The Influence of Educational Determinants on Children's Health: A Scoping Review of Reviews.

Objectives: Education is one of the most important social determinants shaping the development and wellbeing of children. The purpose of this review of reviews is to inform policymakers, practitioners and public health stakeholder involved in developing child-friendly policies outside of the healthcare system. Methods: We carried out a scoping review of reviews. It included 32 reviews. Results: We identified four main categories of educational determinants in relation to children's health: 1) the organization and structure of educational activities, 2) the interpersonal relations in the educational facilities and structures, 3) the spatial environment of educational facilities and structures, 4) social inequalities in the educational facilities and structures. This last category highlighted the capacity of education system to act on inequalities derived from the way social structures are organized. Conclusion: We suggest a conceptual framework for action which distinguishes structural determinant (gender, race, social class, etc.) and structuring determinant (public policy, systems of governance, organization of cultures/values consideration). Finally, we discuss on how these social structures and structuring determinants influence the intermediary educational determinants collated in the review.

The lived experience of receiving and providing antenatal care during the Covid-19 crisis in Southern Europe: An exploratory qualitative study.

OBJECTIVE: The Covid-19 pandemic led to a reorganization of antenatal care including the cancellation or shift into telemedicine of consultations and restrictions to the presence of an accompanying person. The aim was to explore healthcare professionals' and women's lived experience of such reorganisation consequences on the quality of care and specific challenges they faced, with a particular emphasis on telemedicine and equity. METHODS: Exploratory qualitative study using semi-structured interviews and focus group discussions of women and healthcare providers in New Aquitaine (France) and in the Basque Country (Spain). We collected data from a purposive sampling of women (n = 33) and professionals (n = 19) who had received or provided antenatal care in hospitals and ambulatory facilities between March 2020 and December 2021. Participants' narratives were thematically analysed to identify themes that were subsequently contextualised to the two territories. RESULTS: Antenatal care professionals and pregnant women experienced strong emotions and suffered from organizational changes that compromised the quality and equity of care. The pandemic and associated restrictions were sources of emotional distress, fear and loneliness, especially among more disadvantaged and isolated women. Among professionals, the lack of adequate means of protection and the multiple changes in caring protocols generated burnout, feeling of abandonment and emotional distress. CONCLUSIONS: The Covid-19 experience should serve to critically consider the unexpected consequences of reorganising healthcare services and the need to meet patients' needs, with a particular consideration for disadvantaged groups. Future scenarios of telemedicine generalisation should consider a combination of in presence and remote consultations ensuring antenatal care quality and equity.

La participation citoyenne dans les évaluations d'impact sur la santé en France.

OBJECTIVE: Citizen participation is one of the core values of Health Impact Assessment (HIA). Nevertheless, there is a gap between the ideal described in HIA foundational texts and its current practice as reported in the international literature. In the light of HIA recent development in France, this article provides some insights to better understand this concept and the challenges associated to its actual implementation in France. METHODS: This exploratory study is based on semi-structured interviews, on-site observations and document analysis of a panel of 11 HIAs carried out in 8 French regions between 2011-2018. Citizen participation is analyzed according to 5 dimensions: stakeholders’ perceptions and expectations, scope of participation, scale, methods of engagement, constraints. RESULTS: As reported in other studies published abroad, the concept of citizen participation remains unclear in France. Despite some progress observed in more recent HIAs, its actual implementation remains incomplete due to political, financial and human constraints and to competition with other existing mechanisms for public participation at a local level. CONCLUSION: While accumulated experience may contribute to effectively integrate citizen participation in HIA, this study shows that in order to better bond this practice to health promotion values, it is important to clearly define the objectives of such participation, to sensitize city counselors in advance, to strengthen HIA practitioners’ capacities, and to rely on participation specialists.

L'efficacité de l'évaluation d'impact sur la santé : leçons tirées d'une expérience dans l'agglomération bordelaise.

INTRODUCTION: This work presents the results of an impact evaluation applied to an HIA of an urban development project. The purpose of the evaluation was to assess the direct effects of the HIA procedure on the decision making by the implementation of the recommendations as well as its indirect effects in terms of stakeholders’ appropriation and use of the information produced throughout the process. METHODS: 12 semi-structured interviews were conducted with HIA stakeholders including regional public health directors and professionals, local elected officials, and technical staff from the engaged local authorities. RESULTS: Data collected confirmed HIA indirect impacts in terms of interviewees’ enhanced values and beliefs according to a holistic model of health, changes in professional practices through appropriation of the knowledge generated throughout the process and strengthening of intersectoral collaborations for health. More modest results were identified regarding HIA direct effects on decision making through the consideration of the proposed recommendations because of their redundancy with technical teams’ routine practices and their late timing. Nevertheless, interest in capitalizing on these recommendations for future municipal and metropolitan projects suggests deferred effects on decision making that should not be neglected. CONCLUSIONS: This study provides new data on the effectiveness, to varying degrees, of one of the first HIAs conducted in the region of Nouvelle Aquitaine. Other evaluations should be promoted in France to demonstrate HIA value and to draw useful lessons to inform its further development and consolidation in the coming years.

Lecciones desde fuera. Otros países en ésta y otras crisis anteriores. Informe SESPAS 2014 / Lessons from abroad. Current and previous crisis in other countries. SESPAS report 2014

La evidencia acumulada sobre el efecto de crisis anteriores en la salud presenta patrones muy diferenciados atribuibles al diseño de los estudios, a la naturaleza de cada crisis y a otros factores del entorno socioeconómico y político. Existe, no obstante, un consenso cada vez mayor sobre el papel mediador de las respuestas políticas de los gobiernos, que pueden magnificar, o al contrario mitigar, los efectos adversos de las crisis. Estudios recientes revelan un deterioro en algunos indicadores de salud en el contexto de la crisis actual, fundamentalmente en salud mental y enfermedades transmisibles. En algunos países europeos también se ha constatado un descenso en el consumo de tabaco y alcohol. Por otro lado, algunos gobiernos están haciendo uso del contexto de crisis para avanzar reformas tendentes a la privatización de servicios y prestaciones sanitarias, restringiendo con ello el derecho a la salud y a la atención sanitaria. Se está actuando sobre los tres ejes que determinan el campo de la financiación de los sistemas sanitarios: la población protegida, la contribución del usuario y la cobertura de servicios. Estas medidas están siendo adoptadas a menudo de manera arbitraria basándose en decisiones ideológicas más que en la evidencia disponible, de lo que cabría esperar consecuencias adversas en términos de protección financiera, eficiencia y equidad (AU)

The evidence available on the impact of previous crises on health reveals different patterns attributable to study designs, the characteristics of each crisis, and other factors related to the socioeconomic and political context. There is greater consensus on the mediating role of government policy responses to financial crises. These responses may magnify or mitigate the adverse effects of crises on population health. Some studies have shown a significant deterioration in some health indicators in the context of the current crisis, mainly in relation to mental health and communicable diseases. Alcohol and tobacco use have also declined in some European countries. In addition, this crisis is being used by some governments to push reforms aimed at privatizing health services, thereby restricting the right to health and healthcare. Specifically, action is being taken on the three axes that determine health system financing: the population covered, the scope of services, and the share of the costs covered. These measures are often arbitrarily implemented based on ideological decisions rather than on the available evidence and therefore adverse consequences are to be expected in terms of financial protection, efficiency, and equity (AU)

[Lessons from abroad. Current and previous crisis in other countries. SESPAS report 2014]. / Lecciones desde fuera. Otros países en ésta y otras crisis anteriores. Informe SESPAS 2014.

The evidence available on the impact of previous crises on health reveals different patterns attributable to study designs, the characteristics of each crisis, and other factors related to the socioeconomic and political context. There is greater consensus on the mediating role of government policy responses to financial crises. These responses may magnify or mitigate the adverse effects of crises on population health. Some studies have shown a significant deterioration in some health indicators in the context of the current crisis, mainly in relation to mental health and communicable diseases. Alcohol and tobacco use have also declined in some European countries. In addition, this crisis is being used by some governments to push reforms aimed at privatizing health services, thereby restricting the right to health and healthcare. Specifically, action is being taken on the three axes that determine health system financing: the population covered, the scope of services, and the share of the costs covered. These measures are often arbitrarily implemented based on ideological decisions rather than on the available evidence and therefore adverse consequences are to be expected in terms of financial protection, efficiency, and equity.

Evaluación del impacto en la salud del proyecto de reurbanización de la calle San Fernando en Alcalá de Guadaíra (Sevilla) / Health impact assessment of the San Fernando street renewal project in Alcalá de Guadaíra (Seville, Spain)

Objetivos: Se presenta la experiencia de una evaluación del impacto en la salud realizada en 2010 sobre el proyecto de reurbanización de la calle San Fernando, vía principal de acceso al barrio de San Miguel-El Castillo, en Alcalá de Guadaíra (Sevilla). Constituye ésta una de las primeras actuaciones previstas en el Plan URBAN de regeneración social, urbana y económica del casco histórico del municipio. Métodos: Se han seguido las cinco fases y los procedimientos clásicos de una evaluación del impacto en la salud. La revisión de la evidencia se ha complementado con una consulta a la población afectada en forma de taller participativo, así como con entrevistas a profesionales sociosanitarios con implicación en el barrio. Resultados: Durante las obras, los impactos negativos se relacionan con los efectos nocivos del proyecto sobre la calidad del aire, el nivel de ruidos, las restricciones a la movilidad y el riesgo de siniestralidad, en especial entre la población mayor o con movilidad reducida. Cuando finalicen, se prevén mejoras en determinantes del entorno físico tales como la accesibilidad y la conectividad del barrio con servicios sanitarios y otros bienes y servicios en otras zonas del municipio. También se prevén impactos positivos vinculados a la seguridad y el atractivo del barrio, así como nuevas oportunidades para la sociabilidad, la cohesión social y la autoestima comunitaria. Conclusiones: Se trata de la primera experiencia en Andalucía cuyos resultados se han integrado en un ciclo formal de toma de decisiones de ámbito local. Ello ha permitido valorar el potencial, la aplicabilidad y la aceptación de la evaluación del impacto en la salud en el ámbito municipal, así como facilitar un proceso de aprendizaje y un pilotaje de métodos y herramientas adaptadas (AU)

Objectives: This study describes the design and implementation of a health impact assessment (HIA) conducted in 2010 of the regeneration project of San Fernando Street, the main avenue crossing the San Miguel-El Castillo neighborhood in Alcala de Guadaíra (Seville, Spain). This project is part of the wider URBAN Plan aimed at the social, urban and economic regeneration of the city's historic center. Methods: This experience followed the standard HIA stages and procedures. The review of published evidence was complemented with new qualitative information gathered by means of a participative workshop with the local population and interviews with social and health workers involved in the neighborhood. Results: During the building stage of the project, the adverse impacts were related to a worsening of the air quality, increased noise pollution, mobility restrictions and a higher risk of accidents, particularly among older or disabled people. Once the building stage was finished, the health benefits were associated with significant improvements in physical accessibility and the population's access to health services and other goods and services. Other positive effects were the enhanced safety and attractiveness of the neighborhood and the new opportunities for socializing, social cohesion and increasing the community's self-esteem. Conclusions: This is the first HIA experience in Andalusia whose results have been integrated into a formal cycle of decision making in the local community. This experience has provided new evidence of the potential of HIA and its applicability and acceptance at the municipal level and has has also facilitated a learning process and the piloting of new methods and tools associated with the HIA process (AU)

[Health impact assessment of the San Fernando street renewal project in Alcalá de Guadaíra (Seville, Spain)]. / Evaluación del impacto en la salud del proyecto de reurbanización de la calle San Fernando en Alcalá de Guadaíra (Sevilla).

OBJECTIVES: This study describes the design and implementation of a health impact assessment (HIA) conducted in 2010 of the regeneration project of San Fernando Street, the main avenue crossing the San Miguel-El Castillo neighborhood in Alcala de Guadaíra (Seville, Spain). This project is part of the wider URBAN Plan aimed at the social, urban and economic regeneration of the city's historic center. METHODS: This experience followed the standard HIA stages and procedures. The review of published evidence was complemented with new qualitative information gathered by means of a participative workshop with the local population and interviews with social and health workers involved in the neighborhood. RESULTS: During the building stage of the project, the adverse impacts were related to a worsening of the air quality, increased noise pollution, mobility restrictions and a higher risk of accidents, particularly among older or disabled people. Once the building stage was finished, the health benefits were associated with significant improvements in physical accessibility and the population's access to health services and other goods and services. Other positive effects were the enhanced safety and attractiveness of the neighborhood and the new opportunities for socializing, social cohesion and increasing the community's self-esteem. CONCLUSIONS: This is the first HIA experience in Andalusia whose results have been integrated into a formal cycle of decision making in the local community. This experience has provided new evidence of the potential of HIA and its applicability and acceptance at the municipal level and has has also facilitated a learning process and the piloting of new methods and tools associated with the HIA process.

[Toward a new organization of public health services in Spain. 2008 SESPAS Report]. / Hacia una nueva organización de los dispositivos de salud pública en España. Informe SESPAS 2008.

Public health in Spain shows significant weaknesses. Spanish public health services respond reasonably well in crisis situations but tend to be invisible and occupy a marginal position in political agendas and in relation to health services. The organization of the public health subsystem is clearly out of date in terms of its ability to promote and protect community health, to prevent diseases, and to cope effectively with the new public health threats and challenges related to the physical and social environment in today's globalized world. Consequently, there is broad consensus on the need to rethink functions, strategies and the organization of public health in Spain, in line with European and international trends. Thus, public health reform is currently a pending challenge and a strategic priority. Indeed, some Autonomous Communities have initiated a process of modernization and change. Empowerment of public health in the political agendas and in relation to the health services is strongly recommended by promoting intersectorial approaches, the Health in All Policies strategy and Health Impact Assessment. There is also a need for a specific law that would update public health functions, organization and structures, allocate competencies by facilitating alliances and partnership, and regulate coordination and intersectorial intervention. The following key elements related to this reform are described: 1) a participatory leadership in public health; 2) the generation of intelligence and evidence in public health; 3) improvement of professional education and development; 4) the importance of transparent, independent and competent performance and communication, and 5) new and flexible organization coherent with the new strategies and close to the local level and primary health care services. Coordination between the State and the Autonomous Communities should involved a functional and intelligent relationship by building up common spaces, alliances, networks and shared initiatives for public health.

[Health impact assessment: the state of the art]. / La evaluación del impacto en salud: el estado de la cuestión.

Health impact assessment (HIA) is being increasingly used due to governments' growing interest in putting health high on their agendas. HIA provides a structured framework to estimate the potential consequences of non-health sector policies in community health. The ultimate goal of this framework is to maximize health gains and, as far as possible, to reduce health inequalities. HIA is believed to have significant potential to address health determinants and to promote intersectorial action in health. Challenges for the future include the need to strengthen its methodological bases, particularly those concerning the process of impact prediction, and the need to promote its progressive incorporation into decision-making processes, either independently or integrated within other impact assessment tools. The strategic affinity of HIA with the European "Health in All Policies" strategy strengthens current opportunities for the implementation of this tool in Spain, especially in the context of the ongoing debate on the future of public health and the need to give public health higher priority in political-institutional agendas. To move forwards, we should promote debate on HIA, as well as research and the practice of this tool in Spain, where only some pioneer experiences exist. The public health sector should lead the development of HIA pilot studies in order to assess its current contribution to the formulation of healthy public policies. In addition, HIA should be promoted among policy makers and other stakeholders in order to facilitate its adoption and integration into strategic planning and relevant agencies and decision-making structures. The ultimate goal is to find new formats for intersectorial collaboration and new tools for putting the principles of Health in all Policies into practice, thus successfully achieving health and public health goals.

La evaluación del impacto en salud: el estado de la cuestión / Health impact assessment: the state of the art

La evaluación del impacto en la salud (EIS) se está utilizandocada vez más en los países europeos, paralelamente al interéscreciente de los gobiernos por incorporar el valor saluden las agendas. La EIS ofrece un marco estructurado paraevaluar las posibles consecuencias de políticas extrasanitariasen la salud comunitaria. Su objetivo último es el de maximizarlas ganancias en salud y, en la medida de lo posible,reducir las desigualdades. Se le atribuye un gran potencial parael abordaje de los determinantes y la acción intersectorial ensalud. Como retos de futuro se apunta la necesidad de fortalecersus fundamentos metodológicos, especialmente en loque se refiere al proceso de estimación de impactos, así comola necesidad de avanzar en su integración progresiva en losprocesos formales de decisión, ya sea por sí sola o como partede otras evaluaciones de impacto.Su afinidad estratégica con la política europea de «Salud entodas las políticas» refuerza la oportunidad para su desarrolloen España, especialmente en el contexto actual de reflexiónen torno al futuro de la salud pública y la necesidad dedotar a ésta de una mayor prioridad en las agendas politicoinstitucionales.Para avanzar en este sentido hay que promoverel debate, la investigación y la práctica de la EIS en nuestropaís, donde apenas se han realizado algunas experienciaspioneras. Desde salud pública hay que impulsar nuevas experienciaspiloto que permitan evaluar su potencial efectivo parala formulación de políticas saludables. Además, hay que darlaa conocer entre decisores políticos y gestores para facilitar suapropiación e integración en procesos de planificación estratégicay en instancias y niveles de decisión adecuados. Se trata,en definitiva, de buscar nuevos formatos de trabajo intersectorialy nuevas herramientas que hagan efectivos los principiosde la estrategia de la «Salud en todas las políticas» y, conella, el logro de los objetivos de salud y salud pública

Health impact assessment (HIA) is being increasingly useddue to governments’ growing interest in putting health high ontheir agendas. HIA provides a structured framework to estimatethe potential consequences of non-health sector policiesin community health. The ultimate goal of this framework isto maximize health gains and, as far as possible, to reducehealth inequalities. HIA is believed to have significant potentialto address health determinants and to promote intersectorialaction in health. Challenges for the future include the needto strengthen its methodological bases, particularly those concerningthe process of impact prediction, and the need to promoteits progressive incorporation into decision-making processes,either independently or integrated within other impactassessment tools.The strategic affinity of HIA with the European«Health in All Policies» strategy strengthens current opportunitiesfor the implementation of this tool in Spain, especiallyin the context of the ongoing debate on the future of publichealth and the need to give public health higher priority in political-institutional agendas. To move forwards, we should promotedebate on HIA, as well as research and the practice ofthis tool in Spain, where only some pioneer experiences exist.The public health sector should lead the development of HIApilot studies in order to assess its current contribution to theformulation of healthy public policies. In addition, HIA shouldbe promoted among policy makers and other stakeholders inorder to facilitate its adoption and integration into strategic planningand relevant agencies and decision-making structures.The ultimate goal is to find new formats for intersectorial collaborationand new tools for putting the principles of «Healthin all Policies» into practice, thus successfully achieving healthand public health goals

Hacia una nueva organización de los dispositivos de salud pública en España. Informe SESPAS 2008 / Toward a new organization of public health services in Spain. 2008 SESPAS Report

El análisis de situación de la salud pública en nuestro paíspone de manifiesto la existencia de debilidades significativas.Sus dispositivos responden razonablemente en situacionesde crisis, pero resultan en general invisibles y ocupan una posiciónmarginal en las agendas político-institucionales y respectoal sistema asistencial. La organización de los serviciosde salud pública resulta obsoleta para promover y protegerla salud comunitaria, prevenir enfermedades y enfrentarse alos retos emergentes del mundo globalizado relacionados conel medio ambiente físico y social.Hay consenso sobre la necesidad ineludible de replantearlas funciones, estrategias y organización de la salud públicaen España en la misma línea de las tendencias europeas einternacionales. Esta reforma constituye una asignatura pendientey una prioridad estratégica hoy. De hecho, algunas comunidadesautónomas han iniciado en los últimos años procesosde reestructuración y cambios.Recomendamos dotar a la salud pública de más peso y prioridaden el sector sanitario y en las agendas político-institucionales,promoviendo los abordajes intersectoriales, la estrategiade ®Salud en Todas las Políticas» y la evaluación del impactoen salud. Se sugiere una norma específica en salud pública queactualice funciones, organización y estructuras, distribuya claramentecompetencias posibilitando consorcios y alianzas, y regulela coordinación e intervención intersectorial(AU)

Se describen elementos clave de la reforma: a) un nuevo liderazgoparticipativo en salud pública; b) generar inteligencia y evidencia;c) mejorar la profesionalización y competencia profesional;d) la importancia de una actuación y comunicación eficaz,transparente e independiente, y e) una organización nueva y flexiblecoherente con las nuevas estrategias, y cercana al ámbitolocal y los servicios sanitarios. En relación con la relación Estado/comunidades autónomas, se apunta hacia una articulacióninteligente y funcional que, más allá de la actual debilidad, construyaespacios comunes de interlocución y corresponsabilización,como redes, alianzas e iniciativas por la salud pública(AU)

Public health in Spain shows significant weaknesses. Spanishpublic health services respond reasonably well in crisissituations but tend to be invisible and occupy a marginalposition in political agendas and in relation to health services.The organization of the public health subsystem is clearlyout of date in terms of its ability to promote and protectcommunity health, to prevent diseases, and to cope effectivelywith the new public health threats and challenges relatedto the physical and social environment in today’s globalizedworld.Consequently, there is broad consensus on the need to rethinkfunctions, strategies and the organization of public healthin Spain, in line with European and international trends.Thus, public health reform is currently a pending challenge anda strategic priority. Indeed, some Autonomous Communitieshave initiated a process of modernization and change.Empowerment of public health in the political agendas andin relation to the health services is strongly recommended bypromoting intersectorial approaches, the Health in All Policiesstrategy and Health Impact Assessment. There is also a needfor a specific law that would update public health functions,organization and structures, allocate competencies by facilitatingalliances and partnership, and regulate coordination andintersectorial intervention(AU)

The following key elements related to this reform are described:1) a participatory leadership in public health; 2) the generationof intelligence and evidence in public health; 3) improvementof professional education and development; 4) theimportance of transparent, independent and competent performanceand communication, and 5) new and flexible organizationcoherent with the new strategies and close to the locallevel and primary health care services.Coordination between the State and the Autonomous Communitiesshould involved a functional and intelligent relationshipby building up common spaces, alliances, networks and sharedinitiatives for public health(AU)(AU)

Hacia una nueva organización de los dispositivos de salud pública en España. Informe SESPAS 2008 / Toward a new organization of public health services in Spain. 2008 SESPAS Report

El análisis de situación de la salud pública en nuestro país pone de manifiesto la existencia de debilidades significativas. Sus dispositivos responden razonablemente en situaciones de crisis, pero resultan en general invisibles y ocupan una posición marginal en las agendas político-institucionales y respecto al sistema asistencial. La organización de los servicios de salud pública resulta obsoleta para promover y proteger la salud comunitaria, prevenir enfermedades y enfrentarse a los retos emergentes del mundo globalizado relacionados con el medio ambiente físico y social. Hay consenso sobre la necesidad ineludible de replantear las funciones, estrategias y organización de la salud pública en España en la misma línea de las tendencias europeas e internacionales. Esta reforma constituye una asignatura pendiente y una prioridad estratégica hoy. De hecho, algunas comunidades autónomas han iniciado en los últimos años procesos de reestructuración y cambios. Recomendamos dotar a la salud pública de más peso y prioridad en el sector sanitario y en las agendas político-institucionales, promoviendo los abordajes intersectoriales, la estrategia de «Salud en Todas las Políticas» y la evaluación del impacto en salud. Se sugiere una norma específica en salud pública que actualice funciones, organización y estructuras, distribuya claramente competencias posibilitando consorcios y alianzas, y regule la coordinación e intervención intersectorial. Se describen elementos clave de la reforma: a) un nuevo liderazgo participativo en salud pública; b) generar inteligencia y evidencia; c) mejorar la profesionalización y competencia profesional; d) la importancia de una actuación y comunicación eficaz, transparente e independiente, y e) una organización nueva y flexible coherente con las nuevas estrategias, y cercana al ámbito local y los servicios sanitarios. En relación con la relación Estado/ comunidades autónomas, se apunta hacia una articulación inteligente y funcional que, más allá de la actual debilidad, construya espacios comunes de interlocución y corresponsabilización, como redes, alianzas e iniciativas por la salud pública

Public health in Spain shows significant weaknesses. Spanish public health services respond reasonably well in crisis situations but tend to be invisible and occupy a marginal position in political agendas and in relation to health services. The organization of the public health subsystem is clearly out of date in terms of its ability to promote and protect community health, to prevent diseases, and to cope effectively with the new public health threats and challenges related to the physical and social environment in today¿s globalized world. Consequently, there is broad consensus on the need to rethink functions, strategies and the organization of public health in Spain, in line with European and international trends. Thus, public health reform is currently a pending challenge and a strategic priority. Indeed, some Autonomous Communities have initiated a process of modernization and change. Empowerment of public health in the political agendas and in relation to the health services is strongly recommended by promoting intersectorial approaches, the Health in All Policies strategy and Health Impact Assessment. There is also a need for a specific law that would update public health functions, organization and structures, allocate competencies by facilitating alliances and partnership, and regulate coordination and intersectorial intervention. The following key elements related to this reform are described: 1) a participatory leadership in public health; 2) the generation of intelligence and evidence in public health; 3) improvement of professional education and development; 4) the importance of transparent, independent and competent performance and communication, and 5) new and flexible organization coherent with the new strategies and close to the local level and primary health care services. Coordination between the State and the Autonomous Communities should involved a functional and intelligent relationship by building up common spaces, alliances, networks and shared initiatives for public health (AU)