The meaning and scope of the concept institutional development, implies being centered on the continuous improvement of the capabilities, competences and abilities of the work force, as well as the means and instruments that give support to health systems public in order to fulfill with its task of performing the essential functions appropriately, effective,efficient andsustainable.

Lines of acction for the institutional development

Public Health Infrastructure

The Steering Role

Lines of acction for the institutional development

It is important that the preparation of the national agenda for the strengthening of the Essential Public Health Functions responds to two linchpins: 

a) To the development of national health objectives

b) To The development of institutional objectives of the NHA in order to improve the practice of public health in the countries. 

This framework of health challenges should constitute the basis that reorients the sectoral reform under way process, locating health problems that affect the population as the central element in order to guide the health policies. 

The institutional objectives for improving the practice of the ASNs should be guided toward and be involved in the sanitary objectives, which demand design new institutional configurations of the ASNs that are on a par with those national health challenges. 

Public Health Infrastructure

• The set of mechanisms and resources available to implement public health actions. (Public Health in the Américas, PAHO/WHO, 2002)

• The underlying bases that support planning, delivery, and evaluation of all public health actions. (Turnock, 2001)

• The nervous center of the public health system, which represents the necessary capacity to implement the basic public health functions. (CDC)

The improvement of the health status of the population in Latin America and the Caribbean depends on the development and maintenance of a strong health infrastructure fully capable of supporting the implementation of the EPHF. Specifically, efforts to improve public health should center on strengthening the infrastructure through policies, strategies, and plans designed to improve the quality of the public health work force , strengthen health information systems, increase the efficiency of physical resources , and develop organizational capacity.

Public HealthWork Force

Public health workers include not only the employees of public health institutions, but also those who work in private non-profit organizations, the academic and the private sector, community organizations, and other public health agencies.

The most common professional disciplines are physicians, nurses, environmental specialists, laboratory technicians, health educators, researchers, extension workers, and managers. In addition, public health human resources include dentists, social workers, anthropologists, psychologists, economists, political scientists, information technology specialists, public health information specialists, epidemiologists, biostatisticians, and lawyers. (Centers for Disease Control and Prevention (CDC). [“Public Health Infrastructure: A Status Report.” CDC, 2001]

Integrated health information systems are an indispensable input for public health infrastructure.

Data produced by health surveillance systems provide information on disease; disability; death by acute and chronic diseases; injury; personal, environmental, and occupational risk factors; preventive and curative services; and costs. For health data to be useful, access to information must be precise and timely, and should follow norms of strict confidentiality. Also, it is necessary to emphasize the importance of public health research to identify opportunities to improve health, strengthen health systems, and allow more efficient and effective use of existing resources.

Information systems should be integrated, adequate, and current, and must produce the necessary intelligence for concrete public health actions. Without information, or with ineffective or insufficient information, the design and implementation of public health strategies and plans become extraordinarily difficult.

 And capacity of institutional development

This is the element that articulates the resources, that gives them functional unity, and that makes public health actions possible. Organization defines the institutional characteristics of public health, and specifically those that relate to the implementation of the EPHFs. It comprises the legal basis of public health – that is, the relationship of the NHA with public health, its competencies and responsibilities, the assignment of such competencies and responsibilities to the different actors at different levels, and the mechanisms and processes through which evaluation is performed, among others.

In sum, it defines the way in which infrastructure is organized and managed to implement public health actions. In addition, it comprises fundamental processes that orient public health practice and the implementation of its essential functions and basic administrative and management processes.

The Steering Role

The Steering Role is one of the four functions of the health systems in addition to service provision, financing and assurance.

In the Region of the Americas, the steering role in health refers to the performance of the specific and non-delegable substantive responsibilities and competencies of public policy in health in the context of the new scheme of relations between government and society in the modern State; it is a specific competence of the government; and it is performed by the Health Authority.

Even though different taxonomies may be adopted to describe the steering role function, PAHO/WHO has proposed six dimensions of the sectoral steering role. Depending on the degree of decentralization of the health sector, as well as on the characteristics of the country’s institutional organization, these dimensions will fall under different levels of the health authority (national, intermediate or local), and, at times, they will be shared among these different levels. This taxonomy was formally approved by the PAHO/WHO Directive Council in 1997, in which the conduct/lead and regulation were defined as the main axis of the steering role.



The purpose of the steering role function is to define and implement public decisions and actions in order to fulfill and guarantee, according to the adopted national development model, the health needs and legitimate aspirations of all social actors. In this context, the process of strengthening the steering role capacity of the health sector should be oriented toward reducing health inequities within the framework of sustainable and comprehensive development as well as minimizing unjust inequalities in health services access and in the financing of these services.


PAHO/WHO Technical Cooperation
In view of deep changes taking place as part of the Sectoral Reforms in the Region, it is necessary to strengthen the political commitment of the National Health Authority as the steward of the health system by defining its institutional competencies which cannot be delegated– in order to build integrated health systems.

PAHO/WHO has viewed the development of the concept and practice of the steering role in health as a priority, intrinsic to the State modernization process. To that effect, and with the purpose of presenting a consensual view of the NHA as the steward of the health sector, PAHO/WHO elaborated in 2003 the instrument “Evaluation of the Performance of the Steering Role Function of the NHA.” The main goal of the instrument is to encourage debate between national working groups and promote an analysis of the steering role performance of the NHA, thus contributing to the identification of strengths and weaknesses, and of concrete strategies for strengthening the NHA.

The process of performance evaluation of the NHA’s steering role consists of two phases: