Communities can play a vital role in addressing social determinants of health and reducing health inequalities, as they are uniquely positioned to identify and respond to the specific needs and challenges faced by their populations. Community-led initiatives often reach groups that are underserved by mainstream health systems, helping to reduce barriers to care and promote equity. When people are actively involved in shaping the policies and services that affect their lives, it fosters trust, empowerment, and more sustainable health improvements.
The Basque Government, through its Department of Health (DHBC), is developing a strategy to strengthen and better organise community action across the region. This report supports that effort by assessing the current landscape, identifying key challenges and providing recommendations for a strategy on community action for the Basque Country.
The OECD assessment shows that the Basque Country has a rich and vibrant activity on community action:
Community action for health is an objective of the Directorate of Public Health and Addictions (DPHA) and the Health Plan Euskadi 2030. This Directorate, through the Health Promotion unit, has the mandate of working on the promotion of health in the Basque Country and is focussing on community action for health and well-being to facilitate achieving its mandate. The Health Promotion unit acts through three different channels: (i) by developing a framework to facilitate the implementation of community action; (ii) by elaborating guides, web pages and other documents to support the work of professionals involved in community action; and (iii) by financing specific projects for the community (e.g. grants on community action programmes).
There are many ongoing community action initiatives in the Basque Country, spread across the region and across stakeholders. Initiatives often target young people and the elderly, but also women, individuals with substance use disorders and immigrants. They are dispersed widely across localities in the Basque Country, with a concentration around the three largest cities. Diverse stakeholders are involved in driving community action, ranging from the DPHA within the DHBC to healthcare services (Osakidetza), municipal governments and third sector organisations.
Most actors collaborate with each other through local or institutional networks for community action. Almost 90% of respondents report to be part of at least one network for community action. Often, network members are government staff as well as Osakidetza’s community nurses and other health professionals, while representatives of excluded groups rarely form part of local networks.
The assessment also identified a range of challenges:
There is no overarching structure to co‑ordinate efforts in community action in the Basque Country. At municipal level, initiatives for community action are numerous and address different needs; each initiative requires a leadership in line with its scope and with the resources available. There is no specific platform with such a purpose in the Directorate of Public Health and Addictions, although certain institutions within the Basque health system have crafted their own strategies for co‑ordinating which could be used for community health initiatives. Strengthening horizontal and vertical co‑ordination between actors could help to create a better environment for the development of community initiatives.
Staff of the DPHA focussed on community action (mostly in the Health Promotion unit) are not present in the districts where field work occurs. Other professionals play an active role in community-based projects without an official mandate. To enhance focus on community action among staff in district units, it is advisable to explicitly include health promotion in their mandate.
Current staff in the DPHA often have professional backgrounds and skills not well suited to working with communities. Due to the strong focus on health protection, recruitment has historically emphasised scientific disciplines such as public health technicians and epidemiologists, with no recruitment for social workers or staff trained to work with communities. If the DHBC intends to emphasise community action, it should consider specific training or recruit new hires with appropriate education background.
Public financial and human resources dedicated to community action activities are scarce. Public health and addictions budget lines receive approximately 1.3% of the total DHBC budget, including staff and operational expenditures, with less than 10% of this amount dedicated to funding community health promotion projects through grants to municipalities and associations.
Monitoring and evaluation efforts vary strongly across sectors, with serious commitment to continued monitoring and evaluation only observed in some third sector organisations. Other organisations either do not evaluate at all or do so only for selected initiatives. The main obstacles for regular monitoring and evaluation are both a general lack of personnel as well as a lack of trained personnel, combined with insufficient budget to finance such efforts.
The OECD has provided recommendations to elaborate a strategy with a long-term vision for community action and well-being. The development of the strategy is a multi-step process, essential for ensuring its long-term success and relevance and the process should include a thorough review by different stakeholders and multiple rounds of consultation to ensure engagement and support. OECD’s recommendations for the strategy are structured around three lines: (1) developing a governance structure to facilitate community action, (2) promoting community action at the local level, and (3) fostering awareness and policy evaluation. These strategic lines intersect with several policy areas, including human resources planning and co‑ordination of efforts across relevant sectors. The recommendations can be summarised as follows:
Strategic Line 1:
Ensure sufficient personnel to promote community action at the local level, design and implement education and training programmes on community action, and diversify workforce profiles in the DHBC.
Strengthen co‑ordination structures at the local level, include local communities in these co‑ordination structures, and develop co‑ordination between the institutions involved in community action.
Strategic Line 2:
Strengthen the role of health promotion within the DHBC.
Implement a mechanism to ensure stronger emphasis on health promotion at the local level and encourage municipalities to develop programmes for health protection, promotion, and addiction prevention; develop a network of local entities to promote community action; build a knowledge‑sharing database available to local communities; facilitate access to public spaces; and create new community-friendly public spaces.
Strategic Line 3:
Develop a dissemination plan for the strategy and create a tool allowing the citizens to express their views on specific health matters.
Actively promote research on community action among Basque academic institutions.
Create a self-evaluation tool for local communities, design indicators to monitor and evaluate the impact of community action initiatives, and evaluate the implementation of the strategy.