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Abstract
Objectives The success of National Public Health Institutes (NPHIs) in low-income and middle-income countries (LMICs) is critical to countries’ ability to deliver public health services to their populations and effectively respond to public health emergencies. However, empirical data are limited on factors that promote or are barriers to the sustainability of NPHIs. This evaluation explored stakeholders’ perceptions about enabling factors and barriers to the success and sustainability of NPHIs in seven countries where the U.S. Centers for Disease Control and Prevention (CDC) has supported NPHI development and strengthening.
Design Qualitative study.
Setting Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda and Zambia.
Participants NPHI staff, non-NPHI government staff, and non-governmental and international organisation staff.
Methods We conducted semistructured, in-person interviews at a location chosen by the participants in the seven countries. We analysed data using a directed content analysis approach.
Results We interviewed 43 NPHI staff, 29 non-NPHI government staff and 24 staff from non-governmental and international organisations. Participants identified five enabling factors critical to the success and sustainability of NPHIs: (1) strong leadership, (2) financial autonomy, (3) political commitment and country ownership, (4) strengthening capacity of NPHI staff and (5) forming strategic partnerships. Three themes emerged related to major barriers or threats to the sustainability of NPHIs: (1) reliance on partner funding to maintain key activities, (2) changes in NPHI leadership and (3) staff attrition and turnover.
Conclusions Our findings contribute to the scant literature on sustainability of NPHIs in LMICs by identifying essential components of sustainability and types of support needed from various stakeholders. Integrating these components into each step of NPHI development and ensuring sufficient support will be critical to strengthening public health systems and safeguarding their continuity. Our findings offer potential approaches for country leadership to direct efforts to strengthen and sustain NPHIs.
- Health policy
- Public health
- QUALITATIVE RESEARCH
Data availability statement
Data are available on reasonable request. The data presented in this article are not readily available because of confidentiality agreements with participants. Any reasonable requests should be directed to Dr. Mahlet A Woldetsadik (mwoldetsadik@cdc.gov).
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
The study involved the participation of key stakeholders from National Public Health Institutes (NPHIs), government organisations, as well as non-governmental organisations in seven low-income and middle-income countries (LMICs), providing rich and diverse perspectives.
Data were collected from seven countries that were purposively selected and might not be representative of all NPHIs supported by U.S. Centers for Disease Control and Prevention (CDC) in LMICs.
Stakeholder perspectives from NPHIs that receive CDC support might differ from those in countries not supported by CDC, as perceived indicators of sustainability can differ by country context.
Introduction
National Public Health Institutes (NPHIs) provide countries with the tools to conduct strategic, evidence-based public health system strengthening.1–3 They serve as focal points for the coordination and implementation of critical global health security functions, including workforce development, emergency preparedness and response, laboratory and disease surveillance.2 They also have strategic functions relevant to the long-term strategic development of health systems, such as partnership development, programme management and long-term planning. By unifying key national public health functions, NPHIs can improve coordination and increase efficiency,4 which is especially critical during public health emergencies. Without an NPHI, public health programme implementation can often be fragmented across multiple entities within a health system. An NPHI aims to consolidate activities in a coordinated science-based structure with strong leadership and accountability.4
In low-income and middle-income countries (LMICs), NPHIs are often established with financial and technical support from partners, including the World Bank, the International Association of NPHI (IANPHI) and the U.S. Centers for Disease Control and Prevention (CDC). Since 2011, CDC has collaborated with country government ministries of health (MoH) and other partners to support the establishment or strengthening of NPHIs in over 30 countries.5 As part of its global health strategy,6 CDC provides technical and financial support to NPHIs to strengthen their functions in various areas, including strategic and operational planning, relevant scientific projects, human resource development, financial management and communications. CDC supports countries with NPHIs in all stages of development: those looking to establish a new NPHI, nascent NPHIs recently established (less than 5 years), and those with mid to long year leadership roles in the public health system (ranges from 10 years to 100+ years).
A successful NPHI is able to effectively meet its mandate and perform the functions for which it is responsible. In addition, success in NPHI capacity strengthening should be measured not only by short-term gains, but also by the sustainability of those gains and of the NPHI itself. There is increasing interest among country governments and partners, including CDC, to understand what is necessary for NPHIs to become sustainable in the long term.7 Sustainability, within the context of international development, refers to the continuation of programmes,8 specifically a programme’s ability to successfully deliver intended benefits for an extended period after major financial and technical assistance from external donors is terminated.9 This can directly apply to NPHIs that endure through changes in government leadership, have direct government funding, and a dedicated workforce. The NPHI may also have bilateral and multilateral partners but is not fully dependent on these partnerships for continuity. The sustainability of NPHIs is critical to countries’ timely detection of, and response to, public health threats. The novel COVID-19 pandemic has shown the vital role NPHIs can play to mitigate the impact of infectious diseases in LMICs.10 11
However, there is a dearth of data on enabling factors and barriers to the sustainability of NPHIs and other public health programmes in LMICs. In late 2019, we assessed the impact of CDC’s investment to the development and strengthening of NPHIs in seven countries. As part of this evaluation, we sought to understand stakeholder perceptions of what helps and hinders NPHIs achievement of success and sustainability.
Methods
Study design
Setting
We purposively selected seven countries from 30 countries where CDC has partnered on NPHI development and strengthening: Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda and Zambia. We included countries where CDC’s financial investment was relatively high and accounted for geographic variation, and whether CDC support was provided directly or through cooperative agreements with implementing partners, and the country’s NPHI development stage. At the time of the study, Liberia and Zambia were established less than 5 years ago; Cambodia, Nigeria and Rwanda were mid-range (6–25 years); and Mozambique and Colombia were longstanding organisations (40+ years).
Participant recruitment
Potential participants were selected through a collaborative process among NPHI and CDC staff in the seven countries and CDC’s NPHI Programme. We conducted interviews in each country with a broad range of stakeholders with diverse perspectives. Participants included NPHI leadership (eg, NPHI director, emergency operations centre leader, laboratory leader), non-NPHI government staff (eg, MoH permanent secretaries, public health directors, district health office directors) and partners collaborating with the NPHIs (eg, universities, non-governmental organisations, United Nations agencies, international organisations). We sought to interview 13–15 participants in the capital of each country after considering the human and financial resources available to implement the evaluation.12 13 We contacted participants by email, shared the evaluation goals and asked for their participation.
Data collection
MAW and KF conducted interviews with all participants from August 2019 through January 2020. MAW was the lead of the evaluation and is a PhD researcher with extensive experience conducting evaluations in low-income settings. KF was a fellow with CDC’s NPHI Programme and had experience working in sub-Saharan Africa. MAW provided refresher training on qualitative methods to team members who participated in data collection, data analysis and writing. After obtaining information about participants’ demographics and their roles in their respective institutes, the semistructured interview protocol explored participants’ perception around factors they identified to be important for their NPHIs’ success and sustainability, if there were activities that were currently being implemented towards these goals, potential barriers or threats to achieving NPHIs’ success and sustainability, the types of activities needed to ensure the continuation of these institutes, and the key stakeholders or partners that should be involved in this process. Interviews lasted 41–96 min (median=47.5 min) and explored participants’ perceptions of enabling factors and barriers to NPHIs’ sustainability. All interviews were conducted in private in English, except 14 interviews in Colombia and one interview in Cambodia, which were conducted through experienced interpreters in Spanish and Khmer, respectively.
Analysis
All recordings were transcribed verbatim and coded using MAXQDA V.20.0.2.14 We analysed transcripts using a directed content analysis approach, which began with the interview questions as a guide for developing initial themes but allowed flexibility for additional themes to emerge directly from the data.15 Four team members, including MAW and KF, coded the interviews. The first iteration of the codebook was used to code six transcripts independently and was then checked, refined and expanded. The team reviewed a random selection of coded transcripts to ensure consistent application of theme categorisations and used an iterative process to resolve any discrepancies in the coding application. This process established intercoder reliability, including consistency and consensus coding application within the MAXQDA platform. On coding completion, the team reviewed the coded excerpts for key themes and identified themes through repetitions, a well-established technique to identify themes.16
To assess the validity of our conclusions, we employed ‘member checking’ (ie, sharing and soliciting feedback on the results and conclusions from a small group of representatives at each of the seven NPHIs) and triangulation (ie, collecting data from multiple sources and using more than one interviewer).17 18 The team regularly debriefed to discuss the results, emerging themes and potential conclusions, which mitigated the potential for researcher bias during data analysis.19
Patient and public involvement
It was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting, or dissemination plans of our evaluation.
Results
Participant characteristics
A total of 96 stakeholders from the seven countries participated in the interviews (10–19 stakeholders per country). Twelve stakeholders who had initially agreed were unable to participate due to last-minute scheduling conflicts. Of the 96 persons interviewed, 43 (45%) were NPHI staff, 29 (30%) were non-NPHI government staff and 24 (25%) worked in non-governmental or international organisations. Sixty-six (69%) participants were male. Institutions represented included MoH, District Health Departments, Ministry of Foreign Affairs, Ministry of Agriculture, Ministry of Statistics, Universities, World Bank, WHO and the West African Health Organisation. A detailed list of participants’ positions and institutions for the seven countries is presented elsewhere.20
Enabling factors for success and sustainability of NPHIs
All NPHI staff, 23 (79%) non-NPHI government staff and 21 (88%) non-government partner staff identified factors they considered critical for the success and sustainability of NPHIs in their countries. Five themes emerged: (1) strong leadership, (2) financial autonomy, (3) political commitment and government ownership, (4) building capacity of NPHI staff and (5) maintaining strong relationships with partners (table 1).
Participants’ perceptions of key enabling factors for the success and sustainability of National Public Health Institutes (NPHIs) in the seven countries included in the NPHI evaluation (N=96), August 2019–January 2020
Strong leadership
Participants across all groups and countries identified strong leaders at the top and within the NPHIs’ divisions as one of the most important enabling factors for NPHIs’ success and sustainability. Participants noted the importance of leaders who understand the value of NPHIs and can articulate a clear vision and a strategic direction for the institutes. Participants added that having leaders that are respected and recognised by senior governments officials can foster trust and confidence, while also contributing to NPHIs’ reputations both internally and among partners. Trusted leaders can navigate evolving political landscapes, negotiate with other government officials, and secure the resources needed to run and sustain the organisation. Participants also emphasised the importance of having a leader who was committed to improving the competencies of the public health workforce both at national and subnational levels, which they considered critical for NPHIs’ sustainability.
Financial autonomy
Participants noted that most NPHIs, including six of the seven included in this evaluation (Colombia being the exception), depend heavily on donor funding to support core public health activities, such as laboratory and surveillance. Therefore, participants underscored financial autonomy as a key driver for long-term NPHI sustainability. Some suggestions for reaching financial autonomy included applying for research grants, charging for public health services, conducting cross-cutting research and building strategic partnerships with both the public and private sectors, such as research institutes and universities.
Political commitment and country ownership
Participants identified political commitment as another important factor for the success and sustainability of NPHIs. They emphasised the link between government ownership of NPHIs and increased government funding, and that both are essential for NPHIs’ continuation and longevity. In addition, participants noted that political commitment and financial support facilitate public recognition and credibility of NPHIs, which are crucial to building trust with citizens and effective risk communications during public health emergencies. Moreover, political commitment could lead to increased government funding for NPHIs, which reduces their dependence on donor funding and positions them to respond effectively to major public health threats as they occur.
Building capacity of NPHI staff
Participants across countries and groups described the importance of strengthening staff knowledge and skills to conduct the core public health work of NPHIs, such as laboratory, surveillance and research activities. Furthermore, participants underscored that sustainability of NPHIs will depend on having skilled staff who are committed to the mission of their institutes; are subject matter experts in core public health functions, including emergency preparedness and response and disease detection; and can implement programmes and manage resources efficiently. Participants also emphasised that having a skilled workforce can improve the quality of public health activities, strengthen NPHIs to carry out current and future public health work and increase the perception of value of NPHIs among the public, which can contribute to regional, national and global health security.
Forming strategic relationships with partners
Participants noted that forging strategic relationships with sub-national health entities, other government sectors, other nations and multilateral organisations was essential for NPHIs’ sustainability. Participants shared that improving collaborations across various partners can lead to a more integrated public health response during emergencies. In addition, partnerships built on trust and mutual benefits can broaden the scope of NPHIs’ public health activities, lead to additional economic opportunities and result in financial autonomy.
Barriers or threats to success and sustainability of NPHIs
Thirty-one (72%) NPHI staff, 11 (38%) non-NPHI government staff and 9 (38%) non-government staff identified potential barriers or threats to NPHI sustainability, which were categorised into three themes: (1) reliance on partner funding to maintain NPHI activities, (2) changes in NPHI leadership or countries’ political landscape and (3) NPHI staff attrition and turnover (table 2).
Participants’ perceptions of barriers or threats to the success and sustainability of National Public Health Institutes (NPHIs) in the seven countries included in the NPHI evaluation (N=96), August 2019–January 2020
Reliance on partner funding to maintain NPHI activities
Over 50% of participants said that dependence on partner funding to maintain core public health activities was a significant threat to NPHIs’ long-term sustainability. They underscored the risk of heavily relying on inconsistent funding, which can jeopardise NPHIs’ ongoing public health work and can hinder timely and effective response to public health emergencies. Participants cautioned that NPHIs would not be able to fulfil their mandates without sufficient financial support from their governments. They believed that it was the responsibility of country governments to allocate adequate funding for NPHIs, which can mitigate the impact of reductions in donor support and demonstrate national commitment to public health priorities.
Participants across all countries said that government funding for NPHIs is inadequate when compared with the financial support received from partners. In many cases, most operational costs were covered by donor funding, which participants found to be problematic and unsustainable, especially because partners often do not fund public health activities at the local level. They added that insufficient funds could limit long-term strategic public health and preparedness planning, consistently forcing NPHIs into a reactive posture. Participants stressed that a combination of consistent government support and NPHIs’ ability to generate income, in addition to donor funds, is needed for NPHIs to address the most salient public health challenges in their countries and become sustainable.
Changes in NPHI leadership or countries’ political landscape
A second threat to NPHIs’ success and sustainability included changes in NPHI leadership as a result of evolving political conditions in countries. Participants emphasised that NPHI leadership positions should be selected based on individuals’ skills and experience to lead these institutions. This issue was identified as a risk to NPHI sustainability because leadership changes often shift public health priorities based on political pressures that can be misaligned with the NPHI strategic plan and public health needs of the country. Participants indicated that political changes could weaken collaborations between NPHIs and partners if the new political direction does not support these relationships. Suggestions to mitigate these issues included implementing a plan to maintain partner relationships even if the leadership of the country changes.
NPHI staff attrition and turnover
NPHI staff attrition and turnover were identified as threats to NPHI success and sustainability. Losing trained staff can be costly for institutions because they must spend limited resources on training new people on a rolling basis. Participants’ recommendation to mitigate these issues included attracting and retaining experts with diverse backgrounds by providing competitive salaries, enhancing knowledge and skills through trainings and offering opportunities for advancement in the organisation.
Discussion
Our findings provide new evidence to inform NPHI development from local stakeholders in countries at varied income levels on three continents, with different political systems and at different stages of NPHI maturity. Although the importance of sustainability and factors contributing to sustainability have been described in guidance documents and commentaries,2 21 empirical data in peer-reviewed journals have been limited. In a mixed-methods study of leadership roles in sustaining evidence-based interventions in the USA, Aarons et al found leadership to be a predictor of sustainability.22 In a best practices document on Legal Mandates and Governance of NPHIs, IANPHI described strong leadership as essential to an NPHI’s identity,2 an assertion supported by our findings. Our findings demonstrate that strong leadership is anchored both in the traits and success of individuals empowered to lead an NPHI. The authority intrinsically provided by the positioning of the NPHI within the broader government structure tends to increase visibility, credibility and the ability to implement interventions and mobilise funds during an emergency. Thus, a crucial decision point in the process of establishing an NPHI is anchoring the NPHI within or closely linked to the government structure to effectively fulfil its mandate.
Political commitment and country ownership of NPHIs are essential guiding principles of donors who support NPHI development,23 and were identified as critical enabling factors by our participants. A clear understanding of the purpose and objective of an NPHI within the public health system of a country is key to country ownership and political support behind the organisation. Legislation can play an important role in defining an NPHI’s mandate and also helps mitigate against uncertainties that may arise with changes in political leadership.7 Often, this comes from demonstrating value of an NPHI and its role in the economics of public health investments. Recent global pandemics have highlighted the need for effective coordinating entities to prevent, detect and respond to health emergencies.10 11 However, chronic underspending in public health and the difficulty of demonstrating how public health investments decrease morbidity and mortality remains a challenge. In addition, long-term government commitment, including dedicated financial, infrastructural and human resources support for NPHIs in the national budget, is critical to their sustainability.7
Inconsistent government funding is a challenge to the sustainability of NPHIs in LMICs.24 Our findings indicate that reliance on donor funding was believed to be a major threat to NPHIs’ ability to maintain key public health activities, including emergency preparedness and response. We found that an important distinction was made between increased funding from the government and the NPHI being able to raise funds to contribute to its sustainability. This distinction may lay in the phased approach of NPHI establishment as more developed NPHIs—after having sustainable funding from the government or foundational funding from donors—can expand to generate income for increased financial flexibility. Our findings indicate that having a semiautonomous financial system in place, which would allow NPHIs to quickly deploy resources, could result in effective emergency response. In addition to self-generated income, NPHIs could be authorised to access emergency contingency funding to scale up operations, ensure critical operations and reduce the reliance on donor funding. Staff attrition and turnover were identified as additional threats, a finding that comports with those of previous studies that identified a skilled workforce and expertise as essential components for organisations’ sustainability.25 26 Building a skilled NPHI workforce is crucial to undertaking new and existing public health challenges, tackling complex health problems and the overall sustainability of NPHIs.27–29
Our evaluation had some limitations. We collected data from only seven countries that were purposively selected and might not be representative of all NPHIs supported by CDC in LMICs. In addition, stakeholder perspectives from NPHIs that receive CDC support might differ from those in countries not supported by CDC, as perceived indicators of sustainability can differ by country context.30 Our evaluation was exploratory in nature and did not use validated indicators to measure NPHIs’ sustainability, which currently do not exist. Therefore, we could not assess how different indicators might contribute to the sustainability of NPHIs and evaluate how they might interact. However, the main enabling factors and barriers identified in our evaluation can be used as the first step to creating quantitative measures of sustainability. These measures can then be validated and used to assess the progress toward sustainability of young NPHIs receiving donor support. Moreover, validated sustainability measures can be incorporated into existing NPHI maturity models, like the Stage Development Tool,31 to measure ongoing status and develop plans for improvement.
NPHIs success and sustainability is an important concern of country governments, CDC and organisations interested in the success of these vital public health agencies. Our findings contribute to the scant literature on the sustainability of NPHIs by identifying essential components of sustainability and the types of support needed from various stakeholders. Integrating these components into each step of NPHI development,7 and ensuring sufficient support from different actors, especially country governments, will be critical to strengthening public health systems and safeguarding NPHIs’ continuity. As next steps, countries’ leadership might consider the potential implications of our findings and determine what may work best for their institution and country.
Supplemental material
Data availability statement
Data are available on reasonable request. The data presented in this article are not readily available because of confidentiality agreements with participants. Any reasonable requests should be directed to Dr. Mahlet A Woldetsadik (mwoldetsadik@cdc.gov).
Ethics statements
Patient consent for publication
Ethics approval
This evaluation was reviewed through CDC’s project determination process and the Office of Management and Budget and 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. Interviews were recorded if the participant agreed. Two participants declined to be recorded.
Acknowledgments
The authors thank Natalie Brown and Basia Tomczyk for protocol review, Camila Florez, Dilia Ballen and Kanha Sar for interpretation services in Colombia and Cambodia. We are grateful to Martha Knuth, Alice Williams, Stephanie K. Young, Jacob Clemente and Whitney Remy for assistance with literature reviews, Augusto Lopez for Portuguese and Spanish translations of tools and CDC country offices and NPHIs in the seven countries for logistical support and recruitment of participants. We also thank the Division of Global Health Protection’s Science and Strategic Information Office in the Centre for Global Health at CDC for reviewing and providing constructive feedback on various drafts of this manuscript. Lastly, we greatly appreciate all the participants who agreed to be interviewed and shared their perspectives. This publication was supported in part by RTI International Contract Number # 200–2017 F-96261, funded by CDC.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors MAW, SB, DJ, CRC, FR, CHC and HB conceptualised the study. CC, FPA, JM, IJ, EI, SN and VMM facilitated the implementation of the evaluation in the seven countries. MAW and KF collected the data. MAW, KF and LDC analysed the data. MAW, KF, FR, KJM and HB drafted the manuscript. All authors reviewed all drafts and approved the final version of the manuscript and MAW is the guarantor author.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.