A Heuristic Governance Framework for the Implementation of Child Primary Health Care Interventions in Different Contexts in the European Union.

To adopt and implement innovative good practices across the European Union requires developing policies for different political and constitutional contexts. Health policies are mostly decided by national political processes at different levels. To attain effective advice for policy making and good practice exchange, one has to take different models of governance for health into account. We aimed to explore which concepts of governance research are relevant for implementing child health policies in a European Union context. We argue that taking into account the insights of good intersectoral and multilevel governance in research and practice is essential and promising for future analyses. These governance concepts help to understand what actors and institutions are potentially of relevance for developing and implementing child-centric health care approaches not only within health care but also outside health care. The framework we developed has the potential to advise on and thus support effectively the spreading and implementation of good practices of child-centric health policy approaches across the European Union. With this heuristic framework, the variety of relevant stakeholders and institutions can better be mapped and taken into account in implementation processes. Also, the normative side-particularly stressing values that make governance "good governance"-is to be taken into account.

Introduction and Background

The health of children is an important goal for any health care system. Child mortality and maternal mortality are basic performance indicators that are frequently consulted. Children depend on good primary health care services, such as immunizations, checkups, other forms of routine health care, or coordination of specialist care. But these services are structured differently throughout the world and even within Europe, and there is little research into what primary care models for children work best. To help every child benefit from optimum primary health care, the European Union (EU) funded the project “MOCHA—Models of Child Health Appraised.” Within this large-scale project (engaging researchers from 11 EU countries, the United States, and Australia, collaborating with national experts in 30 EU and other European countries), a systematic, scientific appraisal of the types of child primary health care (CPHC) that exist was performed.[1] To appraise the types of models, one has to understand what works in practice and is worth transferring as good practice to other contexts, eg, other national health care systems. However, to adopt and implement innovative good practices across the EU requires developing policies and interventions for different political and constitutional contexts. Health policies are mostly decided by national political processes at different administrative levels within a country, and the EU has no competence to determine models of care within its Member States.[2,3] To successfully implement good practices, policy makers need to understand what decisions have to be taken and who are other relevant actors to involve in the implementation of a good practice to make it effective in practice. This article offers the concept of “governance” for framing contexts in which policy makers and implementers of child health care act. “Governance” is a complex term, with different existing definitions which are often not directly compatible.[4,5] Yet, the essence of governance can be described as “the systematic, patterned way in which decisions are made and implemented.”[6] A heuristic virtue of the concept “governance” is that its different models and concepts support the constructive analysis of the context in which CPHC innovations might be implemented. Governance draws the attention to actors—as taking roles in decision making and implementation—and their relations to each other. More concretely, for policy making and good practice exchange in our health context, we—as others[7]—follow Kickbusch and Gleicher who speak of “governance for health” and define it

as the attempts of governments or other actors to steer communities, countries or groups of countries in the pursuit of health as integral to well-being through both whole-of-government and whole-of-society approaches. It positions health and well-being as key features of what constitutes a successful society and a vibrant economy in the 21st century and grounds policies and approaches in such values as human rights and equity. Governance for health promotes joint action of health and non-health sectors, of public and private actors and of citizens for a common interest. It requires a synergistic set of policies, many of which reside in sectors other than health as well as sectors outside government, which must be supported by structures and mechanisms that enable collaboration. It gives strong legitimacy to health ministers and ministries and to public health agencies, to help them reach out and perform new roles in shaping policies to promote health and well-being.[8]

Against this background, the aim of this article is to explore relevant aspects of governance for health that have to be taken into account for effective and responsible CPHC governance. This article shall offer a heuristic framework that can support further analysis of the context of and implementation in the field of CPHC development and good practice exchange, especially in the EU.

Methods

This explorative article is built on a critical review methodology[9] to construct and argue for a heuristically helpful governance framework supporting decision makers in CPHC to plan and implement good practices. This form of review goes beyond a description of the literature and is typically used for conceptual innovations. The strength of this methodology is that it provides an opportunity to evaluate and include what is of value from the existing body of work. Thereby, a critical review puts the emphasis on the conceptual contribution of the literature to embody existing or to derive new theory.[9] This allowed us to integrate literature relevant for understanding the main themes to inform a governance framework for CPHC.

The aim of the literature search in a critical review is to identify the most significant items in the field.[9] Hence, our approach to construct a governance framework for CPHC is based on literature and expert consensus. This approach makes the elements that form notions of governance explicit for the context of CPHC. Identifying the processes and actors involved in health system governance (HSG) illustrates the potential pathways and means of improving health systems.

To identify basic concepts as a starting point for the search of key literature, we performed an initial orientation search on the topic of governance using PubMed and Google Scholar. As a conceptual point of departure, the approach of Kickbusch and Gleicher’s “governance for health”[8] was used, which is key in WHO’s policy making. Key concepts reflected in there, such as intersectoral governance (IG), multilevel governance (MLG), and HSG, have informed our basis for research. Thus, we focus on the concepts of IG, MLG, and HSG—rather than on other conceptions such as smart governance, hierarchical governance, vertical governance, networked governance,[4] or micro-meso-macro governance[10]—as IG, MLG and HSG have proven to be of heuristic value in discussions of EU health systems.[8,11] Furthermore, we explore what constitutes “good governance” as a basis for CPHC and what elements of governance can be found especially in primary health care.

The literature was searched using PubMed and Google Scholar in July 2017. Single search terms and combinations of keywords were applied, including “governance,” “intersectoral governance,” “multilevel governance,” “health system governance,” “good governance,” “primary care,” “child,” and “child health.” In addition, snowball sampling was used with the screening of references. All types of publications (including original research papers and opinion pieces) from all geographical contexts and all years were included. Publications in English language were taken into account. Publications were included in the review if they described elements of (1) the key concepts of governance for health mentioned above, (2) good governance, and/or (3) governance in CPHC. Essential elements of governance in these concepts were extracted and compared between the publications. The main relevant findings were synthesized according to the respective concept, and examples were drawn that referred to the literature but also included the expertise of the 10 authors (see Table 1).

Table 1.

Example of Actors and Policies Within a Scheme of Multilevel Governance.

	Public/state actors[connections to other actors]	Nonstate actors/private[connections to other actors]
Global	• United Nations (eg, Millennium Development Goals, Sustainable Development Goals) [advising, setting targets]• UNICEF [advising, setting targets]• UNESCO [advising, setting targets]• WHO (eg, Department of Maternal, Newborn, Child, and Adolescent Health; policies like Declaration of Alma Ata, Ottawa Charter for Health Promotion, Framework Convention on Tobacco Control; programs like The WHO Child Growth Standards, Global Plan of Action for Children’s Health and the Environment) [advising, informing]	• Professional Associations (eg, World Medical Association) [guiding]• Clowns without borders [providing service]• NGOs: Red Cross/Red Crescent [providing service]
European	• EU (eg, Common Values for Health Systems; Horizon2020) [regulating, financing, agenda setting]• Council of Europe (eg, policies: European Social Charter) [regulating, financing, agenda setting]• WHO/Europe (eg, Investing in children: the European child and adolescent health strategy 2015-2020, European Vaccine Action Plan 2015-2020) [advising, informing]	• NGOs (eg, patient/consumer/children advocates—eg, EACH: European Association of Children in Hospitals) [advising, lobbying]• Professional Associations (physician specialists, nurses—eg, European Medical Association) [advising, educating]
National	• National Ministries (Health, etc.—see different sectors) [regulating, implementing, enforcing]• National Health System (NHS organizations) [providing service, financing, etc.]• National Public Health Institutes (eg, National Institute for Health and Care Excellence [NICE] in the United Kingdom, National Institute of Public Health and the Environment [RIVM] in the Netherlands) [advising, assessing, monitoring]• WHO country office [advising], WHO collaborative centers [researching]	• Insurances [financing]• Professional Associations (physician specialists, nurses—eg, National Medical Associations) [advising, educating, etc.]• Pharmaceutical companies [providing, financing, etc.]• NGOs (eg, patient/consumer/children advocates) [advising, lobbying]
Subnational/regional	• Regional Ministries (Health, etc.) [regulating, implementing, enforcing, financing]• Regional Institutes of Public Health [monitoring, etc.]	• Regional Professional Associations (eg, Pediatric Society of Northern Greece [PEVE]) [guiding]
Local	• Local governments [implementing, financing, etc.]• Public Health Service [delivering service]• Public hospitals, outpatient/inpatient health care units [delivering service]• Institutes of Social Pediatrics [delivering service, monitoring]• (Public) Schools [educating]	• Private hospitals, outpatient/inpatient health care units [delivering service]• NGOs (eg, local Red Cross, local civic associations) [advising, lobbying]• General practitioners, pediatricians, other health professions (physiotherapy, occupational therapy, etc.) [delivering service]• (Private) Schools [educating]

Note. The terminology of the connection in brackets is inspired by Scholtes et al.[12] UNICEF = United Nations International Children’s Emergency Fund; UNESCO = United Nations Educational, Scientific and Cultural Organization; WHO = World Health Organization; NGOs = nongovernmental organizations; EU = European Union.

Subsequently, the group of 10 authors of this article weighed these findings and—based on their senior level expertise in health governance and child primary care—constructed a concise governance framework for the planning and implementation of good practices of CPHC. For this, all experts discussed the findings and contributed their knowledge to weigh their conceptual contribution in terms of their relevance for CPHC and to integrate them for conceptual innovation.[9] Consensus was reached, as all authors agreed on the integrated literature and the final framework.

Results

No articles or reports were originally found specifically on CPHC governance, although recent literature has begun to apply governance models to general and country-specific child health topics.[7] We present findings from these articles and the more general discussions of governance (for health) according to the key concepts MLG and IG already mentioned above, deduced from the “governance for health”[8] framework. The synthesis revealed that elements of HSG recurred in these key concepts and thus were not described separately.

Multilevel Governance

When analyzing how decisions regarding the implementation of CPHC are taken, it is evident that national and international actors are involved in one way or another. To give an example: If one wants to understand the governance of vaccination, one also has to take policies from the supranational level into account. The WHO, eg, sets the goal to eradicate measles: How is the “European Vaccine Action Plan 2015-2020”[13] conceived and dealt with by the national government, and how do the actors on the national level (eg, national government, national institute of public health) collaborate with the regional or local health authorities on the implementation of vaccination policies? The interactions of supranational with national, regional, and local tiers of governance are important to analyze and to understand the complex determinants that shape the success or failure of vaccination policies.

When considering governance in the health sector, it is relevant to acknowledge with Kuhlmann and Larsen that governance shall aim at making a “transnational impact.”[14] The MLG is a concept that includes per definition the international levels as perspective for decision making also on lower national levels. The MLG has been particularly conceptualized for questions of public policy and European integration but is now also used in the international context, including questions of global governance.[15,16] MLG is, still, being differently interpreted from different schools of thought.[17] However, in the following, MLG is understood as a concept that focuses on actors, their competencies, and complex relations among actors that are involved in decision making regarding child health policies and interventions, on different levels such as local, regional (subnational), national, and supranational.[12,18] The latter is the European level (including the EU) and can also refer to the global level. Indeed, MLG reflects the notion that decision-making competencies—also in child health—are dispersed across different territorial levels,[12,19,20] and actors have different tactics and strategies to take decisions.[17] MLG refers to actors that are different government organizations on different levels, eg, how central state government organizations give competencies to state government organizations on the subnational levels or to the levels above. But MLG also takes into account that not only state actors but also nonstate and private actors are relevant for policy making, who are often neglected in policy analyses.[17,21] In either case, MLG sets the focus of analysis on the connection of actors.[12,14]

Zürn and Enderlein define MLG as “a set of general-purpose or functional jurisdictions that enjoy some degree of autonomy within a common governance arrangement,”[16] and they add a goal of the actions, namely insofar that actors “claim to engage in an enduring interaction in pursuit of a common good.” Concretely for the context of health care, Kuhlmann and Larsen identify the relevance of MLG and underline the often flexible and uneven connection of actors.[14] They use the concept of “hierarchical levels of governance” to illustrate that actors—including the professional groups on which they focus—are situated on different levels that are often distinguished as “micro-meso-macro levels” to which they add an additional level above “macro”: the transnational level. Thus, their distinction has some parallels with the ideas of MLG. However, they also underline an often observed lack of connection of actors across levels. In the last few decades, health care systems in Europe have tended to decentralize, which can have different implications, positive (regarding democracy and responsiveness) and also negative ones (coordination problems, complex accountability, etc.).[6] Kringos et al reflect the decentralization of governance in primary care to regional and also local authorities, in the context of priority setting and supply planning.[22] The extent of decentralization and the impact on health and health equity are a matter of ongoing research and debate.[23]

Table 1 shows examples of specifications of the different levels of governance and relevant actors and policies. The different actors are often acting on different levels and have different connections and relations to each other (eg, advising, assessing, cooperating, educating, enforcing, financing/funding, informing, monitoring, recommending).[20] The actors can be associated in different forms. There can be linear connections (eg, one actor gives advice to the other), but there can also be networks of collaboration.[12]

Intersectoral Governance

Child health is shaped not only by the influence of direct health services but also by factors outside the health care sector: eg, school, day care, social services, social life, financial support to families—factors which, in turn, are influenced by the wider social environment.[24] Here it becomes clear that different sectors play a role for child health—and these are governed by different actors who all have a direct or indirect influence on child health (and thus can be of relevance to CPHC). For example, the economic situation has an impact on child health and development, and thus, the sectors influencing the financial situation of families—including the social sector that mitigates poverty—are relevant for child health. Wolfe et al[7] identified that in England the need for IG for children’s health was not fully acknowledged, nor realized, but that the intersectoral, long-term collaboration of different departments of governments is key to effective child health policies. The MOCHA working model shown in Figure 1 refers to the work of Kringos et al and also to the aspects that relate directly to governance.[22,25] It presents determinants of child health regarding different life stages and proximal determinants of primary care quality relating to child health. To improve the health status and participation of children, the system, in which they live, has to be taken into account, as structures and processes of child care influence desired outputs. With this focus on quality of primary care, the model relates to features of governance in addressing not only the wider political context but also inherent levels and sectors of governance for child health, particularly regarding workforce governance. Furthermore, it puts an emphasis on the role of children, youth, and carers, who are directly influenced by decisions of governance.[1] Thus, the model expresses that different sectors are relevant for the quality of primary care and healthy children.

Figure 1.

MOCHA working model.[1]

Note. MOCHA = Models of Child Health Appraised; TBI = traumatic brain injury; LTV = long-term ventilation.

Accordingly, it is important to understand CPHC as an area and task in a wider concept of IG. Also in a recent research, de Leeuw[26] stresses that other sectors than the health sector necessarily need to be engaged for healthy children. Yet, so far, only one list of different sectors for child health regarding child safety has been published, in which 27 sectors were identified (listed in Figure 2).[20] As CPHC also deals with prevention of injuries and the care and rehabilitation of injuries, the sectors for child safety are also considered of relevance for CPHC.

Figure 2.

The GIM-Governance framework.

When different sectors work together for the health of the child, one might encounter challenges, eg, actors’ “ideological and structural differences,”[27] as was identified for the care of children with disabilities in Canada: Combining sectoral differences with questions of MLG, they found that health policy at the regional level was more decentralized, valuing diversity and also focusing more on liberalist market solutions, whereas the educational and youth service sector focused more on equity and meeting individual needs. Also, for service integration and coordination of care, challenges of sectoral collaboration were documented.[28] Wolfe et al argue that not only collaboration across sectors is a challenge, but also within sectors or within well-established intersectoral collaboration, dividing lines can go between, eg, primary and secondary care.[29]

Good Governance

Values do play a role in and for governance.[8,16] One can differentiate between the descriptive account (how something is governed) and the normative account (how something ought to be governed).[4] Values are often formulated to show the direction in which governance ought to lead. Barbazza and Tello list fundamental values of governance after an encompassing review: control of corruption, democracy, human rights, ethics and integrity, conflict prevention, public good, and rule of law. Further dimensions of governance, they mention, also reflect values: accountability, participation and consensus, transparency, effectiveness, efficiency, equity, sustainability, and improved health.[4]

Often, this normative dimension of governance is also called “good governance.”[4,30] Good governance is a concept that is widely used, recently also in the context of public health. According to Wismar et al, good governance in health systems exists if

overarching societal goals and values such as solidarity, equity and participation are realized. It requires a process of decision-making and effective implementation and can be judged on the basis of how government institutions conduct their public affairs, manage resources and respond to their citizen’s needs.[31]

The values Wismar et al mention resemble the health (care) values of the EU that were issued in Council Conclusions[32] and are thus also relevant for every EU member state.[33] The values are solidarity (this value “is closely linked to the financial arrangement of our national health systems and the need to ensure accessibility to all”), equity (“relates to equal access according to need, regardless of ethnicity, gender, age, social status or ability to pay”), universality (“means that no-one is barred access to health care”), and access to good quality of care.[32] These specific health care values of the Council are also reflected in the child’s rights perspective of the “Convention on the Rights of the Child.”[34] Equality, dignity, freedom, and solidarity—among others—are the core values that frame the “spirit” under which children shall be raised. Equity aspects in the context of health care are made explicit when stating in Article 24 that “health care to all children with emphasis on the development of primary health care” shall be provided. Furthermore, quality of services is implicit when the many dimensions of health (care), including healthy environments and lifestyles, are focused in this Convention. Thus, the Council values are somewhat overlapping and mutually supportive—at least not incompatible—with the values and rights entailed in the Convention. Also, the Council of Europe’s guidelines on child-friendly care build on the convention and offer a framework very similar to the Council and the United Nations’ (UN) convention by emphasizing rights, dignity, equitable access to quality health care, and best interest of the child.[35]

Specific to health systems—however for citizens and patients of all ages—Greer et al[6] identified 5 key attributes of health systems governance that combine different values. They call their approach TAPIC—as acronym of their care criteria and values of good health systems governance: transparency, accountability, participation, integrity, policy capacity. If there are problems with health (systems) governance, they claim that it is due to (at least) one of these attributes. There is “too much, too little, or the wrong kind of them.”[6] The parallels among the normative ambitions of these different documents are apparent.

In most definitions of governance—especially the ones talking of good governance—values were reflected as well, eg, equity in the context of primary care. Also, the values of health systems and the EU health (care) systems should be considered in account of CPHC governance. As mentioned above, many of the values overlap. Thus, we focus on the formulation of the relevant values for good governance as they were formulated particularly in the TAPIC Health Systems Governance approach.[6,11] In addition, we add the specific EU health care system values: solidarity, equity, universality, and access to good quality of care[32] which are also highlighted by the UN Convention[34] and the Council of Europe guidelines.[35] The related terminologies of dignity and rights are also added to express that a child rights–based approach contributes to good governance in a child-specific framework.

Visualizing the Governance Framework

To summarize, the 3 dimensions of Governance that are considered of being applicable for the implementation of innovative good practices in CPHC are Good, Intersectoral, and Multilevel (called GIM-Governance). It has been widely discussed and accepted in the literature that “vertical and horizontal relations”[36] between actors and organizations exist and need to be taken into account when analyzing and planning the governance of public policy implementation. Figure 2 integrates the vertical dimensions (multilevel) and horizontal dimensions (different sectors) and also adds as third dimension the values. In the literature, a lack of awareness of relations and connections for effective implementation of evidence-based policies and interventions was observed; thus, the model also reminds us that effective and coherent connections of the various dimensions are of importance. A goal of governance was said to be the “common good,”[16] and thus, this is also included.

Discussion

No fully developed governance concepts exist specific for developing and implementing (innovative) CPHC models, although the need for IG, good governance, and MLG of integrated CPHC is demanded.[29] Thus, it is suggested in this article that general concepts of governance have to be embraced in such a way that CPHC policy makers can be supported in their work. Most promising concepts seem to be governance approaches that pronounce the importance of IG and MLG (including hierarchical). In fact, MLG and IG offer a helpful 2-dimensional framework for research, policy analysis, policy development, and policy implementation. These governance concepts help to understand what institutions are of relevance for developing child-centric health care approaches not only within health care but also outside health care (eg, educational sector).

The MLG is relevant to understand the actors’ networks and interactions in which—especially in an intersectoral perspective—the decision and implementations have to take place. The complexity is described and an analytic framework is offered to understand the issues and ultimately to plan successful implementation. An important aspect that has to be focused on is the inclusion of nonstate actors next to the standard “health care actors” that are often public or semipublic. Also, supranational institutions, which are often overlooked—not only in Euro-skeptic perspectives—do play a role in the context in which CPHC models are developed and implemented. Even if the EU institutions do not have much to say in implementing models of child primary care in member states, they indeed are involved in networks of institutions and do have impacts (directly or indirectly) on member states. In fact, quite diverse actors form collaborative networks of negotiation and implementation. Key are aspects of coproduction of policies and intervention and enforcement.[36] These actors, their sectors, and connections among each other have to be known for effective and good implementation.[37]

The GIM framework and examples (of actors, connections, sectors) are intended to help inform actors in the field to prepare implementation of evidence-based models and policies in practice. It aims to sensitize them to the political and constitutional context of implementation and should inform governance of child health care in different countries and settings. The framework with its examples draws attention on aspects to be considered and that would otherwise potentially be overlooked. Thus, with this framework at hand, policy makers can and have to ask themselves, “Did we consider all these actors and their connections, levels, and values as factors for the implementation?” When taking different aspects of governance into account—including the normative aspects of good governance—one has to keep in view that and how different changes in governance (eg, decentralization of authority) might be in conflict with values such as equity.

Concise Illustration

To illustrate how the framework can be used for analysis (or/and subsequently planning of the implementation of a similar health intervention), one concise case study is presented. This is an example from Norway where an intervention was established to prevent burns among children in the city of Harstad.[12,38] The intervention was initiated by the health care sector (especially the local hospital) and aimed at parents and local vendors of cooking stoves: Parents were counseled on installing protective measures and vendors were encouraged to supply and sell security shields for kitchen stoves. Media supported this intervention. It turned out that cooperation of different actors in the field was helpful to reach parents and vendors. Nongovernmental organizations (NGOs) were involved as well. To know (potential) actors in advance to such an intervention is essential. Cooperation, giving information, educating, and financing are the different connections that are highlighted, as is the fact that the private sector and NGOs do play a role. The funding came from a different level organization than the implementation. The intervention was clearly value-driven, but required buy-in and effective collaboration between multiple actors.

Analyzing this case according to the actors and criteria of the GIM-Governance gives insights into how this successful intervention was planned and implemented and thus gives hints for policy makers elsewhere how to proceed in their own context (Table 2).

Table 2.

Community Prevention of Childhood Burns (Own Table Based on Information from Literature[12,38]).

Example 1: Community prevention of childhood burns
	Good governance	Intersectoral governance	Multilevel governance
Funding			National Ministry of Health funded this local initiative.
Implementation	Equity (special focus on immigrants).	Nongovernmental organizations (Red Cross, Women’s organization), local media, vendors cooperated to implement safety measures	Local level organizations.

Limitations

This article has several limitations. The literature review that informed this article was not systematic, but a critical narrative review. With the aim of identifying and integrating key literature, the interpretative elements are necessarily subjective.[9] Thus, the literature review may not be reproducible nor complete, and might include bias of the authors. However, the framework presented here is built on our literature review supplemented with the expertise and experience of this group of authors. With its conceptual innovation, grounded in experiential evidence, the framework is offered as a starting point for further refinement and evaluation.[9]

This article is written for the context of the EU and associate states and arose through work in the EU project “MOCHA.” Therefore, we included concepts of MLG and values of the EU that are pertinent for this context. In how far this framework can also be helpful for other contexts and regions in a global perspective remains to be determined, but we hope to contribute to the debate.

Conclusions

When implementing models of CPHC—be it in the European or in different contexts—one has to take different sectors and different levels of governance into account. This may vary from country to country, even from region to region. Contextualization, however, is key for effective implementation.[36] We believe that MLG and IG offer a helpful 2-dimensional framework for research, policy analysis, and policy development. These governance concepts help to understand what actors and institutions are of relevance for developing child-centric health care approaches. A third dimension is added with the leading values for good governance—and thus integrating key aspects of Kickbusch and Gleicher’s “governance for health” concept.[8]

Taking the insights of good, IG, and MLG into account in research and practice is essential and promising for future analyses and policy advice—it sensitizes for different institutions and actors, their relations, their competencies and networks, and the values that should guide decision making and implementation. Recognizing the GIM-Governance framework will help to effectively spread and implement good practices of child-centric health policy approaches across different governance models in the EU, as the variety of relevant stakeholders and institutions can be mapped more effectively and taken into account in implementation processes.