Introduction

Published March 27, 2014, Oxford Bibliographies

More than eighty-five countries around the world have established national public health institutes (NPHIs) to coordinate and lead their public health systems. Some, such as the US Centers for Disease Control and Prevention (CDC), the Dutch National Institute for Public Health and the Environment, the South African National Institute for Communicable Diseases, the Brazilian Oswaldo Cruz Foundation (FIOCRUZ), and China’s Center for Disease Control and Prevention, have developed over time, whereas others, such as the institutes in Canada and the United Kingdom, were created in response to recent global public health threats such as severe acute respiratory syndrome (SARS) and bovine spongiform encephalopathy. NPHIs range from those with a focus only on infectious diseases to those with a comprehensive mandate to lead national efforts for prevention and control of both infectious and noncommunicable disease threats. The International Association of National Public Health Institutes (IANPHI) was envisioned in 2001 and chartered in 2006 to link and catalyze the capacity of NPHIs around the world through a robust international professional and scientific network. IANPHI works closely with the World Health Organization (WHO), with which it has a formal partnership agreement. Its activities are supported by the Bill and Melinda Gates Foundation, the Rockefeller Foundation, member dues and peer assistance, bilateral cooperative agreements, and private-sector partnerships. IANPHI’s members represent close to 90 percent of the world’s population and include, among others, the NPHIs of India, Ethiopia, Bangladesh, Rwanda, Kenya, Nigeria, Mexico, El Salvador, Myanmar, Afghanistan, Sudan, Peru, Russian Federation, Tanzania, Angola, Brazil, China, Cote d’Ivoire, Ghana, Thailand, Uganda, Cambodia, and Vietnam. IANPHI’s three objectives include supporting a robust scientific community of NPHI directors (through an annual meeting, a list-serv, and other activities); developing policies that inform decision making on public health systems strengthening (including an NPHI framework, NPHI-to-NPHI evaluation guidance, and a NPHI toolkit); and investing in projects that strengthen public health systems in low-resource countries through creation and enhancement of NPHIs. IANPHI helps the world’s NPHIs by advocating for strong and well-supported NPHIs. The authors wish to thank Allison Greenspan, MPH, for her assistance in formatting this article.

Introductory Works

NPHIs vary in scope and size, from fledgling institutes focusing only on infectious diseases to those with comprehensive responsibility for research, programs, and policy for almost all public health issues and threats. Their scope and functions were defined by IANPHI in its 2007Framework for the Creation and Development of National Public Health Institutes (seeInternational Association of National Public Health Institutes 2007, cited under Best Practice Guidelines). NPHIs have a national scope of influence and recognition and focus on the major public health problems affecting the country. NPHIs use scientific evidence as the basis for policy implementation and resource allocation and are accountable to national governments and the public. Their key functions—including disease surveillance, detection, and monitoring; outbreak investigation and control; health information analysis for policy development; operational research; training; health promotion and health education; and laboratory science—are particularly critical in low-resource nations. Several works, including Frieden and Koplan 2010, outline the importance of creating NPHIs to give countries (a) a focal point for developing and strengthening their national public health systems; (b) increased technical capacity to better respond to major causes of disease, death, and disability; and (c) the skills to deliver public health programs for HIV/AIDS, tuberculosis, malaria, vaccine-preventable diseases, emerging diseases, and chronic conditions. Leaders of European NPHIs outline the purpose and scope of their institutions and perspectives for the future in International Association of National Public Health Institutes/Europe 2011Frenk and Gonzalez-Block 2008 notes that NPHIs can foster national long-term strategic plans for an evidence-based, sustainable system that addresses major public health challenges, as well as more organized and efficient use of existing resources and a plan to fill gaps moving forward, including leveraging vertical resources from the donor community around a central national strategy. Rodier, et al. 2007 asserts that NPHIs provide a strategic approach not only to meeting the requirements of the International Health Regulations and national and regional regulations but also to responding decisively to public health threats (e.g., avian influenza, SARS) and opportunities. Koplan, et al. 2005 and Jousilahti 2006 outline the important functions of NPHIs as well as their key role in public health training and as a career home for a cadre of locally educated public health experts: the workforce needed to prevent and control disease outbreaks and improve health outcomes. Committee on the US Commitment to Global Health 2009 outlines the importance of NPHIs, including their role in evidence-informed policy development and public health program execution as well as their contributions to improving the public’s health. Pierre-Louis, et al. 2012 calls NPHIs a key component of global health strategies and states that the World Bank will make NPHI creation a pillar of its global development efforts. The World Health Organization 2013 notes in its Global Action Plan that strong national capacity is crucial to supporting international goals and calls for the establishment of NPHIs to strengthen public health systems.

  • Committee on the US Commitment to Global Health, Institute of Medicine. 2009. Invest in people, institutions, and capacity building with global partners. In The U.S. commitment to global health: Recommendations for the new administration, 107–129. Washington, DC: National Academies Press.

    This report cites the importance of NPHIs to strong national public health capacity, noting that “[c]oordinating core public health functions through an NPHI can result in a more efficient use of resources, improved delivery of public health services, and increased capacity to respond decisively to public health threats and opportunities” (p. 112).

  • Frenk, J., and M. A. Gonzalez-Block. 2008. Institutional development for public health: Learning the lessons, renewing the commitment. Journal of Public Health Policy 29:449–458.

    Using the development of Mexico’s National Institute of Public Health as an example, the authors discuss the importance of NPHIs in solving complex public health challenges and boosting national capacity in resource allocation and policy development. NPHIs strengthen national research capacity in low-resource nations and counter the silos of vertical programs. The IANPHI and National Institute of Public Health have worked to build capacity in Mesoamerica.

  • Frieden, T., and J. Koplan. 2010. Stronger national public health institutes for global health.Lancet 376:1721–1722.

    This commentary describes the core functions of NPHIs, based on the IANPHI Framework (seeInternational Association of National Public Health Institutes 2007, cited under Best Practice Guidelines) and notes that effective public health response requires a multidisciplinary effort (encouraged by NPHIs), with scientific credibility and independence from political interference. The authors call on developing countries to increase the resources to and authority of NPHIs.

  • Heymann, D. L. 2008. NPHIs as focal points for leadership in prevention and control of infectious diseases. Journal of Public Health Policy 29:374–376.

    WHO Deputy Director David Heymann outlines the role of NPHIs as governmental focal points for science-based public health policy and resource allocation. Citing efforts to combat specific infectious diseases such as SARS, HIV-AIDS, malaria, and tuberculosis, he posits that the infrastructure from these disease-specific investments can become the keystone of the national, coordinated public health infrastructure necessary to comply with the International Health Regulations.

  • International Association of National Public Health Institutes/Europe. 2011. National public health institutes: European perspective. Report 40/2011. Helsinki: National Institute for Health and Welfare.

    Directors of NPHIs from European countries share their perspectives on the functions, scope, and importance of NPHIs.

  • Jousilahti, P. 2006. Improving the world’s health: The role of national public health institutes.Central European Journal of Public Health 14:3–5.

    This article summarizes the importance of NPHIs in fostering and sustaining a competent public health workforce. NPHIs, because they are primarily scientific organizations, are not subject to political changes and can provide a stable base for national expertise. They also encourage collaboration within and between nations on public health challenges.

  • Koplan, J. P., P. Puska, P. Jousilahti, K. Cahill, J. Huttunen, and NPHI partners. 2005. Improving the world’s health through national public health institutes. Bulletin of the World Health Organization 83.2: 154–157.

    This article lays out the functions of NPHIs, including research, monitoring and surveillance, infectious disease control, noncommunicable disease control, emergency preparedness, diagnostic services, health promotion and health education, and training. It further outlines the main activities of IANPHI, which include training, collaborative research, and benchmarking.

  • Pierre-Louis, A. M., S. El-Saharty, A. Stanciole, et al. 2012. Connecting sectors and systems for health results. Washington, DC: World Bank.

    The World Bank team notes that “experience has shown that achieving and sustaining positive impact in public health is best served by a national organization which can help ensure a strong and coordinated focus on public health to assist the government in its stewardship role” (p. 21). As a key pillar of its work, the Bank will be “supporting client countries’ capacity to perform the essential public health functions, supported in this effort by the establishment of NPHIs, or similar institutions adapted to local contexts” (p. 31).

  • Rodier, G., A. L. Greenspan, J. M. Hughes, and D. L. Heymann. 2007. Global public health security. Emerging Infectious Diseases 13:1447–1452.

    Given the complexity of modern-day disease transmission, including newly emerging infections, the need for cross-border collaboration, strong and well-linked surveillance capacity, and outbreak investigation expertise, NPHIs and IANPHI will play a major role in ensuring that countries are ready for the International Health Regulations.

  • World Health Organization. 2013. Global action plan for the prevention and control of NCDs 2013–2020. Geneva, Switzerland: World Health Organization.

    The WHO resolution calls for the strengthening of capacity and innovation through such measures as the establishment of NPHIs (p. 38).

Role in Disease Prevention and Control

Several authors describe the contributions of NPHIs to national, regional, and international disease control efforts. Koplan, et al. 2007 notes the role of NPHIs in infrastructure development, and Buss, et al. 2009 describes how NPHIs coordinate efforts to combat infectious disease threats such as influenza A (H1N1). Public health leaders directly involved in the recognition of and response to the 2002–2003 outbreak of SARS (Koplan, et al. 2013) cite the value and need for strong NPHIs as one of the major lessons learned from the global emergency a decade ago.Adigun, et al. 2007 outlines the importance of NPHIs to disease surveillance and response activities in sub-Saharan Africa.

  • Adigun, L., C. Dusenbury, and B. D. Schoub. 2007. Public health in Africa: The role of national public health institutes. South African Medical Journal 97:1036–1039.

    An “NPHI continuum” explains how systems develop over time; NPHIs in Angola, Nigeria, South Africa, and Uganda are discussed. “The benefits of an NPHI in focusing resources and improving health outcomes cannot be over-emphasized . . . Substantive, long-term improvements to the public health infrastructure cannot take place without a central location and organizational focus such as an NPHI” (pp. 1037, 1039).

  • Buss, P., J. P. Koplan, S. Dusenbury, S. Binder, and F. Rosenberg. 2009. National public health institutes: A coordinated and comprehensive approach toward influenza A H1N1 and other threats to public health. Pan American Journal of Public Health 26.2: 184–188.

    This article (also in Spanish) references the numerous NPHIs that have developed in Latin America and the Caribbean and underscores their vital importance in disease control efforts as demonstrated by the A H1N1 epidemic. The article provides a brief history of NPHIs in Peru, Brazil, and Colombia. Strong NPHIs are a public good that reduces death and disability and improves health.

  • Koplan, J. P., D. Butler-Jones, T. Tsang, and W. Yu. 2013. Public health lessons from severe acute respiratory syndrome a decade later. Emerging Infectious Diseases 19.6: 861–863.

    Among the lessons learned from the 2002–2003 SARS outbreak is the value of having a NPHI that is prepared to control disease outbreaks and designed to both coordinate a national response and assist localities in their responses. This article calls attention to the opportunity provided by SARS to recognize the value of NPHIs when present and the risk for added toll of illness when absent.

  • Koplan, J. P., C. Dusenbury, P. Jousilahti, and P. Puska. 2007. The role of national public health institutes in health infrastructure development. British Medical Journal 335:834–835.

    The benefits of public health institutes are outlined: better coordination of vertical donor resources; a career path for public health professionals; the ability to set and implement national priorities; and the human resources systems and infrastructure needed to respond to traditional and emerging disease threats. A description of IANPHI member institutes is provided; funders are encouraged to allocate 10 percent of their donations to public health infrastructure development, including NPHIs.

National Perspectives

National public health institutes have developed over decades and even centuries. National perspectives on the importance of NPHIs are laid out in a series of letters, including Silva 2008and Rodriguez-Lopez 2008Coura 2000 profiles Brazil’s FIOCRUZ. The creation of the Public Health Agency of Canada is detailed on its website and in archived publications, including Public Health Agency of Canada 2007Peng, et al. 2003 outlines the history and functions of the Shanghai Center for Disease Control and Prevention and its interactions with China’s NPHI (the Chinese Centers for Disease Control and Prevention).

  • Coura, J. R. 2000. The Oswaldo Cruz Institute and its importance in the Brazilian society: Perspectives for the 21st centuryMemórias do Instituto Oswaldo Cruz 95 (Suppl. 1): 9–16.

    FIOCRUZ was established in 1900; this article examines its history and functions. The various departments and divisions are described and put into historical perspective. FIOCRUZ plays a key role in ensuring the health of all Brazilians and will be expanding its geographic scope.

  • Hassar, M. 2008. NPHIs and public goods: A perspective from Morocco. Journal of Public Health Policy 29:22–25.

    Professor Mohammed Hassar, director of Morocco’s Pasteur Institute, writes that having three separate agencies responsible for public health has limited the country’s ability to attract research funds and fulfill its public health mission. A merging of the institutes, or better networking, could foster a stronger and more efficient public health system.

  • Peng, J., S. N. Zhang, W. Lu, and A. T. L. Chen. 2003. Public health in China: The Shanghai CDC perspective. American Journal of Public Health 93.12: 1991–1993.

    The Shanghai Center for Disease Control and Prevention was established in 1998. Officials in China studied various models for NPHIs, including those from the United States, Russia, Japan, and Singapore, and modeled the new institute—which consolidated seven existing organizations—on the US CDC.

  • Public Health Agency of Canada. 2007. Learning from SARS: Renewal of public health in Canada. Ottawa, ON: National Advisory Committee on SARS and Public Health.

    The 2003 SARS epidemic in Canada led to the creation of the Public Health Agency of Canada. This government publication explains the history underlying the decision to create the agency and its scope and functions.

  • Rodriguez-Lopez, M. H. 2008. NPHIs and public goods: A perspective from Mexico. Journal of Public Health Policy 29:26–31.

    Mexico’s National Institute of Public Health was created in 1987 to “support a health reform process designed to achieve a more equitable, effective and efficient health system” (p. 27). The National Institute of Public Health is working with IANPHI to assess essential public health functions at NPHIs and build capacity in the region.

  • Silva, A. P. 2008. Letter from Guinea-Bissau: Follow up to article by Binder et al and accompanying articles. Journal of Public Health Policy 29:377–378.

    Development of the Guinea-Bissau National Institute of Public Health was funded by IANPHI, with technical assistance from IANPHI member FIOCRUZ. Using the IANPHI Framework (seeInternational Association of National Public Health Institutes 2007, cited under Best Practice Guidelines), an NPHI was conceived and a long-term vision and strategic plan developed. This roadmap will be used by donors to build a strong, sustainable public health system.

Best Practice Guidelines

The IANPHI in 2006–2007 convened a task force of experts from NPHIs around the world to develop a framework to define an NPHI and its functions and to provide recommendations to governments interested in creating or strengthening these institutions. The Framework for the Creation and Development of National Public Health Institutes (International Association of National Public Health Institutes 2007) guides IANPHI project development activities and is the internationally recognized standard for NPHI functions and creation. The major steps IANPHI uses in assisting ministries of health to create NPHIs include strategic planning linked to national goals and policy change; in most countries, legislation or a decree outlining the mission of the new NPHI and its organizational structure and functions is developed and agreed to by government leaders. These steps are followed by the development of a funding plan; based on the NPHI’s strategic plan, priorities for IANPHI and other funders are identified by the country. A budget template is prepared and shared by NPHI leaders with other potential donors/stakeholders, whose support is then matched to specific parts of the plan such as training, equipment, infrastructure, and other needs. Finally, the Framework recommends that ministries of health use NPHI strategic plans to harness and leverage donor funds and focus them on long-term national capacity and self-sufficiency. The long-term vision becomes a platform for sustainable, prudent donor investment, including funds and technical assistance from national governments, IANPHI, and other partners. With funding from the Rockefeller Foundation, the IANPHI Framework was reconsidered by an international panel of experts, and an updated policy brief on essential public health functions was presented in 2009. The Framework is based on and links to previous international guidelines, notably World Health Organization 2007Public Health Functions, andEssential Public Health Functions. Other resources for public health systems standards include those from the World Bank (Khaleghian and Das Gupta 2005) and World Health Organization, Western Pacific Region 2003National Public Health Performance Standards presents the US agency’s perspective on the role of NPHIs in global health system strengthening.

  • Essential Public Health Functions. Pan American Health Organization.

    The Pan American Health Organization considered CDC’s Public Health Functions when developing its Essential Public Health Functions, and there are many similarities. This document provides detailed information about each function.

  • International Association of National Public Health Institutes. 2007. Framework for the creation and development of national public health institutes. IANPHI Technical and Policy Brief 1. Atlanta: International Association of National Public Health Institutes.

    Developed by a task force of IANPHI members and formally approved by the organization in 2007. It is internationally recognized as the “gold standard” for NPHI creation and includes a description of the major functions of NPHIs as well as their attributes.

  • International Association of National Public Health Institutes. 2012. Report of Bellagio Meeting: Role of essential public health functions, national public health institutes, and IANPHI in the 21st century. IANPHI Technical and Policy Brief 3. Atlanta: International Association of National Public Health Institutes.

    This report summarizes NPHI directors’ conclusions on the role of NPHIs and their essential public health functions.

  • Khaleghian, P., and M. Das Gupta. 2005. Public management and the essential public health functionsWorld Development 33.7: 1083–1099.

    Khaleghian and Das Gupta assess the essential public health functions and their role in building functioning public health systems that contribute to the public good.

  • National Public Health Performance Standards. US Centers for Disease Control and Prevention.

    CDC’s National Public Health Performance Standards provide a framework to assess the capacity and performance of public health systems and public health governing bodies. The assessment can be used by state public health systems, local public health systems, and public health governing entities.

  • Pan American Health Organization. 2002. Public health in the Americas: Conceptual renewal, performance assessment and bases for action. Washington, DC: Pan American Health Organization.

    In 2002, Pan American Health Organization countries participated in performance assessment activities; the results are compiled in this report, which notes that “the State has the primary institutional responsibility for public health. It is the basic social institution that should interpret the needs of a society, respond to them, and work to meet this in the most effective way possible” (p. 69).

  • Public Health Functions. US Centers for Disease Control and Prevention.

    CDC’s key public health functions were defined in 1994 and are outlined here. They include monitoring health status to identify and solve community health problems; diagnosing and investigating health problems and health hazards in the community; and informing, educating, and empowering people about health issues.

  • World Health Organization. 2007. Everybody’s business: Strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva, Switzerland: World Health Organization.

    This is a report that outlines the need for strong and sustainable health and public health systems to improve health outcomes, particularly in resource-limited nations.

  • World Health Organization, Western Pacific Region. 2003. Essential public health functions: A three-country study in the Western Pacific region. Geneva, Switzerland: World Health Organization.

    WHO’s Western Pacific region assessed public health capacity in Vietnam, Fiji, and Malaysia using a modified version of Pan American Health Organization’s Essential Public Health Functionsframework. The results are outlined in this document, along with recommendations on capacity development for each country.

NPHI Development

IANPHI has assisted NPHIs and ministries of health in more than thirty-five countries in developing or strengthening their capacity. Wise 2009Dusenbury 2009Binder, et al. 2008, andBinder and Lang 2009 report on successful national NPHI creation activities.

  • Binder, S., L. Adigun, C. Dusenbury, A. Greenspan, and P. Tanhuanpää. 2008. National public health institutes: Contributing to the public good. Journal of Public Health Policy 29:3–21.

    Results from a 2007 survey of IANPHI members’ functions are outlined. The authors argue that national governments are being called upon to modify and improve their national public health infrastructures and enhance such functions as disease surveillance, with much of the responsibility for answering these calls falling to NPHIs.

  • Binder, S., L. Adigun, and A. L. Greenspan. 2008. NPHI creation: Lessons learned and future directions. Journal of Public Health Policy 29:459–466.

    The authors summarize interviews with current or former directors of NPHIs from Nigeria, the United States, Canada, Morocco, and South Africa. A chart comparing the institutes’ budgets, staffing, and other characteristics is included. National leadership, funding, and coordination of public health functions are key factors to success.

  • Binder, S., and A. Lang. 2009. The national public health institutes of the world: Update. Journal of Public Health Policy 30:467–468.

    Provides data updating IANPHI’s 2007 survey of NPHIs.

  • Dusenbury, C. Spring 2009. Strengthening health systems for disease surveillance. Corporate Council of Africa HIV/AIDS Health Initiative Newsletter: 5.

    IANPHI’s NPHI development projects in Guinea-Bissau and Ethiopia are discussed, with an emphasis on their contributions to disease control priorities.

  • Wise, J. 2009. IANPHI launches first long-term project. The Lancet Infectious Diseases 9.2: 82.

    This article introduces the IANPHI organization and its NPHI creation project in Guinea-Bissau. Wise concludes: “IANPHI has an important role to play in helping countries comply with the revised International Health Regulations, which set tough standards for addressing national public-health threats, and rely on each country having a strong national public-health institute” (p. 82).

Case Studies

The IANPHI website gathers information from the world’s NPHIs, including 2007 case studies from Morocco, the United StatesSouth Africa, and Canada. The four institutes developed at different times and in response to different political, geographic, and socioeconomic imperatives, from infectious disease control in the United States, vaccine control in Morocco, laboratory services in South Africa, and SARS in Canada.

  • International Association of National Public Health Institutes. 2007a. Morocco: Institut Pasteur du Maroc. NPHI Case Study: Profile of Creation and Growth. Atlanta: International Association of National Public Health Institutes.

    The history of the Pasteur Institute of Morocco is presented. Its focus was originally on producing vaccines and sera and infectious disease research and now includes research, laboratory testing, and quality control. It is one of three Moroccan institutes responsible for essential public health functions; this has led to an inefficient use of resources.

  • International Association of National Public Health Institutes. 2007b. National Institute for Communicable Diseases, South Africa National Institute for Communicable Diseases (NICD). NPHI Case Study: Profile of Creation and Growth. Atlanta: International Association of National Public Health Institutes.

    Created in 2002, South Africa’s National Institute for Communicable Diseases is a branch of the National Laboratory Health Service and has close ties to the Department of Health. Its functions include infectious disease monitoring and evaluation, surveillance, outbreak investigations, laboratory services, research, and response to emergencies and disasters.

  • International Association of National Public Health Institutes. 2007c. Public Health Agency of Canada (PHAC). NPHI Case Study: Profile of Creation and Growth. Atlanta: International Association of National Public Health Institutes.

    The Public Health Agency of Canada was created in response to a 2003 outbreak of SARS. After a year-long process of meetings and reports, the Public Health Agency of Canada was designed and implemented. Major issues debated during the development process included the NPHI’s location, essential functions, and placement within the government.

  • International Association of National Public Health Institutes. 2007d. United States: Centers for Disease Control and Prevention (CDC). 2007. NPHI Case Study: Profile of Creation and Growth. Atlanta: International Association of National Public Health Institutes.

    The US CDC started in 1946 as the Malaria Control in War Areas organization. Dr. David Sencer, CDC director from 1966–1977, was interviewed for this case study. He notes the institute’s steady expansion of scope and functions over time as new disease threats emerged.