This chapter outlines recommendations for designing a strategy on community action in the Basque country. The recommendations detail three strategic lines: developing a governance structure, promoting community action at the local level and fostering awareness and policy evaluation.
Community Action to Strengthen Health Equity in the Spanish Basque Country
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8. Recommendations for a strategy on community action for health and well-being
Copy link to 8. Recommendations for a strategy on community action for health and well-beingAbstract
Introduction
Copy link to IntroductionCommunity action for health in the Basque Country builds on a strong existing foundation. Basque communities have a long-standing tradition of community action, and as shown in Chapter 6, the landscape is vibrant with numerous projects and actors across the region. In addition, recent legislative developments, highlighted in Chapter 2, supports the participation of citizens in public health interventions. The community focus is further embedded in strategic planning documents, such as the new Health Plan 2030 (2023[1]), the Osakidetza Strategic Plan 2023-2025 (2023[2]) and the Basque Pact on Health (Pacto Vasco en Salud) launched in 2024, all of which emphasise the importance of community-oriented health services to promote well-being.
At the same time, the analyses conducted in this report reveal significant potential to further strengthen community action for health and well-being. Chapter 7 shows that initiatives are often fragmented and there is a lack of co‑ordination among various stakeholders. This highlights the need for a more structured and community-centred approach. As community action is inherently intersectoral, support for community projects should be organised through partnerships that include health stakeholders as well as other non-health stakeholders representing policy areas such as social services, environment, sport, and education. Operating within the health-in-all-policies framework, these stakeholders can support initiatives to address social determinants of health and foster population health and well-being.
The DHBC, along with Osakidetza, has already begun addressing these challenges through strategic efforts. Building on this momentum, the present chapter sets out a series of recommendations for establishing and implementing a dedicated, overarching strategy for community action on health and well-being, led by the DHBC (including Osakidetza). This strategy should serve as a unifying framework and governance structure to co‑ordinate efforts across Basque institutions and local authorities, ensuring cohesive, sustainable, and impactful support for community-based health initiatives.
8.1. Recommendations for the strategy are developed around three main strategic lines
Copy link to 8.1. Recommendations for the strategy are developed around three main strategic linesThis section presents the structure of recommendations for a strategy on community action for health and well-being in the Basque Country. These recommendations are intended to serve as a reference for the DHBC as it develops its official strategy.
The recommendations are developed around three broad strategic lines: (1) developing of a governance structure to facilitate community action, (2) promoting community action for health at the local level, and (3) fostering awareness and policy evaluation. Strategic lines cut across several policy areas (e.g. the governance structure should oversee, among other, human resources planning). For the sake of clarity, specific objectives associated to each strategic line are presented by policy area.
Table 8.1 provides a concise summary of the objectives. The remainder of this chapter is divided into three sections that outline the scope of each strategic line and policy area, along with the rationale behind each objective. Additionally, the section includes relevant good practice examples when they close to the thematic of each objective.
Table 8.1. Recommendations for the strategy – summary table
Copy link to Table 8.1. Recommendations for the strategy – summary table8.2. Strategic line 1: Developing a governance structure to facilitate community action
Copy link to 8.2. Strategic line 1: Developing a governance structure to facilitate community actionStrategic Line 1 focusses on building a governance structure that empowers local communities to undertake health and well-being initiatives, while ensuring they are supported throughout the project. It emphasises two key areas: the allocation of dedicated human resources to guide and assist communities, and the co‑ordination between various government actors to ensure cohesive and effective support across different policy areas and at government levels.
8.2.1. Ensuring human resources in health sector to co‑ordinate and support community initiatives
Well-trained public health professionals, especially those with expertise and experience in health promotion, can support local communities in the development and implementation of health-related projects. They can help communities to improve the planning and targeting of interventions. By analysing health data, they can identify priority areas and allocate resources to address specific social determinants of health, ensuring initiatives align with broader health objectives. Their expertise in monitoring and evaluation can support progress tracking and project improvement. Combined with social skills, competencies in project management, leadership, and social work enable public health professionals to empower communities to take ownership of their health initiatives. Drawing from their experience from various projects, they can guide the adaptation and implementation of good practices and play a key role in co‑ordinating efforts with professionals from other sectors, ensuring a comprehensive approach to health and well-being.
Public health professionals can also play a role of connectors within the community, sharing information and helping to shape priorities in collaboration with local actors. Based on their expertise and access to health data, they can facilitate the dissemination of information about health risks, preventive measures, and available resources, ensuring that this information reaches the entire community, particularly vulnerable population. This role is not just to inform, but to empower community members to take actions. By building awareness and providing the necessary guidance, public health professionals support the growth of local health initiatives. This community-driven approach strengthens trust in the health sector, which is essential for encouraging participation and achieving a lasting impact.
Nursing, medical, and administrative staff within primary care units are well-positioned to facilitate community action. Their regular contact with individuals from diverse socio‑economic backgrounds enables them to support community networks in effective identification of health needs. Their involvement in community projects help ensure inclusive and equitable participation. Rather than leading all efforts, they also act as connectors between local community and the health system, fostering trust, which is crucial for increasing participation and enhancing the overall effectiveness and impact of these initiatives.
To fully make use of the potential of health professionals in community action, several conditions must be met. First, health professionals need recognition and sufficient time allocated to engage with communities, as mapping community health needs and work collaboratively with local actors requires sustained efforts. Second, health professionals should be equipped with the necessary knowledge and skills to address evolving health challenges and support communities in their efforts towards better health outcomes. Objectives 1.1 to 1.3 build the appropriate context for these conditions to occur by ensuring sufficient personnel, implementing training programmes, and diversifying the workforce to support effective community action.
Objective 1.1. Ensure sufficient personnel are in place to effectively co‑ordinate and promote community action at the local level
To effectively co‑ordinate and promote community initiatives, it is crucial to ensure a sufficient health personnel at the local level, notably including public health professionals as well as nursing, medical, and administrative staff within primary care units. In part, this might require granting staff a mandate on health promotion and competences in community action for health in the territorial units of the DHBC in order to improve the ability to design, implement, and sustain more impactful local interventions Without an adequate workforce, even the most well-designed initiatives can face logistical challenges, as community projects are often complex, labour-intensive, and require sustained effort over time. Health professionals play a vital role in bridging the gap between public health policies, healthcare system and community needs, acting as key facilitators of local health promotion efforts.
The NICE guidelines (2016[3]) emphasise that health staff must have time explicitly and officially dedicated to community action. Many programmes and strategies have recognised the importance of securing adequate staffing for community action. For example, Osakidetza introduced the role of community nurse, providing dedicated time for health promotion, including community initiatives. In Valencia, the Xarxa Salut programme assigns one or two professionals in each health centre to work one day per week on health promotion, supported by the professionals from General Directorate of Public Health. Catalonia’s strategy (2023[4]) incorporates time for community health activities into professionals’ schedules, with provisions for compensation if these tasks extend beyond regular hours. In Grunau Moves (2019[5]), effective programme co‑ordination required both a health professional and a social worker.
Objective 1.2. Design and implement education and training programmes in the field of community action
Equipping public health professionals with the right mix of skills is key to enhancing the effectiveness of community action for health and well-being. While many public health professionals are well-trained in health protection, they often lack expertise in engaging and partnering with communities. Developing, in collaboration with Basque higher education institutions, training providers, and the Department of Science, Universities and Innovation, dedicated education pathways for community action, including integrated training programmes, is essential. These programmes should cover key areas, as recommended by the Centers for Disease Control and Prevention (United States), including communication, conflict resolution, event planning, evaluation, and monitoring techniques. Additionally, promoting lifelong learning in community action would ensure that professionals in public health continuously adapt to evolving challenges and opportunities in working with communities. Health authorities might also consider creating incentives for health professionals to participate in the training and work with educational institutions to provide training in a flexible way, since participating in training in addition to the work responsibilities can be challenging. This comprehensive training approach would better prepare public health professionals to engage with communities and collaborate across sectors, promoting a more holistic and responsive approach to health initiatives within diverse social contexts.
Across Spanish regions, there is a clear recognition that health professionals are not always adequately trained to promote community action. To address these learning gaps, in 2024 the University of the Basque Country offered comprehensive training programmes in health promotion and community health, including a university specialisation in Health Promotion and Community Health and a (lifelong learning) Masters’ in Health Promotion and Community Health. One of the fundamental elements of the Osakidetza’s strategy (2023[6]) is the training on addressing health from the community perspective. Similarly, Asturias Community Health Strategy (2023[7]) includes training for professionals at regional, local, and municipal levels, covering public health, healthcare, and social services staff. Castile‑La Mancha (2023[8]) prioritises fostering collaboration across various agents involved in community action through its continuous training programmes, including training of trainers. La Rioja (2023[9]) and Madrid emphasise expanding digital training, with a focus on short, practical courses, while Madrid (2021[10]) also advocates for participation in conferences related to community action in health. Both La Rioja (2023[9]) and the Canary Islands (2024[11]) stress the importance of sustaining these training efforts over time, ensuring that new staff receive the necessary education and that evolving methods are integrated. Tracking progress through indicators, such as the number of professionals trained, can provide valuable insights.
Objective 1.3. Adapt the human resources management strategy to diversify workforce profiles in the DHBC and the healthcare sector
Adjusting the human resources management strategy to incorporate more diverse profiles in the territorial units of the DHBC is crucial for aligning the workforce skills-mix with the evolving needs of community action initiatives. In the long run, it is important to ensure that the background and skills of public health professionals are better matched with the specific demands of community projects. This includes hiring individuals with expertise in areas such as community action, social sciences, and health promotion, which are important to ensure effectiveness of support for community action at various government levels.
A similar process of adapting hiring strategies has been outlined in both Osakidetza’s strategy (2023[6]) and Catalonia’s Community Health Strategy for Primary and Community Care (2023[4]). Osakidetza introduced a new role of community nurse, specialising in family and community care, which integrates expertise from nursing, public health, and social sciences. Likewise, in Catalonia, new units and professional profiles were incorporated into primary and community care, explicitly focussing on community health. These roles include specialists in emotional well-being and dietitian-nutritionists, further enhancing the community-centred approach to health and care.
8.2.2. Building mechanisms and structures to co‑ordinate community action
Co‑ordination between different actors ensures the efficient use of resources in implementing a holistic approach to community action for health. Without effective co‑ordination, efforts may lack a broader perspective, and resources may be used inefficiently. This can result, among other potential issues, in the duplication of initiatives or even competing projects, which undermines their overall effectiveness. Furthermore, without a co‑ordinated effort, the Basque Government’s strategy may become fragmented, leading to delayed communication and inconsistent support for community health projects. Beyond the efficient use of resources, there is an urgent need to create clear governance structures and co‑ordination mechanisms that take into account the different institutional levels. Defining an organisational structure dedicated to community health also helps streamline and support co‑ordination efforts across all levels – from regional governance down to the neighbourhood level.
Currently, the mechanisms that co‑ordinate the action of various actors of the Basque health system predominantly follow a top-down approach. This process is led by institutional representatives from local government, public health, and Osakidetza, who take the initiative and guide the community projects. In the initial phase, the co‑ordination is largely managed at the institutional level, without direct input from local communities. While this approach ensures that key stakeholders are aligned, it limits the involvement of local communities in the early stages of decision making. As a result, local actors and community organisations are often only brought in after the framework and key objectives are established by higher-level authorities. This top-down structure restricts the capacity of communities to independently initiate projects, reducing the flexibility needed to tailor health initiatives to the specific needs and priorities of local populations.
A key challenge for the current co‑ordination mechanism is the lack of a robust institutional framework at the local level. There is no consistent approach for initiating co‑ordination efforts across municipalities, resulting in fragmented and uneven implementation. Engagement in co‑ordinating activities is often determined by local preferences or voluntary efforts, with smaller municipalities particularly disadvantaged due to limited human resources. A new co‑ordination mechanism or structure should facilitate collaboration between professionals in local governments, health professionals, and community organisations, ensuring that health strategies are aligned and responsive to the specific needs of each community.
Objective 1.4. Strengthen co‑ordination structures among professionals supporting community action at the local level
Strengthening the co‑ordination structures for community action for health can be done by establishing clear, consistent mechanisms, protocols, or structures for the co‑ordination process. Such a permanent co‑ordination structure should involve public health professionals, healthcare professionals working in primary care units, social services, and representatives of local municipalities. To achieve this, it is crucial to ensure that all municipalities, especially smaller ones, have the necessary resources to effectively co‑ordinate its activities across different sectors. By providing municipalities with the support they need, the framework creates a more structured and sustainable approach to community health initiatives. This ensures that all relevant stakeholders are involved in community health projects from the beginning, improving their long-term sustainability and effectiveness across the whole territory.
Efforts to strengthen co‑ordination mechanisms are included in the community action strategies of Asturias (2023[7]) and Castilla-La Mancha (2023[8]). In Asturias, the Integrated Community Health Action Network is being established to co‑ordinate local actions in public health and guarantee consistent public action across the entire autonomous territory. This initiative aims to ensure that local governments and community agents work together towards collective well-being. In Castilla-La Mancha, the strategy emphasises improving co‑ordination between various sectors, including Primary Healthcare, Public Health, local entities, and other sectors, to create a more integrated and collaborative approach to community health. Asturias’ community health strategy stresses the need for close collaboration of health services with education and social services, which includes actions such as expanding municipal intersectoral health tables, reviewing the makeup of existing commissions and technical working groups, and co‑ordinating efforts between educational centres and social services.
Objective 1.5. Include local communities in the co‑ordination structure at the local level
To foster more effective collaboration, it is crucial to enable local communities to be involved in the new co‑ordination structure. Strengthening local co‑ordination mechanisms must go beyond institutional involvement to actively include community representatives, such as NGOs, local community leaders, and engaged citizens ensuring their voices are heard from the outset. By creating opportunities for local communities to be part of decision making forums and co‑ordination groups, the strategy reinforces a community-centred, bottom-up approach, ensuring that health initiatives are more responsive to local needs and priorities. Direct community participation also helps build trust, strengthen a greater sense of ownership over health projects, and encourages long-term engagement.
Examples of good practice of citizen’s involvement in such structures is present in many strategies for community action and community health. The strategy of the Province of Gipuzkoa (2022[12]) stresses that the role of public administration is to facilitate participation of citizen, promoting dialogue, negotiation, mutual recognition, commitments from all parties, and shared leadership. In the strategy of Castilla-La Mancha (2023[8]), enabling citizen participation is seen as essential to promoting dialogue between different sectors and disciplines, enhancing opportunities for community actions, and encouraging social participation. In Switzerland, The Canton of Zurich established in 2004 the “Forum for Prevention and Health Promotion”, open to all actors, organisations, and institutions involved in community action. This forum includes local communities in co‑ordination efforts and serves as a platform for proposing key topics, exchanging information, and fostering networking among stakeholders. Additionally, the Ministry of Health of Spain (2022[13]) has recommended the formation of governance structures to co‑ordinate community health efforts, linking primary care, public health, local authorities, citizens, patient groups, education, social services, and other key actors at regional and local levels.
Objective 1.6. Develop institutional co‑ordination mechanisms between the departments or sectors which are related to community action for health
Although the strategy is designed and managed by the DHBC, its implementation involves the co‑ordination with other departments within Basque Government. At the central level, the strategy should prioritise the establishment of mechanisms to co‑ordinate support for community initiatives across various departments of the Basque Country Government, as appropriate. Given that these initiatives often intersect multiple sectors – such as health, social protection, sports, and culture – effective interdepartmental collaboration is essential. This co‑ordination should ensure that critical areas like funding, human resource allocation, expertise sharing, and communication are systematically addressed, fostering comprehensive and holistic support for community-driven actions. This approach will strengthen the sustainability and impact of initiatives by aligning resources and efforts across relevant sectors.1
In Spain, several regions provide useful examples of how high-level co‑ordination mechanisms can improve interdepartmental collaboration for community health efforts. Extremadura (2022[14]) has created institutional and technical commissions, bringing together social services, healthcare, and socio-health planning departments to ensure a unified approach. Castilla y Leon (2023[15]) has developed networks to address key health issues collectively, working with sectors like education, social services, the environment, and local governments. The Basque Country also provides examples of such co‑ordination efforts. Since 2022, the Basque Council for Social and Healthcare has facilitated co‑operation between the Basque Social Services System and the Health System, building an integrated approach to addressing shared challenges.
8.3. Strategic line 2: Promoting community action at the local level
Copy link to 8.3. Strategic line 2: Promoting community action at the local levelStrategic Line 2 addresses the key areas for the support of community action at the local level. Firstly, it stresses the need to strengthen the role of health promotion within the DHBC, ensuring that it becomes an important component of public health strategy. Secondly, it highlights the importance of securing appropriate funding to effectively support and sustain community initiatives. Together, these actions can empower local communities and reinforce their role in promoting health and well-being.
8.3.1. Incentivising health promotion
Effective health promotion co‑ordinated with initiatives to address social determinants of health can significantly reduce health inequalities and offer a high return on investment. However, despite this proven cost-effectiveness, health promotion initiatives are seldom prioritised. Resource constraints, the need to focus on immediate care for sick patients, and the perception that certain public health interventions encroach upon personal decision making often make it difficult to justify investment in health promotion.
Increasing the importance of health promotion places greater emphasis on community actions, both directly and indirectly. Directly, it can increase funding for community projects, enabling more initiatives to take place. Indirectly, raising social awareness about public health issues can encourage communities to act on these topics through various initiatives. As a result, this approach can lead to a rise in the number of community-driven health projects.
Compared to other interventions, well-designed community action projects are a valuable cost-effective tool in health promotion. Additionally, community-led initiatives are better positioned to address local needs, making them more effective. They also contribute to raising general health awareness, generating positive externalities such as improved public health outcomes. Moreover, these projects strengthen local ties, with positive spillover effects that extend beyond health, fostering social cohesion and community resilience.
Objective 2.1. Strengthen the role of health promotion within the DHBC
To strengthen health promotion, the DHBC could consider adopting a broader role for this area, building on the precedent set by the new Public Health Law of the Basque Country, which emphasises citizens’ health and the importance of social determinants of health. This it can be implemented by strengthening the current scope of work on health promotion, both at the central and county level. A strengthened health promotion team could oversee organising public health campaigns while also assisting municipal governments with the implementation of health-promoting projects. Possible topics which could be overseen within health promotion could include issues like substance use, healthy eating, and health literacy. One approach to securing these resources is by designating a specific portion of the DHBC’s public health budget for health promotion and community health initiatives. Gradually setting this target can help ensure adequate funding without negatively affecting other public health programmes. This phased approach allows for sustainable support for community health while balancing other important priorities.
Several regions and organisations have already established a dedicated structure within their administration to prioritise health promotion. Action 1.2 of Osakidetza’s strategy (2023[6]) involves creating a reference team for the community approach within the Sub-Directorate for the Co‑ordination of Primary Healthcare, focussing on prevention and health promotion. Valencia has a subdirectorate for health promotion and prevention which encompasses the services of addictions, health policy evaluation, immunisation, screening, and health prevention at work. The Canton of Zurich has a department focussed on health promotion with a substantial budget and 12 full-time staff. The department works on two fronts: the canton and the municipality. At the cantonal level, it organises health campaigns pertaining to drug addiction or mental health. At the municipal level, the department assists local governments in the implementation of health-promoting projects (OECD, 2025[16]). A good practice example of resource allocation for is found in the autonomous community of Asturias. Asturias has recognised that, internationally, around 4% of total health spending is typically allocated to public health, and the region is planning to progressively increase its own allocation.
8.3.2. Ensuring stable resources for community action at the local level
Community projects need sufficient financial support to cover basic expenses. Without this support, communities may struggle to sustain their initiatives in the long run. Otherwise, over-reliance on volunteers can lead to burnout and negatively affect the mental health of those involved, ultimately causing the project to fail. Sufficient funding ensures the longevity of these efforts and fosters a sense of recognition and value among those involved in an initiative.
Community-friendly public spaces also play an important role in fostering a strong sense of community, encourage civic participation and volunteering, and contribute to overall well-being (Francis et al., 2012[17]). A strong sense of community is linked to feelings of safety and security, increased civic participation, voting, volunteering, and improved well-being. In this context, public spaces that promote gathering and shared belonging further strengthen these community bonds. To maximise their potential, these spaces should be reimagined to better facilitate social interaction and community building. Beyond creating new spaces, it is equally important to ensure communities have easy access to existing public facilities and areas that can be repurposed for organising and hosting community projects.
In addition to financial resources, community projects also need intellectual resources. While a community may identify a health issue and be eager to address it, they may lack the necessary knowledge on how to carry out an effective intervention. Poorly designed interventions can lead to underwhelming results or, in extreme cases, even produce unintended negative effects. Furthermore, without the proper expertise, communities may become discouraged and abandon the idea of initiating an intervention altogether. Sufficient health staff at the municipal level is needed for that purpose.
Objective 2.2. Implement a mechanism to ensure stronger emphases on the health promotion at the municipal level
A mechanism to ensure stronger emphasis on the health promotion at the municipal level should be established in accordance with the new Public Health Law of the Basque Country. This law assigns municipalities the responsibility of developing programmes for health protection, promotion, and addiction prevention, as well as overseeing compliance with health standards. To be effective, the mechanism should guarantee that municipal health promotion programmes are carefully planned, adequately funded and staffed, and integrated into broader municipal plans.
Asturias strategy for community action (2023[7]) suggests that the work at the municipal level is essential for achieving health and well-being objectives for citizens. This approach is supported by a new public health law, which clarifies local-level responsibilities. To facilitate this, Asturias has introduced a catalogue of health promotion activities for municipalities, helping to define their role in implementing the broader strategy.
Objective 2.3. Develop a network of local entities to promote community action for health
Municipal networks can enhance community action in several ways. They enable municipalities to leverage shared resources to address funding challenges that might be difficult to tackle individually (this is particularly important for smaller and rural communities). By forming a network, municipalities can collaborate to develop more targeted and impactful programmes that better serve their communities. Additionally, these networks provide a valuable platform for the exchange of information and expertise, fostering collaboration and knowledge‑sharing. This exchange can lead to the adoption of better practices and innovative solutions and build capacity to address local challenges collectively.
XarxaSalut created in the Valencian Community serves as a successful example of municipal networks fostering community action for health. It is a network of municipalities or municipal associations committed to implementing local health promotion initiatives as part of the region’s V Health Plan (2022[18]). Municipalities formally communicate their commitment to both health centres and the DHBC and inform their citizens about joining the network. Through this network, municipalities participate in workshops and meetings to exchange experiences, share best practices, and showcase their activities.
Objective 2.4. Build a knowledge‑sharing database available to local communities
Community initiatives often struggle due to a lack of know-how among their participants. To reduce the negative effects of this situation, the strategy should include creating a database of tools and resources, developed in collaboration with leading experts. This database could take a form of a website offering downloadable materials such as project guidelines, evaluation reports, and good practice reports. Also, incentives for grant recipients to share documentation of their projects in the database should be created. This would generate a positive spill-over effect, allowing successful initiatives from different parts of the Basque Country to be shared and replicated more easily. This open-access database would enable communities to use best practices for tailored initiatives and serve as inspiration for new groups looking to launch community projects.
An example of such a database can be found in Switzerland, managed by the Health Promotion Switzerland foundation. Projects that receive funding from the foundation are required to provide comprehensive documentation, which is then published on the foundation’s website. Additionally, applicants who lack the technical expertise to implement their projects are offered support and guidance from the Department of Health Promotion. This approach empowers local communities by enabling them to apply for funding directly, while also significantly lowering the barrier to entry for those with limited technical knowledge.
Objective 2.5. Facilitate access to public spaces and create new community-friendly public spaces
The DHBC can collaborate with local governments to improve urban space design, particularly in terms of walkability and accessibility for people of all ages, enhancing community action. Making streets more pedestrian- and bike‑friendly – through measures such as restricting vehicle access, building more bike paths, and creating additional playgrounds for children – can strengthen community ties. This collaboration could also extend to maximising the use of existing public spaces, encouraging local governments to make these areas available for community projects. Additionally, adapting and opening public buildings and spaces to support these initiatives fosters a more inclusive and active environment, encouraging greater participation in community activities.
An example of the role of community-friendly public spaces can be seen in the strategy of Asturias (2023[7]), which highlights urban development as a crucial sector for promoting intersectoral collaboration in health, particularly at the local level. This approach is significant because municipalities hold responsibility for urban planning, including the creation of technical and regulatory tools to manage land use, as well as its transformation or preservation. In the Basque Country, the strategy of the Province of Gipuzkoa (2022[12]) propose to introduce changes to the physical design of the space and, above all, adjustments in how services are organised and delivered to better support, accompany, and facilitate interpersonal connections. The Province of Utrecht has put this concept into practice, requiring that all urban initiatives be reviewed by health professionals to ensure that they are assessed from a health perspective, fostering a healthier and more inclusive urban environment. Another example of successful collaboration between community projects and local authorities in the use of public infrastructure is the Mugiment project, which promotes physical activity by utilising existing sports infrastructure managed by local governments.
8.4. Strategic line 3: Fostering awareness and policy evaluation
Copy link to 8.4. Strategic line 3: Fostering awareness and policy evaluationStrategic Line 3 focusses on raising awareness of community action and developing the framework to evaluate community projects. It begins with the dissemination of the community action and the new strategy, ensuring broad understanding and engagement. Next, it emphasises the promotion of community action among researchers to increase academic interest and innovation. Finally, it highlights the importance of developing a robust quality framework for evaluating community initiatives, ensuring their effectiveness and sustainability.
8.4.1. Designing the communication plan for the community action
An effective communication plan is essential for rising awareness and fostering engagement in community action. Clear and well-managed communication delivers numerous benefits, both within the Basque multi-level governance structure and among potential beneficiaries, including initiative leaders and local communities. It enhances participation and engagement by encouraging local communities to take part in the consultations and planning as well as designing and management of community projects.
A successful communication plan should address two key areas. First, it should effectively promote the new strategy on community action to both institutional stakeholders and local communities. A well-structured communication plan reduces confusion and misunderstanding surrounding the strategy. Poor communication, on the other hand, can lead to resistance, conflict, and the spread of misinformation, which could jeopardise the strategy’s objectives.
The second area focusses on enabling citizens to freely express their opinions and ideas about community action. Since the strategy is community-centred, it is crucial to provide tools that allow citizens to share their perspectives. This approach fosters a sense of ownership, strengthens citizens’ role in the community process, and creates opportunities for mutual learning and the exchange of ideas and good practices. Moreover, it supports continuous citizen engagement in consulting and designing policies and projects related to community action, which represents the highest level of community involvement, fostering a deeper connection and commitment to these initiatives.
Objective 3.1. Develop a dissemination plan for the new strategy
Communities needs to be well-informed about the strategy, its objectives and implementation. Dissemination plan should rely on various communication channels. Outreach efforts could include providing clear and accessible information through a dedicated online portal creating a space for questions and idea submissions, The portal could also host an evolving set of Frequently Asked Questions, creating a dynamic resource for community members. To increase efficiency and benefit from synergy gains, this online portal can be integrated with the knowledge‑sharing database (see Objective 2.4.). Additionally, an information campaign could be launched within the primary care units and pharmacies to raise awareness about the new strategy and benefits associated with it. This approach would enable the strategy to reach a wide audience, including socially disadvantage groups, who might otherwise have limited access to digital resources.
The organisation of awareness-raising campaigns promotes behavioural change, encourages collaboration among different stakeholders, and can mobilise public support for the strategy. Osakidetza’s Strategy on Addressing Health from a Community Perspective in Primary Care (2023[6])provides an example of dissemination efforts. A key component of this strategy focusses on raising awareness, with specific actions such as developing a community notebook at each primary healthcare centre, providing information and training services to citizens (Osasun Eskola), and organizing Good Practice Conference to foster knowledge exchange. These initiatives aim to increase the visibility of community activities and is designed with an intersectoral and multidisciplinary approach. Asturias has taken a different routh by establishing an annual meeting on well-being and community health, where the Directorate of Public Health conducts training workshops on topics relevant to community action in health (2023[7]). Madrid, in addition to a meeting on community health also suggests the idea of handing in regional prizes on community health, co‑ordinated by both the Department of Health and by primary healthcare provider (2021[10]). Finally, La Rioja has developed an online platform, the School for health, and plans to offer training sessions for citizens within healthcare centres (2023[9]).
Objective 3.2. Create a tool allowing citizens to express their views, and health authorities to consult the community, on specific health matters
Developing a tool that enables citizens to express their views and allows health authorities to consult the community on specific health matters is an important component of building community-centred strategy. For example, the consultations can be conducted through associations representing people directly or indirectly affected by specific diseases or disabilities, as well as patient associations. A potential framework for this consulting tool might be aligned with the 2023 Basque Public Health Law, which incentivises citizen’s participation and consultation on specific health topics. To increase efficiency of community consultations and improve citizen feedback on specific public health issues, it would be beneficial to develop comprehensive guidelines on engaging with citizens to informing health policy. These guidelines, designed to support local authorities or DHBC’s professionals working on the ground, are crucial to maintain and increase the adherence of potential beneficiaries to community action programmes.
In Austria, the Federal Ministry of Social Affairs, Health, Care, and Consumer Protection launched the Future Health Promotion participatory strategy process, engaging experts, stakeholders from multiple sectors, and community representatives to prioritise health measures for the next five years (2022[19]). This process employed participatory methods to define long-term goals and establish short- to medium-term priorities. An online platform was created as part of the initiative, allowing citizens to share their opinions and stay informed about ongoing initiatives and progress in implementing the strategy. Similarly, Scotland introduced national guidance, Planning with People (2024[20]), to support municipalities and health services in fostering community action. This guidance emphasises timely engagement and a two‑way communication process, ensuring communities are informed and involved in project development. In Spain, XarxaSalut developed user-friendly guides offering practical information on organizing new initiatives and local networks, further supporting effective community engagement (OECD, 2025[16]).
8.4.2. Promoting research and capacity building in community health
Communities themselves are the central actors in community action, supported by professionals who assist in designing and implementing initiatives aimed at improving health and well-being. However, both community members and the professionals supporting them often lack the technical expertise needed to effectively implement and evaluate interventions. They may also face challenges in identifying the most pressing health issues without relying on external sources or frameworks.
Academic research serves as a vital and reliable resource for developing, implementing, and evaluating community projects. It provides evidence on the effectiveness of interventions, designs indicators to measure impact, studies optimal intervention models, develops innovative approaches, and creates evaluation tools. Research also draws on international experiences, enabling the exchange of good practices across countries, further enriching the knowledge base for community interventions.
Understanding social determinants of health, the influence of living environments, and the role of lifestyles on health outcomes is essential for accurately assessing local needs. Academic research plays a critical role in documenting changes in population health and identifying key factors that shape health outcomes. By pinpointing the main drivers of health inequalities, research enhances the effectiveness of community efforts and raises awareness about the root causes of health inequalities, ultimately supporting more targeted and impactful interventions.
Objective 3.3. Actively promote research on community action among Basque academic institutions
Basque academic institutions are well-positioned to support local community projects through their research on social determinants of health within the Basque context. This research is crucial for informing policy design, setting mid- and long-term health strategy objectives, and developing tools to achieve them. The strategy should actively promote relevant research among Basque universities and research institutions operating in the Basque Country while fostering collaboration between academic researchers, health institutions, and community action networks. This promotion can include targeted grants for designing and evaluating community initiatives in the region. Additionally, Basque research centres can contribute to creating a knowledge database to support communities (see Objective 2.4.). The future Basque Institute of Public Health could play an important role in co‑ordinating this process and maintaining the overall coherence of the academic curricula and the training of the many professionals working in the health system.
Promotion of research on community action and health promotion is part of the Osakidetza’s strategy (2023[6]) and additional examples of promoting research on community action can be drawn from other regions. In Asturias (2023[7]), one strategic line of action involves creating a Chair on Community Action and Health Promotion at the University of Oviedo and providing funding for related research projects. Asturias also emphasises the importance of incorporating citizens’ experiences into research on social determinants of health. Similarly, the Strategy for Community Health in Castilla-La Mancha (2023[8]) prioritises research, with a specific focus on gender perspectives and citizen involvement. The strategy also seeks to strengthen teaching, training, and research as part of its primary care health plan. In Zurich Canton, Switzerland, the Department of Prevention and Health Promotion employs full-time academic staff, including university professors and researchers from the University of Zurich (OECD, 2025[16]). This integration of academic expertise ensures that the latest scientific advances are embedded in health promotion programmes.
8.4.3. Developing a quality framework
Monitoring and evaluation are integral components of the quality framework for community action. Monitoring involves the continuous collection and analysis of data to track the performance of initiatives, enabling the early identification of issues and introducing timely adjustments. Evaluation, in contrast, is the systematic assessment of whether the goals of initiatives are being achieved. It measures the effectiveness, efficiency, and impact of interventions. Together, monitoring and evaluation are crucial for informed, evidence‑based decision making and effective policy development.
Additionally, the results of evaluation and monitoring allow for identifying and sharing good practices across communities. Collected quantitative and qualitative indicators should be included in a centralised knowledge‑sharing database (see Objective 2.4.). Developing such a database, however, requires defining the standardised set of indicators to ensure consistency across initiatives. The selection of these indicators should be conducted via the consultation process, engaging the DHBC, Osakidetza, local municipalities, and community representatives. This approach ensures the indicators are both informative and practical, balancing the need for meaningful data with feasibility to avoid overwhelming communities.
However, both monitoring and evaluation are resource‑intensive processes. They require significant effort as well as technical expertise, which many communities may lack. This limitation can hinder the ability of communities to conduct these processes effectively, potentially weakening the development of initiatives and leading to inefficient use of available resources. At the same time, it also hinders policymakers deciding on reallocating responsibilities, adjusting budget allocations, and engaging professionals more effectively in community initiatives.
Beyond evaluating and monitoring individual initiatives, it is also crucial to analyse their overall impact. Assessing the influence of all community initiatives on the public health system and health outcomes is essential. This evidence can inform policymakers in adjusting public health policies or reallocating resources to maximise the effectiveness of health policies. Additionally, it helps identify emerging trends, opportunities, and potential challenges in community health.
Finally, the new strategy should also undergo evaluation, with its implementation closely monitored. While the strategy is developed in collaboration with experts and through a consultative process, the dynamic nature of the health landscape means that some recommendations may prove more effective than others over time. Regular evaluation can provide valuable insights for Basque policymakers, enabling them to adjust implemented initiatives as needed and enhance their support for communities in achieving improved health and well-being.
Objective 3.4. Create a self-evaluation tool for local communities
The self-evaluation tool for community action can empower communities to implement effective health initiatives while clearly demonstrating how they are meeting their goals. It should guide community leaders in understanding the characteristics of high-quality community action. Rather than focussing solely on activities, the tool should prioritise outcomes, such as the tangible impact of community projects, changes implemented based on feedback, efforts made to reach socially disadvantaged groups, or the mechanisms for monitoring potential impacts. Additionally, the self-evaluation can include key quantitative indicators such as budget information, participant numbers, frequency of meetings, or other technical details that could be valuable for other communities considering similar initiatives. Developing such self-evaluation tools should be a collaborative effort between local communities, the DHBC, and Basque research institutions.
An example of such a self-evaluation tool can be found in Scotland, where Healthcare Improvement Scotland developed a tool for healthcare providers, social workers, and local authorities. This tool helps to identify shared outcomes and define steps to improve engagement with local communities. Similar tools are also used in Canada, such as the guide published by Active Neighbourhoods Canada (2017[21]), which offers a framework for evaluating local community projects. In Spain, the Escuela Andaluza de Salud Pública published Tools to Assess the Impact of Public Health Programmes and Community Interventions from an Equity Perspective on Social Determinants of Health and Equity (Suárez Álvarez et al., 2018[22]), which serves as a resource for assessing the health impact of community initiatives.
Objective 3.5. Design quantitative and qualitative indicators to monitor progress and evaluate impact of community action
Health Observatories play a key role in analysing and disseminating data on various aspects of health, including community health and social determinants of health. The Basque Health Observatory, potentially in collaboration with the Basque Institute of Statistics (Eustat) should contribute to defining the methodological approach for collecting data on community action. It should also take the lead in using and disseminating this data to inform and enhance community initiatives. However, it is essential to approach such analyses with caution due to several challenges: (i) the effects of community action policies tend to be slow and can only be meaningfully assessed several years after their initial implementation; (ii) isolating their impact from other influencing factors, such as economic conditions, demographic changes, and broader healthcare policies, is often complex; and (iii) data sources on programme outcomes are frequently scarce, incomplete, and difficult to compare.
In other regions of Spain, for example in Extremadura, Health Observatories often monitor the impact of community action on health. Similarly, in Valencia, municipalities participating in the Xarxa Salut commit to sharing information on the implemented activities through the Health Observatory. In Andalusia, the Health Observatory collects and analyses health data to guide and improve community health interventions. Beyond Spain, Finland offers a benchmark with its comprehensive data collection on health promotion across municipalities, covering seven dimensions such as commitment, management, population health monitoring, and public participation. These indicators enable municipalities to assess citizen engagement in service planning and collaboration between municipal authorities and associations, with extra funding awarded based on performance. In the United States, the PLACE project (formerly the 500 Cities project) provides neighbourhood- and city-level data on chronic diseases, health behaviours, social determinants of health, and preventive services across major U.S. cities. The project disseminates its data, methodology, and interventions through a dedicated webpage (Centers for Disease Control and Prevention, 2024[23]).
Objective 3.6. Evaluate the implementation of the new strategy on community action
The comprehensive evaluation of the new strategy should combine both quantitative and qualitative data collection and analyses. Quantitative indicators could focus on measuring the changes in the reach and process of community action, including metrics such as the number of beneficiaries, the diversity of initiatives, and the impact on fostering a sense of community or shifting perceptions on its role and significance. Qualitative feedback from citizens, local municipalities, and Osakidetza’s and DHBC’s professionals is equally valuable for impact evaluation and for making evidence‑based recommendations for adjustments to the strategy. For example, information about the clarity of information or the dynamism of collaboration between health and municipal authorities can help to evaluate whether changes, such as a new co‑ordination mechanism, have led to improved collaboration between different public sector units.
Currently, there are limited examples of evaluations assessing entire strategies comprehensively. One such example is the evaluation currently being conducted by Osakidetza. To address this gap, Output 5.3 of this project proposes a monitoring and evaluation framework aimed at addressing the most critical aspects of the strategy, providing a structured approach to assessing its implementation and impact.
References
[21] Active Neighbourhoods Canada (2017), Evaluation Guide for Local Community Projects, https://participatoryplanning.ca/sites/default/files/upload/document/tool/evaluation_guidebook_compressed_0.pdf.
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Note
Copy link to Note← 1. Suggested solutions for the practical implementation of co‑ordination mechanisms, such as inter-departmental councils (mesas) and bilateral co‑ordination instances are detailed in the Action Plan report.