Understanding the dynamics of multisectoral policy: an examination of implementation networks and governance practices of tobacco control in India

Multisectoral action (MSA) has been a long-standing priority of health systems. The objective is to improve health status and health equity through policy implementation and organizational practice. The United Nations Sustainable Development Goals reinforced the realization that health inequities cannot be addressed by one sector alone. Despite the key importance of the need to work across sectors, there remains little evidence to indicate how these multisectoral processes actually function in implementation or in the local policy environment. This gap in our knowledge on local governance has repercussions for our understanding and influence on policy outcomes and effectiveness. Thus, there is a need to harness local level knowledge and create enabling environments at higher levels that nurture local, multisectoral governance.
In this thesis, I address and bridge this knowledge gap by mapping, understanding, and explaining the implementation of a multisectoral policy in health. Using the case study of the district level implementation of the National Tobacco Control Policy in India, I examine the multi-level context (national and state) and political processes to better understand how multisectoral action and governance practices at the local level are implemented. Furthermore, by detailing multi-level issues related to providing a supportive policy environment, this research aims to show how the more effective implementation of such important public health policies can have a better impact on outcomes.
The dissertation begins with a review of the literature on multisectoral action which goes beyond the health literature alone. The meta-narrative review presents a conceptualization and enquiry of multisectoral action across different applied knowledge domains in health, public administration, political science, and environmental sciences. Second, an analysis of the national and state-level policy context by means of a policy landscaping study of the National Tobacco Control in India was conducted, including a review of key drivers for collaboration. Third, a mixed- methods explanatory design study considers local implementation of multisectoral action in tobacco control in two districts in the southern Indian state of Karnataka. This district-level study maps the actual implementation structure, the key actors involved and the relationships between them using social network analysis (SNA) and then using a qualitative enquiry enables understanding of perspectives and experiences of
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actors regarding their perceived roles and multisectoral governance practices using complexity-oriented network governance theory.
The overall thesis findings suggest that multisectoral policies and practices need to be supported by a nurturing multi-level (national and state) policy environment that provides adequate decision space and leadership at the local level, leaving space for experimentation and adaptation in line with local conditions. The district-level implementation highlights adaptive governance practices used to navigate hierarchical and authoritative structures. There is evidence of an early shift in these districts towards a more agile form of governance, which maybe more conducive to multisectoral implementation. At the national and state level, policy formulation and adoption require a collaborative effort through leadership across multiple levels and sectors. These processes are politically embedded; however, the presence of a legal framework, adequate implementation structure, advocacy and mobilization can provide momentum for national and state level action and support local level action and adaptation.
The research presented in this thesis contributes to a better understanding of a multisectoral policy’s actual governance practices at a district level, in a LMIC context. The knowledge generated around policy implementation processes contributes to health systems and policy research and helps facilitate thinking and action on multisectoral policies in diverse LMIC settings.