Innovation, proximity and services to the municipality. The Dipsalut model

Innovation,
proximity and services
to the municipality
The Dipsalut Model
Marc Alabert i López

Preface by Manuel Férez, ESADE Professor
Epilogue by Dr. Ramon Brugada, Dean of the Medicine Faculty,
University of Girona

Marc Alabert i López
(Besalú, 1974)

Dipsalut Managing Director. History
graduate (UdG) and MBA (UdG). Master’s
Degree in Marketing Management (EADA),
Postgraduate in Service Company Management (EADA), Program for Management
Development (PMD) at ESADE and
Executive Master in Public Administration
(EMPA) at ESADE. He has managed
different organizations, Retevisión Interactiva (Madrid) and the Open University of
Catalonia, among others. He has combined
his professional activity with teaching and
research work in different universities and
business schools. At present, he collaborates
with the University of Girona.

Innovation, proximity and services to the municipality
The Dipsalut Model

INNOVATION, PROXIMITY
AND SERVICES TO
THE MUNICIPALITY
The Dipsalut Model
MARC ALABERT LÓPEZ

© of the original text: the author
© of the images: the authors
© of the edition: Diputació de Girona
D.L.: GI.294-2013
Girona, 2013

INDEX

Preface

15

Introduction

19

PART I. Public health and local level: an opportunity
for the province of Girona

23

1.1. Provincial Council, health and financial resources; historical perspective

26

1.2. Public health and municipalities; duties

27

1.3. The creation of Dipsalut

30

1.4. Background and political agreement

30

1.5. Guidelines for the construction of an innovative organization

31

1.6. Defining transformation

32

1.7. The relational framework

34

PART II. The keys of the model

37

2.1 Health protection: idea of risk management

39

2.2 Health promotion

40

2.3 Diagnosis: local public health in the province
of Girona before Dipsalut

41

2.4. From the subsidy model to the service provision model

46

2.5. Service model: functions and features

47

PART III. Implementation process and initial results

53

3.1. Value proposal and service request

55

3.2. The City Council role; service catalogue membership

62

3.3. Proximity: public health agents’ network

64

3.4. Service production: market structure versus own structure

66

3.5. Dipsalut: service production

68

3.6. New technologies. Applying ICTs to the management model

70

3.7. Local Public Health Local Plan (PMSP in Catalan)

74

PAR IV. Innovative projects, evaluation and future challenges

77

4.1. Innovation and evaluation. The role of the Health Promotion Chair

79

4.2. Projects and creation of value

81

4.2.1. Urban health parks and healthy itineraries

81

4.2.2. Cardio-protected territory

83

4.3. Future challenges

85

Bibliography

87

Epilogue

91

TABLE, FIGURE AND
CHART INDEX

Table Index
Table 1. Health promotion actions in detail (2008)

45

Table 2. Health protection programmes

56

Table 3. Health promotion programmes

60

Figure Index
Figure 1. Dipsalut relational model diagram

34

Figure 2. Health protection and promotion actions (2008)

43

Figure 3. From the subsidy model to the service provision model

47

Figure 4. Dipsalut value chain

48

Figure 5. Dipsalut model

49

Figure 6. Organisational diagram

51

Figure 7. Territorial distribution of the health protection
programme request. Catalogue 2009-2010

59

programme request. Catalogue 2011

59

Figure 9. Territorial distribution of the health promotion
programme request. Catalogue 2009-2010

61

programme request. Catalogue 2011

61

Figure 11. Territorial distribution of overall programme requests from the
Catalogue 2009-2010

62

Figure 12. Territorial distribution of overall programme requests
from Catalogue 2011

62

Figure 13. Comparison between inclusions
in December 2009 and October 2010

63

Figure 14. Comparison of the evolution of the program
demand between December 2009 and October

65

Figure 15. SIMSAP diagram

72

Figure 16. Evolution of the value communication/provision axis

74

Figure 17. Construction of the evaluation model

80

Chart Index
Chart 1. Distribution by concepts (2008)

43

Chart 2. Expense budget (approximate)

52

Chart 3. Evolution of the number of requests (2008-2011)

57

Chart 4. Evolution of the number of actions (2008-2011)

57

Chart 5. Evolution of the number of facilities where action is taken
(2008-2011)

58

Chart 6. Evolution of the number of requests and the no. of
actions requested (2008-2011)

58

Chart 7. Evolution of users/interaction with SIMSAP

71

Chart 8. Evolution of the representatives’ profile in
the 1st visit of the by health agents

73

Chart 9. Evolution of the representatives’ profile
in the 2nd and 3rd visits of the by health agents

73

PREFACE

It is not very often that we have the privilege to see how an innovative
experience in local public management is born. And even less often do we
have the opportunity to read a rigorous and honest essay, and to share the
genesis and the learning process of an experience that combines political
consensus, professional managing capacity and technical excellence so that
such an experience is successfully implemented. Due to the above, Dipsalut
is a great piece of news, and not only to citizens in the municipalities in the
province of Girona –who directly benefit from the possibility of improving their
health and quality of life– but also to the other public entities –which it can
serve as inspiration to, in our present changing times–, and to the academic
world –which has the opportunity to analyse the implementation of some
specific concepts and theoretical models.
I would like to emphasize some of the most relevant lessons from this book.
The first lesson relates to the origin of Dipsalut. Its promoters are able to
identify a gap to be covered in order to help municipalities comply with their
legal duties in health matters. Thanks to the institutional loyalty towards
the Generalitat of Catalonia and county councils, they have taken the
opportunity to implement a new perspective on the future role of provincial
councils as intermediate local governments, i.e. from the subsidy model to
the service provision model, by setting up a modern and flexible organization
that supports municipalities, and with which it creates a commitment that
strengthens their independence. In order to evaluate this option in detail,
it is highly recommended to read The Green Book: Intermediate local
governments in Spain, by Professor Rafael Jiménez Asensio (printed by the
Democracy and Local Government Foundation, Madrid, 2011).

16

Innovation, proximity and services to the municipality: the Dipsalut model

The second lesson is related to the ability to structure a service provision model
that includes the complicated, and often controversial, public management
service, and that adapts it to the respective specificities in a large number of
municipalities (a municipality of less than 1,000 inhabitants is very different
from one with more than 25,000 inhabitants, and a coastal tourist town is very
different to an inland one). This is why the project starts with an ambitious
and clearly identified objective (known as outcome in public policies), i.e. to
improve citizens’ quality of life in municipalities in the province of Girona, by
reducing the environmental elements that generate risk to people, and by
improving personal health for citizens, thus empowering them to manage
their health, and providing them with the necessary tools and knowledge.
In accordance with this objective, a service provision model that combines
specialized management and local prominence is implemented.
The third lesson, where most innovative experiences fail, is related to the
implementation of the respective management model. This is why a rigorous
diagnosis was made first, and then a service catalogue was created. All
the municipalities (221) adhered to this catalogue, a well-balanced mix
of pedagogy and pragmatism. And this relationship would lead to the
commitment to generating the respective health local plans, which are the
key tool for defining local priorities in this area. In order to successfully reach
this point, it was necessary to face and solve, among others, one of the most
controversial debates in public health, i.e. either to produce service on the
basis of an in-house structure or to use the existing structures in the market.
The second alternative has been selected. A very well-profiled outsourcing
system has been implemented, which provides an agile service at a lower
cost, an exhaustive control of information, greater proximity of the service
provider and a promotion of local supplying companies.
The fourth lesson is related to the organizational culture, which is the real
Achilles’ heel in most of our public organizations. One of the big successes
has consisted of selecting a result and innovation-oriented organizational
culture. This sign of identity is fully integrated into Dipsalut’s DNA and allows
this organization to prioritize innovative projects based on result evaluation in
local service, with the aim of improving local health. In this book, there is an
incredible amount of quantitative data on results. This perspective has led to
the setting up of the Health Promotion Chair in the University of Girona, which
is the first chair of this speciality in Spain.
The last lesson –and the most important one to me– is related to the absolutely
necessary balance among the political level, the professional management
level and the network management model to achieve the expected results
which, in Dipsalut, are always related to local health. This difficult and fragile
balance is technically known as governance, and it shows the permanent
tension between wanting, knowing and doing. Wanting is in the hands of

Preface

17

legitimate politicians, so that they can set up priorities and take decisions
about distribution of resources. In this level, the key consists of, on the one
hand, combining clear ideas and the ability to reach consensus and, on the
other hand, listening to and trusting managers and professionals within the
organization. Here, we should refer both to the politician who promoted this
organization, Jaume Torramadé, and to its manager right from the beginning,
Josep Marigó. They have been able to preserve its original spirit and to
consolidate it. Knowing exists at the professional management level –the
managing director– who is responsible for identifying the best alternatives for
achieving the objectives determined by the political level and to set up the
appropriate strategy of relationships to achieve some goals. As Lluís Recoder
and Jordi Joly state, “politics need to include a new, strong and powerful
element, a new perspective of public managers, i.e. a CEO with the same
competences, or even more, than those in private companies” (Next politics.
Public competitiveness to face challenges in the 21st century, Barcelona:
Proa, 2010). And doing is based on a network management model, where
Dipsalut has no hierarchical authority, as this is kept in municipalities,
which are the core of the network which, depending on their needs, other
public administrations, universities, third sector, professional associations,
suppliers, etc. can join. Marc Alabert has very appropriately named it the
Dipsalut community.
All this reflection and management effort to set up Dipsalut –even if it only
has 30 months of existence– has already yielded some important results,
as municipalities in the Girona province have already verified. As a citizen,
however, I would like to emphasize two examples of Dipsalut activity, because
they are a reality that will become a benchmark to improve quality of life: 1)
the “Girona, cardio-protected territory” project, managed by the very wellknown Dr. Ramon Brugada, which has turned the province of Girona into
the most important cardio-protected area in Europe. The Faculty of Medicine
in the University of Girona supports this project by providing it with scientific
advice, and the Brugada Foundation and the Medical Emergency System
also collaborate with it. 2) The “Urban health parks and healthy itineraries”
project – the biggest project in a public space in the Mediterranean area (181
health urban parks in 120 municipalities and 1,200 km of healthy itineraries
in 105 towns).
And I would like to finish with some words about the author of this valuable
book, who is a symbol of the enthusiasm and efforts of all the individuals who
have taken part in the creation and in consolidation of Dipsalut. In 2009, I had
the opportunity to meet Marc Alabert and Natàlia Alcaide, when they told me
that they had decided to take the Public Management Master at ESADE, with
the aim of completing their training and to continue to design and implement
Dipsalut. And I must say that very few times have I seen such a quick and

18


sound process of assimilation and implementation of our teachings in public
health, such as the brilliant presentation of their final project showed. Marc
Alabert is an example of a professional public manager who is able to turn
an ambitious and brave political mandate into reality with the collaboration
of a motivated and efficient professional team, which has been the key issue
for the consolidation of this innovative experience. He has also shown that
he can apply both thinking and action, and he has the necessary sensitivity
to set up a network of professional and personal commitments that have
contributed to institutionalizing a public management model that is going to
become a benchmark in the local health world.
IIn such a complicated and hard time as the present one, where people are
disoriented and uncertain both at the public and private level, the Dipsalut
example illustrates the Chinese saying that goes: “It is better to light a candle
than to curse darkness”.
Manuel Férez
Professor at the ESADE Governance
and Public Management Institute
Ramon Llull University

INTRODUCTION

The paradigm of public management is changing. And it is changing very
quickly, boosted by the present economic and financial crisis that has an
impact on the whole public system, especially on local administrations, which
have traditionally been underfinanced. Therefore, there is a period of reforms
that cannot be postponed, and that will affect all public administration levels
and turn intermediate administrations into the focus of debate.
New issues on the new public administration will be discussed, e.g. new
organizational models, the role of intermediate administrations, the political
and technical space, new management figures (public managers) and
leadership for a change of model.
A natural evolution has taken place in service provision to citizens by (large
and small) municipalities, i.e. from municipalities that acted as regulators
(licenses, permits, basic services… and their functions according to the
law) to more complicated service provider municipalities. In most cases,
this process means enlarging the structures of local administrations. That
enlargement, however, has not occurred in a framework with working
proceedings and relationships that are different from those in strictly public
administration, which has significantly decreased competitiveness in the
public sector, i.e. complex services (nursery schools, business centres, elderly
people’s homes…) are produced in a not very flexible and highly regulated
legal framework, which means having to invest more resources to provide the
same services, and transferring the demands from functional management
into administrative structures.
The present analysis does not have any doubts about civil servants’
professionalism. As Longo states (2010), most civil servants are individually
regarded as competent and devoted. The problem arises when public work,
as well as management procedures that regulate it1, are observed from a
general perspective.

1 Longo, Francisco. Civil Servants’ Productivity. El País, 21/11/2010.

20


This low competitive provision service context, as well as the dramatic
decrease of funding in local public administrations, leads to generating much
more efficient management systems, and also service production structures
(public, public-private or private structures) that evolve from the local level to a
supra-municipal framework.
In this scenario, intermediate administrations have a key role, especially in
provincial councils, due to their financial capacity and territorial reach.
Municipalities become more demanding before higher administration structures,
so that they are offered solutions to the existing paralysis due to the lack of
resources. There is a risk of offering the ever-present solutions to structural
problems, i.e. municipalities should not only be offered financing solutions
so that they could reduce the pressure they are under due to their level of
indebtedness. Instead, management solutions (a “management shock”2)
should be offered for higher efficiency in the permanent provision of services
from the municipality, which are globally oriented to improving competitiveness
in the public sector. This is a key issue in all the work in the present book, where
we can observe a successful model in this respect.
The new public management models also involve reviewing the level of political
intervention in technical management, a space called political management3 by
Moore. The public manager figure is developed in that environment. He/she should
manage, in accordance with political guidelines, the public service production.
This is an emerging figure in the public management background, which has
already been foreseen in the civil servants’ basic statute, although it is not very
much in use yet. This figure is also promoted by the Generalitat of Catalonia in
the 2011-2014 Government Plan.4 Public managers will have a key role in the
local public management professionalization process, especially in exclusively
service-based organizations. According to Mintzberg, public management is a
mix of a high dose of skills and a certain degree of art and science that lead to a
profession that involves, above all, practice, which especially is a practice5.
A transformation process in public administration, and even more clearly in local
administrations, has started. It is a point of no return. Society changes, citizens’
2 Moore, Mark H. Strategic management and creation of value in the public
sector. Paidós Iberica, 1998.
3 In its axis 7 (out of 8) the 2011-2014 Government Plan includes sis items
which focus on the reform of the Generalitat and which, among others, aim at
«including the figure of the professional public manager».
4 Mintzberg, Henry. Managers not MBAs: A hard look at the soft practice of
managing and management development. San Francisco: Berret-Koehler
Publishers Inc., 2004.
5 Report on the review of the Catalonia territory organization model. Parliament
of Catalonia, December 2000.

Introduction

21

requirements from public administration evolve, services required are more
and more complicated and segmented, and types of management and public
models must change. This process has raised some debate at many attempts.
From a theoretical framework, multiple debates have led to different models
and nuances, depending on the school that promotes them. On the one hand,
works such as the Roca6 report, commissioned by the Parliament of Catalonia
in 2000, already proposed a territorial and administrative reorganization of
Catalonia. This proposal puts forward a key issue, i.e. the efforts to improve
public administration and to guarantee equity in access to public services for
all citizens will involve renouncing some powers which have always existed in
municipalities and which, in a scenario of common structures, will remain at
the supra-municipal decision-making level and, in some cases, even at the
technical level.
In the way to achieving higher levels of competitiveness in the local public
sector and, in a broader sense, in the change of cycle in public management,
public professionals will be required to make important efforts. This change
comes from within the system and will be led by silent technical leaders.
According to Badaracco: “A discreet leadership carried out by people who
act in a sensible and gradual way, who do not call for attention. Even if this is
a slow leadership, it is usually the quickest way to improve an organization,
because most important problems can only be solved through long doses of
small efforts”7.
The aim of the present essay is to share the knowledge generated in the
Dipsalut design and implementation process. This organization has been
structured into a model that could be considered as “modern administration”.
This entire process has generated much debate and many doubts, and it has
also unveiled the legal, organizational, technological and cultural limitations that
arise when innovation is applied in public management. This process has been
structured from the perspective of the intermediate administration, which is
committed to supporting municipalities. Although it develops the relationship
with the municipality model, it does not analyse in depth the citizens’ perspective
(demands, types of representation, etc.). This would be a different debate.
To summarize, this is a chronological and well-documented report that aims to
reflect on decision-making in the different phases of the Dipsalut model, and
to contribute to raising further debate about the modern public administration.

6 Badaracco, Joseph L., Jr. Silently leading and with excellent results. Ediciones
Deusto, 2006.
7 Regulatory Law of the Local Regime Basis (7/1985).

PART I.
PUBLIC HEALTH AND
LOCAL LEVEL: AN
OPPORTUNITY FOR THE
PROVINCE OF GIRONA

People live and carry out their working and social activities within the municipality,
where the city council is the closest public administration to citizens. For this
reason, the legislation has gradually transferred many competences and
responsibilities to the local level.8 However, these increased responsibilities are
often not accompanied by the resources required to implement them.
Both the national government and the regional governments have gradually
increased pressure and responsibilities on the municipalities. Territorial
situations, however, vary greatly and there are many different types of
municipalities. Big cities and their metropolitan areas are not the same as small
inland rural villages. Therefore, the ability of these towns and cities to manage
their competences and duties is different and almost always very limited.
The province of Girona is no exception. It has a resident population of 752,026
people living in an area of 5,835 km2, plus a seasonal influx of 2,982,771
visitors, who account for 10,142,299 overnight stays2 –an essential element
to be taken into consideration when calculating the need for public services. In
addition, there are many second homes in the province.
Girona consists of 221 municipalities, 70% of which have less than 1,500
inhabitants. Except for the cities of Girona and Figueres, which are inland cities,
all the other big municipalities are located in the south of the Costa Brava, and
in the Baix Empordà, Selva and Alt Empordà counties, where most people live.

8 Idescat, 2010.
9 Gil Tort, Rosa María. «Medical care», Cuadernos de la Revista de Girona, No. 112.

26


Within this context, supra-municipal governments, such as provincial councils,
are important, as their aim is to rebalance the territory. These councils use
state funds to support municipalities and prioritise the needs in each territory,
i.e. not all provincial councils act in the same way or with the same intensity
in the different areas of activity, nor do they necessarily follow similar patterns.
Historically speaking, Girona Provincial Council’s main activity has consisted
of financing municipalities and its organisational structure has been set up
in accordance with this pattern. Over the years, the municipalities have
increasingly required technical support more than just financial support. The
council has responded by providing services in an increasingly structured
way.
In order to promote this growing area of action, Girona Provincial Council
created two independent organisations, whose aim strictly consists of
providing technical support to municipalities: 1) XALOC (the local tax collection
and advisory network), whom most municipalities in Girona have delegated
their tax collection function to, and, later on, 2) Dipsalut, responsible for public
health issues at the municipal level.

1.1 Provincial Council, health and financial resources; historical
perspective
In order to understand the context in which Dipsalut was set up, we should
look back at the process followed by the Provincial Council in connection
with health issues. The relationship between provincial councils and charities,
hospices, hospitals and psychiatric centres has evolved differently depending
on the territories.
With the 1849 Public Charity Act, the national government transferred
responsibility for the poorest sick people to the provincial councils. Centres
such as the Santa Caterina Hospital were taken over by the Provincial
Council, becoming provincial institutions that cared for citizens from all the
Girona Counties.10 Later on, the Provincial Council bought the property Mas
Cardell in the town of Salt, where mental health patients started being cared
for from 1891. In 1931, responsibility for the Salt Psychiatric Hospital and the
Santa Caterina Hospital passed into the hands of the republican Generalitat
(Catalan government) for a short period of time, until returning to the Provincial
Council again in 1940.

10 Sentece of the Constitutional Court, 48/2004

Part I. Public health and local level

27

At the end of the Spanish political transition, the 1986 General Health Law
was approved with the aim of organizing the national health system, by
decentralizing it and, thus, allowing the country’s autonomous communities
to create their own health services. In Catalonia, for example, the Catalan
Health System was set up. Then, in 1990, the Catalan Health Regulation Law
–as well as a later decree from 1992 (167/1992)– transferred the ownership
of the health centres and services managed by Girona Provincial Council to
the Generalitat of Catalonia.
In accordance with Decree 87/1994 of the Generalitat of Catalonia this
transfer of ownership meant that the state funds given to the provincial
councils for health services were also transferred to the Catalan government.
This move was not welcomed by supra-national authorities, which insisted
on the importance of maintaining these resources to address the health
needs of municipalities, which should be covered by provincial councils. This
is still an ongoing debate that often depends on the relationship between
the political parties that are in power in provincial councils or in the Catalan
government (Generalitat).
Lleida and Girona Provincial Councils appealed against this decree from the
Generalitat, and in 2004, a sentence was pronounced by the Constitutional
Court in their favour, which stated that the transfer of local funds to the
Generalitat violated the local and financial autonomy principle, and that the
resources granted by the national government to the provincial councils
should be used to finance the actions of the latter.
Girona Provincial Council, which owned the health centres that were
transferred to the Generalitat, recovered some of the resources that it had
given up for lost in 1994, although they were to be used exclusively for
health purposes. A report from Martín Bassols, a well-known professor in
administrative law, concluded that these resources could be used to support
local entities for covering public health issues which municipalities are
responsible for. This then led to the idea of creating a public health technical
tool to support municipalities.

1.2 Public health and municipalities; duties
Under the Catalan Health Regulation Law (15/1990), public health became
one more service in the Catalan system and, thus, a right for all citizens.
Thirteen years later, in 2003, the Health Protection Law was approved. This
was a first step towards the regularisation of public health actions –in this

28


specific case, of health protection actions. The Law introduced the concepts
and activities associated with health protection, it details risk evaluation and
management, and proposes the creation of the Health Protection Agency
(APS). The Health Protection Agency would include all health protection
services and activities which the Generalitat is responsible for, and would
also provide technical support and minimum services to local bodies that
request them.
In October 2009, the Catalan Public Health Law (18/2009) was passed.
This law encompasses a broader framework and develops some principles
included in previous laws. It also defines public health, regarded as the
different organised actions of both public authorities and society, through the
mobilisation of human resources and materials, in order to promote people’s
health, to prevent illnesses and to care for public health. In accordance
with the text approved by Parliament, public health stands for the health
of the population, and it largely depends on structural and environmental
factors, such as education or security, but also on factors related to lifestyles,
such as consumption of tobacco, physical activity and nutrition. In fact, life
expectancy has increased in the last century in Catalonia, especially due to
an improvement in hygiene, nutrition, housing and work, and also to progress
in health care.
As for public health services provided by local entities, the 2009 Law
increased the competences held by municipalities by including the control of
tattoo, micro-pigmentation and piercing businesses. It is worth remembering
that the 2003 Health Protection Law had already increased local authorities’
minimum services by granting them competences in health education, risk
management of water for human consumption and risk management of pets
and peridomestic animals.
City councils must therefore provide some minimum public health services,
such as the following:
• Environmental pollution health risk management.
• Public water consumption health risk management.
• Management of health risks in public facilities and inhabited places,
including swimming-pools.
• Management of health risks in tattoo, micro-pigmentation and piercing
activities.
• Management of health risks from food products in retail and service
activities, and in direct sales of processed food products to consumers
- as a main or a secondary activity in a business, whether such products
are home-delivered or not –in relation to the local sphere and to urban
transport. The delivery of processed food products to groups, to other
businesses or to points of sales is excluded.


29

• Management of health risks from domestic animals, pets, urban wild
animals and pests.
• Mortuary health police at the local competence level.
• Health education within local competences.
• The other public health activities which city councils are responsible for,
in accordance with the regulation in force on this issue.
The local level is still responsible for competences in public health related to
health protection, but it does not receive any financial support to undertake
the actions required. In addition, most towns in Catalonia do not have the
knowledge or the technical and financial capabilities to comply with these duties
and, as this is a sensitive issue, in the event of an incident/accident, the local
councillor who is responsible for such a competence could be charged with a
penal offence.
In accordance with the regulation in force, the Federation of Catalan
Municipalities and the Association of Catalan Municipalities, together with the
Health Protection Agency (the future Catalan Public Health Agency) agreed upon
the provision of some minimum services. This means that the latter agrees to
support municipalities as much as possible. Although this is a good agreement
from the local level, it has been implemented in an irregular and intermittent way.
From the local perspective, the Public Health Agency in Barcelona (ASPB) and
Barcelona Provincial Council are the two institutions that have most actively
supported city councils in public health issues. If we focus on the Girona area,
however, very few municipalities fully understand their duties in this field, let
alone undertake any action, apart from exterminating urban pests, or controlling
and chlorinating drinking water –which is sometimes done by the companies
who are responsible for supplying it.
There are two good experiences, but with a very local reach and impact: 1)
Girona City Council has been very active and efficient in the development of
public health actions; and 2) the SIGMA consortium (Olot City Council and
Garrotxa Provincial Council), which guarantees the provision of technical
services to the municipalities in the area.
Although some other city councils also have highly qualified technicians, they
lack the necessary financial resources and political support to promote public
health actions –which are not very well understood and lead to poor political
performance.
In the light of this situation, we could conclude that a public health service that
supports municipalities in Girona is required, and also that Girona Provincial
Council, due to its importance at the local level and to its financial capacity, is
the most capable organisation to lead it.

30


1.3 The creation of Dipsalut
The recovery of resources and the need to support municipalities in their public
health competences led to the creation of Dipsalut –promoted by Jaume
Torramadé, who was then the vice president of the Provincial Council. Dipsalut
is an independent governmental organisation11 with its own legal status and
under the responsibility of Girona Provincial Council, which it reports to only to
approve its budget and staff, and to carry out the activities of its Secretariat,
Intervention and Treasury Departments.
This entity did not become active until the 2007-2011 mandate. After the local
elections in May 2007, the new Provincial Council was set up. This time, the
relationship between the political parties was different to the previous mandate.
Josep Marigó, the provincial representative, became its president and assumed
responsibility for starting up the new entity. Thanks to his experience as mayor
of a large town (Blanes), he was very well aware of the situation and difficulties
municipalities face when managing public health responsibilities. Marigó
wanted an organisation that was agile, modern and close to the municipality.
Rather than limiting that organisation to just providing financial support, he
considered the possibility of providing services to cover the lack of technical
capacity in municipalities. This vision was also provided by Torremadé during
the process of creating the organisation in 2007. These ideas had an impact
on the nature of Dipsalut.

1.4 Background and political agreement
The recovery of the earmarked resources and the creation of Dipsalut generated
some debate about its use and aims. Some people advocated transferring
resources to municipalities so that they could manage them directly. Others
considered that the funds should be delivered to provincial councils throughout
the lifecycle of the programme agreement –with provincial councils acting as
technical operators for the municipality. In this debate, some other people
preferred Dipsalut to be turned into a technical tool for services at the provincial
level, based on a modern and agile governmental model. This last idea was
established and supported by all the political representatives on the Dipsalut
Governing Council.
The key to Dipsalut’s success is the ability to reach political agreement with all
political parties within this organisation who share an ambitious, generous and
long-term vision, according to which Dipsalut would become a benchmark

11 The plenary session in the Regional Council in March 2007 approved the
creation of the Public Health Independent Organization in the Girona Regional
Council.


31

organisation due to the nature of its activity, as well as an example of proximity
to the local level in Girona and of modern government.
These trends started the process of elaborating and designing this organisation
and its model.

1.5 Guidelines for the construction of an innovative organisation
The answers to what should be done and to how to do it formed the guidelines
for developing the Dipsalut philosophy as well as the organisation and service
model that would be structured.
In September 2007, the first Governing Council of this organisation was set
up, and a preliminary study was commissioned from the Hospital Consortium
in Catalonia (the present CSC). The study identified some organisational
and service guidelines that should be developed. In June 2008, when the
managing director –a statutory position–was elected, the strategic diagnosis
and planning process that led to the implementation of the service model
started.
The mission (What should be done?) consisted of providing technical and
financial support for municipalities in order for them to comply with their
public health duties, and carry out projects to improve citizens’ quality of
life. The mission reflected the priority of providing services for municipalities,
especially for them to comply with their responsibilities (health protection) but
it also marked a horizon of new guidelines for citizens, i.e. it opened the door
to health promotion.
As for its vision, Dipsalut aimed to become a benchmark in the design and
implementation of local public health policies and programmes designed
to improve citizens’ quality of life. What are the future trends designed by
the vision? The most relevant element is its will to go further, to become
a benchmark. This means accepting leadership, supporting innovation and
generating, publishing and sharing evidence, both on what to do and in how
to do it.
Often overlooked in the world of management, mission and vision are
two important elements that make up the purpose and aspirations in an
organisation, and which should be taken into consideration when we have
doubts about where to go or how to approach a critical situation.
These principles accompany the decision-making process of this organisation.
Most of the steps would not be understood without these two parameters.

32


1.6 Defining transformation
Public policies can be considered as a circular flow with the main phases
below: definition of the problem; formulation of alternatives; decision-making,
implementation and evaluation. The process starts by defining the problem
and including it in the public agenda, i.e. on the list of items which public
powers must take decisions about. The way a problem is defined and the
terms used to define it, rather than being neutral, directly determine the
framework in which the different alternatives in public policies will apply
(Subirats, 2008).
Public policies are often confused with their short-term results or output,
ignoring the fact that policies should contribute to generating a visible medium
and long-term transformation, known as the outcome.
Let us imagine a municipality with different districts separated by a holography
of land and by communications that do not favour the interrelation of such
districts. Each one of them develops its own different consciousness, and
there is no sense of belonging among citizens. Under these circumstances,
it is likely that the city council could consider the possibility of changing this
situation. The first step might consist of deciding what the precise outcome
would be, for example, “to unite the districts in order to generate one sense
of belonging”. This would translate into different policies that would generate
interdepartmental programmes and intergovernmental participation (regional
government, national government, provincial council, county council) and
citizens’ participation (neighbours’ associations, traders’ associations,
entities…) in order to change the road networks and, therefore, make
mobility between the different districts easier and distribute the different
public facilities among them to increase mobility, which would turn into very
evident outputs: roads, facilities, activity planning, etc., leading to achieving
the transformation required.
Going back to the case of Dipsalut, its final goal, the situation that it wishes
to change (outcome), is to improve citizens’ quality of life in municipalities in
Girona. And it aims to do so by reducing the elements in the environment that
generate a risk for people, as well as by providing citizens with a higher level
of health, by empowering them to manage their health and by providing them
with the tools and knowledge required.
This goal can be achieved in different ways, which consist of:
I) Providing municipalities with services and resources, and by defining
a set of technical standardised programmes that cover the needs in
municipalities.
II) Giving precise and limited financial support for specific investments
and actions. Promoting investments to reduce risks and obtain tools for
improving quality of life.


33

III) Reinforcing the capacity of third parties (other governments, university,
non-profit-making entities…) with networks in the territory and power
of transformation. When we consider taking action in order to improve
citizens’ quality of life, we should avoid applying a general vision. The
need for improvement and the way to achieve a higher quality of life are
not the same for everybody, and even less for groups affected by illnesses.
Therefore, associations of people affected and specialised entities are
key tools for the design and implementation of programmes with the
aforesaid aim. The fact of reinforcing their capacities –through financial
support and investment in goods–contributes to that aim. In this respect,
Dipsalut has made an outstanding contribution towards consolidating
studies in Medicine at the University of Girona. Beyond the items in public
health in the different degrees, the presence of this faculty allows for the
development of a common work and of permanent training resources for
the municipality.
IV) Promoting innovation. Innovation –as well as the definition of public
policies– is a key issue in public management. It reviews processes and
incorporates technology that improves efficacy, efficiency and effectiveness,
thus reducing time and costs, and accumulating knowledge. The demand
for public services required in the future should also be foreseen; this is
a complex and indispensable diagnosis. Demography, social changes,
migrations, energy, etc. are challenges that will require different, new or
evolved and more complicated services from the government.
One of the most important elements in the provision of public services
(and, especially, of social and health services) in Europe is the projection
of ageing. Dipsalut has promoted the MESGi55 study (a multidisciplinary
study about healthy ageing in Girona) with the aim of analysing the ageing
situation of people in Girona and, thus, to project which policies and
services should be provided by the government and, more precisely,
from the local level. This study, which is in the design phase, is led by
a committee of well-known scientists in Girona with the participation of
a panel of international experts and it falls within the framework of other
benchmark studies, such as the Health and Retirement Study (USA), the
English Longitudinal Study of Ageing and the Survey of Health, Ageing
and Retirement in Europe. A sample of 6,000 people over the age of
55, which is representative of the Girona municipalities, will be analysed
in order to study the impact of environmental, social, psychological,
biochemical, genetic and health factors, as well as the lifestyles that
favour a satisfactory ageing process.

34


1.7 The relational framework
Beyond its correct design, the success of public policies is directly related to
its ability to generate alliances among the different agents in the working area
where a specific policy is applied. The aim of policies is to change a situation.
Such change can rarely be achieved by just one organisation because there
are many diverse elements related to the achievement of the results required.
Besides this, it should also be taken into account that different policies
promoted by different stakeholders often seek the same transformation. Where
is the sense in not setting up a common strategy and developing programmes
that address different elements of the same outcome?
This is why it is important to have a defined and structured relational plan that
determines the alliances required to define actions and to generate legitimacy
and, therefore, to guarantee the objective and minimise the risk of failure. This
is not a static element. On the contrary, it should be permanently evolving
and adapting to the changing situation.
Figure 1 – Dipsalut relational model diagram

Concurrent
administrations

Ser
vice
ca
tal
og
ue
Health
age
nts
ne
tw
o

DIPSALUT

MUNICIPALITY
City Council

rk

Non-profit Organisations
Professional associations,
associations, foundations

CITIZEN
Groups

Dipsalut has developed a relational diagram based on two key axes (figure 1):
the Dipsalut-City Council axis and the Dipsalut-Citizen axis, while being well
aware of the fact that the first axis encourages the City Council-Citizen axis.


35

Both axes interact with groups of agents who actively work in the area of
public health policies or initiatives and services in the broad sense. In the
first group, there are the participating governments with public health
responsibilities, competences or programmes (Generalitat of Catalonia,
public consortia, county councils, among others.) In the second, more
heterogeneous, group, there are professional associations, organisations
of people suffering from different pathologies, non-profit organisations,
foundations, educational centres, universities, etc., who take specific actions
in their respective environments and who contribute with a great capacity
for influencing and spreading awareness among the different populations.
While being strengthened by public support, they often act in areas which
governments do not have the capacity to reach. The diagram above shows
the relational flows in the organisation in this initial implementation phase and
helps to identify the existing stakeholders in the ecosystem where we are
interacting.
Actions in public health policies (as in most public policies) require
the aforesaid collaboration. A public policy not based on a multilevel
intergovernmental relationship in collaboration with the third sector will very
rarely be a successful policy. Links with international institutions are also part
of the relational dynamic, and the objective is to share knowledge about
experiences and best practices.

PART II.
THE KEYS OF THE MODEL

Three ideas should be developed: definition of the action areas, analysis
of public health in the Girona province before Dipsalut and definition of an
organisation model.

2.1 Health protection: idea of risk management
Unlike other governments with health authority functions (basically, the Generalitat
of Catalonia and, in some areas, city councils), Dipsalut does not have any explicit
competences and, therefore, must consider the role it wants to play. Although it
would make sense for city councils to delegate their public health competences
to it, Dipsalut was against this idea, as it considers that the municipality should
be provided with such authority.
Instead, Dipsalut selected the option of risk manager, i.e. it decided to act as
a public supplier of public health solutions. From the user’s perspective, as the
owner of facilities, the city council should abide by the regulations in force on
health measures and, at the same time, it is subject to inspections from a higher
authority (in this case, the Generalitat of Catalonia, through its health agencies.)
Within this context, Dipsalut executes all maintenance, disinfection and analysis
actions required in accordance with regulations in order to guarantee the
compliance of the publicly owned facilities.
Besides this, the city council must guarantee compliance with health guarantees
in private centres/facilities with public attendance. Otherwise, it will be the
subsidiary responsible in the event of an accident or bad practices. This fact
applies to private swimming-pools (in hotels, campsites, etc.), to food businesses

40


(butcher’s, fishmonger’s) and to other activities (piercing, etc.). This organisation
carries out the screening visits required by the city council, which it then delivers
a report to. Due to the fact that Dipsalut is not a health authority, this is not
a binding report. However, in the event of serious deficiencies, it alerts local
technicians and contributes to announcing preventive measures.

2.2 Health promotion
In order to develop health promotion policies that improve quality of life, it is
necessary (and it is not a trivial issue) to define and limit the health promotion
concept. This definition establishes the nature and the objectives of the health
promotion programmes in this entity.
Health promotion has often been mistaken for disease prevention. This is a
reductionist perspective, and it is related to the principle that considers health
as lack of illness.
With the Ottawa Charter,12 a new dimension was added to the definition of health
promotion, which was then considered as the process that allows people to
increase control over their health, so that they can improve it. It is described as an
empowering process for both individuals and community to improve a series of
determining factors that have an impact on health. It is, thus, a process designed
to emphasise people’s abilities and capacities, so that they can take action as
individuals and as a group and can have control over the determining factors that
generate health and, therefore, they can achieve a positive change.
The determining factors of health are the personal, social, economic and
environmental factors that determine the health condition of individuals and
populations (WHO, 1998), such as: behaviours, life-styles, socio-economic
level, educational level, job status, physical environment, age, gender… It has
been proven that there is a direct connection between social determining factors
and health. The cultural level, academic failure, participation in society, place
of residence, access to new technologies, gender, etc. have a direct impact
and determine people’s health and life expectancy. Therefore, when it comes to
designing health promotion policies, multidisciplinary actions should be taken
into consideration, i.e. in order to have better health, action should be taken in
very different areas, which multiple stakeholders are responsible for.
Starting from a positive perspective about health and about the ability of both
people and communities to generate health, Dipsalut considers action in health
promotion as the optimisation of public resources when it comes to implementing

12 World Health Organization, Otawa Charter for health promotion. Otawa
(Canada), 1986.

Part II. The keys of the model

41

local public health programmes, projects and actions in order to promote a better
quality of life. Thus, Dipsalut suggests the implementation of actions that include
the determining factors of health and that provide people with tools so that they
can understand, manage and give a sense to their lives –thus promoting healthy
life-styles–, as well as actions that increase people’s control over their health and
over the determining factors of their health, so that they can improve it. Dipsalut’s
value proposal to municipalities is generated from this perspective.

2.3 Diagnosis: local public health in the province of Girona before
Dipsalut
If we look at the existing literature, we find recent studies that attempt to
analyse public health management from the local perspective. In 2001,
Líndez et al.13 analysed the role of large and medium-sized municipalities
(more than 25,000 inhabitants) in connection with public health. Their main
contribution consists of distinguishing between functions in public health
(needs evaluation, generation of policies, guarantee of provision) and activities
in public health (epidemiological vigilance; health protection, prevention and
promotion).
In 2004, Barcelona Provincial Council also published a study about
expenses first in municipalities with more than 20,000 inhabitants and then
in municipalities with more than 10,000 inhabitants.14 This study provides
interesting information from the perspective of large municipalities (expenses
generated, management structures, service provision…), which cannot easily
be transferred to municipalities in the Girona province.
Two more recent studies, one from the Health Department, coordinated by
Xavier Llebaria15 (2010), and another one promoted by Barcelona Provincial
Council (2010),16 delve deeper into the analysis of public health at the local
level. The first study focuses on the public health activities, services and
structure in municipalities of more than 10,000 inhabitants. The second study
analyses the variables that determine the existing differences in public health

13 Líndez, P. et al. Public health functions, activities and structures. The role of big
and medium-sized municipalities. Gaceta Sanitaria, 15, 2001.
14 Barcelona Regional Council. Expenses in public health in municipalities in
Catalonia, 2004.
15 Llebaria, X. (coord.) Public health service activities and structures. Study in
municipalities >10,000 inhabitants. Generalitat of Catalonia, Health Department,
2010.
16 Barcelona Regional Council. Public health municipal management. Municipalities
>10,000 inhabitants in the Barcelona province, 2010.

42


among municipalities with similar characteristics. Despite the progress made
studying the situation of public health at the local level, there is an important
lack of information and limited access to data about smaller municipalities. In
this respect, Dipsalut could provide significant information in the near future.
In order to make Dipsalut evolve, it is absolutely vital to gain a snapshot of
public health at the local level in the Girona province. How many risk elements
are there? Who is acting on them? Who is not doing anything about them?
Are there any health promotion activities being carried out? What do they
involve? In what groups are they being carried out? What financial contribution
are Girona’s local authorities making on their own in these areas?
Different options were evaluated, and finally an extra subsidy was proposed,
so that all municipalities could recover part of their investments in public
health. This subsidy was announced in October 2008, and was retroactively
applied to actions undertaken during that year. It consisted of €2 million,
and minimum staggered funding of between 50%-90%, depending on the
type of municipality, was guaranteed. This was Dipsalut’s first action towards
municipalities.
This analysis has some obvious methodological limitations, apart from the
lack of knowledge in municipalities about health protection and promotion
items. In order to minimise such limitations and to gather as much (reliable)
data as possible, dissemination actions were carried out about the concepts
where a subsidy could apply.
A great deal of data was gathered, which was used to create a georeferenced
file of actions and risk objects, in order to generate an activity map and a
preliminary register of facilities. Thus, it was possible to conduct a detailed
analysis of actions undertaken in municipalities (with suppliers and costs) and
to highlight the actions that should be carried out but were not.
From this data, we observe that municipalities with less than 1,000 inhabitants
barely took part in this announcement (19%). After looking further into the
reasons for this, it is clear that most of these municipalities do not comply
with, or even know about, their responsibilities in public health. Out of the
221 municipalities in this province, at least 107 (48%) have been supported
by this announcement –67 of them in health protection and 75 in health
promotion. The other 117 (52%) municipalities have probably not taken any
action in these areas. The €1.9 million awarded (chart 1) can be grouped
into the following concepts: 1) health promotion actions, €967,011; 2) health
protection actions, €702,811; 3) justified and urgent actions (investments in
health risk issues that cannot be postponed) €159,626; and 4) a series of
other actions, €155,759.

43


Chart 1 – Distribution by concepts (2008)
155.759,00 €
159.626,00 €

967.011,00 €

Health promotion
Health protection
Justified urgency
Miscellaneous

702.811,00 €

The geographical analysis of the most active areas indicates large areas in
the province where no public health actions have been carried out (Figure 2).
Figure 2 – Health protection and promotion actions (2008)

Municipalities with 4 - 8 requests
Municipalities with 1 - 3 requests
Municipalities with 0 requests

Most protection activities are organised in cities and large towns – the
same as for promotion activities, and also in medium-sized cities and some
smaller cities.

44


Health protection actions
A detailed analysis of the health protection actions carried out in municipalities
reveals that the bulk of the resources granted to protection actions were
spent on actions related to urban pest control and peridomestic animals
(accounting for 43.7%). This was followed by drinking water (15%), and high
and low risk Legionella prevention (requested by 21 municipalities, 10% of
municipalities in Girona), 13.8% of resources. Thus, in municipalities that act
in health protection, 72.3% of the investment is dedicated to pest control,
drinking water and Legionellosis prevention. The incidence of these actions,
both in volume and nature, is low; generally little action is taken and it is partial,
and not all areas of responsibility are covered. The smaller the municipality is,
the lower the level of action in these areas. Out of 31 municipalities with less
than 1,000 inhabitants (INE, 2008), only 24 of them take some type of health
protection action.
Health promotion actions
34% of municipalities in Girona have requested some support for health promotion
actions carried out in 2008. Within the context of the announcement, promotion
has been interpreted in a large sense. Nevertheless, in the near future, it will be
reviewed by Dipsalut. Some of the actions that, in this case, are considered as
promotion actions, will be excluded in Dipsalut’s definition of health promotion.
In accordance with requests from municipalities, investment in materials and
equipment, encouragement and physical exercise are the main items –together,
they account for 77% of requests. The remaining items (23%) are: cognitive
stimulation, healthy nutrition, drug dependency, and sexuality and sexually
transmitted diseases (table 1).
Although the data is not very precise, most of the health promotion actions
implemented by municipalities focus on the axes of elderly people –young people
/ physical activity –sports.

45


Table 1 - Health promotion actions in detail (2008)
Area

Actions

Observations

Investments
Equipment for
physical activities

39

Healthy itineraries

21

Acquisition of
defibrillators

3

Purchase of other
materials

4

Municipalities: 49
59% of resources allocated to urban sports
equipment and 32% to path signposting (PAFES programme).
89% of actions aimed at the general population

Encouragement
Different activities

36

Programmes for
specific groups

4

Support programmes

4

Physical exercise
Maintenance

18

Sports promotion

6

Municipalities: 24
83% of resources allocated to different
activities.
54% of actions aimed at the general population and 24% at elderly people
Municipalities: 22
75% of resources allocated to maintenance
activities.
46% of actions aimed at the general population and 54% specifically at elderly people.

8

Municipalities: 8
All resources (100%) specifically aimed at
elderly people.

Workshops

5

Talks

2

Campaigns

1

Studies

1

Municipalities: 6
62% of resources allocated to studies and
38% to miscellaneous activities.
78% of actions aimed at young people

Cognitive stimulation

Nutrition

Drug dependency
General and
cross-cutting
programmes

7

Smoking

1

Alcoholism

Municipalities: 6
94% of resources allocated to general programmes.
67% of actions aimed at young people.

1

Sexuality + Sexually
Transmitted Diseases
General and
cross-cutting
programmes

5

AIDS

2

Services

1

Municipalities: 7
44% of resources allocated to AIDS programmes.
100% of actions aimed at young people.

46


Conclusions:
Municipalities with less than 1,000 inhabitants do not carry out any public health
activities. An unequal and partial level of actions is undertaken in the remaining
municipalities. Most actions are organised in the biggest cities.
• In health protection, activities are related to pest control and drinking
water.
• In health promotion, activities are mostly related to physical activity and
sports.
Based on this study, three future working guidelines can be proposed:
• To define an offer of standardised public health services for the municipalities
in this province, totally or partially financed through recovered earmarked
resources.
• o create a public health structure of technicians who act closely with the
T
municipality. This is especially necessary in small municipalities.
• o define and limit health promotion working areas, target populations and
T
scope.

2.4 From the subsidy model to the service provision model
After defining the organisation’s philosophy and analysing the situation, the
province started the migration process from the subsidy model to the service
provision model.
The service model should be based on efficacy, efficiency and also effectiveness.
These elements do not exist when a subsidy model is selected. Intermediate
governments too often prefer to make a general redistribution of resources, mainly
in accordance with socio-demographic criteria, and without knowing the impact
they wish to produce. There is no doubt about the distribution of resources or
about the sources of funding in local authorities, however, in most cases funding
becomes the aim in itself. This funding could be used by the target populations
in similar projects and could generate synergies and efficiencies among them.
And this is even more significant when funding should be used to build public
facilities. We should move from facilities that, due to their proximity, will compete
with each other (in order to achieve a given number of users and, thus, to be
able to ask for maintenance support, or to hold events…) to complementary
facilities that generate an inter-municipal balance. Sometimes, when equity is
misunderstood, it leads each municipality to build its own sports pavilion and
(often indoor) swimming-pool, which are underused and consume an important
part of its resources. If a funding-based model is selected, it would be better to
define some policies that are agreed by consensus and that generate funding
programmes for specific aims.

47


Reviewing in detail the subsidy announcements made by Dipsalut in 2008, it is
obvious that the purchase of these services, by different municipalities from one
or many suppliers, could be highly inefficient and lead to municipalities paying
up to ten times more than necessary for the same service. On the contrary,
a service-oriented model allows the activity being developed to be designed
in detail, objectives to be set, processes specified, for it to be executed or
outsourced, and the results evaluated. And this all can be achieved before any
action starts to be carried out, i.e. results-oriented planning.
Thanks to standardisation and activity management, outstanding levels of
efficiency can be achieved. If the territory and people living (groups) in it are
clearly understood, programmes can be adjusted for a higher efficacy and
effectiveness. In Dipsalut, efficiency determines the service catalogue, and
efficacy determines the structure of proximity to the territory (the health agents’
network). See Figure 3.
Figure 3 – From the subsidy model to the service provision model

Efficiency

+

-

Optimum management of resources (capacity to manage volume, to reduce cost)

From the subsidy model to the service provision model

-

Dipsalut 2011/n
Dipsalut 09/10
Service Catalogue

Local Public
Health Plan
Local Public Health
Agents’ Network

Dipsalut 2008

Level of knowledge and indexation of objects / Groups where action should be taken

Efficacy

+

2.5 Service model: functions and features
Bearing in mind the medium-term vision, it is necessary to define the service
model, to specify the team and to build the value proposal. The political
agreement very clearly defines the two action areas: health protection (in
accordance with the local competences determined by law) and health

48


promotion, which states that municipalities can and should become an active
agent in improving healthy habits and, therefore, reducing risk factors that
have an impact on citizens’ quality of life.
Right from the beginning, there are multiple question marks ahead: What
service model do we wish to implement? What is the role of municipalities?
How can the value proposal be built and structured? How could services
be provided (provision versus production)? What human resources are
required?, etc.
When the model is specified, there is a unique opportunity to include some
elements and visions in it that provide the organisation with an innovative,
agile, flexible, cross-sectional and close operation. The model is based on
a reduced organisation with intensive knowledge, a highly qualified and
continuously trained staff, close links with the municipality, an intensive use
of new technologies and technical capacity.
In accordance with the aforesaid, Dipsalut is responsible for the service
programme design, planning and evaluation, i.e. for all the activities with
intensive knowledge, which generate learning and provide direct value to
the mission of the organisation. The activities will be externally developed in
collaboration with both private and public operators. (Figure 4)
Figure 4 – Dipsalut value chain

Dipsalut
Willingness to transform
Outcome
Definition of policies

Programme
design

Service production process
follow-up and evaluation

Service production
Technical capacity in the
market

Result
evaluation
Outputs

Generation of
public value

Impact
evaluation

Market

Considering these first criteria, the model will have the features below.
a) Efficacy: It should be able to effectively act on the risk objects in the
territory (nursery schools, water supply equipment, sports facilities,
swimming-pools, etc.), as well as on groups in risk.
b) Efficiency: The value proposition should include standard services that

49


could be implemented in all types of municipalities, in order to manage a
significant volume that allows for cost efficiency (service catalogue).
c) Own flexible and professional structure: In this model, the design of
policies and programmes, as well as their evaluation, are the responsibility of
Dipsalut. This is mainly a technical structure that should adjust to the service
offer in the organisation and to the intensity of demand by municipalities.
d) Suppliers’ network: The existence of suppliers who are able to cover
the outsourcing activities should be guaranteed; and a rigorous information
system, as well as a protocol for relationships with municipalities, should be
ensured in order to prevent information from being lost and to implement a
proper relationship with local stakeholders.
e) Proximity to the municipality: In order for services to reach the territory
the municipality should have its own local technical team. Due to the fact
that most municipalities in the Girona province are small and have very little
or no public health technical capacity, the health agents’ network is a key
element in this model.
f) Local public health local plan: In order for citizens to reach optimum levels
of risk reduction and improvement in quality of life, public health actions
–protection and promotion activities– should be organised in long-term
plans. This is the reason why they are explained in the local plan that should
be approved by each city council.
Figure 5 – Dipsalut model

Service
catalogue

Technical
support

Training,
dissemination and
communications

Research and
innovation

Municipality
City Council

Resource
centre

Local Public
Health
Information
System
(SIMSAP)

Financing

Local Public
Health Plan

Local Public Health
Agents’ Network
(XASPM in Catalan)

50


This model (Figure 5), the core element of which is the municipality, is based
on three key axes: the service catalogue (solutions/added value), the public
health agents’ network (proximity) and the local public health plan (planning).
These axes are complemented by:
I) Technical assistance. Apart from the standard service programmes in the
catalogue, technicians in the organisation should assist municipalities in all
aspects related to public health that are required – from the elaboration of
reports to intermediation actions between municipalities and higher levels
of government.
II) Funding in the municipality. Investments related to improvements in
facilities or to technology, which cover critical existing deficiencies and
reduce risk factors in a city.
III) Training and dissemination. In the service processes, the municipality
should act in a coproduction scenario. Local technicians, and squads,
gardening, maintenance, reception and sports centre staff… should know
which public health actions are being implemented, as well as which regular
preventive actions should be carried out by the municipality.
All these groups should be trained and empowered. After requesting the
service programme, municipalities are obliged to train the local staff.
IV) Local Public Health Local Information System (SIMSAP). A solution
that turns data into useful information for decision-making actions, which
generates a working environment that interrelates the entire service provision
process (from requests by the municipality) to production, result evaluation,
corrective measures and access to all historical actions.
V) Resource centre. All pedagogic, disseminating and training resources
are made available to municipalities, so that they can use them within the
context of their own programmes.
VI) Research and innovation. Innovation should be constantly implemented
in the organisation. It should be capitalised by generating evidence and
scientific reports. This is part of the vision.
In May 2009, the Governing Council approved this model, together with the
service catalogue. In December 2009, the agents’ network started to work.
And at the end of 2011, the Local Public Health Plan would start to be
implemented.
In order for this organisation to operate, it should be based on four technical
areas (Figure 6): health protection, health promotion and policies, management
and administration, and management and quality information. This is a clearly
customer-focused and process-structured organisation, based on the idea of
proximity to the municipality.

51


Figure 6 – Organisational diagram
Governing Council

Presidency

Direction

Health protection
area

Health promotion
and policy area

Programme
Managers

Administration
area

Information area for
management and quality

Central Services

Local Public Health
Information System

Local Public Health
Agents’ Network

Dipsalut’s staff consists of thirty full-time working professionals and of a main
structure of technicians. These professionals have a dot-matrix responsibility,
i.e. they own one or many programmes, are responsible for a managing
process and take part in internal or external projects.
Due to their nature, the programmes, processes and projects require crosssectional and interdepartmental team work, which often means that the staff
in this organisation has a double dependency – both organic and functional.
Technicians in Girona Provincial Council should be added to this organisational
design. They are responsible for some functions that have been delegated to
Dipsalut, such as the secretariat, intervention and treasury. Their efforts and
commitment to the model designed have been crucial. They have sought
appropriate and necessary legal and fiscal solutions to develop this design.
Some of the supporting processes are related to Provincial Council services
that cover the specific needs in the organisation.
The selection of the Scientific and Technological Park in the University of
Girona as Dipsalut headquarters was the last decision to be taken in the
process of the model design.
The park environment and its location, in one of the best connected areas in
Girona, provide highly technologically equipped spaces and facilitate a direct
relationship with water, environment, biology and food product research
groups and labs – a real cluster.

52


Dipsalut’s working environment is a determining internal factor for making it
a catalyst for innovation and proving its ever-present entrepreneurial spirit..

Budget
The income of this organisation is mainly based on the transfer of resources from
the national government and also on taxes and contributions from municipalities
involved in some of the programmes.
Overheads (<15% of the budget) are due to staff, consumption, vehicle renting,
consumables, etc.). (Chart 2) The other resources go to the production of
services required by municipalities (50%), to funding investments in municipalities
(18%), to financial support programmes (12%) and to investment in goods for
the organisation (5%).
Chart 2 – Expense budget (approximate)
5%
12%

15%

Structure
Service production

18%

50%

Investments in the municipality
Financial support
Investment in own goods

PART III.
IMPLEMENTATION
PROCESS AND INITIAL
RESULTS

In order to understand the present situation of Dipsalut, the implementation
process of this organisation should be taken into consideration, i.e. on the one
hand, the territorial coverage and service provision, as well as the first visible
results and, on the other hand, the development of the parties that generate its
service model.

3.1 Value proposal and service request
The catalogue includes all the programmes and is the value proposal to
municipalities. The first catalogue was approved in May 2009, for an 18 month
period (2009-2010). The second catalogue (2011), approved in November 2010,
was in force for one calendar year, and continues. It consists of 21 programmes
for the two large areas of activity.
In these catalogues, programmes of a different nature coexist: most are directly
provisioned services, but there are also some financial support programmes. The
latter focus on areas where direct management in municipalities is more efficient
at the moment, with a view to these areas becoming services. Most programmes
relate to health protection, and their aim is to cover municipal responsibilities.
The protection programme design (Table 2) is a combination of local public
health responsibilities and services provided by regional governmental agencies
in this area, in order to avoid duplicating resources and to cover needs in a
better way. Within this context, technical commissions are created. They will
make collaboration easier in those areas where organisations provide the same
services, i.e. in the areas in which all agents are part of the same value chain.
These risk management programmes develop all the actions in regulations for
each type of risk, and they also establish protocols for urgent intervention if
critical risk levels are detected.

56


Then, the municipality involved is informed of the issue and, in parallel to this, first
intervention teams apply the corrective measures required.
Table 2 – Health protection programmes
AREA
Environmental
health

Drinking water

PROGRAMME
Support programme for management and control of facilities with high risk of Legionellosis transmission
Support programme for management and control of facilities
with low risk of Legionellosis transmission
Support programme for direct local management of drinking water supply
Drinking water quality control and evaluation programme
Public swimming-pool hygiene and health evaluation programme
Support programme for risk management in public
swimming-pools owned or managed by municipalities
Beach risk management support programme
Financial support programme for safety, vigilance, rescue and
first aid on beaches

Public facilities
and inhabited
places

Support programme for risk management of children’s sand
areas
Financial support programme for integrated urban pest
control actions
Tiger mosquito (Aedes albopictus) risk control and management programme
Simuliidae risk control and management programmes

Food product
safety

Programme to disseminate control plans in municipal food
production facilities

Technical advice

Advice and technical support programme for local health
protection policies

57

Part III. Implementation process and first resultsy

Although most programmes do not involve a cost for the municipality –they
are financed through the earmarked resources of Dipsalut from the national
government– four of them have a tax (10%-50%, depending on the nature
of the action and on the type of municipality) so that the municipality is also
responsible for the action.
As for protection, the first service catalogue (June 2009 - December 2010)
registered 760 action requests for 2,514 public places/facilities, which meant
9,322 actions for Dipsalut. If this data is matched with the 2008 data, as
well as with data about actions requested and under execution in the first
quarter 2011, we can see a rapid rise in requests for services (Charts 3 and
4). This highlights the historical deficit of actions on local public health risk
management.
Chart 3 - Evolution of the number of requests (2008-2011)
900
800
760

700

776

600
500
Requests

400
300
200
100

67

0

Sub. 2008*

Cat 09-10

2011**

Chart 4 - Evolution of the number of actions (2008-2011)
14,000
12,000

11.739

10,000

9.322

8,000

Actions

6,000
4,000
2,000
0

144
Sub. 2008*

Cat 09-10

2011**

* Information taken from documents on the subsidy announcement in 2008
** Requested in the 1st quarter and to be executed throughout the year

58


There is also a very important growth in the number of facilities where action
is being taken (Chart 5).
Chart 5 – Evolution of the number of facilities where action is taken (2008-2011)
3,500

3.310

3,000
2,500

2.514

2,000

Facilities

1,500
1,000
500
144

0

Sub. 2008*

Cat 09-10

2011**

* Information taken from documents on the subsidy announcement in 2008.

If we compare the periods in Catalogue 2009-2010 and in Catalogue 2011, we
can see a very important rise in the number of facilities requested compared
to the number of requests, i.e. municipalities increase the number of facilities
requested in each service programme request (Chart 6). This is due, on the
one hand, to a better knowledge of the programmes and, on the other hand,
to the public health responsibilities from the municipality and to the activity
of the health agent. This increase could also be interpreted as a high level of
satisfaction with the service received during the previous year.

Chart 6 - Evolution of the no. of requests and of the no. of actions
requested
3,500

3.310

3,000
2,500

2.514

2,000

Requests
Facilities

1,500
1,000
500
0

144
Sub. 2008*

Cat 09-10

2011**

* Information taken from documents on the subsidy announcement in 2008.

59


Figures 7 and 8 show the intensity of programme request by the Girona
province and the evolution between Catalogue 2009-2010 and Catalogue
2011.
programme request – Catalogue 2009-2010

Municipalities with >8 programmes requested
Municipalities with 4-8 programmes requested
Municipalities with 0 programmes requested

programme request – Catalogue 2011


With regard to health promotion, the areas in the programmes in the catalogue
are: healthy nutrition, promotion of physical activity and improvement of
quality of life, shown more precisely in the table below (Table 3)

60


Table 3 – Health promotion programmes
AREA
Nutrition and
physical activity

PROGRAMME
Urban health parks and healthy itineraries programme
Young people’s health and local technical advice service
programme
Dental health programme

Quality of life

Programme on psychological support and assistance in
emergency situations in the municipality
«Girona, cardio-protected territory» programme
Financial support programme on health promotion activities

Technical advice

Programme on advice and technical support for local health
promotion policies

Priorities in promotion are established in accordance with World Health
Organisation (WHO) guidelines. A proposal is presented about the
programmes to be implemented thanks to multiple supports from the Health
Department, the Secretary General of Sports and municipalities, among
other entities.
Unlike protection programmes, promotion programmes have a much longer
implementation process, and some time is required until the first indicators
can be evaluated. Nevertheless, the aim of the urban parks and healthy
itineraries programme is to create 181 health parks and to signpost 1,200 km
of healthy itineraries, while the “Girona, cardio-protected territory” programme
has 500 fixed and 150 mobile defibrillators. These brand new actions stand
out as the most important projects from Dipsalut. In health promotion, over
9,000 children have seen the exhibition “Take care of your teeth”, which is
part of the dental health programme, and over 7,000 children have taken part
in the educational programme about tiger mosquito prevention. As for the
training offer, 40 courses have been organised and over 900 professionals
have attended them.
The analysis of the health promotion programme in municipalities in Girona
shows substantial growth between the Catalogue 2009-2010 and the
Catalogue 2011 (Figures 9 and 10).

61


programme request – Catalogue 2009-2010


programme request – Catalogue 2011

municipalities with >3 programmes requested
municipalities with 1-3 programmes requested
municipalities with 0 programmes requested

After analysing the service request data, we can observe that not all the
municipalities need to access all the programmes, due to their features,
geographical location, type of public facilities, etc. Thus, the challenge for
municipalities is to request the programmes required that cover their needs.
The study that compares the implementation of services shows, on the one
hand, a very rapid (intensive) growth in service requests by municipalities
during Catalogue 2009-2010 (Figure 11) and, on the other hand, intensive

62


growth in the number of programmes requested by each municipality during
Catalogue 2011 (Figure 12).

Figure 11. Territorial distribution of overall programme
requests from the Catalogue 2009-2010


Figure 12. Territorial distribution of overall programme
requests from Catalogue 2011


3.2 The City Council role; service catalogue membership
In order to guarantee the success of this model, the involvement of city
councils is an absolutely necessary condition. The implementation of the

63


service model and the agents’ network depends on them. One of the
important challenges was to transfer the responsibilities of the local entities
in public health – a process that has caused confusion among many local
politicians. In individual meetings and with the advice of mayors, between
July and December 2009, a dissemination plan was implemented. It had
a double challenge: to publicise this organisation and its services, and to
emphasise the idea of local responsibilities.
In most towns and cities, public health does not have a relevant role in the
local agenda. With the aim of including public health in the political agenda
in the municipality, any city council that wishes to access the services of
this organisation should have the full agreement of all its political members,
and thus adhere to the service catalogue and agree about the requirements.
Joining the service catalogue implies three commitments from the municipality:
1) to nominate a political and a technical representative; 2) to accept from
Dipsalut the designation of a health agent, and 3) to agree to take part in the
writing and future approval of its own public health local plan (such writing
will be financed by Dipsalut). The number of city councils involved is the key
indicator for evaluating the level of knowledge about the organisation, as well
as the suitability and the understanding of the catalogue value proposal.
The first inclusions in the catalogue were made in August 2009; basically,
from medium-sized and large municipalities. In the smaller municipalities,
plenary sessions are held less often and, therefore, membership takes longer
(Figure 13).
Figure 13 – Comparison between inclusions in December
2009 and October 2010
Municipalities included
in December 2009

Municipalities included
in October 2010

non-member municipalities

non-member municipalities

member municipalities

member municipalities

64


From December 2009 onwards, the deployment of the agents’ network
significantly increased the number of inclusions and, in October 2010, 218
municipalities (out of 221) had already joined, i.e. 97% of the territory and 99.9%
of the population in the Girona province. In January 2011, all municipalities
had joined that network. As the organisation and the implantation model
were based on a proximity model, the relationship became easier and the
communication was intense and fluid which, in turn, generated activity and
demand for services.

3.3 Proximity: public health agents’ network
Dipsalut has designed its structure clearly thinking of service proximity to
the municipality. Proof of this proximity is the public health agents’ network,
which is the main resource available in this organisation, which all the other
areas depend on.
The public health agents’ network acts as a technician for member
municipalities, with the aim of guaranteeing that they comply with their
duties in this area by reinforcing their own catalogue or their services in other
concurrent governmental levels. In the smaller municipalities, their own agent
usually requests the catalogue programmes, which will later be validated by
the mayor. In addition, the agents also do an exhaustive follow-up of Dipsalut
suppliers’ actions. Sometimes, they could also carry out control activities –
analysis, sample collection, etc.
In order to make the network as multi-purpose as possible, each agent is
assigned different types of municipalities: small and large municipalities and
cities, both in inland rural areas and in coastal areas in one district of the
province and in different counties. Although many agents are working in one
region, only one is its representative, which makes his/her relationship with
the respective county council easier. Thus, more knowledge is acquired, and
it is possible to work on the specific cases and it makes for an easier rotation
of professionals.
This network has greatly contributed to the rapid implementation of Dipsalut
and of services in the territory (Figure 14).


Figure 14. Comparison of the evolution of the program demand
between December 2009 and October
December 2009

October 2010

Municipalities with no programmes requested
Municipalities with programmes requested

65

66


3.4 Service production: market structure versus own structure
In a quickly evolving global context, with more interactions than ever between
public and private sectors, the government is being asked to provide
increasingly complicated and segmented services that require some level
of knowledge and technology that, sometimes, the government alone is not
able to generate. At present, there is no doubt that, in order to provide quality
public services, these collaboration scenarios are required. We are moving
towards relational governance models, in which non-governmental agents
–private sector, third sector and citizens– take part in defining public policies
and coproducing public services.
The public sector has repeatedly shown its capacity for managing and
producing services. Nobody has the slightest doubt about it. The aim of
public-private collaboration is to put an end to the traditional isolation of
public service self-production in an environment in which all organisations
are interconnected and they share, generate and exchange knowledge and
innovation, and they also define a network governmental model, a government
which is connected to the other organisations, no matter what their nature
is (public, private, profit or non-profit organisations) as well as with citizens’
organisations. Due to this complexity, some new services, related to new
types of management and production, are required.
There is also much debate about outsourcing: What should be outsourced?
What are the control mechanisms for it? Who keeps the knowledge?
In terms of outsourcing production, it is often considered that, for some services
(partially or totally) the market has the technology and capacity required to
produce them better and at a lower cost. Outsourcing means including a third
party’s technology and knowledge in the public provision process, which leads
to cost reduction. Part of the risk related to that service is transferred to the
private sector and this, in turn, is granted some benefits.
Outsourcing risks depends on the control mechanisms from the government
over that supplier so that the quality of service is guaranteed. This is a more
obvious risk in the governments who outsource complete packs of services,
i.e. all of their production chain. These private production processes of public
services are granted through tenders which, in very elaborate specifications,
describe in detail the service features, as well as all the quality guarantees and
sanctions in the event of non-compliance by the company the service has
been granted to. This public-private collaboration model is the most common
model in local government, but it is not the only one.
Public-private collaboration is especially used in public-private partnerships, i.e.
in alliances between both parties to implement large projects, mainly related to
the development of infrastructures.


67

Apart from being responsible for the technology and innovation related to this
type of projects, the private sector is usually also responsible for financing the
action; and the government repays this financing through annual payments
over a long period of time (20, 30, 50 or more years). After that period, the asset
or infrastructure is totally publicly owned. This approach introduces the idea of
“intergenerational equity” - the cost of infrastructure is paid for throughout its
years of existence, i.e. it is paid for by all generations who are going to be using
it. This model has become corrupted in cases where governments have been
obliged to develop some projects in this way, with the aim of turning them
into financing formulae and, thus, access to debt levels that are not allowed in
government.
In the literature, there are two types of partnerships – contractual and
institutionalised. In contractual partnerships, the initiative is taken by the
public sector, which commissions a specific project or service from the private
market which is limited in time and based on a hierarchical relationship –
an output-oriented relationship. Institutionalised partnerships, however, are
based on a strategic alliance between public and private sector to develop
a project which aims to change the immediate situation (social, economic,
environmental reality, etc.). It is set up in a horizontal trust-based relationship
where all parties share the same level of involvement and risk. These
partnerships are closer to the outcome than to the output (Ysa, 2009).
There are some guidelines in international organisations about partnership
(UNO,17 European Commission18 …). In our country, however, the publicprivate relationship still does not have a conceptual framework that regulates
which areas and services can be outsourced and which ones should never
be (Ramió, 2005).
Before decisions about outsourcing are taken, an evaluation should be
made of how much is paid for what, i.e. what value will be obtained from the
resources invested in it – value for money19 . In this case, public managers are
accountable for explaining the value that is going to be created with public
resources.

17 UNO, Guidebook on Promoting Good Governance in Public-Private Partnerships,
2008.
18 European Commission, Green book on public-private cooperation, 2004.
19 Grimsey, D. and Lewis, M. (ed.) «Value for money is an optimum combination of
whole-life costs, benefits, risks and quality (fitness for purpose) to meet the user
requirement and getting the best possible outcome at the lowest possible price
(…)». In: The Economics of Public Private Partnerships, 2005.

68


The opportunity cost, a constant point in management, should also be taken
into consideration when outsourcing. The needs in public services tend to
be infinite, whereas resources are limited. The allocation of resources to a
service and to a form of production of that service excludes the assignment
of such resources to other purposes. It is a matter of prioritizing.

3.5 Dipsalut; service production
Dipsalut is considering the need to produce the services and programmes
in the catalogue. To this end, the existing structures in the market are used.
Outsourcing the activities is a key challenge for this organisation, which
should find solvent suppliers, who have the capacity to generate an increasing
demand and work with variable costs. There are some difficulties in this
process. On the one hand, the public health products/services offered by
the market are accessories (not a core business element) that other service
suppliers offer to the municipality (the swimming-pool cleaning company
makes self-control plans; the water lab that has the dealership of the local
network offers disinfection in sports facilities, etc.) There is no specialisation
in one area, but additional services from usual suppliers. This is probably due
to a low or almost zero demand for such services.
Besides this, small suppliers (self-employed/micro-companies) with limited
production capacity are very fragmented. Public operators also have a low
capacity in this respect.

One programme, one supplier
Dipsalut decides that each programme, which involves a series of consecutive
actions, can only have one supplier. The aim of such a decision is, on the one
hand, to avoid a lack of coordination (when there is more than one supplier)
and, on the other hand, to have only one person responsible in the event of a
deficient action. By doing this, companies that are interested in programmes
will need to create a Temporary Union of Companies (UTE in Spanish) when
they wish to participate in a tender, because very few suppliers can carry out
all the actions in a programme only with their own means.

Variable cost model
Another significant feature of outsourcing is to define a cost unit-based tender
for the service provision.
When this organisation was first set up, municipalities could not foresee the
demand for service units or their growth. In the health protection area, there
was not a real register of public facilities with risky objects. This is why the
market is requested (tender) to produce cost unit-based services, with no

Innovation, proximity and services to the municipality. The Dipsalut model

Innovation, proximity and services to the municipality. The Dipsalut model

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