Development of a school-based health education program

This project was aimed at creating a curriculum for an 8-session-long health club for primary education, that could be used by schoolteachers and school nurses to provide health development activities in a classroom setting. The sessions covered the following topics: (1) Introduction, health, (2) Dietary habits, (3) Physical activities, (4) Sleeping, (5) Relationships, (6) Television, computers, phones, (7) Health care, (8) Summary.

The main and novel idea of the project was the direct inclusion of parents in the activities of the health club. This idea was supported by the fact that family background (knowledge, attitudes and actual health behavior of parents) is a significant influencing factor of the health behavior of children. This way, health clubs were considered in schools as extra-curricular activities, held in afternoon time slots, when one parent per child could be present. Participation was voluntary. This setup was unfamiliar for all participants (pupils, parents, teachers, school nurses), but also created unique opportunities to enhance family-school cooperation.

Stakeholders & Beneficiaries

The beneficiary of this project part was the University of Szeged, with four local schools recruited as pilot sites. Schoolteachers and school nurses are considered as the key stakeholders in promoting health in primary education. Participation in the pilot was considered as extra-hour work for them, with additional remuneration. The target group of the program was 8- or 9-year-old children, however, we can consider their parents as a secondary target group as their involvement was one of the cornerstones and distinctive attributes of the health club. Service users were not involved in the preliminary design processes, their feedback at the end of the club meetings was the way they contributed and got involved in the shaping of the current and later health club activities.

Co-creation process

The project consisted of the following steps. University researchers began the development of curriculum by reviewing literature and available evidence. It was decided that a workbook would be the central “organizing force” of the activities. It was clear that the workbook had to be designed to fit pupils’ and parents’ needs (both content and outlook) so that a designer was contracted. Schoolteachers and school nurses as well as students from the medical and district nurse programs were involved in further development activities during six workshops (the last one focused only on the administrative tasks required for project documentation). Those experts who participated in the development process, teachers and school nurses, medical students, school nurse students made a “test-run”: all the assignments had been tried by the experts and educators themselves (for example, children had “fruit names” during the health club, so “fruit names” were used during the trial as well). The health club was piloted at four schools. All of the sessions were visited by an observer (the above mentioned students from the medical and the health sciences faculties), who took notes. Assignments and sessions were evaluated by teachers and school nurses as well as the children. Health-related knowledge of participants were measured before and after the intervention so that the pilot project could have been evaluated.

Digital Transformation Process

Not applicable.

Results, Outcomes & Impacts

A pre-post evaluation of health-related knowledge of parents was measured by using a questionnaire. The average score grew from 6.78 to 7.16, however, this change cannot be considered as a significant change. Due to voluntary participation, the preselection of children and parents with better health-related knowledge might have played a role here. While the health club itself was discontinued after the pilot, several assignments are still used by teachers, and some skills acquired or strengthened during the pilot are evaluated positively (e.g. the school nurse communicates with parents more frequently and more easily).

Challenges & Bottlenecks

Due to the voluntary nature of participation, a selection bias occurred in the class: those pupils and parents who had already been more health-centric were more willing to participate. Although the design builds on parents a lot and it is part of its key success factors, it also emerges as a bottleneck: it needs a lot of time and attention from them. This way not everyone can participate, only those, who can attend club activities in the afternoon on a weekly basis (e.g. working parents with less flexible schedules have difficulties). The sustainability of the programme is mostly endangered by the required high resource use: the programme is quite time-intensive from the perspective of both parents and the school staff. It requires preliminary trainings and week-by-week preparation from school nurses and teachers. This amount of after-school activity for 8 consecutive weeks is quite difficult to manage for parents as well. Even though kids enjoyed the activities and did not regard the club as an obligation, it was a serious commitment from all the other parties.

Transferability & Replicability

The main outputs of the project are a workbook and an accompanying teachers’ manual (as well as additional materials, like evaluation sheet, leaflets, “key messages to parents” sheets, or a further education short program for school nurses). As intended, any school would be able to reproduce the program based on these materials. However, there was no school continuing or reproducing the program after the pilot. The main reason for this seems to be connected to the high resource use the program requires.

Success Factors

The development process was very user-centric and relied on expertise about how to communicate with children (strengthened by the participation of a service designer). This way, the program was tailored to the needs of children (and parents). On the other hand, the pilot was not followed by a wider-scale implementation (see Challenges).

Lessons learned

The main innovation of the programme was the inclusion of parents in health education activities in schools. It is rare that the children and their parents spend time together in school; this feature of the health club had an immense positive impact on the success of the programme by creating a safe atmosphere for the kids at school and engaging them at home, too. It also strengthened child-parent relationships by spending focused quality time together and creating common experiences. The situation was also new for school nurses and teachers because of this model, however, the novelty of the applied interactive methodologies provided a source of innovation for their practices. However, there was a selection bias: those children (and parents) who wanted to participate in the pilot had already been interested in living a healthy lifestyle, and had already deeper knowledge about health. High-risk groups (e.g. children struggling with obesity) were not participating. Moreover, the sustainability of the programme is endangered by the required high resource use: the programme is quite time-intensive from the perspective of both parents and the school staff.

Stakeholders & Beneficiaries

Stakeholders include:

Consejería de Educación, Formación y Empleo (the Department of Education, Training and Employment)
The unions (UGT, CCOO)
The regional association of enterprises (FER)
Other relevant social stakeholders in the region (Asociación Promotora de personas con Discapacidad intelectual Adultas, ASPRODEMA, Consejo Estatal de Representantes de Minusválidos, CERMI, and the political parties)

Beneficiaries include:

The citizens of La Rioja

Co-creation process

This was a project that aimed at providing citizens with services, co-designed and co-produced with them (through the unions and most representative companies’ association in the region). This is demonstrated in the 2, 3, 4, 5 and 6 (out of 6) objectives stated by the working group for this Plan: (2) To set specific priority objectives in terms of PE and employment to guide the development of skills through-out space and time along the current office term, and promote them among citizens. (3) To lead the strategic approach of all the actors involved in PE and active employment policy in La Rioja, seeking to link their actions to the proposed objectives. (4) To integrate and coordinate the available resources in terms of PE and employability, both in the educational and employment markets, so that they support the objectives more effectively and efficiently. (5) To improve the interrelation between the different PE-providing subsystems and modes and, essentially, between all of them and actual employment. A greater involvement of the regional production system is essential. (6) To reach the highest degree of consensus in the formulation of the Plan from the technical, social and political points of view, so that public and private actions are mainly oriented towards shared strategic objectives.

Digital Transformation Process

Not applicable.

Results, Outcomes & Impacts

The general guidelines that grouped the results of this project aimed at improving employment qualification of human resources were:

To reduce structural unemployment and to promote employment of quality;
To achieve a qualified active population through lifelong learning;
To improve the quality and results of education and training systems at all levels;
To promote social inclusion and to alleviate poverty reinforcing social protection systems, lifelong learning and active and comprehensive inclusion policies, with special attention to women.

Additionally, the EU 2020 Strategy helped identify other results along the objective of smart, sustainable and inclusive growth:

Smart growth, through the development of an economy based on knowledge and innovation;
Sustainable growth, by promoting an economy that uses resources more efficiently, that is green and more competitive;
Inclusive growth, through the promotion of an economy with a high level of employment that results in economic, social and territorial cohesion.

Challenges & Bottlenecks

Regarding R&D and innovation investment, La Rioja presented certain weaknesses. According to Eurostat data, it reaches 0.87% of regional GDP. This is lower than the national average (1.33%) or that of the European Union (2.02%) and far from the 3% target of the Europe 2020 Strategy. La Rioja had 23,083 companies in 2015. Out of the total, 99.92% were companies without employees, micro-enterprises and SMEs. More than 50% of business units do not have salaried workers (12,314, according to the latest published statistics). This atomization is also reflected in the fact that most of the companies in the region are legally formed as solo-corporations or freelances. Likely, this bears an individualization effort to promote and engage these individuals into employment and training policy.

Transferability & Replicability

The Plan FP+E is a complex strategical project. Our selection of this case is justified as an example of the tremendous impact that PSINSIs may have in all sorts of public sector initiatives. In this case, a strategic plan for a social issue of major relevance such as unemployment and your professional education was handled with such a type of network. What surprised us from this case, beyond the formation of the network itself, is the publicity and openness of the initiative. It is true that it was subject to criticism, but the Working Group developments and final version of the plan was publicly and easily available from the regional government website. Moreover, the sessions of the Working Group, being a heterogeneous group including less qualified organisations, or certainly, not used to develop strategic political and operational plans, must have been rather complex to coordinate. Still, using the European, Spanish and earlier regional mandates and frameworks, they put together a complex plan that includes not only young people entering the labour market, but also long-term unemployed, disabled people, and those willing to re-qualify to improve their employability.

Success Factors

One of the major drivers for this Plan FP+E is the willingness of all economic actors to regain the competitiveness of the economy of La Rioja. Even along the economic crisis of the 2008-2013, the greater weight of the secondary sector justified that the economy of La Rioja was more productive than the Spanish economy. Measured through the relationship between GDP and the number of hours worked, La Rioja’s productivity was 36.37 in 2012, compared to 34.75 in Spain as a whole (Regional Accounting, Base 2008, INE). Another decisive driver of this Plan was the (EU) 2015/1848 Decision of the Council (October 5, 2015) on the guidelines for the employment policies of the member states for 2015. It set the following guidelines in terms of employment within the EU:

Boost the demand for labour.

Improve the job offer, qualifications and skills.

Improve the functioning of labour markets.

Promote social integration, fight poverty and promote equal opportunities.

Lessons learned

The 3rd Plan for Professional Education and Employment (Plan FP+E: Plan de Formación Profesional y Empleo of La Rioja) for the 2016-2019 office term represented an effort towards facilitating access to employment of the citizens of La Rioja, a region in the central northern Spain, World-famous for its wines, shoes and agriculture. The new federal government of La Rioja soon declared the care for its youth and unemployed a priority of its policies and public actions. And it embarked in a new plan towards improving professional education and employment in the region. This initiative was led by the Consejería de Educación, Formación y Empleo (the regional Department of Education, Training and Employment) and was the result of a very close temporal collaboration with the most representative unions (UGT, CCOO), enterprise association (FER) and other relevant social stakeholders in the region. Together, they built a Working Group to design and implement a new plan for professional education (PE) and employment for the 2016-2019 term. This has been a project then that can be associated with the new public governance paradigm (NPG) paradigm, and fits into the public sector innovation networks for social innovation. Besides the specific context described earlier, there have been several news concerning the implementation of the Plan FP+E since its inception. Maybe the most relevant is that the Spanish Court of Auditors, in its evaluation of the different instruments for employment policies in La Rioja, 2016 has observed a degree of implementation of the objectives of the Annual Employment Policy Plan higher than the average of the Autonomous Communities. In the case of Plan FP+E though, there is an absence of an evaluation. Also, some criticism from the political opposition publicised the plan was delayed in some of its proposals.

The Spanish General Secretary for Digital Administration

The General Secretary for Digital Administration offers the best case study in Spain for approaching value co-creation in the field of digital transformation, as it is the digital service team from central government in charge of national leadership and coordination. Fourteen head of Units and project managers of some of the most relevant projects have been selected to share their experience and opinions regarding co-creation of value in their area. In particular, they have been asked about their organisation, the most relevant project in which they have worked, other actors involved in those projects, recurring challenges, involvement of public servants, citizens and other stakeholders in their projects, replication of practices across levels of government, public value creation and the future of digital transformation.

Stakeholders & Beneficiaries

Stakeholders and Beneficiaries include:

Civil servants
Other national, regional and local public administration
Associations, representatives and intermediaries
Citizens as final users and professionals
Businesses and third sector associations

Co-creation process

Civil servants, citizens, business, intermediaries and other stakeholders participate during the whole cycle of creation of value. For example, when thinking about the projects launched to create some of the most relevant services nowadays, it was clear that the voice of the large number of stakeholders was collected and taken into account. It is worth noting that direct participation is not the most relevant way of co-creating value, the role of the intermediaries and external evaluation plays a central role. The main barrier to involve citizens in the early stages of the development of a project is the lack of an interlocutor. The administration usually collaborates with citizens when they are part of an association or a civil society cluster. It is especially during the legislative reform and the evaluation phases that the opinion of citizens, public servants and other stakeholders is gathered and taken to the continual improvement process. Nonetheless, efforts have been done during the last years to create spaces for collaboration. For example, the current administrative laws include some steps in which collecting the opinion of stakeholders is a legal requirement for their publication. Also, formal groups have been created within the governance structure which meet often to share opinions regarding digital transformation. During the phase of evaluation, the feedback of the stakeholders is the main indicator of the success of the service. In the case of the coordination between different administrations and different administration levels, formal working groups with the participation of the CIOs and other managers are arranged and some of them are even regulated by law. This multiple structure of collaboration and cooperation is deemed necessary because of the complexity of the territorial model and of the administration.

Digital Transformation Process

The provision of digital public services in Spain involves multiple actors, different in their powers and interactions amongst them. Even though there is a basic legal framework that applies for all the national territory, there are different competencies that result in the fact that strategies, legislation and public services are not unique Spain. The Law 11/2007 recognised citizens’ right to use electronic means in their relations with public administration. Afterwards, two new administrative laws integrated eGovernment into its core. These established the citizens’ right to communicate via an electronic channel with the public administrations and the obligation of the public administrations to use electronic means in their communications. Alongside, it was created the figure of the CIO of the Public Administration of the State, in charge of promoting the digital transformation process and the coordination with other administrations and with the European Union, together with the General Secretary for Digital Administration. One example. A relevant success case about co-creating value in digital administration is in the selection of the non-working days for notifications in the Tax Agency. Citizens, businesses and the public administration are able to enjoy a complete vacation period without problems derived from failed notifications, with the corresponding improvement in management. The quality of the service of the Tax Agency has been improved when taking into account massive feedback from all stakeholders.

Results, Outcomes & Impacts

Improvement of user-centricity, accessibility and quality of digital public services.
Satisfaction of the final user.
Reduction of the average time of processing of the administrative procedure.
Reduction of the development cost of the digital public services.
Reduction of fraud and increase of revenue.
Transparency and openness.
Better skills for digital transformation among civil servers and the civil society.
Improvement of knowledge about the public administration among citizens and other stakeholders.

Challenges & Bottlenecks

Interviewees identified an attitude of risk aversion among the public servants, as a consequence of fear to possible negative outcomes. Some interviewees declare that the coordination of a large number of stakeholders of different nature required a lot of effort, both with other administrations and with the private sector. Technical challenges have been identified, such as the use of some services by a large number of users complying with the requirements of availability, together with the digital divide, which complicated the adoption of some projects by all users and made it necessary to give several alternatives for the different groups of users. Other challenges are in changes in the direction of the project and varying degrees of support through time. It was also noted that the resistance to the projects was often against the way and the conditions of implementation and not against digital transformation. Starting the projects with quick-wins or clear advantages from the beginning can help to advantages and benefits to be noted from the beginning. In some of the more complex services, training and appropriate technological equipment has been necessary. It is needed an especial effort in training a deployment of technological equipment for its success. In the case of public servants who are involved in the design and operation of the projects, it is important to value and reward the whole team in the case of success, so that they feel co-responsible in future digital transformation projects. It has been identified in the surveys that the resistance to change among civil servants and ICT experts often comes from previous projects which were not successful.

Transferability & Replicability

There is a culture of cooperation and coordination among administrations, implemented through technical committees and working groups with representatives from the state administration, the regions and the municipalities. In the surveys, all of the interviewees from the Digital Secretariat for Public Administration declared that the source code of the digital services they were responsible for was published. Cloud computing is particularly relevant, as it allows this segment of users to access services without the need of meeting specific requirements in terms of infrastructure, budget or human resources. The current model is usually based on offering the service on the cloud to the final administrative user without a payment, as a policy to increase the use of digital services among small administrations. This model was preferred by most of the interviewees. The Law 39/2015, of the Common Administrative Procedure, establishes that regional administrations must reuse the common digital services unless otherwise justified in terms of efficiency. This helps the smaller municipalities to adopt digital transformation services, being usability crucial for the success of the project.

Success Factors

Participation of stakeholders should avoid one-size-fits-all strategies; idiosyncrasy matters and as well as the nature of the service, project, sector and type of users.
Prioritisation is essential as well as fast interactions along the value co-creation life cycle.
Moving from service offering model to on-demand model.
Key issues for involvement of stakeholders: dedication, selection, competences, awareness.
Less bureaucracy, direct on-line relationships and closeness to the citizens and other stakeholders.
Starting the projects with quick-wins or clear advantages from the beginning, so the advantages and benefits can be noted from the beginning.
In the case of public servants who are involved in the design and operation of the projects, it is important to value and reward the whole team in the case of success, so that they feel co-responsible in future digital transformation projects.

Lessons learned

The main conclusion of this report is that co-creation of value is a reality in the public sector of Spain. Direct participation is not the most relevant way of co-creating value, the role of the intermediaries and external evaluation plays a central role. Statistics of use as an indicator of the success and importance of a digital public service are regarded as a central piece. This study has identified some challenges regarding co-creation of value. It is necessary to improve the digital skills of citizens and other stakeholders in order to encourage their participation in the creation of value in digital transformation. It was identified that some of the services are not known by some of the segments of potential users and this reduces the success of the project. The organisation of the different stakeholders, their dedication and implication in the administrative affairs is very unequal and for that reason the co-creation of value could favour some stakeholders against others. It was declared by most of the interviewees that an improvement of the digital skills of the Spanish society would help to increase the quality introduced in the projects by the external stakeholders. It was a general opinion collected in the interviews that, by working further on the topic of co-creation of value, public administration will be able not only to be transparent and improve their accountability, but it will be possible to deliver services of a higher quality, user centric and which give a better response to the necessities of the society.

Simplified follow-up

This case concerns efforts to improve counselling and follow-up services within the Norwegian Labour and Welfare Services (NAV). The aims of the ‘simplified follow-up’ project were to simplify, enhance quality and make the work-related follow-up of users more effective. The project was carried out between 2015 and 2019 and involved the development of various digital solutions launched at different points of time throughout the project period. A preliminary project was carried out in 2015, based on a service design approach.

A new concept for the follow-up methods was presented as a ‘service journey’ based on the perspective of users and frontline employees. Needs for innovation and development in the (digital) support systems were identified, and 30 ideas for new tools that could support the new directions for follow-up were presented. In the final stage of the preliminary project, a set of these ideas were prototyped, tested and assessed based on a cost-benefit analysis.

One of the central solutions that emerged from the simplified follow-up project was the development and implementation of a digital activity plan with an integrated chat for direct communication between users and frontline employees.

Stakeholders & Beneficiaries

The main beneficiaries are the service users that receive follow-up services from the employment and welfare services. Consultancies providing design and programming expertise are involved stakeholders.

Co-creation process

A service design approach was explicitly adopted for the preliminary part of the project. In the project document, it was stated that the project ‘uses service design as a method to ensure a holistic approach in the development of new concepts. Service design is used throughout all phases of the preliminary project, with a continuous focus on the user’. Hence, a ‘holistic approach’ and ‘continuous focus on the user’ underpinned the service design approach. The project is anchored in qualitative and quantitative user research, and designers worked closely with frontline employees responsible for follow-up work in the development process.

Digital Transformation Process

The simplified follow-up project is closely connected to digital transformations in the organization. It is specifically interlinked with the introduction of a new system, called Modia, supporting new work methods in frontline work and digital interactions with clients. Moreover, the project was taking place in parallel to a broader organizational shift towards more agile methods for system development and organizational learning.

Results, Outcomes & Impacts

The central results and outputs of the service design process in this case was the development of a digital activity plan with an integrated chat function for direct communication between councillors and users. The interactive functionality was enabled by broader system changes in the organization related to the introduction of the administrative system Modia, developed to support two-way interaction between users and councillors. There are indications that the new solutions are well received among frontline employees and users, and it seems generally perceived as an improvement to how service interactions and follow-up is being carried out. It is not possible to say whether these improvements have broader impacts regarding employment rates. Calculations of benefits realization were still ongoing at the time of the case study.

Challenges & Bottlenecks

The case highlights various potential dilemmas related to the use of service design for public service innovation. First, service design assumes open, creative innovation processes in which time is spent on deeply understanding the service and its ‘pain points’. At the same time, service design stresses the importance of iterations as central to the creative processes, which require a proposed solution that can be prototyped. In this case, there was a concern that the main solution was launched too early, which somewhat closed the innovation process. It was reasoned that the result perhaps became less ‘revolutionizing’ than it could have been. Second, service design also underlines the importance of working both holistically and iteratively. The case shows how this can involve dilemmas in the sense that iterations may lead to a narrow focus on testing and improving specific solutions, in which the broader, holistic perspective of the services gets lost. Third, it was acknowledged that the insight work informing service design processes may run the risk of becoming detached from existing research knowledge.

Transferability & Replicability

The case can serve as inspiration for similar public service organizations seeking to digitalize service interactions, or to improve existing digital platforms for interaction with users. There are potential for learning from the service design approach underpinning the innovation process, and there are potential for learning and transferability when it comes to the concrete digital solutions that were developed and implemented.

Success Factors

Not relevant.

Lessons learned

There are valuable lessons to be learned from this project when it comes to efforts to rethink relations and interactions between public services and users in the context of labor and welfare services. These relations tend to be largely asymmetrical, and the users can feel inferior and alienated from the administrative processes of the public service organization. The outputs of this project (the digital activity plan and the chat for communication between users and frontline employees) challenge these asymmetries. The new solutions seem to provide platforms for improved interactions between employees in the welfare bureaucracy and users. The case shows that interactions through digital platforms can strengthen relations and interactions between service providers and users.

Stakeholders & Beneficiaries

Policy makers

Public health managers

Health professionals

Chronic Patients

Co-creation process

The interaction between professional health providers and chronic patients is of great value in order to improve quality of life of patients and the evolution of their illness. At the same time, health policy makers and health managers affect this process with their understanding of the relationship between health providers and patients and their allocation of the scarce resources in the public health system.

Digital Transformation Process

This project is not about digital transformation process.

Results, Outcomes & Impacts

Value created in the provision of health services to chronic patients is much more than curing individuals. The main goal is to improve quality of life of the elderly taking into account both physical and mental capacities. Quoting one of our health managers, “it is about filling the years with life and not filling the life with years” Value is created in all stages (co-design, co-production, co-construction and co-innovation) and by all stakeholders. In fact , the stage at which co-creation is more important mostly depends on the type of service. However, the most important interaction is that of public service staff and patients. Quoting another of our health managers, “about 70% of the quality of life of the elderly has to do with their lifestyles (diet and habits), which are much more important than genetics. Therefore it is very important that the elderly takes a leading role in the provision of public service provision through prevention, and through the patient empowerment”.

Challenges & Bottlenecks

Each stakeholder performs differently in the co-creation of value. Health policy makers allocate the resources and decide which services are the priority for their health policies. Their interaction and communication with health managers but also with the society in general will make them more sensitive to their needs. Chronic patients find that the Community is not engaged with them, and in a sense, they feel a bit abandoned. This is important as the Community may affect the direction of health policies. There is room for increasing the importance of the role of patients in the provision of health services. Even if in the last decades, there has been a continuous process of taking more and more into account the patient, in what has been named as a patient centred health system, they still feel that they are not sufficiently asked about their needs and levels of satisfaction.

Transferability & Replicability

Even if this case study was performed with a special focus on Parkinson patients, with the collaboration of Asociación Parkinson Madrid (an association of Parkinson patients in Madrid), most of the lessons are applicable, with limitations, to the co-creation of value in the interaction of the different stakeholders in the organisation and provision of care for patients with other chronic conditions.

Success Factors

The interaction between health professionals, providing health services and patients is a success in the creation of value, which is not only to cure patients (many times unfeasible solution for chronic conditions) but to improve the quality of life of patients. They, through a better engagement in the process of health provision, may understand better their condition and improve their quality of life through their lifestyle and habits, delaying the progression of the disease.

Lessons learned

The interaction of the different stakeholders is key in all stages, from realizing the need of a change or innovation to the design of the service provision, or to the actual production and construction of the health service provision. The clearest interaction is that of health professionals with chronic patients. However, health policy makers and the Community, are somewhat disengaged with the real needs of patients.