The coronavirus pandemic and a “prehistory of cooperation” were the “starting conditions” (3) that triggered our efforts to strengthen collaboration. There was an urge to build on existing collaboration to mitigate the risk of disruption of MNH services. The challenge was too urgent and overwhelming to be tackled by individual efforts and the following aims emerged from the situation: 1.

Combine wider skills and resources to tackle the threatened disruption of MNH services that might have cost the lives of women and newborns;

The first case of COVID-19 in the ESA Region was reported in March 2020 in South Africa. Countries urgently requested guidance from the UN ESA team since the global guidance at that time did not include specific guidance on pregnancy and childbirth. The first joint webinar was held on 9 April to discuss the regional situation regarding COVID-19. The emphasis fell on the MNH situation in South Africa, where the lockdown measures had been implemented a few days before. By 17 April, joint technical guidance on the continuity of MNH services during COVID-19 had been developed and shared, later to be updated as global guidance became available. The joint ESA team decided to work together to avoid potentially fragmented operational guidance and technical briefs that would have led to inefficient service implementation. The aim was to provide easy, practical, step-by-step guidance to inform the provision of MNH services in the ESA countries (9).

When restrictive pandemic lockdown measures came into effect, in-person technical support to countries was suspended due to prevailing travel restrictions. With global evidence generation advancing rapidly, it was important to obtain synthesized evidence-based guidance from the global secretariat without delay. The initial task of the collaboration was to disseminate operational guidance on the provision of MNH services during the pandemic. Face-to-face training had to be replaced by virtual or hybrid models of blended learning, where country teams implemented the interventions at selected learning sites after receiving some didactic sessions. This need for guidance led to the following joint activities by the three agencies to support countries in three phases (see also Figure 1): (i) an initial series of webinars held between April and October 2020; (ii) virtual capacity building in quality of care (June to October 2020) and maternal and perinatal death surveillance and response (MPDSR) (November 2020 to July 2021); and (iii) the development and testing of online e-learning modules as part of continuous professional development (CPD) during the remaining months of 2020 and in 2021. These activities reached more participants than traditional face-to-face activities.

Phase 1. Webinars (10). An initial series of 15 webinars was held with a diverse group of 1,841 participants. Attendance ranged between 85 and 164 participants per webinar (median 124 participants) who included officials from ministries of health (and social services), UN agencies at country level, development agencies (e.g., Save the Children, PATH), professional organizations, universities, and country-level non-governmental organizations. The organization of each webinar was a joint responsibility, with each agency undertaking specific tasks (see Supplementary Table S1 in the Supplementary File). The regional focal persons of the collaboration agreed on key topics, deliberated which agency had the comparative technical advantage to present the topic, and analysed the different organizations to see which administrative and logistical measures could more easily be undertaken by each agency. For example, UNICEF was responsible for setting up the zoom facilities and sending out invitations, which were then further distributed through the other two agencies. The topics included the following: COVID-19 themes related to various aspects of service delivery and care across the MNH continuum; country experiences with the pandemic; guidance on clinical care during pregnancy, childbirth and immediately after birth in the context of COVID-19 (including quality care for small and sick newborns, who are the most vulnerable when the health system is strained); infection prevention and control (including personal protective equipment); gender-based violence (which showed high increases in some countries during the early phase of the pandemic); and MPDSR.

The webinars were inclusive and participatory. From the beginning feedback was collected from participants on the usefulness of the sessions, and actions taken at country level as a result of the webinars were checked. Participants were also asked to indicate specific areas on which they needed a webinar or more information and guidance. These requests were then used to plan for subsequent webinars and training events with a view to developing the national capacities around unified guidelines and technical support, and to creating a place for cross-learning and experience-sharing among member states.

Phase 2. Virtual capacity building. In addition to the webinars, the collaboration launched a regional virtual training program in MPDSR under the 2gether 4 SRHR program. The aim was to support countries to accurately document the magnitude of maternal and perinatal deaths, and identify, classify, and report the underlying causes of death so as to inform correct management and systems strengthening. This was also critical for identifying maternal and perinatal deaths associated with COVID-19. Over 70 participants from Kenya, Namibia, Rwanda, Uganda, Zambia and Zimbabwe took part in the 13 consecutive sessions. Topics included the following: identification and notification of maternal deaths occurring in health facilities; medical certification of cause of death; international classification of cause of death; linking MPDSR with Integrated Disease Surveillance and Response (IDSR) and health management information systems (HMIS); and report-back from countries.

There were also country initiatives to strengthen quality of care in MNH. One example was the virtual capacity-building workshops in quality improvement for multidisciplinary teams and coaches organized by the regional MNH collaboration and the agencies' country offices in coordination with ministries of health in Kenya and Ethiopia (11). The main goal of these workshops was to prepare and equip a pool of resource personnel for effective implementation of the quality improvement agenda at the national, regional, district and health facility levels. Observers from Ethiopia, Tanzania, Malawi, and Namibia attended the Kenya workshop with the aim of generating interest and replicating similar workshops in their respective countries.

Phase 3. E-learning. With the increasing demand for practical information and the high attendance of webinars even beyond ESA, it became imperative to transfer existing modules onto an e-learning platform. This was intended to increase access to a wider audience, while allowing health workers to obtain CPD points.

Nine e-learning modules were developed and hosted in the World Continuing Education Alliance (WCEA) platform. The modules cover the WHO Labour Guide (1 module), Maternal Death Surveillance and Response (MDSR) (4 modules) and Perinatal Death Surveillance and Response (PDSR) (4 modules) (see Supplementary Table S2 in the Supplementary File). All modules are available in English, and some have also been translated into French and Portuguese. Between February 2021 and October 2022, 216,487 course modules were taken by 99,440 learners, with about half of the participants residing in the ESA Region and the other half in other regions.

A key feature of this collaboration was the ability to leverage the comparative advantage of each agency. The regional offices of the agencies are geographically dispersed, each with their own varied governing structures, administrative procedures, and program niches. WHO is mandated to avail and promptly share the most up-to-date evidence-based global guidance; UNICEF and UNFPA support strengthening the capacity of national health systems and processes so that no child or mother is left behind. The synergy between the interagency partners was further enhanced by the WHO's ability to harness area experts to address the technical elements of the webinars and training, with UNFPA having the edge in monitoring and evaluation, data analytics and oversight of the virtual training platforms. UNICEF had the edge in perinatal and child health issues and quality of care, and took the lead in coordination. Furthermore, the members of the regional collaboration were committed to transparency in working together towards a common goal.

Negotiating the “ground rules” for collaboration (12) was facilitated by the fact that all three agencies were part of the UN institutional family, each with its own extensive network of other partners. The collective commitment of the three agencies to ensuring continuity of MNH services during the pandemic steered the collaboration in three main areas of the H6 model: technical support, convening role, and advocacy (2). The technical area included availing up-to-date evidence-based guidance to facilitate the continuity of MNH services during the pandemic, monitoring and evaluation of the provision of services, monitoring of program data, and the periodic dissemination of reports. Convening entailed setting up a technical advisory group, coordinating the webinars, establishing the e-learning platform, and convening other collaborative meetings. Advocacy was focused on guiding national governments to prioritize MNH services within the pandemic agenda to ensure that COVID-19 measures integrated actions to enhance the continuity of MNH services. There was also a focus on promoting collaboration on digital health for MNH with regional communities such as the Southern African Development Community (SADC), the East African Community (EAC), and the African Union Commission (AUC).

We used and adapted Ansell and Gash's dimensions of a collaborative process (12) to organise information and observations of how our collaboration functioned. The dimensions include: a common vision; commitment to the process; dialogue; building relationships and trust; communication and information sharing; sharing of technical and financial resources and expertise; mobilization of additional resources; celebration of intermediate outcomes and “small wins”; facilitative leadership; and institutional design. Table 1 contains a more detailed description of each dimension.

Commitment is a critical element in initiating and maintaining collaboration. The commitment of the ESA team inspired greater commitment from the teams of the three agencies at regional and headquarters levels to trusting and supporting this interagency collaboration at a time when there was no evidence as to the best way to ensure continuity of MNH services during the pandemic. Commitment to stepping into the unknown involved risk taking, since we did not know whether initiatives would go wrong. The collaboration facilitated regional learning and provided guidance on MNH in the context of COVID-19 while we waited for conclusive guidance from headquarters. Risk taking also took the form of pushing the boundaries, asking for help without always following the usual channels of communication and fast-tracking contracts with service providers. The focal persons were also committed to acquiring new virtual communication skills and learning to be flexible about working hours.

Collaboration between agencies, without loss of autonomy, can result in enhanced efficiency through the sharing of functions and resources. In our collaboration the three agencies largely retained their own internal structures (support, administration, and indirect costs), but provided time and management to the partnership regardless of the form. During the health emergency there was insufficient time to develop a formal collaborative framework that explicitly quantified the trade-off between shared function gains and collaboration costs. On the other hand, the pre-existing ties between the agencies made it possible to achieve good results through collaboration.

Having a common goal can break down existing silos based on categories of RMNCAH. We adopted the mantra “together each achieves more” (TEAM) to move away from ad hoc joint tasks and develop a longer-term joint plan incorporating milestones of results to be achieved along the way. Our interagency collaboration also meant improved representation as a single UN body—when one agency was absent, the others ensured the issues related to the absent agency were addressed.

Through joint work, opportunities arose to link up with broader UN interagency mechanisms and there was potential to attract bigger collaborators such as the African Centers for Disease Control and Prevention (CDC).

The harmonized TEAM approach during the pandemic had the following advantages: •

A unified approach was adopted when exploring connections with country offices. This avoided fragmentation and reduced countries' transaction costs (particularly costs incurred by national government focal persons) as they only had to respond to one instead of three requests from the agencies. The UN agencies also saved time by jointly monitoring countries’ RMNCAH service continuity.

When the global pandemic emergency and accompanying travel restrictions set in and rendered commonly used capacity building modes like workshops and field missions impossible, innovation and the use of technology offered a solution. The joint UN–ESA offices realized that there were more participants requiring support than could be reached through webinars. A concept paper was developed which envisioned collaboration between (a) the three UN agencies to ensure customization of global guidance to the regional context, (b) educators (professional associations and councils) to develop training content and train their members, and (c) a reliable technology company to convert the training content to e-learning modules.

The World Continuing Education Alliance (WCEA) was competitively selected as the technology company for hosting the e-learning modules and disseminating the training. A major advantage of using a technology platform was cost saving. We calculated that a physical workshop would cost on average US$100,000 per workshop for about 70 participants, whereas the initial cost of setting up the modules on the technology platform was US$70,000. The program has now been running for more than two years and is reaching a much higher number of participants. Other advantages of harnessing technology include: real-time feedback and data disaggregated by demographic variables; increased reach and influence; and online and offline access to modules through downloadable documents and videos. In addition to the formal arrangement with WCEA, countries and individuals were also encouraged to explore the contents and courses available on other e-learning platforms such as the WHO Academy.

Our collaboration contradicts the widely held belief that less formalized collaboration does not result in increased levels of harmonization between implementing agencies. This style of informal collaboration with a small number of important partners can be highly beneficial in instances where collaboration is required in an emergency or for a time-sensitive effort. Examining the context in which a collaborative framework operates is critical for creating an understanding of the incentives that influence agency decisions about cooperation levels and types. A common vision and agreement on shared ideas and skills can be a game changer.

Developing collaboration tools can also have an impact in times of emergency. Such tools include planning strategies for operational coordination and implementation, joint concept notes and terms of reference for specific tasks, designing communication strategies with other partners and potential funders, and utilising virtual communication, training and survey tools.

Any kind of collaboration has its challenges. In our case we faced frequent changes in global guidance early in the pandemic, necessitating reorientation of country teams and eroding trust. Competition for resources continued and the regional interagency collaboration was difficult to replicate at country level. Sustaining collaboration became challenging when key members of a country team moved away from the region. Time pressures sometimes led to delays in responding to urgent requests. Lastly, the virtual environment posed challenges for e-learning participants who had difficulty in familiarizing themselves with the app feature for accessing the e-learning modules. Discussions are ongoing to functionalize the community of practice feature of the app.