Community action for health and well-being

3. Boosting community action by regional and central governments

This section presents two examples of actions taken by regional and central governments to support community initiatives for health and well-being. The first example presents the creation of the XarxaSalut network in the Valencian Community, Spain, which involves municipalities committed to promoting health at the local level through community participation, intersectoral collaboration, and an equity perspective. The policy process evaluation of the implementation of XarxaSalut undertaken in 2019 highlights the importance of resource optimisation, exchange of experiences, training, and economic support the regional authorities to implement the network. The second example documents health promotion in the Swiss canton of Zurich, where health promotion is primarily managed by two entities with a legal mandate for health promotion: the Department of Prevention and Health Promotion and the foundation Health Promotion Switzerland. This example illustrates the effectiveness of broad, centralised stakeholder co‑ordination in advancing health promotion initiatives.

3.1. Network of municipalities to facilitate and co‑ordinate community health initiatives – Valencian Community, Spain

3.1.1. Context

XarxaSalut is the network of municipalities or associations of municipalities in the Valencian Community (5.2 million inhabitants) that have committed to implementing local health promotion actions as part of the V^th Health Plan of the Valencian Community and follows the “health in all policies” framework (Peiro Perez et al., 2020[11]; Mas-Pons et al., 2019[12]).

Launched in 2017, XarxaSalut initially involved 17 municipalities committed to promoting health at the local level through community participation, intersectoral collaboration, an equity perspective and including health aspect in their all-decision-making processes (Generalitat Valenciana, Conselleria de Sanidad, 2017[13]). By 2024, the network has expanded to 350 municipalities covering approximately 80% of the region’s population. In March 2024 a new law1 was passed that gave the network legal bases and incentivised the formation of these intersectoral and participatory organisational changes (espacio de partipación), which can be led by the city councils and in some cases by the primary care centres in conjunction with the city councils. Of these municipalities, 87% were in a process of an organisational change through the intersectoral decision-making and participative working groups, while 45% were analysing health situation and determinants, building mapping assets and prioritising health promotion actions.

The regional government, notably through the Valencian Unit of Community Action for Health (Unidad Valenciana de Acción Comunitaria para la Salud),2 co‑ordinates the intervention of the many actors involved in XarxaSalut. The Valencian Unit of Community Action for Health also leads the publication of guides and reports, co‑ordinates the provision of technical support (e.g., specific training in community action) to professionals working in local entities and offers grants to support the process of organising experience‑exchanging meetings in which participate municipalities, primary health centres and the local population. The Valencian Federation of Municipalities and Provinces (which is the entity that represents the interests of local entities at regional level), also participates in the development of XarxaSalut and contributes to the support of experience‑exchanging and dissemination among municipalities.

3.1.2. Description

Any municipality in the Valencian Community can join the Valencian Community Health Plan, and through it, XarxaSalut. Membership can be initiated by the municipal authorities. Comprehensive information about XarxaSalut is available at all public health centres and through the Valencian Unit of Community Action for Health. The process for joining XarxaSalut is well-structured and involves the following steps:

a. Approval by the city council plenary of the letter of commitment to the current Health Plan of the Valencian Community (now its fifth edition).

b. Appointment by the town council of a reference person, a XarxaSalut participation space, and the XarxaSalut steering group, to work on actions and proposals.

c. Preparation of a report assessing the health situation and creating a map of health-promotion assets in the municipality. The report must identify needs and priorities as perceived by health professionals and/or the community.

d. Design and implementation of actions that address the needs identified, leveraging assets identified in the previous step.

e. Evaluation of the actions undertaken in step 4 and re‑iteration of steps 3 to 5, as necessary.

The commitment to the Health Plan, formalised by the letter of commitment from the city council plenary, is open-ended and offers several advantages, including access to funding for community initiatives provided by the Consellería de Sanitat, the opportunity to participate in meetings, workshops, and conferences to exchange experiences with other municipalities in XarxaSalut, and the dissemination of their initiatives through the Valencian Observatory of Health, which has a dedicated web space for health promotion. Community action is featured in the observatory to enhance visibility and social support for XarxaSalut. The municipality is also required to inform the population about their commitment using all available means, particularly the municipal website.

Once the membership process is completed, the work within the local network is organised around the reference person, the participation space and the steering group.

• The role of the reference person is crucial, encompassing internal and external communication on all community health matters within the municipality, co‑ordination of reporting activities, identification of members of the steering group and participation space, identification of potential sources to finance XarxaSalut initiatives, and overseeing communication and outreach efforts. Generally, the reference person is a technician working in municipal services, supported by municipal services (typically in health or social services) and local health centre staff.

• The participation space is composed of professionals from diverse areas and profiles, including technical staff working in various municipal services (such as health, environment, and sport), staff from the local health centre, professionals from the education sector (such as teachers and associations of parents), and representatives of the civil society. The composition of the participation space guarantees diversity and a multidisciplinary approach to the initiatives.

• The steering group includes the reference person and some members of the participation space. The main mission of the steering group is to lead the implementation of initiatives on the ground, apply community action methodologies, co‑ordinate XarxaSalut activities with municipal services, and document and report on the activities undertaken.

To facilitate the work of municipalities and professionals engaged in XarxaSalut, Valencian Community’s authorities, through the Consellería de Sanitat and the Federació Valenciana de Municipis i Provinces, have released four guides (Generalitat Valenciana, Conselleria de Sanitat Universal i Salut Pública, 2018[14]). The guides provide practical information on organising local networks, methodological advice on identifying priorities and needs and implementing initiatives with the community. In addition to the valuable information they provide, the widespread use of these guides contributes to harmonising community action practices in the whole Valencian territory and improves co‑ordination. The guides have different objectives:

• Guide 1 focuses on the procedures and explains how to organise local networks.

• Guide 2 defines numerous concepts frequently used in health promotion and community action. By defining these concepts, the guide aims to facilitate the dialogue between different actors.

• Guide 3 is a toolbox to support the work of professionals in the field.

• Guide 4 is a compilation of the topics and actions for improving health at the local level, organised into nine key themes, covering areas from the first year of life to older adulthood, as well as urban planning, culture, emotional well-being, and working environments.

In addition to the guides for community action, there are funds that municipalities can apply for to support actions related to training, promoting health actions for vulnerable populations, asset mapping, participation processes, and initiatives in vulnerable neighbourhoods. Interdisciplinary training processes with health and municipal professionals have been developed to ensure a common language and to strengthen competencies for health promotion.

The Valencian Community, through Consellería de Sanitat, also established a network of public health centres. Each centre includes a health promotion unit that works closely with municipalities to support co‑ordinated community health action in partnership with the community action unit. Approximately 23 professionals across the Valencian Community, working full- or part-time, contribute to this programme. Since its inception, more than EUR 2 000 000 in grants have been allocated to municipalities for the development of XarxaSalut by the end of 2024. However, municipalities have expressed that current resources are insufficient, and additional support is needed to fully develop community health action and integrate health and equity perspectives into local policies.

A policy process evaluation of the implementation of XarxaSalut was undertaken in 2019 (Peiró Pérez et al., 2020[15]). For this evaluation, different approaches have been used: a questionnaire addressed to the municipalities after they joined the XarxaSalut including data on intersectoral representation, participation, promotion of health actions and open questions; a description of instruments that Regional Public Health Authorities have mobilised, and an analysis of barriers and strengths. The evaluation identified as main barriers to the implementation of the network and its activities the lack of economic and personal resources, difficulties to achieve citizen participation, and poor co‑ordination between different administrations and primary health centres at local level. The main benefits were the optimisation of resources, the exchange of experiences, training, and economic support from the Regional Public Health Authorities.

3.1.3. Relevant lessons

The structured approach of XarxaSalut offers valuable opportunities for other countries in building a strategy for community action. By developing a long-term vision for health promotion and being part of a broader plan co‑ordinated with the Valencian Strategy of Community Health 2023‑25, XarxaSalut ensures that strategic action lines are aligned with both short- and medium-term plans. This approach includes a clear and well-documented procedure for municipalities to join the programme and organise local networks. Moreover, participant municipalities can benefit from funding and methodological support from the Consellería de Sanitat and can join workshops and meetings to exchange experiences and disseminate their activities through the Valencian Observatory of Health.

However, some challenges must be addressed to adapt this approach effectively to the context in other countries. One significant challenge is the lack of resources, particularly in smaller municipalities that may struggle with economic and human resource constraints. While funding and technical support from the Consellería de Sanitat are beneficial, they cannot fully replace the need for dedicated personnel to manage community action. This challenge underscores the importance of ensuring sufficient resource allocation and support structures to sustain community health initiatives. Additionally, co‑ordination between different administrations and primary care centres at local level should also be improved.

Monitoring and evaluation also remain a challenge. Evaluation processes often lack depth and do not facilitate regular assessments of the overall programme. The absence of methodological recommendations for evaluation and common statistical indicators for regional monitoring hinders the ability to measure the programme’s impact effectively.

3.2. Centralised co‑ordination of actors to guide health promotion initiatives – Canton Zurich, Switzerland

3.2.1. Context

The competence centre Prevention and Health Promotion Canton Zurich is affiliated with the University of Zurich and works on behalf of the Zurich Department of Health, which establishes the framework for preventive and health-promoting measures in the canton. The competence centre’s aim is to promote mental, physical, social, and environmental health, as well as to foster social networks that embed health activities in the community. First established in 1987, the centre lies within the Institute for Epidemiology, Biostatistics and Prevention at the University of Zurich since 1991 (Kanton Zürich Gesundheitsdirektion Amt für Gesundheit, 2024[16]).

Prevention and Health Promotion Canton Zurich works in close collaboration with the Switzerland-wide foundation Health Promotion Switzerland (Gesundheitsfӧrderung Schweiz). The foundation co‑ordinates the health promotion strategies. With its legal mandate, the foundation also initiates, co‑ordinates and evaluates measures to promote health and prevent disease. To this end, it also co-finances cantonal programmes. A further role of the foundation is related to knowledge exchange, as it produces detailed guidelines for the implementation of cantonal health programmes. Through these guidelines, the foundation promotes the application of proven programmes throughout Switzerland. Overall, the foundation facilitates the successful implementation of proven programmes and allows for a fruitful exchange of knowledge across Cantons, municipalities and professional organisations.

3.2.2. Description

Prevention and Health Promotion Canton Zurich is composed of 12 staff members (prevention specialist and communication specialists) who work at the University of Zurich and integrate the latest scientific advances into the programmes for health promotion. The centre works on two fronts: action plans are developed for the canton as well as for individual municipalities. At the cantonal level, the centre organises health campaigns pertaining to consumption of addictive substances or mental health and diffuses these thanks to a well-developed outreach strategy – through the internet, apps, advertisement, or pamphlets. At the municipal level, the centre assists local governments in the implementation of health-promoting projects. The centre provides both training and close guidance to local municipalities or NGOs as well as funding for local projects. The total budget for Prevention and Health Promotion Canton Zurich is CHF 2.957 million, of which two‑third is allocated to the funding of the competence centre Prevention and Health Promotion Canton Zurich and the remaining one‑third to cantonal projects.

Additional funding (CHF 1.032 million) for health promotion projects in the canton of Zurich is provided by the Health Promotion Switzerland foundation. This foundation is supported both by the cantons and by a yearly additional insurance premium that every Swiss resident pays to their insurer (CHF 4.80). The totality of the funds raised is divided across cantons in two ways. First, the foundation defines areas and programmes they wish to promote, and cantons, municipalities, NGOs, or other entities can apply to receive the funds allocated for the implementation of projects in those areas. The programmes promoted by the foundation have extensive and detailed guidelines, to allow for projects to be implemented fruitfully even if local teams do not possess the necessary training.

Second, entities can propose their own projects, for which the allocation of funds must be approved, and which are then conditional on the collaboration with the competence centre Prevention and Health Promotion Canton Zurich. The centre supports and guides the entities through the process and provides knowledge and expertise in health promotion. Each project is extensively documented, and the documentation is made publicly available on the website of the Health Promotion Switzerland foundation, thus ensuring knowledge transfer across institutions and cantons. Two examples of such community-led projects are Ageing socially integrated in the community – which addresses healthy and socially engaged ageing – and the How are you campaign – a canton- and community-led effort to encourage people to talk about mental health (how-are‑you.ch). Municipalities also have the possibility of running and funding their own projects, though this is a less common strategy, given the generosity of the funding and the extensiveness of the guidelines provided by the Health Promotion Switzerland foundation.

This bidirectional mechanism comes with three advantages. The first is that there is fruitful collaboration between the public sector, municipalities, NGOs and the foundation toward health-promoting objectives. The second is that the implementation of projects is always guided by health experts as projects receive support from the competence centre Prevention and Health Promotion Canton Zurich. The third advantage is that knowledge is actively shared between the university, the foundation, the cantonal Health Department and the municipalities, as well as NGOs, which document their good practices and make them publicly available.

3.2.3. Relevant lessons

The example of health promotion in the canton of Zurich can be of help in the design of community-based health promotion in other countries in at least two directions. Firstly, the competence centre Prevention and Health Promotion Canton Zurich lies under the scientific authority of the Institute for Epidemiology, Biostatistics and Prevention at the University of Zurich. This set-up ensures a constant knowledge flow from most recent health research to the implementation of projects and is beneficial for the collaboration between policy and academia. Secondly, the public sector and the Switzerland-wide foundation Health Promotion Switzerland collaborate in a centralised manner for the provision of funds for health-promoting projects. The extensive documentation requisites for projects to receive funding ensures that knowledge is centrally collected and that successful projects become easily transferrable across locations.

There are also potential challenges in transferring the health promotion strategy from the canton of Zurich to context in other countries. First of all, the Canton of Zurich has significant economic resources, which allows for strong investments in health prevention. Furthermore, the funding of health promotion activities in Switzerland is highly dependent on the Health Promotion Switzerland foundation, which has a nationwide not regional structure. This setup requires country-wide agreements between regions, private health insurers and non-governmental entities, and may thus be hard to transfer to other countries.

Notes

← 1.  Decree 47/2023, of 31 March, of the Consell, regulating basic health councils and other spaces for participation in the Valencian Community, available via: https://dogv.gva.es/datos/2023/04/06/pdf/2023_3591.pdf.

← 2.  This Office is part of the Directorate of Public Health of the Valencian Community.