This section describes the informant sample; participants’ views about NPHI contributions to health security, universal health coverage, and health promotion; strategies used by NPHIs to bridge global health agendas; and key enabling factors critical to NPHI success.

Key informant sample

We included key informants based in all six WHO-defined geographic regions (Africa, the Americas, Europe, Eastern Mediterranean, South East Asia, and the Western Pacific) who worked in the following countries: Burkina Faso [2], Brazil [3], China [1], Ethiopia [1], Finland [1], India [1], Mali [1], Mexico [1], Morocco [2], Mozambique [1], Netherlands [1], Nigeria [2], Palestine [1], Republic of Moldova [1], Sierra Leone [1], South Africa [2], Ukraine [1], and the US [1]. Twenty-one informants were male and three were female.

Informants in the sample had extensive knowledge of NPHIs. Seventeen informants had been acting or former Director or deputy Director of a NPHI or similar agency. Several had worked to establish their NPHI. Others had professional experience in academia or held a leadership role in a regional or global public health organization. The sample also included individuals with experience in different size NPHIs including large (1000 + staff), medium (101–999), and small (less than 100) agencies. Similarly, experience with NPHIs included mature (20 + years), established (6 to 19 years old), and newly created NPHIs (5 years or fewer). To preserve anonymity, we refer to comments expressed by informants by number in parentheses (i.e., #1–#24). We present illustrative quotes from key informants in Table S5 in the Supplemental Material and referred to in parentheses (for example, Table S5, line #, informant #).

NPHIs’ contributions to global health agendas

While many informants acknowledged the interdependence of the agendas, several informants commented that WHO’s definitions of health security, universal health coverage, and health promotion are often not understood at local and national levels (#1, #5, #14, #16). Others remarked that this terminology may not resonate with national views (#13, #17, #19). Conceptual overlap made it challenging to pigeonhole NPHI functions into categories as noted by one informant (Table S5, line 1, #5).

NPHIs and health security

The legacy of NPHIs’ historic roots in sanitation, laboratories, hygiene, and outbreak detection is still evident in their prevailing health security focus. According to informants, most NPHIs prioritize health security efforts through several core functions such as disease surveillance, laboratory diagnostics, investigation of health threats, emergency preparedness, and response. Many NPHIs engage in activities related to the International Health Regulations (IHR) and Joint External Evaluations as part of national health security efforts (#1, #7, #10, #12, #24). Specific examples include efforts dedicated to development of National Action Plans for Health Security or aimed at strengthening biosafety and biosecurity in support of the Global Health Security Agenda (#8, #11, #12, #24).

NPHIs and universal health coverage

Many informants indicated that MoHs or other state agencies often spearhead universal health coverage efforts (#1, #2, #9, #10). Although one informant reported that universal health coverage was the primary focus, all others mentioned indirect involvement through promotion, surveillance, or research activities. Several noted that focus on fiscal mechanisms can overshadow attention given to quality or service-oriented components (#2, #5, #16). One observed overlap among agendas for planning purposes (Table S5, Line 2, #1).

NPHIs and health promotion

Informants’ responses about health promotion reflect a broad range of approaches. A few indicated the top priority to be health promotion (#7, #15) while several considered this the weakest pillar (#2, #12, #21). Other informants commented on the importance of this agenda to reduce demand for services (#4, #22). Several cited generating relevant evidence as an example of NPHIs’ indirect contribution to health promotion. National HIV survey data, for example, revealed decreasing levels of knowledge that led governments and funders to renew their investments in promoting healthy behaviors (#12). Another theme, tackling social determinants, underscored the cross-sectoral nature of public health (Table S5, line 3, #10).

Strategies for bridging global health agendas

This section describes respondents’ insights into how NPHIs have successfully bridged global health agendas. Respondents articulated five actionable strategies NPHIs have used to bridge agendas, namely serving as a trusted scientific advisor to inform policy, priorities, and decision making; convening actors across and within sectors; prioritizing multi-, inter-, and transdisciplinary areas; developing public health capacity through teaching and training; and integrating public health infrastructure for multipurpose use. Table 1 provides a summary of these strategies, country examples, and resulting links across agendas.

Table 1 Actionable strategies, country examples, and resulting linkages across agendasServe as trusted scientific advisor to inform policy, priorities, and decision making

Informants acknowledged that NPHIs’ unique position of scientific independence facilitates serving as a credible, trusted advisor to the MoH, the government, and the general public (#6, #10–14, #16, #18, #20, #23). As science-based agencies, NPHIs gather evidence and generate data that, in turn, lends credibility to policy decisions that contribute to building public trust (Table S5, line 4, #16). Informants also mentioned the value of data and health information systems as building blocks of research and catalysts for decision making (#4, #6, #11, #12, #18, #21, #23). NPHIs can collectively add value by collecting and working with data (Table S5, line 5, #14). Similarly, an informant commented more generally on the challenge of prioritizing investment in research (Table S5, line 6, #22).

Convene actors within and across sectors

Informants often mentioned the intersectoral convening role orchestrated by NPHIs (#3, #6, #7, #10, #12, #21, #23, #24). One informant described a NPHI-driven initiative involving a multisectoral consensus-building process to develop a National Action Plan for Health Security (#12). Several ministries and external stakeholders engaged throughout the process resulting in consensus building, buy-in, and ownership (Table S5, line 7, #12). Adapting the process to their cultural context resulted in an instrument with relevance and national value. They incorporated elements from health promotion and universal health coverage into the document underscoring the added value of multisectoral cooperation. Other informants described situations having involved convening diverse stakeholders from health, food safety, animal, environment, and economic agencies to address issues such as antimicrobial resistance (#7), listeria (#16), and dengue (#3).

Prioritize multi-, inter-, and transdisciplinary approaches

Given the complexity of many public health challenges, multi-, inter-, and transdisciplinary approaches are critical (#3, 10, #17, #18, #22). One informant provided addressing obesity as an example of integrating knowledge from several disciplines into a holistic approach (#3). Epidemiologic studies identified national obesity trends leading to research investigating social and environmental drivers of obesity. Economic surveys and analysis of consumer databases on food expenditure and entertainment revealed a dramatic rise in soda consumption and decline in healthy foods. Presentation of this research to the MoH led to multilevel, multisectoral, and multidisciplinary interventions such as school guidelines, food labeling, adoption of national policy documents, and a sweetened beverage tax illustrating the value of integrating approaches.

Integrate public health research infrastructure for multipurpose use

Several informants described the potential of NPHIs to facilitate integration of public health infrastructure for multipurpose use (#3, #4, #11, #13, #17, #20). As one informant observed, in resource-constrained settings, it is essential to maximize efficiency and minimize disease-specific approaches (Table S5, line 8, #11). Such a strategy may remedy vertical programming’s parallel systems, wasted resources, and missed opportunities. (Table S5, line 9, #11). In sum, informants describe NPHIs as well positioned to advocate for building platforms, pooling activities, and sharing resources.

Develop capacity through teaching and training

Many informants mentioned developing public health capacity through teaching and training as an integral part of their NPHI’s mission (#3, #6, #7, #12, #13, #14, #15, #18, #23). Respondents reported various types of educational opportunities including field epidemiology training courses, professional training programs, or postgraduate coursework. Brazil and Mexico have adopted a unique approach to building public health education systems by establishing accredited schools of public health programs, each under the umbrella of their NPHI with the explicit aim of developing the national public health workforce (#3, #13). Building educational opportunities into the ethos of NPHIs may reduce brain drain, repatriate talent of individuals studying abroad, consolidate expertise, provide inspiring career tracks, and stimulate local research activities (#18).

Findings gleaned from interview data suggest that NPHI-initiated strategies depend on key enabling factors to thrive as described in Table 2. Factors facilitating success clustered around five themes, namely a strong legal foundation with a multidisciplinary mandate; political will and acceptance of scientific independence; public trust and legitimacy; networks and partnerships at global, national, and local levels; and stable funding.

Table 2 Key enabling factors

Nearly all respondents mentioned the necessity of a firm legal footing; failure to pass a law, act, or decree proved to be the principal deterrent in establishing a NPHI (#4, #10). The value of articulating a multidisciplinary mandate safeguards engagement in emerging public health challenges. Informants coupled a strong legal foundation with need for high-level political will to spearhead the process (#4, #5, #14, #18). They also deemed as critical for NPHI functionality, acceptance of scientific independence by politicians to avoid partisan interference (#13, #18, #20, #21, #23). Public trust and legitimacy rely on scientific independence as well as the credibility, integrity, and relevance of the work produced by NPHIs. Leveraging NPHI partnerships and networks on local, regional, and global levels indicates the importance of collaboration, particularly during crises. Finally, stable core funding from domestic budgets or external funds is essential for organizational sustainability and longevity (#1, #3, #14, #16, #18, #21).