Background
Methods
Design
Inclusion criteria for the three cases
The Netherlands | Denmark | Romania | |
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National political and administrative structure | |||
Political system | Parliament Democracy; representatives in the Parliament are chosen every 4 years | Decentralised administrative system | The executive power is represented by the Government, led by a Prime Minister, designated by the President of the state |
Administrative structure | National authorities develop and present national planning policies and provide guidance for regional (regions) and local (municipal) level Decentralised administrative system with part of the tasks transferred from national to the local level, which affects health, and HEPA policies on local (municipal) level, ‘make the healthy choice the easy choice’ | National level facilitates guidance and policies for regional and local level The political and administrative structures regarding the tasks given to the municipalities after the structural reform in 2007 vary significantly among the municipalities; there are three different overall models for organisation of health-related tasks – in some municipalities the new tasks are handled in a separate health department, other municipalities have chosen a model where the new tasks are incorporated in a larger department, for instance, together with social care; this is the most widespread model among the Danish municipalities. Finally, some municipalities have placed all health-related tasks in the central administration of the municipality | The National Government develop policies that are implemented at county and local level by the ministries representatives and by the public administrative authorities Although efforts are made for decentralisation the administrative system is still centralised, with minimal autonomy for county and local level structures in regards for policies development |
Responsibility HEPA | Regions are accountable for planning, healthcare and recreation; municipalities are accountable for education, planning,welfare and social affairs | Regional level being responsible for healthcare services and local (municipal) level for health promotion The policy state, that the responsibility for the implementation of the policy is a common responsibility, which go across each of the sectors in the municipality; the policy does not mention concrete implementation initiatives, but state that such initiatives will be announced yearly | According to the law, the Ministry of National Education is the Governmental structure responsible for organising the physical education and sport activities in the pre-university and university system The ministry of Youth and Sport and its structures (i.e. national sport federations, ounty youth and sport directions) are responsible for organising the performance sport and the sport for all at national level The Ministry of Health (through the National Institute of Public Health) has a role in evaluating the health status and health-related behaviour of school aged population – including PA levels |
Who develops the local public health policy, including HEPA | The policymaking process follows a 4-year prevention cycle, based on the Public Health Act. For local level, this means that every municipality, which is an autonomous authority with an elected city council, writes their own local policy document based on the national policy document (main priorities and recommendations) and on the epidemiologic information collected by the Community Health Services of the local health situation | Municipalities are autonomous authorities with elected councils The Parliament and the government are responsible for passing laws and developing general policies The Ministry of Health is the principal health authority, which presents specific action plans on how to implement the Parliament’s health policies | The county representatives of the national governmental structures have the role of administrating and implementing the governmental programs in the fields of HEPA and physical education and sport (i.e. the County Youth and Sport Department) and education (i.e. the County School Inspectorate, Children Palace, School Sports Club) Local and county public administrative authorities also assume some marginal responsibilities in maintaining and promoting population health, but very few (if none) responsibilities related to HEPA promotion; private and civil society representatives are also involved in HEPA promotion, not as part of any structured policy, but by implementing targeted programs (e.g. running, cycling, etc.) |
Cases | |||
Size of the city: | Average size municipality | Average size municipality | Highly populated municipality with a high student population |
Setting: | Local | Local | Local/county |
Stage policy plan: | New developed health policy, working towards an implementation plan | New developed health policy and needed an implementation plan | HEPA policy plan was in the development phase |
Focus policy plan | Focus on the Dutch national umbrella policy ‘Youth on Healthy Weight’ (in Dutch: JOGG) and the national health policy ‘Health close to the people (2011)’, with main focus youth and physical activity | Focus of the plan was on physical activity promotion, with the target group children and young adults and citizens with special needs and chronic diseases | One of the working groups on physical activity was specifically at local level and focusing on the development of the local HEPA Strategy for 2014–2020, ‘Sport and Community’ |
Theme | Specific HEPA policy | General health policy, including HEPA | Sports policy, including HEPA |
Responsible local public health policy | The administrative level of the municipality was accountable for the HEPA policy plan; the responsibility of implementation of JOGG was assigned to the Regional Sport Service | Primarily the administrative level in the sector Health and Care was responsible for health promotion, but responsibility of the implementation of the policy is a common responsibility, which goes across each of the sectors in the municipality | None of the stakeholders is specifically responsible for the implementation of the policy plan |
Starting point for the systems analysis
Performing the systems analysis
The Netherlands | |
Previous work REPOPA (Oct 2011–Jan 2013) | Data from interviews (14) with local, regional and national stakeholders on use of evidence in the process of developing 1 national and 1 local HEPA policy |
Preparatory meetings with research team: focusing on context and specifics of the local setting with respect to HEPA policymaking | Research team: • Two researchers in Public Health Tilburg University • Two policy advisors (Dutch Institute for Healthcare Improvement) • One expert in conducting systems analyses |
Previous research on cross sectoral policymaking, stakeholders and networks at local level in the Netherlands | |
Policy documents related to HEPA policy at national and local levela
| - National level policy documents: six documents - Regional level policy documents: six documents - Local level policy documents of other municipalities: 14 documents - Local level policy documents of case: 12 documents |
Semi-structured interviews (individual and group) | General level: Individual (three documents)b and group (one document)b, role and institute: |
- Researcher on local public health policy, Tilburg University | |
- Policy advisor, National Institute of Public Health and the Environment | |
- Policy advisor, Regional Public Health Service West-Brabant | |
- Two policy advisors, Regional Public Health Service Hart voor Brabant | |
Case level: Individual (one document)b and group (four documents)b, role and institute: | |
- Two policy advisors, Regional Public Health Service West-Brabant (one time) | |
- Policy advisor, Regional Sport Service West-Brabant | |
- Key figure group case (three times): • One policy advisor, Regional Public Health Service West-Brabant • One policy advisor, Regional Sport Service West-Brabant • One policymaker, Municipality Dutch case | |
Denmark | |
Previous work REPOPA (Oct 2011–Jan 2013) | Data from interviews (17) with local and regional stakeholders on use of evidence in the process of developing one regional and three local HEPA policies |
Preparatory meetings for research team: focusing on context and specifics of the local setting with respect to HEPA policymaking | Research team • Two researchers/policy advisors of Research Centre for Prevention and Health • Two researchers in Public Health of University Southern Denmark |
Books on cross sectoral policymaking, stakeholders and networks in Denmark | |
Policy documents related to governance and HEPA policy at national and local levela
| - International policy documents: one document - National level policy documents: 12 documents - National level law document: one document - Regional level policy documents: two documents - Local level policy documents from other municipalities: four documents - Local level policy documents of case: 10 documents |
Discussion over email | General level: Individual (one document), role and institute: |
- Researcher/policy advisor, Local government Denmark (email contact) | |
Semi-structured interviews (individual and group) | Case level: Group (five documents)b, role and institute: |
- Key figure group case (four times face-to-face and once by telephone) • Three policymakers of Centre of Health, Sport and Citizenship (two from health and one from sports) | |
Romania | |
Previous work REPOPA (Oct 2011–Jan 2013) | Data from interviews (four) with local, regional and national stakeholders on use of evidence in the process of developing two national HEPA policies |
Preparatory meetings with research team: focusing on context and specifics of the local setting with respect to HEPA policymaking | Research team: • Three researchers in public health, Babes-Bolyai University |
Policy documents related to HEPA policy at national and local levela
| - International policy documents: four documents - National level policy documents: one document - Documentation from the actual local strategy of the case |
Semi-structured interviews (individual) | National level: Individual (three documents)b, role and institute: |
- General Secretary of the National Sport for All Federation; | |
- General Inspector, Ministry of Education; | |
- Policy advisor, National Focal Point - HEPA Europe Network, National Institute of Public Health) | |
Case level: Individual (27 documents)b, role and institute: | |
Local level public sector
| |
- Three stakeholders city hall, two policy advisors and one director | |
- Three stakeholders city council, two policy advisors and one director | |
County level public sector
| |
- One stakeholder county council, director | |
- Five stakeholders sector education, one inspector education, three directors, one assistant director (five different organisations) | |
- Two stakeholders sector public health, one policy advisor, one director (two different organisations) | |
- Four stakeholders sector sports, one dean, one director, one manager (three different organisations) | |
Local organisations
| |
- Four stakeholders private sector, three directors, one press officer (four different organisations) | |
- Five stakeholders civil society, five directors (four different organisations) | |
Websites for general information | Looked for documents on the official websites of public institutions at national and local level to explore multiple documents for each of these institutions |
Comparison between countries
Results
Description of the systems analyses
Step 1 – Main stakeholders
Dutch case
Danish case
Romanian case
Step 2 – Positioning stakeholders in the preliminary schematic model
Dutch and Danish cases
Romanian case
Steps 3 – The underlying driving forces
Box 1 Relations characterised by driving forces
Dutch case
Danish case
Romanian case
Step 4 – Verification of the models of the systems analyses
Dutch case
Danish case
Romanian case
Comparison of the systems analyses of the three cases
The Netherlands | Denmark | Romania | ||
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HIERARCHICAL POSITIONS IN THE SYSTEMS | ||||
Authorization and accountability of the local policy | • Local Authority, City council and Board of Mayor and Aldermen | • Local authority, City council, Mayor and political committees | • Accountability not specifically defined locally: National level strategy developed by Ministry Youth and Sport, locally embedded by County Youth and Sport department (main stakeholder in charge of implementing the national developed strategy) | |
Final accountability | • Board of Mayor and Aldermen | • Board of Mayor and Aldermen | • No strict accountability | |
Allocation of tasks | • Civil servants in sectors • Municipality services • Local organisations | • Civil servants in sectors • Municipality services • Local organisations | • Local organisations | |
STAKEHOLDERS WITH SIMILAR POSITIONS IN THE SYSTEMS | ||||
Local/ County | Local & County authority | • City council • Board of Mayor and Aldermen • Sectors at local level • Municipality services | • City council • Political committees • Mayor and Directors • Sectors at local level • Municipality services | • Mayor and City Council • County Council • Sectors at county level, representative of sectors national level |
Part of municipality services | • Combination functions • Centres for youth and family | • Schools • Day care • Health service • Social neighbourhood co-workers | ||
Local organizations, including private and civil society | • Schools and day care • Sport clubs • Health and Care organisations • Private partners • Local councils and citizen’s platform | • Local councils, such as sports, youth • Interest groups, e.g. local sports associations • Private partners • Media | • Sport equipment companies • Running clubs • Cycling clubs • Paralympics sport organisation • Media • Student NGOs | |
Regional | Regional stakeholders influencing local level | • Public Health Service • Regional Sport Services | • Research Centre for Prevention and Health | • County Sport for All Association |
National | National stakeholders influencing local level | • Ministry of Health, Welfare and Sports • Health Inspectorate • Knowledge institutes: National Institute for Public Health and the Environment, National Institute for Physical Activity and Sportsa, National Youth on Healthy Weight Bureau | • Ministry of Health • Danish Nature Agency • Healthy cities network • Local Government Denmark • Universities • Danish Health and Medicines Authorities | • Ministry of Youth and Sport • Romanian Sport for all Federation • Ministry of Education • Ministry of Health • National Institute for Sport Research • National Physical Education and Sport University • Private Sector and Civil Society |
Main stakeholders
Relations between stakeholders in local HEPA policymaking
Formal relations
DRIVING FORCE: FORMAL RELATIONS | ||||
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The Netherlands | Denmark | Romania | ||
Within local level | Guidance (1) | • Board of Mayor and Aldermen > Sectors • Sectors > Municipality services • City council > Sectors | • Political Committees > Sectors • Sectors > mayor • Sectors > Municipality Services | |
Formal acceptance (2) | • City Council > Board of Mayor and Aldermen | • City Council > Political Committees | • Local authorities > Local organisations | |
Financial support (3) | • Local Authority > Regional Public Health Service & Regional Sport Service | • Patient organisations > sectors | • Local authorities > Local organisations | |
From regional towards local level | Formal acceptance (2) | • County authorities > Local organisations | ||
Financial support (3) | • Other municipalities > Regional Public Health Service & Regional Sport Service | • County authorities > Local organisations | ||
From national towards other levels | Guidance (1) | • Danish Health and Medicines Authority > Local Authority • Local Government Denmark > Sectors • Knowledge institutes > Sectors • Healthy Cities Network > Sectors | • Romanian Government > Ministries • Ministry of Education > County school inspectorate • Ministry of Health > County public health • Ministry of Youth and Sports > County Youth and Sport & Romanian Sport for All Federation & National Institute for Sport Research • Romanian Sport for All Federation > County Sport for All Association • Private sector and civil society > Local organisations • Physical Education and Sport University > Ministry of Youth and Sport | |
Formal acceptance (2) | • Health inspectorate > Regional Public Health Service • Health inspectorate > Local authorities | • Danish Nature Agency > Sectors | • Private Sector and Civil Society > Local organisations | |
Financial support (3) | • Ministries > Municipalities | • Ministries > Municipalities • Danish Nature Agency > Sectors • NGOs > Sectors | • Ministry of Education > County Sector Education • Ministry of Health > County Sector Health • Ministry of Youth and Sports > County Sector Sport & Romanian Sport for All Federation • Romanian Sport for All Federation > County Sport for All Association | |
Giving direction (4) | • Ministries > Local authorities • National Institute for Public Health and the Environment > Regional Public Health Service | • Ministries > Local authorities | • Ministry of Education > County Sector Education • Ministry of Health > County Sector Health • Ministry of Youth and Sports > County Sector Sport • Romanian Sport for All Federation > County Sport for All Association |
Informal interaction
DRIVING FORCE: INFORMAL INTERACTION | ||||
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The Netherlands | Denmark | Romania | ||
Within local level | Informal acceptance (5) | • Sectors > City council • Regional public health service > Care and welfare organisations | • Mayor > Executive chiefs sectors • Directors > Executive chiefs sectors • Municipality services > Sectors | • Local authorities > Local organisations |
Direct communication (6) | • Between Board of Mayor and Aldermen • Between sectors • City council <-> sectors • Local council <-> sectors • Local council <-> city council • Private partners <-> Board of Mayor and Aldermen • Private partners <-> Sectors • Private partners <-> Regional public health service | • Between political committees • Between sectors • Directors <-> Mayor • Interest groups <-> City council • Patients organisations <-> City council • Patient organisations <-> Sectors • Local councils <-> Political committee • Local councils > Sectors | • Between local organisations • Local organisations <-> City council, County council, Sectors education and health • Between local organisations | |
Project-based interaction (7) | • Schools <-> Sectors | • Interest groups <-> Sectors • Center of volunteers <-> Sectors • Private parties <-> Sectors | • Local authorities <-> Local organisations • Between local organisations | |
Between local and regional level | Informal acceptance (5) | • County authorities > Local organisations | ||
Direct communication (6) | • Within regional public health service • Regional sport service <-> Local authorities • Regional public health service <-> Regional sport service | • County council <-> County sector sport • Local organisations > County Council & Children Palace & Sector Health • County Sport for All Association <-> Local organisations | ||
Project-based interaction (7) | • Regional public health service <-> Sectors • Regional sport service <-> Sectors | • Between county sectors • County authorities <-> Local organisations • County Sport for All Association <-> Local organisations | ||
From national towards other levels | Direct communication (6) | • National Institute for Physical Activity and Sporta <-> Sectors • Ministry of Health, Welfare and Sports <-> National Institute for Public Health and the Environment, National Institute for Physical Activity and Sportsa, Youth on Health Weight, Health inspectorate, other ministries | • Danish Health and Medicines Authority <-> Local authorities • Danish Nature Agency <-> Sectors • Ministry of Health <-> Local Government Denmark • Ministry of Health <-> Danish Health and Medicines Authority | • Romanian Sport for All Federation <-> County Sport for All Association • Private sector and civil society <-> Local organisations |
From national towards other levels | Project-based interaction (7) | • National Institute for Physical Activity and Sporta <-> Sectors |
Knowledge exchange
DRIVING FORCES: KNOWLEDGE EXCHANGE | ||||
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The Netherlands | Denmark | Romania | ||
Within local level | Giving feedback (8) | • Municipality services > Sectors • Sectors > Board of Mayor and Aldermen • Board of Mayor and Aldermen > City council | • Municipality services > Sectors • Sectors > Political committees • Political committees > City council | |
Research utilisation (9) | • Local authorities <-> Media | • Local authorities <->Local organisations | ||
Research utilisation (9) | • Regional Public Health Service <-> Sectors • Regional Sport Service <-> Sectors • Regional Sport Service <-> Regional Public Health Service | • Research Centre for Prevention and Health > Local authorities | • County authorities <-> Local organisations | |
From and between national and other levels | Giving feedback (8) | • Ministry of Education <-> County Sector Education • Ministry of Health <-> County Sector Health • Ministry of Youth and Sports <-> County Sector Sport • Romanian Sport for All Federation <-> County Sport for All Association • Physical Education and Sport University > Ministry of Youth and Sport Private Sector and Civil Society <-> Local organisations | ||
Research utilisation (9) | • National Institute for Physical Activity and Sporta <-> Regional Public Health Service • Universities <-> Regional Public Health Service | • Local Government Denmark <-> Sectors • Universities <-> Sectors • Healthy Cities Network <-> Sectors | • Romanian Sport for All Federation <-> County Sport for All Association |