Search and selection process
Completed in May 2020, the search yielded 5827 potentially relevant records. Of these, 121 full text records were retrieved and reviewed independently by two reviewers. All discrepancies in the review process were adjudicated by two reviewers. Appendix 3 includes a PRISMA flow diagram of the screening results. A total of 43 publications met the eligibility criteria and were included in the final collection.
Article characteristics
Key attributes from each article include author, year of publication, first author’s country of origin, primary focus, type of article, methods, language, and geographic focus. Article characteristics are summarized in Table 2.
Publication year. Approximately half of the articles (n = 21) were published in from 2011–2020 while the other half (n = 22) were published in 2000–2010. A spike in articles was noted in 2008 due to a special journal issue dedicated to NPHIs. No other temporal trends were noted.
First author affiliation. First author country affiliation included North America (USA, Mexico, Canada) (22), Europe (France, United Kingdom, Czech Republic, Slovenia, Switzerland, Sweden) (9), Africa (South Africa, Burkina Faso, Nigeria, and Guinea Bissau) (5), South America (Brazil, Columbia) (3), and India (1).
Article type and study design. Most articles were classified as commentaries (25), followed by editorials/letters to the editor (10), historic profiles (3), empirical studies (3) and technical papers (2). Interestingly, few articles collected original data, either qualitative or quantitative. Only three articles include a methods section describing the type of research methods that were used in the study design. Of the three including a methods section, the methodology included document review (legal and country documents), survey data analysis, and case study design. Comparative analysis of country level experiences was described in a few articles.
Primary topic. The primary topic of articles varied although several themes emerged. Some articles described the historic legacy of NPHIs (13–17) while others focused on the mandate and or scope by exploring NPHIs’ engagement with public health core functions (18–21), health infrastructure (22), and One Health (23). The role of NPHIs in national and global health security was discussed in several articles (24–27). The potential of NPHI partnerships, collaborations, and regional and global networks such as the IANPHI was addressed in several articles (28–30). Governance challenges (31, 32), leadership (33), legal frameworks (34), and organizational structure (35) were discussed in several papers. Finally, technical tools to assist in NPHI development were also presented (34, 36).
Language. Most articles were published in English (n = 38) although two were in Spanish, two in French, and one in Russian. All foreign language articles included English abstracts explaining how they were captured in our search.
Geographic focus. The geographic focus of the articles included more than 20 countries in North America (Canada, Mexico, USA), Europe (Czech Republic, France, Slovenia, Sweden, the United Kingdom), South America (Brazil, Columbia), Africa (Ethiopia, Guinea Bissau, Liberia, Mozambique, Nigeria, South Africa) and the Eastern Mediterranean region (Morocco). Relatively few articles focus on countries in Asia with the exception of articles referring to China, Hong Kong, and India. Fifteen articles discussed NPHIs from an international perspective many of which focused on the global and regional potential of NPHI networks and collaboration.
Table 2
NPHI literature findings: authorship, year, origin of first author, topic, article type, methods, language and geographic focus
#
|
Authorship
|
Year
|
Origin of 1st author
|
Primary topic
|
Article type
|
Method section
|
Study method
|
Language
|
Geographic focus
|
1
|
Rosenfeld et al (34)
|
2020
|
USA
|
Comparative analysis of NPHI legal frameworks
|
Legal review
|
Yes
|
Document review
|
English
|
Nigeria, Ethiopia, Guinea Bissau, Mozambique, Liberia
|
2
|
Verracchia et al (21)
|
2019
|
UK
|
NPHI networks, global health
|
Commentary
|
No
|
-
|
English
|
International
|
3
|
Campos-Matos et al (37)
|
2019
|
UK
|
NPHI and health inequalities
|
Commentary
|
No
|
-
|
English
|
United Kingdom
|
4
|
Barzilay et al (36)
|
2018
|
USA
|
Development tool for NPHIs
|
Technical
|
No
|
-
|
English
|
International
|
5
|
Njidda et al (38)
|
2018
|
Nigeria
|
Nigeria CDC
|
Commentary
|
No
|
-
|
English
|
Nigeria
|
6
|
Puska et al (29)
|
2017
|
Finland
|
NPHIs and IANPHI
|
Editorial
|
No
|
-
|
English
|
International
|
7
|
Rubin (17)
|
2017
|
USA
|
Mexico’s INSP
|
Editorial
|
No
|
-
|
English
|
Mexico
|
8
|
Meda et al (30)
|
2016
|
Burkina Faso
|
African NPHI network
|
Letter
|
No
|
-
|
English
|
West Africa
|
9
|
Bourdillon (39)
|
2016
|
France
|
Santé Publique France
|
Commentary
|
No
|
-
|
French
|
France
|
10
|
Faford et al(32)
|
2016
|
Canada
|
PHA Canada
|
Commentary
|
No
|
-
|
English
|
Canada
|
11
|
Spahic et al (40)
|
2016
|
Canada
|
Governance of PHA Canada
|
Commentary
|
No
|
-
|
French
|
Canada
|
12
|
Ihekweazu et al (28)
|
2015
|
South Africa
|
Collaboration of NICD (South Africa) and PHE (UK)
|
Commentary
|
No
|
-
|
English
|
South Africa, UK
|
13
|
Roa et al (41)
|
2015
|
Brazil
|
Fiocruz NPHI network
|
Commentary
|
No
|
-
|
English
|
Brazil, Mozambique
|
14
|
Lahariya (42)
|
2015
|
India
|
Lack of NPHI capacity in India
|
Commentary
|
No
|
-
|
English
|
India
|
15
|
Valladares LM et al (43)
|
2015
|
Mexico
|
Graduate education
|
Commentary
|
No
|
|
English
|
Mexico
|
16
|
Beer (23)
|
2013
|
USA
|
NPHIs and ecohealth
|
Letter
|
No
|
-
|
English
|
USA, Canada
|
17
|
Koplan et al (27)
|
2013
|
USA
|
NPHIs and health security
|
Commentary
|
No
|
-
|
English
|
Canada, China, Hong Kong, USA
|
18
|
Bloland et al (44)
|
2012
|
USA
|
US CDC and health system strengthening
|
Technical
|
No
|
-
|
English
|
International
|
19
|
Lopez (45)
|
2012
|
Columbia
|
Columbia’s NPHI
|
Editorial
|
No
|
-
|
Spanish
|
Columbia
|
20
|
Anonymous (46)
|
2012
|
Unknown
|
NPHI models
|
Commentary
|
No
|
-
|
Russian
|
International
|
21
|
Magana-Valladares et al (47)
|
2011
|
Mexico
|
Mexico’s NPHI and policy
|
Commentary
|
No
|
-
|
English
|
Mexico
|
22
|
Frieden et al (18)
|
2010
|
USA
|
NPHI core functions
|
Commentary
|
No
|
-
|
English
|
International
|
23
|
Fierlbeck (31)
|
2010
|
Canada
|
NPHI governance
|
Commentary
|
No
|
-
|
English
|
Canada
|
24
|
Binder et al (48)
|
2009
|
USA
|
NPHI overview
|
Letter
|
No
|
-
|
English
|
International
|
25
|
Buss et al (26)
|
2009
|
Brazil
|
NPHI Latin American network and health security
|
Commentary
|
No
|
-
|
Spanish
|
Latin America, Caribbean and international
|
26
|
Hassar (49)
|
2008
|
Morocco
|
Morocco’s 3 NPHI agencies
|
Commentary
|
No
|
-
|
English
|
Morocco
|
27
|
Heymann (24)
|
2008
|
Switzerland
|
NPHIs and health security
|
Letter
|
No
|
-
|
English
|
International
|
28
|
Rodriguez-Lopez (16)
|
2008
|
Mexico
|
Profile of Mexico INSP
|
Commentary
|
No
|
-
|
English
|
Mexico
|
29
|
Binder et al (20)
|
2008
|
USA
|
Survey data on NPHIs
|
Survey data
|
Yes
|
Survey of NPHIs
|
English
|
International
|
30
|
Binder et al (35)
|
2008
|
USA
|
Canada PHA, Morocco, Nigeria CDC, South Africa NICD, US CDC
|
Case study
|
Yes
|
Document
review, Interviews
|
English
|
Canada, Nigeria, USA
Morocco, South Africa
|
31
|
Silva (50)
|
2008
|
Guinea Bissau
|
Guinea Bissau NPHI
|
Letter
|
No
|
-
|
English
|
Guinea Bissau
|
32
|
Anonymous (51)
|
2008
|
NA
|
NPHI potential
|
Editorial
|
No
|
-
|
English
|
International
|
33
|
Frenk et al (52)
|
2008
|
Mexico
|
NPHI building
|
Commentary
|
No
|
-
|
English
|
International
|
34
|
Wilson et al (33)
|
2008
|
Canada
|
NPHI leadership models in US, UK, and Canada
|
Commentary
|
No
|
-
|
English
|
Canada
|
35
|
Butler-Jones (53)
|
2007
|
Canada
|
PHA Canada
|
Commentary
|
No
|
-
|
English
|
Canada
|
36
|
Koplan et al (22)
|
2007
|
USA
|
NPHIs and public health infrastructure
|
Commentary
|
No
|
-
|
English
|
International
|
37
|
Adigun et al (54)
|
2007
|
USA
|
NPHI development
|
Commentary
|
No
|
-
|
English
|
Africa
|
38
|
Rodier et al (25)
|
2007
|
Switzerland
|
NPHIs and health security
|
Commentary
|
No
|
-
|
English
|
International
|
39
|
Jousilahti (55)
|
2006
|
Finland
|
NPHI overview
|
Commentary
|
No
|
-
|
English
|
International
|
40
|
Koplan et al (19)
|
2005
|
USA
|
NPHI core functions
|
Commentary
|
No
|
-
|
English
|
International
|
41
|
Kriz (13)
|
2005
|
Czech Republic
|
Prague NPHI historic review
|
Narrative - historic
|
No
|
-
|
English
|
Czech Republic
|
42
|
Hogstedt et al (15)
|
2004
|
Sweden
|
Sweden NIPH historic review
|
Narrative - historic
|
No
|
-
|
English
|
Sweden
|
43
|
Klavs et al (14)
|
2003
|
Slovenia
|
Slovenia NIPH historic review
|
Narrative - historic
|
No
|
-
|
English
|
Slovenia
|
Public health capacity building domains
Articles identified in the scoping review were assessed using the domains of the public health capacity building framework developed by Allutis and colleagues (11). Table 3 presents a summary of the public health building capacity domains, description, and examples from the NPHI literature.
Table 3
Public health capacity building domains and NPHI literature examples
Domain
|
Description
|
Examples from the literature
|
Organizational structure
|
Institutional model of NPHI (single versus network of agencies), mergers, mandate, scope of work, essential core public health functions, and role as IHR focal point
|
Single vs multiple agency model (49)
Mergers (35, 39, 40)
Public health core functions (18–20)
Spectrum of NPHI scope (54)
IHR focal point (24, 25)
|
Governance and leadership
|
Legal foundation and authority, autonomy, regulatory mechanisms, policies, oversight and advisory boards, and leadership models
|
Legal frameworks (34)
Governance and autonomy (31, 33)
Oversight and advisory boards (52)
NPHI leadership models (32, 33)
|
Knowledge development
|
Development of knowledge products including routine data collection (e.g., surveillance, registries) and research (e.g., reports, reviews, briefs, etc.)
|
Research informing policy (47)
NPHI surveys and studies (16, 52)
One Health (23)
Applied research (20, 24, 44)
|
Partnerships and networks
|
NPHI partnerships, regional or international NPHI networks that enhance capacity by pooling or sharing resources or expertise
|
Collaborative partnerships (28)
Regional networks (21, 30)
International cooperation (41)
International network, i.e., IANPHI (20, 29)
|
Workforce
|
Higher graduate and postgraduate education, continuing education, field epidemiology training programs, technical training, and workforce development activities
|
Graduate education/training (17, 43)
Field epidemiology, laboratory training programs (38)
Technical exchange and training (28)
Workforce development (52)
|
Financial resources
|
Domestic funding, core budgets, external funds supporting NPHIs (i.e., IANPHI, donors, external grants)
|
Domestic budgets/funding (35)
IANPHI support (21, 25, 50)
Donor investment (19)
|
Country specific context
|
Social, cultural, environmental, and political features influencing public health institutes
|
Country engagement in development assessment tool (36)
Contextual lessons (26, 27)
|
Organizational structure
The concept of organizational structure is clearly relevant to NPHIs given that how national agencies are designed (i.e., institutional model), their designated scope, and role in performing core public health functions, may influence their overall impact and effectiveness.
Organizational models. Several articles describe organizational models operationalized in different countries underscoring the diversity of how countries choose to structure NPHIs within the overall institutional architecture of a nation (22, 27, 49, 55). Latin American and Caribbean countries’, for example, have a longstanding legacy of infectious disease agencies evolving into NPHIs as evidenced by Chile’s Institute of Public Health (1892), Peru’s National Institute of Health (1896), Brazil’s Oswaldo Cruz Institute (1900), Argentina’s National Administration of Laboratories and Health Institutes (1916), Columbia’s National Institute of Public Health of Colombia (1917), Panama’s Gorgas Institute (1921), Cuba’s Pedro Kouri Tropical Medicine Institute (1937), and Mexico’s National Institute of Public Health (1987) (26). Similarly, other articles acknowledge the transformation of European institutes originating in laboratory settings, hygiene efforts, and communicable disease traditions into NPHIs as evidenced by Germany’s Robert Koch Institute (initially the Royal Prussian Institute of Infectious Disease (1891) (21), Prague’s NPHI (1925) (13) and the NIPH of the Republic of Slovenia (1923) (14).
Many articles describe different models of organizing the work of NPHIs into either a network of closely coordinated agencies or institutes concentrating resources and expertise in one single entity (20, 27, 44, 49). Several articles discuss the process and perceived advantages of organizing NPHIs into one agency (39, 40, 49, 50). Advantages of consolidating public health functions under one roof are described as: optimizing scarce resources (i.e., financial, personnel, technical); reducing costs, fragmentation, and duplication; increasing efficiency; and acquiring a critical mass of research and technical expertise (49).
A consolidated model, with regard to emergency response, may also confer benefits such as generating evidence to inform public health decisions and facilitating coordinated and quick responses (26, 27). Maintaining institutional continuity during political fluctuations or instability was also considered an advantage (55). One study investigating the initial formation NPHIs found that merging ‘precursor’ organizations is common (35). Moreover, mergers were often the result of leaders leveraging opportunities to broaden their mandates through consolidation or reorganization (35).
Scope. Several articles state that the scope of NPHI tasks varies reflecting level of maturity, resources, and staff (21, 35, 54). Adigun and colleagues describe NPHI development as evolving along a continuum of institutional maturity from countries with little to no public health infrastructure to fledgling organizations and mature agencies managing comprehensive mandates (54). Similarly, Koplan and colleagues note that while, historically, many NPHIs emerged to address infectious disease and environmental issues affecting the public’s health, 21st century public health challenges (i.e., noncommunicable disease, antimicrobial resistance, climate change and traffic injury) have redirected and expanded their mandates (22). Verracchia and colleagues note, however, that the scope of NPHIs in LMICs may be limited by resource constraints and fragmented health systems (21).
Essential public health functions. The extent to which NPHIs engage and contribute to essential public health functions is discussed in more than half of the articles (n = 28). NPHI survey data collected in 2008 reveals that NPHIs often engage in a set of core public health functions (20). The scope of these core functions are often delineated in legal documentation as reported by Rosenfeld and colleagues (34).
Acknowledging limited national public heath capacity in some countries, however, Meda and colleagues recommend that NPHIs initially focus on five essential “axes” (i.e., disease surveillance and monitoring of health trends, field research, field investigation of acute health events, laboratory support, and field training) and rely on regional collaboration for other functions (30). Given that many core public health functions involve health security, increased attention to adherence and compliance with the International Health Regulations (IHR) has recognized NPHIs as natural focal points for IHR implementation and communication (24, 25).
Institutional development. The concept of NPHI building was introduced more than a decade ago by Frenk and González-Block in their article that called for a global movement to support the establishment, expansion, and strengthening of NPHIs worldwide (52). Their premise was that investment in NPHIs as a strategic capacity building approach would contribute to achieving equity and global health goals. This theme has also been discussed in the context of NPHIs’ contributions to health infrastructure (19, 22), public health capacity (21) and IANPHI’s efforts to strengthen NPHIs (29).
Governance and leadership
Governance and leadership issues concerning NPHIs are discussed in the literature in terms of legal authority, autonomy, leadership models, oversight mechanisms and advisory boards.
Legal authority. Commonly established as legal parastatal entities, many NPHIs have institutional ties with the Ministry of Health (MoH) although some are situated in settings such as universities. A review of five countries’ NPHI legal frameworks illustrates variability with respect to autonomy, accountability, leadership structure, reporting requirements, oversight mechanisms (i.e, advisory boards), core functions and operations, and financial resources (34). Countries also vary in terms of formal and informal administrative links with other agencies and their positioning within the broader health portfolio (31).
Scientific independence and autonomy. Maintaining scientific integrity in public health advice, recommendations, and communication is dependent on ensuring the scientific independence of NPHIs. Loss of autonomy described in several articles (32, 33) may compromise the independence of public health authority and underscores the importance of preserving public health leadership particularly in emergency situations that may result in downplaying, silencing or altering public health advice that is not aligned with agendas of those with political power.
Leadership. Several articles discuss the role of leadership in setting priorities, promoting research agendas, developing guidelines and recommendations, and engaging in policy analysis and implementation (18, 34, 35, 44). Diminished power of NPHI leadership, on the other hand, is discussed by some authors revealing the vulnerability of NPHIs losing influence when leadership roles are weakened (32, 33).
Oversight and advisory boards. The role of advisory boards to support NPHIs was mentioned in several articles. Analysis of five NPHI laws observed that all included legal provisions for NPHI oversight or advisory boards or a board of directors (34). One case in the literature, for example, described the value of an international advisory committee composed of prestigious public health leaders that provided mentoring and guidance thereby shielding the NPHI from external threats. The advisory board also facilitated valuable institutional networks, funding streams, and talent recruitment (52).
Knowledge development
As science-based organizations, knowledge development is at the core of NPHIs’ identity. Knowledge production may assume many different forms such as disease surveillance and registry data, and scientific research (i.e., original studies, systematic reviews, Health Technology assessments, reports, etc.) that provide information necessary for policy and decision-making. One aim of dedicating resources to research conducted by NPHIs is to develop a knowledge base capable of managing public health issues and anticipating future public health trends, needs, and challenges.
Knowledge-generation. Nearly three-fourths of the articles (n = 32) mentioned NPHIs’ engagement in knowledge production and research to give the best evidence base to inform recommendations, guidelines, and policy decision-making. Several articles cited this as a vital NPHI function (18, 20). Routine disease surveillance systems and health information management systems are other examples of data that is essential to the public health community. Hogstedt and colleagues (15) described the role of NPHIs as a “knowledge go-between’’ conveying information from the research community to public health practitioners. NPHI historical narratives also mentioned the role of research in their legacies (13, 14).
Research. Many articles discuss how NPHI-initiated research has been instrumental in driving public policy decisions in the implementation and development of social programs as well as influencing health care practices (17, 47). The emerging importance of interdisciplinary approaches (e.g., One Health) (23), mission-oriented research (47), country-led public health research agendas (18) and cultivating research environments that address health inequities (37) was also discussed. The science-based nature of NPHI institutes is considered fundamental to the credibility and public trust in NPHIs.
Partnerships and networks
Partnerships and networks was discussed in terms of benefits derived from collaborations between countries as well as regional and international networks that facilitate sharing of resources and expertise (21, 22, 26, 30, 41, 55).
Partnerships. NPHIs work collaboratively with international organizations, academia, NGOs, and engage in collaborative relationships with sister institutes on research projects, implementation, or technical issues. Ihekweazu and colleagues, for example, describe a North South technical exchange program between the United Kingdom and South Africa that benefitted both organizations by promoting a reciprocal exchange of information, skills, and advice (28).
Regional networks. Recognition that public health crises, such as infectious disease and natural disasters, may cross borders indiscriminately demonstrates the necessity of regional and global responses. The launch of Africa CDC in 2016 (30) and the activities of the Mesoamerican Institute of Public Health are two examples of regional initiatives (47). Several articles discuss the value of leveraging regional networks. Africa CDC, for example, established five Regional Collaborating Centres strategically situated in the north, south, east, west and central regions of Africa (30, 38) that serve as hubs for surveillance, preparedness, and emergency response. Similarly, the Network of National Institutes of Public Health of the Community of Portuguese-Speaking Countries (RINSP-CPLP) facilitated by Brazil’s NPHI (Fiocruz) illustrates how regional networks can strengthen NPHIs (41). Moreover, the RINSP-CPLP utilizes a unique structural cooperation approach that prioritizes partnerships and states’ endogenous resources and capacity (41).
International networks. The launch of the international NPHI consortium – the International Association of National Public Health Institutes (IANPHI) – brought global attention to the potential of peer assistance, advocacy, and networking opportunities (18–20, 22, 55). With more than a decade of experience, IANPHI has demonstrated value by providing support to members through leadership mentoring, resource sharing, guidance, peer-to peer support and has been instrumental in organizational development and establishment processes (29).
NPHI creation. While many articles in this literature focus on discussions around the functions, mission, and challenges of NPHIs, two articles published in Russian and Indian journals advocated for the establishment of a public health institute in their specific country (42, 46).
Workforce
Many articles described the need for a competent public health workforce (18, 19, 44, 55) and direct NPHI engagement with workforce development, training, and higher educational opportunities (13–15, 17, 43, 47, 52).
Graduate education. Articles discussing experiences from Mexico (16, 17, 43, 52) and Brazil (41) are unique in that their mandates includes accredited educational opportunities in public health disciplines, training, and workforce development. The result of engagement with education and training is the increased potential for repatriating individuals that may stem ‘brain drain’ that depletes countries of skilled, trained individuals. The importance of a competent public health workforce (20) the value of continuing education and graduate level programs (34), and increasing potential for distance learning (18) was also highlighted.
Field Training. Several articles mentioned opportunities for public health training and support for field epidemiology and laboratory training programmes (38) often modelled after the US CDC Epidemic Intelligence Service program (21, 44). NPHIs may also address health care worker performance and patient care which has been exemplified by the Integrated Management of Childhood Illness (IMCI) strategy that focuses on frontline health care workers (44).
Exchanges and peer learning. Training exchanges among NPHIs that facilitate secondments is another avenue to enhance capacity building, skills development, and competence with mutual benefit to participating NPHIs (28). Peer learning was also mentioned as a way to facilitate knowledge exchange (21).
Financial resources
Domestic and external funding. Finaancial resources were also discussed in the literature. A few articles recommended investment in public health infrastructure, specifically for strengthening NPHIs (22, 54). Similarly, Frenk and Block called on the global community to support the establishment and strengthening of NPHIs in developing countries with the aim of improving health system performance (52). Several articles discuss external funding opportunities available from IANPHI (21, 29, 35, 50) while others suggested external donors invest in national infrastructure such as NPHIs (22).
Country level context
Examples from the literature suggest that historical, situational and political factors impact the development and direction of NPHIs (35). NPHI historic narratives (13–15, 46) discuss the impact of events and trends while public health emergencies may reflect situational, political, cultural, and environmental factors (27, 33) influencing the emergence, institutional design and strategic direction of NPHIs. Comparative analyses highlight the unique context at the country level with regard to legal frameworks (34), leadership models (33), and organizational structures (35) illustrating diversity among NPHIs at the country level. Each country’s unique approach to the institutional structure, leadership, and legal footing reflect political, legal, and cultural mores. NPHI development tools also emphasize the importance of incorporating country context by encouraging country-owned and led assessments (36).