<b>Bijsluiter</b>. De hyperlink naar het originele document werkt niet meer. Daarom laat Woogle de tekst zien die in dat document stond. Deze tekst kan vreemde foutieve woorden of zinnen bevatten en de opmaak kan verdwenen of veranderd zijn. Dit komt door het zwartlakken van vertrouwelijke informatie of doordat de tekst niet digitaal beschikbaar was en dus ingescand en vervolgens via OCR weer ingelezen is. Voor het originele document, neem contact op met de Woo-contactpersoon van het bestuursorgaan.<br><br>====================================================================== Pagina 1 ======================================================================

<pre>Aletta Jacobs School of Public Health
          Strengthening public
          health in the Netherlands
          Lessons from global public health system
          Final report - 23 June 2022
                               Simon van der Pol - Amrit Sandhu - Jochen Mierau - Danielle Jansen
            This report was commissioned by the Raad voor Volksgezondheid & Samenleving. The Hague, the Netherlands
</pre>

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<pre>  “I will prevent disease whenever I can, for
           prevention is preferable to cure.”
                           Modern Hippocratic Oath (Lasagna, 1964)
    The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
2
         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>  Managementsamenvatting
  Publieke gezondheid kan worden gedefinieerd als: “de wetenschap en kunst van het bevorderen van gezondheid, het
  voorkomen van ziekte en het verlengen van het leven door de georganiseerde inspanningen van de samenleving”. Het
  is één van de drie belangrijkste subfuncties van de gezondheidszorg, naast eerstelijnszorg en specialistische zorg. Om
  de gezondheid wereldwijd te verbeteren, is het belangrijk lessen te trekken uit de verschillende internationale stelsels
  voor de publieke gezondheid. In dit rapport werden de volgende landen en regio’s met elkaar vergeleken: Denemarken,
  Engeland, Italië, Letland, Nederland, Australië, British Columbia (Canada) en Singapore. Vier bouwstenen (bestuur,
  genereren van middelen, financiering en dienstverlening) binnen het “Health System Performance Assessment” (HSPA)-
  kader, zoals gedefinieerd door de WHO, werden gebruikt om de stelsels voor volksgezondheid te vergelijken, met behulp
  van literatuuronderzoek en twee rondes van vragenlijsten die naar nationale deskundigen werden gestuurd.
  De publieke gezondheid omvat verschillende overheidsdepartementen, en dit wordt weerspiegeld in de
  gezondheidsdoelstellingen die de onderzochte landen willen bereiken: deze variëren van gezondheidsgerelateerde
  doelstellingen tot arbeidswetgeving en vervoersdoelstellingen. Het bestuur van de stelsels voor volksgezondheid lijkt
  niet in alle gevallen geschikt om te opereren binnen dit zeer brede terrein en is vaak meer gericht op gezondheidszorg
  dan op gezondheid in het algemeen. Tot de beroepsbeoefenaren die werkzaam zijn in de volksgezondheid behoren
  gezondheidswerkers, zoals verpleegkundigen, artsen en psychologen, maar ook beleidsmakers, epidemiologen,
  gezondheidseconomen en managers. De uitgaven voor preventieve gezondheidszorg vormen in de meeste landen
  slechts een fractie van de totale uitgaven voor gezondheidszorg. Ten slotte kan de dienstverlening worden onderverdeeld
  in twee niveaus: het individuele niveau, waar een burger bijvoorbeeld gevaccineerd kan worden, en het beleidsniveau,
  waar programma’s ter bevordering van de publieke gezondheid worden opgesteld en uitgevoerd.
  Een sterk stelsel van publieke gezondheid heeft het potentieel om de samenleving als geheel te versterken, vooral als
  gezondheid een integraal onderdeel wordt van de besluitvorming in alle overheidsdepartementen. Financiering voor
  preventie moet worden gezien als een investering in de gezondheid van morgen en niet zozeer als een uitgave op
  de Rijksbegroting, zoals momenteel het geval is. Momenteel hebben veel landen moeite om de volledige reikwijdte
  van de publieke gezondheid in hun gezondheidsstelsel op te nemen, ook al zijn er samenwerkingsverbanden tussen
  de verschillende overheidsdepartementen gaande. Een belangrijke les voor Nederland is dat breed gedragen
  gezondheidsdoelen essentieel kunnen zijn om verschillende departementen op één lijn te krijgen en beleid te maken
  dat daadwerkelijk effect heeft. Regeringen moeten verantwoordelijk worden gehouden voor de resultaten van hun
  gezondheidsbeleid, niet alleen voor hun inspanningen, en de financiering moet gaan naar programma’s die het gewenste
  effect hebben, of dat nu op individueel niveau of op bevolkingsniveau is.departementen op één lijn te krijgen en beleid
  te maken dat daadwerkelijk effect heeft. Regeringen moeten verantwoordelijk worden gehouden voor de resultaten
  van hun gezondheidsbeleid, niet alleen voor hun inspanningen, en de financiering moet gaan naar programma’s die het
  gewenste effect hebben, of dat nu op individueel niveau of op bevolkingsniveau is.
                   The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
3
                        the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>  Executive summary
  Public health can be defined as: “the science and art of promoting health, preventing disease and prolonging life
  through the organized efforts of society”. It is considered one of the three major sub-functions of healthcare service
  delivery, next to primary care and specialist care. To improve public health worldwide, it is considered important to
  derive lessons from the various public health systems internationally. In this report, the following countries and
  regions were compared: Denmark, England, Italy, Latvia, Italy, the Netherlands, Australia, British Columbia (Canada) and
  Singapore. Four building blocks (governance, resource generation, financing, and service delivery) within the Health
  System Performance Assessment (HSPA) framework as defined by WHO were used to compare public health systems,
  using literature searches as well as two rounds of questionnaires sent to national experts.
  Public health includes various government departments, and this is reflected in the health goals that the countries
  surveyed aim to achieve: these vary from health-related goals to labour laws and transport goals. The governance of the
  public health systems seems not in all cases able to cope with this wide scope and is often focussing more on healthcare
  than health in general. Professionals working in public health include healthcare professionals, such as nurses, doctors,
  and psychologists, but also policy makers, epidemiologists, health economists, and managers. Spending on preventive
  health is only a fraction of total health expenditure in most countries. Finally, service delivery can be separated into
  two levels: the individual level, where a citizen may receive services such as vaccinations, and the policy level, where
  programmes to promote public health are drafted and executed.
  A strong public health system has the potential to strengthen society as a whole, especially in the case when health
  becomes an integral part decision making throughout all government departments. Funding for prevention should be
  seen as an investment in the health of tomorrow and not so much as a budgeted expense, as is currently the case in
  the Netherlands. Currently, many countries struggle to incorporate the full scope of public health within their health
  system, even though collaborations between the various departments of governments are ongoing. An important
  lesson for the Netherlands is that widely supported goals can be essential to get various departments aligned and make
  policies that have impact. Governments should be held accountable for the outcomes of their public health policies, not
  only for their efforts, and funding should flow to programmes that have the desired impact, whether that is provided at
  the individual level or at the population level.
                   The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
4
                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>  Table of contents
  1. Synthesis and recommendations				                                                                                6
            1.1 Public health defined				                                                                             6
            1.2 A solid foundation: the four building blocks of public health systems			                              7
                        1.2.1 Governance				                                                                          7
                        1.2.2 Resource generation				                                                                 8
                        1.2.3 Financing				                                                                           9
                        1.2.4 Service delivery 				                                                                   9
            1.3 Aiming for the stars: public health goals				                                                         10
            1.4 Public health redefined				                                                                           11
  2. Introduction				 13
            2.1 The definition of public health				                                                                   13
            2.2 Comparing health systems: the HSPA framework 				                                                     14
            2.3 Aims of this project				                                                                              15
  3. Methods 				 16
            3.1 Country selection                                                      			 16
            3.2 Data collection				                                                                                   16
                        3.2.1 Expenditure data 				                                                                   16
                        3.2.2 Demographic data				                                                                    16
            3.3 Questionnaire				                                                                                     17
                        3.3.1 Selection of tracer themes				                                                          17
            3.4 Procedure				                                                                                         17
  4. Results				 20
            4.1 Country agent responses				                                                                           20
            4.2 The focus of public health				                                                                        20
            4.3 Spending on preventative health services in relation to GDP			                                        24
            4.4 Intersectoral collaboration in public health				                                                      25
            4.5 Building blocks of public health				                                                                  27
                        4.5.1 Governance 				                                                                         27
                        4.5.2 Resource generation				                                                                 38
                        4.5.3 Financing				                                                                           43
                        4.5.4 Service delivery				                                                                    45
            4.6 Limitations and tensions related to public health				                                                 48
            4.7 The role of public health in the overall health system				                                            49
                        4.7.1 Health data sharing				                                                                 49
                        4.7.2 Role of GPs in the public health system				                                             49
                        4.7.3 Embedding of public health in the mental health system			                               50
  5. Discussion				                                                                                                   52
  6. Conclusion				                                                                                                   53
  7. Acknowledgements				                                                                                             54
  8. References				                                                                                                   55
  Appendix I - Questionnaire ‘Public health system comparison’				                                                    64
                 The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
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                      the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>  1. Synthesis and recommendations
  Around the world, public health systems are challenged by various factors, such as limited resources, both in monetary
  terms1 and qualified personnel2; a growing importance of prevention, including the reduction of health disparities
  between citizens of different social-economic status3, rising healthcare costs4, the resurgence of infectious diseases
  due to the COVID-19 pandemic5 and a growing threat of antimicrobial resistance6.
  The Dutch Council for Health and Society (Raad voor Volksgezondheid en Samenleving in Dutch, RVS) is preparing an
  advisory report on the structure and implementation of a system for public health that is capable of dealing with future
  challenges. To inform this advice, the Aletta Jacobs School of Public Health was asked to compare international public
  health systems, including legal, organisational, and financial differences.
  The recent COVID-19 pandemic has led to a renewed drive to strengthen health systems on the national4 as well as the
  global level5,7. Increased investments in the public health system can be regarded as a collective insurance against the
  future threats mentioned above. Comparative research is an important element in health system strengthening: what
  are best practices in public health internationally, and what can we learn from this in the Netherlands?
  1.1 Public health defined
  The definition of public health is very broad: “the science and art of promoting health, preventing disease and prolonging
  life through the organized efforts of society”8. This broad definition allows countries to design public health in a way
  that fits their society. In this international comparison we see that all included countries have tailored their public health
  systems to their respective settings and needs. However, many countries struggle to incorporate the full scope of public
  health within their health system, even though collaborations between the various departments of governments are
  ongoing. While there is not much debate on the key public health activities, there are often differences when considering
  if some activities (i.e., health promotion) or intersectoral action (i.e., collaboration on urban planning) fall within the
  defined boundaries of the public health system. This lack of clarity leads to uncertainty in key actors that should be held
  accountable for the public health system performance itself.
  A health system with a broad scope, that incorporates health through all government policies may better represent all
  factors which influence health system outcomes. A health system with a narrow approach on the other hand may make
  it easier to identify stakeholders responsible for the systems performance, however, may overlook important factors
  (i.e., education, employment) that do impact health system goals9. There is a clear distinction between the fields of
  “medicine”, which emphasizes disease treatment and care on the individual level, and “public health”, which concerns
  health promotion and prevention on the population level. “Health” is a broad term, historically defined by the World
  Health Organization (WHO) as “a state of complete physical, mental and social well-being and not merely the absence
  of disease or infirmity”10 and more recently as “the ability to adapt and to self-manage”11. It may be tempting to narrow
  down public health to the health sector, closely aligned with medicine, without applying a more comprehensive view
  considering citizens’ health in all policies. Although we see an increased interest in the Netherlands in including health
  in matters such as urban planning, housing, and education, this is not always included by default. We recommend
  applying a broad perspective as this is necessary to benefit from the full potential of public health as a
  society, including improved health in terms of physical and mental health, but certainly also granting citizens
  autonomy in their way of living. To apply this broad perspective, the health capability model by Prah Ruger may
                     The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
6
                          the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>  be helpful, which balances an individual’s health functioning and the ability to pursue health, i.e., paternalism versus
  autonomy12.
  1.2 A solid foundation: the four building blocks of public health systems
  Four building blocks outline the fundamental functions of a health system, as described by the Health System
  Performance Assessment (HSPA) framework9. Through governance, there are appropriate oversight, regulations,
  coalitions, and strategic policies in place to meet the demands of the country. Governance functions in collaboration
  with other sectors and stakeholders outside of the health system. Resource generation equips a health system with
  all inputs needed to function. It ensures inputs are produced, procured, and made available or maintained when needed,
  including adequate human resources and medical equipment. Financing is an integral function of a health system
  which ensures stable and sufficient funds can maintain and support the health system and its beneficiaries. Service
  delivery ensures effective, safe, and health interventions of high quality are delivered in all settings: the community, the
  GP practice, and the hospital.
  1.2.1 Governance
  Most included regions have an explicit public health act such as England, the Netherlands, Australia, British Colombia
  (Canada), and Chile which covers health promotion and protection. Singapore and Latvia have an infectious disease
  control and epidemiological safety act, respectively. Divided responsibilities on both the national and regional levels is
  common for public health, although the “regional level” varies between countries depending on their governance system.
  All countries have a public health vision or plan which is either state or nation specific. Denmark and Italy have national
  guidelines that can be tailored by each region or municipality. Australia has both national and state specific plans. Chile,
  Latvia, and Singapore have nation specific guidelines outlining their public health goals and vision. These goals can
  be tailored to specific populations, an example could be minority populations, such as Aboriginals: there are specific
  goals and policies to improve the health of the Aboriginal populations in Australia and British Columbia. Although the
  Netherlands currently has national health goals, these are divided over many different documents and are not always
  embedded on the municipal and district level. We recommend having clear national public health goals, with
  tailored policy on the regional level and subgroup level to achieve these goals. Local decision makers should
  prioritize their contributions to achieving the national public health goals based on local opportunities and
  needs. While drafting these policies, collaboration with various levels of government, health professionals, and public
  and private organizations is important, and is implemented in all countries to varying degrees. Responsibilities for these
  health goals should be clearly defined, a good example is Latvia: for every health goal the main responsible institution is
  detailed, as well as co-responsibilities13. This is an important step to ensure accountability within the democratic system.
  The process to include all important stakeholders in the policy-making process is not formalized in many countries;
  in general, we believe there is room for improvement there. Promising examples include Latvia, which ensures public
  involvement through legal mandate, and Italy, Chile, and British Columbia who have discussion forums to encourage
  stakeholder participation. National data on performance indicators and health status is publicly available through
  governmental websites for policy makers and researchers for all countries. We recommend actively monitoring the
  health goals using the most recent data regarding the underlying indicators on a publicly available webpage.
  An example is the English Public Health Outcomes Framework14. This requires a well-supported data infrastructure
  supporting the design, monitoring, and evaluation of public health policy at the national and regional levels. For the
  Netherlands, there is a monitor available, but this is hardly an inspiring webpage and certainly not easy to understand
  for lay audiences15.
                   The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
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                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>  1.2.2 Resource generation
  There are various groups of public health professionals involved in the public health system. All countries have expert
  public health professionals who serve as consultants, frontline workers to deliver care, managers responsible for
  oversight of programs, and medical officers or professional bodies who have a legislative responsibility to manage
  public health issues on a broad scale. In Italy, England, Latvia, Netherlands, and Canada, the role of consultants can
  be fulfilled by epidemiologists, medical technicians, health scientists, quality officers/health inspectors, medical
  doctors, policy analysists, and environmental specialists. Singapore, Chile, and Australia mainly refer to epidemiologists
  or policy analysists as their consultants and Denmark relies on its regional councils. The most visible public health
  professionals are the frontline workers such as nurses, doctors, dentists, nutritionists, psychologists, social workers,
  and pharmacists. Some countries have specific support for minority groups, such as Aboriginal health workers in
  Australia. England, Latvia, Australia, and British Columbia have administrators, health service coordinators, and public
  health directors in their supervisory roles. England, Australia, and British Columbia have an explicit chief medical officer
  which is an important individual in major public health decisions. This person acts as the principal medical advisor to
  the government and provides advice on public health to the Minister of Health and other government departments.
  In Singapore and Chile, there are directors of public health and vice-ministers of public health who similarly are
  accountable for major public health decisions. We recommend appointing a person, such as a chief medical officer,
  who is responsible for ensuring the inclusion of health-related matters throughout the Dutch government,
  and for reaching the national public health goals. Some countries offer specific education to train public health
  professionals, with schools of public health being very prevalent in Anglo-Saxon countries, such as England, Canada
  and Australia16. Ongoing education after starting to work as a public health professional is focussed more on frontline
  workers than on workers in fields such as policy and epidemiology. Healthcare professionals need to continue their
  professional development to retain their licence, so this group receives ongoing training in all countries. In addition
  to the existing programmes offered by the Netherlands School of Public & Occupational Health (NSPOH), we
  recommend further developing ongoing professional education programmes for public health policy makers
  and advisors. Additionally, the Netherlands is one of the few countries without dedicated academic public
  health programmes (i.e., Master of Public Health); introducing these programmes both for under-graduate
  and graduate degrees may benefit public health in general.
                   The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
8
                        the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>  1.2.3 Financing
  The public health system is funded through national or local taxation schemes in many countries. In Denmark, British
  Columbia, and Italy, taxes are pooled and distributed to regions or municipalities based on needs and health targets
  set. Danish municipalities can also gain additional earmarked funding from national sources if needed. In England, the
  Department of Health and Social Care allocates such funds to the National Health Services for public health spending
  and local authorities receive funding though a Public Health Ring Fenced Grant based on population needs to meet
  health goals. The Dutch national government finances the municipalities through a fixed budget based on specific
  policy programmes to be carried out and the needs of the population. Latvia and Chile have both publicly funded
  (thought taxation) and out of pocket payments schemes for their health care systems in which some public health
  programmes such as vaccinations are free whereas patients may be charged for screenings. Public health in Australia
  is primarily funded through the tax-based health system, resulting in many public health services such as vaccinations
  and screenings being free of charge). For most countries, specific public health services for target groups are often
  free of charge for example though childhood vaccination programmes or elderly flue vaccination programmes. Still,
  compared to medical care, spending on public health is very low: spending on preventive health services ranges from
  1% and 3% of all health expenses17. In health-economic terms, the willingness-to-pay threshold for government
  spending on public health interventions such as vaccines is €20,000 per quality adjusted life year (QALY), compared to
  up to €80,000 for curative care18,19. This implies more societal value to interventions that prolong the life of already-
  ill patients, than preventing disease in the first place20. It may be considered unbalanced that curing already existing
  diseases is prioritized to such a degree over preventing illness. For the Netherlands, we recommend applying the
  same willingness-to-pay thresholds to prevention, i.e., ranging from €20,000 to €80,000 based on the burden
  of disease19.
  1.2.4 Service delivery
  Service delivery is often the broad responsibility of regions, municipalities, local health authorities and local health
  professionals. They must ensure health promotion and prevention services are available for their population. In
  Singapore this responsibility is shared amongst the Ministry of Health and the Health Promotion Board. Similarly in
  Latvia, the Ministry of Health, local governments, non-governmental organizations (NGOs), and private enterprises have
  a joint effort to deliver public health services. A General Practitioner’s (GP) office is regarded as a place for screenings and
  vaccinations in all countries. However, certain public health programmes such as childhood vaccination programmes
  are delivered in schools and mass vaccination programs (i.e., pandemic or flu vaccines) are delivered in health centres
  or health authorities. The Netherlands has child health clinics (“consultatiebureaus”) which are specialized facilities
  for childhood screenings, vaccinations, and parenting support. For the indigenous population in British Columbia, the
  first nations health authority is responsible for service delivery. In Singapore, Chile, Denmark, and Latvia, public health
  services can be delivered in primary care facilities as well. Quality assurance for service delivery for health promotion
  activities, environment, and service providers is found in most countries such as Netherlands, British Columbia, Italy,
  Australia, England, and Denmark while other countries have more established guidelines on healthcare providers and
  their practice. We recommend having approachable and visible public health centres for civilians, whether
  these are sexually transmissible disease (STD) clinics, child health clinics or embedded within GP practices.
  For the Netherlands, child health clinics and municipal health service offices are already available, but they are not
  very approachable for the public, also compared to other health centres such as pharmacies, primary care centres
  (“gezondheidscentra”) or hospitals. The approachability and visibility of public health services may be improved by
  rebranding current offices or integrating more closely with these other health centres. Imagine walking into the local
  public health office to get a flu shot whenever it suits you or getting tested for STDs at the pharmacy right before
  doing the groceries. For the policy level, a similar approach may be relevant as well. We recommend implementing
                    The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
9
                          the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   transparent (online) points of access for public health policy, targeting lay audiences, health professionals
   and policy makers. The Singaporean Health Hub provides a nice example, a website with clear information on the
   various public health programmes, as well as the overall health system21.
   1.3 Aiming for the stars: public health goals
   Health system goals and indicators are important to understand the health system’s aims and performance. Already,
   most countries, including the Netherlands, included in the comparison adopted widely supported public health goals to
   get various government departments aligned and make policies that have the desired impact. For example in Australia
   the goal is to add at least two additional years of life lived in full health between 2021 and 203022. In the United
   Kingdom, the 2020 aim was to reduce the smoking prevalence among adults to 12%, the percentage of pregnant
   women smoking at the time of delivery to 6% and the rate of regular smoking at age 15 to 3% by 202223. In some cases,
   the goals do not describe outcomes, but outputs, such as the start of a national marketing campaign or the introduction
   of an innovative programme. This may not be the right approach as the outputs may not translate to the outcomes
   needed to reach the eventual impact. For example: if the government’s aim is to reduce child obesity and the policy
   output is the availability of healthy snacks in school canteens, it is not necessarily true that this also contributes to the
   outcome that children have a healthy diet, see also the example in Figure 1.
               OUTPUT                                                                                            GOAL
                                                             OUTCOME
        Availability of healthy                                                                               Reduce child
                                                        Children eat healthy
          snacks in schools                                                                                      obesity
   Figure 1 Example of a public health goal, including a potential policy output and outcome
   What may be necessary to reduce child obesity is free healthy lunches in schools, or a reduction in fast food chains around
   schools, or sugar taxes, or a combination of these measures. In terms of the building block framework as described
   before, the output describes something happening in the four building blocks - governance, resource generation,
   financing, and service delivery – the outcome is an intermediate objective, and the goal is a final goal as also displayed
   later in this report (Figure 2). Of course, often assumptions or findings from previous research do not hold up in practice,
   and outputs do not have the desired impact on reaching outcomes or goals. Using a flexible approach, policies can
   be quickly adapted to generate new outputs that aid in reaching the goals. We recommend to held governments
   not only accountable for the realization of the outputs, but also for the outcomes and goals24. Using close
   monitoring of indicators by means of a well-established data infrastructure, policies can be dynamically
   adapted if the outputs do not contribute to reaching the desired outcomes.
   Optimalisation of the four building blocks combined are necessary to reach the outcomes: governance should be aligned,
   on all levels of government, there should be sufficient staff, resources, and funding available, and the intervention
   should be delivered effectively. To return to the previous example and assuming that the availability of healthy snacks
   is effective to let children eat healthy, within governance the goal should be well defined and embedded within the local
   government, with both schools, parents, and maybe even local farmers on board. As for resource generation, there
   should be processes in place to ensure that the healthy snacks are sufficiently available, fresh, and free of pesticides.
   The funding should be available so that the price of the healthy snacks is competitive, maybe even free. Finally, there
   should be someone to sell or give away the healthy snacks, capable of aiding the children in consuming the snacks. We
                     The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
10
                           the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   do believe that doing this comprehensively requires focus, having too many goals will not work as citizens, public health
   professionals, and policy makers will lose track. A public health officer, such as a chief medical officer, can ensure the
   government stays on track with their established health goals and objectives. These individuals can be held accountable
   for the outcomes of public health and must ensure the government makes the right decisions to benefit the population.
   1.4 Public health redefined
   We started off by investigating the building blocks of the health system and worked towards the impact each of the
   countries wants to make. For a moment, let us consider an opposite approach starting with the main goals of the health
   system and how all the building blocks should be arranged to maximize the impact of the public health system. From
   the various included countries, we see that most of the goals focus on health improvement and equity within the health
   system. The main benefit of the public health is that, unlike the field of medicine, you do not have to wait for citizens
   to become patients, i.e., get ill. This truly enables to focus on health broader than the absence of disease; to focus on
   preventing disease instead of curing it; and to focus on reaching all citizens, instead of only those that pro-actively
   seek medical care. To reach these goals, a mission-based approach may be needed25, where the public sector actively
   collaborates with the private sector, each acting to their strengths. The central mission of the Dutch Ministry of Health,
   that the Dutch live at least five years longer in good health, and the differences in health between the lowest and highest
   socio-economic groups have decreased with 30% in 2040, of a good example of a mission26. The scope is broad and
   requires active participation from all stakeholders in the Netherlands. For the public health system specifically, a separate
   vision is most important, notably that the burden of disease due to a unhealthy lifestyle and unhealthy environment is
   reduced with 30% in 204026. Reaching these goals requires a clear agenda-setting role from the government. Policies
   should be in place to ensure that the health system’s building blocks fully support the government mission. Additionally,
   all relevant layers of government and departments should contribute towards reaching these goals.
   A governance should be in place that enables all departments within government to promote health in all
   policies, laid out in clear goals and responsibilities. This really does require a different system than the field of
   medicine, where governance lies with the medical professionals whenever possible9. The greatest medical advance,
   sanitation27, required a collective effort to be achieved, from researchers finding the relation between polluted water
   and disease, to policy makers deciding that it was worth fundamentally changing the infrastructure of 19th century
   cities. For resource generation, we would prioritize one of the key assets: public health professionals. Currently, medical
   education is primarily focussed on treating patients, as opposed to preventing patients and we expect only a small
   fraction of health professionals is working in public health, although it is quite challenging to quantify this28. This is also
   somewhat related to prestige, still, in the medical field a career as a specialist brings the most authority, even though
   we may consider it a collective failure that we need so many cardiologists, pulmonologists and orthopaedic surgeons
   to treat conditions that could have been avoided. To truly reinvigorate the health of society, the brightest minds,
   both in the public as well as the private sector, need to be educated in and enabled to contribute to public
   health. Financing of public health is inherently different from medicine; usually medical services are budgeted with the
   aim to reduce an increase in costs as much as possible. Over the years, this has resulted in a focus on implementing cost-
   effective interventions, usually valued at a cost per QALY, and evidence-based medicine, where non-proven interventions
   are no longer reimbursed. This budgeting approach makes sense for medicine, to keep the whole system sustainable,
   but not so much when considering public health. Public health funding should be considered more like an
   investment, enabling citizens to lead a fulfilling and productive life, with long-term benefits for educational
   attainment, labour productivity and overall wellbeing. We believe the core aim of public health policy should not
   be to reduce healthcare usage in the future, although this may of course be a positive side effect.
                    The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
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                          the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   With regards to service delivery, the final building block, having recognizable, low-barrier points of entry into
   public health services is important, both for citizens and policy makers. This may be separate from the curative
   health sector but can also be combined with primary care centres or pharmacies for citizens. In the 21st century, an
   effective digital presence of the public health system can be an important asset, not only for citizens, but also for
   professionals and policy advisors working in all sectors that collaborate on public health topics. This digital presence
   should be fuelled by a health data infrastructure to monitor and evaluate health policy at all policy levels.
   Contrary to the field of medicine, which mainly incrementally improves the health of patients, public health has
   the potential to fundamentally improve the health of all citizens. The issues mentioned above are organizational,
   financial, and societal issues combined. Having clear goals is key, but it requires support from a public health
   system that is both effective and accountable. The system should be working towards clear outputs and
   outcomes, dynamically changing its approach whenever the outputs do not reach the intended outcomes.
   The responsibility for reaching these goals should be defined and scrutinized by parliaments and regional
   democratic councils.
                    The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
12
                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   2. Introduction
   Everyone, whether we are considering patients, doctors, or policy makers, will agree that it is better to prevent disease,
   than to cure it. Also, in the focus on keeping global health systems sustainable, prevention is considered an important
   pillar. Therefore, most countries have a public health system which is focussed on exactly this aspect, in addition to the
   community care and hospital care systems where patients can turn to in case of illness. These public health systems
   vary greatly between countries and cover topics such as health promotion, environmental health, child healthcare,
   vaccination programmes and infectious disease prevention29–31.
   Although everyone will agree prevention is a priority within the health system, this is often not reflected in the expenditure
   on public health. Expenditure on preventive care in 2019 ranged between 1% and 3% of all health expenses for most
   Western countries17. Previously, concerns have been raised concerning cutbacks on the public health budget32 and also
   concerning the availability of reliable data to quantify the investments in public health28,32. At the same time, the sense
   of urgency for well-developed public health systems is increasing, considering a rise in preventable diseases such as
   obesity in children33, an ageing population34 and a potential increase in infectious disease outbreaks, as illustrated by
   the COVID-19 pandemic. Although many public health measures are unlikely to save healthcare costs in the future,
   there may often be future benefits such as improved health and enhanced productivity both in paid (i.e., jobs) as well as
   non-paid activities, such as informal care and education35. Standard market mechanisms in the healthcare system seem
   to drive funding away from prevention to curative care36. A process which may be further accelerated in the Netherlands
   as the willingness-to-pay threshold for prevention usually is €20,000 per QALY, while this is up to €80,000 per QALY for
   curative care18; in effect, applying more societal value to interventions that prolong the life of already-ill patients, than
   preventing disease in the first place20.
   2.1 The definition of public health
   Public health is defined as: “the science and art of promoting health, preventing disease and prolonging life through the
   organized efforts of society”8. It is considered one of the three major sub-functions of healthcare service delivery, next
   to primary care and specialist care9. Public health encompasses a large array of health topics, ranging from services
   targeting new-borns, to the elderly, and from the eradication of certain communicable diseases to improving social
   determinants of health9. Even civilians who never consult a GP or are admitted to a hospital will encounter the public
   health system through various stages of their lives: whether they are vaccinated for a range of infectious diseases as a
   young child, fill in a survey on mental health as an adolescent wear a safety helmet on a building site as a construction
   worker or see a photograph of smoker’s lungs on a pack of cigarettes as a retiree. Virtually all disease areas have a
   connection to public health, including communicable diseases, non-communicable diseases, social and mental health,
   maternal and child health, environmental health, occupational health, injuries and violence, antibiotic resistance, and
   health inequalities29.
   In 2011, the WHO published the Essential Public Health Operations and Services in Europe29,30. In this framework,
   various operations that need to take place within a public health system are described, divided into intelligence,
   services delivery, and enablers. Intelligence covers surveillance and monitoring and response to various diseases and
   health hazards. Services delivery covers health protection, health promotion and disease prevention. Enablers are
   necessities for a well-functioning public health system: governance, workforce, funding, communication, and research.
                     The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
13
                           the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   2.2 Comparing health systems: the HSPA framework
   To understand a health system’s structure and functioning and to identify which parts of the health system can be
   strengthened, we can look the building blocks within the Health System Performance Assessment (HSPA) framework as
   defined by WHO9. These have been established to lay the foundation for each well-functioning health system and should
   be universal regardless of a country’s context. All health systems should have effective stewardship, deliver interventions
   to those who need them, have enough skilled workers to meet a country’s demand, and have a sustainable financing
   system that is inclusive and fair. Strengthening these building blocks will lead to intermediate outcomes such as safe
   and high-quality care and to good access, which will consequently lead to the attainment of health systems goals, both
   on a personal level (better health and higher productivity) and population level (less inequity in health) (Figure 2).
   Figure 2 the WHO health system performance assessment (HSPA) framework9
   Governance is one of the most important core functions within the health system as it lays the foundation for resource
   generation, financing, and service delivery functions. Through governance, there are appropriate oversight, regulations,
   coalitions, and strategic policies in place to meet the demands of the country. Governance functions in collaboration
   with other sectors and stakeholders outside of the health system. Therefore, governance is not solely dependent on
   the health sector alone but also those that surround it (e.g., education and environment). It can be viewed through four
   subfunctions: policy and vision, stakeholder voice, information and intelligence, legislation, and regulation.
   Resource generation equips a health system with all inputs needed to function. It ensures inputs are produced,
   procured, and made available or maintained when needed. For example, adequate human resources (health workforce)
   that are sufficient, well-trained, responsive, and able to achieve the best health outcomes given their circumstances.
   Other sub-functions such as infrastructure and medical equipment, and pharmaceuticals and other consumables are
   important physical resources for a strong health system.
                    The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
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                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   Financing is an integral function of a health system which ensures stable and sufficient funds can maintain and support
   the health system and its beneficiaries. As such it is closely linked to each of the other building blocks. For example, it
   can provide governance the appropriate monetary resources needed to implement policy or ensure there are adequate
   funds for human and physical resources needed for the public. It is also key in enabling interactions between various
   actors in the health system and can be broken down into three sub-functions explaining the flow of financial resources
   through the health system: revenue raising, pooling resources, purchasing goods and services.
   Service delivery directly impacts intermediate health system objectives and the achievement of health system goals.
   It ensures effective, safe, and health interventions of high quality are delivered in all settings: the community, the GP
   practice, and the hospital. As service delivery is an outcome of governance, financing, and resource generation, the
   performance of this block will reflect the performance of the others.
   These building blocks outline the fundamental functions of a health system, as such, its performance can also be
   assessed in relation to the goals that are set. The intermediate objectives and final goals are an important part of the
   HSPA framework. All health systems aim to improve the health of the population it serves, to provide care that is person
   centered by incorporating the citizens needs and rights, and to protect individuals from catastrophic spending to
   maintain health. The pursuit of these goals is influenced directly by the building blocks or indirectly through intermediate
   outcomes. For example, governance can directly influence people centredness if it involves them in the decision-making
   process whereas service delivery acts indirectly on the final goals through delivering effective and accessible services
   to achieve health improvements in the population. Thus by understanding a health system’s function, intermediate
   objectives, and final outcomes, its strengths and weaknesses can be identified.9
   2.3 Aims of this project
   For this comparison, the research question is: where does the Dutch public health system differ from public health
   systems in other countries with different constituent principles and systems, and what can we learn from these other
   systems? As public health is very broad, we focus primarily on what interventions and policy domains are considered to
   be part of public health systems internationally, how these are governed and funded, and what opportunities we see to
   improve public health. We select various countries and compare their performance using the WHO HSPA framework.
   The information we gather through this model are used to answer six sub questions for each of the public health systems:
   1.   What is considered “public health”, what are the commonalities and differences?
   2.   What percentage of the Gross Domestic Product (GDP) is spent on prevention?
   3.   Which domains are included in the public health system, in addition to healthcare?
   4.   Which building blocks lay the foundation to each health system and how?
   5.   Which limitations or tensions are known?
   6.   What is the role of the public health services within the health system? Is this primarily an executive, signalling or
        advising role?
   The systematically collected information on different public health systems can be used to inform and inspire policy
   makers and advisory councils, including the RVS, on potential changes that can be made to national public health
   systems, based on evidence from abroad. For the scientific community, this project is novel as, to the best of our
   knowledge, there are no international comparisons of public health systems available. Additionally, the updated HSPA
   framework has not been applied before, as it was published very recently, and may guide future comparisons of health
   systems.
                   The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
15
                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   3. Methods
   3.1 Country selection
   In addition to the Netherlands, four European countries and four non-European countries or states, were selected for
   the comparison. These countries were selected based on guidance from the European Observatory on Health Systems
   and Policies, which involved consulting several public health experts in health systems as well as looking at geographical
   spread of the countries. This led to the selection as displayed in Table 1.
   To collect up-to-date and country-specific information, two national experts in public health, referred to as “country
   agents” were approached for each country to complete a questionnaire designed to gather information regarding the
   building block model (see Appendix I for the full questionnaire).
        European                                Global
        Italy                                   Australia
        Denmark                                 Chile
        England (United Kingdom)                Singapore
        Latvia                                  British Columbia (Canada)
   Table 1 overview included countries in comparison
   3.2 Data collection
   Prior to receiving the data from the country agents, a scoping literature search was performed on Google and PubMed
   to find relevant literature on public health and the tracer themes for each of the countries. Additionally, relevant
   governmental websites (e.g., ministry of health) were searched to ensure up-to-date information. This search strategy
   included both scientific and non-scientific sources. The information collected in the literature search was used to pre-
   fill the questionnaire sent to the country agents and to interpret the results.
   3.2.1 Expenditure data
   To answer the sub question on spending on preventative health, the most recent data on health expenditure (year 2019)
   was extracted from the Organisation for Economic Co-operation and development (OECD)17 and WHO37. The database
   includes health expenditure data for many countries and can be used to filter on various functions of the health system,
   including preventive care, which roughly translates to public health38. Additionally, within preventative care the various
   subfunctions were explored. In this analysis, only government and compulsory financing schemes were included, which
   excludes out-of-pocket and voluntary financing. Singapore was not included in these analyses, as this country was not
   included in the OECD data; instead of data for British Columbia and England, data were reported for the Canada and
   United Kingdom, respectively.
   3.2.2 Demographic data
   To place the included countries into context, demographic data were collected, from sources such as the World Bank39,
   WHO40, OECD17, the central intelligence agency (CIA)41 and a map from MapChart42. Data from the most recent year
   were used. For British Columbia and England, localized data were not always available. In these cases, data for Canada
                    The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
16
                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   and the United Kingdom were reported. The following indicators were included:
   •    Population
   •    Population 65 years and over
   •    Governance system
   •    Life expectancy at birth
   •    Healthy life expectancy
   •    Type of health system (e.g., single payer, insurance)
   •    Gross Domestic Product (GDP) per capita, in international dollars, corrected for purchasing power parity (PPPs)
   •    Health expenditure as a percentage of GDP
   •    Spending on prevention, as a percentage of overall health expenditure
   •    Out-of-pocket spending on health, as a percentage of overall health expenditure
   3.3 Questionnaire
   The HSPA framework as published by the WHO’s European Observatory of Health Systems and Policies was used
   to develop a questionnaire that focusses on the four main functions of health systems: governance, resource
   generation, financing, and service delivery9. The questions were phrased so that the answers would contribute to
   a broad understanding of the public health system. An overview is displayed in Table 2. We asked feedback on this
   approach from two health system experts of the European Observatory on Health Systems and Policies.
   3.3.1 Selection of tracer themes
   As public health is a broad area, we focus on six of “tracer themes”; a selection of themes considered to provide a
   comprehensive overview of various areas of focus of the public health system. The themes were determined since
   they cover three important aspects of the public health system: collective prevention, infectious disease control, and
   youth health care. Urban planning concerns the development of the public space, which can be adapted to encourage
   citizens to use healthy modes of transportation43. Also related to urban planning is particulate matter, which are
   very small particles in the air, and is an important indicator for air pollution, which is estimated to cause 7 million
   deaths annually44. HPV can cause various types of cancer and genital warts, causing almost 8 million years of life lost
   in 200845, which can largely be prevented using screening programmes46 and vaccination47. Influenza is a viral disease
   with a high burden of disease, affecting citizens of all ages. In the public health setting, annual vaccination programmes
   for the elderly can prevent disease, while the public health system has an important role in preparing for pandemic
   influenza48. In Child Screening Services, children are screened and vaccinated, thereby detecting and preventing
   diseases; improving health outcomes in the long term28. Mental health programmes are important to support citizens
   coping with mental diseases and to prevent mental health problems in the long run49.
   3.4 Procedure
   Country agents were consulted in two rounds. In the first round, the questionnaire was sent to the country agents. If
   sufficient scientific literature was available from the literature search, the questionnaires were pre-filled by the main
   investigators, with the explicit request to check this information. In the second round, clarification questions were
   asked if necessary. Input was asked primarily for the overall public health system, but country agents were also asked
   to provide specifics for the tracer themes. In both rounds, country agents were asked to provide references to relevant
   literature if possible.
                    The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
17
                          the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   Table 2 overview of the country agent questionnaire (round 1)
                                                                                                                                                                                           Specifics regarding the
      Funtion                 Subfunction                    Questions for the public health system overall
                                                                                                                                                                                           tracer themes
                                                              •     Is there national health sector policy/ strategy/ plan with goals and targets?
                                                              •     What is the public health vision, including long-term measurable goals?
                               1. Policy and
                                                              •     Does the public health policy / strategy / plan clearly mention indicators allowing for regular
                               vision
                                                                    monitoring and evaluation? If yes, which indicators?
                                                              •     Does the public health policy / strategy / plan include multisectoral coordination? If yes, how?
                                                              •     Do key stakeholders participate during the preparation of new public health policies / strategies /
                                                                    plans and the review? If yes, which stakeholders are involved?
                                                              •     Can you provide one great example of collaboration between the various stakeholders on a public
                               2. Stakeholder voice                 health topic?                                                                                                          •     Urban planning
                                                              •     To what extent are communities, NGOs, and the private sector involved?                                                 •     Particulate matter
     1. Governance                                            •     Which mechanisms and dialogue platforms are in place to ensure involvement of key stakeholders in                      •     HPV
                                                                    the health decision-making process?                                                                                    •     Influenza
                                                                                                                                                                                           •     Mental health
                                                              •     Are relevant data collection database available, such as health surveys, birth and death registration,                 •     Child screening services
                                                                    census, health facility reporting, health system resource tracking?
                               3. Information and
                                                              •     Can you provide a website where these data ae publicly available?
                               intelligence
                                                              •     How is data sharing arranged between various layers of government?
                                                              •     How is data sharing arranged between various providers of public health services?
                                                              •     Which legislation is applicable to the public health system?
                               4. Legislation and
                                                              •     Are existing health laws aligned with the government’s health policies and plans?
                               regulation
                                                              •     To what extent are measures taken to effectively implement and enforce health legislation?
18                The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG, the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>                                                          •     Which professionals are involved in the public health system?
                           1. Health                      •     Do public health professionals receive training regarding vulnerable populations?
                           workforce                      •     Are there systems for continuing professional development available for public health professionals?
                                                          •     If the previous answer was yes, please explain which professional development is available?                            •     Urban planning
                                                                                                                                                                                       •     Particulate matter
   2. Resource                                            •     Which organizations are involved with public health?                                                                   •     HPV
                           2. Infrastructure and
   generation                                             •     Where are public health services delivered usually?                                                                    •     Influenza
                           medical equipment
                                                          •     What is the density of public health facilities?                                                                       •     Mental health
                                                                                                                                                                                       •     Child screening services
                           3. Pharmaceuticals
                           and other                      •     Are pharmaceutical and other consumable available where and when needed?
                           consumables
                                                          •     How is the public health system financed?
                                                                                                                                                                                       •     Urban planning
                                                          •     To what extent are out-of-pocket funds requested?
                                                                                                                                                                                       •     Particulate matter
                           1. Revenue collection          •     How are the funds allocated to the public health providers?
                                                                                                                                                                                       •     HPV
   3. Financing            2. Pooling                     •     Are funds sufficient and stable?
                                                                                                                                                                                       •     Influenza
                           3. Purchasing                  •     Is revenue collection and pooling equitable?
                                                                                                                                                                                       •     Mental health
                                                          •     To what extent is the payment of providers driven by information on the health needs of the
                                                                                                                                                                                       •     Child screening services
                                                                population they serve?
                                                          •     Which is mainly responsible for delivering public health services?                                                     •     Urban planning
                           1. Public health               •     How is the public health system integrated within the overall health system?                                           •     Particulate matter
    4. Service             2. Primary care                •     How do the professionals working in the public health system collaborate with other health                             •     HPV
      delivery             3. Specialist care                   providers?                                                                                                             •     Influenza
                           4. Social care                 •     Which quality assurance measures are in place regarding the delivery of public health services?                        •     Mental health
                                                          •     Are the services delivered in an equitable manner?                                                                     •     Child screening services
                                                          •     What are you most proud of considering the public health system in your country?
      5. Final
                           -                              •     If there is one thing you could change in the public health system, what would that be?
    questions
                                                          •     Do you have any final comments relevant for this study
19            The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG, the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   4. Results
   4.1 Country agent responses
   Two country agents for all nine included countries responded on the first round of questions. For the second round, which
   included validation and follow-up questions, the country agents from Denmark, England, Italy, Latvia, the Netherlands,
   Australia, British Columbia, and Singapore responded.
   4.2 The focus of public health
   As explained in the introduction, public health is defined as: “the science and art of promoting health, preventing disease
   and prolonging life through the organized efforts of society”8. This definition was provided to all country agents, but we
   were interested in differences in the interpretation of public health and related policies across the nine countries. Some
   countries had well-defined public health system with clear boundaries whilst others were hard to distinguish from their
   overall healthcare systems. The differences amongst countries could be due to differences in their interpretations of
   health systems boundaries and the responsibilities within them9. These differences may be most clear from the formal
   goals and indicators linked to public health that we received from the country agents. In Table 3, an overview of policy
   documents detailing various public health-related goals and indicators is provided, which could be categorized in 14
   different themes. These are: child and maternal health, life expectancy and quality of life, health equity, lifestyle and
   food, substance (ab)use, communicable diseases, reproductive health, mental health, dental health, non-communicable
   diseases, safety and the workplace, environmental health, health system strengthening and health workforce. Some
   of these themes clearly link to the tracer themes, such as child and maternal health, communicable diseases, mental
   health and environmental health. There are differences between the countries; the focus of the public health goals in
   Italy includes very explicitly food safety, while Australia very explicitly includes improving the health of minorities.
                    The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
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                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>  Table 3 Public health goals and appropriate policy with relevant indicators for the nine included countries
                                                                                                                                                                        British
      Indicators          Denmark                 England                    Latvia                   Italy            Netherlands             Australia               Columbia,             Chile                Singapore
                                                                                                                                                                         Canada
                                                                                                                                            National Action         British Colum-
   Child and            Health               The Public Health           Public Health          National                                    Plan for the            bia’s Guiding       National Health
                                                                                                                                                                                                                Healthy Living
   maternal             Promotion            Outcome Frame-              Policy Guidelines      Prevention Plan                             Health of               Framework for       Strategy (2021-
                                                                                                                                                                                                                Master Plan
   health               Package              work                        (2020-2027)            (2020-2025)                                 Children and            Public Health       2030)
                                                                                                                                            Young people            (2017)
                                             The Public Health
                                                                                                                                                                    British Colum-
                                             Outcome Frame-
   Life expectancy                                                       Public Health          National              Mission               National                bia’s Guiding       National Health
                                             work                                                                                                                                                               Healthy Living
   and quality of                                                        Policy Guidelines      Prevention Plan       Document              Preventive              Framework for       Strategy (2021-
                                                                                                                                                                                                                Master Plan
   life                                                                  (2020-2027)            (2020-2025)           Health & Care         Health Strategy         Public Health       2030)
                                             Levelling Up White
                                                                                                                                                                    (2017)
                                             Paper (2022)
                                                                                                                                                                    British Colum-
                        Health               The Public Health           Public Health          National              National Health       National                bia’s Guiding       National Health
                                                                                                                                                                                                                Healthy Living
   Health equity        Promotion            Outcome Frame-              Policy Guidelines      Prevention Plan       Policy (LNG)          Preventive              Framework for       Strategy (2021-
                                                                                                                                                                                                                Master Plan
                        Package              work                        (2020-2027)            (2020-2025)           2020-2024             Health Strategy         Public Health       2030)
                                                                                                                                                                    (2017)
                                             The Public Health
                                                                                                                                                                    British Colum-
                                             Outcome Frame-
                        Health                                           Public Health          National                                    National                bia’s Guiding       National Health
   Lifestyle and                             work                                                                     National Preven-                                                                          Sport Singapore
                        Promotion                                        Policy Guidelines      Prevention Plan                             Preventive              Framework for       Strategy (2021-
   food                                                                                                               tion Agreement                                                                            Vision 2030
                        Package                                          (2020-2027)            (2020-2025)                                 Health Strategy         Public Health       2030)
                                             The National Food
                                                                                                                                                                    (2017)
                                             Strategy (2022)
21                 The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG, the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>                                                                                                                                                                        British
      Indicators         Denmark                   England                    Latvia                  Italy           Netherlands             Australia              Columbia,               Chile              Singapore
                                                                                                                                                                       Canada
                                            The Public Health
                                            Outcome Frame-              Public Health
                                            work                        Policy Guidelines
                                                                        (2020-2027)
                                                                                                                                                                  British Colum-
                                            The Tobacco Con-
                       Health                                                                  National             National              National                bia’s Guiding       National Health
   Substance                                trol Plan (2017)            Reducing the                                                                                                                          Healthy Living
                       Promotion                                                               Prevention Plan      Prevention            Preventive              Framework for       Strategy (2021-
   (ab)use                                                              Prevalence of                                                                                                                         Master Plan
                       Package                                                                 (2020-2025)          Agreement             Health Strategy         Public Health       2030)
                                            From Harm to Hope:          Alcohol and Drug
                                                                                                                                                                  (2017)
                                            A 10-year Drugs             Use 2023-2025
                                            Plan to Cut Crime           (Draft)
                                            and Save Lives
                                            (2022)
                       Health               The Public Health           Public Health          National                                   National                                    National Health
   Communicable
                       Promotion            Outcome Frame-              Policy Guidelines      Prevention Plan                            Preventive                                  Strategy (2021-
   diseases
                       Package              work                        (2020-2027)            (2020-2025)                                Health Strategy                             2030)
                       Health               The Public Health           Public Health          National                                                                               National Health
   Reproductive                                                                                                                           National
                       Promotion            Outcome Frame-              Policy Guidelines      Prevention Plan                                                                        Strategy (2021-
   health                                                                                                                                 STI Strategy
                       Package              work                        (2020-2027)            (2020-2025)                                                                            2030)
                                                                                                                                          National                                    National Health
                                                                                                                                          Preventive                                  Strategy (2021-
                                                                                                                                                                  British Colum-
                                                                                                                                          Health Strategy                             2030)
                       Health               The Public Health           Public Health          National             National Health                               bia’s Guiding
   Mental health       Promotion            Outcome Frame-              Policy Guidelines      Prevention Plan      Policy (LNG)                                  Framework for
                                                                                                                                          National Mental                             Mental Health
                       Package              work                        (2020-2027)            (2020-2025)          2020-2024                                     Public Health
                                                                                                                                          Health and                                  Action Plan
                                                                                                                                                                  (2017)
                                                                                                                                          Suicide                                     (2019-2025)
                                                                                                                                          Prevention Plan
                                            The Public Health           Public Health          National
                                                                                                                                          National Oral                                                       Healthy Living
   Dental health                            Outcome Frame-              Guidelines             Prevention Plan
                                                                                                                                          Health Plan                                                         Master Plan
                                            work                        (2021-2027)            (2020-2025)
22               The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG, the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>                                                                                                                                                                         British
      Indicators          Denmark                  England                    Latvia                    Italy           Netherlands             Australia             Columbia,               Chile              Singapore
                                                                                                                                                                        Canada
                                                                                                                                           National
                                                                                                                                           Preventive
                                                                                                                                           Health Strategy
                                             The Public Health           Public Health          National              Mission                                                          National Health
   Non-communi-                                                                                                                                                                                                Healthy Living
                                             Outcome Frame-              Guidelines             Prevention Plan       Document             National                                    Strategy (2021-
   cable diseases                                                                                                                                                                                              Master Plan
                                             work                        (2021-2027)            (2020-2025)           Health & Care        strategic                                   2030)
                                                                                                                                           framework for
                                                                                                                                           chronic
                                                                                                                                           conditions
                                                                                                                                                                   British Colum-
                        Health                                           Public Health          National                                                           bia’s Guiding
   Safety and the                                                                                                                          Work Health &                                                       Healthy Living
                        Promotion                                        Guidelines             Prevention Plan                                                    Framework for
   workplace                                                                                                                               Safety Strategy                                                     Master Plan
                        Package                                          (2021-2027)            (2020-2025)                                                        Public Health
                                                                                                                                                                   (2017)
                                                                                                                                                                   British Colum-
                                             The Public Health           Public Health          National              Healthy Green                                bia’s Guiding       National Health
   Environmental                                                                                                                                                                                               Health Living
                                             Outcome Frame-              Guidelines             Prevention Plan       Environment                                  Framework for       Strategy (2021-
   health                                                                                                                                                                                                      Master Plan
                                             work                        (2021-2027)            (2020-2025)           Programme                                    Public Health       2030)
                                                                                                                                                                   (2017)
                                                                                                                                           National
                                                                                                                                           Preventive              British Colum-
                                                                         Public Health          National              Mission              Health Strategy         bia’s Guiding
   Health system
                                                                         Guidelines             Prevention Plan       Document                                     Framework for
   strengthening
                                                                         (2021-2027)            (2020-2025)           Health & Care        Primary Health          Public Health
                                                                                                                                           Care 10 year plan       (2017)
                                                                                                                                           (2022-2032)
                                                                         Public Health          National                                   National Medical
   Health
                                                                         Guidelines             Prevention Plan                            Workforce
   workforce
                                                                         (2021-2027)            (2020-2025)                                Strategy
23                The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG, the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   4.3 Spending on preventative health services in relation to GDP
   National spending on the various functions of the health system as a percentage of the GDP are displayed in Figure 217.
   No data were available for Chile. Spending on preventive care ranged from 0.16% of GDP for Latvia to 0.50% for the
   United Kingdom. Compared to other functions in the health system, preventive care can be considered to account for a
   minor contribution to the overall expenditure, compared to curative and rehabilitative care, long-term care, or medical
   goods. For Singapore no OECD data was available by healthcare function. According to the Singaporean Ministry of
   Health, 5% of overall healthcare spending is on preventive health services50; around 4% of GDP in Singapore is spent on
   healthcare, so the percentage of GDP spent on preventative healthcare can be estimated at around 0.2%37.
   Figure 2 expenditure on health as a percentage of the GDP by country and function in 2019
   For the United Kingdom, Denmark, and Latvia more
   details are available on the subfunctions within
   preventive care expenditure, which is displayed in
   Figure 3. The most prominent contributor are healthy
   condition    monitoring      programmes,        followed      by
   information, education and counselling programmes.
     Figure 3 expenditure on preventive care as a percentage
                 of GDP by country and subfunction in 2019
                    The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
24
                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   4.4 Intersectoral collaboration in public health
   As described in the HSPA framework, intersectoral collaboration is important to deal with factors outside the health
   system that shape the health of populations9. Hence, domains of government not directly focussed on health are often
   involved in public health policies and programmes. As public health cannot function as a single entity, multisectoral
   collaboration is often essential to have effective public health policy. Simple, yet common public health measures such as
   vaccination programmes are often developed in collaboration with the ministry of education to deliver these in schools
   to children early in life. Collaboration within domains can be seen in various stages of developing, implementing, or
   enforcing public health policies or programmes. Table 4 highlights the different domains which work in collaboration
   with the ministries of health on public health in the various countries under consideration.
   Some examples on collaboration across domains are the “Crece Contigo” in Chile, a law that aims to improve living
   standards and care for children in the first years of life, a shared responsibility between the Chilean Ministry of
   Education, Ministry of Social Development and Ministry of Health. Another example is the Comprehensive School
   Health Programme in British Columbia (British Columbia) which addresses school health and education in a planned,
   integrated, and holistic manner51. This programme is a joint effort between the Ministry of Health and Education,
   NGO’s, health authorities, educational partners, and other key stakeholders (teachers, students, families)52. In Latvia,
   the Ministry of Health has created a National Commission on Smoking Control which aims to fulfil the right to clean,
   smoke free air for its citizens. It is in collaboration with numerous stakeholders from the public, private and community
   sectors including but not limited to, the Ministry of Education, state police, the Public Health association, and Public
   health professionals53.
                   The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
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                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   Table 4 multisectoral coordination of public health system with different government departments (green = yes)
                                                                                                        British
                  Denmark       England         Latvia        Italy           NL         Australia                   Chile Singapore
                                                                                                      Columbia
     Education
        Social
   Development
       Labor &
     workforce
       Food &
     agriculture
      Transport
        Justice
       & crime
       Finance
     Economics
    Environment
         Sport
                   The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
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                        the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   4.5 Building blocks of public health
   4.5.1 Governance
   The governance of public health systems varies between the included countries. Table 5 provides an overview of relevant
   legislation applicable to public health in the different countries, such as dedicated public health laws and separate acts.
   In countries such as Latvia, Netherlands, Chile, Italy, and Australia, the right to health is fundamentally established in
   their constitution. Considering the governance structure, in smaller countries, such as Singapore and Latvia, public
   health is centralized. The responsibilities of public health goals and performance is thus with the Ministry of Health in
   these countries. The larger countries commonly have a more decentralized public health system, including Canada,
   Australia, Chile, and Italy, where the responsibility mainly lies with either provinces or states. Similar to the Netherlands,
   Denmark, a relatively small country, also is decentralized.
   Table 5 overview of public health legislature across countries
            Country                  Public Health Legislation                               Public Health Programmes
                                                                                National Childhood Immunization Programmes
                                            “Sundhedsloven” or
             Denmark                                                            New-born & Childhood Screening Programmes
                                         Danish Health Care Act*54
                                                                                Cancer Screening Programmes
                                                                                NHS Vaccination Programme
                                                                                Screening Programme
                                                                                Influenza Preparedness Strategy
             England                     England Public Health Act*
                                                                                Healthy Child Programme
                                                                                NSH Long Term Plan
                                                                                Mental Health Workforce Plan
                                                                                Cancer screening Programme
                                                                                State Immunization Programme
                                        Epidemiological safety Law55
              Latvia
                                    Sexual and Reproductive Health Law          Newborn & Childhood Screening Programmes
                                                                                Psychological & Psychotherapeutic Assistance
                                                                                Programmes
                                                                                Gaining Health-Promoting Healthy Choices Programme
                                           Article 32 of the Italian            National Immunization programme
               Italy
                                               Constitution**                   Screening Programmes
                                                                                School Based Mental Health Programmes
                     The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
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                          the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>                                                                                   National Prevention Agreement
                                          “Wet publieke gezondheid” or             National Vaccination Programme
            Netherlands
                                                 Public Health law                 Childhood Screening & Prevention Programme
                                                                                   Healthy Green Environment Programme
                                                                                   National immunization programme
                                                                                   National Mental health & suicide prevention strategies
                                                 Public Health Act*
               Australia                                                           Neonatal screening programme
                                                  (state specific)
                                                                                   Pandemic Influenza Plan
                                                                                   National Cancer Screening
                                                                                   Healthy Child and Youth Development Programme
                                                                                   Healthy living programmes (tobacco control, physical
                                                                                   activity, diet)
          British Columbia,                                                        Life Time Prevention Programme (screenings &
                                             The Public Health Act *56             vaccinations)
                Canada
                                                                                   Influenza Prevention Policy
                                                                                   Mental Health Promotion & Prevention
                                                                                   Newborn Screening Programme
                                                                                   Cancer Screening Programme
                                                                                   National Immunization Programme
                                           “Sistema Elige Vivir Sano” or           Contrapeso (‘Against Overweight’) Programme
                 Chile
                                           Healthy Living Systems Law              Early Child Development Program
                                                                                   National Mental Health Plan (2017-2025)
                                                                                   Adolescents and Youth Health Programme
                                                                                   School Dental Services programme
                                                                                   Healthy Lifestyle & Healthy Aging Programmes
                                             Infectious Disease Act*57             Student Immunisation & Screening Programme
              Singapore
                                       Environmental Public Health Act57
                                                                                   Screening for Life- National Health Screening
                                                                                   Programme
                                                                                   Anti-smoking Programmes
   *Acts give power to Public Health Authority figures to prevent and control infectious disease
   ** Italian constitution highlights right to health protection and equitable health infrastructure for all
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28
                            the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   The main health law in Denmark is the “Sundhedsloven”,
                                                                                                          Denmark
   the Danish healthcare act, which provides a framework for
   more specific legislation54. This law covers health promotion,
   protection, as well as treatment 54. Denmark has not had an
   overarching health strategy since the programme “Healthy
   throughout life” from 2002 to 2010. Since then, the Danish
   Health Authority has provided municipalities with Health
   Promotion Packages to provide technical guidance to
   implement effective public health prevention and promotion
   programmes with performance indicators covering 11 focus
   areas (Table 3)58,59. Public health in Denmark is thus a shared
   responsibility between the national government, regions, and
   municipalities 60. The regions contract healthcare providers,                    Land area                         40000 km²
   mainly GPs and hospitals, and draft healthcare agreements
   with the municipalities. Each municipality has its own health                    Population (millions)             5.8
   policy which is relevant to the needs of the population it
   serves, and runs general prevention programmes, schools
                                                                                    Population ≥65 years              20%
   nursing services, and health promotion programmes60. The
   98 municipalities are organized on the national level within
                                                                                                                      Parliamentary
   the “Kommunerns landsforening”, which represents aims
                                                                                    Governance system                 constitutional
   to safeguard the interests of the municipalities as well as                                                        monarchy
   assist them with consultancy services needed to function
   with up-to-date information61. Collaboration on health                           Life expectancy at birth          81 years
   policy in Denmark is mainly governed by the idea of “public
   corporatism” which includes a wide range of stakeholders,
                                                                                    Healthy life expectancy           71 years
   both formally and informally. This entails each stakeholder
   to be responsible for different parts of health service
   delivery. For example, regions are specialized in patient                        Type of health system             Single-payer
   care and municipalities are responsible for population level
   preventative care. most influential factors in this field are the                GDP per capita
                                                                                                                      $60230
   government and medical professionals, although patient                           (PPP-corrected USD)
   organizations also may be consulted. Public health data at
   the regional, municipal, and hospital level is publicly available                Health expenditure
                                                                                                                      10%
                                                                                    (% of GDP)
   for patients, researchers and health care professionals to
   access62
                                                                                    Spending on prevention (%
                                                                                                                      2.5%
                                                                                    of health expenditure)
                                                                                    Out-of-pocket spending
                                                                                    on health (% of health            14%
                                                                                    expenditure)
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                          the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   England’s Public Health Act which was formed in 1848 is the
                                                                                             England, United Kingdom
   main legislation covering public health policy and ensuring
   adequate protection from diseases           63
                                                 . The Public Health
   England 2020-2025 plan aims to protect and help people live
   longer in good health23. The overarching goals - to improve
   the wider determinants of health, health improvement,
   health protection, and healthcare and preventing premature
   mortality - have relevant indicators and monitoring in
   place clearly described in the Public Health Outcomes
   Framework14 (Table 3). Each goal is taken forward nationally,
   regionally, and locally across relevant organizations. Up until
   2021, the public health system was under one governing
   body (Public Health England) but is now divided over the UK                      Land area                        130279 km²
   Health and Security Agency whose main role is to protect
   from infectious diseases and health threats, the Office for                      Population (millions)            56.6
   Health Improvement and Disparities which aims to improve
   the nation’s health so everyone can live in good health
                                                                                    Population ≥65 years             19%*
   longer through health promotion activities, and the National
   Health Service (NHS)64. While these governing bodies are
                                                                                                                     Parliamentary
   responsible for public health, multisectoral coordination
                                                                                                                     constitutional
   is key in executing each goal specified in the Public Health                     Governance system                monarchy; a
   Outcomes Framework14. The Department of Health and                                                                Commonwealth
                                                                                                                     realm
   Social Care works with 25 agencies and public bodies as well
   as a variety of key stakeholders such as Health Education
                                                                                    Life expectancy at birth         81 years*
   England, professional and representative public health
   organizations and the NHS England65. Voluntary, Community
   and Social Enterprise Health and Wellbeing Alliance serves                       Healthy life expectancy          70 years*
   to engage these stakeholders in co-producing public health
   guidelines and local health authorities in addressing health
                                                                                    Type of health system            Single-payer
   inequalities. Furthermore, there are mechanisms in place
   such as requirements to consult, online platforms to provide
   input and meetings with key professional groups. Patient data                    GDP per capita
                                                                                                                     $46483
                                                                                    (PPP-corrected USD)
   is collected in accordance with legal frameworks and data
   protection laws. There must always be a valid lawful basis for
                                                                                    Health expenditure
   the collection and processing of data66. All data is available                                                    10%
                                                                                    (% of GDP)
   through public health profiles , a large public health data
                                      14
   collection portal with information on key health indicators as                   Spending on prevention
   well as their health system performance indicators.                              (% of health                     5%
                                                                                    expenditure)
                                                                                    Out-of-pocket spending
                                                                                    on health (% of health           17%
                                                                                    expenditure)
                                                                                  * Data for the whole of the United Kingdom
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                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   The Italian constitution section 3.2 provides the right
                                                                                                              Italy
   to health and health protection for each citizen and the
   community is the primary legislation applicable to public
   health. It emphasises population health is a fundamental
   value and the state must provide sufficient services to all
   in an equitable manner. In addition, the NHS, established in
   1978, is a legal structure which covers universal access and
   non-discriminatory access to health services. The National
   Prevention Plan is the main policy and planning instrument
   regarding Italy’s public health system67. The current plan
   (2020-2025) adopts a “one health” approach considering
   the relationships between environment- animals-humans in
   Public Health67. The plan is at the state level but leaves rooms                  Land area                         297730 km²
   for the regions to develop their own relevant goals in regional
   prevention plans, which are updated every 3-5 years. As such,                     Population (millions)             59.6
   the states and regions are held responsible for meeting
   the goals as there is no centralized authority structure.
                                                                                     Population ≥65 years              23%
   The National Prevention Plan has a systematic framework
   of performance indicators (Table 3) in place for adequate
   monitoring of the plans goals which is contextualized to each                                                       Parliamentary
                                                                                     Governance system
                                                                                                                       republic
   region/territory68. The plan is intersectoral in nature and
   includes collaboration with a wide range of ministries from
   agriculture to employment60. It also encourages participation                     Life expectancy at birth          83 years
   from citizens/ communities, the private sector and NGO’s
   which play an important role in the implementation of health
                                                                                     Healthy life expectancy           72 years
   and social health services60. Through regular discussion
   forums, diverse groups and ideas are involved in the decision-
   making process in collaboration with different leading                            Type of health system             Single-payer
   authorities involved in the governance of the health. The
   Ministry of Health also creates national platforms to engage                      GDP per capita
                                                                                                                       $41829
   stakeholders in creating and implementing policies. All                           (PPP-corrected USD)
   finalized public health decisions are made at the highest level
   in government and all involved ministries and institutions                        Health expenditure
                                                                                                                       9%
                                                                                     (% of GDP)
   must act accordingly with the goals set. The New Health
   Information System which was created in collaboration
   with the states, regions, and provinces is a universal system                     Spending on prevention (%
                                                                                                                       4.6%
                                                                                     of health expenditure)
   of electronic records connecting all levels of care60. It also
   serves to monitor and evaluate the NHS at all levels by using
                                                                                     Out-of-pocket spending
   a large set of indicators on six dimensions (population health,                   on health (% of health            23%
   regional strategy compliance, quality measures, patient                           expenditure)
   satisfaction and experience, staff satisfaction, efficacy, and
   financial performance)       63
                                  . Some regions have developed
   electronic networks to facilitate communication between
   various health service providers60.
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                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   In Latvia, there is no single public health law, however their
                                                                                                              Latvia
   Epidemiological Safety Law and the Sexual Reproduction Law
   cover a wide range of public health issues such as disease
   prevention and health promotion activities.              Additionally,
   there are various regulations for certain themes, including:
   addiction, infectious diseases, environmental health, and
   hygiene69. Public health is a centralized affair in Latvia; with
   the Ministry of Health in charge, although municipalities
   have certain responsibilities such as the provision of
   support for health promotion measures and organization
   of school health examinations. To support municipalities,
   Latvia’s Network of Healthy Local Governments, an advisory
   board is in place which aims to promote good practices                             Land area                         62090 km²
   and support in solving various public health issues at the
   local level and to educate local governments in the field                          Population (millions)             1.9
   of public health70. The Centre for Disease Prevention and
   Control is responsible for informing the public on health
                                                                                      Population ≥65 years              21%
   prevention and promotion activities. Latvia has long-term
   Public Health Policy Guidelines (2021-2027) which support
   the development of Latvia’s public health policy by building                                                         Parliamentary
                                                                                      Governance system
                                                                                                                        republic
   on previous public health policy and updating as needed
   and to ensure the continuous involvement of stakeholders.
   These guidelines lay the foundation for their public health                        Life expectancy at birth          75 years
   vision, focusing on reducing inequities in health, reducing
   mortality from non-communicable diseases and external
                                                                                      Healthy life expectancy           66 years
   causes, and promoting a healthy work environment with
   clear results and performance indicators in 18 different
                                                                                                                        Universal public
   policy areas, including the baseline and targets for 2024                          Type of health system
                                                                                                                        insurance
   and 2027 (Table 3)13,71. These guidelines then ensure the key
   objectives which are set out in the National Development                           GDP per capita
                                                                                                                        $31465
   Plan of Latvia (2012-2027) are indeed met. This national                           (PPP-corrected USD)
   plan clearly indicates five multisectoral areas for action in
   their first priority for a health population: lifestyle, infections,               Health expenditure
                                                                                                                        7%
                                                                                      (% of GDP)
   integrated health care, human resources and sustainability.
   Multisectoral coordination is led by the Ministry of Health,
   which collaborates within a network such as the Ministries                         Spending on prevention (%
                                                                                                                        2.6%
                                                                                      of health expenditure)
   of Welfare, Food, Interior, Education, Economics, Finance,
   and Transport. In Latvia, public involvement such as
                                                                                      Out-of-pocket spending
   including NGOs and the private sector, is mandated by                              on health (% of health            36%
   law . Universities, professional associations, and patient
       72                                                                             expenditure)
   associations are involved at early stages of development of
   the Public Health Guidelines. Various health indicators are
   collected by the Centre for Disease Prevention and Control,
   the NHS, and the Central Statistical Bureau73. The Open Data
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                          the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   Portal provides an overview of all authorities performing
                                                                                                         Netherlands
   public functions74.The Open Data Portal provides an overview
   of all authorities performing public functions74
   The Public Health law (“Wet publieke gezondheid”) is the
   main legislation on public health in the Netherlands
   and describes public health as “the health protective and
   promotive measures for the population or specific groups,
   including preventing and early discovering disease”. The
   law covers the organization of the public health system,
   measures to reduce the transmission of infectious diseases
   (including quarantines), and care for the youth and elderly.
   Other relevant laws for public health are the constitution,                        Land area                         33670 km²
   which states that the government should promote the health
   of all citizens, the law on security regions, which is used in                     Population (millions)             17.4
   emergency situations (such as pandemics), the law on
   municipalities, which outlines the municipal duty to protect
                                                                                      Population ≥65 years              20%
   health, and the law for social support, which includes the
   care for the homeless. In the still-to-be-applied environment
                                                                                                                        Parliamentary
   law, municipalities must consider health in urban planning
                                                                                      Governance system                 constitutional
   projects. Although occupational health is considered part                                                            monarchy
   of public health in many countries, this is considered a
   separate field in the Netherlands. The government has far-                         Life expectancy at birth          82 years
   reaching authority to enforce rules on preventing the spread
   of infectious disease. Although there are various ambitions
                                                                                      Healthy life expectancy           71 years
   for public health in various domains, in some cases clear
   targets are absent75, while in other cases a clear monitoring
                                                                                                                        Universal private
   programme is set up76. Various stakeholders collaborate                            Type of health system
                                                                                                                        insurance
   in the drafting and execution of public health policies, the
   different layers of government, professionals, scientists,                         GDP per capita
                                                                                                                        $59268
   the public and private organizations, but the level of                             (PPP-corrected USD)
   collaboration varies between different plans. Although there
   are various ambitions for public health in various domains, in                     Health expenditure
                                                                                                                        10%
                                                                                      (% of GDP)
   some cases clear targets are absent , while in other cases a
                                              75
   clear monitoring programme is set up76. In general, the topic
   “health” is mainly contained within the Ministry of Health on                      Spending on prevention (%
                                                                                                                        3.2%
                                                                                      of health expenditure)
   the national level and the health and social policy areas on the
   local level. Various stakeholders collaborate in the drafting
                                                                                      Out-of-pocket spending
   and execution of public health policies, the different layers of                   on health (% of health            11%
   government, professionals, scientists, the public and private                      expenditure)
   organizations, but the level of collaboration varies between
   different policy plans. This is known as the ÒpolderÓ model,
   where there is an active discussion between all stakeholders
   to reach consensus agreements that are then enacted by the
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33
                          the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   government. There are various sources of data related to
                                                                                                           Australia
   public health, such as the National Institute of Public Health
   and the Environment, the Statistics Netherlands and the
   municipal health services (GGD). Data is shared between the
   layers of government through national registration systems
   and health monitors, which provide various indicators
   collected on the local level by the municipal health services
   and shared nationally every four years. Data sharing among
   health providers is a problem, as various systems do not
   communicate properly.
   There is no single law in Australia that defines the public
   health system. Within Australia’s health system different parts                   Land area                        7692020 km²
   have responsibilities for public health. The Australian health
   system itself is complex, with various levels of funding and                      Population (millions)            25.7
   responsibilities within the federal and state governments77.
   There are various public health acts on the state level who
                                                                                     Population ≥65 years             16%
   are each responsible for health promotion; as well as some
   programs run from the central (federal) government. A
                                                                                                                      Federal
   range of policies and strategies contain long-term targets
                                                                                                                      parliamentary
   for public health, including the National Obesity Strategy                        Governance system                democracy under
   (still in consultation phase), the National Aboriginal and                                                         a constitutional
                                                                                                                      monarchy
   Torres Strait Islander Health plan, the National Action Plan
   for the Health of Children and Young People and the National
                                                                                     Life expectancy at birth         83 years
   Preventive Health Strategy. Usually, public consultations
   are an important aspect of new policies. Development of
   the National Preventive Health Strategy development was                           Healthy life expectancy          71 years
   guided by a multi-sectoral expert steering committee with
   members from Commonwealth, state, academia and NGOs.
                                                                                     Type of health system            Single-payer
   Then, a draft consultation paper was developed and in an
   open consultation round a large number of responses was
   collected. The responsibility of change is shared among                           GDP per capita
                                                                                                                      $53330
                                                                                     (PPP-corrected USD)
   governmental layers, the healthcare sector, academia, the
   private sector, industry, communities and individuals. NGOs
                                                                                     Health expenditure
   in the form of peak bodies are important organizations in the                                                      10%
                                                                                     (% of GDP)
   development and drafting of national strategies, these are
   organisations that are widely regarded as representatives of                      Spending on prevention
   patients or professionals. Health-related data are primarily                      (% of health                     2%
                                                                                     expenditure)
   shared by the Australian Institute for Health and Welfare. The
   Australian Health Performance Framework supports system-                          Out-of-pocket spending
                                                                                     on health (% of health           16%
   wide reporting on the performance on the health sector.
                                                                                     expenditure)
   Health data sharing between providers of healthcare services
   is more dispersed and although there is a standard medical
   record, its use is not universal.
                    The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
34
                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   Canada has three main levels of government; federal,
                                                                                              British Columbia, Canada
   provincial,    and    municipal,      each      with     their      own
   responsibilities78. The federal government is responsible
   for setting and administering the national standards of the
   health system whereas the provincial/territorial governments
   are responsible for managing, organizing, and delivering
   healthcare services for its residents. Thus, each province
   has its own unique health system in place which differs
   based on the needs of the population it serves79. In British
   Columbia, public health is governed through the Public
   Health Act (formerly known as the British Columbia health
   Act, 1893), a piece of legislation which serves to address
   current and emerging public health issues by providing                            Land area                        944735 km²
   public health authorities with certain tools and measures
   necessary to respond to public health emergencies56.                              Population (millions)            5.2
   This along with the Food Safety Act, Community Care
   and Assisted Living Act, Drinking water Protection Act,
                                                                                     Population ≥65 years             18%*
   Tobacco Control Act, and School Act all work together to
   ensure public health standards are maintained56. British
                                                                                                                      Federal
   Columbia’s Guiding Framework for Public Health highlights                                                          parliamentary
   their vision and long-term measurable goals for promotion,                                                         democracy
                                                                                     Governance system                (Parliament of
   protection, and prevention through four core domains
                                                                                                                      Canada) under
   in health improvement, prevention of disease, injury and                                                           a constitutional
   illness, environmental health, and public health emergency                                                         monarchy
   management51. These guidelines are accompanied by strict
   indicators for each goal and updated every 10 years (Table 3).                    Life expectancy at birth         82 years*
   The ministry of health is responsible for ensuring that quality,
   appropriate, cost-effective health services are available to its                  Healthy life expectancy          71 years*
   citizens. It supports and funds the regions to execute their
   public health obligations80. There are 6 provincial health
                                                                                     Type of health system            Single-payer
   authorities responsible for service delivery with a sixth health
   authority responsible for the quality of services delivered80.
   While the responsibilities of public health are with the                          GDP per capita
                                                                                                                      $46611*
                                                                                     (PPP-corrected USD)
   regional health authorities, the ways in which programs are
   shaped and delivered is a combined effort across all sectors
   and levels of government. Local communities, patient                              Health expenditure
                                                                                                                      11%*
                                                                                     (% of GDP)
   partners, NGO’s, the private sector, and First Nations and
   Aboriginal groups are also key in creating health promoting                       Spending on prevention
   and health protecting environments51. By inter-sectorial                          (% of health                     6.2%*
   planning and coordination ÒtablesÓ these key stakeholders                         expenditure)
   can be involved in the decision-making processes. For First                       Out-of-pocket spending
   Nations and Aboriginal people, the First Nations Health                           on health (% of health           15%*
                                                                                     expenditure)
   Authority works closely with the Public Health system to
   design and deliver public health programs that fit their needs                  * Provided data are for the whole of Canada
                    The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
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                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   and priorities51. The Public Health officer delivers reports
                                                                                                             Chile
   to assess progress in achieving health targets, establishes
   standards of practice for and conducts reviews of medical
   health officers, as well as works with the British Columbia
   Centre for Disease Control to ensure their legislated
   mandates on disease control and health protection.
   In Chile, public health is mainly a responsibility of the 15
   regional health authorities (Secretaria Regional Ministerial de
   Salud) that ensure compliance with health norms, plans and
   programmes. Municipalities are responsible for education
   and social services. The law ‘‘Sistema Elige Vivir Sano’’, or the
   healthy living system, promotes healthy living, sport, self-care                  Land area                         743532 km²
   and family development81. Under this law, all state institutions
   should incorporate policies related to health promotion                           Population (millions)             19.1
   and prevention. This includes national, regional, and local
   collaboration. An interministerial committee with ministers
                                                                                     Population ≥65 years              12%
   from many relevant ministries, such as health, education,
   social security, urbanism and sport, ensures collaboration
   on public health themes81. Stakeholders collaborate in the                                                          Presidential
                                                                                     Governance system
                                                                                                                       republic
   governance on public health, including patients, NGOs and
   industry, although the use of public consultations varies
   between various topics as they are not mandatory. There is                        Life expectancy at birth          80 years
   a ‘‘healthy parliament of children’’ where children discuss
   health-related topics. The ‘‘Consejos de Desarrollo Local y
                                                                                     Healthy life expectancy           70 years
   Consejos Consultivos’’ are local advisory councils that discuss
   health priorities within the community. Additionally, there                                                         Universal
   are various organizations that are dedicated to promoting                         Type of health system             public-private
                                                                                                                       insurance
   specific public health themes, such as the movement
   coalition, founded by the Chilean medical societies and the
                                                                                     GDP per capita
                                                                                                                       $25110
   National Federation of Independent Street Markets, which                          (PPP-corrected USD)
   promotes healthy diets. Chile’s National Health Strategy
   (Estrategia Nacional de Salud) (2021-2030) has recently                           Health expenditure
                                                                                                                       9%
   been drafted after extensive consultation with scientific                         (% of GDP)
   and academic organizations, professional associations,
   representatives of civil society, and patient groups82. Four                      Spending on prevention (%
                                                                                                                       Unknown
                                                                                     of health expenditure)
   health objectives have been identified: improve the health
   and well-being of the population; reduce health inequalities;
                                                                                     Out-of-pocket spending
   ensure the quality of health care; and more towards building                      on health (% of health            33%
   healthy communities and environments13. Indicators for                            expenditure)
   set goals are still being finalized13. Data on health-related
   indicators are collected through several surveys, such as
   the national socioeconomic characterization survey and
   epidemiolocal surveillance, which is carried out every seven
                    The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
36
                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   years. The Department of Health Information and Statistics
                                                                                                          Singapore
   of the Ministry of Health provides health-related data on
   utilization of services and health facility reporting.
   In Singapore the responsibility for public health mainly
   lies within the Ministry of Health and the Health Promotion
   Board83. In addition to these organizations, other involved
   governmental organizations are the National Environment
   Agency and the Urban Redevelopment Authority. Singapore
   has a Healthy Living Master Plan, which was drafted using
   feedback from a wide range of community members and
   professionals to ensure that the perspectives and needs of
   citizens were at the forefront. This plan was completed in                        Land area                         709 km²
   2014 with a vision for 203084. This plan emphasises health
   that is natural, effortless, and accessible to all Singaporeans                   Population (millions)             5.7
   through creating healthy environments, communities, and
   increasing the affordability for healthy living options. Various
                                                                                     Population ≥65 years              13%
   organizations collaborate on public health, such as schools,
   employers, religious organizations, community centres and
   grassroot organizations. For some issues there are public                                                           Parliamentary
                                                                                     Governance system
                                                                                                                       republic
   consultations. Singapore does not have one universal Public
   Health legislation but several, such as the Infectious Diseases
   Act85, the Environmental Public Health Act, Sale of Food                          Life expectancy at birth          83 years
   Act 57
          and the Health Promotion Board Act . They also have
                                                     86
   many laws governing unhealthy behaviours such as an anti-
                                                                                     Healthy life expectancy           74 years
   smoking law, alcohol consumption law, and misuse of drugs
   laws. The responsibility to enforce these laws is with the
                                                                                                                       Universal
   National Environment Agency, Tobacco Regulation Branch,                           Type of health system
                                                                                                                       public insurance
   Health Science Authority, and Central Narcotics Bureau. The
   Ministry of Health and Health Promotion Board periodically                        GDP per capita
                                                                                                                       $98520
   conduct national surveys to gain insights in the health status                    (PPP-corrected USD)
   and lifestyle of Singaporeans and are responsible for sharing
   data to appropriate stakeholders and service providers.                           Health expenditure
                                                                                                                       0%
                                                                                     (% of GDP)
                                                                                     Spending on prevention (%
                                                                                                                       Unknown
                                                                                     of health expenditure)
                                                                                     Out-of-pocket spending
                                                                                     on health (% of health            30%
                                                                                     expenditure)
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                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   4.5.2 Resource generation
   The second building block is resource generation, which mainly covers the health workforce and availability of products necessary for the delivery of healthcare services. Table
   6 provides an overview of the different professionals working in public health for the included countries, categorized following British Columbia’s framework into consultants/
   specialists, frontline workers, managers/supervisors and medical health officers. Consultants/ Specialists are those with advanced education and training in a particular domain
   in public health and provide expert advice and support to the other public health professionals87. Frontline workers are defined as individuals with post-secondary education in
   public health and work directly with patients and communities to execute public health care functions87. Managers/ supervisors are often responsible for oversight of major public
   health programs or functions and often have staff reporting to them87. Medical Health officers are trained physicians with a legislative responsibility for monitoring, preventing, and
   controlling communicable and chronic diseases and thus play a leading role in the public health system87.
   Table 6 overview of professionals working in public health and public health training institutes
                                                                                                      Managers/             Medical health
                     Consultants/specialists                      Frontline workers                                                                         Public health Institutes & Programmes
                                                                                                     supervisors                officers
                    Regional councils                         Nurses, health visitors,              Managers in         Staff in Danish Health          University of Copenhagen – School of Global Health &
                                                              doctors, dentists,                    municipalities      Authority                       Public Health
                                                              psychologists, dieticians,
                                                              physiotherapist, and                                                                      University of Southern Denmark- Public Health
   Denmark
                                                              occupational therapists
                                                                                                                                                        Aarhus University- Public Health
                                                                                                                                                        Danish National Institute of Public Health- PhD Public
                                                                                                                                                        Health training
                    PH intelligence analyst,                  Registered nurses, school             Directors of        Deputy chief medical            Various universities, such as the London School of
                    epidemiologists, PH                       nurses, PH nutritionists, PH          public health,      officer and Chief               Hygiene and Tropical Medicine
                    consultants, PH research                  practitioners, GPs, Health            regional            medical officer
   England          analysis/ assistants, PH                  Visitors                              directors of
                    specialists, PH specialist                                                      public health                                       Health Education England
                    registrars, Dental PH
                    consultants
38         The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG, the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>                                                                                                        Managers/             Medical health
                       Consultants/specialists                      Frontline workers                                                                         Public health Institutes & Programmes
                                                                                                       supervisors                officers
                      National institution of Health,           GP’s, psychologists,                  States and          Local health units              University of Milan- Public Health
                      medical doctors, health                   nurses, health care                   regions
                      scientists, epidemiologists,              assistants, technicians, and          governing                                           University of Verona-Diagnostic and Public Health
                      and technicians                           administrative personnel,             bodies
       Italy
                                                                social workers, educators,                                                                Catholic University of the Sacred Heart- School of
                                                                occupational therapists,                                                                  Public Health
                                                                and rehabilitation workers
                                                                                                                                                          University of Bologna- School of Health Policies
                      Epidemiologist, public                    GP, nurses, psychologists,            Coordinators        State operational               Rīgas Stradiņa University- Institute of Public Health
                      health specialist, data                   nutritionists, social workers         of health           medical comity
      Latvia          analysts, health economists,                                                    promotion           (OECD,2022)
                      environmental specialists, and
                      lawyers
                      Epidemiologists, , medical                Public Health physicians,             Minister,           N/A                             No public health programmes
                      environmentalists medical                 paediatricians, public                alderman,
                      technical staff, toxicologists,           health nurses, speech                 Director of
                      quality officers, health                  therapists, psychologists,            public health (of
                      scientists, policy analysts               dental preventive staff,              municipal health
   Netherlands                                                  occupational therapists,              service, GGD)
                                                                social nurses, psychiatric
                                                                nurses, social workers,
                                                                prevention workers,
                                                                switchboard operators,
                                                                Central Post Ambulance
39           The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG, the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>                                                                                                        Managers/             Medical health
                       Consultants/specialists                      Frontline workers                                                                         Public health Institutes & Programmes
                                                                                                       supervisors                officers
   Australia          Policy analysts and officers              GPs, nurses, Aboriginal               Administrators      Chief Medical Officers;         University of Sydney- School of Public Health
                      (including public health                  health workers, mental                                    Chief Health Officers
                      trained specialist, (health)              health workers, social                                                                    University of Queensland - School of Public Health
                      economists, epidemiologist,               workers, psychologists,
                      medical officers.                         allied health workers                                                                     University of Technology Sydney- School of Public
                                                                (dental hygienists,                                                                       Health
                                                                physiotherapists)
                                                                                                                                                          University of Adelaide- School of Public Health
                                                                                                                                                          University of New South Wales- School of Population
                                                                                                                                                          Health
                                                                                                                                                          University of Melbourne- School of population and
                                                                                                                                                          Global Health
                                                                                                                                                          University of Western Australia- School of Population
                                                                                                                                                          and Global Health
                                                                                                                                                          University of Newcastle- School of Medicine and
                                                                                                                                                          Public Health
                                                                                                                                                          Monash University – School of Public Health and
                                                                                                                                                          Preventative Medicine
                                                                                                                                                          Royal Australasian College of Physicians- Australasian
                                                                                                                                                          Faculty of Public Health Medicine
40           The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG, the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>                                                                                                        Managers/             Medical health
                       Consultants/specialists                      Frontline workers                                                                         Public health Institutes & Programmes
                                                                                                        supervisors               officers
   British            Epidemiologists,                          GP, PH nurses, PH/                    PH                  Chief medical officers          University of British Columbia- School of Population
   Columbia,          environmental health                      environmental health                  administrators                                      and Public health
   Canada             scientists, evaluators,                   officers, PH dietitians,              and population
                      nurse, health inspectors,                 dental hygienists,                    health directors                                    University of Northern British Columbia- Community
                      practitioners, and advanced               nutritionist, public health                                                               Health
                      practice nurses                           dentists, social workers, and
                                                                health promoters                                                                          University of Victoria – School of Public Health &
                                                                                                                                                          Social Policy
                                                                                                                                                          Simon Fraser University- Population and Public
                                                                                                                                                          Health
   Chile              Epidemiologist                            GP, registered nurses,                Local health        Vice-Minister for Public        University of Chile - School of Public Health
                                                                dietitians, psychologists,            care service        Health, (OECD,2019)
                                                                dentists, physiotherapists,           administrator,
                                                                social workers, speech                Health services
                                                                therapists, pharmacists and           coordinator
                                                                midwives
   Singapore          Epidemiologists, statisticians            GP, nurses, dentists,                 Programme           Director of medical             National University of Singapore- Saw Swee Hock
                                                                physiotherapists,                     administrators      services, Director-             School of public health
                                                                pharmacists                           in Ministry         General Public Health
                                                                                                      of Health
                                                                                                      and Health
                                                                                                      Promotion
                                                                                                      Board
41           The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG, the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   In Denmark, the regional councils function as advisors to the municipal councils to ensure they are able to fulfil
   their public health obligations88. The municipal council serves as a supervisor role and is responsible for establishing
   preventative and health promoting services for the populations they serve88. Nurses, health visitors, doctors, dentists,
   psychologists, dieticians, physiotherapists, and occupational therapists make up the frontline professionals involved
   in the Danish public health system. These professionals are trained regarding vulnerable populations and have access
   to continuing professional development.
   England’s public health consultants/specialists are public health intelligence analysists, research analysists/
   assistants, epidemiologists and public health consultants. Their frontline workers include GPs, registered nurses,
   school nurses, public health nutritionists, and public health practitioners. Directors of public health and regional
   directors of public health have a supervisory role on the public health system. Their deputy chief medical officer
   and chief medical officer are responsible for managing the overall public health system regarding monitoring and
   prevention of diseases and are the most senior government advisors on all health matters. Public health professionals
   receive training on vulnerable populations and have access to continuing professional development including
   through UK’s public health registry offering more than 100 programmes. All registered public health consultants
   must demonstrate annual continuous professional development to be in good standing with the Faculty of Public
   Health, a membership organization for all public health professionals across the UK and around the world89.
   The NHS in Italy consults the National Institution of Health, medical doctors, health scientists, epidemiologists,
   and technicians. Frontline workers such as GPs, psychologists, nurses, health care assistants, technicians, and
   administrative personnel make up the local health units. In some cases social workers, educators, occupational
   therapists, and rehabilitation workers may be involved as in cases for mental health promotion and care. The states
   and regions act as managers for the public health system as they are responsible for public health and the local
   health units can be regarded as the medical officers providing guidance and oversight. Both training for vulnerable
   populations and continuing professional development programmes are available. The National Continuing Education
   commission (ECM) is legislation for obligatory continuing education for health professionals to meet national goals
   and to be up to date on the needs of the patient, needs of the health services, and their own professional development.
   In Latvia epidemiologist, public health specialist, data analysts, health economists, environmental specialists, and
   lawyers serve as consultants or specialists. Healthcare providers such as family doctors, specialist doctors, nurses,
   psychologists and nutritionists make up their core frontline workforce. Coordinators of health promotion oversee
   public health programs and the state operational medical committee which ensures appropriate health measures
   are in place to prevent and control the spread of disease and management of chronic diseases90. No continuing
   professional development programmes are available and although there is attention to working with vulnerable
   groups in vocational training, this is not something public health specialists are trained for specifically.
   There are various health professionals working in public health in the Netherlands. On the policy side, there
   are consultants/specialists such as epidemiologists, researchers, policy advisors. Key frontline workers include
   paediatricians, (paediatric) nurses, and public health doctors. There are systems available for continuing professional
   development, which is mandatory for medical professionals, which also includes training regarding vulnerable
   populations. On the national level, various organizations are involved with public health, such as the National Institute
   for Public Health and the Environment, the Council for Health and Society and the Trimbos institute. On the regional
   level, there are 25 municipal health services which execute many public health tasks that have to be carried out by
   the 352 municipalities. These services employ both health professionals that see patients, and employees with roles
                    The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
42
                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   in research and policymaking.
   In Australia, policy analysts and officers function as consultants in the public health system and may have a
   range of different qualifications including epidemiologists, (health) economists, medical officers, sociologist and
   biostatisticians. They have the responsibility to draft health promotion programmes. Doctors, nurses, mental health
   workers, social workers, and Aboriginal health workers make up some of the core frontline workers. Administrators take
   on a supervisor role in public health ensuring policies and programmes are implemented. The Chief Medical Officer is
   the principal advisor to the government responsible for health protection of citizens and this role is replicated in each
   of the states under the title of Chief (Public) Health Officer. Public health workers do receive continuing training, but
   this varies depending on the profession, including dedicated training regarding vulnerable populations.
   In British Columbia, consultants are epidemiologists, environmental health scientists, evaluators, nurses,
   practitioners, and advanced practice nurses. Frontline workers are GPs, public health nurses, public health/
   environmental health officers, public health dietitians, dental hygienists, social workers, and health promoters.
   Managers and supervisors are public health administrators and population health directors. Medical health officers
   have the most senior position in public health and are responsible for monitoring the health of the population and
   providing independent advice to the ministers and public officials on public health issues. Public health professionals
   receive training regarding vulnerable populations such as cultural safety training and must also engage in continuing
   professional development as required by employers or licencing authorities. Institutions such as the British Columbia
   Centre for Disease Control is a leading information body to provincial and national health authorities by providing
   surveillance, detection, treatment, and consultation services. The population-public-health surveillance team
   collects, analyses, interprets, and disseminates data about the population’s health (i.e., health status, risk factors, and
   socioeconomic status).
   Professionals working in public health in Chile are in the health districts, where epidemiologists are employed; on the
   municipal level, where community prevention plans are drafted; and within primary health centres, where epidemiology
   liaisons are employed in addition to primary healthcare providers who offer health services for individuals. GPs,
   registered nurses, dietitians, psychologists, dentists, physiotherapists, social workers, speech therapists, pharmacists
   and midwives make up the essential frontline workers91. Local health care service administrator, and health services
   coordinator supervise public health programmes and functions. The vice-minister for public health functions as their
   chief medical officer81. There are systems for continuing professional development, but for the most part they are
   self-funded. The main motivation for state-funded continuing professional development programmes is for health
   professionals to further specialize and gain residency as a specialist healthcare provider. The training regarding
   vulnerable population is heterogenous across the country.
   In Singapore, epidemiologists and statisticians have a consultancy role whereas doctors, nurses, pharmacists, and
   physiotherapists are essential frontline workers in public health. The director of medical services can be regarded as
   the chief medical officers in Singapore. For health professionals continuing professional education is mandatory to
   renew their licenses, and they receive training regarding vulnerable populations.
   4.5.3 Financing
   The third building block concerns the financing of the public health system. In paragraph 4.2 we already provided an
   overview of the expenditure on preventative care for most of the countries we included. In this part, we dive deeper in
   how these funds are raised and how they are spent in each of the countries.
                   The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
43
                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   The Danish public health system is funded through national and local taxes at the level of municipality. Municipalities
   raise their own taxes and receive funds from the national level but can also apply for additional, earmarked funding
   from national sources (SATS pulje). Hospitals receive a fixed budget which is adjusted for population characteristics
   as well as payments for specific services such as diagnosis related groups. General practitioners receive capitation
   fees and fee-for-service payments for services such as vaccinations. National government, regions, and municipalities
   complete yearly budget agreements which are driven by the health targets outlined by the Health Promotion
   Packages58.
   Public health in England is funded by general taxation and users do not have to pay out of pocket for public health
   services. The department of Health & Social care allocates these funds to the NHS for public health spending. Local
   authorities may receive funding for public health through a Public Health Ring Fenced Grant based on the populations
   needs to ensure they can provide the mandated services. In addition, local authorities produce Joint Strategic Needs
   Assessments to assess the current and future health, care, and well-being needs of the local community to inform
   local decision making.
   Italy’s public health system is primarily financed through corporate tax which is pooled nationally but allocated to
   each region. A fixed proportion of national value added tax revenue collected by the central government can also be
   redistributed to regions who have inadequate funds to provide essential level of care. Regions are also allowed to
   generate their own additional revenue. Annually, the Standing Conference on Relations between the states, regions,
   and autonomous provinces set criteria for allocation of funding to regions. Italy’s “budget law” communicates to
   parliament about public expenditure and the revenue foreseen for the following year according to the laws in force
   and this helps guide the public health financing. Italy’s current health expenditure reflects the national health needs.
   The level of health needs is determined through regulatory interventions and agreements between the states and
   regions. In 2013, the standard cost methodology was implemented in legislation and aimed to improve the allocation
   of resources, analysis of situations of inefficiency or inadequacy (compare between regions) and provide elements for
   evaluating programmes.
   The Latvian healthcare sector is funded publicly through general taxation for about 61%, while out-of-pocket
   funding is used to cover over a third of health expenses. GPs are paid using a mix of a per-capita allocation and quality
   bonuses, which include health prevention. No specific funding is allocated to preventive care and health promotion.
   For some programmes, such as influenza vaccinations, specific target audiences have been identified that are offered
   the intervention free of charge. For other programmes, NGO’s deliver public health programmes in the domains of
   mental health, diabetes, oncology, and HIV for example.
   The Dutch national government finances public health through funds for the municipal fund, which is then distributed
   to the municipalities. Municipalities also have limited options to tax their inhabitants. The national government
   also funds specific policy programmes that can be carried out by the municipalities or other organizations. The
   municipalities decide on the funding of the municipal public health services. Municipalities with an older or less
   healthy population, receive more money from the municipal fund. As municipalities have very tight budgets, this is
   a risk for the stable allocation of funding to public health services. The National Institute for Public Health and the
   Environment is funded through the Ministry of Health. Public health services are free for everyone who is considered
   the target audience, but some services are paid out-of-pocket, such as traveller’s vaccinations.
                    The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
44
                         the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
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<pre>   Various levels of funding are available for public health in Australia, including national, state, local, private, and
   charitable funding. Funding is allocated through a mix of evidence, policy windows, political preferences, and public
   demand and fixed at a department level. Vaccination and screening services are provided free of charge, as well as
   all services provided by public hospitals. Out-of-pocket spending in Australia is rather high, especially for specialized
   medical services that are provided by private practitioners. Health spending from public means is drawn mostly from
   progressive income taxes. Contracts with local health networks are based on local demographics.
   Most of the public health system in British Columbia is financed through provincial taxation. A portion of the health
   sector funding also comes from a transfer to provinces from the federal government (Canada Health Transfer). The
   provincial government can distribute this funding for health care through the Ministry of Health with the approval
   of the members of the provincial democratic institutions. Out of pocket funds are not requested for public health
   services. The revenue collection is through progressive income taxes and consumption taxes. The funds are allocated
   to public health providers through regional health authorities and the Provincial Health Service Authority with
   program-based funding from the provincial government. For services such as immunizations, physicians are paid
   in three different ways; fee-for-service, Ministry of Health’s alternative payment programme, and rural programs.
   While funding for public health services varies amongst the regional authorities their funding is sufficient and stable.
   These funds are delivered by the ministry which uses the previous year’s funding as a base, then assesses where
   the government must support each health authorities regarding its commitments such as funding for new facilities
   or wage increases. The unallocated funding is then allocated using a population needs-based funding tool. This
   assess the health needs based on factors such as population size, age structure, and health status, where services are
   delivered, and cost adjustment factors.
   Healthcare in Chile is funded through both a public health fund and private coverage schemes, through contributions
   from employed persons. About half of overall healthcare expenditure is paid out-of-pocket. Certain public health
   services, such as vaccinations, are fully covered by the government.
   In Singapore, the public health system is mainly financed through general taxation. Vaccinations for children and
   some screenings are provided free of charge, such as tuberculosis screening. Other screening programmes are also
   funded through co-payments, including chronic diseases and cancer. Except for private providers, public health
   providers are salaried government employees.
   4.5.4 Service delivery
   The final building block concerns the delivery of public health services. Here, we make a distinction between the
   delivery on the individual level, e.g., a consult between a doctor and a civilian, and policy level interventions with the
   aim of reaching many civilians simultaneously. The latter are often specific programmes, for example to promote a
   healthy lifestyle. An overview of providers delivering public health services for the included countries is displayed in
   Table 7.
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<pre>   Table 7 providers of public health services at the individual and the policy levels
                                                     Individual-level                                           Policy level
                                 GPs, hospitals, school nursing services, public                  Municipality medical services
          Denmark                health centres, community mental health services
                                 (socialpsykriatrien), health visiting services
                                 GP practices, schools, families own home, primary                Governmental institutions, NHS
                                 care centres, secondary care centres, local health               England, Academic public health
           England
                                 authorities, voluntary organizations, health                     institutions
                                 visiting services, dental practices
                                 GP practices, vaccination centres.                               Governmental institutions,
             Latvia
                                                                                                  specialized institutes, laboratories.
                                 GP practices, public hospitals, local health unit,               Governmental institutions
              Italy              private hospitals affiliates with the Public Health              (Ministry of Health, regional
                                 System                                                           governments)
                                 Child health clinics, STD clinics, municipal health              Municipal health services (GGD),
         Netherlands             service office, schools, GPs                                     National Institute for Public Health
                                                                                                  and the Environment (RIVM)
                                 GPs, hospitals, schools, community health clinics                States, local governments,
          Australia                                                                               Communicable Diseases Network
                                                                                                  Australia
                                 Community/public health units, community                         British Columbia centre for disease
                                 health centres, primary care homes, schools,                     control, population-public-health
      British Columbia
                                 street clinics, youth centres, nursing outposts, GP              surveillance team
                                 offices, certain pharmacies.
                                 Primary health centres, rural clinics, schools,
              Chile              Therapeutic Diagnostic Centers, Health Reference
                                 Centers, hospitals
                                 Schools, workplaces, primary care facilities, GP                 Health Promotion Board, National
          Singapore              clinics and community care clinics                               Environment Agency, Urban
                                                                                                  Redevelopment Authority
   In Denmark the responsibility of public health delivery is with the GPs, hospitals, and municipalities. GPs provide
   services such as screening programmes and vaccinations, while hospitals provide disease-specific prevention as
   well. General prevention and health promotion is the responsibility of the municipality, services are delivered in
   schools, public health centres, and the community setting, e.g., through community-based mental health services.
   The integration of the public health system is relatively high with the overall healthcare system. To ensure quality,
   the Danish Quality Model has been designed to integrate and systematize existing quality initiatives. This serves to
   create standards in hospitals and patient treatment but can also be applied to private practitioners and municipal
   health services. The Danish Institute for Quality and Accreditation in Healthcare holds the standards and indicators
   for quality service delivery by health professionals. Data generated through the Danish Model is available for sharing
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<pre>   amongst health professionals and the public. This Model serves to make information readily available for those who
   need it.
   In England, public health services are delivered in a range of settings such as schools, families own homes, local
   community or primary care settings, and secondary care settings. The UK Health and Security Agency is responsible
   for prevention, detection, and leading response in health protection. The Chief Medical Office leads the national
   efforts in health promotion and prevention and is responsible for data and monitoring of policy. NHS England is
   responsible for various public health services such as immunization and screening. Local authorities are responsible
   for improving the health of their local population by providing them with adequate public health services. All public
   health service providers are required to register with the Care Quality Commission. All diagnostic laboratories
   must be accredited by the UK Accreditation Service to ensure they meet several mandatory internal standards.
   Public health services are delivered in the local health authorities’ health units in Italy. These autonomous bodies
   organize and plan the health care system for specific areas for the population they serve. Vaccinations or screenings
   are carried out in health units, but GPs also carry out public health activities in their own offices. Italy’s Ministry of
   Health is the central governing body of the NHS which is responsible for the functions of the states and regions in
   their execution of public health measures. The NHS covers all citizens, legal foreign residents, and undocumented
   immigrants for urgent and essential services. The aim of health protection is a goal of the social systems in both the
   public and private sectors. The National Health Plan requires collaboration with many professionals working in the
   public health system which is seen through integrated networks. These integrate the various levels of prevention and
   care to ensure appropriate coordination and continuity of health care and social services. The National Health Plan
   indicators allow for proper monitoring of health services to ensure goals are being met and services are delivered
   equitably.
   In Latvia, the organizations delivering public health services are quite broad: from the Ministry of Health on the
   national level, to local governments, NGOs and private enterprises. The level of collaboration between the various
   organizations depends on the specific issue and seems to be best established for infectious diseases. Public health
   services are delivered for individuals at GP practices, vaccination centres and private centres. On the population level,
   there are governmental institutions and specialized institutes and laboratories.
   In the Netherlands, the municipal health services deliver most public health-oriented services. The most prevalent
   patient-oriented public health centre is the child health clinic, which is mainly focussed on children (e.g., vaccination
   and screening programmes). In most regions, there is a child health clinic within a 10-20 km radius. Although
   everyone can receive public health services free of charge, there are groups that are more difficult to reach, such as
   elderly with a migration background. There are quality systems for the municipal health service, registrations for
   health professionals and guidelines for care processes.
   On the policy level, the states are mainly responsible for the delivery of public health services in Australia; with
   many programs delivered by local health authorities that have contractual agreements with state governments to
   deliver those services. Examples include early childhood and community health clinics. Local governments monitor
   sanitation and hygiene, food safety and water quality. Patient-level health services are delivered mainly through the
   standard health system, usually through GPs. During the pandemic, there were specialized public health services,
   such as mass vaccination hubs. Certain services, such as childhood screenings, may occur in schools.
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<pre>   British Columbia’s public health system is integrated and complementary to the overall healthcare system with a
   population health, health promotion and disease prevention lens. Public health services can be delivered in a wide
   range of settings such as community/public health units, community health centres, or primary care homes (in some
   areas of British Columbia), schools, street clinics, youth centres, nursing outposts, GP offices, and approved pharmacies
   depending on the service. The Ministry of Health ensures overall quality and that appropriate, cost-effective, and
   timely health services are available for its citizens. The ministry’s Population and Public Health division is key for
   the provincially coordinated and regionally delivered public health system which in turn are responsible for health
   service delivery. However, the First Nations Health Authority is only responsible for service delivery and improvement
   of health outcomes for First Nations peoples in British Columbia and have their own goals and indicators. Regarding
   quality assurance of public health delivery, the Provincial Health Officer is responsible for monitoring the population’s
   health and advises the ministry and public health officials of emerging issues.
   In Chile, Regional Ministerial Secretaries (SEREMIS) and the primary healthcare networks are responsible for delivering
   public health services. The main entry point for these services is through primary health centres. Vaccinations are
   delivered through schools within the School Vaccination Programme. Although the primary care network is integrated
   with secondary and tertiary levels of care, the coordination with the public health services is often not clearly defined.
   In Singapore, service delivery is monitored through the submission of indicators, e.g., on mortality and re-admissions.
   The public health system is integrated with the regular healthcare system, while the Health Promotion Board offers
   education and training resources. Public health services are usually delivered within schools and workplaces, in
   collaboration with primary care facilities and within the community. While quality assurance measures are well
   established for healthcare providers, they are less established for health promotion activities.
   4.6 Limitations and tensions related to public health
   With respect to any system, there are always points for improvement. There is agreement amongst all country agents
   that more effective governance and funding for public health is required. Regardless of a centralized or decentralized
   health system within the compared countries, there seems to be a common lack of organizational clarity. This
   comment directly relates to the building block of governance and as previously mentioned, this is key to the success
   of all subsequent blocks. Some countries express there is lack of organizational leadership and dialogue between
   various actors in governance for public health. That may be between different ministries such as education or finance,
   or even within the same ministry. Similarly in our results, it is not often clear who is responsible or accountable for
   the public health goals. This can then lead to confusion of responsibilities and may impact the performance of the
   public health system directly. Another issue which emerged was related to data collection, sharing and utilization. As
   we are well into the 21st century, there have been major rapid advancements to be able to collect and utilize data for
   health system performance and for the health status of the population it serves. While many countries have advanced
   systems in place, there are still gaps which remain regarding sharing the data with key actors as well as utilizing it to
   drive policy.
   Funding for public health is relatively low in all countries and this fact is acknowledged as a weakness in all health
   systems by country agents. The low public funding available makes it so some countries have to charge for basic
   public health services such as cancer screenings. Others have structures which favours certain socioeconomic groups
   over others which may increase health inequities. Investment in prevention and early detection is deemed important
   by all country agents to better optimize population health outcomes and reduce health inequities.
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<pre>   4.7 The role of public health in the overall health system
   4.7.1 Health data sharing
   In Denmark electronic medical records are available to all individuals and health professionals. Additionally, a unified
   health data portal is available for researchers and policy makers. The data infrastructure is regarded as having played
   an important role in dealing with the COVID-19 pandemic92. In England there is a legal framework covering how patient
   data is handled and processed. This requires the data collection and processing to be transparent, fair, and lawful, that
   is there must be a lawful basis for obtaining and using the data. In England patient data entails information on tests
   results and information for various healthcare providers to discuss appropriate treatment options with patients and
   carers93. In Italy, the New Health Information System is a universal system of electronic records connecting all levels
   of care. It also serves to monitor and evaluate the NHS. Some regions have developed electronic networks to facilitate
   communication between various health service providers to improve continuity of care. Few regions have developed
   personal health records for patients to access their medical information (i.e., prescriptions, hospital discharge
   instructions). In Latvia, there are regulations on a unified electronic information system within the health sector94,
   but in practice, the data exchange between various healthcare providers is limited to mostly electronic prescriptions
   for drugs, sick leave certificates and GP referrals. In Latvia, there are regulations on a unified electronic information
   system within the health sector94, but in practice, the data exchange between various healthcare providers is limited
   to mostly electronic prescriptions for drugs, sick leave certificates, and GP referrals. In the Netherlands, every four
   years the 25 municipal health services collect local, regional, and national data on population health, social status, and
   lifestyle. This data is shared amongst key decision makers to drive policy. For health care providers there is a computer
   system (“Landelijk Schakelpunt”) which is used to share patient data between providers of healthcare. Australia has
   system wide reporting on population health and health care performance across all states and territories. Patient data
   is often stored at the GPs office but is slowly being integrated into a single standard medical record. Local hospital
   networks also store data providing data sharing opportunities for local public hospital districts, primary care providers,
   schools, and private hospitals. The National Health Agreement facilitates data sharing amongst states and the federal
   government. In British Columbia, health data is available for all health system partners such as health organizations,
   public bodies, or researchers. Their Health Data Platform provides anonymized data on a single platform supporting
   the flow between research and analysis between the health sector and academia. All data is governed by legislation and
   governing policies. In Chile, health data sharing is not formally established across health institutions, however, there
   are some specific examples such as a COVID-19 pass. Public health providers in Chile are integrated in the health care
   network, but no national framework is available to share data across health providers. In some health districts common
   IT services do facilitate the sharing of information. An exception is the Immunization Registry, which is an integrated
   system that provides data on vaccinations for the whole Chilean population. In Singapore, public health data is readily
   available on the Ministry of Health’s webpage. Here there is information on various health system indicators as well
   as resources for the public and healthcare professionals. Patients can also log-in to view their personal health and
   appointments.
   4.7.2 Role of GPs in the public health system
   In Denmark, GPs are responsible for screenings and vaccinations. For example, new-born screening, and HPV or
   influenza vaccinations can all be done by GP in their office. In England, the GPs serve to facilitate screenings (i.e.,
   cervical cancer screening) as patients registered to a GP will receive regular reminders for when they are required
   to have a screening. GPs also serve to diagnose and test for diseases and illnesses as well as provide vaccinations
   if needed. In Italy, GPs working at the local health units or in their own practice can administer vaccinations and
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<pre>   screenings. In Latvia, GPs have an important role regarding screenings and receive €2 per screening for patients
   aged below 65 or €1 for those over 65 years old95.In Latvia, GPs have an important role regarding screenings and
   receive €2 per screening for patients aged below 65 or €1 for those over 65 years old95. In the Netherlands, the
   public and primary health systems are quite separate, although there seems to be a trend to increase integration of
   public health with curative health. GPs provide vaccinations for the elderly and are paid per vaccination. In Australia,
   GPs are a main entry point to the public health system, also for preventive services such as screenings. For example,
   a GP may refer a female patient to a breast screening service. In British Columbia, GPs can screen and vaccinate
   individuals for a variety of conditions. In Chile, preventive screenings (“Examen de Medicina Preventiva”) and some
   vaccinations are delivered through primary care centres and rural health clinics. In Singapore, the Ministry of Health
   works closely with GPs particularly for screenings and vaccinations which are often delivered in their offices.
   4.7.3 Embedding of public health in the mental health system
   The Danish Health Authority focuses on the treatment of mental illness and early interventions. The “socialpsykiatrien”
   organizes community based mental health interventions. In England, mental health is an integrated part of the
   goals defined by Public Health England: promoting good mental health, preventing mental illness and suicides23. The
   Prevention Concordat for Better Mental Health is a programme that is facilitating local and national action around
   mental health promotion96.The Prevention Concordat for Better Mental Health is a programme that is facilitating
   local and national action around mental health promotion96. Italy has a Mental Health Services Network which is
   under the Department of Mental Health, a set of structures responsible for the care, assistance, and protection of
   mental health within each defined local health authority97. Mental Health Centres are known to be the first reference
   point for citizens as they coordinate all interventions related to prevention, treatment, and rehabilitation. The National
   Prevention Plan also includes promotion of mental well-being for all citizens throughout all stages of life98. There is
   also an explicit Mental Health Plan (2022-2027) which outlines mental health promotion and prevention activities99.
   Latvia’s mental health system is integrated into all levels of health care. Primary care focuses on prevention, early
   diagnosis and treatment. The Plan for Improving of Availability Mental Health Care also focuses on promotion and
   prevention of mental health. Since 2021, Latvians have an opportunity to receive state-funded psychological and
   psychotherapeutic assistance to overcome the increased burden of mental illness since the COVID-19 pandemic.
   Additionally, resources are available for GPs to learn how to identify and support patients with mental illness100.
   In the Netherlands, youth health care professionals are working to prevent mental health problems in children
   and have a role in the early detection of problems. The public mental health care, which focusses on patients that
   cannot be reached by the regular mental health system, often is part of the municipal public health services101. In the
   Netherlands, youth health care professionals are working to prevent mental health problems in children and have
   a role in the early detection of problems. The public mental health care, which focusses on patients that cannot be
   reached by the regular mental health system, often is part of the municipal public health services101. In Australia,
   mental health inpatient and outpatient services are most often provided through public hospitals. There is a dedicated
   mental health commissioner with a formal position to guide policy on mental health issues. Policy is implemented
   through several programmes and services. A main strategy is the National Mental Health and Suicide Prevention Plan.
   British Columbia’s guiding public health framework includes mental health promotion and prevention as well as
   prevention of harms associated with substances. The Healthy Minds, Healthy People plan addresses mental health
   and substance use in British Columbia with a focus on lifelong mental wellbeing. This plan involves partnership
   across all sectors and communities. Namely the Ministry of Health's efforts for harm reduction, mental health
   promotion and integrated primary and community care102. In Chile the first National Mental Health and Psychiatry
   Plan was introduced in 1993 and served to integrate mental health care in primary healthcare. The current National
   Mental Health Plan (2017-2025) emphasises a community-based approach to mental health care and to adhere to
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<pre>   standard human rights principles103. Mental health is also incorporated to broader public health policies such as
   “Chile Crece Contigo” or “Chile Grows with you”, which is an integrated system of social interventions that fit the
   needs of a child, family or community104. In Chile the first National Mental Health and Psychiatry Plan was introduced
   in 1993 and served to integrate mental health care in primary healthcare. The current National Mental Health Plan
   (2017-2025) emphasises a community-based approach to mental health care and to adhere to standard human
   rights principles103. In Singapore, the Institute of Mental Health is the designated mental health hospital which
   also serves to provide guidelines and support for the community. In 2006, the National Mental Health Blueprint was
   created with a focuses on promotion, prevention, early detection and treatment of mental health105. The Community
   Mental Health Masterplan was created to complement the existing plan but focus more on mental health care in the
   community, care close to home. These plans shifted the focus from institutionalized care to community care106.
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<pre>   5. Discussion
   This is an up-to-date review on public health policies and practices based on nine countries around the world. Previous
   work is dated, limited to Europe, focuses on health only, and/or lacks information sources107–109. We provide a conclusive
   comparison with high levels of detail and insight into the themes and focus of public health in each country. We
   highlight the similarities and differences amongst each of the countries and current areas which need attention. From
   a previous public health system comparison (2012) performed by the WHO European Observatory, information was
   not as accessible and was a major obstacle in understanding how each country views public health and the policies
   and practices in place109. Over the last decade since information has been digitized and more transparent, we were
   able to leverage on both scientific and grey literature to gain insight into the public health structure in all country. We
   also used country agents, experts in public health policy, to provide context and validate our findings for each country.
   This allowed us to identify even more relevant and up to date policies and visions which were being drafted since the
   COVID-19 pandemic.
   This research is not without limitations. First it is important to clarify this is a comparison of public health policy only.
   While we take note of each country’s public health vision, governance structure, workforce, and service delivery, we
   do not assess if indicators are reached nor the actual overall performance of their public health system. Similarly,
   we do not assess if mechanisms are in place such as forums for citizen participation on policy development or laws
   mandating private sectoral participation are indeed utilized. However, understanding the underlying health system
   structure in each country is a necessary to move forward with any such performance reviews. By identifying these
   building blocks in place, we give space to discuss what aspects are lacking and where improvements can be made on
   the policy level. For example, while it is clear all countries have a vision and goals, there is no clear indication on who
   is accountable for achieving these goals. Thus, future work can be directed towards filling the gaps that exist on the
   policy level, which will ultimately impact the citizen level.
   Next, we would like to mention the use of the WHO health system framework to assess the public health of each
   country9. As this framework was originally intended to assess complete health systems, we found it may not fully
   capture the scope of public health. Not all countries have a defined public health system but rather it is an extension
   of their health system, and primary care and prevention often overlap. Also, the building blocks are mainly dealing
   with issues related to the health system, while they are not necessarily designed to capture information on health
   from the full societal level, including other policy domains.
   While this is an international comparison, only nine countries are present and are not a conclusive representation
   of the different public health systems that may exist. These countries were selected on expert opinions rather than
   performance indicators themselves. As the countries were both culturally and geographically distinct and have varying
   governance and health systems, we believe this research provided lessons that are quite generalizable to many public
   health systems in developed countries. Of course, within developing countries the relevant health-related issues are
   quite different from developed countries; this could be a topic for a follow-up research project.
   With the aforementioned points in mind, we highlight strengths and limitations of this study. While we highlight the
   policies in place and areas for improvement, we showcase how these countries while different contextually have many
   overlapping practices in place. Thus, this research can pave the road for future developments in the field of public
   health policy assessments.
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<pre>   6. Conclusion
   Using the WHO Health System Performance Assessment (HSPA) framework9, we compared the public health systems
   of nine countries. An important lesson from this comparison is that a strong public health system has the potential to
   strengthen society as a whole, as health becomes an integral part of the whole government. This approach differs from
   medicine on a fundamental level, in that it is not focussed on curing patients, but preventing citizens from becoming
   patients in the first place. The introduction of clear health-related goals is fundamental in having health through all
   policies, as it can be used to align all actors within a health system. Focussing on outcomes, rather than outputs, and
   ensuring that decision makers are accountable for reaching the goals, are important aspects in improving the health
   of citizens.
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<pre>   7. Acknowledgements
   The authors thank Dheepa Rajan and Katja Rohrer-Herold for their feedback on the questionnaires based on the
   building block model, Bernd Rechel for his feedback on the country selection process. We would also like to thank all
   country agents for their country-specific input through the questionnaires and various conversations:
   Denmark
   •    Viola Burau
   •    Helle Terkildsen Maindal
   England
   •    Ingrid Wolfe
   •    Marilena Korkodilos
   Italy
   •    Palmieri Luigi
   •    Chiara Donfrancesco
   Latvia
   •    Anita Villerusa
   •    Ģirts Briģis
   The Netherlands
   •    Rinske Keuken
   •    Anja Koornstra
   Australia
   •    Carmen Huckel Schneider
   British Columbia
   •    Lillian Bayne
   •    Michael Hayes
   •    Perry Kendall
   Chile
   •    Cristóbal Cuadrado
   •    Maria Soledad Martínez
   Singapore
   •    Lay Hoon Goh
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<pre>   Appendix I
   Questionnaire ‘Public health system comparison’
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<pre>university of
groningen

Aletta Jacobs

SCHOOL OF PUBLIC HEALTH

Public health system comparison

Country expert form

Thank you for agreeing to participate in this comparison between public health systems. Below are
questions on five different themes: governance, resource generation, financing, service delivery
and final questions. We ask you to fill in the various questions to the best of your ability, if possible,
please provide references.

This form is a fillable PDF, meaning you can input your replies in the text boxes below the questions.
We recommend using Adobe Acrobat software for this, the free Acrobat reader can be downloaded
here.

After you filled in the form, replies can be sent to Simon van der Pol - s.van.der.pol@umcg
questions you may have can also be sent to this address.

‚nl. Any

Definition of public health

For this research project, we use the definition of public health from the World Health Organization:

“The science and art of promoting health, preventing disease and prolonging life through the organized
efforts of society”,

Country / state

1
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<pre>Theme 1: governance

1. Is there a national health sector policy / strategy / plan with goals and targets?

Yes

2. What is the public health vision, including long-term measurable goals?

3. Does the public health policy / strategy / plan clearly mention indicators allowing for
regular monitoring and evaluation? If yes, which indicators?

E.g. increase healthy life years by a certain amount?

4. Does the public health policy / strategy / plan include multisectoral coordination? If
yes, how?

Deliberate collaboration amongs stakeholders to reach the goals set forth in the health policy

2
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<pre>5. Do key stakeholders participate during the preparation of new public health policies /
strategies / plans and the review? If yes, which stakeholders are involved?

E.g. national/local governments, patients groups, medical professionals

6. Can you provide one great example of collaboration between the various
stakeholders on a public health topic?

7. To what extent are communities, non-governmental organizations and the private
sector involved?

8. Which mechanisms and dialogue platforms are in place to ensure involvement of key
stakeholders in the health decision-making process?

Eg. legal procedures, online platforms to provide input

3
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<pre>9. Are relevant data collection databases available, such as health surveys, birth and
death registration, census, health facility reporting, health system resource tracking?

10. Can you provide a website where these data are publicly available?

11. How is data sharing arranged between various layers of government?

E.g. sharing of effects of policies that are recorded in national databases with local governments

12. How is data sharing arranged between various providers of public health services?

E.g. patient data

4
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<pre>13. Which legislation is applicable to the public health system?

E.g. applicable articles in the constitution, specific public health acts

14. Are existing public health laws aligned with the government's public health policies
and plans?

15. To what extent are measures taken to effectively implement and enforce public
health legislation?

16. Regarding the governance, are there specific differences to the input above for
urban planning?

5
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<pre>17. Regarding the governance, are there specific differerences to the input above for
particulate matter?

18. Regarding the governance, are there specific differences to the input above for HPV
vaccination and screening?

19. Regarding the governance, are there specific differences to the input above for
annual and pandemic influenza?

20. Regarding the governance, are there specific differerences to the input above for
mental health in the public health sector?

6
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<pre>21. Regarding the governance, are there specific differerences to the input above for the
screening of diseases within children?

Theme 2: resource generation

22. Which professionals are involved in the public health system?

E.g. school doctors, psychologists, nurses, dentists, epidemiologists

23. Do public health professionals receive training regarding vulnerable populations?

24. Are there systems for continuing professional development available for public
health professionals?

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<pre>25. If the previous answer was yes, please explain which professional development is
available.

26. Which organizations are involved with public health?

E.g. specific public health centres, schools, municipalities

27. Where are public health services delivered usually?

E.g. specific publc health centres, the GP office, schools

28. What is the density of public health facilities?

Depending on the answer to the previous question, how many individuals do these facilities serve?

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<pre>29. Are pharmaceutical and other consumables available where and when needed?

30. Regarding the resource generation, are there specific differences to the input above
for urban planning?

31. Regarding the resource generation, are there specific differences to the input above
for particulate matter?

32. Regarding the resource generation, are there specific differences to the input above
for HPV vaccination and screening?

9
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<pre>33. Regarding the resource generation, are there specific differences to the input above
for annual and pandemic influenza?

34. Regarding the resource generation, are there specific differences to the input above
for mental health in the public health sector?

35. Regarding the resource generation, are there specific differences to the input above
for the screening of diseases within children?

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<pre>Theme 3: financing

36. How is the public health system financed?

E.g. national funding, local funding

37. To what extend are out-of-pocket funds requested?

38. How are the funds allocated to the public health providers?

E.g. based on the population they serve

39. Are funds sufficient and stable?

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<pre>40. Is revenue collection and pooling equitable?

41. To what extent is the payment of providers driven by information on the health
needs of the population they serve?

42. Regarding the financing, are there specific differences to the input above for urban
planning?

43. Regarding the financing, are there specific differences to the input above for
particulate matter?

12
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<pre>44. Regarding the financing, are there specific differences to the input above for HPV
vaccination and screening?

45. Regarding the financing, are there specific differences to the input above for annual
and pandemic influenza?

46. Regarding the financing, are there specific differences to the input above for mental
health in the public health sector?

47. Regarding the financing, are there specific differences to the input above for the
screening of diseases within children?

13
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<pre>Theme 4: service delivery

48. Which organization is mainly responsible for delivering public health services.

E.g. a dedicated public health organization

49. How is the public health system integrated within the overall health system?

E.g. referrals to primary care or specialized care

50. How do the professionals working in the public health system collaborate with
other health providers (e.g. school doctors, general practitioners)

51. Which quality assurance measures are in place in regarding the delivery of public
health services?

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<pre>52. Are the services delivered in an equitable manner?

Are all populations served?

53. Regarding the service delivery, are there specific differences to the input above for
urban planning?

54. Regarding the service delivery, are there specific differences to the input above for
particulate matter?

55. Regarding the service delivery, are there specific differences to the input above for
HPV vaccination and screening?

15
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<pre>56. Regarding the service delivery, are there specific differences to the input above for
annual and pandemic influenza?

57. Regarding the service delivery, are there specific differences to the input above for
mental health in the public health sector?

58. Regarding the service delivery, are there specific differences to the input above for
the screening of diseases within children?

Theme 5: final questions

59. What are you most proud of considering the public health system in your country?

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<pre>Internal submission button, please do not use</pre>

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<pre>E: aletta@rug.nl
W: rug.nl/aletta
The Aletta Jacobs School of Public Health is a joint partnership of the University of Groningen, UMCG,
     the Hanze University of Applied Sciences and NHL Stenden University of Applied Sciences
</pre>

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