Unpacking Power Dynamics in Intersectoral Collaboration: A realist evaluation

Background: Intersectoral Collaboration (ISC) involves the joint efforts of multiple sectors or agencies working together to address complex shared challenges or goals that cannot be effectively tackled by any single sector. Increasingly, there are calls for such collaboration, particularly in global health, where interconnected challenges require a holistic, collective approach. While the influence of power dynamics on ISC outcomes is acknowledged, a significant gap remains in the in-depth understanding of the underlying mechanisms through which these dynamics operate within diverse contexts, particularly in LMIC settings. This research aims to address this gap by investigating the intricate interplay of power dynamics in ISC within the specific context of Assam, India, seeking to elucidate how, why, for whom, and in what circumstances power dynamics influence ISC. Methods: This research undertakes an in-depth exploration of power dynamics in ISC using a realist evaluation case study approach. This theory-driven approach involves an iterative process of developing, testing, and refining programme theories. Initially, a qualitative study with 11 programme managers contextualised ISC. Subsequently, a realist review synthesised literature on power dynamics in ISC within LMICs to elicit Initial Programme Theories (IPTs). An empirical testing phase in Dibrugarh district was conducted with 18 programme managers. In-depth interviews and observational data collection were analysed using a retroductive approach to refine the IPTs. Finally, the transferability of these refined theories was assessed in a different context within Assam through in-depth interviews with eight programme managers. Results: An initial qualitative study in two districts identified facilitators, barriers, and the influence of power dynamics in ISC. A realist review of 23 studies revealed 73 Context-Mechanism-Outcome configurations (CMOCs) organised into 17 demi-regularities, explaining the influence of power in diverse setting of LMICs. The realist review and empirical evidence helped to elicit a total of six initial programme theories on equal ownership, leadership dynamics, resource allocation, communication and trust, role clarity, and interpersonal connections. Subsequently, a realist evaluation in Dibrugarh district identified 62 CMOCs, refining these six IPTs into detailed programme theories that explain the causal mechanisms of how, why, for whom, and under what circumstances power influences ISC within national nutrition programming. Finally, an assessment of the transferability of these refined programme theories in a different district (the Cachar district of Assam) highlighted challenges in applying them in daily implementation, alongside opportunities for improved transferability through adaptation and stakeholder engagement. Conclusions: Using a realist lens, this research advances the understanding of power dynamics in ISC by uncovering the causal mechanisms that shape collaborative processes. By integrating theoretical development, empirical validation, and contextual adaptation, it demonstrates how power operates through both structural and relational pathways, influencing the effectiveness and sustainability of ISC. This research contributes to the broader discourse on collaborative governance, equity, and policy implementation, highlighting the need to move beyond formal structures and address the nuanced ways power manifests in ISC. By bridging theory and practice, this study provides a framework for policymakers, practitioners, and researchers to design and implement adaptive, inclusive, and power-sensitive intersectoral strategies. Future research should further test and refine these insights across different contexts and policy domains, contributing to the development of middle-range theories that enhance the transferability and sustainability of ISC within complex systems.