According to the online survey results, frequent reorganizations of the national institutions created overlaps in the tasks and competencies of these organizations. The day-to-day functioning of the HPOs was negatively affected by the changes in administrative rules, policy priorities and responsibilities resulting from the frequent restructurings. Apart from the issues at national level, attempt has been made to develop management and coordination at the county level via a 3-year pilot project, where a methodology has been developed and tested (32). According to several survey respondents, at the end of the pilot project, these initiatives were also discontinued, the generated insights and knowledge of the experts were not preserved, in addition the methodological improvements were not adapted by any national organization. Few respondents highlighted that, it was never defined whether HPOs should provide services with their own staff, or contract third-party providers, leading to a patchwork approach with significant heterogeneity.

HPO staff perceived the lack of knowledge-sharing mechanisms across the network as a problem, as well as the not up-to-date methodological guidance from the national level.

According to the results, the current base financing method does not take into account the size and socioeconomic or epidemiology characteristics of the population in the HPOs respective operational area. The funding mechanism does not differentiate between HPOs operating in various small districts: the service portfolio of an HPO operating in an economically developed urban environment with a younger age group should reflect the needs of the community, thus differ from an HPO operating in a less urbanized district with an aging and socioeconomically disadvantaged population. In addition, local health needs are less well identified, with only a small proportion (8%) of HPOs in our survey having developed or participated in the creation a community health plan. Moreover, significant differences can be identified in terms of the extra resources available based on the type of institutions responsible for the upkeep of HPOs. For example, a medical university or hospital with a larger institutional budget can support its HPO to a greater extent in terms of financial, methodological, health infrastructural, and human resources compared to HPO owned by a small town municipally with more limited resources.

According to several survey respondents, the operation of the funding system is not transparent, as the details of the HPOs' service procurement are not well regulated, it is challenging to control activities and costs. As a result, HPOs operate on a fixed monthly amount and, as payments do not take performance into account, the current practice encourages the spending of all the resources rather than focusing on increased efficiency or improved quality of services.

Other problems with the current funding method include the low level of external funding. According to the online survey, only 12% of HPOs could obtain extra financial support from their owner organization. Only three HPOs reported receiving other non-financial resources (such as in-kind contributions or voluntary work) from other organizations. This may be partly due to HPOs' lack of motivation to raise extra resources. However, the online survey results also suggest that the problem is due to HPOs' lack of knowledge of effective fundraising methods and lack of clarity on the rules for external fundraising.

At present, HPOs operate in only 63% of the Hungarian small districts, representing only 55% of the Hungarian population. Thus, a significant part of the population still does not have access to the health promotion services that these organizations provide free of charge. According to the questionnaire results, HPOs have heterogeneous human resources with different skills and a heterogeneous service portfolio. Respondents found it particularly difficult to recruit suitably qualified staff for specific occupations (Supplementary Figure 1). Respondents also varied in assessing the difficulty of organizing health promotion services (Supplementary Figure 2). Most HPO managers identified incomplete and outdated protocols and guidelines as a problem for the inconsistent quality of health promotion programmes.

Furthermore, owner organizations can influence the service portfolio of HPOs, for example, by making the activities of HPOs belonging to health service providers focus on healthcare-related services rather than health promotion programmes. According to the survey results, the COVID-19 pandemic has also negatively impacted access to services and cooperation with local partners. Many health promotion programmes were canceled due to the restrictions, the vast majority in community settings (schools, workplaces). Although HPOs have been able to provide many services and programmes online, disadvantaged social groups with limited internet connection, such as the older individuals and the Roma communities, have had less access to these services. Having said that, nearly 15% of HPOs do not use online communication tools in their communication activities, which might make reaching younger generations difficult (Supplementary Figure 3). In addition, cooperation with GP practices was made difficult by the overburdened workload of GPs.

In summary, HPOs have a very diverse pool of workforce with a wide range of qualifications. Nearly 90% of their expenditure spent on salaries and the provision of services. The following issues have been identified in the HPOs' system: frequent reorganizations and overlapping competencies of national institutions; misaligned key performance indicators and evaluation frameworks; lack of knowledge-transfer mechanisms; funding not adapted to local population size and needs; funding system not providing incentives for quality service delivery; lack of country-wide coverage of services, differences in the quality of services.

The eight countries under review have developed a tiered management system based on the division of tasks and responsibilities within the administrative system (33–45). Organizations and actors have different functions but coordinate activities at each operational level. In all cases, the management of the public health system is at the national level. In several countries, a regional level can also be identified, where the organization is responsible for planning, organizing, and coordinating the activities of the health service providers in the region (34, 35, 37, 38, 43). Network-based cooperation is also common, whereby different organizations interested in promoting population health at the same or different operational levels form networks, partnerships, and collaborations. The development of networks and collaborations serves multiple purposes, such as joint development of knowledge and skills, sharing knowledge, information, and resources, and coordinating and harmonizing activities and services (36, 41, 43, 44, 46).

Recommendation for improvement 1: Based on these international experiences, it would be helpful to further develop the management system of HPOs in Hungary by eliminating the current duplication at the country level and adapting the network operating model and regional management functions.

Looking at the public health systems of the countries examined, several organizations operate at national and regional levels to monitor and analyse the factors and trends of the population health, health risks and unmet health burden (34, 35, 37–41, 43, 44, 47–49). These organizations also play an essential role in monitoring the activities and assessing the performance of service providers at the community level. Usually, public health priorities are set at national level, with implementation left to lower management levels (34, 35, 37–39, 41, 44). International experience shows that services can only be evaluated if adequate quality and quantity of data is available for analysis (48).

Recommendation for improvement 2: From the perspective of Hungarian HPOs, it is appropriate to develop the capacity and methodology of monitoring and evaluation organizations and to coordinate their activities at the system level. In addition, further developing the monitoring system would allow for broader monitoring, analysis, and evaluation of the impact of services and programmes provided by HPOs.

Following the best international examples there are numerous examples of organizations at national or regional level responsible for formulating professional guidelines or standards for the provision of public health services (38, 41, 44, 47–54). These national organizations often provide professional support, monitor local providers' operations, and evaluate based on transparent indicators. The expected benefits of standardized service provision is the reduction of variation in service quality between geographical units and ensuring that evidence-based, effective services are provided to the population (48–50, 52, 53, 55, 56). It is important to note however that standardization is a sensitive topic in public health, and local needs have to be taken into account when developing or providing services. These organizations often play an essential role in facilitating two- way information and knowledge transfer (top-down or bottom-up approach), adapting evidence-based programmes developed by national-level organizations to the local level (36, 41, 49). In the countries we studied, universities and professional organizations, along with a variety of regional and community providers are involved in training public health professionals.

Recommendation for improvement 3: In light of these findings, in our view it is worth considering establishing an organization responsible for developing standards and guidelines for HPO services in Hungary, providing the human resources, tools and funding necessary for their operation, and ensuring that the guidelines are continuously updated. The standards developed by the national professional management body, can form the portfolio of services that HPOs can provide, building on international and national good practices. The involvement of HPOs in training health promotion practitioners would also be helpful, with the expected benefits of ensuring the supply of professionals.

In the United States of America, local health departments (LHDs) are responsible for providing public health services to the population (35, 57). LHDs are mainly responsible for serving a single county, usually with a population of tens to hundreds of thousands. However, some LHDs are responsible for areas with populations of up to one million. Both the services provided by LHDs and the number of staff they employ are commensurate with their area of operation: a county with a lower population is served by fewer workforce than average and a narrower, more specific portfolio of services. In comparison, a county with a higher population is served by more health professionals than average and has a broader portfolio of services.

Recommendation for improvement 4: Based on the example of the Local Health Departments in the US, it may be preferable for HPOs to operate in a relatively flexible structure, where the number of human resources and services provided by the organization is proportional relative to the population it aims to serve (35, 57).

In the majority of the countries examined, a local or regional organization is responsible for developing community health plans and implementing, organizing, and coordinating the programmes described (35, 41, 43, 44, 58–61). The expected benefit of regularly updating these plans is that programmes implemented can respond to community needs and efficiently use community resources, with the active involvement of the population and the cooperation of community actors (62).

Recommendation for improvement 5: International experience suggests, it would be preferable for HPOs to play a more active role in preparing and implementing community health plans, with monitoring and methodological support provided by a national organization. The preparation of community health plans can also provide input data for planning the HPO's budget, as it is necessary to prepare a cost plan for the programmes and services included in the health plans both at national as at small district level (63, 64).

Due to their complex and intersectoral nature, the financing of health promotion programmes is far from straightforward (63, 64). Public health services are financed by diverse private and community actors globally (34, 35, 39, 41, 43, 44, 61, 65, 66). However, there are few practical guidelines and good practices available, albeit with different methodologies, in the international literature (63, 66–70). Over the past two decades, there has been increased interest in financing methods that support efficient financial activities and improved service quality (66). Therefore, payment systems have been developed that “pay for performance” by linking part of the payment for an activity to the results achieved or, when results are challenging to measure, by linking payment to the pursuit of processes that are assumed to lead to better results (e.g., service protocols or guidelines) (70).

Recommendation for improvement 6: Based on the international review, we propose to explore a hybrid financing (combined fix and performance-based reimbursement) system for the Hungarian HPOs. The system would have two main components: annual or monthly base and project funding. The base funding element covers the monthly operation and horizontal activities of HPOs. In terms of operating costs, it should cover the costs of maintaining the property or rental premises, human resources, equipment necessary to carry out the work and travel costs. The horizontal activities include tasks that are necessary to perform for all HPOs, such as preparing community health plans, networking and cooperation with local actors, and administrative tasks related to the operation of HPOs. Overall, this base funding is a predetermined monthly amount allocated to HPOs to enable the organization to continue to operate and to carry out its core tasks smoothly and continuously.

Recommendation for improvement 7: As a first step, the base funding methodology requires a cost assessment of the HPOs' operational and horizontal activities, which will allow the definition of a baseline cost element for each activity (66). The baseline cost elements for each activity can then be adjusted using at least two factors (such as population and settlement structure) representative of the HPO's area of operation. For example, the amount of base funding may be influenced by the level of human resources, as an HPO with a larger population and more employees in a municipality will receive more resources for wage costs. Alternatively, an HPO with a large number of small, geographically dispersed settlements will receive more funding for travel costs.

Recommendation for improvement 8: The second element, titled project funding is to provide financing and incentives for implementing specific health promotion programmes and services in Hungary. In this context, it is proposed to establish a national health promotion fund to which HPOs can apply for funding. The range of services and programmes eligible for funding should be defined and evaluated by the national professional organization, based on international and local best practices, with mechanisms to review the program portfolio (50). The budget available for each HPO to submit proposals will be allocated based on a multi-component formula. The baseline for the amount an HPO can apply for project funding is the population of the HPO's area of operation, adjusted by the economic development of the area (e.g., per capita spending), the age composition of the population and the health needs of the small district (66). A helpful indicator for determining health needs is the age-adjusted standardized death rate, which combines various health determinants in a single indicator. Its strengths are that it can be calculated at the national and local levels and is comparable internationally with relative ease.

Recommendation for improvement 9: Given the complex and intersectoral nature of public health activities, innovative financing mechanism might be valid to explore. One such tool is outcome-based contracting, used mostly in Anglo-Saxon countries to combine advantages of public and private sector (71–74). This contractual arrangement allows payment after the demonstration the achievement of mutually agreed outcomes. In an outcome-based contracting framework, the focus is on the milestones for payment and the impacts and results achieved by the activities, not the completion of individual activities. This requires investing in monitoring of outcomes as well the development of measurable key performance indicators, which helps to understand the performance of individual HPOs.

In many countries, innovative forms of external financings, such as social impact bonds, individual or company donations, sponsorship, exist to enable organizations to contribute to the financing of public health services and programmes (75–79).

Recommendation for improvement 10: Based on international practices, it would be helpful to have a legally regulated form of external funding available to HPOs and consistent methodological support on how to include external actors and partners in the financing of community services.

To summarize, based on promising international practices, it is recommended to develop the professional management system and networking model further, improve the monitoring and performance assessment capacities, update the service standards and guidelines, and create a flexible operational structure adapted to the population size and characteristics of HPOs. We also recommend using community health plans and health needs assessment, a hybrid financing system, and legally regulated forms of external funding.