Setting strategic directions and goals

In most European countries, formal instruments and mechanisms are in place to ensure accountability in health systems. They include mechanisms for priority-setting, national health strategy development, strategic planning, target setting, performance measurement and performance reviews. The use of these mechanisms has increased in recent years, partly inspired by Health 2020, the WHO European policy framework for health and well-being (WHO, 2015). The mechanisms involve processes or programmes that have been either formally established (for instance by law, or as part of institutional mandates) or result from informal initiatives. They are usually designed around a systematic framework, such as in the development of a national health policy with longer term horizons (5 to 10 years). Another example is a strategic health plan, which is usually developed for a medium term, is more operational in nature, and assigns responsibilities to specific institutions in the health sector. In countries in which decision-making on public health policy development is less centralized, such as in Germany and Austria, health target programmes have become the predominant form of setting priorities and strategic directions for population health.

Typically, these mechanisms are not kept separate for health care and public health services but are integrated, to varying degrees. They can also be combined formally. For instance, a strategic health plan can operate in combination with a health system performance assessment framework, and a national target programme can work in combination with a national health strategy. The degree to which policy decisions are influenced by these mechanisms differs and is often less dependent on the choice of instruments and more on system features (e.g. the degree of centralized or decentralized decision-making). A prevailing feature in many countries are national priority frameworks, established to inspire and inform subnational strategies. At the subnational level, public health institutions or regional and local authorities have often some degree of flexibility to adjust national frameworks to regional or local requirements, needs and demands. Box 3.2 illustrates some examples of past and ongoing processes to set priorities, strategic directions, as well as goals and targets for public health policy-making.

Box 3.2

Examples of processes and institutions for setting strategic directions for public health services.

As these examples illustrate, most mechanisms for setting health policy priorities are coordinated by central government. Public health institutions often contribute to the design of strategic plans and can also play a role as implementing agents. However, only a few strategies attribute institutional responsibilities to specific public health organizations in terms of implementation and monitoring. Some countries, such as England, France, Germany, Italy, and Sweden, have in recent years expanded the role of national health technology assessment agencies to assess the cost–effectiveness or cost–benefit of public health interventions.

Health monitoring

Health monitoring is the first of the essential public health operations as defined by WHO Europe in 2012 (see Figure 2.1). It enables the systematic and continuous tracking of health indicators, and indicators that are relevant for health and well-being. Public health reporting is one of the most common mandatory tasks of public health institutions in countries of the WHO European Region. However, public health reporting tends to differ markedly in its depth, breath, coverage and frequency. For instance, various national health institutes in northern and western European countries have seen their mandates extended in recent years to monitor noncommunicable diseases. An example is the Robert Koch Institute in Germany, that has gradually taken over noncommunicable disease monitoring and reporting in its regular health status report.

Health protection

Key aspects of health protection include health security, occupational health and environmental health services. Institutional arrangements for health protection are typically fluid, integrated, and build on intersectoral collaboration mechanisms that cross institutional boundaries. In the United Kingdom, for example, Parliament is responsible for making legislation and the executive for implementing it, including through the activities of government agencies. Policies derived from the legislation may be developed by individual ministries or, in some cases, interministerial cabinet committees. Parliament then has the ability, through its select committees, to hold the executive to account.

Institutions engaged in environmental health protection must have the ability to monitor aspects of the environment that may have an effect on population health (Leonardi & Rechel 2014; WHO, 2014b). However, many elements may lie outside the responsibility of the health ministry, involving sectors such as housing, transport, agriculture, and employment. Consensus on the urgency and means of addressing developments through the public health infrastructure is often lacking (WHO, 2012).

Occupational health services are important settings for health protection in terms of preventing accidents and injuries, but they can also contribute to health promotion and disease prevention. Most occupational health services are provided at primary health care units in larger workplaces, whereas employees in smaller and medium-sized companies often do not receive services beyond a minimum (Kim et al., 2014). An earlier study has drawn attention to the deterioration of occupational health services in countries that have seen a trend to deregulate, privatize and outsource public services, but occupational health services in Europe have also seen a decline following the global financial crisis after 2007 and an increase of precarious working conditions (White, 2015).

Health care public health, disease prevention and health promotion

The separation of public health institutions from the provision of health care is somewhat artificial (McKee et al., 2014). The term “health care public health” refers to the roles of public health institutions (and public health professionals) to maximize health gains through the delivery of health care to individuals and population groups; however, this role is underdeveloped in most European countries or does not exist at all (McKee et al., 2014). In England, Health and Well-Being Boards were established by the Health and Social Care Act 2012 as a means of coordinating preventive and curative services. The Boards are established by local authorities and include representatives from the National Health Service (NHS), public health institutions, social and child care.

In most countries, public health institutions are involved in the coordination or implementation of disease prevention and health promotion programmes. They may also play a role in the coordination of screening programmes for cancer and inborn errors of metabolism. Health care providers, in particular at primary care level, are often crucial for the delivery of health promotion and disease prevention services. In some countries, NGOs also play a role in service provision, but their work is sometimes made challenging by the lack of systematic quality monitoring, a competent public health workforce, and sustainable financing.

There are marked differences between countries (WHO, 2012). Classical prevention services, including immunization and mother and child health services, are provided in primary health care settings in nearly all countries of the WHO European Region, whereas the organization of screening programmes differs greatly across countries (WHO, 2012). An example of a country that has strategically enhanced public health functions at primary health care level is Slovenia (Box 3.3).

Box 3.3

Scaling up public health services in primary health care in Slovenia.

Box 3.4 presents examples of health promotion and primary, secondary and tertiary disease prevention services provided by GP practices or community health centres.

Box 3.4

Examples of health promotion and disease prevention services provided by health care institutions.

Research

Many public health institutions at the national level are involved in public health research, including in England (Public Health England), Germany (Robert Koch Institute), the Netherlands (National Institute for Public Health and the Environment), Italy (Istituto Superiore di Sanità), the Republic of Moldova, Portugal (Institute Ricardo Jorge), Slovenia, and Spain (Institute of Health Carlos III). Public health institutes at the subnational level tend to have more limited roles in research, reflecting limited capacity to attract project grants, whereas at least some research funding for national public health institutes is often allocated directly by the state.

Yet, the landscape for public health research is dynamic and differs greatly between countries. For instance, in France the coordination and financing of public health research was recently enhanced through several means. An initiative to coordinate public health research across the country led to the creation of the Institute for Research in Public Health that coordinates financing of public health research through competitive funding calls. There are also some regional institutes with a mandate to undertake public health research, such as the Public Health Institute for Epidemiology and Development in Rennes. Another recent development is the creation of France Assos Santé that represents 72 NGOs and aims to improve the use of health data for research in public health.

In the Netherlands, academic collaborative centres were set up in 2006 with government funding and a mandate to improve the evidence base on health promotion and forge collaboration between policy-makers, public health professionals and researchers. However, it has proven difficult to steer research into directions serving the public interest and the programme was terminated in 2014, although some regional public health institutes are continuing the activities of academic collaborative centres.

In Germany, local public health offices do not have an explicit mandate to undertake public health research, although they are not prohibited from undertaking it either. They can undertake research with their own resources or can mobilize project funding. Often, they collaborate with universities, as they lack the research skills, facilities and overall capacity.

Forms and features of vertical organization

We identified three principal ways in which institutions providing public health services are organized vertically, some of which may operate in parallel within a country (Fig. 3.1):

• national public health institutions, mostly giving strategic directions;
• regional public health institutions, mostly coordinating and planning services;
• local public health institutions, mostly involved in service provision.

Fig. 3.1

Principle vertical forms of institutions providing public health services. Source: Authors’ compilation

However, in several countries, there is a fourth layer of services or administration, so that there can be, for example, institutions at the regional, municipal and local level.

National public health institutions

National public health institutions usually assume specific responsibilities, such as population health monitoring, research, public health policy advice, inspection services or issuing guidance for public health professionals. Most countries in Europe have a national public health institution with similar mandates and roles. Table 3.2 exhibits functional and structural features of national public health institutes in selected European countries.

Table 3.2

Features of national public health institutions in selected European countries.

Regional public health institutions

Regional public health institutions can be independent organizational units or subordinate units of national agencies (Box 3.5). One of their tasks can be to provide public health services for lower levels of administration (e.g. municipalities) that do not have the capacity to provide these services themselves. In other cases, regional public health offices are mostly responsible for coordinating public health services. In some countries, such as France and Italy, regional public health offices have responsibilities for coordination and planning of public health services but are also tasked with some delivery responsibilities (e.g. for health protection, some disease prevention and health promotion).

Box 3.5

Examples of regional public health institutions.

Local public health institutions

Local public health offices exist in all European countries, but they differ in the degree of autonomy and the level of integration with local health authorities, health service providers and other sectors. At one end of the scale, there are examples of full autonomy (at least in some areas of public health) where national bodies delegate decision-making to local public health institutions. These then take on responsibilities for setting strategic priorities, establishing organizational structures and raising funds. At the other end of the scale, local public health institutions are branch offices of central or regional authorities without any decision-making authority. Public health authorities at the local level can create opportunities to integrate public health services into the municipal health policy process, although this potential is rarely realized in practice.

The existence of, and degree of independence afforded to, local public health offices usually reflects the political and administrative structures in the country and its health system and the degree of decentralization it has embraced. In Sweden, for example, there are self-governing municipalities, based on a tradition of local democracy. They are responsible for the welfare of their residents, providing services such as nursing homes for older and mentally ill people and environmental health services. In the Netherlands public health is understood as a shared responsibility between the central state and local government and the provision of public health services follows the principle of “decentralization unless”, shifting the balance of responsibilities to the country’s municipalities. In Germany, local public health offices are the dominant form of public health service provision, in particular in those federal states where public health offices at the federal state level do not exist. They are responsible for public health reporting, managing health promotion activities and the provision of prevention activities for vulnerable groups. In Italy local health authorities provide public health services related to health protection and promotion.

Table 3.3

Organizational features of local public health institutions in selected European countries.

Relationships between the different levels

Relationships between the different levels of public health services can follow a more or less pronounced hierarchy. At one end of the spectrum is the conventional hierarchy with a top-down chain of command and control in which a central organization has the principle authority for decision-making and the subordinate institutions are following commands, orders and instructions, and report to the central authority. At the other end of the spectrum there is a flat hierarchy, up to complete local independence.

These different types of hierarchy are directly related to the degree of independence afforded to the local level. They are embedded in the broader administrative organization of the country in question and are very much context-dependent. Broadly speaking, stricter, top-down hierarchies of public health services are more prevalent in eastern European countries, while flat hierarchies are more common in western and northern European countries.

However, there are major differences between different types of public health services, with some following a more vertical hierarchy. This applies in particular to infectious disease control and the response to public health emergencies, where even more decentralized systems follow a strict chain of command and control to ensure an effective response. Coming back to the example of the Netherlands, detailed national protocols are available and have to be followed for the more medically-oriented tasks, including infectious disease control, environmental public health, screening programmes and youth health care. This means that, in most countries, a mix between different types of hierarchy exists.

While there is no one-size-fits-all public health service, and what works in one country might not work in another, this variation across different types of public health services indicates that both approaches have advantages and disadvantages, many of which have been identified in the literature on health system decentralization (Saltman, 2008). A top-down hierarchy makes it easier to pursue central directions and objectives and achieve local compliance. However, as subordinate authorities are line-managed by supervisory authorities, it might be more challenging to ensure a corporate identity and allegiance to central directions and objectives. For seamless functioning, this form of organization is also demanding in regard to the need for regular feedback and reporting. Responsiveness to local needs and recognition of what is possible to achieve at the local level may also be compromised. In its worst case, there is a total disconnect between rationales, objectives, and processes of decision-making at central and local level, with potentially draining effects on resources and morale at all levels.

Centralization

Centralization takes place when activities or organizations are concentrated at a higher-level authority. This may take the form of a single authority or a number of institutions. The degree of centralization of public health functions is determined by contextual factors, including the geographical size of a country, its population size, the political and administrative set-up and the number of institutions (Box 3.6).

Box 3.6

Illustrative quotes from the interviews on centralization.

A centralized structure has the potential to take a visionary, strategic and whole-of-government approach, and to respond to major national challenges and risks. The decision to centralize structures and functions can increase economies of scale and facilitate the recruitment of staff. It can also help in the implementation of strategies by establishing more effective oversight arrangements.

Centralization can be comprehensive or partial and can be implemented through mergers or the abolition of subordinate regional or local structures. Centralization can take place with various objectives, for instance to increase decision-making authority by extending coverage and scope of a national public health institution, to save costs by disinvesting in lower-level administrative structures, or subsume key functions into a central level authority to increase coordination.

Institutional mergers of national level public health institutions have been pursued in recent years in Finland, France, Italy and Sweden, while mergers of municipal health services took place in France and the Republic of Moldova (Box 3.7).

Box 3.7

Examples of institutional mergers.

The scope for centralizing public health institutions is shaped by the degree of devolution within each country. It is beyond the scope of this volume to review these in detail as the arrangements that exist are often quite complex, such as those between the four countries of the United Kingdom and its overseas territories, or between France and the Netherlands and their overseas territories. Other examples include Switzerland, a confederation, and federal countries such as Germany and Austria, whereas in Spain and Italy, while not fully federal states, many responsibilities have been devolved to regions. In the Scandinavian countries, decision-making has been traditionally more dispersed to local actors, although in some, most notably Finland, there are current proposals for creating regions from the very large number of municipalities.

Decentralization

Decentralization is when decision-making authority or organizational structures are dispersed to lower-level administrative units. Most countries in Europe have decentralized the provision of public health services to subnational organizational units or more or less autonomous institutions that provide services at the district, municipal and community level (Box 3.8).

Box 3.8

Illustrative quotes from the interviews on decentralization.

In Scandinavian countries, the Netherlands and Switzerland, public health institutions have traditionally been decentralized, in line with constitutional arrangements. In some countries of central and eastern Europe and the former Soviet Union, some public health institutions were decentralized, which included the transfer of some responsibilities from central to peripheral institutions (WHO, 2012).

A particular challenge has been the privatization of public health services in some central and eastern European countries, especially with regard to diagnostic laboratory services to detect environmental hazards (including in air; water; and soil; and related to chemical, radiological and biological hazards) and to test food products. Public health laboratories have started to offer services to the market to generate income, distracting from the core mission of the state-run public health service.

Advantages of decentralized structures can be that decision-making is more responsive to population needs and expectations, that they foster local democracy by enabling direct interaction between institutions and the population, that they facilitate intersectoral working across adjacent policy areas, and that they allow for local innovation. Fragmentation, inequities, competition for funding and lack of institutional alignment are challenges to overcome in decentralized arrangements, although the risk is smaller and can be mitigated with effective coordinating units at the national or regional level, as is being attempted in France and the Netherlands. A number of policy tools are available to support local level public health services in decentralized structures (Box 3.9).

Box 3.9

Policy tools to support local level public health services in decentralized structures.

Models and features of horizontal organization

Vertical relationships require clear institutional boundaries, but in many countries public health services lack them and many actors involved in providing public health services collaborate horizontally under more or less formal mechanisms, both within the health system and beyond.

Scaling up formal and informal collaboration and networking

In most countries, the provision of public health services is scattered and responsibility divided among multiple institutions. Effective coordination requires dynamic and active linkages between institutions responsible for policy-making and regulation and those that provide public health services. These linkages are particularly important at regional and community levels, where geographical distances are closer and regional and local networks can build on informal relations between institutions and staff. Overall frameworks can help to align institutions, facilitating formal and informal collaboration and networking, and ensuring that service provision follows a coherent path. Cooperation and partnerships that have developed in routine settings are particularly relevant in times of crisis and public health emergencies, when time is scarce to set up new networks (Box 3.10). They may also prove important when policy change is needed. Many countries have in place structures or mechanisms to coordinate local, subnational, and national public health actions, although the extent to which they succeed varies greatly and it is always necessary to decide whether the benefits of coordination outweigh the transaction costs that are incurred in maintaining relationships.

Box 3.10

Coordination of health service provision to refugees by local health authorities in Hamburg, Germany.

The situation is much more complicated when developing links with private organizations. Sometimes, such relationships will be uncomplicated, for example when a public health organization contracts with a provider of particular products or services that the organization cannot produce itself. Other cases are more difficult, especially where the private companies have a vested interest in the issue being addressed. Thus, producers of harmful substances, such as alcohol or junk food, are anxious to gain a seat at the table whenever policy is being developed. This was also true once with the tobacco industry but the Framework Convention on Tobacco Control makes clear that any involvement with it is unacceptable and while the industry is actively trying to circumvent this principle using a range of alternative nicotine delivery devices, the World Health Organization and leading public health organizations have completely rejected this. The “public health responsibility deal” in England, consisting of voluntary pledges for action that industries, government and other organizations could sign up to, was one of the most closely studied examples of this approach, with evaluations showing that it achieved very little in terms of concerted public health action (Knai et al., 2015). The industries involved typically advocated those measures that were least effective (and which also did least damage to their profits) while opposing measures that would work.

Another set of relationships involve NGOs, which play an important role in service provision in many countries. They can also contribute through national and international initiatives such as the international network of Health Promoting Hospitals & Health Services and the International Foundation of Integrated Care. The WHO Regional Office for Europe has also inspired practical approaches by adopting a framework for action on integrated service delivery in the WHO European Region (WHO, 2016a).

Boxes 3.11 and 3.12 provide examples of institutional mechanisms deployed by some countries to foster collaboration and partnerships within and across sectors.

Box 3.11

Examples of efforts to enhance collaboration with partners in the health sector.

Box 3.12

Examples of efforts to scale up intersectoral collaboration and partnerships.

Legal and regulatory changes

Public health functions, like any state activity, operate under the law (Dubois et al., 2006). Like all laws, public health legislation must be revised from time to time to keep pace with changing circumstances. Recent legislation changes include the Public Health Act in France (2004), the Public Health Act in the Netherlands (2008), the Law on State Surveillance of Public Health in the Republic of Moldova (2009), the Health and Social Care Act in the United Kingdom (2012), the Law on Public Health in Poland (2015), and the Health Services Act in Slovenia (2013).

The legislation in the Netherlands, responding to judicial claims for financial compensation for failures in ensuring effective health protection during an outbreak of Q fever 2007, reinforced the shared responsibility between the state and the municipalities. The new legislation in France redefined relationships between the national and the regional level. It clarified the need for planning public health services at both levels, with planning at the regional level becoming the responsibility of the newly created regional health agencies (ARSs). The recent legislation in England had a major impact on institutional arrangements, by moving public health services from the NHS to local authorities. The 2009 Law on State Surveillance of Public Health in the Republic of Moldova introduced new functions of noncommunicable disease monitoring, prevention and health promotion, although with limited responsibilities and personnel for these new functions. In Slovenia, the Health Services Act in 2013 separated laboratory from other public health functions, setting up a separate National Laboratory for Health, Environment and Food, alongside the National Institute of Public Health, each with its subordinate regional structures. The reform was partly triggered by the lack of cooperation and coordination between the previously independent regional public health institutes that also provided laboratory services. Another problem was that financially lucrative laboratory services took priority. While some of the regional public health institutes were able to generate additional income, others accumulated debts requiring subsidies from the government budget. Table 3.4 shows some recent public health laws and their implications for organizational reforms of public health services.

Table 3.4

Selected public health laws and their implications for organizational reforms.

Conditions for successful implementation

A number of features have been associated with successful implementation of change (Thomson et al., 2014):

• ensure reforms are underpinned by capacity, investment and realistic time frames;
• ensure reforms are in line with national policy goals, values and priorities;
• ensure transparency in communicating the rationale for reform and anticipate resistance to changes that challenge vested interests;
• improve information systems to enable timely monitoring, evaluation and the sharing of best practice;
• foster strong governance and leadership at national and international levels;
• address gaps in coverage;
• strengthen health financing policy design;
• invest in measures to promote efficiency.

Yet, in practice, whether a reform achieves its objectives will depend, to a large extent, on the prevailing context. This includes the general economic, social and political conditions of a country. Implementation is characterized by complexities, involving multiple actors at all policy levels, that are not easily comparable across countries. In view of the overriding importance of contextual factors, it is impossible to come up with any single or simple model for meeting the challenges of implementation. Simply speaking, there is no one-size-fits-all approach to policy implementation (Cerna, 2013).

A number of observers have pointed out the need for strong governance or leadership for policy reforms to succeed and policies to be implemented (EXPH, 2016). A recent framework for analysing and improving health system governance suggests five key attributes of governance (Greer et al., 2016): transparency, accountability, participation, integrity and capacity. These attributes help to identify the governance elements required for effective implementation.

Participation means that affected parties have access to decision-making and power so that they acquire a meaningful stake (Greer et al., 2016). A key point here is that “good governance” involves “shared governance” among different levels of public sector government (national, regional and local) as well as buy-in from private sector actors, health workers and the general population (Saltman & Duran, 2015). Successful reforms have often been accompanied by consistent coordinated efforts to persuade voters and stakeholders of the need for reform and, in particular, to communicate the costs of nonreform. Real engagement with stakeholders also involves listening to their concerns, and may well result in some modification of reform proposals (EXPH, 2016).

A 2016 WHO Regional Office for Europe report argued for a balance between top-down and bottom-up implementation. Large-scale initiatives require a balance between centralized strategic planning and coordination, and autonomy and empowerment at the local level to generate innovation and more sustainable engagement. Investing in skills and resources at the point of clinical care is vital but needs to be supported by an overarching body that can provide high-level strategic alignment, large-scale coordination, consistent provision of standardized and specialized resources and training, and the removal of obstacles that are beyond the ability of local departments to overcome (WHO 2016a).

Successful implementation of health policies also requires policy capacity. While this is needed for evidence review and policy formulation, it also affects all other stages of the policy process, from the strategic identification of a problem to the actual development of the policy, its formal adoption, its implementation, and even further, its evaluation and continuation or modification (Forest et al., 2015).

Transparency means that “institutions inform the public and other actors of both upcoming decisions and decisions that have been made, and of the process by and grounds on which decisions are being made” (Greer et al., 2016). In the area of policy implementation, transparency in communicating the rationale for reform can help to reduce resistance to changes. This is particularly important when policies directly threaten the incomes of patients, health workers, providers and the suppliers of drugs, devices and equipment (EXPH, 2016).

One of the central questions in discussing policy reform and implementation is whether to opt for so-called big bang or incremental change. The ability to introduce rapid reforms depends mainly on the configuration of the governance structure and on political will, but it is also influenced by contextual circumstances such as the state of the economy and the degree of support from key stakeholders. Radical changes based on ideology may not be politically and technically sustainable in the long run and an incremental approach may lead to more socially sustainable policies than the wholesale changes introduced in so-called big bang reforms (EXPH, 2016).

The best approach depends on the particular circumstances of the country in question, but it is possible to build flexibility into the implementation process even in the case of big bang reforms. For example, one could combine a political big bang approach for the passage of legislation, followed by incremental implementation inside health sector institutions. Two different situations may occur. The first one is when an initial impetus triggers a snowball effect, making it easier to progress through the reform. The second situation is when upon start of a policy reform, barriers and obstacles begin to mount. In this case, persistence is the key to implementing the reform, so rather than a so-called big bang, a continuous reform effort, with increasing force put into it, is necessary (EXPH, 2016).

Monitoring institutional reform

In this book we have postulated that the services that public health institutions are providing can contribute significantly to population health outcomes. It is however difficult to assess outcomes emerging from a change in institutional infrastructure, in particular regarding services that do not have immediate but rather longer term effects. The institutional set-up of some services may be easier to measure and monitor than others. For instance, institutional responses to unclean water or food products can be easier assessed in terms of their health outcomes and compared before and after institutional changes than health promotion services.