By Praveenkumar Aivalli, Post Doctoral Research Fellow, University College Dublin, Ireland
How does power shape the success—or failure—of intersectoral collaboration in global health? That’s the question at the heart of my doctoral journey. Our recent realist review dived into how power dynamics influence intersectoral collaboration (ISC) during health programme implementation in low- and middle-income countries.
While global calls like the SDGs and WHO’s Health in All Policies have put ISC in the spotlight, but real progress remains disappointingly patchy. What’s often missing from these ambitious efforts is an honest conversation about power. Who gets to decide? Who sets the agenda? Whose voices matter—and whose are ignored? These aren’t academic questions—they’re the difference between genuine collaboration and performative partnerships, especially in LMICs where funding dynamics, hierarchical systems, and historical inequities stack the deck.
What does our review add to the conversation?
Most literature encountered framed collaboration failures as problems of coordination, capacity or commitment, treating power differences as side issues. The current review flips that narrative. Power relations aren’t just contextual factors—they’re the fundamental mechanisms explaining why so many well-designed collaborative initiatives fall short. It’s been eye-opening to map how different expressions of power (institutional, financial, epistemic, and relational) interact with specific contexts to shape collaborative outcomes. This hopefully offers others a more nuanced framework than was available before.
The realist journey
Our realist review was chosen to go beyond simply asking “Does it work?” Understanding how collaboration works, for whom, in what contexts, and why was essential. This meant diving into 23 empirical studies from across Africa and Asia, triangulating findings with a qualitative case study, and synthesising 73 Context-Mechanism-Outcome configurations. These CMO configurations were the heart of the analysis—allowing for unpacking the ‘black box’ of collaboration and mapping its causal pathways.
In realist terms, the research found that specific contextual conditions (C) combined with particular resources or interventions triggered reasoning and responses among stakeholders (M – mechanisms), which then produced both intended and unintended outcomes (O). For example, in contexts where health ministries held significantly more institutional power than other sectors (C), the introduction of joint budgeting mechanisms (resource) triggered increased willingness among non-health actors to actively participate (reasoning mechanism), which led to more balanced decision-making processes (O).
But fascinating instances emerged where the same intervention backfired. In contexts marked by historical distrust between sectors (C), those same joint budgeting mechanisms sometimes triggered suspicion and defensive posturing (negative mechanism), resulting in delayed implementation and superficial collaboration (O).
This pattern repeated across the data: identical collaborative approaches produced dramatically different results depending on how they interacted with underlying power structures. By mapping these configurations systematically, it was possible to identify which interventions activated positive collaborative mechanisms under which conditions—and equally importantly, which contextual factors consistently undermined even well-designed collaborative efforts.
What emerged was a nuanced picture of how power operates not just structurally but through the reasoning of individual actors who constantly calculate their interests, opportunities, and risks within collaborative spaces. These CMO configurations helped to move beyond simplistic “best practices” toward a more contingent understanding that respects context and agency.
Six insights that changed our thinking
- Inclusion is not enough. In many settings reviewed, health ministries dominated ostensibly “Intersectoral” committees, while education, agriculture, or NGOs were treated as afterthoughts. Without intentional facilitation and role clarity, inclusive policymaking becomes theatre rather than dialogue.
- Leadership makes or breaks collaboration. This might seem obvious, but the type of leadership matters enormously. Where democratic, rotating, or facilitative leadership was observed, collaboration thrived. Where power was centralised, it withered. Leaders who balance structure with genuine power-sharing are needed.
- Resources drive trust—and conflict. Funding—often controlled by donors or powerful ministries—can either build partnerships or breed resentment. Transparency and equity in resource allocation aren’t luxuries; they’re essential foundations for trust.
- Hierarchies silence voices. Many contexts studied operate within deeply hierarchical systems. Sub-national actors being “consulted” only after decisions were already made was common. This crushes morale and blocks vital information flow. Yet informal relationships—built on trust and mutual respect—can sometimes transcend these rigid structures.
- No clear roles = power vacuums. Time and again, when collaboration lacked defined roles, dominant actors inevitably stepped in to fill the void. This created confusion and fuelled power struggles. Clear mandates and accountability mechanisms are essential to prevent collaborative spaces from being hijacked.
- Relationships can rebalance power. Perhaps the most hopeful finding? When stakeholders build interpersonal trust—beyond institutional boundaries—they create informal spaces where power becomes more balanced. These “soft” dynamics accomplish more for genuine collaboration than formal structures ever could.
What this means for the work
ISC is profoundly challenging. It demands more than coordination meetings and joint action plans. It requires courageous conversations about power—about who leads, who follows, and who feels heard. And it calls for new ways of working that value humility, shared ownership, and patient relationship-building.
Based on the current synthesis, here’s our recommendations:
- Rethink leadership: Move from command-and-control models toward adaptive, facilitative leadership that spans sectors.
- Level the funding field: Design pooled or participatory budgeting mechanisms that prevent any single sector or donor from dominating.
- Make roles explicit: Use MOUs or joint governance frameworks to clarify responsibilities—and revisit them regularly.
- Value informal ties: Create space for cross-sector bonding—shared workspaces, staff exchanges, community forums.
- Evaluate power dynamics: Develop tools that track not just technical outputs but also relational equity—who speaks, who decides, who benefits.
Final reflections: From rhetoric to reality
Power isn’t inherently negative. But when unacknowledged and unchecked, it erodes trust and undermines everything being attempted together. If ISC is to deliver on its promises—whether for health equity, climate resilience, or pandemic preparedness—power must stop being treated as taboo and recognised as the core issue it is. Moving beyond buzzwords, asking harder questions, and co-creating governance models that share not just responsibilities, but also influence is essential.
Want to read the full study? Power dynamics and intersectoral collaboration for health in low and middle income countries: A realist review
