Benefits and challenges of consolidating public health functions into a National Public Health Institute: a policy analysis

Abstract

National Public Health Institutes (NPHIs) around the world vary in composition. Consolidated organizational models can bring together critical functions such as disease surveillance, emergency preparedness and response, public health research, workforce development and laboratory diagnosis within a single focal point. This can lead to enhanced coordination and management of resources and enable more efficient and effective public health operations. We explored stakeholders’ perceptions about the benefits and challenges of consolidating public health functions in an NPHI in seven countries where the US Centers for Disease Control and Prevention has supported NPHI establishment and strengthening. From August 2019 through January 2020, we interviewed a total of 96 stakeholders, including NPHI staff (N = 43), non-NPHI government staff (N = 29) and non-governmental and international organization staff (N = 24) in Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda and Zambia. We conducted a policy analysis using Tea Collins’s health policy analysis framework to assess various possible options for coordinating public health functions and their likely effectiveness. The findings can be used by policymakers as they consider public health infrastructure. We found that consolidating functions in an NPHI, to the extent politically and organizationally feasible, promotes efficiency, flexibility and coordination, as well as supports data-driven health recommendations to government decision makers. Countries pursuing NPHI establishment can weigh the potential challenges and benefits of consolidating functions when determining which public health functions will comprise the NPHI, including clarity of role, access to resources, influence over decisions and political viability.

National Public Health Institutes, CDC, health policy, policy analysis, public health functions, consolidation

Key messages

• Consolidating public health functions in a NPHI, rather than having those functions distributed across the health system, can improve the effectiveness of health systems, including timely outbreak detection and response and efficient use of resources.

• Success in consolidating public health functions in NPHIs relies on strong relationships at multiple levels in the national health system, clarity of roles and the ability to make data-informed recommendations with minimal political influence.

• Although a country may identify consolidation of all relevant public health functions as its goal, considerations such as political viability and institutional reputation may suggest moving towards a country-tailored approach based on a country’s context and need.

Introduction

Many countries have established science-based organizations termed National Public Health Institutes (NPHIs) that provide national-level coordination and leadership to prevent and respond to public health emergencies (Koplan et al., 2005; Huttunen and Puska, 2011). NPHI establishment is a response to the increasing call to develop more comprehensive public health agencies to address emerging public health threats and challenges (Koplan et al., 2005; Adigun et al., 2007; Verrecchia et al., 2019). They can serve as a sound and viable model for countries to use scientific evidence as the basis for strengthening national public health systems and capacity (Adigun et al., 2007). Their core public health functions often include emergency preparedness and response, public health laboratory services, public health workforce development and disease surveillance (IANPHI, 2018). Other public health functions might include public health and health systems research, outbreak investigation, health promotion, epidemiology, information systems and communication, environmental and occupational health and global health and partnerships. Most often, NPHIs are structured within a government organization such as a Ministry of Health (MoH) or very closely linked to it, such as autonomous parastatal organizations that work in collaboration with the MoH (IANPHI, 2007).

NPHIs vary in scope and size, and there is not a single model or approach for organizing an NPHI (Frieden and Koplan, 2010). The uniqueness of each NPHI is reflective of the historical, cultural, social, educational, political and environmental factors that highlight country ownership as a necessity to help inform and facilitate health decision-making (Myhre et al., 2021). For instance, the Nigeria Centre for Disease Control (NCDC), the Rwanda Biomedical Centre (RBC) and the National Institute of Health in Mozambique (INS) have different development histories, organizational approaches and institutional functions. The nucleus of NCDC was first established by moving the Epidemiology Division, the Avian Influenza Project and its laboratories from the MoH (Njidda et al., 2018). NCDC now focuses on emergency preparedness and response, surveillance and epidemiology, laboratory service and prevention programmes (Njidda et al., 2018). RBC was created by joining 14 disease agencies within the Rwandan MoH, and it contains two technical arms, the Department of Biomedical Services and the Institute of HIV/AIDS, Disease Prevention and Control (IHDPC) (Rwanda Biomedical Centre, 2021). INS was formerly under the MoH but is now administratively autonomous with direct links to the Ministry of Finance for budgetary matters (Africa CDC, Africa Union, 2019; Instituto Nacional de Saúde, 2020). The core functions of INS are laboratory services, public health and health systems research, surveillance, outbreak investigations, workforce development and communication (Instituto Nacional de Saúde, 2020).

Consolidating functions within a single entity is an organizational approach to improving efficiency and effectiveness (CDC, 2010). Many NPHIs lead or significantly engage in the investigation of and response to health threats, which often requires coordination of stakeholders, multidisciplinary expertise and collaboration with government leadership (Frieden and Koplan, 2010). A single entity such as an NPHI can achieve this by bringing together essential public health functions to cultivate a critical mass of technical expertise; optimize resources and reduce costs, fragmentation, and duplication of efforts (Frieden and Koplan, 2010). During public health emergencies, a consolidated model can support an efficient response through streamlining the collection and analysis of evidence to inform public health decisions and facilitate quick, coordinated action (Buss et al., 2009; Koplan et al., 2013). In addition to health emergencies, NPHIs have also addressed emerging public health issues such as climate change and antimicrobial resistance (Myhre et al., 2021).

The International Association of National Public Health Institutes (IANPHI) is the global network of NPHIs. IANPHI’s ‘Framework for National Public Health Institutes Development’, which has guided global NPHI development efforts since 2007, describes the importance of commitment and long-term investment from the government, NPHI leadership and the NPHI staff in NPHI development (IANPHI, 2007). There is a range of partner organizations that may support NPHI establishment efforts, such as government agencies, multilateral organizations and non-governmental organizations. IANPHI has developed frameworks, tools, best practices and other practice-based guidance materials to support the establishment of NPHIs around the world (IANPHI, 2007). Similarly, the Africa Centres for Disease Control and Prevention (Africa CDC), the public health agency of the African Union (AU), also prioritizes NPHI development in AU Member States (Africa CDC, 2019a).

IANPHI and Africa CDC created NPHI development frameworks, the latter of which was created as an adaptation of IANPHI’s global framework with consideration for Africa’s context. These describe considerations and guidance for NPHI legal authority and governance structure (often described as mandates), functions and guiding principles (IANPHI, 2007; Africa CDC, 2019a). The frameworks also identify key attributes for an NPHI’s operations and describe suggested steps for NPHI development and strengthening (e.g. locating high-level champion and garnering political support, identifying funding needs and sources and anticipating political and operational challenges) (IANPHI, 2007; Africa CDC, 2019a).

The case for functional NPHIs in every country is based on the premise that coordinated and collective action is needed to combat pandemics such as the coronavirus disease 2019 (COVID-19), the disease caused by the SARS-CoV-2 virus, and long-standing public health challenges (Ihekweazu and Agogo, 2020; World Health Organization, 2020a). However, there is limited evidence on the benefits and challenges of consolidating public health functions within an NPHI. In 2019, we evaluated seven countries to assess CDC’s role in the development and strengthening of NPHIs (Woldetsadik et al., 2021). As part of this evaluation, we asked stakeholders about the benefits and challenges of consolidating public health functions in an NPHI. We used these data to conduct a policy analysis to assess various possible options for coordinating public health functions and the likelihood that the organizational change will be successful and will result in the desired public health outcomes. Our findings can be used by policymakers as they consider public health system organization.

Methods

We recruited participants from August 2019 through January 2020 from seven countries among 30 countries where CDC has partnered on NPHI development and strengthening. We purposively selected countries in which CDC had higher financial support for NPHI development and accounted for institutional development stage, geographic variation and the means by which CDC provided financial support (directly or through partners) (CDC, 2020). The countries were Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda and Zambia. We collaborated with CDC’s NPHI programme, as well as CDC and NPHI staff in the seven countries, to identify potential participants. We chose participants based on their role as public health leaders who could provide expert opinion on the topics being explored. We contacted NPHI staff, non-NPHI affiliated government staff and staff from non-governmental organizations and international entities, who were identified by the NPHI as vital partners in the country’s public health system capacity building and collaboration, and asked them to participate in the evaluation. A complete list of participants’ institutions or their positions is presented elsewhere (Woldetsadik et al., 2021). We provided a document that explained the objectives of the evaluation and information on data safeguarding procedures, including maintaining the anonymity of participants to all participants. Our goal was to recruit 13–15 participants in each country, after considering financial and human resources employable for implementing the evaluation. ‘One co-author’ along with a research assistant conducted one-on-one interviews with participants in a location of their choice. We used semi-structured interview guides to ask participants about the benefits and challenges of consolidating public health functions into a single institution. After obtaining consent from participants, we audio-recorded interviews (two participants declined to be audio recorded) and transcribed the recordings verbatim. This evaluation was reviewed by CDC’s project determination process, was deemed exempt and did not require review by institutional review boards. All participants were notified of their rights regarding participation and data confidentiality and provided written consent before participating in the interviews.

Qualitative data analysis

Transcript data were coded using MAXQDA Version 20.0.2, and the analytic team used an iterative process to identify and resolve discrepancies in the coding application. We used content analysis to analyse the data and identify emerging themes around the benefits and challenges of consolidating public health functions into an NPHI. We used member checking—where results were shared, and feedback was sought from participants—to assess the validity of our conclusions. We applied these themes to identify data for the policy analysis and guide the selection of the evaluation criteria. We used participant quotes to support the understanding of major themes and added parentheses within quotes to maintain the participant’s anonymity, give context or clarify the participants’ quotes.

Policy analysis

Next, we conducted a policy analysis using the health policy analysis framework from Collins (2005). This eight-step process was developed by applying a health lens to Eugene Bardach’s public policy analysis framework and included consideration of the political context, feasibility and value judgements that often accompany development of health policy (Bardach and Patashnik, 2019). The eight steps include the following: (1) define the context, (2) state the problem, (3) search for evidence, (4) consider different policy options, (5) project the outcomes, (6) apply evaluative criteria, (7) weigh the outcomes and (8) make the decision.

We considered three policy options: (1) the status quo of public health functions remaining in disparate parts of the health system (both inside and outside of the MoH), (2) all public health functions consolidated in an NPHI and (3) most—but not all—public health functions consolidated in an NPHI.

We drew evaluative criteria from two primary sources: the IANPHI Framework for the Creation and Development of National Public Health Institutes (IANPHI framework) and thematic analysis of data from the NPHI evaluation. We reviewed the nine attributes that IANPHI framework identifies as describing the circumstances for optimal functioning of the NPHI as an organization (IANPHI, 2007). Through a thematic analysis of the data from our evaluation, we identified nine broad themes from participants’ responses about the benefits and challenges of consolidating public health functions. To establish evaluation criteria, we combined IANPHI attributes and evaluation themes where there was an overlap in definition; for example, we combined two attributes identified in the IANPHI Framework (i.e. adequate human and financial resources and adequate infrastructure support) and themes (resources, leadership and motivation of staff), which were often discussed without differentiation. A list of the evaluation criteria selected, definitions and rationale for selection is presented in Table 1.

Table 1.

Evaluation criteria used for assessing the benefits and challenges of consolidating public health functions in a NPHI in Seven Countries^a

Evaluation criteria	Definition	Rationale for inclusion
Focus on public health priorities	An NPHI is a flexible organization able to respond to the country’s varying health needs. This includes flexibility with financial and other resources during emergencies. (IANPHI framework, paraphrased)	IANPHI framework Thematic analysis: emergency response, flexibility/speed
Linkages and networks	An NPHI can establish and maintain relationships with necessary government and stakeholder groups at various levels (IANPHI framework, paraphrased). The NPHI can effectively collaborate with and coordinate among these stakeholders. (Thematic review)	IANPHI framework Thematic analysis: efficient collaboration, coordination among partners and within the network
Adequate resources and infrastructure	An NPHI has reliable financial resources (ideally with a government budget), sufficient and competent technical and managerial staffing, reliable and appropriate work environment(s) for its scope, and materials and equipment required for its work (IANPHI framework combination of 2 attributes, paraphrase). NPHI leadership views staff as an important resource for successful institute performance. (thematic review)	IANPHI framework: adequate human and financial resources, adequate infrastructure support Thematic analysis: resources, leadership, and motivation of staff
National recognition and scope of influence	The NPHI has authorization describing its national public health role, is recognized by the appropriate levels to develop interventions that affect the country and is considered a resource by government leadership to inform policymaking and programme development. (IANPHI framework combination of two criteria, paraphrase)	IANPHI framework: national recognition, national scope of influence Thematic analysis: clarity of role/avoiding duplication
Lead public health agency	The NPHI serves as a focal point for public health, working with internal and external stakeholders and providing a single management unit for consolidated coordination of public health functions and resources. (Thematic review)	Thematic analysis: effective coordination of public health functions
Scientific basis for programmes	An NPHI’s work is driven by data, and the NPHI is a main source of scientific information for MoH. (IANPHI framework, paraphrased)	IANPHI framework
Limitations on political influence	An NPHI’s work is free from political control and influence (i.e. conducting the scientific work and setting the organization’s priorities) (IANPHI framework, paraphrase)	IANPHI framework
Political viability	Establishing or maintaining the NPHI is an acceptable policy option, given the political context. (Thematic review)	Thematic analysis: political considerations

a

Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda and Zambia.

Data utilized for the policy analysis included responses coded as benefits and challenges of consolidating public health functions. We reviewed each response and identified corresponding evaluation criteria, sometimes multiple criteria per response. Through a further review of responses sorted by evaluation criterion, we identified sub-themes and sorted them by perceived benefits, challenges and key considerations for consolidating public health functions. Participants identified benefits for each of the sub-themes, but challenges and key considerations were not indicated for all. These are summarized in the results, along with illustrative participant quotations.

Results

Ninety-six stakeholders from Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda and Zambia, representing various NPHIs (45%), non-NPHI government offices (30%) and non-governmental and international organizations (25%), participated in the interviews. A detailed list of participants’ institutions and positions by country is presented elsewhere (Woldetsadik et al., 2021). Of the seven countries included in the evaluation, some NPHIs (Colombia, Liberia, Nigeria, Rwanda and Zambia) have been granted the authority and obligation to conduct all core public health functions, while others (Cambodia and Mozambique) have more limited authority and are responsible for conducting fewer functions, with other entities (e.g. MoH departments) authorized to and responsible for performing the other public health functions. Participants noted numerous benefits of consolidating public health functions in an NPHI and highlighted key challenges and considerations. Applying the evaluation criteria to the data led to the identification of sub-themes, which may serve as key factors for those considering NPHI establishment. A summary of responses for all the evaluation criteria used and applied to the data is presented below.

Evaluation criteria: focus on public health priorities

From their experience, participants indicated that for an NPHI to function well, both routinely and during an emergency, flexibility allows quick action and the ability to reallocate resources to priorities. They identified a dedicated entity focused on health security and epidemic detection, prevention and response as a complement to the MoH’s focus on clinical services, minimizing disruptions during emergencies. In addition, participants reported that an NPHI was better able to support sub-national health entities in their responses and training groups at different levels in critical preparedness and response skills.

NPHI can focus solely on health security, with more time and more focus for coordination and understanding what’s going on. Whatever makes us more efficient, makes us effective. [Government official (Zambia National Public Health Institute), Zambia] (4)

Evaluation criteria: linkages and networks

Participants noted that a focused agency with trust from the general public and public health sector can better coordinate public health stakeholders, information and activities in a multisectoral environment and across multiple agencies. During emergencies, they said that an incident management system, often housed within or employed by an NPHI, can improve coordination. Participants commented that an institution with greater flexibility is able to bypass some of the lengthy processes the MoHs often face when collaborating with partners and other ministries. They also noted that a consolidated structure can physically bring together staff for improved coordination and collaboration. Participants stated that strong and trusting connection with the MoH and sub-national levels enabled the NPHI to achieve its function.

Challenges

Participants noted that an NPHI not physically co-located with the MoH can make the collaboration between the two groups more challenging. They further noted that implementing activities with sub-national health entities can be difficult if there is tension between the groups because of the organizational change.

As an agency, you tend to have more trust from partners. And because there is that trust that they can work with you, and you are productive, and partners really see that you are productive, that you are getting things done, partners find it easier to work with the agency. [Government official (NCDC), Nigeria] (9)

Evaluation criteria: adequate resources and infrastructure

Participants described that, in their experience, the narrower mandate and greater flexibility of the NPHI, compared to the MoH, enabled it to better focus on staffing and training to meet the skills required by the institute. NPHIs play roles in training their staff and can also inform or lead trainings for public health staff at all levels within the country. Field epidemiology training programs (FETPs) are often housed in NPHIs, and participants mentioned that current residents and graduates support surveillance and response activities.

Participants stated that, through consolidation, an NPHI can achieve more central coordination and accountability for resources. A combined budget at the NPHI level can lead to greater cost savings and more efficiency, which was cited as a challenge in a MoH running a variety of public health programmes Participants noted that, depending on its mandate, an NPHI is sometimes better able to apply for grants, generate income or receive resources from partners. Participants across all countries emphasized that during emergencies, NPHIs can have access to an emergency fund for public health, divert funds to respond to an unanticipated need and quickly mobilize their workforce.

An NPHI offers a single location where public health staff work, facilitating coordination and collaboration. Participants shared examples of NPHIs both housing and linking to public health laboratories, including an NPHI establishing a dedicated public health laboratory, with such efforts improving the quality of existing laboratories in a country.

Challenges

Participants shared that an NPHI can address common issues within the MoH, such as understaffing for disease surveillance and response, as well as slower mobilization of resources for response. Some participants also noted that in some countries, the NPHI still relies on the MoH for access to resources or infrastructure, whereas others observed that as a separate entity, the NPHI can be overlooked for MoH or other resources. When the NPHI and the MoH are not physically co-located, participants said that collaboration can be more challenging. Participants also cautioned the assumption some might have that the NPHI is more well-resourced than it is. Participants reported that this can lead to an overreliance on the NPHI, resulting in underperformance by partners and sub-national health entities supported by the NPHI.

At a central level it [the NPHI] helped to improve the way we use our resources but also at the facility level, it has improved the way we are working and receiving resources. [Government official (RBC), Rwanda] (10)

Evaluation criteria: national recognition and scope of influence

Participants highlighted that an effective NPHI can increase awareness about public health and health security. With a role in setting the national-level public health vision, particularly for addressing disease outbreaks, participants remarked that an NPHI provides a sense of direction, organizes activities to help sub-national levels, and coordinates across public health programmes They also noted that an NPHI can manage required reporting, such as that related to the International Health Regulations.

Participants identified that an NPHI is often the MoH’s arm for responding to disease outbreaks. As such, they identified clarity, complementarity and trust between the NPHI and MoH as key to successful outbreak responses. Participants observed that the focus of an NPHI helps to increase efficiency versus a large MoH department, allowing the two entities to create a balance between roles in implementation and policymaking. Across all countries, participants also said that an NPHI can respond to MoH requests for information by conducting research and synthesizing surveillance data.

Challenges

When roles and functions of the NPHI are not clear, participants identified potential for duplication or challenges working with partners and sub-national health entities. Participants noted that NPHIs, particularly those recently established, sometimes struggle to have their roles recognized by the MoH, partners and the public. That can lead to missed opportunities for the NPHI to engage in key health activities, such as national health strategic plan development. Some participants identified challenges in effective joint emergency response when the MoH retained a role in response activities but was not adequately resourced or structured to perform the role. Participants said that these challenges can be especially pronounced if the NPHI is organizationally within the MoH and subject to the same administration and processes.

Key considerations

Participants from most countries cited that a legal mandate is important to establish the NPHI’s role at both national and sub-national levels. They noted that this legal document often identifies the NPHI’s relationship to the MoH and other parts of the government, delineates reporting structures and flow of public health information from sub-national health entities and identifies the NPHI’s role in emergency response. The mandate can evolve, enabling the institute’s growth and providing an important opportunity to ensure the best organization of public health functions.

You can’t be a regulator and an implementor. So then before, everything was done by the Ministry of Health, from the policymaking, implementation of the policy, so it was really very difficult. Now, by creating the RBC, they have a bigger number of specialists, of different people with different capacities and skills, and I believe we are doing our job better than before. The Ministry of Health continues to develop policies and the regulations and the guidelines and the standard operating procedures and so on, and RBC now implements all those policies. [Government official (MoH), Rwanda] (4)

Evaluation criteria: lead public health agency

Participants said that having an NPHI identified as the agency to lead public health efforts can help to improve coordination, as well as promote maximum impact. Moreover, they added that some NPHIs serve as the single entity to collect laboratory samples, test and analyse data and respond during emergencies. Furthermore, participants noted that a single public health point of contact mitigates the challenges found in the MoH because of the long chain of command. Participants also commented that an NPHI can provide a unified vision for formerly standalone programmes, promoting efficiency and collaboration. A single entity with interconnected public health functions can work in a more standardized and streamlined manner. Moreover, according to some participants, management, budgeting and reporting can also be more consistent under a single agency. Many participants emphasized that the value of a single public health leadership is critical during emergencies so that NPHIs can lead and divert resources as needed.

Challenges

Some participants noted that if public health functions do not complement each other, it does not always make sense to combine them into a single institute. For example, a country with an effective reference laboratory and limited resources may not need a public health laboratory as part of the NPHI. Whereas focused technical expertise can be seen as a benefit in some instances, participants said that it can also be a challenge when a consolidated agency results in expertise and staffing that is too narrow.

It [a structure that consolidates public health functions] gives you all the tools you need to be the lead in-country for laboratory services. Otherwise, without these high-level skills, we get from research, it would be difficult to have the position of lead in-country for the laboratory services. So, if you split those [public health functions] into the different institutions, so you are not maximizing what you get from research in terms of skills and knowledge, and then from the other end, you are only the laboratory, the same for communication. So, I will say those four key levels - surveillance, research, laboratory reference service, and communication – they come together. [Government official (INS), Mozambique] (5)

Evaluation criteria: scientific basis for programmes

Participants from all countries shared that information generated and synthesized by an NPHI through research and surveillance activities guides decision-making at and responds to requests for information from the MoH and other levels of government. Participants underscored that surveillance activities are often faster in a single organization and can facilitate data analysis that informs decisions. Participants said that the technical, scientific work, specialized staffing and multidisciplinary nature of an NPHI enhance monitoring of health events, raise awareness of disease trends and project health events. This helps to support sub-national levels in a timely and proactive manner.

We can have a vision from the national level, identifying certain areas of risk that require more intervention or greater attention from the Ministry of Health (MoH) or other ministries because this information is shared with all of them. {Government official [National Institute of Health (INS)], Colombia} (7)

Evaluation criteria: limitations on political influence

Participants cited the importance of an NPHI’s technical focus, rather than political engagement, to achieve its public health mandate. According to participants, shielding NPHIs from political interference enables them to work more quickly, generate the evidence needed to inform decisions, communicate candidly and manage resources more independently. In addition to the operational considerations, participants described that stakeholder and public trust in NPHIs was greater when the public did not perceive the NPHI as being unduly influenced by politics. Some participants noted that an autonomous NPHI can better work on public health functions independently, thus separating the political and technical functions that formerly sat with the MoH and enabling the MoH to depend on the NPHI’s technical recommendations.

Decision of MoH to [grant autonomy to] INS is because of perception that INS being an autonomous body has more independence in their work, and less interference with the evidence generated. So, there is more trust in their results and gives INS more flexibility in their operations. [Government official (MoH), Mozambique] (14)

Evaluation criteria: political viability

Participants noted that establishing a new NPHI can require moving elements from existing groups. Participants emphasized that a trusting relationship with stakeholders, government leaders and individuals within the organizational structure facilitates the NPHI’s role.

Challenges

Participants said that the change required to establish an NPHI can lead to groups resisting loss of power. Similarly, participants noted that different institutions that operate independently may resist the harmonized approach of an NPHI. At the sub-national level, some participants noted that the NPHI can also face issues of resistance in working through MoH structures and staff. Participants emphasized that demonstrating the value of a consolidated model helps NPHIs overcome concerns at different levels.

Key considerations

Participants noted that the establishment of an NPHI or expansion of an NPHI’s functions can happen when there is trust in the institution and when it is apparent that the NPHI promotes efficiency and effectiveness. Many participants identified trust as critical for NPHI success, particularly from government leadership, and that involving leadership in setting the mandate for the NPHI helps facilitate this trust. Participants said that a single organization can help to overcome challenges in collaboration associated with vertical mandates and poorly organized public health functions. Some participants said that successful performance during an outbreak, as well as similar demonstrations of NPHI value, has built political will for an NPHI and investment in strengthening its functions.

The outbreak of 2017 until 2018 really just put the NPHI at the center of it all, and they really effectively coordinated a response. And I think it is from there that the relevance of that institution was really appreciated by many, because I think initially some people thought, isn’t this the mandate of the MoH? Why do we have to create a specialized entity? But with the focus that we saw during that outbreak, I think it really did give quite a lot of credibility, support for the decision that was made. [Government official (MoH), Zambia] (9)

Discussion

Our policy analysis identified benefits, challenges and key considerations for consolidating public health functions into a single NPHI. Participants strongly supported the consolidation of public health functions and identified flexibility, efficiency, improved ability to coordinate with partners, a greater focus on health security and emergencies and separation of policy and implementation roles as benefits. They also cautioned about the need for clarity in roles, strong relationships with the MoH and avoidance of duplication of responsibilities. Granting an NPHI legal authorization to operate autonomously has been shown to help address these considerations and enhance the benefits identified for consolidating public health functions (IANPHI, 2017). Participants noted, however, that consolidation of public health functions can result in an NPHI being overlooked for government resources or relied upon for support, struggling for recognition or encountering resistance to organizational change. This may be especially pronounced in parastatal NPHIs (IANPHI, 2017).

Government and public health leaders considering consolidation of public health functions vis-a-vis NPHI establishment can weigh the factors cited above into their decision-making process. Participants raised additional considerations that may influence a country’s ability to establish a highly functional NPHI or support an existing NPHI to operate effectively. Trust and political will at both leadership and technical levels help facilitate the major organizational change often accompanying NPHI establishment (Africa CDC, 2019a). Additionally, participants noted that a legal mandate can grant authority for and clarity to an NPHI’s role and operations (IANPHI, 2017; Africa CDC, Africa Union, 2019). NPHIs can also facilitate the institutionalization and sustainability of programmes such as FETP (Martin and Fall, 2021).

Although there are benefits to consolidating public health functions in a single agency, countries may weigh potential challenges and key considerations in determining the approach that best fits their context. While there may be motivation to consolidate the full spectrum of public health functions into an NPHI, that may not be a practical option in all countries (Africa CDC, 2019a). Also, stakeholders and political decision makers may be wary about committing to a massive organizational shift before understanding the value and relevance of a new institution (World Health Organization, 2021). While some governments may be successful in the effort, others might consider a narrower mandate to avoid a significant delay, help establish trust in the concept and institution and facilitate later expansion (Africa CDC, 2019a).

The interviews conducted for this evaluation were completed in January 2020, in advance of the World Health Organization declaring the COVID-19 outbreak a pandemic, which is a significant limitation of this analysis (World Health Organization, 2020b). The pandemic, and countries’ health sector responses to it, has led to significant dialogue about shortcomings, organization, functions and efficiency of health systems during a response (Lal et al., 2021; Nimako and Kruk, 2021). A publication summarizing points raised by NPHI leaders and related literature review identified both positive impacts and challenges brought about by the COVID-19 pandemic and the NPHIs’ experiences (Binder et al., 2021). Decision-making in public health system organizations may also be influenced by factors outside of the scope of the results reported from our evaluation. Organizational change is a process with many challenges, and reorganization alone does not lead to success or efficiency (World Health Organization, 2021). When it comes to organizational change, there might be several additional elements to consider. First, effecting change is a dynamic process that benefits from frequent evaluation and adjustments (Harvard Business Review, 2005). For public health system organizations such as NPHI establishment, this can be particularly challenging in bureaucratic environments and when the change relies on authorizing legislation (Harvard Business Review, 2005). Second, people are key factors in guiding successful change, from leadership to management to routine performance. Clarity of roles and thoughtful team composition can aid in successful change, whereas a poor performer before the organizational change is not likely to become a strong performer under a new structure. Moreover, organizational change requires additional effort from teams and individuals (Harvard Business Review, 2005). Understanding the overall workload and taking it into account during the change period can enable an organization to maintain performance on priority initiatives while also developing new ways of operating and supporting processes (Harvard Business Review, 2005). Lastly, leadership plays an important role in motivating successful change in the development and sustainability of an NPHI (Woldetsadik et al., 2022). Through demonstrating commitment to and clearly articulating the rationale for the change, leadership—in this case, senior staff in the MoH, NPHI, and elsewhere in the health system—can foster others’ acceptance of the change (Harvard Business Review, 2005).

NPHIs are complex organizations operating in multifaceted environments. In resource-limited NPHIs, there may be tension between the investments needed to build a functional and responsive institution in the long term and the urgent and potentially resource-intensive actions required for outbreak response and surveillance (Verrecchia et al., 2019). Insightful leadership and strategic resource allocation can help to address both immediate needs while positioning the NPHI for greater impact in the future (Jamison et al., 2006). A guide from the World Health Organization (2021) on establishing NPHIs through mergers provides additional public health-specific considerations for success in consolidating public health functions in an NPHI. These include thoughtful communications throughout the change to internal and external stakeholders, early consideration of the administrative and support services required for the NPHI, early branding of the NPHI to create a sense of ownership and identification of training needs for the NPHI staff and leaders (World Health Organization, 2021).Our study had a few limitations. First, we focused on CDC partner countries with highest financial support, which might exclude important perspectives from countries receiving fewer financial assistance. Second, our data were collected only from seven countries that were purposively selected and might not be representative of all NPHIs in low- and middle-income countries. As part of a larger evaluation, the questionnaire did not directly cover topics potentially relevant to this paper, such as the process of consolidating public health functions, impact of consolidation to specific public health functions, NPHI legal mandates, political considerations and organizational change. Future studies could explore these topics further, both at the organizational and individual levels.

Conclusion

As countries consider approaches to strengthening their public health systems, our findings may be a useful resource to inform NPHI establishment, reorganization or expansion. Decision makers can identify potential public health functions from across the public health sector that may benefit from being housed within an NPHI, the potential benefits of consolidating those functions and the potential barriers to organizational change.

Although a country may identify consolidation of all relevant public health functions as its goal, decision makers can also examine their national context to inform if full consolidation is feasible, such as the existing legal environment and organizational location of the public health functions. When effecting a reorganization, there are other factors, such as change management, which may guide decision makers in avoiding common challenges to achieve the desired improvements in the nation’s public health sector (World Health Organization, 2021). When approached thoughtfully and with consideration for the factors mentioned in this article, consolidation of public health functions through NPHI establishment may promote a public health system that countries health systems can benefit from.

Disclaimer

The findings and conclusions in this article are those of the author(s) and do not necessarily represent the official position of the US Centers for Disease Control and Prevention.

Data availability

The data presented in this article are not readily available because of confidentiality agreements with participants. Any reasonable requests should be directed to the corresponding author.

Supplementary data

Supplementary data are available at Heath Policy and Planning online.

Funding

None declared.

Acknowledgements

The authors thank Kelsy McIntosh and Kaitlin Fitzpatrick for assistance with literature review and data collection and CDC country offices and NPHIs in the seven countries for logistical support and recruitment of participants. We greatly appreciate all the participants who agreed to be interviewed and shared their perspectives.

Author contributions

All authors approved the final version of the manuscript that was submitted. Individual contributions are detailed in the following: C.R.C. contributed to conception or design of the work, data analysis and interpretation, drafting of the article and critical revision of the article. M.A.W. contributed to conception or design of the work, data collection, data analysis and interpretation, drafting the article and critical revision of the article. A.S. contributed to data analysis and interpretation and drafting the article. M.G. contributed to data analysis and interpretation and drafting the article. C.C. contributed to data interpretation and critical revision of the article. E.I. contributed to data interpretation and critical revision of the article. I.J. contributed to data interpretation and critical revision of the article. J.M. contributed to data interpretation and critical revision of the article. V.M. contributed to data interpretation and critical revision of the article. S.N. contributed to data interpretation and critical revision of the article. M.L.O. contributed to critical revision of the article. T.R. contributed to critical revision of the article. E.A.S.W. contributed to critical revision of the article. S.B. contributed to conception or design of the work, data interpretation, drafting the article and critical revision of the article.

Reflexivity statement

The authors include nine females and five males and span multiple levels of seniority. Seven authors are senior NPHI leaders or their delegates. Five authors specialize in NPHI development, representing three different organizations (US CDC, Africa CDC and IANPHI). Two authors specialize in public health data analysis, and one author is a health economist and policy researcher. The authors span four regions and represent eight countries including the USA, Colombia, Cambodia, Nigeria, Zambia, Rwanda, Liberia and Mozambique.

Ethical approval

This evaluation was reviewed by CDC’s project determination process, was exempted and did not require review from institutional review boards. Participants were notified of data confidentiality, data safeguarding procedures and their right regarding participation. All participants provided written consent before the interview, and interviews were recorded if the participant agreed.

Conflict of interest statement

None declared.