National Public Health Institutes Organizational Strengthening Module Framework: Applying Organizational Development Principles

OD frameworks

The two main OD models that informed the OSM framework were the STAR model and the Baldrige Performance Excellence Framework [33, 34], which are widely recognized organizational design and performance improvement tools intended for use by private, public, and nonprofit organizations.

The STAR model, developed by Jay R. Galbraith, is an organizational design model that defines five critical and interrelated categories: strategy, structure, processes, rewards, and people. Strategy is seen as the primary driver of other aspects of organizational design, and Galbraith argues that to become a high performing organization it is most critical that these five aspects of the organization are aligned [34, 35]. Strategy concerns the organization’s directions and goals, as set out in its strategic plan. Structure concerns where decision‑making power lies in an organization, and processes address how information flows within and outside of an organization [35]. While distinct, the categories of people and rewards both concern an organization’s workforce planning efforts as they focus on the skills and motivation of employees, respectively [35]. Given the mandate of NPHIs to lead and coordinate public health functions within a country, the model’s emphasis on “form follows function” and that an organization’s structure should be based upon and reflect the functions that it is supposed to assume became an essential element of framework development. The STAR model’s categories also resonated with the themes heard from NPHI leadership regarding the importance of aligning strategic planning, strategic communications, and workforce development.

The Baldrige Performance Excellence Framework is an OD model with a comprehensive and validated set of assessment criteria developed by the Baldrige Performance Excellence Program to guide organizations to performance excellence [33]. The seven categories of the framework are organized into two interlocking triads: leadership and results [33, 36]. The leadership triad connects leadership with the strategy and customer categories, as leadership is key for setting an organization’s strategic objectives, vision, and ongoing success [33, 36]. The results triad connects results with workforce and operations as a means to drive the production of services [33, 36]. Baldrige’s system perspective resonated with what was heard from NPHIs as they desired flexible tools that addressed contextual nuances anchored in objective and leadership‑driven solutions to OD issues.

The team adapted and merged these models to arrive at an overarching framework, tailored to the priority needs of NPHIs.

Tool development and adaptation

The modules in the OSM were developed sequentially, beginning with foundational modules and progressively building toward more advanced areas. For each module, we aimed to identify two pilot NPHIs to test and refine the approach. Development of each module began with a scoping exercise to identify existing tools for assessing organizational capacities within the specified domain. Early meetings with NPHI leaders and teams where the tool was to be piloted shed light on the specific challenges they were facing and focused our exploration of how the modules could support their needs. Insights from these discussions shaped the objectives of each module and informed the selection of tools used to deliver them. In most cases, tools required adaptation to ensure they were relevant to the NPHI context. These adaptations often involved accounting for the complex ecosystem of actors that NPHIs engage with—including both domestic and international partners, as well as health and non‑health sector stakeholders—and modifying financing tools to reflect the nonprofit status of NPHIs and their reliance on government funding. Additional adjustments were also made to reflect varying levels of institutional maturity, governance arrangements within public sector systems, and the need to align tools with existing national public health strategies and planning processes.

Piloting

The OSM framework and tools were piloted in four countries that requested support from the CDC Institutional Strengthening Team (see Table 1). Countries were selected for piloting based upon an alignment between their interests in OD and particular OSMs that the team were developing. Also, in some cases the team developed rapport with particular NPHIs that permitted the piloting of multiple different modules.

Piloting typically occurred over a series of months, including both online and in‑person modalities. The team took process notes throughout the engagement documenting what was and was not working. Frequent course adjustments were made during the process of module implementation, for example to bring a sharper focus to critical OD challenges or simplify tools for use in the field. Upon completion of a pilot, the team took stock of what did and did not work and made adjustments to the approach and tools used.

Framework for NPHI strengthening

The OSM framework is composed of eight organizational strengthening modules, each focused on one priority domain for NPHIs (Figure 2). The dark blue base of the framework addresses the foundational question of what functions the NPHI is responsible for. Moving up the framework, there are two lighter blue OSMs focused on strategy and partnerships. These are also fundamental: the strategic planning OSM enables an NPHI to set out its vision, mission, goals, and strategies that in turn drive other organizational aspects. Partnerships are also fundamental because in many cases NPHIs need to work closely with other partners to deliver core functions, and from the needs assessment, we found that there was frequently confusion around NPHI roles versus those of partners. The next two pale green OSMs speak to core organizational systems, namely workforce and financing, while the two dark green OSMs at the top of the figure address higher level concerns, notably governance and strategic communications. Running through the center of the figure in orange is a focus on change management, reflecting the importance of enabling NPHIs to transition to new organizational arrangements smoothly, minimizing disruptions to the services they provide. In practice, change management concepts are built into each of the other modules.

Figure 2

Organizational strengthening modules

Each OSM is made up of 3–4 concrete steps, beginning with a domain‑specific structured assessment followed by additional steps that facilitate reflection and provide guidance on best practices and strategies for NPHIs to achieve desired OD milestones. Once completed, each OSM produces an actionable strategy that can be feasibly implemented over the next 2–5 years. While each module focuses on a discrete OD domain, all work contributes toward the outcome of independently and sustainably strengthening an NPHIs’ ability to protect and improve the health of the people and communities whom they serve through organizational strengthening.

The OSM Assessment and Mapping of Public Health Functions serves as an anchor for determining, prioritizing, and communicating the organizational priorities of NPHIs. It reflects the principles of Galbraith’s STAR model that form follows function and ensures that before other OSMs are addressed there is a clear understanding of the public health functions that the NPHI is intended to perform. While the completion of the SDT often serves as a helpful first step to ground the discussion in current reality, this OSM goes substantially further identifying specific functions and mapping the role of the NPHI vis a vis other organizations in the delivery of these functions. The first step in the OSM utilizes Decision Space Analysis to identify the current decision‑makers for various NPHI functions, determining where there is a gap or where many people/organizations are responsible for a given function to identify opportunities for growth or greater efficiency. Process mapping is then used as the second step, building off of the Decision Space Analysis activity, to visually represent workflows and decision points, and to identify system bottlenecks. These bottlenecks then feed into the third step, root cause analysis, to tease out the most common and actionable underlying causes of the problem and facilitate identification of areas for change within the NPHI. Finally, step four is a prioritization activity that helps the NPHI identify other OSMs most relevant to its needs.

The Strategic Planning OSM is a logical next step after an NPHI’s core public health functions are mapped. Broadly, strategic planning encompasses strategy development, implementation, and the measurement of progress toward objectives. The OSM integrates key principles of both Baldrige and Galbraith’s STAR models to highlight tools that support NPHIs in the strategy development process. Activities include conducting an environmental scan of the NPHI’s current state to understand the NPHI’s strengths, weaknesses, opportunities, and threats along with what, if any, strategic planning activities have been completed. The OSM then offers guidance on drafting key elements of the strategic plan providing examples of mission, vision, core values, and goal(s) statements from similar entities, and providing a pathway for the NPHI to tailor these to their own needs. Finally, guidance on identifying strategic objectives and strategies to achieve these are provided, leaving the NPHI with a comprehensive draft strategic plan for further refinement.

Building the capacity of NPHIs to both develop and effectively manage stakeholder relationships was a commonly cited OD need. Establishing and maintaining partnerships is complex and requires an intentional approach driven by NPHI leadership given how priorities, operations, and funding models differ between partner organizations. The Partnership Mapping and Strategy DevelopmentOSM helps NPHIs review a broad swathe of stakeholders, identify key partners, and integrate the needs and interests of different local and international partners that expect services from the NPHI, while being strategic about growth and success by identifying opportunities for new partnerships and priorities. Based on concepts of social network analysis, OSM activities focus on using the NetMap tool to determine key linkages between an NPHI and its stakeholders so that NPHIs can better understand stakeholder goals, reasons for investment, and assess the ability of a stakeholder to influence the NPHI’s work [37].

Identified by both Baldrige and Galbraith’s STAR model as a key category to consider in terms of OD and design, and cited as a key issue by NPHI leadership, the Workforce Strategy OSM focuses on how NPHIs can build a competent and capable public health workforce for the NPHI, able to carry out routine and emergency public health functions. The OSM integrates workforce planning approaches with engagement strategies to guide an NPHI toward planning a fit‑for‑purpose workforce while also building an organizational culture that motivates and retains talent. OSM activities focus on conducting a workforce analysis (including assessing workforce supply, demand, and gap analysis) so that NPHI leadership can understand the current state of the NPHI’s workforce, forecast workforce needs, and identify and prioritize gaps to reach the NPHI’s desired workforce state.

NPHIs typically depend on a relatively narrow range of funding sources that could expose them to significant vulnerabilities, hinder sustainability, and lead to challenges in delivering their strategic plan. This dependency can also reduce flexibility in resource allocation and leave NPHIs constrained in their ability to adapt and respond effectively to public health emergencies. The Financial Strategy and Diversification OSM is meant to address some of these concerns, providing tools for an NPHI to strengthen operational autonomy, sustainability, and execution of financial functions. The first step in the OSM is a comprehensive financial health diagnostic assessment to review the NPHI’s current financial infrastructure, revenue streams, and overall financial needs and approach so that opportunities for improvement and strategies can be identified to draft a financial strategy. Tools and guidance on soliciting additional support from Ministries of Finance and development partners are provided.

The Strengthening of Governance Functions OSM focuses on how strong internal regulatory and administrative functions help protect an NPHI’s scientific independence and credibility along with ensuring clear lines of accountability within organizational structures. The OSM focuses on reviewing the current accountability structures of an NPHI. The NPHI maps its financial performance and political accountabilities using an accountability matrix to consider where these may need to be strengthened [38]. In addition, the OSM reviews governing and advisory board arrangements for the NPHI and uses validated approaches for both the assessment and strengthening of advisory or governing boards to ensure the effective operations of these entities [39–41].

Communicating the right message, to the right audience, at the right time is key for NPHIs to build credibility with the public, funders, and other stakeholders. The Strategic Communications OSM focuses on this concept and responds to NPHIs’ identified needs to communicate their mission, advocate more effectively for legal establishment or increased support, and navigate conversations in complex political environments.

Central to the framework is an OSM on Change Management; managing change effectively is crucial to being able to implement any of the other OSMs as well as to the successful establishment of a new NPHI. The OSM is at the center of the framework as it can be either utilized alone to develop a broad change management strategy (for example, for a new NPHI) or used in concert with any of the OSMs as an implementation tool. The Change Management OSM utilizes John Kotter’s Leading Change methodology, walking NPHIs through the validated eight‑step framework to learn how to identify, clearly articulate, disseminate, and sustain the desired lasting change within the NPHI [42].

Table 2 provides additional information on the goal, objectives, suggested activities, and key outputs of each OSM.

Implementation of organizational strengthening modules

While there are strong connections and substantial synergies between the OSMs, each OSM is designed to be a standalone set of tools, meaning that users can employ an OSM on its own or in concert with others. It is recommended, however, that the Assessment and Mapping of Public Health Functions OSM be conducted as an initial step, as it allows users to better understand the functions of the NPHI and helps define priorities across other OSMs.

Tool materials include facilitation guides, worksheets, presentations, case studies, and suggested readings all of which are tailored to the needs of NPHIs and presented in a format that allows users to edit easily for different contexts. While it is recommended that all the tools and activities presented in each OSM are used, there is guidance throughout stating where users can modify or skip activities.

Each OSM is designed to be implemented in a sprint, which is short and defined time periods of 3–6 months. Typically, a team of 3–4 NPHI staff members will serve as OSM leaders. The OSM team meets on a regular basis (either virtually or in‑person) to collect relevant organizational information, review materials, and prepare for an in‑country workshop. The workshop often represents the culmination of work where information is reviewed, strategies are refined, and plans for next steps are put in place. Such workshops also provide an opportunity to collect the perspectives of a broader array of stakeholders and secure buy in to the process.

Piloting

Given the extensive piloting conducted, it is challenging to summarize succinctly key findings from this process; however, we offer insights from two sets of pilots namely the application of (i) the partnership module with ZNPHI in Zambia and (ii) the workforce module in Liberia, as a means of conveying the nature of learnings from pilots, before pivoting to cross‑cutting lessons.

ZNPHI wished to implement the partnership module as it recognized that it had a multitude of domestic and international partners, who did not always clearly understand the role of ZNPHI, and managing these partners and their interests across multiple different technical functions was a significant burden on ZNPHI staff, and also led to role confusion and shifting priorities. Online engagement of the ZNPHI team tasked with taking forward this OSM led to an initial listing of stakeholders and an articulation of key challenges, as well as objectives for what the institute wanted to achieve through the module. The in‑person workshop was designed to enable ZNPHI staff to reflect on what they needed from partners and how they could be more effectively managed, and also bring in a diversity of partners to understand their perspectives. The workshop led to several concrete outcomes, including a more refined categorization of partners, a set of possible strategies for managing partners (from broad all partner communications to more targeted strategic communications with individual partners), as well as a draft partner engagement strategy. Insights from the discussion informed OSM slide decks and templates, enabling other NPHIs to benefit from ZNPHI’s experience. From ZNPHI leadership’s perspective, the workshop created a valuable space to reflect on partnership effectiveness, strengthened ownership of partnership management, and reinforced the importance of at times saying “no” to partners.

NPHIL’s strategic plan identified the critical lack of trained and motivated public health workers in Liberia as a key constraint facing the institute. Accordingly, NPHIL’s leadership was keen to apply the Workforce Strategy and Development module. Leading up to the workshop, the JHU team supported NPHIL in conducting a survey of its existing staff that assessed staff characteristics, pre‑service and in‑service training, roles, and workforce engagement and satisfaction. During the workshop, NPHIL staff reviewed survey findings and discussed priority concerns and what could be done about them. This led to an important shift in priorities. The NPHIL team recognized that with funding constraints it was not possible to hire more skilled staff or conduct extensive training for existing staff, but there were other levers within their grasp such as strengthening orientation for new staff, building clearer career pathways to support promotion, introducing mechanisms for staff engagement, and developing a human resource information system that could all help achieve workforce goals. This shift in perception underscored the importance of purposively building the evidence base, staying open‑minded to alternative perspectives, and using group processes to establish priorities.

Across the pilots, several implementation lessons emerged. First, inclusive participation—engaging both senior leadership and technical leads across core public health functions—was essential for accurate functional mapping and alignment with operational realities. For example, mapping exercises showed that functions such as surveillance are dynamic and differ across preparedness and response phases, requiring flexible, phase‑sensitive maps and cross‑functional comparison. Second, strategic planning was most effective with active leadership engagement; in Liberia, limited ownership of existing strategic plans underscored the need to realign strategic priorities with actual work, with leadership involvement enabling function leads to drive that realignment. Third, modules were interdependent—experience in Zambia revealed an overwhelming and diverse partner landscape, highlighting the need to pair partnership mapping with a strategic communication approach and reinforcing the importance of sequencing modules. Fourth, while virtual, hybrid, and in‑person modalities were feasible, in‑person engagement was particularly valuable for newer NPHIs, such as in Sierra Leone, where physically convening leadership supported alignment, trust‑building, and shared understanding; cultural preferences also shaped modality effectiveness. Across sites, an approximate two‑month time frame per module balanced time for reflection, data gathering, and consensus‑building without prolonging implementation and risking attrition due to competing priorities. Finally, sustainability was strengthened by identifying local champions to co‑lead, who would build familiarity with the methodology, and carry forward the work, particularly in settings with high leadership turnover.