1 Introduction

India was the first country to adopt recommendations of Global Action Plan for Non-communicable Diseases and introduced its indigenous national monitoring framework for prevention and control of NCDs in 2013 [1, 2]. This was followed by launch of National Multi-sectoral Action plan (NMAP) in 2017; a blueprint of required set of actions from different non health sectors to achieve NCD target of reducing premature mortality by 25% by 2025 [3]. Multi-sectoral approach is based on pivot of “whole of government” and “health in all policies” (Hiap) strategies, where all sectors consider health, factors promoting health and actions preventing diseases while articulating their sectoral policies [4]. This requires advocacy, sensitization and knowledge sharing with all sectors by health department for successful implementation [5].

NCDs were responsible for 74% deaths (42 million) globally in 2019 out of which around 4.1 million deaths were reported from India [6]. The disproportionate effect of NCDs on poor, vulnerable population, people between ages of 30–70, in low- and middle-income countries warrants robust and multipronged actions to mitigate NCD burden [7].

India is a low-middle income country wherein, five major risk factors of NCDs are tobacco and alcohol use, unhealthy diet, physical inactivity and air pollution [8]. These behavioural risk factors have many underlying social, economic, environmental, cultural, commercial and political factors; the determinants of health (SDOH). Poverty, education status, nutritional habits, environment and socio-cultural practices etc. are all contributing to the present health status of families and are collectively responsible for NCD pandemic [9, 10].

Within India, the state of Uttar Pradesh (UP) has the largest population of 199,812,341 [11]. According to Global burden of Disease study 2016 the proportionate disease burden for UP was 47.9% due to NCDs and 11.6% for Injuries and 40.5% from all Communicable, maternal, neonatal and nutritional causes combined. The topmost contributor in Years of life lost (YLL) for 2016 was also a NCD (Ischemic heart disease) in UP [12, 13]. The present requirement in NCD control is to implement cost-effective initiatives at the primary care level.

Our research questions were: What is the status of MSA implementation in Uttar Pradesh? What is the perception of different sectoral officials about MSA and its implementation? This qualitative study was planned with an objective to explore the perspectives of various non-health and health sectors policy level stakeholders by conducting Key Informant Interviews.

2 Materials and methods

Using inductive approach, grounded theory was employed to explore the perspectives of diverse stakeholders regarding different aspects of multisectoral action in UP, India. Data was collected from officials of various sectors that directly or indirectly effect health. Since there is hardly any research available on multisectoral action from India, grounded theory was considered specifically useful [14].

Key-informant interviews (KIIs) of senior level officers from health and non-health sectors were conducted using an interview guide to get required information on MSA, SDH and NCDs [15]. There are 16  non-health and one health sector identified as of high priority in the NMAP; i.e., having potential for convergent action much needed against fight for NCDs [3].

Purposive sampling was used to select participants from identified sectors and where it was not possible to identify anyone based on the purpose, nominations were sought from the heads of sectors [14].

An Interview guide was prepared by taking inputs from tools of a study done by School of Public Health, Post Graduate Institute of Medical Education & Research (PGIMER) Chandigarh. It was pilot tested among officers of National Health Mission and modifications were included in final version.

Study was conducted in the capital city of Uttar Pradesh, Lucknow where almost all the secretariat and directorate are situated. Half of the KIIs were conducted in secretariat and the rest half in directorates as the secretaries have nominated other officials due to their busy schedule. The average duration of each KII was around 45–50 min. As these offices are under high security there is a long process for visitors to get the gate passes through the concerned office assistant. The same was followed by the team at each and every visit. The collected data was transcribed and translated in English wherever needed.

Ethical approval (1419/Ethics) was obtained from Institutional Ethics Committee (IEC) of King George’s Medical University, Lucknow for an interview-based study. Participants were explained about purpose of study before starting the interview. They were assured regarding confidentiality, anonymity and voluntary nature of involvement. All queries were answered to their satisfaction, only after which their informed consent was taken. Consent was sought for audio recordings of interview and only for those who allowed, recordings were done. Entire process was executed according to relevant guidelines and regulations.

The data were coded using a code book and themes were generated manually. At times the study participants were revisited to seek clarifications [16]. Data were revisited many a times by two researchers to refine the themes and to ensure more nuanced understanding [17]. The themes were drawn from the codes for descriptive analyses [18]. We analyzed data of 18 KIIs which included officials from 13 non-health sectors of Education, Women and child development, Sports, Information, Housing and urban planning, Labor, Law, Environment, Rural development, Industry, Transport, Agriculture, Horticulture and food processing.

3 Results

3.1 The study participants

We had interviewed 5 (28%) female and 13 (72%) male officers. Participants were all senior officials with most of them (10, 56%) above 50 years of age and majority of them (16, 89%) had served the government for at least 10 years or more, details are given in Table 1 and Fig. 1. KIIs were done at respective offices, at prefixed time and location as given by officers. All the required permissions were taken before data collection. The participants were from a very diverse working background, having expertise in their respective sectors.

Table 1 Participants profile from various sectors
Full size table
Fig. 1
figure 1

Distribution of KIIs across different health and non-health sectors

Full size image

The results are divided into two sections of perceptions; regarding NCDs and MSA. The response to implementation of MSA by both non-health and health sectors has been presented to understand the preparation and intentions for operationalization of MSA. The assessment of MSA is presented in the last section. The themes generated from data of non-health sectors are presented first under each section. The crucial role of health in MSA is clearly highlighted under NMAP [3] for NCDs.

3.2 Perception regarding NCDs

The perception of different sectors regarding risk factors and causes of NCDs is vital to understand before moving to multisectoral activities for its prevention.

3.3 Non-health sectors perceptions regarding NCDs

The participants of the non-health sectors expressed that there are multiple factors that cause NCDs like “habits, behavior, diet, physical inactivity and lifestyle of individual”. Stress for them is an important factor leading to NCDs. They expressed that life is more stressful now than ever before and with increasing workload it is becoming more stressful. They explained that there is no time for physical activity or for relaxing and recreation. Some of them voiced ….

“Excess workload and low resources. No holidays for higher officials. Increased stress in all domains of life is responsible for rise in NCDs”—Transport

“No time for exercise in daily run of life”—Agriculture

Urbanization, pollution, chemical exposure, and dependency on machines were other reasons of NCDs as mentioned by some study participants. The increasing use of chemicals as fertilizers was also reported as cause of rise in cancer cases.

“Urbanization of life is causing NCDs”—Infrastructure & Industrial Development

“All chemical fertilizers are entering our food chain & causing cancers, NCDs” - Horticulture & Food Processing.

The participants of non-health sectors did mention that “accumulation of risk factors predisposes them more towards getting NCD” but they did not deliberate on synergistic action of risk factors.

“The daily busy routine, pollution, environment, improper diet and our health behaviour all are leading to NCDs”—Mahila kalyan

People often relate behaviours with lifestyle. For them lifestyle is a combination of behaviours. The key informants have also ranked lifestyle as the major factor responsible for NCDs. Modern lifestyle, stress at work and poor diet emerged as top three risk factors for NCDs followed by obesity, alcohol, air pollution, tobacco, physical inactivity and urbanisation in decreasing proportions. As lifestyle includes habits, behaviour and other attributes, an overlap of risk factors always co-exists. Almost all major behavioural risk factors of NCDs were reported by the non-health sectors.

3.4 Health sector perceptions regarding NCDs

Unlike non-health sector participants, the health sector participants expressed that “NCDs occur mostly due to imbalance of risk factors already present in and around us”. They were more concerned about NCDs than the non-health sector participants as they were observing it in the health system. The participants from health sector reported common shared risk factors of tobacco, alcohol, unhealthy diet and physical inactivity responsible for major NCD burden. Furthermore, they were concerned about rising burden of NCDs, its present effect on health system and its impact on future generations. The epidemiological transition towards NCDs has also shifted focus of health sector to address it.

“NCDs burden is huge as it itself says - Something that is not an infection is we only” (Jo Infection nahi hain wo hum hain.) - Health03

“We are also shifting our focus from MCH to NCDs”- Health05

The Table 2 show perception of participants regarding NCDs.

Table 2 Perception about NCDs of non-health and health sectors
Full size table

3.5 Perception regarding MSA

Having discussed about perception of NCDs we then explored to understand perceptions regarding multi-sectoral action as detailed in NMAP guidelines by the Ministry and advocated globally by World Health Organization (WHO) for NCDs prevention.

3.6 Non health sectors perceptions on MSA

The non-health sectors of government are working for their sectoral objectives. They were not aware of the MSA guidelines and learnt through our interviews with them. Though they value health but do not look at their sector specific policies or action programs from the health perspective. They were appreciative of the collective efforts needed for health as mentioned below:

“Everyone has to understand their part in controlling NCD Epidemic”—Education

“Health is Wealth- No one should ignore it”—Law

There were some others who were not ready to take the idea of shared responsibility for health and were concerned about revenue, for example the participant of industries mentioned that.

“Health is a non-revenue generating sector, so it cannot control the revenue generators for action”—Industry.

Majority of non-health sectors were not fully aware of MSA. Their perception of MSA is a coordinated activity where two, three or may be four sectors who are stakeholders in any concerned activity converge together to take action.

“MSA means different sectors converge to achieve a target”—Mahila Kalyan

“When many sectors work in coordination, like in election duties”—Law

This low clarity among respondents might be because there has not been any sensitization meeting or training by health sector or by any other stakeholder.

3.7 Health sector perceptions regarding MSA

On the other hand, participants from health sector were well aware of MSA guidelines but were not very clear about its implementation. They feel the ignorance of health and the health sector by public. A media nurtured negative environment exists all around health as the negative sensational news is easily circulated on priority thus demotivating all other sector to join health against NCDs.

“The perception about health in public is not very positive, because 9 out of 10 times we are in light due to some bad news”—Health04

Table 3 shows participant’s perception regarding MSA.

Table 3 Perception regarding MSA
Full size table

3.8 Implementation of MSA

The information was then sought regarding operationalization of MSA in terms of preparation by sectors and their approach towards joint or collaborative actions.

3.9 non-health sector response to MSA implementation

The non-health officials well perceived limitations of Health sector in controlling risk factors of NCDs as these are beyond sectoral mandates of health.

“Health sector is to work when you get a disease”—Sports

Considering multifactorial causation of NCDs; health can neither do it alone nor get it done by others. The contribution of health in MSA could only be technical expertise and monitoring of implementation.

“Health could only give correct knowledge and increase awareness; then every sector has to augment percolation of information to people for behaviour change”—Labour

Health is already understaffed and overburdened, so even a planned preventive action practically takes a backseat.

“Health is already burdened – NCD prevention needs many new actions, so they should first make all other sectors aware for activities like sports, then it should be self-management”—Law

The officers of potential non-health sectors responded that doctors could only provide correct information regarding nutrition and diet, rest is beyond their limit.

“Health sector cannot control how much work you do and how much time you sleep”—Transport

Likewise, health could not do anything for urban lifestyle, decreased sleep and low level of physical activity apart from imparting knowledge.

“People still don’t have right idea of nutrition and balanced diet and they face numerous problems”—Mahila kalyan, Bal Vikas evam Pushtahar

Though non-health sectors were not much clear about actual process of MSA but on exploring about possible role of other non-health sectors in contribution towards NCDs control the response were engaging.

“Tobacco and alcohol sale should be checked by Police as per provisions”—Sports

“Finance dept. should allocate funds to other dept. to work for NCDs”—Industry

Non-health sectors experts have well perceived their potential role individually in convergent action against NCDs. Sectors are already working on their mandates, only gap is a platform for convergent, synchronized and guided unified action towards MSA.

“The increase in production of fruits, vegetables, spices and flower would improve everybody’s health and prevent NCDs”—Horticulture & Food Processing

Like sectors working for awareness of population are ready to integrate healthy behavior content to prevent NCDs as they are already in process of empowering the population to make better and healthier choices.

“Women and child dept. is working with adoption of healthy behaviour; they need to expand it to cover NCDs for family”—Law

This will motivate people for behaviour change and will slowly develop an enabling environment for implementation of MSA.

3.10 Health sector response to MSA implementation

The health sector officials recognized that they alone cannot control the social determinants of health and it needs larger effort from developmental domains to create a synergistic environment to promote health and reduce risk factors.

“The quality of food available in market needs to be strictly controlled by authorities”—Health03

“The road determines approachability of our ambulances for action in golden hour”—Health02

Being technical experts and having a time-tested and established mechanism of implementing and monitoring health programs, health should be team leader but responses of officers were not very promising. It might be based on their previous experiences of conducting coordinated or integrated activities with other non-health sectors.

“Multisectoral action and Hiap are just Buzz words to create an environment, good for a launch. After that who is going to do the legwork, we are already overburdened”—Health01

The Ministries guidelines of NMAP have been received but due to lack of specific budget or training mandates, no activity was started. Even sensitization meeting or training of non-health sectors were not on their cards. Same reflected in non-health sectors response regarding understanding of MSA.

“Every time Central Ministry comes up with new programs and guidelines. No staff no budget, so finally it ends in paper work, replies to their letters, queries and then something else will come”—Health05

Contrary with non-health sectors the torch bearer sector was pessimistic and of low attitude in launching and implementing MSA for NCDs in Uttar Pradesh, based on their previous experiences.

The Table 4 shows the response on implementation of MSA.

Table 4 Response to implementation of MSA
Full size table

3.11 Perception of sectors regarding common methods of coordination

Subsequently, we explored perceptions of participant regarding methods of Intersectoral coordination being used by various sectors of Uttar Pradesh government in executing activities requiring collaboration with other sectors. The most common approach we found being used was “Need based collaboration” without any separate structure for coordinated activities.

3.12 MSA present scenario

Majority of respondents agreed that there is no separate structure or platform for joint activities and most common mechanism in place was information sharing through letter or meeting. Whosoever requires involvement of another sector communicates with them. Type of involvement decides mode of action as in many activities only clearance is needed like from environment, Law and Finance.

“No designated collaborative forum, group or platform is available. No collaborative mechanism exists”—Law

3.13 Some level of cooperation or coordinated activities present between sectors

Alternatively, next type of coordination reported was of joint action between sectors with working groups and forums. It requires more communication and involvement of stakeholders to perform jointly like involvement of education, transport and health in tobacco control rallies or awareness program for traffic rules or Mid-day meal program.

“Committee, Council, Technical working groups all are used. Social media is used most commonly and documented least” – Agriculture

3.14 MSA in action at grass root level

The activity we recognized to be most closely related to MSA was a joint activity between sectors, called as convergent village and health sanitation and nutrition activity between ICDS department and Health sector. This requires effective partnership from survey of beneficiaries to making micro plan and then execution.

“Conducting VHSNC activities at village level is a well-documented and reliable coordination by ICDS and Health sector towards convergence of service”—Health02

The main idea behind this coordination is to do complex things in more easy and effective manner. Similarly, there are examples of single window operations to reduce time in government actions and increase efficiency, by calling all stakeholders to execute together.

“Udyog Bandhu is itself an ideal example of making things feasible by providing one window solution to investors”—Industry

The multisectoral action plan of NCD is to be based on this level of coordination between multiple sectors to address NCDs. As we observed that understanding of non-health sectors regarding MSA was not very promising but still in spite of limited knowledge, we have examples like Tobacco control program, Village health sanitation and nutrition committee (VHSNC) day, Water sanitation and hygiene (WASH) activities and many more to show coordinated and even integrated action exists in different sectors of Uttar Pradesh, which is positive.

Table 5 shows the present level of MSA in action.

Table 5 Level of MSA in action
Full size table

4 Discussion

Grounded theory was employed to investigate diverse stakeholders’ perspectives on various facets of multisectoral action in Uttar Pradesh (UP), India. We collected data from officials representing sectors that directly or indirectly impact health. Given the limited existing research on multisectoral action in India, grounded theory emerged as a particularly valuable methodological choice.

The findings reveal that non-health sectors acknowledge the multifactorial nature of NCDs, with lifestyle factors emerging as primary risk factors. However, while there is awareness; health remains a lower priority for these sectors, posing a significant challenge to successful MSA implementation. Non-health sectors lack clarity on MSA but express willingness to contribute to NCD prevention efforts. Another study conducted in refugee camp also cited lack of motivation as the biggest challenge for MSA in NCDs [19].

Interestingly, the non health sectors are engaged in addressing social determinants such as education and poverty but lack concrete technical knowledge on MSA strategies. While they focus on raising awareness and promoting behavioural changes to mitigate NCD risk factors, there is a gap in implementing MSA practices, necessitating hand-holding guidance from the health sector.

Conversely, the health sector, while understanding the pillars and processes of MSA, lacks proactivity in advocating for its implementation. Despite recognizing the importance of MSA, they have not taken the lead in engaging other sectors. This highlights the need for a dedicated implementation platform with active leadership. Similar need also stressed in research from Nepal [20].

Current joint activities involve periodic meetings where sector officials contribute inputs, but a more permanent platform for planning, monitoring, and evaluation are essential for effective MSA. One can draw lessons from existing models like the one in South Australia, where Health in All Policies (Hiap) unit has been established separately to inform policymakers on impact of policy decisions on health [21, 22]. Another model, more commonly employed in European countries like Finland, France, Sweden, UK, Hungary and Norway is of multisector committees with representatives from all contextually relevant sectors, this structure is formed within the government [23]. The different forms of transitions would be smooth in embedded structures like European model leading to better continuation of activities. The best model has been the one where in structure at municipal or contextually most local level were involved. The community was engaged directly, and health impacts was appreciated and evaluated [24]. The health and wellness centers under Ayushman Bharat yojana are already working on preventive aspects of NCDs, applying the integrated MSA at this level would be definitely give desired results in long terms to achieve the targets of NCD control and UHC [25, 26]. Drawing from the collaborative response experienced during the COVID-19 pandemic, there's hope for enhanced multisectoral cooperation in UP and India.

To address NCDs effectively, strong cross-sectoral collaboration is essential, necessitating a shift towards a Hiap approach to inform public policy across sectors. Implementation of NMAP is being advocated as a high-priority intervention to curb NCDs [27].

This prioritization of MSA to control NCDs aligns with the broader goals of the Sustainable Development Goals (SDGs), particularly SDG 3, emphasizing the importance of social determinants and universal health coverage [28]. Given India's youthful population and the impending NCD burden, preventive actions targeting social determinants are crucial [29]. Holistic efforts are also recommended by researchers from Sub-Saharan Africa to address all blocks of the health systems and reach targets of NCD [30].

Capacity building for non-health sectors, prioritizing children and adolescents in prevention efforts, and establishing a sustainable multisectoral platform for NCD control are the recommendations that emerged from this study.

4.1 Strengths and limitations

First of its kind in Indian context and contributes towards understanding the scenario for implementation of MSA for NCD control.

Being qualitative research the findings are context specific and it might differ for situations in other geographies. Another concern was that we could not interact with policy makers from all sectors and their perspective might be different from nominated nodal officers.

5 Conclusion

While there is recognition of the need for multisectoral action, concerted efforts are required to bring all sectors together effectively for non-communicable disease (NCD) prevention. Capacity building to shift attitudes and prioritize health across sectors is essential for successful implementation.