dr Swarna Rastogi, Muzaffarnagar Medical College,
Muzaffarnagar, Uttar Pradesh; Dr Ashok Kumar and Dr Prabhat Kumar Lal, Darbhanga Medical College,
Darbhanga, Bihar; Dr A Althaf, Government Medical College, Malappuram and Dr Sairu Philip, T.D.
Medical College, Alappuzha, Kerala; Dr Himesh Barman and Dr Star Pala North Eastern Indira Gandhi
Regional Institute of Medical Sciences, Shillong, Meghalaya; Dr Satish Saroshee and Dr Suraj Sirohi,
Mahatma Gandhi Memorial Medical College, Indore and Dr Abhijit Pakhre, All India Institute of Medical
Sciences, Bhopal, Madhya Pradesh.
Disclosure of Interests
The authors have read and understood BMJ policy on declaration of interests. All authors have
completed the Unified Competing Interest form (available on request from the corresponding author)
and declare: support from the World Health Organization (Partnership for Maternal, Newborn and Child
Health) for the submitted work; no financial relationships with any organisations that might have an
interest in the submitted work in the previous three years; no other relationships or activities that could
appear to have influenced the submitted work.
Funding disclosure
The case-study review was partially funded by the Partnership for Maternal, Newborn and Child Health.
The funder had no role in planning, data collection and interpretation of the data collected.
Authorship Statement
VG, MJ, PS, PH, and AC conceptualized the case-study and approach. NKA, MKD, RD, APD and JM
developed the method. Group members (RD, APD, MM, SR, SMSK, HP, PJ, MA, PS and RS) collected the
data. NKA, MKD, RD, SR analysed the data. NKA, MKD, and JM conducted the data synthesis. NKA, MKD,
and JM drafted the manuscript. All authors reviewed and commented on the manuscript prior to
finalization.
The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all
authors, an exclusive licence (or non-exclusive for government employees) on a worldwide basis to the
BMJ Publishing Group Ltd (“BMJ”), and its Licencees to permit this article (if accepted) to be published in
The BMJ’s editions and any other BMJ products and to exploit all subsidiary rights, as set out in our
licence.
Page 14 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
14
References
1. Ministry of Health and Family Welfare, Government of India. Immunization Handbook for Medical
Officers [Internet]. Ministry of Health & Family Welfare Government of India; 2016.
http://www.searo.who.int/india/publications/immunization_handbook2017/en/
2. Lahariya C. A brief history of vaccines & vaccination in India. Indian J Med Res. 2014 Apr;139(4):491–
511.
3. Vashishtha VM. Status of immunization and need for intensification of routine immunization in
India. Indian Pediatr. 2012 May;49(5):357–61.
4. International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-
4), 2015-16: India. Mumbai: IIPS; 2017.
5. Laxminarayan R, Ganguly NK. India’s vaccine deficit: why more than half of Indian children are not
fully immunized, and what can—and should—be done. Health Aff (Millwood) 2011;30:1096–103
6. Kumar C, Singh PK, Singh L, et al. Socioeconomic disparities in coverage of full immunisation among
children of adolescent mothers in India, 1990– 2006: a repeated cross-sectional analysis. BMJ Open
2016;6:e009768. doi:10.1136/bmjopen-2015- 009768
7. Taneja G, Sagar KS, Mishra S. Routine immunization in India: a perspective. Indian J Community
Health. 2013;25(2):188–92.
8. Ministry of Health and Family Welfare (MOHFW). Mission Indradhanush, Operational Guidelines.
[Internet]. Delhi, India: MOHFW;2014 http://164.100.158.44/showfile.php?lid=4258.
9. Travasso C. Mission Indradhanush makes vaccination progress in India. BMJ. 2015 Aug
13;351:h4440.
10. Immunization Technical Support Unit. Report of Integrated Child Health & Immunization Survey
(INCHIS)- Round 1 and 2. [Internet]. Delhi, India: Ministry of Health and Family Welfare; 2014.
http://www.itsu.org. in/integrated-child-health-immunization-surveyinchis-report-rounds-1-2.
11. Ministry of Health and Family Welfare (MOHFW). Intensified Mission Indradhanush, Operational
Guidelines. Delhi, India: MOHFW; 2017
12. BMJ Methods Supplement.
13. The INCLEN Trust International. Intensified Mission Indradhanush Case-Study Protocol.
Delhi,India:The INCLEN Trust International; 2018.
14. The INCLEN Trust International. Intensified Mission Indradhanush Protocol Interview Guides. Delhi,
India: The INCLEN Trust International; 2018.
Page 15 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
15
15. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis
of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117.
doi: http://dx.doi.org/10.1186/1471- 2288-13-117 PMID: 24047204.
16. Bhatnagar P,Gupta S, Kumar R, Haldar P, Sethia R, Bahl S. Estimation of child vaccination coverage
at state and national levels in India. Bull World Health Organ 2016;94:728–734 | doi:
http://dx.doi.org/ 10.2471/BLT.15.167593
17. Ministry of Health and Family Welfare, United Nations Development Programme, Global Alliance
for Vaccine Initiative. Improving Efficiency of Vaccination Systems in Multiple States: e-VIN
Factsheet. [Internet]. United Nations Development Programme; 2017
http://www.in.undp.org/content/india /en /home/operations/projects/health/evin.html
18. Ministry of Health and Family Welfare (MOHFW). Administrative monitoring data for Intensified
Mission Indradhanush. Delhi, India: MOHFW; 2018.
19. Ministry of Health and Family Welfare (MOHFW), United Nations Development Programme, Global
Alliance for Vaccine Initiative. E-VIN Tracking Database, October 2017 – April 2018. Delhi, India:
MOHFW; 2018
20. Ministry of Health and Family Welfare (MOHFW). Financial reports: funds provided to states for
Intensified Misison Indradhanush. Delhi, India: MOHFW; 2017
21. Ministry of Health and Family Welfare (MOHFW). Coverage Evaluation Survey- Intensified Mission
Indradhanush. Delhi, India: MOHFW; 2018.
22. Ministry of Health and Family Welfare (MOHFW). Standard Operating Procedures for engaging with
youth institutions (NCC, NSS, NYKS) and Rotary for social mobilization for Intensified Mission
Indradhanush (IMI) and Routine Immunization. Delhi, India: MOHFW; 2017
23. Microplanning for immunization service delivery using the Reaching Every District (RED) strategy.
Geneva: World Health Organization; 2009.: http://apps.who.int/iris/bitstream/
10665/70450/1/WHO_IVB_09.11_ eng.pdf
24. Ministry of Health and Family Welfare (MOHFW). Intensified Mission Indradhanush- Financial
Guidelines. Delhi, India: MOHFW; 2017.
Page 16 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
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
Page 17 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
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
Page 18 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
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.
Page 19 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
4
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
Page 20 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
5
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.
Page 21 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
6
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
Page 22 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
7
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
Page 23 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
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
1. PMNCH. Success Factors for Women’s and Children’s Health: Multisector Pathways to Progress. 2014.
http://www.who.int/pmnch/knowledge/publications/successfactors/en/.
2. Mays N, Pope C, Popay J. Systematically reviewing qualitative and quantitative evidence to inform
management and policy-making in the health field. J Health Serv Res Policy 2005;10 Suppl 1:6-
20. doi: 10.1258/1355819054308576 [published Online First: 2005/08/02]
Page 24 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
9
3. Global Health Insights. Working report. Case Study Development based on a rapid review of the
evidence: Collaborating Across Sectors for Women’s, Children’s, and Adolescents’ Health. 2017.
http://www.who.int/pmnch/knowledge/working-report-case-study-development.pdf.
4. PMNCH. Methods guide for country case studies on successful collaboration across sectors for health
and sustainable development. 2018. http://www.who.int/pmnch/knowledge/case-study-
methods-guide.pdf.
5. WHO, Alliance for Health Policy and Systems Research. Programme reporting standards for sexual,
reproductive, maternal, newborn, child and adolescent health. 2017.
http://apps.who.int/iris/bitstream/handle/10665/258932/WHO-MCA-17.11-
eng.pdf;jsessionid=1689105592DC13C497459EA1A2AB07F1?sequence=1.
6. Frost L, Hinton R, Pratt BA, et al. Using multistakeholder dialogues to assess policies, programmes and
progress for women's, children's and adolescents' health. Bull World Health Organ
2016;94(5):393-5. doi: 10.2471/BLT.16.171710 [published Online First: 2016/05/06]
7. PMNCH and WHO. Multi-Stakeholder Dialogues for Women’s and Children’s Health: A Guide for
Conveners and Facilitators. 2014.
http://www.who.int/pmnch/knowledge/publications/msd_guide.pdf.
8. Dixon-Woods M, Agarwal S, Jones D, et al. Synthesising qualitative and quantitative evidence: a
review of possible methods. J Health Serv Res Policy 2005;10(1):45-53. doi:
10.1177/135581960501000110 [published Online First: 2005/01/26]
9. Goldkuhl G, Cronholm S. Adding Theoretical Grounding to Grounded Theory: Toward Multi-Grounded
Theory. International Journal of Qualitative Methods, 2010.
10. Patton M.Q. Qualitative Research & Evaluation Methods. 3rd ed: Sage 2002.
11. Barbour RS. Checklists for improving rigour in qualitative research: a case of the tail wagging the
dog? BMJ 2001;322(7294):1115-7. [published Online First: 2001/05/05]
12. Creswell J.W. Research design: Qualitative & quantitative approaches. Thousand Oaks, CA: Sage
1994.
13. Denzin N.K. Handbook of qualitative research. London: Sage 1994.
14. Kuruvilla S, Dorstewitz P. There is no “point” in decision-making: a model of transactive rationality
for public policy and administration. Policy Sciences 2010;43(3):263-87.
15. Dorstewitz P, Kuruvilla S. Revieiwing rationality: a pragmatist perspective on policy & planning
processes. Philosophy of Management 2007;6(1):35-61.
Page 25 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
75x82mm (300 x 300 DPI)
Page 26 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
154x76mm (300 x 300 DPI)
Page 27 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
Confidential: For Review Only
158x74mm (300 x 300 DPI)
Page 28 of 27
https://mc.manuscriptcentral.com/bmj
BMJ
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960