A national public health strategy plays an essential role in defining a country’s vision and framework for improving national population health outcomes (1). It serves as a road map for a national government to align efforts, resources and policies to improve the health and well-being of the population, prevent diseases, reduce health inequalities, and respond effectively to emerging health threats and public health emergencies (1). All encompassing, the broad goals of national public health strategies may be matched in breadth by strategy scope, with strategies often presented as multisectoral, and addressing not only healthcare, but also the wider determinants of health and health inequalities (2).

Given this broad scope, and the multiple factors which may influence population health, such as the national health situation, underpinning national policies, the health system structure and the availability of resources (3), each country must undergo priority setting to identify the key health issues to focus on within a certain time period (3). These priorities form the basis of any given national public health strategy, and can vary from country to country, and over time. For example, previously, issues related to the environment and climate may have been siloed within environmental strategies. However, more recently the significant impact of climate change on population health has led to public health bodies prioritizing the implementation of adaptive strategies to reduce the impact of climate change on health outcomes (4).

Additionally, while a common feature of national public health strategies is the involvement of stakeholders across multiple sectors, the degree to which these stakeholders may participate can vary. For example, stakeholders such as politicians and national health authorities may retain overall governance or oversight of strategy implementation at a central level, while community organizations and the public may act as cooperating partners or facilitators on strategic actions at a local level (3).

Regardless of involvement level, engagement with strategy stakeholders is essential throughout the life cycle of a national public health strategy. This includes strategy development, where clarity on the nation’s key health challenges and supporting structures is crucial to ensure successful and sustainable strategy implementation (2). Previously, inclusive population consultation methods have been used during strategy development to capture opinions and transform the public into active stakeholders in a strategy (3), however the extent to which these methods are used varies considerably worldwide.

Given the many factors which may influence population health, and the number of stakeholders who may be involved in strategy development and implementation, it is increasingly challenging to develop comprehensive strategies which positively impact national health outcomes. Furthermore, the COVID-19 pandemic has sparked a renewed political focus on public health, with a number of countries taking actions to review, strengthen or reform their national public health systems and strategies (5–7). Therefore, gaining an understanding of the issues of importance, the actions undertaken and strategy development methods used internationally may provide insights into effective methods of national public health strategy development and delivery.

In light of the timeliness and complexity of this issue, the aim of this research was to review national public health strategies in selected countries, focusing on both strategy development and strategy content (such as issues of importance and strategy implementation actions). This research was originally undertaken to inform work towards the development of a national public health strategy in Ireland. However, the findings provide insights of interest to politicians, policymakers, and individuals and organizations engaged in public health research and practice internationally.

As outlined by the WHO, national public health strategies “play an essential role in defining a country’s vision, policy directions and strategies for ensuring the health of its population” (1). Complex in nature, national public health strategies need to address national health policies, and align with global health initiatives, while also considering national democratic structures in place and political will at any given time (3). An understanding of how countries develop national public health strategies worldwide, along with understanding the health issues of importance to them and how these may be improved upon, may provide insights into effective methods of national public health strategy development and delivery. An international review of national public health strategies was therefore undertaken, with national public health strategies identified for 10 of 15 countries, selected based on a combination of factors including geographical proximity to Ireland and population size.

The review raised several questions about evaluating the impact of national public health strategies. Key performance indicators (KPI) were linked to strategy themes or priorities in the majority of countries, but the number of indicators outlined varied considerably between countries and two countries had no associated KPIs. Life expectancy, healthy life expectancy or years, disability-free life expectancy, deaths by cause of death, self-assessed general state of health and maternal mortality rate were among the KPIs used in the public health strategies reviewed. The identification of internationally agreed indicators to measure the implementation of public health strategies and assessing the impact on health outcomes of their targeted populations would be valuable. However, only Australia cited outcomes that they wished their strategy to impact. Even then it is difficult to state with certainty that changes in a high level outcome (in this case relating to elements of life expectancy) are attributable to inputs such as a strategy. This is clearly an important area for future health services research. There is an even more fundamental question as to whether the presence or absence of a strategy (and there were four countries which appeared not to have a current one) is associated with overall better, worse or equal health outcomes. This is yet another area which requires further research.

The questions raised by us are: (a) what international core set of themes or priorities should be included in the development of a national public health strategy; (b) what indicators should be used to measure the implementation of a strategy and impact on health outcomes; (c) what is the optimal combination of prescriptive or interpretative approaches depending on national contexts; (d) which elements of governance are critical to successful implementation including the balance of evidence gathering versus stakeholder engagement.

On core priorities, several key aims were identified across the included national public health strategies. These relate to the United Nation’s Sustainable Development Goals (47) and included elimination of health inequities and inequalities; keeping people safe and or monitoring emerging threats; and focusing on sustainable health. These contributed to an over-arching aim identified in all of the included national public health strategies, that is, to improve health and wellbeing. There is good evidence and previous work to guide appropriate responses to these aims (53–55).

In terms of specific priorities, it is clear that many countries aligned around promoting healthy living – the importance of which was demonstrated by the impact of the COVID-19 pandemic on vulnerable populations (55–58). Almost half of the national public health strategies included within this review were published during the COVID-19 pandemic and the experience of the pandemic period may have contributed to the prioritization of promoting healthy living or behaviors. Furthermore, during priority setting, health stakeholders try to preempt foreseeable health problems and mitigate their impact on health outcomes. It is perhaps surprising that preventing ill health was explicitly stated as a priority by only one country. While this might suggest a disconnect with health improving behaviors, it is also important to consider that countries may be addressing preventing ill health within health promotion strategies, rather than disease prevention. Further priorities found in several strategies include actions on climate change and health; actions requiring cross government and cross sector engagement; and strengthening the public health system and workforce. Given the critical role of public health during the COVID-19 pandemic, it is unsurprising that the strengthening of public health was regularly identified as a national public health strategy priority. This is well supported throughout the literature, where improving health workforce resilience and preparedness (56), improving public health training (57) and improving public health infrastructure are all viewed as opportunities for improvement in the post-pandemic period (58). Furthermore, tackling climate change has been described as the ‘greatest global health opportunity’ of the 21st century, and many of the mitigation and adaptation measures for climate change may also benefit population health (59). Additionally, while the wider determinants of health were not specifically identified as strategy priorities or themes, they were included as underpinning considerations throughout all of the national public health strategies. This is supported by the WHO, who have highlighted that the social determinants of health account for 30 to 55% of health outcomes, and that the contribution of sectors outside of health exceeds the contribution of the health sector to population health outcomes (60).

However, while a number of common themes or priorities were identified across the included national public health strategies, political context and health structures vary by country and this can influence the emphasis which is placed on any given priority within a strategy (61). For example, a recent overview of health policy responses to the COVID-19 pandemic found that political leadership, health system organization, and financing impacted a country’s pandemic responses.

The question as to the appropriateness of prescriptive or interpretive approaches bears scrutiny. The answer may depend to some extent on the pre-existing infrastructure of the country, and its familiarity with centralized approaches to accountability. So here, approaches adapted to countries’ cultures and capabilities may be in play. Prescriptive approaches included detailed implementation plans with specific actions and KPIs, such as those described for Finland (30) and Spain (38). More interpretive approaches to implementation were observed for Australia (23), Portugal (35) and Sweden (40). In these countries’ strategies, priorities or high-level strategic actions were outlined, along with principles to support their implementation, rather than specific actions detailing how these priorities were to be achieved. This overarching interpretive approach is necessary due to the decentralized decision-making arrangements across states and territories in Australia, and at local and regional levels in Sweden. In Portugal, sector-specific implementation strategies are planned to be developed at national and regional levels, for the health sector and for other sectors (35). Regardless of the approach used, it should be noted that the inclusion of implementation strategies or frameworks within public health strategies, does not necessarily reflect the actual implementation of the associated strategies. Effective implementation of national public health strategies depends on a number of factors, including but not limited to the population’s willingness to participate and collaborate with local authorities; political and health system structures; contextual factors such as policy relevant to the strategy; and the skills, resources and opportunities available to any nation (62). For example, across a federation like Canada, significant challenges to achieving consistent, coordinated approaches to public health may occur, due to factors such as decentralized decision-making and fragmented systems for the collection and sharing of data (63). These data collection and sharing challenges may influence or limit the selection of KPIs monitored during strategy implementation, whereas a country with advanced national health information systems, such as Finland (29), utilizes a comprehensive number of KPIs. In regards to effective public health strategy implementation, Khorram-Manesh et al. (62) identified that educational initiatives and appropriate communication to the community in a timely manner are key for increasing a population’s willingness to participate and collaborate in a strategy. This is further expanded by Bialek et al. (64) who outline six steps to engaging a community in developing and implementing a collaborative strategy: 1. Establish the urgency and commitment to collaborate on selected health issues; 2. Introduce the new concepts, techniques, and tools for managing a community strategy; 3. Engage the coalition in co-creating a strategy map; 4. Distribute the work of strategy execution; 5. Adopt shared strategy measures and a shared measurement system; and 6. Harness, align, and monitor the actions.

Additionally, strict adherence to a public health strategy during implementation is not necessarily required for effective implementation, and adaptions may enhance implementation, for example modifying programmes to meet local needs.

The role of governance in successful development and particularly implementation of national health strategies is to some extent related to the way countries best operate in getting action on new national initiatives. However, there is also universal evidence on good governance, vital to effective implementation, founded on principles such as responsiveness, competence, transparency and accountability (65). A number of the included national public health strategies relied upon existing, well-established governance structures to oversee strategy implementation. For example, in Sweden (40), the strategy was built upon existing structures, divisions of responsibilities, and cooperative ways of working between government agencies that are set out in national legislation. A number of countries specified that strategy governance came under the remit of the Minister or Ministry of Health, or equivalent (24, 31, 35, 38). Existing boards or institutes with responsibilities relating to public health were tasked with strategy oversight in Finland (29, 30), Portugal (35) and Spain (38). In Australia, a need to enhance existing governance structures was identified as part of the national public health strategy, and this enhancement was proposed to be achieved through establishing an independent, expert-led mechanism along with a mechanism within government across relevant portfolios (23). Of the selected countries, the most detailed description of governance structures was provided for Northern Ireland (31), where new governance structures were established to oversee the national public health strategy at local, regional and national levels. Overall, in the majority of the included national public health strategies, it was apparent that governance structures, and where enhancements or new structures may be required, were considered as part of the strategy development process.

By their nature, national public health strategies involve multisectoral stakeholder engagement (2), and the strategy development processes observed in the selected countries tended to reflect this. In general, the included national public health strategies were developed using evidence-based, collaborative approaches involving stakeholders across multiple sectors, led by a relevant government or government-mandated body with responsibility for public health. However, while evidence review of published research, literature and other national public health strategies was conducted by seven countries, there was little detail of what this entailed. Notably, the included national public health strategies omitted economic analysis to support their development and or implementation plans. Cost–benefit analyses have become increasingly important for government departments and policy makers to gain political support for funding, as well as to assess the return-on-investment of public health interventions in addition to the benefits of a healthy population.

However, as expected, wider stakeholder engagement, such as public consultations and the formation of intersectoral partnerships, was a feature of strategy development in the majority of the included national public health strategies (3). A range of stakeholder groups were consulted including young people, older people, people at risk of poverty, people with migratory backgrounds, and people with disabilities and their carers.

The use of a variety of methods to include the public in strategy development is in keeping with the increasing emphasis on public and patient involvement (PPI) across health research and policy development in general (66, 67). PPI aims to support the development of policies or strategies that are responsive, feasible and supported by all relevant stakeholders through including people’s voices in decision-making, and achieving mutual understanding and increased trust (66, 67). Although there is little evidence currently available on the extent to which PPI has influenced public health policymaking, research has identified a variety of PPI methods that may be appropriate for use when developing health policy (66), factors that may influence the effectiveness of PPI in the health context (66, 67), and “essential” and “desirable” principles for optimizing PPI (68).

Stakeholders with expertise and experience in relevant fields contributed to strategy development in all included countries. Methods used to engage with expert stakeholders varied in the level of participation involved, ranging from stand-alone workshops or opportunities to submit contributions, as seen in Finland (29), to more participatory approaches where expert groups were convened for the purposes of contributing throughout the strategy development process, as seen in Australia (23), Austria (24, 26) and Portugal (35). In Finland, stakeholder engagement allowed for direct input on the strategy implementation plan, with stakeholders developing specific actions, and identifying the partners associated with these actions (29). These participatory approaches draw on design theory and practice, with participatory design and co-design becoming increasingly influential in the design of public services, including health and social services, and public policy (69–71). The proposed benefits of co-design are similar to that of PPI – improved idea generation, shared understanding among stakeholders, development of more feasible and acceptable solutions. However, shared challenges also exist, such as the time-consuming nature of implementing these approaches (69). Although somewhat delayed by the COVID-19 pandemic, the co-creation approach used to develop the Portuguese national public health strategy took three years to complete (35), the longest duration of the strategy development processes observed in this review. It is possible at least to measure the success and degree of public engagement in government strategies through well designed feedback and it is an approach that would have been valuable to see in the strategies reviewed.

The current review of national public health strategies in selected countries provides insights into what countries identified as issues of importance, the actions undertaken, and strategy development methods used internationally. These insights may aid in the development of an evidence-based national public health strategy. There are a number of notable recommendations: