Abstract
Background: There is widespread agreement on the potential of multisectoral action to address the social determinants of maternal health. We conducted an implementation research study in Meghalaya, a northeastern Indian state with a high burden of maternal mortality where the government initiated "Rescue Mission" to strengthen the health system and to address underlying determinants to improve maternal health indicators. The initiative was grounded in building state capability and decentralised leadership. Objective: We developed a theory of change and examined implementation barriers and enablers through an implementation research study with government and community actors and institutions. Methods: We conducted multiple rounds of qualitative data collection over a period of eighteen months across six districts. Participants included primary care providers in the public health system and frontline workers in thirty sampled facilities. We also interviewed officials across three government departments, observed meetings and met regularly in a feedback loop with government. Data were analysed thematically and synthesised according to pathways of change. Findings: The state institutionalised multisectoral collaboration across governance levels through building technical and adaptive leadership. Processes included joint meetings at the facility, district and state levels to develop action plans and facilitate collaboration, community engagement through frontline workers and decentralised use of data. Strength of participation by different sectors varied widely; non‑health cadres reported challenges such as being accountable to multiple departments. Political priority and administrative leadership were the key elements of the State's ability to implement a multisectoral approach. Overall, health outcomes improved and the State largely achieved its commitment to building technical skills, but also recognised the need for further investments to develop a sense of purpose amongst government officials. Conclusions: Meghalaya's experience in multisectoral collaboration demonstrates the potential of health systems reform grounded in a state capabilities enhancement approach, with a focus on participation and building decentralised leadership.