Innovation, proximity and services to the municipality. The Dipsalut model


Published on Innovation, Proximity and Services to the Municipality: the
Dipsalut Model is an analysis and, at the same time, a reection on how public administration could cover the real needs with an innovative and ecient vision. e author uses the challenge, implementation and development of Dipsalut, the Independent
Public Health Organization of Girona Provincial Council, to explore the new educational models and systems of public administration and to emphasize the fact that it is
possible to achieve eciency in management despite the present situation.
Nowadays, Dipsalut is a benchmark in health protection and promotion in the province of Girona, as well as a management model and, as such, it can be used as an example for other services and experiences in public administration.
Author: Marc Alabert

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Innovation, proximity and services to the municipality. The Dipsalut model

  1. 1. Innovation, proximity and services to the municipality The Dipsalut Model Marc Alabert i López Preface by Manuel Férez, ESADE Professor Epilogue by Dr. Ramon Brugada, Dean of the Medicine Faculty, University of Girona
  2. 2. Marc Alabert i López (Besalú, 1974) Dipsalut Managing Director. History graduate (UdG) and MBA (UdG). Master’s Degree in Marketing Management (EADA), Postgraduate in Service Company Management (EADA), Program for Management Development (PMD) at ESADE and Executive Master in Public Administration (EMPA) at ESADE. He has managed different organizations, Retevisión Interactiva (Madrid) and the Open University of Catalonia, among others. He has combined his professional activity with teaching and research work in different universities and business schools. At present, he collaborates with the University of Girona.
  3. 3. Innovation, proximity and services to the municipality The Dipsalut Model
  5. 5. © of the original text: the author © of the images: the authors © of the edition: Diputació de Girona D.L.: GI.294-2013 Girona, 2013
  6. 6. INDEX Preface 15 Introduction 19 PART I. Public health and local level: an opportunity for the province of Girona 23 1.1. Provincial Council, health and financial resources; historical perspective 26 1.2. Public health and municipalities; duties 27 1.3. The creation of Dipsalut 30 1.4. Background and political agreement 30 1.5. Guidelines for the construction of an innovative organization 31 1.6. Defining transformation 32 1.7. The relational framework 34 PART II. The keys of the model 37 2.1 Health protection: idea of risk management 39 2.2 Health promotion 40 2.3 Diagnosis: local public health in the province of Girona before Dipsalut 41
  7. 7. 2.4. From the subsidy model to the service provision model 46 2.5. Service model: functions and features 47 PART III. Implementation process and initial results 53 3.1. Value proposal and service request 55 3.2. The City Council role; service catalogue membership 62 3.3. Proximity: public health agents’ network 64 3.4. Service production: market structure versus own structure 66 3.5. Dipsalut: service production 68 3.6. New technologies. Applying ICTs to the management model 70 3.7. Local Public Health Local Plan (PMSP in Catalan) 74 PAR IV. Innovative projects, evaluation and future challenges 77 4.1. Innovation and evaluation. The role of the Health Promotion Chair 79 4.2. Projects and creation of value 81 4.2.1. Urban health parks and healthy itineraries 81 4.2.2. Cardio-protected territory 83 4.3. Future challenges 85 Bibliography 87 Epilogue 91
  8. 8. TABLE, FIGURE AND CHART INDEX Table Index Table 1. Health promotion actions in detail (2008) 45 Table 2. Health protection programmes 56 Table 3. Health promotion programmes 60 Figure Index Figure 1. Dipsalut relational model diagram 34 Figure 2. Health protection and promotion actions (2008) 43 Figure 3. From the subsidy model to the service provision model 47 Figure 4. Dipsalut value chain 48 Figure 5. Dipsalut model 49 Figure 6. Organisational diagram 51 Figure 7. Territorial distribution of the health protection programme request. Catalogue 2009-2010 59 Figure 8. Territorial distribution of the health protection programme request. Catalogue 2011 59 Figure 9. Territorial distribution of the health promotion programme request. Catalogue 2009-2010 61 Figure 10. Territorial distribution of the health promotion programme request. Catalogue 2011 61 Figure 11. Territorial distribution of overall programme requests from the Catalogue 2009-2010 62 Figure 12. Territorial distribution of overall programme requests from Catalogue 2011 62 Figure 13. Comparison between inclusions in December 2009 and October 2010 63
  9. 9. Figure 14. Comparison of the evolution of the program demand between December 2009 and October 65 Figure 15. SIMSAP diagram 72 Figure 16. Evolution of the value communication/provision axis 74 Figure 17. Construction of the evaluation model 80 Chart Index Chart 1. Distribution by concepts (2008) 43 Chart 2. Expense budget (approximate) 52 Chart 3. Evolution of the number of requests (2008-2011) 57 Chart 4. Evolution of the number of actions (2008-2011) 57 Chart 5. Evolution of the number of facilities where action is taken (2008-2011) 58 Chart 6. Evolution of the number of requests and the no. of actions requested (2008-2011) 58 Chart 7. Evolution of users/interaction with SIMSAP 71 Chart 8. Evolution of the representatives’ profile in the 1st visit of the by health agents 73 Chart 9. Evolution of the representatives’ profile in the 2nd and 3rd visits of the by health agents 73
  10. 10. Innovation, proximity and services to the municipality The Dipsalut Model
  11. 11. PREFACE It is not very often that we have the privilege to see how an innovative experience in local public management is born. And even less often do we have the opportunity to read a rigorous and honest essay, and to share the genesis and the learning process of an experience that combines political consensus, professional managing capacity and technical excellence so that such an experience is successfully implemented. Due to the above, Dipsalut is a great piece of news, and not only to citizens in the municipalities in the province of Girona –who directly benefit from the possibility of improving their health and quality of life– but also to the other public entities –which it can serve as inspiration to, in our present changing times–, and to the academic world –which has the opportunity to analyse the implementation of some specific concepts and theoretical models. I would like to emphasize some of the most relevant lessons from this book. The first lesson relates to the origin of Dipsalut. Its promoters are able to identify a gap to be covered in order to help municipalities comply with their legal duties in health matters. Thanks to the institutional loyalty towards the Generalitat of Catalonia and county councils, they have taken the opportunity to implement a new perspective on the future role of provincial councils as intermediate local governments, i.e. from the subsidy model to the service provision model, by setting up a modern and flexible organization that supports municipalities, and with which it creates a commitment that strengthens their independence. In order to evaluate this option in detail, it is highly recommended to read The Green Book: Intermediate local governments in Spain, by Professor Rafael Jiménez Asensio (printed by the Democracy and Local Government Foundation, Madrid, 2011).
  12. 12. 16 Innovation, proximity and services to the municipality: the Dipsalut model The second lesson is related to the ability to structure a service provision model that includes the complicated, and often controversial, public management service, and that adapts it to the respective specificities in a large number of municipalities (a municipality of less than 1,000 inhabitants is very different from one with more than 25,000 inhabitants, and a coastal tourist town is very different to an inland one). This is why the project starts with an ambitious and clearly identified objective (known as outcome in public policies), i.e. to improve citizens’ quality of life in municipalities in the province of Girona, by reducing the environmental elements that generate risk to people, and by improving personal health for citizens, thus empowering them to manage their health, and providing them with the necessary tools and knowledge. In accordance with this objective, a service provision model that combines specialized management and local prominence is implemented. The third lesson, where most innovative experiences fail, is related to the implementation of the respective management model. This is why a rigorous diagnosis was made first, and then a service catalogue was created. All the municipalities (221) adhered to this catalogue, a well-balanced mix of pedagogy and pragmatism. And this relationship would lead to the commitment to generating the respective health local plans, which are the key tool for defining local priorities in this area. In order to successfully reach this point, it was necessary to face and solve, among others, one of the most controversial debates in public health, i.e. either to produce service on the basis of an in-house structure or to use the existing structures in the market. The second alternative has been selected. A very well-profiled outsourcing system has been implemented, which provides an agile service at a lower cost, an exhaustive control of information, greater proximity of the service provider and a promotion of local supplying companies. The fourth lesson is related to the organizational culture, which is the real Achilles’ heel in most of our public organizations. One of the big successes has consisted of selecting a result and innovation-oriented organizational culture. This sign of identity is fully integrated into Dipsalut’s DNA and allows this organization to prioritize innovative projects based on result evaluation in local service, with the aim of improving local health. In this book, there is an incredible amount of quantitative data on results. This perspective has led to the setting up of the Health Promotion Chair in the University of Girona, which is the first chair of this speciality in Spain. The last lesson –and the most important one to me– is related to the absolutely necessary balance among the political level, the professional management level and the network management model to achieve the expected results which, in Dipsalut, are always related to local health. This difficult and fragile balance is technically known as governance, and it shows the permanent tension between wanting, knowing and doing. Wanting is in the hands of
  13. 13. Preface 17 legitimate politicians, so that they can set up priorities and take decisions about distribution of resources. In this level, the key consists of, on the one hand, combining clear ideas and the ability to reach consensus and, on the other hand, listening to and trusting managers and professionals within the organization. Here, we should refer both to the politician who promoted this organization, Jaume Torramadé, and to its manager right from the beginning, Josep Marigó. They have been able to preserve its original spirit and to consolidate it. Knowing exists at the professional management level –the managing director– who is responsible for identifying the best alternatives for achieving the objectives determined by the political level and to set up the appropriate strategy of relationships to achieve some goals. As Lluís Recoder and Jordi Joly state, “politics need to include a new, strong and powerful element, a new perspective of public managers, i.e. a CEO with the same competences, or even more, than those in private companies” (Next politics. Public competitiveness to face challenges in the 21st century, Barcelona: Proa, 2010). And doing is based on a network management model, where Dipsalut has no hierarchical authority, as this is kept in municipalities, which are the core of the network which, depending on their needs, other public administrations, universities, third sector, professional associations, suppliers, etc. can join. Marc Alabert has very appropriately named it the Dipsalut community. All this reflection and management effort to set up Dipsalut –even if it only has 30 months of existence– has already yielded some important results, as municipalities in the Girona province have already verified. As a citizen, however, I would like to emphasize two examples of Dipsalut activity, because they are a reality that will become a benchmark to improve quality of life: 1) the “Girona, cardio-protected territory” project, managed by the very wellknown Dr. Ramon Brugada, which has turned the province of Girona into the most important cardio-protected area in Europe. The Faculty of Medicine in the University of Girona supports this project by providing it with scientific advice, and the Brugada Foundation and the Medical Emergency System also collaborate with it. 2) The “Urban health parks and healthy itineraries” project – the biggest project in a public space in the Mediterranean area (181 health urban parks in 120 municipalities and 1,200 km of healthy itineraries in 105 towns). And I would like to finish with some words about the author of this valuable book, who is a symbol of the enthusiasm and efforts of all the individuals who have taken part in the creation and in consolidation of Dipsalut. In 2009, I had the opportunity to meet Marc Alabert and Natàlia Alcaide, when they told me that they had decided to take the Public Management Master at ESADE, with the aim of completing their training and to continue to design and implement Dipsalut. And I must say that very few times have I seen such a quick and
  14. 14. 18 Innovation, proximity and services to the municipality: the Dipsalut model sound process of assimilation and implementation of our teachings in public health, such as the brilliant presentation of their final project showed. Marc Alabert is an example of a professional public manager who is able to turn an ambitious and brave political mandate into reality with the collaboration of a motivated and efficient professional team, which has been the key issue for the consolidation of this innovative experience. He has also shown that he can apply both thinking and action, and he has the necessary sensitivity to set up a network of professional and personal commitments that have contributed to institutionalizing a public management model that is going to become a benchmark in the local health world. IIn such a complicated and hard time as the present one, where people are disoriented and uncertain both at the public and private level, the Dipsalut example illustrates the Chinese saying that goes: “It is better to light a candle than to curse darkness”. Manuel Férez Professor at the ESADE Governance and Public Management Institute Ramon Llull University
  15. 15. INTRODUCTION The paradigm of public management is changing. And it is changing very quickly, boosted by the present economic and financial crisis that has an impact on the whole public system, especially on local administrations, which have traditionally been underfinanced. Therefore, there is a period of reforms that cannot be postponed, and that will affect all public administration levels and turn intermediate administrations into the focus of debate. New issues on the new public administration will be discussed, e.g. new organizational models, the role of intermediate administrations, the political and technical space, new management figures (public managers) and leadership for a change of model. A natural evolution has taken place in service provision to citizens by (large and small) municipalities, i.e. from municipalities that acted as regulators (licenses, permits, basic services… and their functions according to the law) to more complicated service provider municipalities. In most cases, this process means enlarging the structures of local administrations. That enlargement, however, has not occurred in a framework with working proceedings and relationships that are different from those in strictly public administration, which has significantly decreased competitiveness in the public sector, i.e. complex services (nursery schools, business centres, elderly people’s homes…) are produced in a not very flexible and highly regulated legal framework, which means having to invest more resources to provide the same services, and transferring the demands from functional management into administrative structures. The present analysis does not have any doubts about civil servants’ professionalism. As Longo states (2010), most civil servants are individually regarded as competent and devoted. The problem arises when public work, as well as management procedures that regulate it1, are observed from a general perspective. 1 Longo, Francisco. Civil Servants’ Productivity. El País, 21/11/2010.
  16. 16. 20 Innovation, proximity and services to the municipality: the Dipsalut model This low competitive provision service context, as well as the dramatic decrease of funding in local public administrations, leads to generating much more efficient management systems, and also service production structures (public, public-private or private structures) that evolve from the local level to a supra-municipal framework. In this scenario, intermediate administrations have a key role, especially in provincial councils, due to their financial capacity and territorial reach. Municipalities become more demanding before higher administration structures, so that they are offered solutions to the existing paralysis due to the lack of resources. There is a risk of offering the ever-present solutions to structural problems, i.e. municipalities should not only be offered financing solutions so that they could reduce the pressure they are under due to their level of indebtedness. Instead, management solutions (a “management shock”2) should be offered for higher efficiency in the permanent provision of services from the municipality, which are globally oriented to improving competitiveness in the public sector. This is a key issue in all the work in the present book, where we can observe a successful model in this respect. The new public management models also involve reviewing the level of political intervention in technical management, a space called political management3 by Moore. The public manager figure is developed in that environment. He/she should manage, in accordance with political guidelines, the public service production. This is an emerging figure in the public management background, which has already been foreseen in the civil servants’ basic statute, although it is not very much in use yet. This figure is also promoted by the Generalitat of Catalonia in the 2011-2014 Government Plan.4 Public managers will have a key role in the local public management professionalization process, especially in exclusively service-based organizations. According to Mintzberg, public management is a mix of a high dose of skills and a certain degree of art and science that lead to a profession that involves, above all, practice, which especially is a practice5. A transformation process in public administration, and even more clearly in local administrations, has started. It is a point of no return. Society changes, citizens’ 2 Moore, Mark H. Strategic management and creation of value in the public sector. Paidós Iberica, 1998. 3 In its axis 7 (out of 8) the 2011-2014 Government Plan includes sis items which focus on the reform of the Generalitat and which, among others, aim at «including the figure of the professional public manager». 4 Mintzberg, Henry. Managers not MBAs: A hard look at the soft practice of managing and management development. San Francisco: Berret-Koehler Publishers Inc., 2004. 5 Report on the review of the Catalonia territory organization model. Parliament of Catalonia, December 2000.
  17. 17. Introduction 21 requirements from public administration evolve, services required are more and more complicated and segmented, and types of management and public models must change. This process has raised some debate at many attempts. From a theoretical framework, multiple debates have led to different models and nuances, depending on the school that promotes them. On the one hand, works such as the Roca6 report, commissioned by the Parliament of Catalonia in 2000, already proposed a territorial and administrative reorganization of Catalonia. This proposal puts forward a key issue, i.e. the efforts to improve public administration and to guarantee equity in access to public services for all citizens will involve renouncing some powers which have always existed in municipalities and which, in a scenario of common structures, will remain at the supra-municipal decision-making level and, in some cases, even at the technical level. In the way to achieving higher levels of competitiveness in the local public sector and, in a broader sense, in the change of cycle in public management, public professionals will be required to make important efforts. This change comes from within the system and will be led by silent technical leaders. According to Badaracco: “A discreet leadership carried out by people who act in a sensible and gradual way, who do not call for attention. Even if this is a slow leadership, it is usually the quickest way to improve an organization, because most important problems can only be solved through long doses of small efforts”7. The aim of the present essay is to share the knowledge generated in the Dipsalut design and implementation process. This organization has been structured into a model that could be considered as “modern administration”. This entire process has generated much debate and many doubts, and it has also unveiled the legal, organizational, technological and cultural limitations that arise when innovation is applied in public management. This process has been structured from the perspective of the intermediate administration, which is committed to supporting municipalities. Although it develops the relationship with the municipality model, it does not analyse in depth the citizens’ perspective (demands, types of representation, etc.). This would be a different debate. To summarize, this is a chronological and well-documented report that aims to reflect on decision-making in the different phases of the Dipsalut model, and to contribute to raising further debate about the modern public administration. 6 Badaracco, Joseph L., Jr. Silently leading and with excellent results. Ediciones Deusto, 2006. 7 Regulatory Law of the Local Regime Basis (7/1985).
  19. 19. People live and carry out their working and social activities within the municipality, where the city council is the closest public administration to citizens. For this reason, the legislation has gradually transferred many competences and responsibilities to the local level.8 However, these increased responsibilities are often not accompanied by the resources required to implement them. Both the national government and the regional governments have gradually increased pressure and responsibilities on the municipalities. Territorial situations, however, vary greatly and there are many different types of municipalities. Big cities and their metropolitan areas are not the same as small inland rural villages. Therefore, the ability of these towns and cities to manage their competences and duties is different and almost always very limited. The province of Girona is no exception. It has a resident population of 752,026 people living in an area of 5,835 km2, plus a seasonal influx of 2,982,771 visitors, who account for 10,142,299 overnight stays2 –an essential element to be taken into consideration when calculating the need for public services. In addition, there are many second homes in the province. Girona consists of 221 municipalities, 70% of which have less than 1,500 inhabitants. Except for the cities of Girona and Figueres, which are inland cities, all the other big municipalities are located in the south of the Costa Brava, and in the Baix Empordà, Selva and Alt Empordà counties, where most people live. 8 Idescat, 2010. 9 Gil Tort, Rosa María. «Medical care», Cuadernos de la Revista de Girona, No. 112.
  20. 20. 26 Innovation, proximity and services to the municipality: the Dipsalut model Within this context, supra-municipal governments, such as provincial councils, are important, as their aim is to rebalance the territory. These councils use state funds to support municipalities and prioritise the needs in each territory, i.e. not all provincial councils act in the same way or with the same intensity in the different areas of activity, nor do they necessarily follow similar patterns. Historically speaking, Girona Provincial Council’s main activity has consisted of financing municipalities and its organisational structure has been set up in accordance with this pattern. Over the years, the municipalities have increasingly required technical support more than just financial support. The council has responded by providing services in an increasingly structured way. In order to promote this growing area of action, Girona Provincial Council created two independent organisations, whose aim strictly consists of providing technical support to municipalities: 1) XALOC (the local tax collection and advisory network), whom most municipalities in Girona have delegated their tax collection function to, and, later on, 2) Dipsalut, responsible for public health issues at the municipal level. 1.1 Provincial Council, health and financial resources; historical perspective In order to understand the context in which Dipsalut was set up, we should look back at the process followed by the Provincial Council in connection with health issues. The relationship between provincial councils and charities, hospices, hospitals and psychiatric centres has evolved differently depending on the territories. With the 1849 Public Charity Act, the national government transferred responsibility for the poorest sick people to the provincial councils. Centres such as the Santa Caterina Hospital were taken over by the Provincial Council, becoming provincial institutions that cared for citizens from all the Girona Counties.10 Later on, the Provincial Council bought the property Mas Cardell in the town of Salt, where mental health patients started being cared for from 1891. In 1931, responsibility for the Salt Psychiatric Hospital and the Santa Caterina Hospital passed into the hands of the republican Generalitat (Catalan government) for a short period of time, until returning to the Provincial Council again in 1940. 10 Sentece of the Constitutional Court, 48/2004
  21. 21. Part I. Public health and local level 27 At the end of the Spanish political transition, the 1986 General Health Law was approved with the aim of organizing the national health system, by decentralizing it and, thus, allowing the country’s autonomous communities to create their own health services. In Catalonia, for example, the Catalan Health System was set up. Then, in 1990, the Catalan Health Regulation Law –as well as a later decree from 1992 (167/1992)– transferred the ownership of the health centres and services managed by Girona Provincial Council to the Generalitat of Catalonia. In accordance with Decree 87/1994 of the Generalitat of Catalonia this transfer of ownership meant that the state funds given to the provincial councils for health services were also transferred to the Catalan government. This move was not welcomed by supra-national authorities, which insisted on the importance of maintaining these resources to address the health needs of municipalities, which should be covered by provincial councils. This is still an ongoing debate that often depends on the relationship between the political parties that are in power in provincial councils or in the Catalan government (Generalitat). Lleida and Girona Provincial Councils appealed against this decree from the Generalitat, and in 2004, a sentence was pronounced by the Constitutional Court in their favour, which stated that the transfer of local funds to the Generalitat violated the local and financial autonomy principle, and that the resources granted by the national government to the provincial councils should be used to finance the actions of the latter. Girona Provincial Council, which owned the health centres that were transferred to the Generalitat, recovered some of the resources that it had given up for lost in 1994, although they were to be used exclusively for health purposes. A report from Martín Bassols, a well-known professor in administrative law, concluded that these resources could be used to support local entities for covering public health issues which municipalities are responsible for. This then led to the idea of creating a public health technical tool to support municipalities. 1.2 Public health and municipalities; duties Under the Catalan Health Regulation Law (15/1990), public health became one more service in the Catalan system and, thus, a right for all citizens. Thirteen years later, in 2003, the Health Protection Law was approved. This was a first step towards the regularisation of public health actions –in this
  22. 22. 28 Innovation, proximity and services to the municipality: the Dipsalut model specific case, of health protection actions. The Law introduced the concepts and activities associated with health protection, it details risk evaluation and management, and proposes the creation of the Health Protection Agency (APS). The Health Protection Agency would include all health protection services and activities which the Generalitat is responsible for, and would also provide technical support and minimum services to local bodies that request them. In October 2009, the Catalan Public Health Law (18/2009) was passed. This law encompasses a broader framework and develops some principles included in previous laws. It also defines public health, regarded as the different organised actions of both public authorities and society, through the mobilisation of human resources and materials, in order to promote people’s health, to prevent illnesses and to care for public health. In accordance with the text approved by Parliament, public health stands for the health of the population, and it largely depends on structural and environmental factors, such as education or security, but also on factors related to lifestyles, such as consumption of tobacco, physical activity and nutrition. In fact, life expectancy has increased in the last century in Catalonia, especially due to an improvement in hygiene, nutrition, housing and work, and also to progress in health care. As for public health services provided by local entities, the 2009 Law increased the competences held by municipalities by including the control of tattoo, micro-pigmentation and piercing businesses. It is worth remembering that the 2003 Health Protection Law had already increased local authorities’ minimum services by granting them competences in health education, risk management of water for human consumption and risk management of pets and peridomestic animals. City councils must therefore provide some minimum public health services, such as the following: • Environmental pollution health risk management. • Public water consumption health risk management. • Management of health risks in public facilities and inhabited places, including swimming-pools. • Management of health risks in tattoo, micro-pigmentation and piercing activities. • Management of health risks from food products in retail and service activities, and in direct sales of processed food products to consumers - as a main or a secondary activity in a business, whether such products are home-delivered or not –in relation to the local sphere and to urban transport. The delivery of processed food products to groups, to other businesses or to points of sales is excluded.
  23. 23. Part I. Public health and local level 29 • Management of health risks from domestic animals, pets, urban wild animals and pests. • Mortuary health police at the local competence level. • Health education within local competences. • The other public health activities which city councils are responsible for, in accordance with the regulation in force on this issue. The local level is still responsible for competences in public health related to health protection, but it does not receive any financial support to undertake the actions required. In addition, most towns in Catalonia do not have the knowledge or the technical and financial capabilities to comply with these duties and, as this is a sensitive issue, in the event of an incident/accident, the local councillor who is responsible for such a competence could be charged with a penal offence. In accordance with the regulation in force, the Federation of Catalan Municipalities and the Association of Catalan Municipalities, together with the Health Protection Agency (the future Catalan Public Health Agency) agreed upon the provision of some minimum services. This means that the latter agrees to support municipalities as much as possible. Although this is a good agreement from the local level, it has been implemented in an irregular and intermittent way. From the local perspective, the Public Health Agency in Barcelona (ASPB) and Barcelona Provincial Council are the two institutions that have most actively supported city councils in public health issues. If we focus on the Girona area, however, very few municipalities fully understand their duties in this field, let alone undertake any action, apart from exterminating urban pests, or controlling and chlorinating drinking water –which is sometimes done by the companies who are responsible for supplying it. There are two good experiences, but with a very local reach and impact: 1) Girona City Council has been very active and efficient in the development of public health actions; and 2) the SIGMA consortium (Olot City Council and Garrotxa Provincial Council), which guarantees the provision of technical services to the municipalities in the area. Although some other city councils also have highly qualified technicians, they lack the necessary financial resources and political support to promote public health actions –which are not very well understood and lead to poor political performance. In the light of this situation, we could conclude that a public health service that supports municipalities in Girona is required, and also that Girona Provincial Council, due to its importance at the local level and to its financial capacity, is the most capable organisation to lead it.
  24. 24. 30 Innovation, proximity and services to the municipality: the Dipsalut model 1.3 The creation of Dipsalut The recovery of resources and the need to support municipalities in their public health competences led to the creation of Dipsalut –promoted by Jaume Torramadé, who was then the vice president of the Provincial Council. Dipsalut is an independent governmental organisation11 with its own legal status and under the responsibility of Girona Provincial Council, which it reports to only to approve its budget and staff, and to carry out the activities of its Secretariat, Intervention and Treasury Departments. This entity did not become active until the 2007-2011 mandate. After the local elections in May 2007, the new Provincial Council was set up. This time, the relationship between the political parties was different to the previous mandate. Josep Marigó, the provincial representative, became its president and assumed responsibility for starting up the new entity. Thanks to his experience as mayor of a large town (Blanes), he was very well aware of the situation and difficulties municipalities face when managing public health responsibilities. Marigó wanted an organisation that was agile, modern and close to the municipality. Rather than limiting that organisation to just providing financial support, he considered the possibility of providing services to cover the lack of technical capacity in municipalities. This vision was also provided by Torremadé during the process of creating the organisation in 2007. These ideas had an impact on the nature of Dipsalut. 1.4 Background and political agreement The recovery of the earmarked resources and the creation of Dipsalut generated some debate about its use and aims. Some people advocated transferring resources to municipalities so that they could manage them directly. Others considered that the funds should be delivered to provincial councils throughout the lifecycle of the programme agreement –with provincial councils acting as technical operators for the municipality. In this debate, some other people preferred Dipsalut to be turned into a technical tool for services at the provincial level, based on a modern and agile governmental model. This last idea was established and supported by all the political representatives on the Dipsalut Governing Council. The key to Dipsalut’s success is the ability to reach political agreement with all political parties within this organisation who share an ambitious, generous and long-term vision, according to which Dipsalut would become a benchmark 11 The plenary session in the Regional Council in March 2007 approved the creation of the Public Health Independent Organization in the Girona Regional Council.
  25. 25. Part I. Public health and local level 31 organisation due to the nature of its activity, as well as an example of proximity to the local level in Girona and of modern government. These trends started the process of elaborating and designing this organisation and its model. 1.5 Guidelines for the construction of an innovative organisation The answers to what should be done and to how to do it formed the guidelines for developing the Dipsalut philosophy as well as the organisation and service model that would be structured. In September 2007, the first Governing Council of this organisation was set up, and a preliminary study was commissioned from the Hospital Consortium in Catalonia (the present CSC). The study identified some organisational and service guidelines that should be developed. In June 2008, when the managing director –a statutory position–was elected, the strategic diagnosis and planning process that led to the implementation of the service model started. The mission (What should be done?) consisted of providing technical and financial support for municipalities in order for them to comply with their public health duties, and carry out projects to improve citizens’ quality of life. The mission reflected the priority of providing services for municipalities, especially for them to comply with their responsibilities (health protection) but it also marked a horizon of new guidelines for citizens, i.e. it opened the door to health promotion. As for its vision, Dipsalut aimed to become a benchmark in the design and implementation of local public health policies and programmes designed to improve citizens’ quality of life. What are the future trends designed by the vision? The most relevant element is its will to go further, to become a benchmark. This means accepting leadership, supporting innovation and generating, publishing and sharing evidence, both on what to do and in how to do it. Often overlooked in the world of management, mission and vision are two important elements that make up the purpose and aspirations in an organisation, and which should be taken into consideration when we have doubts about where to go or how to approach a critical situation. These principles accompany the decision-making process of this organisation. Most of the steps would not be understood without these two parameters.
  26. 26. 32 Innovation, proximity and services to the municipality: the Dipsalut model 1.6 Defining transformation Public policies can be considered as a circular flow with the main phases below: definition of the problem; formulation of alternatives; decision-making, implementation and evaluation. The process starts by defining the problem and including it in the public agenda, i.e. on the list of items which public powers must take decisions about. The way a problem is defined and the terms used to define it, rather than being neutral, directly determine the framework in which the different alternatives in public policies will apply (Subirats, 2008). Public policies are often confused with their short-term results or output, ignoring the fact that policies should contribute to generating a visible medium and long-term transformation, known as the outcome. Let us imagine a municipality with different districts separated by a holography of land and by communications that do not favour the interrelation of such districts. Each one of them develops its own different consciousness, and there is no sense of belonging among citizens. Under these circumstances, it is likely that the city council could consider the possibility of changing this situation. The first step might consist of deciding what the precise outcome would be, for example, “to unite the districts in order to generate one sense of belonging”. This would translate into different policies that would generate interdepartmental programmes and intergovernmental participation (regional government, national government, provincial council, county council) and citizens’ participation (neighbours’ associations, traders’ associations, entities…) in order to change the road networks and, therefore, make mobility between the different districts easier and distribute the different public facilities among them to increase mobility, which would turn into very evident outputs: roads, facilities, activity planning, etc., leading to achieving the transformation required. Going back to the case of Dipsalut, its final goal, the situation that it wishes to change (outcome), is to improve citizens’ quality of life in municipalities in Girona. And it aims to do so by reducing the elements in the environment that generate a risk for people, as well as by providing citizens with a higher level of health, by empowering them to manage their health and by providing them with the tools and knowledge required. This goal can be achieved in different ways, which consist of: I) Providing municipalities with services and resources, and by defining a set of technical standardised programmes that cover the needs in municipalities. II) Giving precise and limited financial support for specific investments and actions. Promoting investments to reduce risks and obtain tools for improving quality of life.
  27. 27. Part I. Public health and local level 33 III) Reinforcing the capacity of third parties (other governments, university, non-profit-making entities…) with networks in the territory and power of transformation. When we consider taking action in order to improve citizens’ quality of life, we should avoid applying a general vision. The need for improvement and the way to achieve a higher quality of life are not the same for everybody, and even less for groups affected by illnesses. Therefore, associations of people affected and specialised entities are key tools for the design and implementation of programmes with the aforesaid aim. The fact of reinforcing their capacities –through financial support and investment in goods–contributes to that aim. In this respect, Dipsalut has made an outstanding contribution towards consolidating studies in Medicine at the University of Girona. Beyond the items in public health in the different degrees, the presence of this faculty allows for the development of a common work and of permanent training resources for the municipality. IV) Promoting innovation. Innovation –as well as the definition of public policies– is a key issue in public management. It reviews processes and incorporates technology that improves efficacy, efficiency and effectiveness, thus reducing time and costs, and accumulating knowledge. The demand for public services required in the future should also be foreseen; this is a complex and indispensable diagnosis. Demography, social changes, migrations, energy, etc. are challenges that will require different, new or evolved and more complicated services from the government. One of the most important elements in the provision of public services (and, especially, of social and health services) in Europe is the projection of ageing. Dipsalut has promoted the MESGi55 study (a multidisciplinary study about healthy ageing in Girona) with the aim of analysing the ageing situation of people in Girona and, thus, to project which policies and services should be provided by the government and, more precisely, from the local level. This study, which is in the design phase, is led by a committee of well-known scientists in Girona with the participation of a panel of international experts and it falls within the framework of other benchmark studies, such as the Health and Retirement Study (USA), the English Longitudinal Study of Ageing and the Survey of Health, Ageing and Retirement in Europe. A sample of 6,000 people over the age of 55, which is representative of the Girona municipalities, will be analysed in order to study the impact of environmental, social, psychological, biochemical, genetic and health factors, as well as the lifestyles that favour a satisfactory ageing process.
  28. 28. 34 Innovation, proximity and services to the municipality: the Dipsalut model 1.7 The relational framework Beyond its correct design, the success of public policies is directly related to its ability to generate alliances among the different agents in the working area where a specific policy is applied. The aim of policies is to change a situation. Such change can rarely be achieved by just one organisation because there are many diverse elements related to the achievement of the results required. Besides this, it should also be taken into account that different policies promoted by different stakeholders often seek the same transformation. Where is the sense in not setting up a common strategy and developing programmes that address different elements of the same outcome? This is why it is important to have a defined and structured relational plan that determines the alliances required to define actions and to generate legitimacy and, therefore, to guarantee the objective and minimise the risk of failure. This is not a static element. On the contrary, it should be permanently evolving and adapting to the changing situation. Figure 1 – Dipsalut relational model diagram Concurrent administrations Ser vice ca tal og ue Health age nts ne tw o DIPSALUT MUNICIPALITY City Council rk Non-profit Organisations Professional associations, associations, foundations CITIZEN Groups Dipsalut has developed a relational diagram based on two key axes (figure 1): the Dipsalut-City Council axis and the Dipsalut-Citizen axis, while being well aware of the fact that the first axis encourages the City Council-Citizen axis.
  29. 29. Part I. Public health and local level 35 Both axes interact with groups of agents who actively work in the area of public health policies or initiatives and services in the broad sense. In the first group, there are the participating governments with public health responsibilities, competences or programmes (Generalitat of Catalonia, public consortia, county councils, among others.) In the second, more heterogeneous, group, there are professional associations, organisations of people suffering from different pathologies, non-profit organisations, foundations, educational centres, universities, etc., who take specific actions in their respective environments and who contribute with a great capacity for influencing and spreading awareness among the different populations. While being strengthened by public support, they often act in areas which governments do not have the capacity to reach. The diagram above shows the relational flows in the organisation in this initial implementation phase and helps to identify the existing stakeholders in the ecosystem where we are interacting. Actions in public health policies (as in most public policies) require the aforesaid collaboration. A public policy not based on a multilevel intergovernmental relationship in collaboration with the third sector will very rarely be a successful policy. Links with international institutions are also part of the relational dynamic, and the objective is to share knowledge about experiences and best practices.
  31. 31. Three ideas should be developed: definition of the action areas, analysis of public health in the Girona province before Dipsalut and definition of an organisation model. 2.1 Health protection: idea of risk management Unlike other governments with health authority functions (basically, the Generalitat of Catalonia and, in some areas, city councils), Dipsalut does not have any explicit competences and, therefore, must consider the role it wants to play. Although it would make sense for city councils to delegate their public health competences to it, Dipsalut was against this idea, as it considers that the municipality should be provided with such authority. Instead, Dipsalut selected the option of risk manager, i.e. it decided to act as a public supplier of public health solutions. From the user’s perspective, as the owner of facilities, the city council should abide by the regulations in force on health measures and, at the same time, it is subject to inspections from a higher authority (in this case, the Generalitat of Catalonia, through its health agencies.) Within this context, Dipsalut executes all maintenance, disinfection and analysis actions required in accordance with regulations in order to guarantee the compliance of the publicly owned facilities. Besides this, the city council must guarantee compliance with health guarantees in private centres/facilities with public attendance. Otherwise, it will be the subsidiary responsible in the event of an accident or bad practices. This fact applies to private swimming-pools (in hotels, campsites, etc.), to food businesses
  32. 32. 40 Innovation, proximity and services to the municipality: the Dipsalut model (butcher’s, fishmonger’s) and to other activities (piercing, etc.). This organisation carries out the screening visits required by the city council, which it then delivers a report to. Due to the fact that Dipsalut is not a health authority, this is not a binding report. However, in the event of serious deficiencies, it alerts local technicians and contributes to announcing preventive measures. 2.2 Health promotion In order to develop health promotion policies that improve quality of life, it is necessary (and it is not a trivial issue) to define and limit the health promotion concept. This definition establishes the nature and the objectives of the health promotion programmes in this entity. Health promotion has often been mistaken for disease prevention. This is a reductionist perspective, and it is related to the principle that considers health as lack of illness. With the Ottawa Charter,12 a new dimension was added to the definition of health promotion, which was then considered as the process that allows people to increase control over their health, so that they can improve it. It is described as an empowering process for both individuals and community to improve a series of determining factors that have an impact on health. It is, thus, a process designed to emphasise people’s abilities and capacities, so that they can take action as individuals and as a group and can have control over the determining factors that generate health and, therefore, they can achieve a positive change. The determining factors of health are the personal, social, economic and environmental factors that determine the health condition of individuals and populations (WHO, 1998), such as: behaviours, life-styles, socio-economic level, educational level, job status, physical environment, age, gender… It has been proven that there is a direct connection between social determining factors and health. The cultural level, academic failure, participation in society, place of residence, access to new technologies, gender, etc. have a direct impact and determine people’s health and life expectancy. Therefore, when it comes to designing health promotion policies, multidisciplinary actions should be taken into consideration, i.e. in order to have better health, action should be taken in very different areas, which multiple stakeholders are responsible for. Starting from a positive perspective about health and about the ability of both people and communities to generate health, Dipsalut considers action in health promotion as the optimisation of public resources when it comes to implementing 12 World Health Organization, Otawa Charter for health promotion. Otawa (Canada), 1986.
  33. 33. Part II. The keys of the model 41 local public health programmes, projects and actions in order to promote a better quality of life. Thus, Dipsalut suggests the implementation of actions that include the determining factors of health and that provide people with tools so that they can understand, manage and give a sense to their lives –thus promoting healthy life-styles–, as well as actions that increase people’s control over their health and over the determining factors of their health, so that they can improve it. Dipsalut’s value proposal to municipalities is generated from this perspective. 2.3 Diagnosis: local public health in the province of Girona before Dipsalut If we look at the existing literature, we find recent studies that attempt to analyse public health management from the local perspective. In 2001, Líndez et al.13 analysed the role of large and medium-sized municipalities (more than 25,000 inhabitants) in connection with public health. Their main contribution consists of distinguishing between functions in public health (needs evaluation, generation of policies, guarantee of provision) and activities in public health (epidemiological vigilance; health protection, prevention and promotion). In 2004, Barcelona Provincial Council also published a study about expenses first in municipalities with more than 20,000 inhabitants and then in municipalities with more than 10,000 inhabitants.14 This study provides interesting information from the perspective of large municipalities (expenses generated, management structures, service provision…), which cannot easily be transferred to municipalities in the Girona province. Two more recent studies, one from the Health Department, coordinated by Xavier Llebaria15 (2010), and another one promoted by Barcelona Provincial Council (2010),16 delve deeper into the analysis of public health at the local level. The first study focuses on the public health activities, services and structure in municipalities of more than 10,000 inhabitants. The second study analyses the variables that determine the existing differences in public health 13 Líndez, P. et al. Public health functions, activities and structures. The role of big and medium-sized municipalities. Gaceta Sanitaria, 15, 2001. 14 Barcelona Regional Council. Expenses in public health in municipalities in Catalonia, 2004. 15 Llebaria, X. (coord.) Public health service activities and structures. Study in municipalities >10,000 inhabitants. Generalitat of Catalonia, Health Department, 2010. 16 Barcelona Regional Council. Public health municipal management. Municipalities >10,000 inhabitants in the Barcelona province, 2010.
  34. 34. 42 Innovation, proximity and services to the municipality: the Dipsalut model among municipalities with similar characteristics. Despite the progress made studying the situation of public health at the local level, there is an important lack of information and limited access to data about smaller municipalities. In this respect, Dipsalut could provide significant information in the near future. In order to make Dipsalut evolve, it is absolutely vital to gain a snapshot of public health at the local level in the Girona province. How many risk elements are there? Who is acting on them? Who is not doing anything about them? Are there any health promotion activities being carried out? What do they involve? In what groups are they being carried out? What financial contribution are Girona’s local authorities making on their own in these areas? Different options were evaluated, and finally an extra subsidy was proposed, so that all municipalities could recover part of their investments in public health. This subsidy was announced in October 2008, and was retroactively applied to actions undertaken during that year. It consisted of €2 million, and minimum staggered funding of between 50%-90%, depending on the type of municipality, was guaranteed. This was Dipsalut’s first action towards municipalities. This analysis has some obvious methodological limitations, apart from the lack of knowledge in municipalities about health protection and promotion items. In order to minimise such limitations and to gather as much (reliable) data as possible, dissemination actions were carried out about the concepts where a subsidy could apply. A great deal of data was gathered, which was used to create a georeferenced file of actions and risk objects, in order to generate an activity map and a preliminary register of facilities. Thus, it was possible to conduct a detailed analysis of actions undertaken in municipalities (with suppliers and costs) and to highlight the actions that should be carried out but were not. From this data, we observe that municipalities with less than 1,000 inhabitants barely took part in this announcement (19%). After looking further into the reasons for this, it is clear that most of these municipalities do not comply with, or even know about, their responsibilities in public health. Out of the 221 municipalities in this province, at least 107 (48%) have been supported by this announcement –67 of them in health protection and 75 in health promotion. The other 117 (52%) municipalities have probably not taken any action in these areas. The €1.9 million awarded (chart 1) can be grouped into the following concepts: 1) health promotion actions, €967,011; 2) health protection actions, €702,811; 3) justified and urgent actions (investments in health risk issues that cannot be postponed) €159,626; and 4) a series of other actions, €155,759.
  35. 35. 43 Part II. The keys of the model Chart 1 – Distribution by concepts (2008) 155.759,00 € 159.626,00 € 967.011,00 € Health promotion Health protection Justified urgency Miscellaneous 702.811,00 € The geographical analysis of the most active areas indicates large areas in the province where no public health actions have been carried out (Figure 2). Figure 2 – Health protection and promotion actions (2008) Municipalities with 4 - 8 requests Municipalities with 1 - 3 requests Municipalities with 0 requests Most protection activities are organised in cities and large towns – the same as for promotion activities, and also in medium-sized cities and some smaller cities.
  36. 36. 44 Innovation, proximity and services to the municipality: the Dipsalut model Health protection actions A detailed analysis of the health protection actions carried out in municipalities reveals that the bulk of the resources granted to protection actions were spent on actions related to urban pest control and peridomestic animals (accounting for 43.7%). This was followed by drinking water (15%), and high and low risk Legionella prevention (requested by 21 municipalities, 10% of municipalities in Girona), 13.8% of resources. Thus, in municipalities that act in health protection, 72.3% of the investment is dedicated to pest control, drinking water and Legionellosis prevention. The incidence of these actions, both in volume and nature, is low; generally little action is taken and it is partial, and not all areas of responsibility are covered. The smaller the municipality is, the lower the level of action in these areas. Out of 31 municipalities with less than 1,000 inhabitants (INE, 2008), only 24 of them take some type of health protection action. Health promotion actions 34% of municipalities in Girona have requested some support for health promotion actions carried out in 2008. Within the context of the announcement, promotion has been interpreted in a large sense. Nevertheless, in the near future, it will be reviewed by Dipsalut. Some of the actions that, in this case, are considered as promotion actions, will be excluded in Dipsalut’s definition of health promotion. In accordance with requests from municipalities, investment in materials and equipment, encouragement and physical exercise are the main items –together, they account for 77% of requests. The remaining items (23%) are: cognitive stimulation, healthy nutrition, drug dependency, and sexuality and sexually transmitted diseases (table 1). Although the data is not very precise, most of the health promotion actions implemented by municipalities focus on the axes of elderly people –young people / physical activity –sports.
  37. 37. 45 Part II. The keys of the model Table 1 - Health promotion actions in detail (2008) Area Actions Observations Investments Equipment for physical activities 39 Healthy itineraries 21 Acquisition of defibrillators 3 Purchase of other materials 4 Municipalities: 49 59% of resources allocated to urban sports equipment and 32% to path signposting (PAFES programme). 89% of actions aimed at the general population Encouragement Different activities 36 Programmes for specific groups 4 Support programmes 4 Physical exercise Maintenance 18 Sports promotion 6 Municipalities: 24 83% of resources allocated to different activities. 54% of actions aimed at the general population and 24% at elderly people Municipalities: 22 75% of resources allocated to maintenance activities. 46% of actions aimed at the general population and 54% specifically at elderly people. 8 Municipalities: 8 All resources (100%) specifically aimed at elderly people. Workshops 5 Talks 2 Campaigns 1 Studies 1 Municipalities: 6 62% of resources allocated to studies and 38% to miscellaneous activities. 78% of actions aimed at young people Cognitive stimulation Nutrition Drug dependency General and cross-cutting programmes 7 Smoking 1 Alcoholism Municipalities: 6 94% of resources allocated to general programmes. 67% of actions aimed at young people. 1 Sexuality + Sexually Transmitted Diseases General and cross-cutting programmes 5 AIDS 2 Services 1 Municipalities: 7 44% of resources allocated to AIDS programmes. 100% of actions aimed at young people.
  38. 38. 46 Innovation, proximity and services to the municipality: the Dipsalut model Conclusions: Municipalities with less than 1,000 inhabitants do not carry out any public health activities. An unequal and partial level of actions is undertaken in the remaining municipalities. Most actions are organised in the biggest cities. • In health protection, activities are related to pest control and drinking water. • In health promotion, activities are mostly related to physical activity and sports. Based on this study, three future working guidelines can be proposed: • To define an offer of standardised public health services for the municipalities in this province, totally or partially financed through recovered earmarked resources. • o create a public health structure of technicians who act closely with the T municipality. This is especially necessary in small municipalities. • o define and limit health promotion working areas, target populations and T scope. 2.4 From the subsidy model to the service provision model After defining the organisation’s philosophy and analysing the situation, the province started the migration process from the subsidy model to the service provision model. The service model should be based on efficacy, efficiency and also effectiveness. These elements do not exist when a subsidy model is selected. Intermediate governments too often prefer to make a general redistribution of resources, mainly in accordance with socio-demographic criteria, and without knowing the impact they wish to produce. There is no doubt about the distribution of resources or about the sources of funding in local authorities, however, in most cases funding becomes the aim in itself. This funding could be used by the target populations in similar projects and could generate synergies and efficiencies among them. And this is even more significant when funding should be used to build public facilities. We should move from facilities that, due to their proximity, will compete with each other (in order to achieve a given number of users and, thus, to be able to ask for maintenance support, or to hold events…) to complementary facilities that generate an inter-municipal balance. Sometimes, when equity is misunderstood, it leads each municipality to build its own sports pavilion and (often indoor) swimming-pool, which are underused and consume an important part of its resources. If a funding-based model is selected, it would be better to define some policies that are agreed by consensus and that generate funding programmes for specific aims.
  39. 39. 47 Part II. The keys of the model Reviewing in detail the subsidy announcements made by Dipsalut in 2008, it is obvious that the purchase of these services, by different municipalities from one or many suppliers, could be highly inefficient and lead to municipalities paying up to ten times more than necessary for the same service. On the contrary, a service-oriented model allows the activity being developed to be designed in detail, objectives to be set, processes specified, for it to be executed or outsourced, and the results evaluated. And this all can be achieved before any action starts to be carried out, i.e. results-oriented planning. Thanks to standardisation and activity management, outstanding levels of efficiency can be achieved. If the territory and people living (groups) in it are clearly understood, programmes can be adjusted for a higher efficacy and effectiveness. In Dipsalut, efficiency determines the service catalogue, and efficacy determines the structure of proximity to the territory (the health agents’ network). See Figure 3. Figure 3 – From the subsidy model to the service provision model Efficiency + - Optimum management of resources (capacity to manage volume, to reduce cost) From the subsidy model to the service provision model - Dipsalut 2011/n Dipsalut 09/10 Service Catalogue Local Public Health Plan Local Public Health Agents’ Network Dipsalut 2008 Level of knowledge and indexation of objects / Groups where action should be taken Efficacy + 2.5 Service model: functions and features Bearing in mind the medium-term vision, it is necessary to define the service model, to specify the team and to build the value proposal. The political agreement very clearly defines the two action areas: health protection (in accordance with the local competences determined by law) and health
  40. 40. 48 Innovation, proximity and services to the municipality: the Dipsalut model promotion, which states that municipalities can and should become an active agent in improving healthy habits and, therefore, reducing risk factors that have an impact on citizens’ quality of life. Right from the beginning, there are multiple question marks ahead: What service model do we wish to implement? What is the role of municipalities? How can the value proposal be built and structured? How could services be provided (provision versus production)? What human resources are required?, etc. When the model is specified, there is a unique opportunity to include some elements and visions in it that provide the organisation with an innovative, agile, flexible, cross-sectional and close operation. The model is based on a reduced organisation with intensive knowledge, a highly qualified and continuously trained staff, close links with the municipality, an intensive use of new technologies and technical capacity. In accordance with the aforesaid, Dipsalut is responsible for the service programme design, planning and evaluation, i.e. for all the activities with intensive knowledge, which generate learning and provide direct value to the mission of the organisation. The activities will be externally developed in collaboration with both private and public operators. (Figure 4) Figure 4 – Dipsalut value chain Dipsalut Willingness to transform Outcome Definition of policies Programme design Service production process follow-up and evaluation Service production Technical capacity in the market Result evaluation Outputs Generation of public value Impact evaluation Market Considering these first criteria, the model will have the features below. a) Efficacy: It should be able to effectively act on the risk objects in the territory (nursery schools, water supply equipment, sports facilities, swimming-pools, etc.), as well as on groups in risk. b) Efficiency: The value proposition should include standard services that
  41. 41. 49 Part II. The keys of the model could be implemented in all types of municipalities, in order to manage a significant volume that allows for cost efficiency (service catalogue). c) Own flexible and professional structure: In this model, the design of policies and programmes, as well as their evaluation, are the responsibility of Dipsalut. This is mainly a technical structure that should adjust to the service offer in the organisation and to the intensity of demand by municipalities. d) Suppliers’ network: The existence of suppliers who are able to cover the outsourcing activities should be guaranteed; and a rigorous information system, as well as a protocol for relationships with municipalities, should be ensured in order to prevent information from being lost and to implement a proper relationship with local stakeholders. e) Proximity to the municipality: In order for services to reach the territory the municipality should have its own local technical team. Due to the fact that most municipalities in the Girona province are small and have very little or no public health technical capacity, the health agents’ network is a key element in this model. f) Local public health local plan: In order for citizens to reach optimum levels of risk reduction and improvement in quality of life, public health actions –protection and promotion activities– should be organised in long-term plans. This is the reason why they are explained in the local plan that should be approved by each city council. Figure 5 – Dipsalut model Service catalogue Technical support Training, dissemination and communications Research and innovation Municipality City Council Resource centre Local Public Health Information System (SIMSAP) Financing Local Public Health Plan Local Public Health Agents’ Network (XASPM in Catalan)
  42. 42. 50 Innovation, proximity and services to the municipality: the Dipsalut model This model (Figure 5), the core element of which is the municipality, is based on three key axes: the service catalogue (solutions/added value), the public health agents’ network (proximity) and the local public health plan (planning). These axes are complemented by: I) Technical assistance. Apart from the standard service programmes in the catalogue, technicians in the organisation should assist municipalities in all aspects related to public health that are required – from the elaboration of reports to intermediation actions between municipalities and higher levels of government. II) Funding in the municipality. Investments related to improvements in facilities or to technology, which cover critical existing deficiencies and reduce risk factors in a city. III) Training and dissemination. In the service processes, the municipality should act in a coproduction scenario. Local technicians, and squads, gardening, maintenance, reception and sports centre staff… should know which public health actions are being implemented, as well as which regular preventive actions should be carried out by the municipality. All these groups should be trained and empowered. After requesting the service programme, municipalities are obliged to train the local staff. IV) Local Public Health Local Information System (SIMSAP). A solution that turns data into useful information for decision-making actions, which generates a working environment that interrelates the entire service provision process (from requests by the municipality) to production, result evaluation, corrective measures and access to all historical actions. V) Resource centre. All pedagogic, disseminating and training resources are made available to municipalities, so that they can use them within the context of their own programmes. VI) Research and innovation. Innovation should be constantly implemented in the organisation. It should be capitalised by generating evidence and scientific reports. This is part of the vision. In May 2009, the Governing Council approved this model, together with the service catalogue. In December 2009, the agents’ network started to work. And at the end of 2011, the Local Public Health Plan would start to be implemented. In order for this organisation to operate, it should be based on four technical areas (Figure 6): health protection, health promotion and policies, management and administration, and management and quality information. This is a clearly customer-focused and process-structured organisation, based on the idea of proximity to the municipality.
  43. 43. 51 Part II. The keys of the model Figure 6 – Organisational diagram Governing Council Presidency Direction Health protection area Health promotion and policy area Programme Managers Administration area Information area for management and quality Central Services Local Public Health Information System Local Public Health Agents’ Network Dipsalut’s staff consists of thirty full-time working professionals and of a main structure of technicians. These professionals have a dot-matrix responsibility, i.e. they own one or many programmes, are responsible for a managing process and take part in internal or external projects. Due to their nature, the programmes, processes and projects require crosssectional and interdepartmental team work, which often means that the staff in this organisation has a double dependency – both organic and functional. Technicians in Girona Provincial Council should be added to this organisational design. They are responsible for some functions that have been delegated to Dipsalut, such as the secretariat, intervention and treasury. Their efforts and commitment to the model designed have been crucial. They have sought appropriate and necessary legal and fiscal solutions to develop this design. Some of the supporting processes are related to Provincial Council services that cover the specific needs in the organisation. The selection of the Scientific and Technological Park in the University of Girona as Dipsalut headquarters was the last decision to be taken in the process of the model design. The park environment and its location, in one of the best connected areas in Girona, provide highly technologically equipped spaces and facilitate a direct relationship with water, environment, biology and food product research groups and labs – a real cluster.
  44. 44. 52 Innovation, proximity and services to the municipality: the Dipsalut model Dipsalut’s working environment is a determining internal factor for making it a catalyst for innovation and proving its ever-present entrepreneurial spirit.. Budget The income of this organisation is mainly based on the transfer of resources from the national government and also on taxes and contributions from municipalities involved in some of the programmes. Overheads (<15% of the budget) are due to staff, consumption, vehicle renting, consumables, etc.). (Chart 2) The other resources go to the production of services required by municipalities (50%), to funding investments in municipalities (18%), to financial support programmes (12%) and to investment in goods for the organisation (5%). Chart 2 – Expense budget (approximate) 5% 12% 15% Structure Service production 18% 50% Investments in the municipality Financial support Investment in own goods
  46. 46. In order to understand the present situation of Dipsalut, the implementation process of this organisation should be taken into consideration, i.e. on the one hand, the territorial coverage and service provision, as well as the first visible results and, on the other hand, the development of the parties that generate its service model. 3.1 Value proposal and service request The catalogue includes all the programmes and is the value proposal to municipalities. The first catalogue was approved in May 2009, for an 18 month period (2009-2010). The second catalogue (2011), approved in November 2010, was in force for one calendar year, and continues. It consists of 21 programmes for the two large areas of activity. In these catalogues, programmes of a different nature coexist: most are directly provisioned services, but there are also some financial support programmes. The latter focus on areas where direct management in municipalities is more efficient at the moment, with a view to these areas becoming services. Most programmes relate to health protection, and their aim is to cover municipal responsibilities. The protection programme design (Table 2) is a combination of local public health responsibilities and services provided by regional governmental agencies in this area, in order to avoid duplicating resources and to cover needs in a better way. Within this context, technical commissions are created. They will make collaboration easier in those areas where organisations provide the same services, i.e. in the areas in which all agents are part of the same value chain. These risk management programmes develop all the actions in regulations for each type of risk, and they also establish protocols for urgent intervention if critical risk levels are detected.
  47. 47. 56 Innovation, proximity and services to the municipality: the Dipsalut model Then, the municipality involved is informed of the issue and, in parallel to this, first intervention teams apply the corrective measures required. Table 2 – Health protection programmes AREA Environmental health Drinking water PROGRAMME Support programme for management and control of facilities with high risk of Legionellosis transmission Support programme for management and control of facilities with low risk of Legionellosis transmission Support programme for direct local management of drinking water supply Drinking water quality control and evaluation programme Public swimming-pool hygiene and health evaluation programme Support programme for risk management in public swimming-pools owned or managed by municipalities Beach risk management support programme Financial support programme for safety, vigilance, rescue and first aid on beaches Public facilities and inhabited places Support programme for risk management of children’s sand areas Financial support programme for integrated urban pest control actions Tiger mosquito (Aedes albopictus) risk control and management programme Simuliidae risk control and management programmes Food product safety Programme to disseminate control plans in municipal food production facilities Technical advice Advice and technical support programme for local health protection policies
  48. 48. 57 Part III. Implementation process and first resultsy Although most programmes do not involve a cost for the municipality –they are financed through the earmarked resources of Dipsalut from the national government– four of them have a tax (10%-50%, depending on the nature of the action and on the type of municipality) so that the municipality is also responsible for the action. As for protection, the first service catalogue (June 2009 - December 2010) registered 760 action requests for 2,514 public places/facilities, which meant 9,322 actions for Dipsalut. If this data is matched with the 2008 data, as well as with data about actions requested and under execution in the first quarter 2011, we can see a rapid rise in requests for services (Charts 3 and 4). This highlights the historical deficit of actions on local public health risk management. Chart 3 - Evolution of the number of requests (2008-2011) 900 800 760 700 776 600 500 Requests 400 300 200 100 67 0 Sub. 2008* Cat 09-10 2011** Chart 4 - Evolution of the number of actions (2008-2011) 14,000 12,000 11.739 10,000 9.322 8,000 Actions 6,000 4,000 2,000 0 144 Sub. 2008* Cat 09-10 2011** * Information taken from documents on the subsidy announcement in 2008 ** Requested in the 1st quarter and to be executed throughout the year
  49. 49. 58 Innovation, proximity and services to the municipality: the Dipsalut model There is also a very important growth in the number of facilities where action is being taken (Chart 5). Chart 5 – Evolution of the number of facilities where action is taken (2008-2011) 3,500 3.310 3,000 2,500 2.514 2,000 Facilities 1,500 1,000 500 144 0 Sub. 2008* Cat 09-10 2011** * Information taken from documents on the subsidy announcement in 2008. ** Requested in the 1st quarter and to be executed throughout the year If we compare the periods in Catalogue 2009-2010 and in Catalogue 2011, we can see a very important rise in the number of facilities requested compared to the number of requests, i.e. municipalities increase the number of facilities requested in each service programme request (Chart 6). This is due, on the one hand, to a better knowledge of the programmes and, on the other hand, to the public health responsibilities from the municipality and to the activity of the health agent. This increase could also be interpreted as a high level of satisfaction with the service received during the previous year. Chart 6 - Evolution of the no. of requests and of the no. of actions requested 3,500 3.310 3,000 2,500 2.514 2,000 Requests Facilities 1,500 1,000 500 0 144 Sub. 2008* Cat 09-10 2011** * Information taken from documents on the subsidy announcement in 2008. ** Requested in the 1st quarter and to be executed throughout the year
  50. 50. 59 Part III. Implementation process and first resultsy Figures 7 and 8 show the intensity of programme request by the Girona province and the evolution between Catalogue 2009-2010 and Catalogue 2011. Figure 7. Territorial distribution of the health protection programme request – Catalogue 2009-2010 Municipalities with >8 programmes requested Municipalities with 4-8 programmes requested Municipalities with 1-3 programmes requested Municipalities with 0 programmes requested Figure 8. Territorial distribution of the health protection programme request – Catalogue 2011 Municipalities with >8 programmes requested Municipalities with 4-8 programmes requested Municipalities with 1-3 programmes requested Municipalities with 0 programmes requested With regard to health promotion, the areas in the programmes in the catalogue are: healthy nutrition, promotion of physical activity and improvement of quality of life, shown more precisely in the table below (Table 3)
  51. 51. 60 Innovation, proximity and services to the municipality: the Dipsalut model Table 3 – Health promotion programmes AREA Nutrition and physical activity PROGRAMME Urban health parks and healthy itineraries programme Young people’s health and local technical advice service programme Dental health programme Quality of life Programme on psychological support and assistance in emergency situations in the municipality «Girona, cardio-protected territory» programme Financial support programme on health promotion activities Technical advice Programme on advice and technical support for local health promotion policies Priorities in promotion are established in accordance with World Health Organisation (WHO) guidelines. A proposal is presented about the programmes to be implemented thanks to multiple supports from the Health Department, the Secretary General of Sports and municipalities, among other entities. Unlike protection programmes, promotion programmes have a much longer implementation process, and some time is required until the first indicators can be evaluated. Nevertheless, the aim of the urban parks and healthy itineraries programme is to create 181 health parks and to signpost 1,200 km of healthy itineraries, while the “Girona, cardio-protected territory” programme has 500 fixed and 150 mobile defibrillators. These brand new actions stand out as the most important projects from Dipsalut. In health promotion, over 9,000 children have seen the exhibition “Take care of your teeth”, which is part of the dental health programme, and over 7,000 children have taken part in the educational programme about tiger mosquito prevention. As for the training offer, 40 courses have been organised and over 900 professionals have attended them. The analysis of the health promotion programme in municipalities in Girona shows substantial growth between the Catalogue 2009-2010 and the Catalogue 2011 (Figures 9 and 10).
  52. 52. 61 Part III. Implementation process and first resultsy Figure 9. Territorial distribution of the health promotion programme request – Catalogue 2009-2010 Municipalities with >3 programmes requested Municipalities with 1-3 programmes requested Municipalities with 0 programmes requested Figure 10. Territorial distribution of the health promotion programme request – Catalogue 2011 municipalities with >3 programmes requested municipalities with 1-3 programmes requested municipalities with 0 programmes requested After analysing the service request data, we can observe that not all the municipalities need to access all the programmes, due to their features, geographical location, type of public facilities, etc. Thus, the challenge for municipalities is to request the programmes required that cover their needs. The study that compares the implementation of services shows, on the one hand, a very rapid (intensive) growth in service requests by municipalities during Catalogue 2009-2010 (Figure 11) and, on the other hand, intensive
  53. 53. 62 Innovation, proximity and services to the municipality: the Dipsalut model growth in the number of programmes requested by each municipality during Catalogue 2011 (Figure 12). Figure 11. Territorial distribution of overall programme requests from the Catalogue 2009-2010 municipalities with >8 programmes requested municipalities with 4-8 programmes requested municipalities with 1-3 programmes requested municipalities with 0 programmes requested Figure 12. Territorial distribution of overall programme requests from Catalogue 2011 municipalities with >8 programmes requested municipalities with 4-8 programmes requested municipalities with 1-3 programmes requested municipalities with 0 programmes requested 3.2 The City Council role; service catalogue membership In order to guarantee the success of this model, the involvement of city councils is an absolutely necessary condition. The implementation of the
  54. 54. 63 Part III. Implementation process and first resultsy service model and the agents’ network depends on them. One of the important challenges was to transfer the responsibilities of the local entities in public health – a process that has caused confusion among many local politicians. In individual meetings and with the advice of mayors, between July and December 2009, a dissemination plan was implemented. It had a double challenge: to publicise this organisation and its services, and to emphasise the idea of local responsibilities. In most towns and cities, public health does not have a relevant role in the local agenda. With the aim of including public health in the political agenda in the municipality, any city council that wishes to access the services of this organisation should have the full agreement of all its political members, and thus adhere to the service catalogue and agree about the requirements. Joining the service catalogue implies three commitments from the municipality: 1) to nominate a political and a technical representative; 2) to accept from Dipsalut the designation of a health agent, and 3) to agree to take part in the writing and future approval of its own public health local plan (such writing will be financed by Dipsalut). The number of city councils involved is the key indicator for evaluating the level of knowledge about the organisation, as well as the suitability and the understanding of the catalogue value proposal. The first inclusions in the catalogue were made in August 2009; basically, from medium-sized and large municipalities. In the smaller municipalities, plenary sessions are held less often and, therefore, membership takes longer (Figure 13). Figure 13 – Comparison between inclusions in December 2009 and October 2010 Municipalities included in December 2009 Municipalities included in October 2010 non-member municipalities non-member municipalities member municipalities member municipalities
  55. 55. 64 Innovation, proximity and services to the municipality: the Dipsalut model From December 2009 onwards, the deployment of the agents’ network significantly increased the number of inclusions and, in October 2010, 218 municipalities (out of 221) had already joined, i.e. 97% of the territory and 99.9% of the population in the Girona province. In January 2011, all municipalities had joined that network. As the organisation and the implantation model were based on a proximity model, the relationship became easier and the communication was intense and fluid which, in turn, generated activity and demand for services. 3.3 Proximity: public health agents’ network Dipsalut has designed its structure clearly thinking of service proximity to the municipality. Proof of this proximity is the public health agents’ network, which is the main resource available in this organisation, which all the other areas depend on. The public health agents’ network acts as a technician for member municipalities, with the aim of guaranteeing that they comply with their duties in this area by reinforcing their own catalogue or their services in other concurrent governmental levels. In the smaller municipalities, their own agent usually requests the catalogue programmes, which will later be validated by the mayor. In addition, the agents also do an exhaustive follow-up of Dipsalut suppliers’ actions. Sometimes, they could also carry out control activities – analysis, sample collection, etc. In order to make the network as multi-purpose as possible, each agent is assigned different types of municipalities: small and large municipalities and cities, both in inland rural areas and in coastal areas in one district of the province and in different counties. Although many agents are working in one region, only one is its representative, which makes his/her relationship with the respective county council easier. Thus, more knowledge is acquired, and it is possible to work on the specific cases and it makes for an easier rotation of professionals. This network has greatly contributed to the rapid implementation of Dipsalut and of services in the territory (Figure 14).
  56. 56. Part III. Implementation process and first resultsy Figure 14. Comparison of the evolution of the program demand between December 2009 and October December 2009 October 2010 Municipalities with no programmes requested Municipalities with programmes requested 65
  57. 57. 66 Innovation, proximity and services to the municipality: the Dipsalut model 3.4 Service production: market structure versus own structure In a quickly evolving global context, with more interactions than ever between public and private sectors, the government is being asked to provide increasingly complicated and segmented services that require some level of knowledge and technology that, sometimes, the government alone is not able to generate. At present, there is no doubt that, in order to provide quality public services, these collaboration scenarios are required. We are moving towards relational governance models, in which non-governmental agents –private sector, third sector and citizens– take part in defining public policies and coproducing public services. The public sector has repeatedly shown its capacity for managing and producing services. Nobody has the slightest doubt about it. The aim of public-private collaboration is to put an end to the traditional isolation of public service self-production in an environment in which all organisations are interconnected and they share, generate and exchange knowledge and innovation, and they also define a network governmental model, a government which is connected to the other organisations, no matter what their nature is (public, private, profit or non-profit organisations) as well as with citizens’ organisations. Due to this complexity, some new services, related to new types of management and production, are required. There is also much debate about outsourcing: What should be outsourced? What are the control mechanisms for it? Who keeps the knowledge? In terms of outsourcing production, it is often considered that, for some services (partially or totally) the market has the technology and capacity required to produce them better and at a lower cost. Outsourcing means including a third party’s technology and knowledge in the public provision process, which leads to cost reduction. Part of the risk related to that service is transferred to the private sector and this, in turn, is granted some benefits. Outsourcing risks depends on the control mechanisms from the government over that supplier so that the quality of service is guaranteed. This is a more obvious risk in the governments who outsource complete packs of services, i.e. all of their production chain. These private production processes of public services are granted through tenders which, in very elaborate specifications, describe in detail the service features, as well as all the quality guarantees and sanctions in the event of non-compliance by the company the service has been granted to. This public-private collaboration model is the most common model in local government, but it is not the only one. Public-private collaboration is especially used in public-private partnerships, i.e. in alliances between both parties to implement large projects, mainly related to the development of infrastructures.
  58. 58. Part III. Implementation process and first resultsy 67 Apart from being responsible for the technology and innovation related to this type of projects, the private sector is usually also responsible for financing the action; and the government repays this financing through annual payments over a long period of time (20, 30, 50 or more years). After that period, the asset or infrastructure is totally publicly owned. This approach introduces the idea of “intergenerational equity” - the cost of infrastructure is paid for throughout its years of existence, i.e. it is paid for by all generations who are going to be using it. This model has become corrupted in cases where governments have been obliged to develop some projects in this way, with the aim of turning them into financing formulae and, thus, access to debt levels that are not allowed in government. In the literature, there are two types of partnerships – contractual and institutionalised. In contractual partnerships, the initiative is taken by the public sector, which commissions a specific project or service from the private market which is limited in time and based on a hierarchical relationship – an output-oriented relationship. Institutionalised partnerships, however, are based on a strategic alliance between public and private sector to develop a project which aims to change the immediate situation (social, economic, environmental reality, etc.). It is set up in a horizontal trust-based relationship where all parties share the same level of involvement and risk. These partnerships are closer to the outcome than to the output (Ysa, 2009). There are some guidelines in international organisations about partnership (UNO,17 European Commission18 …). In our country, however, the publicprivate relationship still does not have a conceptual framework that regulates which areas and services can be outsourced and which ones should never be (Ramió, 2005). Before decisions about outsourcing are taken, an evaluation should be made of how much is paid for what, i.e. what value will be obtained from the resources invested in it – value for money19 . In this case, public managers are accountable for explaining the value that is going to be created with public resources. 17 UNO, Guidebook on Promoting Good Governance in Public-Private Partnerships, 2008. 18 European Commission, Green book on public-private cooperation, 2004. 19 Grimsey, D. and Lewis, M. (ed.) «Value for money is an optimum combination of whole-life costs, benefits, risks and quality (fitness for purpose) to meet the user requirement and getting the best possible outcome at the lowest possible price (…)». In: The Economics of Public Private Partnerships, 2005.
  59. 59. 68 Innovation, proximity and services to the municipality: the Dipsalut model The opportunity cost, a constant point in management, should also be taken into consideration when outsourcing. The needs in public services tend to be infinite, whereas resources are limited. The allocation of resources to a service and to a form of production of that service excludes the assignment of such resources to other purposes. It is a matter of prioritizing. 3.5 Dipsalut; service production Dipsalut is considering the need to produce the services and programmes in the catalogue. To this end, the existing structures in the market are used. Outsourcing the activities is a key challenge for this organisation, which should find solvent suppliers, who have the capacity to generate an increasing demand and work with variable costs. There are some difficulties in this process. On the one hand, the public health products/services offered by the market are accessories (not a core business element) that other service suppliers offer to the municipality (the swimming-pool cleaning company makes self-control plans; the water lab that has the dealership of the local network offers disinfection in sports facilities, etc.) There is no specialisation in one area, but additional services from usual suppliers. This is probably due to a low or almost zero demand for such services. Besides this, small suppliers (self-employed/micro-companies) with limited production capacity are very fragmented. Public operators also have a low capacity in this respect. One programme, one supplier Dipsalut decides that each programme, which involves a series of consecutive actions, can only have one supplier. The aim of such a decision is, on the one hand, to avoid a lack of coordination (when there is more than one supplier) and, on the other hand, to have only one person responsible in the event of a deficient action. By doing this, companies that are interested in programmes will need to create a Temporary Union of Companies (UTE in Spanish) when they wish to participate in a tender, because very few suppliers can carry out all the actions in a programme only with their own means. Variable cost model Another significant feature of outsourcing is to define a cost unit-based tender for the service provision. When this organisation was first set up, municipalities could not foresee the demand for service units or their growth. In the health protection area, there was not a real register of public facilities with risky objects. This is why the market is requested (tender) to produce cost unit-based services, with no