3.5 Health promotion model: Semi-autonomous agency
Introduction
Let's learn about the semi-autonomous agency and its relevant case studies.
Model 2: Semi-Autonomous Agency
The semi-autonomous agency (composite model)
A health promotion arm funded through dedicated taxes is set up within the appropriate government structure such as the department of health, but as a separate unit or a branch within the department. In this model, the government through the Ministry of Health determines the annual budget allocation and sets the priority action areas, while the independent Board of Directors have autonomy over the development of action plans and their implementation.
There is no doubt that this model may be attractive to some governments that may be resistant to committing large sums of money to an organisation which, through its structure, is at arm’s length from the government.
Case Study of Health Promotion Switzerland, 1994
Governance structure
Semi - autonomous agencyGoverned and chaired by
Foundation council and independent chairReport to
Federal Department of Home Affairs and to both Committees for Social Security and Health of the Parliament (National Council, Council of States)Funding source
Health Insurance (USD2.6/head)
Estimate total annual budget (USD)
19.4 million (2012)
Purpose of the fund
- Health insurers promote the prevention of diseases.
- Together with the cantons (Swiss federal state), establish and maintain an institution which initiates, coordinates and evaluates measures for the promotion health and for the prevention of diseases. If the formation of the institution is not achieved, the Federal Authorities of the Swiss Confederation will undertake it.
Health Promotion Switzerland
Health Promotion Switzerland is a semi-autonomous foundation established by an Act of Government (Federal Health Insurance Act of 1994). Established in 1989, it was originally known as “Swiss Foundation for Health Promotion” and later in 1998 “Foundation 19” when it was modeled to implement Article 19 of the Swiss Federal Health Insurance Act. It was renamed, “Health Promotion Switzerland” in 2002.
The foundation is mandated through the Federal Health Insurance Act to initiate, coordinate and evaluate policies to promote health and prevent disease. Stipulated by law, the Foundation Council is composed of representatives from different interest groups within the Swiss healthcare system. These include the federal government, the cantons (states), Swiss health insurance companies, the Swiss Accident Insurance Fund (SUVA), medical and other healthcare professionals and public health researchers, agencies active in health promotion and consumer protection, as well as other partners. This governance structure facilitates key stakeholders to collaborate to promote health and improve the quality of life for the Swiss.
Foundation Council members are proposed by the foundation and appointed by the Federal Department of Home Affairs for a four-year term. A scientific Advisory Board conducts knowledge-based strategic development and the assessment of activities. The foundation is accountable to the Federal Department of Home Affairs and, in practice, to both Committees for Social Security and Health of the Parliament (National Council, Council of States). It is semi-autonomous as health promotion agency legally established.
Generally, the Council decides how resources are allocated in order to contribute to the goals of the long-term strategy. The Federal Sickness Insurance Law from 1994 committed Swiss insurance companies and cantons to establish an institution for disease prevention and health promotion. Therefore, insurers and cantons hold the majority of seats in the council.
Collaboration between government, foundation and private sector will ensure effective implementation of health promotion activities
Health Promotion Switzerland has about 30 full-time staff hired from all parts of Switzerland and from some other countries. They are committed to achieving professional standards expected of one of Switzerland’s leading health promotion organizations.
Health Promotion Switzerland source of funding is derived from health insurance that imposes a surcharge of USD 2.6 per insuree. Each insuree is required to pay annually to invest in health promotion. This financing source was proposed during larger revisions of the Sickness Insurance Act in 1994. `Health or sickness insurance is mandatory in Switzerland. The amount of the funding varies, depending on the population size (number of insurees) and currently the annual budget accounts for USD19.4 million, which represents a small portion of the total amount spend on health promotion. In 2010, it was estimated that USD 1.61 billion was spent on “prevention” (including health promotion) by state agencies, cantons, municipalities, social insurances, private households and other private financing according to extrapolations of the Federal Office of Statistics.
The foundation has a vision to develop well-informed individuals, capable and motivated to living their lives in ways beneficial to their health and well-being and quality of life. This process is supported by the best possible societal structures. The foundation has a long term three-pronged strategy for 2007-2018 to achieve their goals: i) strengthen health promotion and prevention through institutional coordination and networking; ii) increasing the proportion of individuals with healthy body weight; and iii) improving mental health and reducing stress, focusing mainly at the workplace by better equipping more people to shape and control their lives. The underlying strategy processes involve members of the foundation council and also other major key stakeholders within the healthcare system.
It is envisaged that the health system in the near future will be unable to finance the health care demands and may lead to a financial crisis. Health promotion and prevention can be a powerful cost-effective way to reduce threat of a financial crisis. A Foundation can be part of the solution. Collaboration between government, foundation and private sector will ensure effective implementation of health promotion activities.
References
Somaini B. Health Promotion Switzerland on the Way to a Ideal Health Promotion Foundation. Presented at Presented at Regional Workshop on Strengthening Capacity for Health Promotion Foundations and Tobacco Control, Hanoi, Vietnam, 14-16 September 2010.
Health Promotion Switzerland. Welcome to Health Promotion Switzerland. Available at: http://www.gesundheitsfoerderung.ch/pages/uebersicht/Ueber_uns/m_ueber_uns.php
Laura K. Schang, Katarzyna M. Czabanowska, Vivian Lin. Securing funds for health promotion: lessons from health promotion foundations based on experiences from Austria, Australia, Germany, Hungary and Switzerland. Health Promotion International doi:10.1093/heapro/dar023, Oxford University Press, 2011.
Swiss Statistics. Costs of health care system by service provider / Costs of health care system by service type, 2012. Available at: www.bfs.admin.ch/bfs/portal/en/index/themen/14/05/blank/key/leistungserbringer.html
Related reports
World Health Organization. (2004). The establishment and use of dedicated taxes for health. World Health Organization Regional Office for the Western Pacific.
Vathesatogkit P, Yen Lian T, Ritthipakdee B. (2013). Health Promotion: Sustainable Financing and Governance. Bangkok, Thai Health Promotion Foundation (ThaiHealth).
World Health Organization. (2016). Earmarked tobacco taxes: lessons learnt from nine countries. Geneva, World Health Organization.
Case Study of Mongolian Health Promotion Foundation, 2006
Governance structure
Ministry of Health
Governed and chaired by
Council of the Fund is chaired by Minister of Health
Funding source
- Government budget:
- 2% of excise tax on tobacco products
- 1% of excise tax on alcohol beverage
- 2% on drug registration
Estimate total annual budget (USD)
1.02 million (MNT 3 billion) (2019)
851,254 (MNT 2.5 billion) (2020)
851,254 (MNT 2.5 billion) (2021)
Purpose of the fund
- Prevention of non-communicable diseases
- Prevention of communicable diseases
- Protect environmental health
- Prevent from accidents and injuries, and support of a healthy and safe living environment
- Protect mental health, and prevent the harmful effects of alcohol, tobacco and drugs
- Promote the rational use of drug
- Improving the ethics of medical professionals, and improving the transparency and accountability of health organizations
Mongolian Health Promotion Foundation
The Mongolian Health Promotion Foundation (MHPF) was stipulated in the Tobacco Control Law, in 2005 and approved by the State Law on Government Special Fund in 2006. The law regulates the collection, expenditure, execution, reporting, and monitoring of 23 funds in total.
Starting from 2006, the MHPF is funded by three sources of funds: two percent (2%) of excise tax on tobacco products, one percent (1%) of excise tax on alcoholic beverages, and two percent (2%) on drug registration. The foundation may also receive funding from other government budget sources, non-refundable aid, and contributions from other countries; however, it currently receives funds from the government only.
The estimated annual total budget of MNT 3 billion (USD 1.02 million) in 2019, and MNT 2.5 billion (USD 851,254) in 2020 and 2021. The fund has supported various health promotion programmes.
The MHPF is a major Government initiative to promote health and reduce exposure to health risks, including tobacco and alcohol. A Council that is responsible for the annual work programme and financial management governs the Foundation. The Ministry of Finance is responsible for monitoring and auditing the Foundation’s activities as it receives Government funding.
The Minister of Health is the Chairman of the Foundation’s Council. Other members of the Foundation Council include government and non-governmental representatives, comprising: the Director of the General Taxation Office; Director of Policy Implementation and Coordination, of the Department of the Ministry of Justice; Director of the Government Fiscal Budget, Department of the Ministry of Finance; Director of the Department of Public Health Policy Implementation and Coordination, Ministry of Health; Director of the Medical Department of Mongolian Army Force; Executive Director of the Mongolian Public Health Professionals Association (subject to approval); and the President of the Mongolian Journalists Union.
The Foundation aims to promote health and reduce exposure to health risks for all Mongolians. The key health promotion strategies are information, education, and public relations. The fund is supporting a wide range of health promotion activities including:
- Prevention of non-communicable diseases
- Prevention of infectious diseases
- Protect environmental health
- Prevent accidents and injuries, and support a healthy and safe living environment
- Protect mental health, and prevent the harmful effects of alcohol, tobacco, and drugs
- Promote the rational use of drugs
- Improving the ethics of medical professionals, and improving the transparency and accountability of health organizations.
The MHPF promotes, coordinates, and guides the implementation of health promotion activities. These activities are targeted at individuals, communities, and government policies at the national, provincial, and local levels.
The MHPF promotes, coordinates, and guides the implementation of health promotion activities
Competitive grants schemes and sponsorships are provided to increase the capacity of organizations, communities, and individuals to improve health. The grant-making programmes are open to all government institutions, non-profit organizations, and citizens. All project proposals go through rigorous screening. The fund is awarded on a competitive basis against the funding and eligibility criteria. Emphasis is given to evidence-informed interventions.
In 2021, the government has amended the “Regulation on spending and monitoring of Health Promotion Fund” with resolution No.323. The amendments include:
- The Health Minister shall give the final approval on the working group’s recommended projects. The working group shall carry out the selection process and make recommendations, and it will consist of at least 2 representatives of NGOs, professional associations, and relevant sub-councils.
- NGOs and legal entities shall submit their project proposals in writing within the first 20 days of each quarter (from 2 times to 4 times a year) to the ministry of health.
A total of 271 project proposals were received from citizens, non-profits organizations, and other institutions in 2021. Of these, 87 projects were selected and funded by the health promotion fund. The funded activities in 2020 and 2021 include:
| Activities | 2020 | 2021 | ||
| Total grant | Total budget (MNT) |
Total grant | Total budget (MNT) |
|
| Prevention of non-communicable diseases | 23 | 382,239,340 | 34
|
1,091,517,100 |
| Prevention of infectious diseases | 7 | 172,656,660 | 16
|
398,542,700 |
| Protect environmental health | 21 | 1,665,014,000 | 1
|
20,721,750 |
| Prevent from accidents and injuries, and support of a healthy and safe living environment | 5 | 152,232,400
|
10
|
298,969,000 |
| Protect mental health, and prevent the harmful effects of alcohol, tobacco and drugs | 5 | 91,774,600 | 15
|
455,239,650 |
| Promote the rational use of drugs | 2 | 46,782,850 | 4
|
64,518,000 |
| Improving the ethics of medical professionals, and improving the transparency and accountability of health organizations | 3 | 78,190,000 | 7
|
176,730,000 |
| Total | 66 | 2,588,889,850
|
87 | 2,506,238,200
|
A key strength of the MHPF is the strong and positive work team. The team has the advantage of working in a constructive policy environment that is underpinned by a political commitment to health sector reform. There is also a high level of commitment to controlling tobacco, alcohol, and drug misuse; maintain an effective monitoring and evaluation system.
Since the MHPF’s inception, there have been improvements in community-based health promotion activities and an annual increase in the grant for the Foundation’s work.
The Foundation faces several challenges including the lack of sustainable long-term leadership and limited resources to consolidate the infrastructure and institutionalize activities. Key concerns include building the capacity of people across sectors to implement health promotion activities and improving the coordination between partners and the number of intersectional collaborations.
References
Law on Government Special fund 2019.
Law on Tobacco Control 2005. (Mongolian, English)
Ministry of Health. (2005). Tobacco Control Law.
Ministry of Health. (2006). Law on Government Special Fund.
Ministry of Health. (2021). Regulation on spending and monitoring of Health Promotion Fund, Government resolutions No 37 and No 323.
Ministry of Health. (2020). Situation of Public Health-II, 2010-2020, Brochure, Ulaanbaatar.
Ministry of Health. (2020). Audit results report-Annual 2019-2020, Mongolian National Audit Office.
Ministry of Health. (2021). Audit results report-Annual 2020-2021, Mongolian National Audit Office.
Khandarmaa.Ts. Mongolian Health Promotion Foundation. Presented at International Seminar on Health Promotion Foundations and 12th Annual Meeting of the INHPF, 25- 27 June 2012, Seoul, South Korea.
Khandarmaa.Ts. Annual report of Mongolian Health Promotion Foundation. Presented at International Seminar on Health Promotion Foundations and 12th Annual Meeting of the INHPF, 25- 27 June 2012, Seoul, South Korea.
Related reports
World Health Organization. (2004). The establishment and use of dedicated taxes for health. World Health Organization Regional Office for the Western Pacific.
Vathesatogkit P, Yen Lian T, Ritthipakdee B. (2013). Health Promotion: Sustainable Financing and Governance. Bangkok, Thai Health Promotion Foundation (ThaiHealth).
World Health Organization. (2016). Earmarked tobacco taxes: lessons learnt from nine countries. Geneva, World Health Organization.
