RESEARCH ARTICLE Open Access

Understanding the role of intersectoralconvergence in the delivery of essentialmaternal and child nutrition interventionsin Odisha, India: a qualitative studySunny S. Kim1*, Rasmi Avula2, Rajani Ved3, Neha Kohli2, Kavita Singh2, Mara van den Bold1, Suneetha Kadiyala4

and Purnima Menon2

Abstract

Background: Convergence of sectoral programs is important for scaling up essential maternal and child health andnutrition interventions. In India, these interventions are implemented by two government programs – IntegratedChild Development Services (ICDS) and National Rural Health Mission (NRHM). These programs are designed towork together, but there is limited understanding of the nature and extent of coordination in place and needed atthe various administrative levels. Our study examined how intersectoral convergence in nutrition programming isoperationalized between ICDS and NRHM from the state to village levels in Odisha, and the factors influencingconvergence in policy implementation and service delivery.

Methods: Semi-structured interviews were conducted with state-level stakeholders (n = 12), district (n = 19) andblock officials (n = 66), and frontline workers (FLWs, n = 48). Systematic coding and content analysis of transcriptswere undertaken to elucidate themes and patterns related to the degree and mechanisms of convergence, types ofactions/services, and facilitators and barriers.

Results: Close collaboration at state level was observed in developing guidelines, planning, and reviewingprograms, facilitated by a shared motivation and recognized leadership for coordination. However, the healthdepartment was perceived to drive the agenda, and different priorities and little data sharing presented challenges.At the district level, there were joint planning and review meetings, trainings, and data sharing, but poorparticipation in the intersectoral meetings and limited supervision. While the block level is the hub for planning andsupervision, cooperation is limited by the lack of guidelines for coordination, heavy workload, inadequate resources,and poor communication. Strong collaboration among FLWs was facilitated by close interpersonal communicationand mutual understanding of roles and responsibilities.

Conclusions: Congruent or shared priorities and regularity of actions between sectors across all levels willlikely improve the quality of coordination, and clear roles and leadership and accountability are imperative.As convergence is a means to achieving effective coverage and delivery of services for improved maternaland child health and nutrition, focus should be on delivering all the essential services to the mother-childdyads through mechanisms that facilitate a continuum of care approach, rather than sectorally-driven,service-specific delivery processes.

Keywords: Collaboration, Coordination, Intersectoral convergence, Nutrition interventions, India

* Correspondence: sunny.kim@cgiar.org1International Food Policy Research Institute, 2033 K Street, Washington, D.C.20006, NW, USAFull list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Kim et al. BMC Public Health (2017) 17:161 DOI 10.1186/s12889-017-4088-z

BackgroundDespite India’s impressive economic growth, undernutri-tion is widespread in the country amongst all ages.Nearly 30% of Indian children under 5 years are under-weight, 39% are stunted, 15% are wasted [1], and over70% are anemic [2]. More than half of all women ofreproductive age are anemic [2]; yet, only 31% of womenreceived any iron and folic acid supplements [1]. Lessthan one-third of the children aged 6–23 months re-ceived adequate complementary feeding, i.e., the mini-mum number of food groups (20%) or the minimummeal frequency (36%) [1]. Interstate variability of healthand nutrition indicators also exist [3], with disparities inhealth systems between and within states [4], calling forthe need to address delivery gaps and increase coverageof essential interventions to reach all target populations.Increasing the coverage of the nutrition interventions

already in place in countries has been suggested to mark-edly reduce maternal and child undernutrition [5]. Theseinclude interventions such as nutritional counseling andfood and micronutrient supplementation for women andyoung children at different life stages - before and duringpregnancy, newborn to infancy period, and early child-hood. Despite a strong consensus on what needs to bedone, less is known about how to operationalize the mixof actions required for scaling up, wherein convergence ofsectoral programs plays an important role [6].Recent studies have described processes of multisectoral

coordination in various countries, identifying challengesand key factors for successful coordination. A five-countrystudy showed that differences in institutional mandateslead to lack of sound coordination mechanisms, anddissent among mid-level actors in formulating and agree-ing upon different intervention strategies are commonbarriers; leadership, defined roles and responsibilities, andindividual and strategic capacity are important to over-come such challenges [7]. A qualitative institutional studyof national policy-making in four Sub-Saharan Africancountries observed that policies and agencies that havecross-sectoral scope do not usually fit the sectoral patternof resource allocation, thus the ministries may view them-selves as in competition with each other [8]. High-levelpolitical support and processes that bring together a widevariety of stakeholders [9] as well as shared vision, cap-acity strengthening, joint accountability, and supervision[10] are critical for multisectoral convergence. While mul-tisectoral coordination and policies are generally viewedas valuable and important, subsequent actions and imple-mentation of such policies require clearly defined methodsand mechanisms at each administrative and operationallevel, particularly for integrative processes to be carriedout in service delivery. There is, however, scarce literatureon how convergence is operationalized and the mecha-nisms required to ensure effective service delivery.

In India, two ministries - the Ministry of Health andFamily Welfare (MoHFW) and the Ministry of Womenand Child Development (MoWCD), share responsibilityfor the implementation of all the essential nutritioninterventions [11, 12]. Two programs, the National RuralHealth Mission (NRHM), or the National Health Mis-sion under the MoHFW, and the Integrated ChildDevelopment Services (ICDS) under MoWCD, aim toimprove maternal and child nutrition and health,through services provided by their respective cadres offrontline workers (FLWs), who are expected to worktogether to deliver the interventions. Integrated govern-ance structures between the health and nutrition depart-ments were documented to be important for improvedcommunity participation, accountability of the publicsystem, and service delivery [13]. However, operationalinconsistencies exist between ICDS and NRHM, specific-ally in the management of severe malnutrition [14]. Inthe state of Odisha, political will, committed policymakers, and fiscal space spurred the health system toinnovate and expand health service provision, reformhealth resource management and development, andintroduce initiatives to achieve greater equity among thepoorest and disadvantaged population groups [15]. Ourprevious document review [11] also revealed that na-tional and state (Madhya Pradesh and Odisha) policyand program documents from the health and WCDsectors demonstrate common recognition of the import-ance of nutrition and consensus regarding the inputsnecessary to address child undernutrition, but there aregaps in providing operational guidelines [16].In this paper, we examine how intersectoral conver-

gence in policymaking and programming is operational-ized between the health and ICDS programs from thestate to village levels in Odisha, one of the pooreststates in India, where steps have been taken to enhancecoordination between the NRHM and ICDS, particu-larly through inter-departmental coordination meetingsand focus on intra-ministerial capacity strengthening[12, 17]. We aim to provide insights into how and whyintersectoral convergence does or does not take placeat different levels of policy implementation and servicedelivery, and the elements that are needed to effectivelydo so.

Conceptual framework and definitions ofconvergenceFrameworks on integration from organizational theoryand other fields concur that degrees of integration existas a continuum or process of evolution that modify overtime [18–20]. Terms such as integration, collaboration,coordination, and cooperation are used interchangeablyor defined differently to describe stages along thecontinuum [9, 18]. In this paper, we use the term

Kim et al. BMC Public Health (2017) 17:161 Page 2 of 12

“convergence” generally, as being synonymous with theoverall continuum of integration. According to Axelssonand Axelsson [21], coordination, cooperation, and col-laboration are usually placed somewhere in the middleof this continuum, between consultation and consolida-tion [of organizations]. Adapted from previous works onmultisectoral approaches in nutrition by Garrett andNatalicchio and others [9, 22], we use the followingworking definitions for integration, collaboration, coord-ination, and cooperation in this paper (Fig. 1).Integration: the highest-order of relationships with

shared structures or merged sectoral remits. Collabor-ation: enhancing one another’s capacity and sharing ofsome resources or personnel to facilitate strategic jointplanning and action on certain issues, while maintainingsectoral remits. Coordination: altering one’s activities toachieve a common purpose; interactions are often un-structured or based on a loose goal-oriented agreementand working together on certain issues while maintain-ing sectoral remits. Cooperation: sharing or exchanginginformation or resources only; continuing to work inseparate sectors with little communication or strategicplanning on issues.

MethodsThis study is part of a larger mixed-method operationalresearch on intersectoral convergence and delivery ofand exposure to essential nutrition interventions inOdisha state [23]. This paper draws primarily on resultsof the qualitative study conducted between July andAugust 2013 and data based on semi-structured inter-views with stakeholders involved with the health and

ICDS programs, as well as from other sectors (i.e.,non-governmental organizations, multilateral agencies,and academia), at the state, district, block, and front-line levels.

Sampling and sample sizeMaximum variation sampling using a combination ofpurposive and random selection at different levels wasapplied to capture heterogeneity in service deliverycontexts [24]. Three districts were purposively selectedfrom among the 30 total districts in the state, to attainvariations between districts. Existing district-level sur-vey data [25, 26] were used to construct a set of criteriapertaining to service coverage and household factors(e.g., coverage of immunization and vitamin A supple-mentation, three or more antenatal care visits, andinstitutional delivery; access to toilet and electricity;and type of cooking fuel), and changes in these indica-tors between two survey rounds were examined. Alldistricts were grouped into three categories: better per-forming districts (i.e., those with positive change overtime), average performing districts (i.e., no change), andpoorly performing districts (i.e., those with negativechange). Then, in a meeting organized by the re-searchers to explain the study and conduct a jointprocess of district selection, state-level officials fromthe Department of Health and Family Welfare (DHFW)and the Department of Women and Child Development(DWCD) randomly drew the name of one district fromeach category: District 1 as better performing, District2 as average performing, and District 3 as a poorlyperforming district.

Fig. 1 Degrees of convergence and their definitions

Kim et al. BMC Public Health (2017) 17:161 Page 3 of 12

In each district, we randomly selected four blocks(subdivision or town) (n = 12) and two villages from twoof the blocks (n = 12) to study service delivery by threedifferent cadres of FLWs within each village. In a village,there is usually one Anganwadi Center (AWC) with anAnganwadi Worker (AWW). The AWW is responsiblefor the AWC and delivers health and nutrition servicesand preschool education under the ICDS program; sheis an honorary female worker selected from the localcommunity. The AWW in each village, along with theAccredited Social Health Activist (ASHA) and the Auxil-iary Nurse Midwife (ANM) working in the same areawere interviewed in this study. The ASHA is a femalehealth worker, selected from the community and servesthe role of community mobilizer to access services andcommunity-level care provider. The ANM is a multipur-pose female health worker who provides a package ofpreventive and curative services largely for women andchildren, at a sub-center that covers a population of3,000–5,000 for rural areas, which is approximately 6–8villages, and through outreach services. We conducted atotal of 145 semi-structured interviews with the threetypes of FLWs, as well as with block, district, and state-level staff of the ICDS and health departments and fromother sectors (Table 1). Interview guides are shown inAdditional files 1, 2, 3, and 4.Written informed consent was obtained from the study

participants prior to interview. This study was approvedby the IFPRI Institutional Review Board and Odisha’sDepartment of Women and Child Development and De-partment of Health and Family Welfare in India.

Data analysisInterviews were conducted in the local language (Odiya)and audio-recorded, then transcribed verbatim andtranslated into English. Extensive field notes were takenonly for state-level interviews. We used a deductiveapproach to data analysis, applying pattern, theme, andcontent analysis for data reduction and to elucidate anysimilarities and differences and patterns of coordinationbetween the ICDS and health programs for the inter-ventions of interest [24]. A systematic process of dataorganization and analysis was led by the first author.The first level of analysis involved data coding usingNVivo, a qualitative data software for computer-assisteddata management and analysis. An a priori code list wasprepared based on the study protocol and interviewguides and tested using an initial set of transcripts.Then, a team of four coders (two coders were involvedfrom the training of interviewers and data qualitymonitoring to summarizing the data) were trained tostandardize the coding process, inter-coder reliabilitywas tested, and the code list was reviewed and revisedby the coding team and senior researchers. Bimonthly/monthly Skype calls were held to review coded data, anycoding issues, and updates to the code list. Outputs ofcoded results using queries (on types of services, co-ordination mechanisms, facilitators and barriers) weregenerated by transcripts pooled at the district, block,and village levels. Then, second-level coding and sum-marizing for emergent themes and patterns were con-ducted. Among the various nutrition interventions thatinvolve both the DHFW and DWCD, we present resultson five intervention or service types (including com-bined interventions that are delivered simultaneously) toillustrate convergence in implementation: antenatal care(ANC) services, including maternal iron and folic acid(IFA) supplementation, child immunization and vitaminA supplementation, pediatric IFA supplementation, in-fant and young child feeding (IYCF) counseling/educa-tion, and growth monitoring and referrals for severeacute malnutrition. There were several driving questionsfor data analysis: To what extent do actors work to-gether (degree of convergence), and how (mechanismsof convergence); on what do they work together (typesof actions or services); and why (facilitators and bar-riers)? Also, are there any similarities or differencesamong the districts, blocks, or villages?

ResultsIn our study, we found that convergence is operational-ized to a different degree at the various levels of thegovernment health and ICDS systems, i.e. from state todistrict, block and frontline levels. This may be expected,given the varied types of functions and relationshipsrequired at the different administrative levels. There are

Table 1 Study sample size by administrative level and sector

Level Health ICDS Other sectors

State 4 1 7 (NGO, multilateralagency, academia)

District 11 6 2 (District collectora,GKS/VHSCb)

Block 23 32 11 (Block developmentofficerc)

Village/Frontline 24 (ANM, ASHA) 12 (AWW) 12 (PRId)

Total: 62 51 32aDistrict collector is the chief administrative and revenue officer, appointed bythe state governmentbGaon Kalyan Samiti/Village Health and Sanitation Committee (GKS/VHSC) isthe local management body instituted by the National Rural Health Mission,comprised of village representatives and headed by a village ward member.GKS is responsible for community-based planning and implementation ofhealth and related activities, and creating awareness and promoting publichealth and sanitation activities. It receives an untied grant of Rs. 10,000annually (approximately USD 160) to ensure that such activities are carried outcBlock development officer is responsible for monitoring the implementationof all programs related to block planning and developmentdPanchayai Raj Institution (PRI) is the oldest system of local government, themost basic administrative unit or assembly of community representatives, thatis responsible for all matters of community development

Kim et al. BMC Public Health (2017) 17:161 Page 4 of 12

also key mechanisms through which actors interact orwork together and factors that influence interactions inthese mechanisms, which differ by levels (Table 2).These elements are elaborated in context in the subse-quent sections of results.

Collaboration in setting policies and program guidelinesat the state levelStunting, wasting, and anemia were identified as themain nutritional problems in Odisha by nearly all state-level respondents. These problems were considered tobe further exacerbated by challenges in the delivery anduse of essential health and nutrition services, such aslow registration of pregnant women and young children,inadequate access to food due to gaps in the supplementdistribution, poor exclusive breastfeeding and comple-mentary feeding practices due to inadequate counseling,and lack of adequate sanitation and hygiene. The statehas taken various actions involving intersectoral collabor-ation in response to these challenges, including adaptingthe 2009 national guidelines for Village Health and Nutri-tion Days (VHND) (a monthly outreach program held atthe AWC for integrated health and nutrition services forpregnant and lactating women, adolescent girls, and chil-dren under five years of age, and managed by all threeFLWs) to state needs and naming it Mamata Divas. In2011, the state government initiated the MAMATA pro-gram (a conditional cash transfer scheme that providespregnant and lactating women with monetary support toimprove nutrition and health-seeking behaviors that re-quires coordination among all three FLWs). Furthermore,

guideline development for community-based managementof severe acute malnutrition, as well as training of officialsand service providers on the importance of and interven-tions for the “first 1,000 days” has been a joint effortbetween Odisha’s DHFW and DWCD.Respondents concurred that improving maternal and

child health and nutrition across the state is a sharedgoal and the joint responsibility of DHFW and DWCD,in addition to other departments. Several mechanismswere in place to facilitate regular coordination and colla-boration, such as monthly meetings convened by (and per-ceived as dominated by) Health, and biannual projectmeetings, held to plan for specific programs or activitiesand convened by Health but chaired by the DevelopmentCommissioner to facilitate horizontal collaboration. Otherexamples included the cross-sectoral coordination commit-tee for NRHM’s urban health program and the frequentcross-sectoral collaboration on guidelines for specific initia-tives. Within these different meetings and activities, well-positioned leadership (or champions for the initiatives orissues) was seen as a key facilitator of convergence, particu-larly leaders involved not just in the line departments butwho transcended departmental boundaries such as theDevelopment Commissioner and the Chief Secretary.Despite these successes, however, challenges to con-

vergent actions remain. For example, despite the sharedgoal to reduce infant and maternal mortality, DHFWfocuses on antenatal care services and DWCD contrib-utes to improving maternal nutrition by providing foodsupplements during pregnancy, and there is little datasharing across these actions to demonstrate process

Table 2 Summary of roles, degree and key mechanisms of convergence, and salient factors by different administrative levels

Level Main role/action Convergence degree andkey mechanism

Salient factor: (+) facilitatorsand (−) barriers

State -Establish state-wide programsand initiatives-Provide guidelines-Monitor and assess data-Allocate resources

Collaboration:-Developing guidelines-Meetings to discuss topics and planand review programs and initiatives

(+) Shared motivation/goals(+) Recognized leadership for coordination(−) Different priority actions(−) Little data sharing(−) Lack of accountability and

feedback mechanisms

District -Prioritize services and activities-Plan annually/monthly-Monitor data reports-Allocate resources-Train block staff and FLWs

Coordination:-Planning and review meetings-Data sharing-Joint training sessions

(+) Clear leadership(+) Mutual understanding of roles(−) Narrow priority topics related to

health and disease(−) Low participation/poor attendance(−) Limited supervision

Block -Plan annually/monthly-Gather data records and registersand report-Supervise and feedback-Train/orient FLWs

Cooperation:-Planning and supervision

(+) Shared motivation(−) Lack of direction or guidelines(−) Heavy workload(−) Inadequate resources(−) Poor communication

Village/Frontline -Schedule and implement servicesand activities-Record/register and report-Build rapport and demand creationin community

Collaboration:-Delivery of services, throughVHND and home visits

(+) Shared motivation(+) Close inter-personal communication

and vicinity(+) Understanding of roles

and responsibilities(−) Unbalanced incentives

Kim et al. BMC Public Health (2017) 17:161 Page 5 of 12

towards the goal, even where common indicators exist.This has resulted in discrepancies in data presentationsand limitations on the extent to which there is collabor-ation on program monitoring. Although policies andplatforms for integrated service delivery have been de-veloped, there is little evaluation and resource allocationto understand the performance of these strategies. Thereis also limited supervision and lack of accountabilitymechanisms for the implementation process from thestate to lower levels, which leads to repercussions (suchas irregular meetings and poor attendance) as discussedin following results.

Coordination in planning, training, and data sharing atthe district levelAt the district level, DHFW and DWCD staff clearlyidentified their roles and responsibilities as applyingstate guidelines for programs, prioritizing services oractivities based on their contexts, planning, monitoringdata, allocating resources, and training block-level staff.District level officials primarily coordinated across sec-tors through review meetings and training sessions forlocal staff on specific common priority actions. However,the extent and nature of coordination between DHFWand DWCD at the district level was dependent mainlyon the specific intervention types and narrow outcomesof interest in common to the individual departments.There was good coordination in implementing the

immunization program in all three districts. The depart-ments often came together to prepare annual or monthlyaction plans, as a district program officer (ICDS) ex-plained: “There is an immunization plan for the entiredistrict, which is the joint action plan of health andICDS departments. It is prepared with coordination be-tween both the departments… so that service is providedin a better way, coverage is expanded, coordination ismaintained, and there are no missed cases.” Districtcoordination meetings were also held for special programssuch as pulse polio and vitamin A supplementationcampaigns. Additionally, the departments coordinated fortraining about IYCF, use of maternal and child (health)protection cards, and MAMATA program guidelines.Coordination at the district level was reported to be drivenby directives issued from the state.In each district, monthly review meetings are convened

by the chief administrative official, i.e., the state-appointeddistrict collector. During these meetings, ICDS and healthstaff reported their activities, reviewed outcomes, andassessed any gaps. The topics discussed most often wereinfant and maternal mortality, immunization, VHND,diseases and other health topics usually decided by healthstaff. While most of the district-level respondents consid-ered these meetings as necessary, poor participation orlow attendance were identified as common problems:

“Attending the coordination meetings should be regular. If[staff] regularly participate in those meetings, we will knowthe gaps and take steps… but they are not regular, so weface some difficulties.” (District community mobilizer,Health). However, little accountability and consequencewere seen for participation in meetings. Data sharing alsotakes place at the district level, but a narrow set of indica-tors was identified across all three districts, particularlyinfant and maternal mortality, verbal autopsy, institutionaldelivery, and immunization.Supervision was reported to be limited, and when it

does take place, it focused mostly on immunization andVHNDs or addressing problems or emergency cases.Lack of time was named as the main barrier to conduct-ing joint supervision. Only in District 2, joint supervis-ory visits and coordination of supervisory activities wasfrequently reported, as described by one district healthofficial: “When I go to an Anganwadi centre, I alwayscheck the registers of that Anganwadi, weights of thechildren, food distribution… I also monitor the instru-ments, logistics, infant registry, and birth registry. Whenthey [ICDS officials] visit, they look into both ICDS andhealth activities, and whenever I visit, I also check bothactivities.”

Limited cooperation for supervision at the block levelThe main responsibilities at the block level includedplanning activities, monitoring and reporting data, andsupervision. “Both departments [DHFW and DWCD] arevery much associated with each other because they havethe same objectives.” (Block program manager, Health).However, most block-level respondents expressed lim-ited cooperation overall. “Each person is doing his or herresponsibilities very well. There is no need of any help[from each other]. We are aware about [each other’s]programs, but we are doing our work, and they are doingtheirs” (Lady supervisor, ICDS). Block-level respondentspointed to the lack of direction or guidelines for inter-sectoral coordination from higher levels, thus it wasunclear how they were expected to work together.Staff worked across sectors primarily for meetings and

supervision. Separate ICDS and health sector meetingsare held regularly and attended by respective block-leveland field staff. Although staff from the other departmentare usually invited to participate at the sector meetings,to learn about planned activities and any outcomes andgaps, cross-sectoral participation was low and irregular.The lack of time or heavy workload, schedule conflicts,lack of physical space to conduct joint meetings, andpoor communication were named as barriers. “They[health staff] do not attend ours [sector meetings], andwe do not attend their meetings. Because it is a fixeddate, when they do not have a meeting and have time,they attend our meeting. And when we don’t have any,

Kim et al. BMC Public Health (2017) 17:161 Page 6 of 12

we attend their meeting,” explained a child developmentproject officer (ICDS). One public health extension offi-cer shared, “I have the letter from ICDS, that they askedme to come on a particular date, and I made plans andsent it to the CDPO [child development project officer]…but that day there was no such meeting, so my staffreturned and complained that you sent us for a meetingbut there was no meeting… they make such changeswithout any notice. We do not know the date of theirplans.” Similar to the district level, the topics discussedwere limited to immunization and infant and maternalmortality, as data for these topics (e.g., tally of birth anddeath cases) are collected by both sectors.Extent of coordination or joint supervision visits and fre-

quency of supervision varied only slightly among blocks indifferent districts. Despite expressing the lack of guidelinesfor coordination in supervision, block staff usually plannedtogether to cover supervision for immunization andVHND. Joint supervision involving staff from both depart-ments was more frequently reported in Districts 1 and 2,particularly for verification of maternal or infant deathsand in case of emergencies or field problems. However,lack of time or heavy workload and insufficient resources(i.e., personnel and vehicle for transport, particularly inDistrict 3) were repeated as barriers to coordination.“There is good relationship, but due to paper work andother work, we cannot attend their meetings or supervision.”(CDPO). In various blocks, there were reports of vacantposts or insufficient staff allocation and vehicles for con-ducting supervision. A public health extension officer ex-plained, “I supervise 25 ANMs in 25 sub-centers… in theblock, there are 4 supervisors for 8 sectors, not enough, and100 plus AWWs and 60 ASHAs in the villages.” Amongthe administrative levels, most gaps and limitations in con-vergence appeared at the block level.

Close collaboration for service delivery in the frontlinesFLW functions involved planning and implementing ser-vices and activities, maintaining data records, submittingreports, and building rapport with communities, particu-larly to create demand for services. All of the FLWs acrossthe districts described working together, facilitated bytheir close vicinity (AWWs and ASHAs usually live withinthe same village) and interpersonal relationship.With overlapping functions and activities, the three

cadres of FLWs work together to deliver nearly all of theessential nutrition interventions. We present findings onFLW roles and factors influencing the provision of fivespecific interventions to illustrate the extent of conver-gence among FLWs (Table 3).The VHND provides a common platform for FLWs to

work together in delivering the ICDS and health servicessuch as ANC, referrals, growth monitoring, and counsel-ing. One AWW stated, “On VHND, ASHA calls all the

children, ANM does checkup of the pregnant ladies, andI weigh young girls and women. We give IFA syrup tochildren. ANM worker checks the health of the 3 to5 years old children”. In all three districts, coordinationamong FLWs varied depending on the type of servicesdelivered. There was a clear understanding of roles andresponsibilities and good coordination among the FLWsfor implementing ANC, immunization and vitamin Asupplementation. One ANM stated, “My duty is tocheck the pregnant women and advise them about theirdiet and give them IFA and TT [tetanous toxoid]. “Ifthe pregnant woman does not come (to VHND) with herchild, then the ASHA worker goes to call and bringsher.” In parallel with these findings, exposure to the in-terventions usually provided during VHND, particularlyANC, immunization and vitamin A supplementation,and growth monitoring across the three districts weregenerally over 50% [23] (Table 3).On the contrary, FLWs across the three districts dem-

onstrated varying levels of understanding of their rolesin providing IYCF counseling and pediatric IFA supple-mentation. For instance, in District 2, one ANM statedthat AWW, ANM and ASHA plan together for counsel-ing over the phone and jointly conduct home visits. InDistrict 1, an ASHA informed that AWW accompaniesher to home visits whenever she calls her, and ANM alsocomes along only when it is required, such as in cases ofan underweight child. In District 3, one ANM stated thatshe plans for home visits with AWW, and another ANMsaid that she coordinates the action plan for home visitswith ASHA and AWW. While there appears to beoverall coordination to deliver the service, there isambiguity on who leads the counseling and how it isorganized. Similarly in the patterns of exposure, lessthan one-third of beneficiaries had been exposed tothese two interventions across the three districts[23] (Table 3).In general, there is a common understanding among

the FLWs that they need each other to effectively deliverservices. One AWW said, “All three of us- ANM, ASHA,and I work together. We all decide before doing any-thing”, and further explained, “We have good coordin-ation; ASHA is always with us. We respect each other’swork and discussion.” However, the lack of time or heavyworkload, scheduling conflicts, and poor communicationwere named as barriers to coordination. AWWs andANMs perceive that VHND increased their workload. Inaddition, after the introduction of the cadre of ASHAsat the village level, some block-level officials observedthat AWWs are less motivated to deliver services forwhich ASHAs are receiving incentives. For example,AWWs usually weigh the children for monthly growthmonitoring, but ASHAs receive incentives specificallyfor referring children (based on the growth

Kim et al. BMC Public Health (2017) 17:161 Page 7 of 12

Table

3Exam

ples

ofrolesandfactorsinfluen

cing

collabo

ratio

nam

ongfro

ntlineworkers,b

yinterven

tiontype

anddistrict

Interven

tions

(Exposurea,%

)District1

District2

District3

Und

erstanding

ofroles

andrespon

sibilities

Factorsen

ablingor

hind

ering

collabo

ratio

n

Und

erstanding

ofroles

andrespon

sibilities

Factorsen

ablingor

hind

eringcollabo

ratio

nUnd

erstanding

ofroles

andrespon

sibilities

Factorsen

ablingor

hind

eringcollabo

ratio

n

1.Anten

atalcare

services,including

maternalIFA

supp

lemen

tatio

n(75.4%

ofwom

enwith

childrenaged

0–5.9mon

ths

received

≥4

ANCvisits)

Clear

understan

dingof

rolesam

ongFLWs;ledby

health

worke

rs.“ASHAwill

know

firstwho

ispregna

ntin

herarea

becausesheis

alwaysvisitingherarea.

Afterthat,she

willinform

theAN

Mto

provideservice.”

(Block

health

prog

ram

manager).Aspartof

ANC,

AWW

registersandweigh

swom

en.A

NM

leads

checkups

andprovides

vaccines.A

SHAandANM

toge

ther

provideIFA

supp

lemen

tatio

n.

MostANC

services

are

provided

atVH

ND,w

hich

isthemain

platform

for

collabo

ratio

nam

ongallFLW

s.

Clear

rolesam

ongFLWs;

ledbyASH

A.A

SHAconven

esallthe

wom

en,p

rovide

scoun

seling,

andcond

ucts

home-basedcare.A

WW

registersandweigh

swom

en.

ANM

cond

uctscheckups.

ASH

Aprovides

IFA

supp

lemen

tatio

n,with

ANM

andAWW

supp

ort.

FLWsknow

each

othe

r’srespon

sibilities,fillinfor

each

othe

r,andclosely

commun

icateabou

tanyprob

lems.

ANCdu

ringVH

ND,

providingplatform

for

integrated

servicede

livery.

Clear

rolesam

ongFLWs;

ledbyhe

alth

worke

rs.

ASH

Aisrespon

siblefor

calling

thebe

neficiaries.

AWW

registerspreg

nant

wom

en.A

NM

isrespon

sible

forcheckups

andproviding

vaccines

andIFA,w

ithsupp

ortfro

mASH

A.

FLWsfillinforeach

othe

r,even

across

sectors.

VHNDprovides

the

platform

forintegrated

servicede

livery.

2.Im

mun

ization

andvitamin

Asupp

lemen

tatio

n(69.6%

ofchildren

aged

12–23.9

mon

thsreceived

vitamin

A)

Clear

rolesam

ongFLWs;

ledbyANM.A

llFLWs

involved

inprep

aring

bene

ficiary

list;ASH

Acalls

bene

ficiariesfor

immun

ization.

ANM

administersim

mun

ization

andvitamin

Awith

ASH

AandAWW

supp

ort.

AllFLWsplan

andattend

mon

thly

immun

ization

sessions

toge

ther.

Guide

lines

outlining

ASH

AandAWW

respon

sibilitiesexist.

Clear

rolesam

ongFLWs;

ledbyANM.“Theaim

ofICDS

isto

reduce

malnu

trition

andinfant

mortality.Thehealth

depa

rtmentalso

hasthe

sameob

jective.100%

immun

izationisthetarget

ofICDSan

dhealth

department.

So,w

eha

vecoordina

tion

toachievethiscommon

target”

(Ladysupe

rvisor).AllFLWs

maintainregistry

anddiscuss

immun

izationplansaday

priorby

phon

e.ASH

Aand

AWW

usually

mob

ilize

bene

ficiaries.ANM

administersvaccines

and

vitamin

Awith

ASH

Aand

AWW

supp

ort.

Immun

izationinvolves

jointactio

nplanning

betw

eenHealth

andICDS.

FLWsjointly

mon

itor

immun

ization.

FLWsfillinforon

eanothe

rwhe

nne

eded

andalso

coordinate

with

GKS.

Clear

rolesam

ongFLWs;

ledbyANM.A

SHAisprim

arily

respon

sibleforcalling

bene

ficiariesto

immun

ization,

usually

atAWC.A

NM

isrespon

sibleforim

mun

ization

andvitamin

A,w

ithsupp

ort.

Planning

,im

plem

entatio

n,and

mon

itorin

gof

immun

izationinvolve

allFLW

s.Lack

oftraining

ofICDSstaffo

rthe

absenceof

ANM

hind

ers

implem

entatio

n.

3.Pediatric

IFA

supp

lemen

tatio

n(5%

ofchildren

aged

6–23.9

mon

ths

received

IFA)

AWW

respon

sible.A

WW

prim

arily

provides

IFA

syrupat

AWC.

AWW

respon

sible

toprovide

pediatric

IFA,b

utstocks

irreg

ular.

Rolesva

ried

across

villa

ges.

ASH

AandAWW

receivestocks

ofIFAsyrupfro

mANM

toadminister,oftendu

ringVH

ND.

SomeAWWsprovide

IFAat

AWC.

IFAisalwayssupp

liedby

Health

,but

distrib

uted

bydifferent

FLWs.Unclear

lead

orprim

arily

respon

sible.

Rolesva

ried

across

villa

ges.

ANM

provides

IFA

syrupwith

supp

ort

ofASH

AandAWW,

orAWW

provides

IFAat

AWC.

IFAisalwayssupp

lied

byHealth

,but

distrib

uted

bydifferent

FLWs.Unclear

lead

orprim

arily

respon

sible.

Kim et al. BMC Public Health (2017) 17:161 Page 8 of 12

Table

3Exam

ples

ofrolesandfactorsinfluen

cing

collabo

ratio

nam

ongfro

ntlineworkers,b

yinterven

tiontype

anddistrict(Con

tinued)

4.IYCFcoun

seling/

education

(32.1%

ofwom

enwith

childrenaged

6–23.9mon

ths

received

CF

inform

ationdu

ring

homevisitsin

last3mon

ths)

Rolesva

ried

across

villa

ges.

AWW

alwayspresen

tfor

homevisits,w

itheither

ANM

orASH

A,toprovide

coun

seling.

AtVH

ND,

ANM

orASH

Acoun

sels.

WhileallFLW

sinvolved

,ASH

Aspecifically

traine

dforIYCF

coun

seling.

Con

flicting

repo

rtson

whe

ther

guidelines

forho

mevisitsexist.

AWW

lead

sho

mevisits;A

NM

lead

sat

VHND.FLW

scoordinate

viaph

oneregardingho

mevisits,

butAWW

cond

uctsho

mevisits

mostoften,with

ANM

and

ASH

Asupp

ort.ANM

seen

aslead

forcoun

selingdu

ring

VHND,alth

ough

allFLW

sinvolved

.

WhileallFLW

sreceived

IYCFtraining

,AWW

considered

asno

tqu

alified

tocoun

selo

nhe

row

nby

health

workers.H

omevisits

areoftenmisseddu

eto

lack

oftim

e.

ANM

respon

sible,b

utrolesva

ried

across

villa

ges.

FLWscoordinate

home

visits,b

utvariedon

who

cond

ucts.A

NM

playslead

rolein

IYCFcoun

seling.

AllFLWsrepo

rted

lyreceived

IYCFtraining

.FLWscoordinate

home

visitsforIYCF

coun

seling.

5.Growth

mon

itorin

gandreferrals

forsevere

acute

malnu

trition

(44.6%

ofchildren

aged

0–5.9

mon

ths,and

51.5%

aged

6–23.9mon

ths

received

grow

thmon

itorin

g)

AWW

lead

swithsupport

from

othe

rFLWs.AWW

isrespon

sibleforweigh

ing

andplottin

ggrow

thcharts,

mainlydu

ringVH

ND.A

SHA

andANM

supp

ortwith

coun

selingabou

tgrow

th.

AtVH

ND,A

WW

weigh

sandmeasuresand,

toge

ther

with

ANM,p

rovide

sreferrals.ASH

Ausually

accompanies

referred

childrento

hospital.

VHNDisakey

platform

for

coordinatio

n.

AWW

respon

sible,o

ften

alon

e.AWW

respon

sibleforweigh

ing

andprep

aringcharts,m

ostly

durin

gVH

ND.A

SHAor

ANM

helpsin

few

village

s.AWW

fillsou

treferralslips.PR

I,SH

G,and

mon

itorin

gcommittee

sometim

eshe

lpAWW

with

referrals.

ASH

Aor

AWW

accompanies

referred

children.

AWW

feelsoverbu

rden

edby

grow

thmon

itorin

glarge

numbe

rsof

childrenalon

eandasks

formoresupp

ort

from

ASH

AandANM

inthisactivity.

AWW

lead

swithsupport

from

othe

rFLWs.AWW

respon

siblewith

supp

ort

from

ASH

AandANM.

AWW

followsup

with

grow

thmon

itorin

gdu

ring

homevisitsifabsent

onVH

ND.

AtVH

ND,A

WW

weigh

schildren,andANM

makes

referrals.ASH

Aaccompanies

child

toNutritionRehabilitation

Cen

ter,sometim

esaccompanied

byAWW.

FLWsfillinforeach

othe

r.VH

NDiskeyplatform

forcoordinatio

n.Guide

lineforreferrals

exists.

a Meanexpo

sure

ofinterven

tions

across

thethreedistricts;little

differen

cesexistedam

ongthedistricts

[23]

Thebo

ldface

entriesaresummarystatem

ents,sum

marizingthelong

ersubseq

uent

text

Kim et al. BMC Public Health (2017) 17:161 Page 9 of 12

monitoring results) to the nutrition rehabilitation center;thus, AWWs become discontented by the unbalancedincentive system.

DiscussionIntersectoral convergence may be considered as a processtowards achieving higher efficiency, quality, coverage, andeffectiveness or as an end in itself, i.e. holistic approach topublic health and nutrition. In our study, we focus on theconditions of convergence as a process in service delivery,but with the ultimate vision of a holistic approach to im-prove maternal and child health and nutrition. Effectiveconvergence between the health and nutrition sectors re-lies on various factors for improved intersectoral actionsand positive outcomes. The findings of our study highlightthe existence of a mandate for convergence for health andnutrition in the form of policy and guidelines at the statelevel, understood and articulated by the leadership in bothsectors. There is a shared understanding of the goals andpriority actions. In practice, however, we find that there islimited joint planning and coordination due to demandsarising from the core sectoral priorities. The district isintended to be the site of planning and capacity building;the block is the site of training, supervision and support,(joint review meetings, supervisory field visits, training,and periodic data review); and village includes the site ofservice delivery, which is the domain of the FLWs. Our re-sults indicate that the nature and extent of coordination atthe district, block, and village levels varied and wereservice-specific, with largest gaps in coordination appearingat the block level. Heavy workloads, narrow accountabilityto sectoral outcomes, and limited supervisory mechanismswere common challenges to coordination across all levels.Our findings concur with results from another field studyof various sites in India that highlighted needs fornutrition-focused outreach to families and more structuredcollaboration between health and nutrition [27].Historically, the DHFW and DWCD worked toward a

common goal to reduce infant mortality, which facili-tated coordinated action and effective program imple-mentation [28]. At the state level, several joint guidelinesand program reviews have been implemented aroundthis common goal. However, the sectoral domination ofthe health department is perceptible in our results. Thisis likely because several of the essential interventions toreduce infant mortality such as immunization are deliv-ered by the health department. In addition, the focus onreducing infant mortality and treatment of severelymalnourished children during the last two decades haspotentially diverted action from strengthening preventiveactions such as counseling for IYCF and prevention ofillness [28], thus lending salience to the activities of thehealth department. Indeed, in our analysis, we find thatthe district-level and block-level coordination meetings

are predominantly driven by reviewing of the health in-dicators and tallying of numbers rather than a compre-hensive feedback or review of programmatic operations.Although NRHM has a broad objective of strengtheningthe primary healthcare system, it focuses its efforts oninfant and maternal mortality, thus coordination meet-ings are dominated by a numerical review of their indi-cators [29]. This narrow focus of priorities andprocesses, however, is unlikely to result in effective andmeaningful improvements coordination or service de-livery for nutrition interventions like counseling.Frontline worker coordination, therefore, appears to be

good for services that are primarily driven by the health de-partment (e.g., ANC and immunization) than for servicesthat require more joint planning such as counseling forIYCF. Coordinated functioning is a result of understandingamong FLWs of their tasks, guided by protocols, tools andinstruments; these are well defined for most of the healthservices. Similarly, for VHND, where several health and nu-trition services are provided, there is a protocol and clearguidelines for FLW roles. Although guidelines for IYCFcounseling exist, FLWs are not fully aware of them. Fur-thermore, services such as immunization have been deliv-ered by the health system for much longer time than themore recent IYCF counseling services, which could contrib-ute to better coordination among the FLWs in the deliveryof health services compared to other services.In our study, FLWs valued working together and realized

their interdependent roles in delivering the services. How-ever, inadequate or unbalanced incentives, differences intraining (e.g., ANM is a trained paramedic while ASHAand AWW are not) and work roles (e.g., ANM vaccinateschildren, while AWW and ASHA mobilize them) may leadto resentment [29]. Mutual respect, support andunderstanding of their own responsibilities is critical forFLWs to work together, and this can be facilitated from thedistrict and block levels through issuing of clear guidelinesand ensuring that each of the FLW’s work is given adequaterecognition and prominence.Overall, service-specific coordination, for example, co-

ordination focused solely on mobilizing mothers forimmunization services, hinders the vision of achieving aholistic approach. An integrated approach to ensuring thedelivery of all the essential services to the mother-childdyad during the first 1000 days is needed to avoid thecurrent service-specific coordination that prioritizes cer-tain services over others. While the sectoral focus is im-portant to deliver on the outcomes for specific services, itcan dilute the efforts to ensure coverage of all the requiredservices for the mother-child dyads. Thus, for example, re-view meetings focusing on immunization and vitamin Asupplementation may be strengthened by including the re-view of food supplement distribution and counseling, bothof which are also often targeted to the same eligible

Kim et al. BMC Public Health (2017) 17:161 Page 10 of 12

mothers and children. It is also imperative that leadershipat higher levels ensures that the two departments are heldaccountable for planned actions and delivering of all theservices using the continuum of care approach.There are a few limitations to our study. First, the study

was conducted in purposively selected districts; therefore,the results are not representative of the entire state. How-ever, our sampling was performed to draw from differentdistricts to maximize the variations in service deliverycontext within the state, and the qualitative data were col-lected from all key actors at the different administrativelevels involved with the health and ICDS programs. Ourstudy is based on single cross-sectional interviews, and wedo not claim causal relationships between the degrees andoutcomes of convergence, apart from linkages stated dir-ectly by interview respondents. We analyzed iteratively forthemes and patterns of influencing factors and linked con-sequences that emerged from the qualitative data, in orderto examine potential processes and relationships. Whileresponses were based on recall, which is vulnerable tobias, we triangulated findings from various respondents.Our study findings contribute to the growing evidence on

multisectoral convergence processes and hold relevance forother countries committed to scaling up nutrition interven-tions, where coordination has been identified as a majorchallenge [30]. We applied a comprehensive approach toexamine the degrees and conditions of intersectoral conver-gence at the different administrative and operational levelsof the health and nutrition systems and to trace implemen-tation of specific interventions, and this systematic ap-proach may be useful in other settings to identify gaps andelements needed for strengthening coordination.

ConclusionsDelivery of health and nutrition services operate on theassumption that intersectoral coordination is importantand will take place accordingly based on common objec-tives/purposes, but multiple factors influence on conver-gence decision and action points. Also, different degreesand conditions of convergence are in play among actors atdifferent operational levels. This may be reflective of thevarying administrative and operational functions at thedifferent levels, thereby uniformity of relations may not befeasible nor necessary. However, across these forms ofinterrelations, there is a need for congruence or sharedpriorities in actions, clear roles and leadership, and regu-larity of participation and actions across all levels, as wellas sectoral accountability for convergence. As convergenceis a means to achieving effective coverage and delivery ofservices for improved maternal and child health and nutri-tion, focus should also be on delivering all the essentialservices to the mother-child dyads through mechanismsthat facilitate a continuum of care approach, rather thansectorally-driven, service-specific delivery processes.

Additional files

Additional file 1: State-level Interview Guide: Guide used for interviewingdistrict-state officials from Health and ICDS as well as development partners.The interview guide includes questions about work responsibilities andconvergence at the state, district and block levels. (PDF 508 kb)

Additional file 2: District-level Interview Guide: Guide used forinterviewing district-level officials from Health and ICDS such as thedistrict program manager, district community mobilizer, and districtproject officer. The interview guide includes questions about workresponsibilities, coordination of Health and ICDS services, and specificmechanisms of convergence at the district level. (PDF 642 kb)

Additional file 3: Block-level Interview Guide: Guide used forinterviewing block-level officials from Health and ICDS such as the blockprogram manager, block community mobilizer, and child developmentproject officer. The interview guide includes questions about workresponsibilities, coordination of Health and ICDS services, specific mechanismsof convergence, VHND, supervision and training, and work support at theblock level. (PDF 686 kb)

Additional file 4: Frontline Worker Interview Guide: Guide used forinterviewing frontline workers from Health and ICDS, particularly theANM, ASHA, and AWW. The interview guide includes questions aboutworkload, coordination of Health and ICDS services, specific mechanismsof convergence, VHND, supervision, and job motivation and satisfactionat the FLW level. (PDF 679 kb)

AbbreviationsANC: antenatal care; ANM: Auxiliary Nurse Midwife; ASHA: Accredited SocialHealth Activist; AWC: Anganwadi Center; AWW: Anganwadi Worker;DHFW: Department of Health and Family Welfare; DWCD: Department ofWomen and Child Development; FLW: Frontline worker; ICDS: IntegratedChild Development Services; IFA: Iron and folic acid; IYCF: Infant and youngchild feeding; MoHFW: Ministry of Health and Family Welfare;MoWCD: Ministry of Women and Child Development; NRHM: National RuralHealth Mission; VHND: Village Health and Nutrition Days

AcknowledgementsThe authors would like acknowledge the support from the Odisha statehealth and ICDS departments, and district and block officials, who made thisresearch possible. We gratefully acknowledge data collection by SambodhiInc., New Delhi, and data coding and analysis support from Elizabeth Beckerand Shibani Kulkarni. We would like to thank all the study participants fromthe state to the villages for sharing their time and information.

FundingThis research was supported by the Bill & Melinda Gates Foundation,through Partnerships and Opportunities to Strengthen and HarmonizeActions for Nutrition in India (POSHAN), an initiative led by the InternationalFood Policy Research Institute (IFPRI) in India. Additional financial support forthis study was provided by the CGIAR Research Program on Agriculture forNutrition and Health (A4NH), led by IFPRI.

Availability of data and materialsGiven the rich nature of the qualitative data and the potential foridentifying individual human participants and violating confidentiality ofthe key informants who participated in the semi-structured interviews,our study dataset will not be shared openly but may be available uponspecific request.

Authors’ contributionsSSK and RA contributed to the study design, developing research questions,management of study activities, data analysis and interpretation, and draftingand revising the manuscript. NK, KS, and MB contributed to data analysis andinterpretation. RV supported in data interpretation, reviewed and edited themanuscript. SK and PM contributed to the study design, developing researchquestions, overall supervision of research activities, data interpretation, andreviewed and edited the manuscript. All authors read and approved thefinal submitted manuscript.

Kim et al. BMC Public Health (2017) 17:161 Page 11 of 12

Competing interestsThe authors declare that they have no competing interests.

Ethics approval and consent to participateInformed consent was obtained from study participants prior to interview.This study was approved by the IFPRI Institutional Review Board andOdisha’s Department of Women and Child Development and Department ofHealth and Family Welfare in India.

Author details1International Food Policy Research Institute, 2033 K Street, Washington, D.C.20006, NW, USA. 2International Food Policy Research Institute, NASCComplex, CG Block, Dev Prakash Shastri Road, Pusa, New Delhi 110012, India.3National Health Systems Resource Center, National Institute of Health andFamily Welfare campus, Baba Gangnath Marg, Munrika, New Delhi, India.4London School of Hygiene & Tropical Medicine, 133b LSHTM Keppel Street,WC1E 7HT London, England.

Received: 25 June 2016 Accepted: 30 January 2017

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