Transforming Capacity into Impact: New Systemic Pathways to Realizing the Vision of National Public Health Institutes

Abstract

BACKGROUND Numerous publications and frameworks have described health systems and public health responsibilities of countries, often focusing on clinical care while neglecting the need for population-centered approaches to achieve public health impact. Meanwhile, recent crises (e.g., Ebola, COVID-19) have highlighted the importance of strengthening public health capacities, pushing countries to recognize the value of robust systems to prevent, detect, and respond to health threats. As such, the acceleration and growth of national public health institutes (NPHIs) has been a welcome response to the persistent threats to the health and well-being of populations. As their capacity increases, however, most still compete with a myriad of other government programs and agencies to define their distinct and critical role, garner funding, and build a sizable, highly capacitated workforce that will allow them to successfully sustain their missions. Even when the functions of an NPHI (generally associated with the 12 Essential Public Health Functions, as defined by WHO) are cultivated and supported, the competencies that these public health institutions must have to successfully translate these functions into successful performance and demonstrable impact is unclear. Given the limited resource environments and complex contexts of public health, particularly in low- and middle-income settings, understanding the pathways that successful public health systems have followed to achieve positive outcomes and impact could be critical to the future success and sustainability of public health institutions worldwide. AIMS This project aims to develop an operational framework that describes the complex adaptive pathways linking inputs to functional ability and, more importantly, the pathways from function to meaningful public health impact. The project has three key objectives. First, to initiate a new dialogue in public health around defining and achieving impact, with a focus on structuring capacity-building efforts to support these goals, particularly in national public health institutes and government health systems. Second, to explore how non-technical capacities and competencies contribute to public health success and impact. Third, to realign global health capacity-building efforts to more directly advance public health practice, improve quality, and enhance the measurable impact of public health initiatives. METHODS This study employed three complementary qualitative research methods: a literature review, key informant interviews, and exploratory case studies in Bangladesh and Jordan. The literature review synthesized existing research on National Public Health Institutes (NPHIs) and their roles in global health. Key informant interviews were conducted with experts from the global health ecosystem, including those with significant involvement in NPHIs in various countries. Exploratory case studies involved in-depth interviews with individuals both within and outside the NPHIs studied, observational data collection, and a document review. Data collection efforts were designed to address the following research questions:

Given the positionality and authority of NPHIs in low- and middle-income countries, which essential public health functions are they best positioned to perform? Based on the essential public health functions identified, what additional capacities are needed for NPHIs to functionally succeed or achieve demonstrable public health impact? What factors enable or inhibit NPHI efforts to:

build the capacity to perform essential public health functions? build additional capacities necessary to achieve functional success or demonstrable public health impact?

FINDINGS The study finds that, while the implementation of the 12 Essential Public Health Functions provides value to populations served by government health systems, responsibility for their execution does not need to rest solely with the NPHI. In many cases, shifting these functions entirely to the NPHI can disrupt the system and overwhelm the institution. A more effective approach may involve focusing on a “Core 4” or “Core 5” set of data-driven functions while coordinating with other entities to perform additional functions. Furthermore, while technical capacities and tools—such as those supporting surveillance, emergency response, public health research, and disease prevention—are critical, non-technical “strategic accelerators” that also play a significant role in achieving public health impact. Using retrospective outcome analysis four strategic accelerators enable NPHIs to progress beyond functionality to impact were identified: Systems Awareness and Collaboration, Adaptive Capacity, Sustainability Thinking, and Population Engagement and Prioritization. The constructs and sub-constructs of these strategic accelerators were further defined based on the analysis of qualitative data collected. However, it is notable that these accelerators have been largely overlooked in public health capacity-building efforts in the past. Finally, this study identifies a hypothesized pathway linking institutional functions to measurable public health outcomes to impact. This proposed pathway provides a new approach to understanding NPHI success and impact but also underscores the need for operational frameworks that consider both direct and systemic contributions to health. By taking a more holistic approach to capacity building and NPHI development that integrates technical acumen with strategic and structural expertise, future approaches to public health capacity building, systems change, and population impact may be demonstrably improved moving forward. Moreover, this more robust approach may prove invaluable to the support and sustainment of national public health institutes in the future.