Invest4Health White Book: Bridging the “Missing Middle” Between Innovation and Sustainable Health Systems
Why do promising health promotion and disease prevention initiatives so often struggle to survive once project funding ends? A new White Book developed through collaboration between Invest4Health, the European Partnership on Transforming Health and Care Systems (THCS), and the AAL Programme explores this challenge and proposes practical ways to address it.
The White Book, Hard but Not Impossible: Scaling What Works in Health Promotion, Disease Prevention and Integrated Health and Care through the ‘Missing Middle’, brings together experiences and lessons from three European initiatives working to support innovation, sustainable financing and the transformation of health and care systems.
Understanding the “Missing Middle”
Across Europe, many promising initiatives demonstrate positive results during their funded project phase but struggle to become part of routine practice. Even when an intervention is effective, the organisations, financing arrangements and governance structures needed to sustain it may not be in place.
The White Book describes this gap between a funded project and its sustainable integration into health and care systems as the “missing middle”.
The problem is not simply a lack of funding. It also involves fragmented responsibilities, different organisational priorities, short-term budgets, limited coordination and the absence of clear ownership once a project ends.
Addressing these challenges requires new approaches to financing, governance and collaboration between public authorities, healthcare organisations, investors, communities and other stakeholders.
Combining Experience from Three European Initiatives
The White Book was developed by a joint working group involving:
- Invest4Health, contributing its Smart Capacitating Investment (SCI) approach and experience from eight European regional testbeds.
- The European Partnership on Transforming Health and Care Systems (THCS), Work Package 9, contributing knowledge on strengthening regional health and care ecosystems.
- The AAL Programme, contributing lessons from more than two decades of supporting innovative solutions and their transition towards implementation and wider adoption.
The publication draws on five practical cases from Wales, Sweden, Italy, Finland and Austria, illustrating different approaches to financing, governance, stakeholder collaboration and scaling.
What Needs to Change?
The White Book identifies several interconnected barriers that prevent successful initiatives from continuing beyond their initial funding period.
These include financing systems that do not adequately recognise the long-term value of prevention, benefits that appear in different organisations or budgets, fragmented governance, and difficulties maintaining the relationships and knowledge developed during projects.
It also highlights several conditions that can help overcome these barriers:
- Establishing governance and collaboration arrangements early, rather than waiting until a project ends.
- Identifying clear responsibility for sustaining and further developing successful initiatives.
- Developing financing and business models that reflect the needs of different stakeholders.
- Building trust and a common understanding between sectors.
- Involving citizens and patients in decisions about priorities, value and future investment.
- Making the wider social and economic value of prevention more visible.
An important message is that planning for long-term sustainability must begin during project development, not after project funding has ended.
From Project Results to Long-Term Impact
The publication builds on Invest4Health’s work on Smart Capacitating Investment, which explores how health promotion and disease prevention can be supported through more sustainable and collaborative financing approaches.
It also identifies opportunities for further cooperation, including testing transition financing approaches in new regional settings, improving the measurement of long-term social value, and making the combined knowledge of the three initiatives available to future projects and policymakers.
The White Book emphasises that scaling successful interventions requires more than additional funding. It requires investment in the relationships, organisational capacity and shared responsibilities that allow effective solutions to become part of everyday practice.
The publication offers lessons and practical recommendations for policymakers, regional authorities, health and care organisations, researchers and other stakeholders seeking to turn promising innovations into sustainable improvements in health and wellbeing.
Read the White Book
Hard but Not Impossible: Scaling What Works in Health Promotion, Disease Prevention and Integrated Health and Care through the ‘Missing Middle’
Developed by Invest4Health in collaboration with the THCS Partnership WP9 and the AAL Programme, with contributions from citizen and patient representatives.
Further SCI resources: https://invest4health.eu/resources
Invest4Health received funding from the European Union’s Horizon Europe Research and Innovation Programme under Grant Agreement No. 101095522.