Stakeholders’ Identification and Understanding of the Multisectoral Governance for Child and Maternal Nutrition During the MDGs Period – A Stakeholders’ Network Analysis of Khyber Pakhtunkhwa Province of Pakistan

doi:10.21203/rs.3.rs-3331937/v1

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Research Article

Stakeholders’ Identification and Understanding of the Multisectoral Governance for Child and Maternal Nutrition During the MDGs Period – A Stakeholders’ Network Analysis of Khyber Pakhtunkhwa Province of Pakistan

https://doi.org/10.21203/rs.3.rs-3331937/v1

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Background

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 had two objectives: 1) to identify the main stakeholders who were responsible for child and nutrition mother nutrition in the MDGs period in Khyber Pakhtunkhwa province of Pakistan, 2) to explore and map the composition and structure of the nutrition component of MDGs, identifying key factors engaged in nutrition policy implementation and their patterns of relationships in provincial-level in the KP.

Methods

Stakeholders identification was furnished using the participatory NetMap tool. Social network analysis (SNA) was used to examine the structure of the actors’ network in compliance with child and maternal nutrition MDGs. The survey was administered producing three distinct network maps about interaction, information-seeking and decision-making patterns. The network measures of centrality, density, reciprocity, centralization was used to understand the network across the province.

Results

a total of 16 stakeholders were identified. The results on network analysis showed MoH, P&D, NGOs, and provincial government were the most frequently consulted actors for interaction, information-seeking and decision-making. The three networks as a whole displayed high centralization with a P&D and MoH having a central role with the highest in-degree centrality. The network as whole also exhibited greater density and reciprocity.

Conclusion

As a whole, 16 stakeholders were identified by NetMap and SNA analysis with MoH, P&D, NGOs, and provincial government as the most frequently consulted actors for interaction, information-seeking and decision-making.

MDGs

nutrition

child nutrition

maternal nutrition

nutrition policy

stakeholders

Khyber Pakhtunkhwa

Malnutrition is a common public-health issue widespread in Pakistan (Asim and Nawaz, 2018). Despite the national efforts across all health sectors in Pakistan, child and maternal nutrition still remains the main obstacle in achieving health targets established by world organizations (Asim and Nawaz, 2018). Over the last few decades, emerging socio-economic trends (e.g. rapid population growth and huge economic shocks/inflation rates) have negatively affected Pakistan’s development potential, which in turn have led to stagnation in food security and nutrition trends with Pakistan identified as one of 36 countries that account for 90% of the global burden of malnutrition (Bhutta et al., 2016).

There have been both challenges and opportunities in nutrition confronted to Pakistan (Rizvi et al., 2015). In terms of opportunities, the MDGs era (2000–2015) was an excellent prospect for framing national nutrition policy in Pakistan (Rizvi et al., 2015; Bhutta et al., 2016). However, due to prevailing national and regional political situation, this opportunity was not fully exploited (Bhutta et al., 2016). Many researchers reported that Pakistan performed poorly, particularly, on child and maternal nutrition during the MDGs era despite the fact that it was a period of internationally driven collaboration directed to eradicate child and mothers’ malnutrition. The Government launched the national maternal, neonatal and child health programs in 2007 to promote access to evidence-based cost-effective interventions; strengthen district health system capacities; empower communities; expand the community mialdwives’ cadre; and promote utilization of essential services (Shadoul et al., 2010). Pakistan’s national MDG report of 2004 charted a road map for enhancing maternal and child survival by placing greater emphasis on reducing maternal and neonatal mortality through a number of strategies also including balanced diet and other related efforts of healthy nutrition. Factors that contributed to poor performance of Pakistan include gaps in legislation (Manzoor et al., 2016), low pace of women impowerment (Shafiq et al., 2019), nutrition-specific but nor nutrition -sensitive approach (Khan and Khalid, 2015) etc.

The nutrition landscape of any country is a complex network of diverse actors across different government departments, civil society institutions, development and research organizations, donors and associations (Acosta et al., 2012). In order to understand such landscapes, a stakeholder network analysis, which also includes stakeholders’ identification, is a must. There is clearly a vigorous exchange of information related to research and advocacy leading to a very complex nutrition landscape in a state under investigation. Some organizations may appear to be at the core of research and advocacy flow, but the presence of several other stakeholders in the network makes it a complicated setting to function in. While several government departments appear on the network, some may be of low relative influence or have lesser links connecting them to the overall network. Even though the influence levels of stakeholders on the nutrition landscape may greatly vary, stakeholders supportive of nutrition programs must be explicitly identified. Based on reports and research articles published during and after the MDGs era (Asim and Nawaz, 2018; Rizvi et al., 2015; Bhutta et al., 2016), we hypothesized that no comprehensive study has been conducted to identify the stakeholders that were responsible for child and maternal nutrition in the MDGs era.

A retrospective analysis of the previous large-scale community-based programs is crucial in understanding the factors responsible for success or failure of these programs. In this study, we try to identify the stakeholders who were involved in one way or the other in programs initiated during the MDGs era aiming at child and maternal nutrition. The findings of the study are believed to be important for successful conclusion of the unfinished agenda of child and maternal nutrition left over from MDGs to sustainable development goals (SDGs).

Therefore, the broader objective of the stakeholders’ analysis in the present study is to capture a snapshot of the stakeholders and to develop an understanding of how they interact with each other to achieve nutrition outcomes. The results of the analysis are meant to inform about which stakeholders were engaged and how they could have facilitated interaction between these stakeholders in Pakistan during the MDGs era. The results of the analysis are meant to assist in their efforts towards understanding who were or could be, influential in tackling undernutrition in Pakistan. This study will provide a map of implementation structures in local districts, identifying key actors and relationships among them.

The Case: The Millenium Development Goals (MDGs)

In September 2000, the United Nations General Assembly adopted a number of resolutions aimed at alleviating poverty and promoting equitable and sustainable development in developing countries. One of these resolutions identified eight areas for concrete action with measurable results to be achieved by the year 2015. All 189 member-states of the United Nations endorsed these Millennium Development Goals (MDGs) and vowed to make concerted efforts in achieving them. In subsequent summit-level meetings in Monterrey, Mexico (2001), Doha, Qatar (2002), and Kananaskis, Canada (2002), the Development Assistance Committee (DAC) of the industrialized world adopted a number of complementary measures to help developing countries achieve the MDGs. Increasing development assistance, gradual untying of aid, and providing greater access for the developing country goods to the markets of the industrialized world, constitute some of these complementary measures.

Three of the eight MDGs are explicitly health related - goal numbers 4 (reduce under-5 child mortality), 5 (improve maternal health), and 6 (combat HIV/AIDS, malaria, and other diseases). Goals 4 and 5 call for the reduction of under-five child mortality rate by two-thirds and the maternal morality ratio by three-quarters within the next fifteen years (taking 1990 as the base year). Similarly, by 2015, the goal (six) is to "halt and begin to reverse the spread of HIV/AIDS and the incidence of malaria and other major diseases." Another three Millennium Development Goals are intricately related to health - eradication of extreme poverty and hunger (goal 1), achieving universal primary education (goal 2), and promoting gender equality and empowerment of women (goal 3). The relevance and importance of these three goals in achieving the directly health-related ones can hardly be overemphasized. Since their adoption, the MDGs received wide endorsement from civil society organizations in both the developed and developing countries. Various development agencies expressed their commitment to work with the developing countries in achieving the MDGs. Following the Johannesburg World Summit for Sustainable Development (WSSD) in September 2002, the United Nations has urged the member states to redouble their efforts to achieve the MDGs. It has been stressed that "meeting these goals is feasible but far from automatic. Indeed, on our current trajectory, those goals will not be met for a significant proportion of the world's poor. Success in achieving the MDGs will require a seriousness of purpose, a political resolve and an adequate flow of resources from high-income to low-income countries on a sustained and well-targeted basis".

For Pakistan two health-related Millennium Development Goals − 4 and 5 – have been of particular relevance. One calls for the reduction by two-thirds the under-5 mortality rate, while the other demands a reduction of the maternal mortality ratio by three-quarters by the year 2015. The goal number 6 is also relevant insofar as malaria and other major communicable diseases (such as tuberculosis) are concerned. The base-year for these targets is 1990. In other words, countries are committed to reduce their under-5 mortality rate by two-thirds and their maternal mortality ratio by three-quarters between 1990 and 2015 - a span of twenty-five years.

Study Design

The study used a cross-sectional design. This survey developed in the study was part of a more extensive mixed methods research project conducted in the Khyber Pakhtunkhwa province of Pakistan. The data was collected from subjects mainly in Peshawar, the capital of KP province, which were selected based on compliance with the MDGs.

Stakeholders Identification

The literature concerned describes a number of approaches for stakeholders' identification and subsequent classification and analysis, though, this study adopted top-down or analytical categorization approach stakeholders' classification system (Mitchell et al, (1997). The top-down or analytical categorization approach was adopted because it was not in the scope of this study to involve large number of stakeholders, which is one of the preconditions in bottom-up or reconstructive approach. In the present study, our interest was to firstly identify the stakeholders by a panel of experts. Next, we interviewed these identified stakeholders to know about how they had interacted for programs that targeted child and maternal nutrition during the MDGs era. in short, this study collected data from two different types of groups of people – panel of experts and the stakeholders for child and maternal nutrition during the MDGs era. Data from panel of experts was used for identification of stakeholders and data from stakeholders was used for an understanding of the whole scenario of child and maternal nutrition during the MDGs era.

Panel of Experts

Panel of experts was identified from online literature search, personal contacts and applying a snowball methodology. We first developed criteria for an expert to be included in the panel i.e., > 5 years of experience in his/her specialty, interest in nutrition, and at least 5 scientific publications in the area of nutrition and 2 additional publications in health and/or nutrition policy. An additional criterion was the willingness of the expert to give interview, participate in the Focus Group Discussion (FGD) and basic knowledge about NetMap and/or willingness to get training on NetMap. The panel initially consisted of 49 experts (Table 1). However, further screening and reviewing resulted into a final list of 46 experts, of whom only 23 experts participated in the final data collection during the subsequent steps. As a first step, members of the panel of experts were contacted through email, telephone call or in-person and officially invited for “a stakeholder mapping workshop”, followed by an extensive interview session during Focal Group Discussion (FGD).

Table 1

Experts’ categories and designations
Categories	Designation
Academic (n = 22)	Professor/associate professor
International Organizations (n = 14)	Managers/Community
Government Officials (n = 8)	Secretaries/deputy secretaries
Researchers (n = 2)	PI/Co-PI

Orientation Workshop

A workshop (‘Stakeholders and the MDGs Period’) was held in March, 2022. The main objective of the workshop was to elaborate on the nutrition policy status in Pakistan. The proceedings of the workshop have been published elsewhere (Atta et al., 2022). Forty-six of the initially 49 invited experts participated in the workshop (Table 1), of whom 23 participated in all final stages of data collection. The details of the workshop can be seen in the related publication (Atta et al., 2022). Briefly, a brief presentation was given by one of the co-authors (IA) of the workshop elaborating on the MDGs era in general and the child and maternal nutrition in particular. The presentation elicited some discussion that was used for further elaboration on stakeholders’ identification. After the presentation, an open discussion was initiated encouraging the attendees to elaborate on the MDGs era with regard to child and maternal nutrition. The attendees of the workshop were asked to identify departments, sections, organizations and units as well as the individual stakeholders. A questionnaire was distributed asking about various attributes of the stakeholders. These experts were asked to identify various stakeholders with details on their designations and departments, who were the main players of nutrition activities during the MDGs era. “In your opinion, who were stakeholders of child and maternal nutrition during the MDGs era?”

Focus Group Discussion

The workshop was followed by a Focus Group Discussion (FGD) session. Data collection was completed in the form of group interviews and guided by these four questions; (i) which stakeholders are involved in child and maternal nutrition in the KP province of Pakistan? (ii) what roles do they play in the child and maternal nutrition practices? (iii) how do they interact? (iv) how do they influence decision making in relation to these practices? A two-page guide (Annexure-I) was also developed for the panel of experts to help in understanding who might a stakeholder be in the context of child and maternal nutrition during the MDGs era. in short, an actor who had an effect on allocation of resources was defined as “an actor influential in ‘shaping’ decisions” and this was related to the lines of authority. Flow of information and linkages were defined as a formal exchange of technical support (training, technical guides, equipment, information, research evidence, routine data or field experience/case studies). Funding links were defined as exchange of funds or in-kind support related to child and maternal nutrition.

Data Collection from Panel of Experts

Data from panel of expert was collected through a participatory tool known as NetMap, which was developed by the International Food Policy Research Institute (IFPRI) for examining actors and their roles, linkages, influences and goals (Waale, 2008; Puri et al., 2017). The NetMap tool was chosen for this study as it is an interview-based mapping approach that lets people understand, visualize, discuss and improve conditions in which different players with diverse influence levels have the ability to influence outcomes (Puri et al., 2017).

Firstly, discussion was held with the groups regarding the stakeholders that might had any influence on ‘child and maternal nutrition landscape during the MDGs era. Subsequently, a list of likely actors was developed and placed into a blank NetMap sheet. Then, discussion was held of what roles each of these stakeholders had played in the child and maternal nutrition chain, how they interact with each other in relation to provision of training and flow of technical information, funding and lines of authority including direction of interaction (who to whom).

A blank NetMap sheet was used to draw the interaction and direction using different colors for flow of information, funding and lines of authority. Next was to visualize the level of influence of each stakeholder against another, which was done through pairwise analysis where each stakeholder was compared to each other by asking who is more important than the other in relation to research and training, market and input information, as well as provision of funding as key important aspects of child and maternal nutrition. Key challenges of group interview as data collection methodology is to make sense of massive amounts of data, reduce the volume to valuable information, identify significant patterns and constructing a framework to communicate the essence of what the data reveals. Certain biases arose throughout the process including consistency, error and reference biases. Such biases were avoided by devising the interview guide neutrally with clear definitions of terminologies used to address the research questions. Sampling bias was addressed by including respondents from all segments of stakeholders including farmer groups, researchers, development partners, and government bodies.

A first-hand training on the NetMap usage was provided to the participants and a brief description is provided in the Supplementary File 1.

Data Collection from Stakeholders

In accordance to our second objective that how different stakeholders of child and maternal nutrition interacted during the MDGs era, different stakeholders identified in the workshop and the following interviews and FGD sessions were contacted through email, phone and in-person. A simple list of stakeholders identified in the workshop by the panel of experts was shared with them. They were asked to make suggestions for other actors who had a stake with ‘child and maternal nutrition’ during the MDGs era. In this way, applying the snowball method, the stakeholder list was continuously extended by new stakeholders (Alameddine et al. 2011). The process was repeated until a comprehensive list of stakeholders was identified and no new stakeholder was entered.

For the network information, the survey instrument required the interviewees to identify the individuals from the actor list whom they had interacted with (for program sensitization), and for information (implementation assistance) and decision-making support (programmatic or financial approvals). The three specific network interests (program sensitization, information-seeking and decision-making) evolved during the tool piloting, as they were defined as three broad categories of interaction defined by the implementers. Interaction relates to general sensitization about the program, whereas information-seeking and decision-making denote specific purpose or reason behind the interactions, with respect to child and maternal nutrition programs.

The survey was administered online to all stakeholders across different departments, including the departmental heads with higher administrative ranks. In order to increase the response rate and minimize missing data, we administered the survey ourselves in person. The actor list was presented to each participant, and they were asked to identify individuals with whom they interacted one-to-one, via face-to-face or telephonic conversation, while working on the MDGs. The participants could also name other actors not on the list but with whom they had discussed the implementation of child and maternal nutrition MDGs.

Data Analysis

Data was analyzed using different approaches according to the objectives of the study. Data was triangulated and collated by cross referencing both the qualitative and quantitative data. Quantitative data was entered into excel sheet for analysis. NetMaps were subjected to quantitative analysis using Organizational Risk Analysis (ORA) tool in Social Network Analysis (SNA) to map, as well as measure relationships and influences of stakeholders and examine relative positions. The ORA tool was used to develop the map of stakeholders and direction of their influences. The details of data analysis are provided in the Supplementary File 2.

As a first step for identification of stakeholders, we needed a panel of experts in the field of nutrition, who could help in identifying and later on help in the analysis of nutrition stakeholders in the MDGs era. For this purpose, an initial list of experts was developed using three criteria: (a) an individual working in community or clinical nutrition (b) at least a master degree in any of these fields: nutrition, food sciences, public health and nutrition or related fields (c) work experience of > 10 years (d) attendees of the NEAT ‘Stakeholders and the MDGs Period’ workshop series; and (e) affiliation to national professional nutrition networks. The details of these nutrition experts (n = 49) are provided in Table 1.

Table 1

Stakeholders identified Panel of Experts

In an effort to ascertain who were the stakeholders for child and maternal nutrition during the MDGs era, members of the panel of experts were provided a list of stakeholders and asked to indicate their level of agreement based on Freeman’s definition of a stakeholder, which is “any group or individual who can affect or is affected by the achievement of the organization’s objectives” (Freeman, 2010, p.46). After a preliminary discussion and identification process as mentioned above, a list of the potential stakeholders was prepared and presented to these experts for further ranking. The experts were asked, the next question: “in the given list of stakeholders, please rank the stakeholders according to their importance for child and maternal nutrition during the MDGs era”. The names of all stakeholders were provided in the form of one-by-one cross table form (Annexure-II). Ranking of stakeholders was done on a 5-point Likert scale (0–5; 0 = not important and 5 = extremely important). The questionnaire also provided separate space for any additional comments. The responses are recorded by category with number of selections made (Table 2).

Table 2

Responses to the question of ’Who is a stakeholder?’
	Strongly Agree (5)	Agree (4)	Neutral (3)	Disagree (2)	Strongly Disagree (1)	Average Likert Score
P_Gov	45	3	1	0	0	4.9
MoH	36	12	0	0	0	4.7
BoI	33	12	2	1	0	4.6
P&D	19	19	5	1	2	4.1
PWD	13	14	13	3	4	3.5
AgD	16	19	6	4	2	3.9
MoE	12	19	7	6	3	3.6
NGOs	30	10	2	6	1	4.3
Acad	21	14	3	4	5	3.9
MoST	11	26	4	5	2	3.8
Med	13	18	6	8	3	3.6
Livestock	10	6	30	2	1	3.45
Charity	10	5	29	2	3	3.35
Elites	12	7	23	3	4	3.41
Parliament	43	5	1	0	0	4.86
Political Parties	22	10	10	4	3	3.90
Provincial government (p_Gov), Planning and Development Department (P&D), Ministry of Health (MoH), Board of Investment (BoI), Population Welfare Department (PWD), Agriculture Department (AgD), Ministry of economics (MoE), Ministry of Science and Technology (MoST), Non-governmental Organizations (NGOs), and Media (Med).

Initially, a large number of actors were identified during the Net-Map activities; however, there were only a few actors which were strongly influential over the ‘child and maternal’ policy environment during the MDGs era. The representative stakeholders in Pakistan included departments from government, academia and research, and NGOs. Stakeholders identified include provincial government (p_Gov), Planning and Development Department (P&D), Ministry of Health (MoH), Board of Investment (BoI), Population Welfare Department (PWD), Agriculture Department (AgD), Ministry of economics (MoE), Ministry of Science and Technology (MoST), Non-governmental Organizations (NGOs), and Media.

Table 2

Stakeholders’ Network Analysis

Once the list of stakeholders was identified, further investigations from the identified stakeholders were carried out to better understand characteristics and perspectives of these stakeholders. For this purpose, a total of 302 questionnaires (Supplementary File 3) were sent out and 139 were returned, of which 108 were valid. This figure representing a response rate of 35.8%, which is normal as a typical response rate for a self-administered mail survey (Sammut et al., 2021). Furthermore, in similar studies, where expert opinions were surveyed through questionnaires, a small number of responses were also used: Bragagnolo and Geneletti (2012) surveyed a total of 12 experts; Polido et al. (2016) collected 16 filled questionnaires; and Peterson (2004) obtained 26 responses.

Provincial-level General Interaction for nutrition

“With whom did you have interaction for the general purposes regarding nutrition in the province?” This question was asked from the identified stakeholders. Respondents were also encouraged to list other actors who have a stake in the maternal and child nutrition (e.g., authorities, companies, groups, organizations) they had contact with, and their level of interaction with them.

Respondents introduced a wide range of actors and acknowledged interaction with them (Fig. 1). Most of the stakeholders have extensive relationships with others as shown by the thickness of the lines (edges) connecting them. The interactions were concentrated with P&D and MoH. P&D is central in the network of information and contact exchange, with close ties to all other stakeholder groups of government, academia, enterprise and NGOs. MoH is also central given its strong ties to other groups and P&D. It acts as health services provider and monitor in the process of health and nutritional care in Pakistan. As shown in Fig. 1, the thickness of the line shows the density of the relationship between the stakeholders; the blue lines show the positive relationship between the stakeholders, and the red lines show the negative relationship between the stakeholders.

Figure 1: Network of stakeholders

The graph shown in Fig. 1 consists of nodes (vertices) and edges (arcs, connections) connecting the nodes. The results of the analysis show that there are more connections between the variables indicating positive relationships. As can be seen in Fig. 1, the total number of connections between the variables is 95. The maximum number of connections for this network is 171. Accordingly, the degree of sparsity is 0.44. This value indicates a low degree of sparsity and shows that there is a high level of density in the network. For a network with 19 variables, this sparsity rate is sufficient. Based on this finding regarding the general structure of the network, it can be said that there is a relationship between the variables and that the variables interact with each other. In the study, four types of measures were used to determine the centrality levels of the products. They were degree, closeness, influence, and betweenness centrality measures.

The introductory information for networking to examine stakeholders’ relationships and importance within the scope of the study are shown in Table 3. Based on the findings given in Table 3, the general structure of the network, we conclude that there exists a relationship among various stakeholders. In addition, the stakeholders interacted with each other. Four measures were used to determine the centricity levels of the products: degree centrality, closeness centrality, influence centrality, and betweenness centrality. Supplementary File 4 are extensions of the results shown in Fig. 1, presenting the centrality levels of stakeholders. The clustering coefficient measures local cohesiveness and is defined as the fraction of connected neighbors for any vertex. These coefficients reveal how strongly the variables are connected with their neighbors. Clustering coefficients for the variables are given in Supplementary Files 5

Table 3

General Structure of the Network
Summary of Network
Number of nodes		Number of non-zero edges		Sparsity
16		48 / 120		0.6

Table 3

The partial deciphering of structural and functional networks was measured by the tendency of nodes/factors to cluster together with Barrat, Onnela, Watts and Strogatz (WS), and Zhang clustering coefficients. The clustering coefficient indicates the strength of the connection. In the SMC group, the highest clustering coefficient values were for AgD (Barrat = 1.468), whereas the lowest was for Poli_Part (Onnela = − 1.889 (Supplementary File 5).

Provincial-level interaction network

“With whom did you have interactions regarding child and mother nutrition activities during the MDGs period?” This question was asked to develop provincial-level interaction network specifically for child and mother nutrition. The interaction network mapped in Fig. 2 shows nodes (actors) as circles, and ties between them are represented as lines (edges). We used the in-degree centrality measure, where the size of the node indicates in-degree centrality, while the thickness of edges (ties) represents how frequently they interact. The frequencies of interaction were used as weights. The key actors across the network were the P&D, members Parliament, MoH, and NGOs. Structurally, the network was more centralized with a few main nodes (actors) with higher betweenness centrality; these nodes can be referred to as broker nodes as they connect other nodes to the network at the subdistrict level. The interaction network was the largest of the three networks. The related statistics for interaction network are shown in Supplementary File 6.

Figure 2: Interaction network

Provincial-level information-seeking network

Figure 3 shows the information-seeking network. Actors were asked to identify resources for implementation within the network, including clarification of guidelines, advice around planning nutrition MDGs enforcement drives and training activities. During the survey, several participants mentioned that they focused on their specific assignment and did not seek information about program implementation. This information was mostly sought by mid-level managerial staff responsible for providing guidance to the field-level implementers.

The information-seeking map reveals a similar pattern. The actors from NGOs, P&D, Provincial government and MoH remain central in terms of providing information on the program. The most central nodes in the information-seeking map were almost the same as in the interaction map. The related statistics for information network are shown in Supplementary File 7.

Figure 3: Information-Seeking Network at Provincial Level.

Provincial-level decision-making network

Figure 4 shows the decision-making network. The respondents required inputs and approvals to make decisions regarding financial and program planning. Very few actors were identified as having such a decision-making role. We observed a similar centralization pattern for decision-making, which corresponds to higher network centralization, where the provincial government, P&D, MoH, and parliament were the key in providing decision-making support to the network such as disbursing funds. The related statistics for decision-making network in Supplementary File 8.

Figure 4: Decision-Making network at Provincial Level

This study was designed to identify stakeholders who acted their role in the area of child and maternal nutrition during the MDGs era in Pakistan. Although the MDGs, in general, and those related to child and maternal nutrition, in particular, were not successful in the eradication of child and maternal malnutrition problem, the documentation of the approach undertaken in this study may provide guidance to others interested in using stakeholder analysis in designing of new approaches to health care delivery and financing. It is hoped that the SDGs and other partners in Pakistan will use this methodology in other health and development work. Health ministries, in turn, will apply this experience to other activities of this nature in other provinces. We hope that the overall result of this chain of experience will benefit the people of India and other parts of the developing world, through improved design of new approaches to the delivery of health services to underserved populations.

We mapped, illustrated and studied the implementation network of child and maternal nutrition programs across in Pakistan. The actors most frequently engaged in the program were from the departments of health, P&D, and provincial government. Government organizations (MoH, P&D etc) remained the lead organization, with high centralization and key actors, in all the three interaction, information-seeking and decision-making networks. Provincial-level health department leads relied on state teams for information support. Across the three network maps encompassing interaction, information and decision-making, a similar pattern emerged i.e., the dominant and more centralized role of the key government organizations. The more centralized network, had the potential for rapid diffusion of information, characterized by high reachability to people in the network who can act as broadcasters. The centralized networks also share more power and influence with the central actors (Valente, 2010). Thus, in such a case, if the central actors are active and embrace the idea of networking and working across departments, diffusion and coordination can be more effective. This indicates that the identified person or node plays a significant part in allowing information to pass from one part of the network to the other. We found they acted as bridges or brokers to the main network as they facilitate the flow of information and resources within the groups of people separated from the main network (Long et al., 2013). These actors can maximize a network’s benefits by reaching actors and people who are difficult to reach (Valente et al., 2010). Engagement and participation from these brokered nodes can facilitate or inhibit joint action of the actors within the network.

Previous studies have shown that actors in a highly centralized network, where most of the interaction is with one or two key actors, completed tasks more easily and effectively (Shaw 1971). This may be related to the explanation that, in a dispersed network, establishing chains of communication require more intensive efforts to involve, establish and maintain the links (Nadri et al., 2002). A dense and reciprocal communication network can lead to higher rapport, cohesion and trust (Hinds and McGrath, 2006) and, hence, facilitate coordination to improve performance. This can be beneficial in a complex multisectoral policy environment, where the dynamic setting needs effective, frequent and open channels of communication between members of the network. As the central tenet of multisectoral collaboration is relationship building, these dense and open information channels can facilitate the mutual understanding, trust and accountability needed to achieve shared goals and opens up mechanisms to provide feedback on processes, and potentially the adaptation required to identify and achieve emergent needs (Kuruvilla et al., 2018; de Leeuw 2017). Such observed patterns of centralization, density and reciprocity can help us understand the structural differences we observed in the two districts, enabling the identification of key nodes or actors that can be effective and robust channels of communication to provide scope for better coordination.

In Pakistan, nutrition programs at national and provincial levels primarily nests within the department of health. Both levels contribute to the program’s financial and human resources. However, to promote coordination across all departments, the head of provincial administration known as the Chief Minister (CM) chairs the provincial-level coordination committee and serves as chair for the overall program to provide guidance, ensure monitoring and conduct performance review. Hence, in the decision-making network, we observe that the health department does rely on the P&D department to take programmatic and planning decisions. Thus, in practice, the health department leads and coordinates the program and takes all operational decisions (Graddy and Chins, 2006), but there is a need for cooperation and coordination from other network members to reach their mutual goals. In both districts, we noted that the key health department actors had to make multiple connections with members of different departments.

Implications for research, practice, and policy

As a means of mapping and exploring implementation of multisectoral coordination, SNA provides a visual structural map of district-level implementation network. A diagnosis in the form of a network map can inform discussions about how different networks can be strengthened. The results of SNA provide more explicit descriptions or ‘mapping’ of key actors, relationships and decision-making, offering insights into health system leaders regarding effective implementation. In this study, both districts relied on key central players for the diffusion of innovation, knowledge and network interventions (Sikkema et al., 2000). We identified stakeholders who acted as crucial role in coordination and building linkages between different groups in the system (Burt, 2002; Newman and Dale, 2005). The SNA approach can also provide a pragmatic network diagnosis to facilitate the ‘rewiring’ of networks, where decision-makers might consider intervening to optimize relationships or connections; for instance, to ‘activate’ key actors who could engage with a greater role in decision-making to enhance the potential of the network (Blanchet et al., 2012). Network metrics can provide insights into the relationships, positions, structure and strength of a network, so as to diagnose weaker relations/ties which have not been fully utilized. Moreover, SNA can be used as a learning instrument by state and district stakeholders to study these districts as ‘learning sites’ for formalized, continuous research and partnerships to promote continuous learning and create an overlap between policy development and implementation. Simultaneously, this can also provide the scope for the improvement of everyday practices at local level and to promote cooperation and coordination for the program by sharing the visual network diagrams that build awareness and invite different departmental partnerships.

SNA can be of value during pilot or developmental, implementation and evaluation phase. During the early phases of intervention, it can enable understanding of complex implementation, by deciphering the networks of multiple professionals and associated sectors. Using the mapping exercise, it can help design strategies considering the social context of program members, its delivery, determining the appropriate methods and channels of communication needs and identify particular change agents and opinion leaders to widen the outreach of network. During the implementation and evaluation phases, when coupled with a mixed methods design, SNA can help analyze network as a whole system and at individual organizational level. Thus, enabling identification of points of influence to create and improve selected strategies for a group or organization. Therefore, SNA as a tool can be adopted to diagnose, map, monitor and intervene in complex multisectoral health programs.

As a whole, 16 different stakeholders were identified who acted a role for child and maternal nutrition during the MDGs era. Based on findings from SNA, Planning and development (P&D) was the most important stakeholder identified, followed by MoH, and NGOs. In case of child and maternal nutrition related policies in Pakistan, a lack of cooperation might have hindered a proper implementation of the MDGs plans. Indeed, many stakeholders tend to consider child and maternal nutrition merely as a priority of the MoH. The identified stakeholders showed different degrees of interest towards child and maternal nutrition policy. Their differing motivation can explain this; for example, interest by the Charity and Pol_party was found to be low despite being important organizations that help poor people. On the other hand, stakeholders rated high for position can have a high impact on other stakeholders.

LIMITATIONS

The study also has several limitations. Out of resource constraints, we mapped the networks at a single point in time. While such a snapshot is useful, the networks are indeed dynamic and studying them over time is important to understand how networks evolve and what shapes these networks. Similarly, while the quantitative approach to SNA that depicts positions and transactions across actors is useful, it falls short of capturing the qualitative nature of these relationships. We explored these qualitative aspects in a larger study, the findings from which are reported in a separate paper. We had high and comparable response rates in the two districts we studied. Yet, we did miss out on some of the actors, whose positions we depicted in the networks but had no data on how they relate to others in the network. The non-response in our study was mainly due to logistical reasons, and the missing data were not concentrated in any specific cadre of officers. While such data could have enhanced our understanding of the networks, it is unlikely that it would have changed our findings substantially. Finally, while we find differences in the network features across the two districts, and such differences could be linked to the differences in the program implementation in these districts, our study was neither aimed at nor designed to explain this association. Future research could potentially explore how network features could explain such program implementation scenarios.

Ethics approval and consent to participate

All participants provided written consents. The Graduate Study Committee (GSC) and the Advanced Study Research Board (ASRB) approved the study design and ethics clearance.

Consent for publication

All authors approved the manuscript for publication

Availability of data and materials

Data can be made available on reasonable request to the corresponding author

Competing interests

The authors have no relevant financial or non-financial interests to disclose.

Funding

No formal funding was available to conduct the study except partial funding to cover the expenses incurred for publication

Authors’ contribution

AJ and IA initiated and designed the study and AJ collected the field data under supervision of IA, SSS and AMA helped in the statistical analysis and the write-up of the first draft of the manuscript. All authors contributed to the critical revision and editing of the manuscript. IA and SSS supervised the study and the guarantor.

Acknowledgments

The authors extend their appreciation to the Researchers Supporting Project number (RSP2023R502), King Saud University, Riyadh, Saudi Arabia.

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Stakeholders’ Identification and Understanding of the Multisectoral Governance for Child and Maternal Nutrition During the MDGs Period – A Stakeholders’ Network Analysis of Khyber Pakhtunkhwa Province of Pakistan

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Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

INTRODUCTION

METHODOLOGY

The Case: The Millenium Development Goals (MDGs)

Study Design

Stakeholders Identification

Panel of Experts

Orientation Workshop

Focus Group Discussion

Data Collection from Panel of Experts

Data Collection from Stakeholders

Data Analysis

RESULTS

Stakeholders identified Panel of Experts

Stakeholders’ Network Analysis

Provincial-level General Interaction for nutrition

Provincial-level interaction network

Provincial-level information-seeking network

Provincial-level decision-making network

DISCUSSION

Implications for research, practice, and policy

CONCLUSION

LIMITATIONS

Declarations

References

Supplementary Files

Status:

Version 1