Community Action to Strengthen Health Equity in the Spanish Basque Country

5. Mechanisms for co‑ordination of community action for health in the Basque Country are scarce

Abstract

This chapter explores the different co‑ordination mechanisms in the Basque Country, both vertical co‑ordination across different levels of government and horizontal co‑ordination across sectors. It identifies existing strengths and gaps, and offers insights into how co‑ordination can be enhanced to better support community action for health and well-being.

Introduction

Involving the community in health-related initiatives can significantly benefit from structured co‑ordination mechanisms. To effectively inform, consult, and involve communities in policies, strategies, and programmes, it is crucial to establish robust networks and exchange mechanisms. The Basque Country features a diverse range of stakeholders involved in community action for health, including various levels of government and sectors. Effective planning and implementation of community action programmes for health and well-being can be facilitated through appropriate co‑ordination between administrations with competencies in different policy and territorial areas, as well as through collaboration between institutional and non-institutional actors. Vertical co‑ordination, which aims to align activities across different levels of government, and horizontal co‑ordination across sectors, are particularly relevant for community action in the Basque Country.

5.1. Co‑ordination for community actions at local level depends on voluntary engagement of professionals

Currently, while a theoretical framework exists for establishing local teams for community action (see Chapter 3, Section 3.2.1 for guides description), its implementation depends on local circumstances. There is no structured network for linking local initiatives to facilitate sharing of experiences and good practices. The OECD mapping survey confirms that information and experiences are almost exclusively shared within individual organisations, not beyond (see Chapter 7, Section 7.5).

The two methodological guides published by the DPHA (see Chapter 3, Section 3.2.1) provide a framework for creating teamwork at the local level for community action in health. According to the guides, the first step is to form a promoting group comprising staff from the DPHA at local level and from Osakidetza. However, the guides do not specify which institution should initiate the action. This initial group should then collaborate with municipal authorities and local networks, focussing on expending and engaging with community assets. If municipal support is lacking, the guide advises seeking alternative local institutional partnerships or directly engaging the community. The second guide (Guide for Participation Generating Well-being and Health) emphasises the importance of working closely with public service employees at municipal or provincial levels. It advocates for utilising local health centres, pharmacies, and other health-related entities’ resources from the onset of community health initiatives, highlighting the critical role of engaging with local communities early in the process.

There is no consistent pattern for initiating community actions in health. Sometimes, community action projects are initiated by district staff of DPHA (who officially have no mandate for health promotion, which leads to challenges in initiating and maintain community networks), and/or health centres who then reach out to municipalities to form a promotor group. In these cases, the promotor group would engage local associations to form a network, jointly assessing local health needs and designs and implements programmes. In other cases, where the district staff of DPHA and/or local staff from Osakidetza are less involved, municipalities take the initiative to form networks with local associations, with or without the involvement of the district units of DPHA and Osakidetza.

This lack of established pattern is not a drawback per se, but it might lead to duplication in activities or hinder the sustainability of projects by not involving all relevant actors. This further compounds with the fact that both DPHA staff at the district level and in Osakidetza do not always have sufficient time to understand the local circumstances and engage with the community due to the other duties and the scale of the population they cover.

The degree of involvement of various actors in creating a promotor group and promoting intersectoral work varies across municipalities and is influenced by local government preferences and resources. Larger cities tend to have more structured strategies or protocols for horizontal co‑ordination between health and social services for community action. For instance, the three province capitals in the Basque Country have dedicated resources for public health within the local administration and their own municipal health plans. In Vitoria-Gasteiz, co‑ordination protocols exist between social services and health centre staff, and community networks have been established in certain areas of the city for joint projects. In Bilbao, each primary health centre has a community health table, which includes representatives of the DPHA, Osakidetza, municipal social services, associations, a general practitioner and two nurses, providing a platform for exchanging experiences and making joint decisions for health. In smaller cities, the existence of community action initiatives and intersectoral work depends on the goodwill of the involved actors rather than structured mechanisms. The initiatives led by DPHA district units (see Chapter 3, Section 3.2.3) are also good examples of local co‑ordination in health community action.

5.2. There are interesting examples of co‑ordination mechanisms that could serve as an inspiration

Specific bodies and protocols exist to facilitate vertical and horizontal co‑ordination among various directorates of the DHPA, Osakidetza and other institutions. Although the examples presented in this section do not include community action among their objectives, they can serve as inspiration for a future strategy.

A notable example of such co‑ordination is the Addictions unit, which has an established vertical and horizontal co‑ordination mechanism. The Interinstitutional Commission on Addictions in the Basque Country fosters collaboration across various sectors to address addiction-related issues. Chaired by the Counsellor of the DHBC and co‑ordinated by the DPHA, this commission includes representatives from several directorates of DHBC, other government departments, municipalities, and provincial councils. Established by Decree 25/2018, it aims to develop and recommend key strategies, tools, and proposals for tackling addictions across Basque public administrations, enhancing inter-administrative co‑ordination through clearly defined collaboration criteria, including legal competencies, budgeting, and financial support.

Horizontal bodies and protocols also enhance co‑ordination between health and social policies, especially for individual requiring joint care. The Directorate for Social and Health Policies Integration has implemented strong governance mechanisms across health and social sectors and various levels of government. Socio-health commissions, which meet biannually to address socio-health needs, have been established. Additionally, the recent strategy of the directorate plans to implement a governance degree on socio-health with clear structures and co‑operation instruments. Protocols for social and healthcare initiatives ensure that professional from both sectors share the responsibility of providing high-quality services to those in need.

A specific guide, “The Guide for the Development of Sociosanitary Primary Care Protocols in Euskadi” (Guía para el desarrollo de protocolos de Atención Primaria Sociosanitaria en Euskadi),1 published in 2014, develops protocols to enhance co‑ordination in social and health initiatives, focussing on the continuity of care within the socio-health space. The protocols outline a structured four‑step process. The process begins with the detection and analysis of cases. Following this, a comprehensive assessment of the case is conducted. The third step involves developing a co‑ordinated intervention plan, which consists of selecting the appropriate professionals from both health and social sectors, securing consent from the individual receiving care, evaluating available resources, and formulating a detailed action plan. The final stage of the process is dedicated to monitoring the case, ensuring continuous oversight and adjustment of the intervention as necessary. The protocols have been positively evaluated and suggest potential for establishing them for other intersectoral collaboration (Dirección de Atención Sociosanitaria de Euskadi, 2022[1]). Although most regions have developed socio-health protocols, the adoption of specific local co‑ordination procedures remains inconsistent across regions.

Osakidetza has introduced co‑ordination mechanisms specific to community action. Its strategy includes governance measures such as setting up a steering committee, ensuring sufficient human and financial resources for community action, building alliances and synergies with stakeholders, providing broad guidelines, and evaluating results. The steering committee is composed of the director of Healthcare, the deputy director for the Primary Care Co‑ordination, the deputy director of Nursing, representatives of the reference team for community action in the Subdirectorate of Primary Care Co‑ordination (all from Osakidetza), the director and deputy director of DPHA, and director of Social and Health Policies Integration. Additionally, the strategy includes the creation of a reference team for community action, consisting of two nurses and administrative staff to co‑ordinate a community action network within Osakidetza, promote best practices and facilitate training within primary care units. The strategy emphasises the need for co‑ordination with DPHA at the district level and establishes structures to address this need.

Osakidetza’s community nurses, as a part of the multi-disciplinary team, play a critical role in these co‑ordination mechanisms. As established in the Osakidetza strategy, community nurses will work closely with the OSI community liaison officer to facilitate intersectoral co‑ordination and relationships with the DPHA, ensuring a cohesive approach to community health initiatives.

5.3. The Public Health law sets a framework for co‑ordination that could be used for community action but more is needed

The 2023 law on Public Health of the Basque Country will establish a more structured institutional framework for co‑ordination in public health, potentially benefiting community action. The Interinstitutional Public Health Commission, as outlined in Article 41, is the primary body for aligning public health policies and facilitating collaboration within the Basque Public Health System. This commission consists of senior representatives from various government levels and departments, tasked with reviewing legislation, proposing strategies, and managing health emergencies. Additionally, the new law mandates co‑ordination between the Public Health System of the Basque Country and Osakidetza (Article 44), with the DHBC responsible for defining the necessary criteria and mechanisms for this co‑operation. The aim is to protect and promote health, prevent disease, provide health education and respond to emergencies. Co‑ordination mechanisms will also be established at the territorial level with Osakidetza, ensuring effective communication and co‑ordination in public health prevention, promotion, and surveillance.

The DHBC is further mandated with setting up monitoring and evaluation mechanisms for collaborative programmes with Osakidetza. Once it is established in 2025, The Interinstitutional Commission could serve as a space for vertical co‑ordination between the DHBC and municipalities. Alternatively, given its broad scope, other bodies such as the recently created Steering Committee under Osakidetza’s strategy could incorporate representatives from municipalities to enhance co‑ordination. The co‑ordination mechanism with Osakidetza at the territorial level could also further enhance joint work in community action through the DBHC and Osakidetza.

There is a broader need to establish a network of community action initiatives linking local actors across the Basque Country. There are currently many initiatives in community action. Sharing experiences and learning from others on setting up similar projects would be beneficial. Establishing local community health tables and networks can promote the topic, recognise those working in the field, share best practices, co‑ordinate initiatives more effectively. Initiatives like Ttipi-Ttapa highlight the value of experience sharing, suggesting that regular meetings among public health technicians could facilitate mutual learning and better co‑ordination. Such networks could also aid in diagnosing challenges and setting policy priorities. Currently, concrete examples of consultation processes with communities are infrequent. A network can help prioritise community action at the local level, but it will also require adequate human resources.

Enhancing horizontal co‑ordination through more structured processes, such as establishing protocols for joint work between health and other sectors, could significantly improve intersectoral projects. The municipality of Vitoria-Gasteiz and the Directorate of Social Services and Health Policies Integration have promoted the use of such protocols and provide useful examples of how structured guidelines for intersectoral work can benefit community action. Broadening participation to include sectors like culture, sports, education, and urban planning, beyond just health and social services, is essential for comprehensive community health promotion.

References

[1] Dirección de Atención Sociosanitaria de Euskadi (2022), Diagnóstico de situación de los instrumentos de coordinación sociosanitarios, https://www.euskadi.eus/contenidos/documentacion/doc_sosa_inform_instr_coord_22/es_def/adjuntos/Informe_diagnostico_Intrumentos-coordinacion-sociosanitaria_07.02.2023_es.pdf (accessed on 17 July 2024).

Note

← 1.  The guide is available here: https://www.euskadi.eus/contenidos/‌documentacion/doc_sosa_c2/‌es_def/adjuntos/c2_b3.pdf.