Learning from intersectoral initiatives to respond to the needs of refugees, asylum seekers, and migrants without status in the context of COVID-19 in Quebec and Ontario: a qualitative multiple case study protocol.

BACKGROUND: Refugees, asylum seekers, and migrants without status experience precarious living and working conditions that disproportionately expose them to coronavirus disease 2019 (COVID-19). In the two most populous Canadian provinces (Quebec and Ontario), to reduce the vulnerability factors experienced by the most marginalized migrants, the public and community sectors engage in joint coordination efforts called intersectoral collaboration. This collaboration ensures holistic care provisioning, inclusive of psychosocial support, assistance to address food security, and educational and employment assistance. This research project explores how community and public sectors collaborated on intersectoral initiatives during the COVID-19 pandemic to support refugees, asylum seekers, and migrants without status in the cities of Montreal, Sherbrooke, and Toronto, and generates lessons for a sustainable response to the heterogeneous needs of these migrants. METHODS: This theory-informed participatory research is co-created with socioculturally diverse research partners (refugees, asylum seekers and migrants without status, employees of community organizations, and employees of public organizations). We will utilize Mirzoev and Kane's framework on health systems' responsiveness to guide the four phases of a qualitative multiple case study (a case being an intersectoral initiative). These phases will include (1) building an inventory of intersectoral initiatives developed during the pandemic, (2) organizing a deliberative workshop with representatives of the study population, community, and public sector respondents to select and validate the intersectoral initiatives, (3) interviews (n = 80) with community and public sector frontline workers and managers, municipal/regional/provincial policymakers, and employees of philanthropic foundations, and (4) focus groups (n = 80) with refugees, asylum seekers, and migrants without status. Qualitative data will be analyzed using thematic analysis. The findings will be used to develop discussion forums to spur cross-learning among service providers. DISCUSSION: This research will highlight the experiences of community and public organizations in their ability to offer responsive services for refugees, asylum seekers, and migrants without status in the context of a pandemic. We will draw lessons learnt from the promising practices developed in the context of COVID-19, to improve services beyond times of crisis. Lastly, we will reflect upon our participatory approach-particularly in relation to the engagement of refugees and asylum seekers in the governance of our research.

Social networks and skilled health worker migration in Nigeria: An ego network analysis.

BACKGROUND: Nigeria provides a good case study for researchers, activists, and governments seeking to understand how social networks can help mitigate the negative impact of skilled health worker (SHW) migration in low and middle-income countries. This study aimed to map the social networks of SHWs and explore how they influence migration intentions. METHODS: We combined semi-structured qualitative interviews with an ego-network analysis of 22 SHWs living in Nigeria, used R-Studio to display and visualise their networks, and NVivo for thematic analysis of transcribed interviews. RESULTS: The network size and frequency of interaction were smaller among SHWs seeking to remain in Nigeria, however when compared to SHWs seeking to migrate, they had ties with a diverse group of stakeholders interested in improving health services. The influence of social networks on SHW migration intentions was observed within the following themes: access to information on migration opportunities, modelling of migration behaviour, support for decision making, and opportunities for policy engagement. CONCLUSION: The social networks of SHWs can aid the diffusion of norms that are relevant for improving SHW migration governance. Through their social networks, SHWs can improve awareness of the challenges associated with SHW migration among state actors and the public.

Using social network analysis to understand multisectoral governance in district-level tobacco control programme implementation in India.

INTRODUCTION: Interest in multisectoral policies has increased, particularly in the context of low-income and middle-income countries and efforts towards Sustainable Development Goals, with greater attention to understand effective strategies for implementation and governance. The study aimed to explore and map the composition and structure of a multisectoral initiative in tobacco control, identifying key factors engaged in policy implementation and their patterns of relationships in local-level networks in two districts in the state of Karnataka, India. METHODS: Social network analysis (SNA) was used to examine the structure of two district tobacco control networks with differences in compliance with the India's national tobacco control law. The survey was administered to 108 respondents (n=51 and 57) in two districts, producing three distinct network maps about interaction, information-seeking and decision-making patterns within each district. The network measures of centrality, density, reciprocity, centralisation and E-I index were used to understand and compare across the two districts. RESULTS: Members from the department of health, especially those in the District Tobacco Control Cell, were the most frequently consulted actors for information as they led district-level networks. The most common departments engaged beyond health were education, police and municipal. District 1's network displayed high centralisation, with a district nodal officer who exercised a central role with the highest in-degree centrality. The district also exhibited greater density and reciprocity. District 2 showed a more dispersed pattern, where subdistrict health managers had higher betweenness centrality and acted as brokers in the network. CONCLUSION: Collaboration and cooperation among sectors and departments are essential components of multisectoral policy. SNA provides a mechanism to uncover the nature of relationships and key actors in collaborative dynamics. It can be used as a visual learning tool for policy planners and implementers to understand the structure of actual implementation and concentrate their efforts to improve and enhance collaboration.

Policy Processes in Multisectoral Tobacco Control in India: The Role of Institutional Architecture, Political Engagement and Legal Interventions.

BACKGROUND: The development and implementation of health policy have become more overt in the era of Sustainable Development Goals, with expectations for greater inclusivity and comprehensiveness in addressing health holistically. Such challenges are more marked in low- and middle-income countries (LMICs), where policy contexts, actor interests and participation mechanisms are not always well-researched. In this analysis of a multisectoral policy, the Tobacco Control Program in India, our objective was to understand the processes involved in policy formulation and adoption, describing context, enablers, and key drivers, as well as highlight the challenges of policy. METHODS: We used a qualitative case study methodology, drawing on the health policy triangle, and a deliberative policy analysis approach. We conducted document review and in-depth interviews with diverse stakeholders (n = 17) and anlayzed the data thematically. RESULTS: The policy context was framed by national law in India, the signing of a global treaty, and the adoption of a dedicated national program. Key actors included the national Ministry of Health and Family Welfare (MoHFW), State Health Departments, technical support organizations, research organizations, non-governmental bodies, citizenry and media, engaged in collaborative and, at times, overlapping roles. Lobbying groups, in particular the tobacco industry, were strong opponents with negative implications for policy adoption. The state-level implementation relied on creating an enabling politico-administrative framework and providing institutional structure and resources to take concrete action. CONCLUSION: Key drivers in this collaborative governance process were institutional mechanisms for collaboration, multi-level and effective cross-sectoral leadership, as well as political prioritization and social mobilization. A stronger legal framework, continued engagement, and action to address policy incoherence issues can lead to better uptake of multisectoral policies. As the impetus for multisectoral policy grows, research needs to map, understand stakeholders' incentives and interests to engage with policy, and inform systems design for joint action.

Dynamic needs and challenges of people with drug-resistant tuberculosis and HIV in South Africa: a qualitative study.

BACKGROUND: There is little evidence of patient acceptability for drug-resistant tuberculosis (DRTB) care in the context of new treatment regimens and HIV co-infection. We aim to describe experiences of DRTB-HIV care among patients in KwaZulu-Natal province, South Africa. METHODS: In this qualitative study using Bury's framework for chronic illness, we conducted 13 focus groups at a tertiary hospital with 55 patients co-infected with DRTB and HIV (28 women, 27 men) who were receiving new bedaquiline-based treatment for DRTB, concurrent with antiretroviral therapy. Eligible patients were consenting adults (aged >18 years) with confirmed DRTB and HIV who were enrolled into the PRAXIS study within 2 weeks of initiating bedaquiline-based treatment for DRTB. Participants were recruited from the PRAXIS cohort to participate in a focus group based on their time in DRTB treatment: early (2-6 weeks after treatment initiation), middle (2-6 months after discharge or treatment initiation if never hospitalised), and late (>6 months after treatment initiation). Focus groups were carried out in isiZulu language, audio recorded, and translated to English within 4 weeks. Participants were asked about their experiences of DRTB and HIV care and treatment, and qualitative data were coded and thematically analysed. FINDINGS: From March, 2017, to June, 2018, distinctive patient challenges were identified at four critical stages of DRTB care: diagnosis, marked by centralised hospitalisation, renunciation from routine life, systemic stigmatisation and, for patients with longstanding HIV, renewed destabilisation; treatment initiation, marked by side-effects, isolation, and social disconnectedness; discharge, marked by brief respite and resurgent therapeutic and social disruption; and continuity, marked by deepening socioeconomic challenges despite clinical recovery. The periods of diagnosis and discharge into the community were particularly difficult. Treatment information and agency in decision making was a persistent gap. Sources of stigmatisation shifted with movement between the hospital and community. Resilience was built by connecting to peers, self-isolating, financial and material security, and a focus on recovery. INTERPRETATION: People with DRTB and HIV undergo disruptive, life-altering experiences. The lack of information, agency, and social protections in DRTB care and treatment causes wider-reaching challenges for patients compared with HIV. Decentralised, community, peer-support, and differentiated care models for DRTB might be ameliorative and help to maximise the promise of new regimens. FUNDING: US National Institutes of Health. TRANSLATION: For the isiZulu translation of the abstract see Supplementary Materials section.

Learning from intersectoral action beyond health: a meta-narrative review.

Intersectoral action (ISA) is considered pivotal for achieving health and societal goals but remains difficult to achieve as it requires complex efforts, resources and coordinated responses from multiple sectors and organizations. While ISA in health is often desired, its potential can be better informed by the advanced theory-building and empirical application in real-world contexts from political science, public administration and environmental sciences. Considering the importance and the associated challenges in achieving ISA, we have conducted a meta-narrative review, in the research domains of political science, public administration, environmental and health. The review aims to identify theory, theoretical concepts and empirical applications of ISA in these identified research traditions and draw learning for health. Using the multidisciplinary database of SCOPUS from 1996 to 2017, 5535 records were identified, 155 full-text articles were reviewed and 57 papers met our final inclusion criteria. In our findings, we trace the theoretical roots of ISA across all research domains, describing the main focus and motivation to pursue collaborative work. The literature synthesis is organized around the following: implementation instruments, formal mechanisms and informal networks, enabling institutional environments involving the interplay of hardware (i.e. resources, management systems, structures) and software (more specifically the realms of ideas, values, power); and the important role of leaders who can work across boundaries in promoting ISA, political mobilization and the essential role of hybrid accountability mechanisms. Overall, our review reaffirms affirms that ISA has both technical and political dimensions. In addition to technical concerns for strengthening capacities and providing support instruments and mechanisms, future research must carefully consider power and inter-organizational dynamics in order to develop a more fulsome understanding and improve the implementation of intersectoral initiatives, as well as to ensure their sustainability. This also shows the need for continued attention to emergent knowledge bases across different research domains including health.

Electronic Dose Monitoring Identifies a High-Risk Subpopulation in the Treatment of Drug-resistant Tuberculosis and Human Immunodeficiency Virus.

BACKGROUND: In generalized drug-resistant tuberculosis (DR-TB) human immunodeficiency virus (HIV) epidemics, identifying subpopulations at high risk for treatment failure and loss to care is critically important to improve treatment outcomes and prevent amplification of drug resistance. We hypothesized that an electronic dose-monitoring (EDM) device could empirically identify adherence-challenged patients and that a mixed-methods approach would characterize treatment challenges. METHODS: A prospective study of patients with DR-TB HIV on antiretroviral therapy (ART) initiating bedaquiline-containing regimens in KwaZulu-Natal, South Africa. Separate EDM devices measured adherence for bedaquiline and ART. Patients with low adherence (<85%) to both bedaquiline and ART were identified as high risk for poor outcomes. Baseline survey, study visit notes, and focus group discussions characterized treatment challenges. RESULTS: From December 2016-February 2018, 32 of 198 (16%) enrolled patients with DR-TB HIV were identified as dual-adherence challenged. In a multivariate model including baseline characteristics, only receiving a disability grant was significantly associated with dual nonadherence at 6 months. Mixed-methods identified treatment barriers including alcohol abuse, family conflicts, and mental health issues. Compared with adherent patients, dual-adherence-challenged patients struggled to prioritize treatment and lacked support, and dual-adherence-challenged patients experienced higher rates of detectable HIV viral load and mortality than more adherent patients. CONCLUSIONS: EDM empirically identified a subpopulation of patients with DR-TB HIV with dual-adherence challenges early in treatment. Mixed-methods revealed intense psychosocial, behavioral, and structural barriers to care in this subpopulation. Our data support developing differential, patient-centered, adherence support interventions focused on psychosocial and structural challenges for subpopulations of at-risk DR-TB HIV patients.

Methodological gaps and opportunities for studying multisectoral collaboration for health in low- and middle-income countries.

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

Can community pharmacists improve tuberculosis case finding? A mixed methods intervention study in India.

INTRODUCTION: India has the world's highest burden of tuberculosis (TB). Private retail pharmacies are the preferred provider for 40% of patients with TB symptoms and up to 25% of diagnosed patients. Engaging pharmacies in TB screening services could improve case detection. METHODS: A novel TB screening and referral intervention was piloted over 18 months, under the pragmatic staggered recruitment of 105 pharmacies in Patna, India. The intervention was integrated into an ongoing public-private mix (PPM) programme, with five added components: pharmacy training in TB screening, referral of patients with TB symptoms for a chest radiograph (CXR) followed by a doctor consultation, incentives for referral completion and TB diagnosis, short message service (SMS) reminders and field support. The intervention was evaluated using mixed methods. RESULTS: 81% of pharmacies actively participated in the intervention. Over 132.49 pharmacy person-years of observation in the intervention group, 1674 referrals were made and 255 cases of TB were diagnosed. The rate of registration of symptomatic patients was 62 times higher in the intervention group compared with the control group (95% CI: 54 to 72). TB diagnosis was 25 times higher (95% CI: 20 to 32). Microbiological testing and test confirmation were also significantly higher among patients diagnosed in the intervention group (p<0.001). Perceived professional credibility, patient trust, symptom severity and providing access to a free screening test were seen to improve pharmacists' engagement in the intervention. Workload, patient demand for over-the-counter medicines, doctor consultation fees and programme documentation impeded engagement. An additional 240 cases of TB were attributed to the intervention, and the approximate cost incurred per case detected due to the intervention was US$100. CONCLUSIONS: It is feasible and impactful to engage pharmacies in TB screening and referral activities, especially if working within existing public-private mix (PPM) programmes, appealing to pharmacies' business mindset and among pharmacies with strong community ties.

India's NCD strategy in the SDG era: are there early signs of a paradigm shift?

BACKGROUND: The Sustainable Development Goals (SDGs) are seen in most corners as the embodiment of a more inclusive and holistic development approach, key to addressing the numerous and urgent challenges the world faces. In the health realm, a true SDG approach will require a five-fold paradigm shift according to Buse and Hawkes. This article explores whether early traces of this paradigm shift can already be witnessed in the Indian context, focusing on Non-Communicable Diseases (NCDs) more in particular. DISCUSSION: By now, NCDs make up a large health burden in India, both individually and on the health system. Inspired by an SDG vision, tackling NCDs will require a comprehensive approach rooted in preventive, curative and rehabilitative services. In India, some early momentum in this respect can already be witnessed, certainly in addressing the first two challenges identified by Buse and Hawkes, leadership and intersectoral coherence, and a shift from treatment to prevention. A central plan addressing health through an inter-sectoral approach has shaped the trajectory so far, moving away from silos to engagement with sectors beyond health. New guidelines addressing comprehensive primary healthcare propose a community outreach and preventive approach for NCDs. At a broader level, NCD prevention is also closely linked to tackling the so called "commercial determinants of health" and will require among others strong (central and state level) regulation, teaming up with global advocacy networks and capitalizing on global frameworks, where they exist. Strong political leadership will be indispensable for this, and is according to Buse and Hawkes closely linked to seeing health as a right and the government as accountable when it comes to providing for the right to health through its policies and actions. CONCLUSION: National stewardship will thus be key, via a more adaptive network governance structure with the central level coordinating with the state level to ensure implementation, while also engaging with other stakeholders, sectors, the private sector and civil society. As one can expect, networked governance, necessary for the battle against NCDs, is a work in progress in India. In sum, some of the early (paradigm shift) signs are encouraging, but by and large it is still too early to assess whether a real paradigm shift has taken place.

Government helper and citizen advocate? A case study of the multiple roles and pressures facing a nongovernmental organization contracted by government to strengthen community health in northern India.

While nongovernmental organizations (NGOs) can potentially strengthen valuable citizen political engagement, NGOs that are increasingly oriented towards donor and government contracts may instead contribute to depoliticizing development. Amidst competing pressures, NGO experiences and agency in managing multiple roles require examination. We present a qualitative case study of an NGO implementing a government-designed intervention to strengthen Village Health, Sanitation, and Nutrition Committees (VHSNCs) in rural north India. Despite a challenging context of community scepticism and poor government services, the NGO did successfully form VHSNCs by harnessing its respected interlocutor status, preexisting relationships, and ability to "sell" the VHSNC as a mechanism for improving local well-being. While the VHSNC enabled community members to voice concerns to government officials, improvements often failed to meet community expectations. NGO staff endured community frustration on one hand and rebuffs from lower-level officials on the other, while feeling undersupported by the government contract. Consequently, although contracted to strengthen a community institution, the NGO increasingly worked alongside VHSNC members to try to strengthen the public sector. Contrary to assumptions that NGOs become "tamed" through taking government contracts, being contracted to deliver inputs for community participation was intertwined with microlevel political action, though this came at a cost to the NGO.

Doing implementation research on health governance: a frontline researcher's reflexive account of field-level challenges and their management.

BACKGROUND: Implementation Research (IR) in and around health systems comes with unique challenges for researchers including implementation, multi-layer governance, and ethical issues. Partnerships between researchers, implementers, policy makers and community members are central to IR and come with additional challenges. In this paper, we elaborate on the challenges faced by frontline field researchers, drawing from experience with an IR study on Village Health Sanitation and Nutrition Committees (VHSNCs). METHODS: The IR on VHSNC took place in one state/province in India over an 18-month research period. The IR study had twin components; intervention and in-depth research. The intervention sought to strengthen the VHSNC functioning, and concurrently the research arm sought to understand the contextual factors, pathways and mechanism affecting VHSNC functions. Frontline researchers were employed for data collection and a research assistant was living in the study sites. The frontline research assistant experienced a range of challenges, while collecting data from the study sites, which were documented as field memos and analysed using inductive content analysis approach. RESULTS: Due to the relational nature of IR, the challenges coalesced around two sets of relationships (a) between the community and frontline researchers and (b) between implementers and frontline researchers. In the community, the frontline researcher was viewed as the supervisor of the intervention and was perceived by the community to have power to bring about beneficial changes with public services and facilities. Implementers expected help from the frontline researcher in problem-solving in VHSNCs, and feedback on community mobilization to improve their approaches. A concerted effort was undertaken by the whole research team to clarify and dispel concerns among the community and implementers through careful and constant communication. The strategies employed were both managerial, relational and reflexive in nature. CONCLUSION: Frontline researchers through their experiences shape the research process and its outcome and they play a central role in the research. It demonstrates that frontline researcher resilience is very crucial when conducting health policy and systems research.

Negotiating power relations, gender equality, and collective agency: are village health committees transformative social spaces in northern India?

BACKGROUND: Participatory health initiatives ideally support progressive social change and stronger collective agency for marginalized groups. However, this empowering potential is often limited by inequalities within communities and between communities and outside actors (i.e. government officials, policymakers). We examined how the participatory initiative of Village Health, Sanitation, and Nutrition Committees (VHSNCs) can enable and hinder the renegotiation of power in rural north India. METHODS: Over 18 months, we conducted 74 interviews and 18 focus groups with VHSNC members (including female community health workers and local government officials), non-VHSNC community members, NGO staff, and higher-level functionaries. We observed 54 VHSNC-related events (such as trainings and meetings). Initial thematic network analysis supported further examination of power relations, gendered "social spaces," and the "discourses of responsibility" that affected collective agency. RESULTS: VHSNCs supported some re-negotiation of intra-community inequalities, for example by enabling some women to speak in front of men and perform assertive public roles. However, the extent to which these new gender dynamics transformed relations beyond the VHSNC was limited. Furthermore, inequalities between the community and outside stakeholders were re-entrenched through a "discourse of responsibility": The comparatively powerful outside stakeholders emphasized community responsibility for improving health without acknowledging or correcting barriers to effective VHSNC action. In response, some community members blamed peers for not taking up this responsibility, reinforcing a negative collective identity where participation was futile because no one would work for the greater good. Others resisted this discourse, arguing that the VHSNC alone was not responsible for taking action: Government must also intervene. This counter-narrative also positioned VHSNC participation as futile. CONCLUSIONS: Interventions to strengthen participation in health systems can engender social transformation. However they must consider how changing power relations can be sustained outside participatory spaces, and how discourse frames the rationale for community participation.

Beyond form and functioning: Understanding how contextual factors influence village health committees in northern India.

Health committees are a common strategy to foster community participation in health. Efforts to strengthen committees often focus on technical inputs to improve committee form (e.g. representative membership) and functioning (e.g. meeting procedures). However, porous and interconnected contextual spheres also mediate committee effectiveness. Using a framework for contextual analysis, we explored the contextual features that facilitated or hindered Village Health, Sanitation and Nutrition Committee (VHSNC) functionality in rural north India. We conducted interviews (n = 74), focus groups (n = 18) and observation over 1.5 years. Thematic content analysis enabled the identification and grouping of themes, and detailed exploration of sub-themes. While the intervention succeeded in strengthening committee form and functioning, participant accounts illuminated the different ways in which contextual influences impinged on VHSNC efficacy. Women and marginalized groups navigated social hierarchies that curtailed their ability to assert themselves in the presence of men and powerful local families. These dynamics were not static and unchanging, illustrated by pre-existing cross-caste problem solving, and the committee's creation of opportunities for the careful violation of social norms. Resource and capacity deficits in government services limited opportunities to build relationships between health system actors and committee members and engendered mistrust of government institutions. Fragmented administrative accountability left committee members bearing responsibility for improving local health without access to stakeholders who could support or respond to their efforts. The committee's narrow authority was at odds with widespread community needs, and committee members struggled to involve diverse government services across the health, sanitation, and nutrition sectors. Multiple parallel systems (political decentralization, media and other village groups) presented opportunities to create more enabling VHSNC contexts, although the potential to harness these opportunities was largely unmet. This study highlights the urgent need for supportive contexts in which people can not only participate in health committees, but also access the power and resources needed to bring about actual improvements to their health and wellbeing.

What rural doctors want: a qualitative study in Chhattisgarh state.

The importance of addressing concerns of rural health worker welfare in order to improve their performance and retention is widely acknowledged; yet there is little empirical research on the needs of rural health professionals. We report findings from a qualitative research study in rural Chhattisgarh, involving indepth interviews with 37 practitioners and data analysis using the "framework" approach. Participants' expressions of their needs encompassed a range of reforms and improvements, including better salaries and job security, more rational posting and promotion procedures, and facility improvements. Opportunities for need-based skills training and better housing also emerged as key needs, as did better schools, assurance of personal security, and recognition and appreciation of their services by the administration. Increased investment in rural infrastructure and training, graded packages of benefits for rural doctors, and governance reforms to improve the internal accountability of government health services emerge as recommendations from the study.

Anchoring contextual analysis in health policy and systems research: A narrative review of contextual factors influencing health committees in low and middle income countries.

Health committees, councils or boards (HCs) mediate between communities and health services in many health systems. Despite their widespread prevalence, HC functions vary due to their diversity and complexity, not least because of their context specific nature. We undertook a narrative review to better understand the contextual features relevant to HCs, drawing from Scopus and the internet. We found 390 English language articles from journals and grey literature since 1996 on health committees, councils and boards. After screening with inclusion and exclusion criteria, we focused on 44 articles. Through an iterative process of exploring previous attempts at understanding context in health policy and systems research (HPSR) and the HC literature, we developed a conceptual framework that delineates these contextual factors into four overlapping spheres (community, health facilities, health administration, society) with cross-cutting issues (awareness, trust, benefits, resources, legal mandates, capacity-building, the role of political parties, non-governmental organizations, markets, media, social movements and inequalities). While many attempts at describing context in HPSR result in empty arenas, generic lists or amorphous detail, we suggest anchoring an understanding of context to a conceptual framework specific to the phenomena of interest. By doing so, our review distinguishes between contextual elements that are relatively well understood and those that are not. In addition, our review found that contextual elements are dynamic and porous in nature, influencing HCs but also being influenced by them due to the permeability of HCs. While reforms focus on tangible HC inputs and outputs (training, guidelines, number of meetings held), our review of contextual factors highlights the dynamic relationships and broader structural elements that facilitate and/or hinder the role of health committees in health systems. Such an understanding of context points to its contingent and malleable nature, links it to theorizing in HPSR, and clarifies areas for investigation and action.

Impact of community-based mitanin programme on undernutrition in rural Chhattisgarh State, India.

BACKGROUND: Community health workers known as mitanins undertook family-level counseling and mobilized the community to improve coverage of maternal and child health services in the state of Chhattisgarh, India. The Nutrition Security Innovation (NSI) project was launched in selected blocks with additional inputs for promoting appropriate complementary feeding practices and disseminating information on Public Distribution System (PDS) entitlement. Within 3 years of project implementation, all NSI inputs in the project group (PG) were scaled up in the entire state. OBJECTIVE: To study the impact of interventions on nutritional status in PG and non-NSI comparison group (CG) blocks. METHODS: Quasi-experimental mixed methods were used. The sample consisted of 3,626 households with children under 3 years of age and 268 mitanins. RESULTS: A ratio of 1 mitanin per 250 to 500 population was effective. The coverage of exclusive breastfeeding, timely introduction of complementary feeding, DPT immunization, and antenatal care services was more than 70%. The PDS reached almost 90% of beneficiaries. In both the PG and the CG, one-third of children were undernourished, with one-quarter of children undernourished by 6 months of age. The prevalence of low birthweight was over 40%, and half of all women were undernourished. The estimated annual average reduction rate (AARR) for the entire state was estimated to be 4.22% for underweight and 5.64% for stunting. CONCLUSIONS: The strategy of Mitanin Programme in the Indian state of Chhattisgarh was unique with the implementation of direct nutrition actions being spearheaded by the health sector and community health volunteers in coordination with the Integrated Child Development Services (ICDS) and the Public Distribution System (PDS). The highest priority was given to interventions in the first 92 weeks of life. This implied ensuring frequent counseling and delivery of services through the entire pregnancy period and continued follow up till the children were at least one year of age. An accelerated decrease in the annual rate of reduction of underweight and stunting was observed. The emerging findings point to the significant contributions that can be made by the National Rural Health Mission (NRHM) in India by involvement of community health volunteers known as Accredited Social Health Activists (ASHAs) towards reducing the persistent problem of undernutrition in the country.

Role of innovative institutional structures in integrated governance. A case study of integrating health and nutrition programs in Chhattisgarh, India.

PURPOSE: The aim of this paper is to highlight the significance of integrated governance in bringing about community participation, improved service delivery, accountability of public systems and human resource rationalisation. It discusses the strategies of innovative institutional structures in translating such integration in the areas of public health and nutrition for poor communities. DESIGN/METHODOLOGY/APPROACH: The paper draws on experience of initiating integrated governance through innovations in health and nutrition programming in the resource-poor state of Chhattisgarh, India, at different levels of governance structures--hamlets, villages, clusters, blocks, districts and at the state. The study uses mixed methods--i.e. document analysis, interviews, discussions and quantitative data from facilities surveys--to present a case study analyzing the process and outcome of integration. FINDINGS: The data indicate that integrated governance initiatives improved convergence between health and nutrition departments of the state at all levels. Also, innovative structures are important to implement the idea of integration, especially in contexts that do not have historical experience of such partnerships. Integration also contributed towards improved participation of communities in self-governance, community monitoring of government programs, and therefore, better services. PRACTICAL IMPLICATIONS: As governments across the world, especially in developing countries, struggle towards achieving better governance, integration can serve as a desirable process to address this. Integration can affect the decentralisation of power, inclusion, efficiency, accountability and improved service quality in government programs. The institutional structures detailed in this paper can provide models for replication in other similar contexts for translating and sustaining the idea of integrated governance. ORIGINALITY/VALUE: This paper is one of the few to investigate innovative public institutions of a and community mobilisation to explore this important, and under-researched, topic.