Survey responses from 23 project staff and stakeholders were included in the sample for this analysis. Geographically, 4 responses were recorded from Colombia, 10 from Ghana, 5 from Kenya, and 4 from Vietnam. By strategic partner, 3 surveys came respondents nominated by C/Can, 3 from NCDA, 9 from PATH, 5 from the World Bank, and 3 from WHF. C/Can and the World Bank distributed surveys exclusively to their employees in the selected countries, whereas NCDA, PATH, and WHF distributed to local affiliates and implementing partners for their projects in each country. Aside from staff from the five strategic partners, stakeholders and affiliates represented among survey respondents included government health authorities, civil society partners, and non-governmental organizations.
The three dimensions of connective tissue
Knowledge creation
In their answers to Likert Scale prompts on knowledge creation, shown below in Fig. 2, respondents largely indicated that they had witnessed opportunities to exchange knowledge (95% answered “Agree” or “Strongly Agree”), willingness to learn from one another (86%), and increased discussion of best practices (86%). However, fewer respondents agreed that knowledge creation opportunities had been utilized to their full potential (77%) or that they had resulted in innovation within the implementation of interventions (73%).
Knowledge creation likert scores
In open format answers, survey respondents indicated that knowledge sharing between partners had streamlined effective resource use and allocation, with one relating that “we learnt from the experience of the implementation of interventions and tried to align our interventions so they could be compliment to one another.” Another stated that “inputs [from partners] help improve our planning and organization capacity in policy advocacy,” while a third explained how “lessons drawn [from partner projects] provide means for effective planning and implementation of subsequent activities and projects.” Respondents also indicated that knowledge sharing contributed to the visibility of some projects, with one respondent in Ghana describing how “sharing of navigator findings with programs such as EPI has led to enhanced interest to use the navigator beyond NCDs.”
Trust
Over three-quarters (77%) of respondents expressed moderate or strong agreement that trust had been established and nurtured between partners. Four-fifths (82%) believed that accumulated trust had facilitated the sharing of data and project insights, with half that group expressing strong agreement. On the other hand, just two-thirds (68%) agreed that it had improved overall effectiveness of project implementation, and (64%) that it had contributed to collaborative decision-making and problem-solving. Only half (50%) of respondents indicated any form of agreement that trust facilitated resource allocation. Full Likert Scale responses to prompts on the dimension of trust are shown below in Fig. 3.
Respondent testimony described how trust was facilitated by knowledge sharing and mutual partnerships between stakeholders. One respondent stated that “workshops with participation from relevant partners and units to share knowledge and data increases transparency of government’s work and build trust among partners.” An implementing partner of NCDA explained how that partnership had helped build their network: “We learn the ways NCDA communicates with country partners. We follow that in building trust with Vietnam NCD alliance members.” Strengthening the network of mutual partners is critical to effective implementation, as one respondent emphasized that “sharing local stakeholder connections plays a huge role in fostering trust and ensuring smooth implementation of activities.”
Social capital
As shown below in Fig. 4, eighty-two percent of respondents indicated agreement that strong communications networks and relationships had been built with Access Accelerated partners, with half that group expressing strong agreement. When considering potential benefits from social capital in the partner network, a strong majority (86%) of respondents reported moderate or strong agreement and that working together had increased the visibility of their projects, compared to majorities nearly three-quarters (73%) agreeing that it had improved their ability to advocate for policy change, two-thirds (68%) that it had had positively influenced their organizational reputation, and just over half (55%) that it had improved their organizational ability to mobilize additional resources.
Social capital likert scores
Open responses clarified how social capital within the Access Accelerated partner network improved opportunities for collaboration and the effectiveness of working relationships. A respondent in Vietnam mentioned how working alongside Access Accelerated helped to “expand social capital across the country partners, including from the government, the party, and the national assembly, at the central and provincial levels.” In Kenya, another explained that “social capital has elevated the profile of our organization, improved our credibility with other stakeholders including the Ministry of Health and fostered a stronger relationship and trust with the [Access Accelerated] partners.” A respondent in Colombia elaborated how “being [Access Accelerated] partners has created the opportunity for local teams to learn from each other’s projects but more interestingly, strengthened personal relationships that allow for more collaboration around the areas we are working towards.”
Facilitators of connective tissue
Respondents were asked specifically about five factors that could facilitate the three dimensions of connective tissue. These were: 1) similarity in project objectives, 2) the existence of knowledge sharing touchpoints, 3) geographic overlap of project implementation, 4) mutual partnerships, and 5) the passage of time.
Sixteen respondents (70% of total) expressed that similar project objectives had caused some improvement or significant improvement in connective tissue among Access Accelerated partners, while 15 (65%) said the same for knowledge sharing touchpoints. Respondents highlighted that having both knowledge sharing touchpoints and similar project objectives facilitates alignment. For example, one suggested that “prior to the initiation of projects and activities, thorough stakeholder engagements are made to ensure that the agenda is in line with the objectives of our supply chain initiatives. This makes it easy for all the interventions to be apt and aligned with our sector wide objective and arrangements.”
Similar project objectives
-
“Having cancer as a common thread allowed strengthening the social capital in at least one of the common geographies where two of these organizations worked. During the interactions, being AA partners created an invisible bond that allowed knowledge sharing and strategy alignment.”
-
“The Ghana NCD Alliance was instrumental in the NCD Navigator project led by PATH Ghana. While the Navigator identified CSOs and areas of operations, the [Ghana NCD Alliance] identified people with lived experience to support advocacy.”
Knowledge sharing touchpoints
-
“Developing shared materials with learning opportunities and participating in panels organized by either organization has allowed to interact, learn from each other and bring local stakeholders to the spotlight.”
-
“Larger pool of knowledge shared among partners increase its robustness and integrity, integration of activities also enhances effectiveness and reduce overlapping in activities implemented, overall trust is improved.”
Only 13 out of 23 (57%) respondents indicated that any improvements in connective tissue could be attributed to mutual partnerships between their organization and other partners, and the same proportion attributed improvements to geographic overlap of partner projects. Respondents also commented on changes in knowledge creation, trust, and social capital over time, indicating that these qualities had strengthened within the working relationships of Access Accelerated strategic partners and stakeholders from 2017 to 2023. The survey elicited the following illustrative quotes from respondents on the ways in which these potential facilitators of connective tissue have impacted their projects:
Geographic overlap
-
“Geographic overlap of office and staff enhances the cooperation between partners, increasing both trust and knowledge sharing”
-
“The fact that the two organizations work together in the same territory strengthens and gives synergy to actions and projects.”
Mutual partnerships
-
“Partnerships can be official or unofficial, and from my perspective with AA partners, mutual partnerships create an unofficial relationship that can be leveraged to either become an official partnership or a common starting point.”
-
“We meet at events and share our individual and sometimes collective advocacy priorities for government consideration.“
Time
-
“Trust has increased over time.”
-
“The more time passes, the stronger these bonds become and the more comfortable teams feel to reach out for support, advice or stakeholder management.”
Respondents suggest that working in the same place at the same time is important and supports collaboration. One noted that an “invisible bond” had resulted from shared objectives and helped develop knowledge sharing, trust, and social capital among partners. Overall, respondents indicate that membership in this network facilitated the mutually beneficial sharing of project insights, advocacy priorities, and local stakeholder connections.
Identification of barriers to connective tissue
The survey inquired about barriers to cooperation, prompting respondents with a free response option in addition to a checklist. Of the 23 respondents, only 6 (26%) suggested that any of the options presented had hindered cooperation. However, two of the 23 surveys indicated that “geographic distance” had hindered cooperation, as did 3 for “competition for funding,” 3 for “differing goals and priorities,” and 4 for “resource constraints.”
Respondents also mentioned busy schedules among partners, lack of knowledge about partners, and interference from alcohol and tobacco industry groups as barriers. The identification of interference from private sector actors highlights the potential for conflicts of interest within public-private partnerships and underscores the importance of strong governance mechanisms within multisectoral coalitions. Although respondents on average identified less than one barrier to the development of connective tissue, cumulative counts of each response are shown below in Fig. 5.
Count of identified barriers to connective tissue
Identification of potential benefits from connective tissue
Respondents were prompted to comment on 10 potential benefits from connective tissue as identified by the review panel. The average respondent agreed with 8 of the options presented, with the most frequently cited benefits, “fostered a collective vision for improving access to NCD care” and “created opportunities for stakeholders to identify and leverage each other’s strengths, resources, and expertise,” each being selected by 20 out of 22 (91%) of respondents. Additionally, respondents wrote in that they had seen knowledge creation, trust, and social capital among partners lead to capacity building, the implementation of best practices, elevated organizational profiles, lower government corruption, and meaningful involvement of stakeholders. The collected responses don’t confirm the existence of these benefits or conclusively attribute them to knowledge creation, trust, and social capital, but they reinforce the usefulness of the connective tissue concept and merit further exploration through studies with more rigorous research methods.