Towards a framework for multisector and multilevel collaboration: case of HIV and AIDS governance in South Africa

Figures & data

Table 1. Challenges impacting on effective implementation of multisector collaboration.

	Challenges amongst AIDS Councils	Lessons
Composition	There is no guidance regarding establishment of AIDS Councils, except that they need to be multisectoral Some of the critical sectors are not represented, while some struggle to define their role Membership is continuously changing AIDS Councils struggle to mobilise stakeholders that need to be involved	Structure is important for effective functioning of the collaborative Buy-in from all sectors is critical for participation and commitment Membership should be informed by a good stakeholder analysis to determine which sectors should be involved, resource needed and the capacity they have that will benefit the collaborative
Operation procedures	The structure relies on a person, the HIV Coordinator, and ceases to function when he or she resigns Lack of decision-making power amongst members, limiting ability to commit or implement resolutions Roles and responsibilities between sectors and amongst members are not defined There is limited capacity amongst members to strategically plan, monitor and report on progress Meetings happen on an ad hoc basis There is no pre-defined plan to inform day to day operation of the structures (e.g., communication, resolving tension)	Administration of the collaborative should be institutionalised and not left to an individual, for continuity Having a leader, someone with influence, legitimacy and respect is critical for credibility of the collaborative A predefined plan with clear activities, and standard operating procedures should inform the process of collaboration
Relations between sectors	There is tension between sectors, with some being undermined because of differences in institutional logic (norms, and practices) There are power issues linked to contribution of resources (the one contributing financial resources viewed as more powerful compared to other sectors) Prior history of adverserialism There are divisions and lack of trust between sectors	Trust, equality and respect for others are some of the key process elements critical to accomplish the goals of the collaborative A communication and conflict resolution strategy must be put in place should such issues arise
Institutional challenges including poor leadership and support	The national level structure is caught up in strengthening itself as an organisation, and neglected its oversight role of capacitating & supporting sub-level structures Coordination of the multisector response is an unfunded mandate, members take own money to pay for activities of the AIDS Council There are many institutions involved at national level, with overlapping roles and responsibilities which are not harmonised	National guidance and availability of resources (financial and human) are critical pre-requisites, which determines the outcome of the collaborative
Evaluation	There is lack of defined systems to measure the impact of the collaboration There is poor tracking of the contribution of the private sector	Monitoring and evaluation and continuous learning are an important part of the process Oversight, and clarification of responsibilities is critical for accountability

Table 2. Challenges of mainstreaming HIV in health and non-health departments.

	Challenges in government departments	Lessons
Mainstreaming	Most departments have workplace policies, but some non-health departments are unclear on how HIV aligns with their core (service delivery) mandate. The NSP does not provide a framework to inform the mainstreaming process	Clarity on individual role and contribution to the collective is a critical structure element that has an influence on performance and outcome
Coordination between levels	HIV programmes within some department were planned and implemented in isolation Lack of a planned processes or systems to identify synergies and ensure that directorates work together Some directorates were prioritising their activities over those of others	Integrated planning and implementation of progammes is a key component of the collaboration process
Coordination across departments	There is a wide recognition of the need for a ‘whole of government’ response to HIV amongst departments; yet limited evidence of collaborations on HIV and AIDS programmes between departments Roles and responsibilities are overlapping	Coordination of efforts and working towards a collective goal versus sector goals is needed for effective use of resources and for collaboration
Systems for intergovernmental relations	Some departments are not represented, and some not regularly participating in multisector platforms meant for coordinated planning and collaboration	Multisector collaboration also requires regular interaction to identify synergies and areas of collaboration
Evaluation	Lack of clarity regarding how the outcome will be measured	Monitoring and evaluation should be defined from the beginning when objectives are set, with continuous monitoring through-out the process, and evaluation at the end of the process
Reporting	Reporting system at national level involves multiple actors (South African National AIDS Council, Department of Planning Monitoring and Evaluation and Department of Public Service and Administration) and is poorly coordinated	Harmonised and integrated system of reporting is critical to ensure that there are no omissions and duplication in reporting.

Figure 1. Flow chart of the integrative review.

Table 3. Synthesis of existing frameworks, models and approaches to multisectoral action.

	Model of collaborative governance [11]	Integrative framework for collaborative governance [24]	Collective impact framework [25]	Framework for cross sector collaboration [5]	A process framework of collaboration [26]	Multisector approach for public health [1]	Governing multisector action for health [3]	Multisector governance for health [9]	Multisector action for health [8]	Multi-sectoral approach to NCD Prevention [41]
Definition of MSA	A governing arrangement where public agencies engage non-state actors in a formal collective decision making	Public policy structures engage levels of government, private and civic spheres to carry out a public purpose	Long-term commitment by different sectors to a common agenda to solve a specific social problem	Partnership involving government, business, nonprofits and philanthropies, communities	Autonomous actors interact through formal and informal negotiation	Deliberate collaboration among various stakeholders to jointly achieve a policy outcome	Brings together various actors sectors to achieve a common goal	A governance mechanism where government and non-government actors solve multidimensional health challenges	Actions undertaken by non-health sectors to protect the health of the population	Involvement of any 2 or more sectors, one of which must be government.
Focus and aim	Visual representation of four elements: starting conditions, institutional design, facilitative leadership and collaborative process, together producing outcomes	Visual representation of five elements: system context, drivers, collaborative governance regime, and its internal collaborative dynamics and collaborative actions that generate impacts and adaptation	Tables five conditions of collective impact: common agenda, shared measurement, mutually reinforcing activities, continuous communication and backbone support	Visual representation of initial conditions, process, structural governance components, constraints and contingencies, outcomes and accountability	Describes five dimensions to be known for effective collaboration: governance, administration, organisational autonomy, mutuality and norms	Describes a conceptual framework, including advantages, prerequisites and bottlenecks, process and outcomes with examples of application	Identifies five key considerations and lessons for successful governance of multisectoral action	Illustrates the complexity of multisectoral governance in real practice	Identifies the challenges, opportunities and capacity development needed for effective multisectoral actions for health in a complex policy environment	Tabulated framework for MSA to Health Policy Analysis made up of four main constructs: context, content, stakeholders, and strategies
Preconditions and prerequisites	Prior history of conflict or cooperation, the incentives for stakeholders to participate, power and resource imbalances, facilitative leadership and institutional design	leadership, consequential incentives, interdependence, and uncertainty, and context which impacts on the success (or not)	An influential champion, adequate financial resources, and a sense of urgency for change.	Precondition for collaboration: general environment, sector failure and direct antecedents	Time, respect for the fragility of the process, and paying close attention to the process will increase the likelihood that success will occur	Willingness at the leadership and mandate at the policy level, sufficient resources and time, open discussion, communication, monitoring and assessment	Distributed leadership, issue framing, negotiation skill, flexibility and learning, communication, and relationship building, ethics and integrity, and institutionalised structure	Sharing a common goal or vision, negotiation skills, good governance, government bureaucracy delays implementation	Mutual gain, consensus across all partners to reach a shared vision, external driving forces, trust among, balance between soft power and legal, and good governance	Establishing means for engagement; funding through joint budgeting; complementary vision; establishing interests and concerns of actors and a government led process are some of the key factors in a policy process
Structure		Focus on who the right people/members should be in collaboratives		Specialisation of tasks and division of labour, rules and standard operating procedures, and designated authority relations		clear roles and responsibilities, an institutional mechanism, coordination committee, channels for regular communication, and measures for problem solving	Leadership role defined, clarity of roles of sectors, mapping of the profile, interests, incentives, and relationships of key individuals and sectors, not depend on an individual	Appoint a lead agency to do internal coordination, balance of power and interest amongst stakeholders, joint financing and monitoring	capacities at individual, institutional and system	Clarification of roles of actors (sectors) in government and outside of government is critical in a policy process
Process	cyclical or iterative rather than linear, communication, face to face dialogue, trust building, commitment to the process and shared understanding	Discovery, definition, deliberation, and determination, sees collaboration as an iterative process	Three phases of getting a collective impact: initiate action, organise for impact, and sustain action and impact.	Process includes forging initial agreements, building leadership, building legitimacy, building trust, managing conflict, and planning.	Collaboration occurs over time as organisations interact formally and informally through repetitive negotiation, & execution of commitments	Strategies and procedures to be defined before implementation All stakeholders need to be made part of decision‑making to make it participatory	governing implementation processes requires explicit attention up front. Requires accountability, transparency, trust, innovation, adaptation, and flexibility			The framework refers to strategies (intentional choices maximising benefits) instead of process, means of engagement of other sectors includes consultations, workshops, or meetings
Outcome	Small wins deepen trust and are critical outcome measure in collaboratives	Results on the ground are an important outcome indicator	Progress happens along the way. Early wins that demonstrate the value of working together are essential to hold the collaborative together.	Differentiates between three categories: public value; first-, second-, and third-order effects: ‘public value’ should be the point of creating and sustaining cross-sector collaboratives		MSA plan has to be defined, monitoring and supervision are to be jointly planned for coordination	Imperative to cultivate a culture of mutual learning among the divergent stakeholders, a shared mental model such as theories of change or logic or outcome models is key		Progress should be monitored through regular reports which are publicly available
Contribution	Conditions under which collaborative governance will be more or less effective, approaches collaborative process as a type of governance. which is easy to understand	Interaction of context (environmental factors) and internal dynamics and actions in collaborations influences outcome. The 10 propositions offered are useful to enquiry and development of theory.	It is realistic about the time factor in collaboratives – describing that collaboratives requires time and should not be undertaken as a quick fix solution	Deliberates on both process and structure, and the challenging nature of collaborating, and makes critical pointers on how to approach failure	The listing of the key process element in collaboratives has been a key contribution of the framework, starting to fill ‘the black box’ the process of collaborating.	Deliberates on the possible positive outcomes/benefits of MSA				A useful framework (for a multisectoral approach) to health policy analysis. It is a useful guide in thinking about the different actors (sectors), their interest and agenda, and their role in the policy process

Figure 2. Framework for multisector and multilevel collaboration.

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