Published 23 September 2009, doi:10.1136/bmj.b3871
Cite this as: BMJ 2009;339:b3871

Feature

Health Policy

Europe’s knowledge broker

¹ BMJ, London WC1H 9JR

The European Observatory on Health Systems and Policies provides evidence to support Europe’s health ministers develop their policies. Tessa Richards looks at its work

Next week policy makers, researchers, and clinicians from across Europe will meet at the annual European Health Forum in Bad Gastein, Austria. Debate will focus on the effect of the financial crisis on Europe’s health systems and strategies to rein in costs, improve efficiency, and meet rising demand for services.

Let’s hope the discussions prove more productive than recent ones in the US. There, a summer of well orchestrated attacks on Barack Obama’s proposed health reforms and scare stories about Britain’s "dreaded NHS" all but drowned rational dialogue.¹ This is regrettable, not least because policy experts on both sides of the Atlantic agree that the US could learn useful lessons not only from the NHS but from several of Europe’s cheaper, equally effective, and more equitable health systems.

One organisation committed to furthering such cross country learning and using it to promote evidence based policy making is the European Observatory on Health Systems and Policies, a major contributor to the agenda and background information for the Gastein meeting.

From small beginnings

The idea of setting up an independent organisation to look at the different ways countries in Europe provide health care, extract policy lessons from their experience, and flag up examples of good practice, germinated in the corridors of two academic centres in London in the early 1990s. Chance brought together a small group of health researchers with a commitment to public health and an interest in policy analysis at the London School of Hygiene and Tropical Medicine and the London School of Economics and Political Science. They included Josep Figueras, the observatory’s full time director; codirector Elias Mossialos, who is also director of LSE Health; and Martin McKee, who heads the observatory’s research arm alongside his job as director of the European Centre on Health Societies in Transition. Professor McKee explained to me how the organisation developed.

"In the 1990s, the newly independent states in central and eastern Europe were attempting to shake off the legacy of the Soviet era and introduce new health reforms. Unsurprisingly, they looked to their Western neighbours and noted the enthusiasm for market reforms. When they sought information about the nature and impact of these reforms, it became obvious to us (and many others) that there was little available, and what there was, was hard to find and of poor quality. Policy was being influenced by ideology as much or more than evidence.

"We concluded that a new body was needed to bridge the divide between politicians on short tenures seeking quick simple fixes to complex problems and academics, who spend their working lives examining the same health issues but from a wholly different perspective—one oriented more towards advancing knowledge than informing current policy."

The way to bring the two camps closer together, the group decided, would be to talk to health ministers to identify what they thought were the pressing problems and policy questions and then to harness the skills of academics to mount a "rapid response" to them. The academics role, facilitated by the observatory, would be to conduct secondary research (mostly in the form of cross country analyses) and present ministers with the best evidence available on policy options and impact relevant to their concerns.

The group first collaborated to inform discussions at the WHO European health ministerial conference in Ljubljana, Slovenia, in 1996. At that meeting 53 health ministers from the WHO European region pledged to provide sustainable, universally accessible, and equitable health services oriented towards primary care—and to exchange experience on implementing health reform.² It was this last commitment that led to the formal establishment of the observatory in 1999.

Since its inception the organisation has accepted requests from health ministers and their advisers for reports to support discussions at a wide variety of national and European health policy meetings. It has also developed a role in anticipating and stimulating the wider European health agenda. One of the regular policy forums to which it contributes background reports is the rotating six monthly presidency meeting of the EU Health Council. Sweden is currently in the driving seat, and one of its priorities is tackling antibiotic resistance. At its request the observatory compiled a report on stimulating research and development of new antibiotics, which fed into last week’s ministerial meeting on the topic. Last year it provided a raft of background papers to support the WHO European region’s second ministerial conference on health systems in Tallinn, Estonia. Ministers at the meeting signed another charter encapsulating the tenet that investing in health systems not only improves health but also the economy. Focus was also put on the need to measure the performance of health systems.³

Output and influence

The observatory’s output is diverse and extensive. It includes analyses of individual countries’ health systems and publications that collate information on the nature and impact of the varied policies countries have implemented to tackle common problems—for example, financing health care and strategies to tackle communicable and chronic diseases. Recent titles look at how countries use health technology assessment to try to "improve value for money in health care" and maintaining Europe’s health workforce. It also publishes short policy briefs, a regular ebulletin, and a monthly magazine. All publications can be downloaded (free of charge) from its website (www.euro.int/observatory).

The organisation is run from a modest base in Brussels by Dr Figueras and lynchpin Suzy Lessof, the director of management. The two work closely with a handful of full time staff and hubs in London, Berlin and Atlanta, Georgia. Many of the requests it gets for reports (and the funding to commission and produce them) come from its partners. These currently include WHO Europe, the World Bank, the European Investment Bank, and the governments of Belgium, Finland, Norway, Slovenia, Spain, Sweden, and the Veneto region of Italy. The European Commission and the governments of France and Ireland are likely to join the partnership soon.

When I asked Professor Mossialos, why the UK was not listed as a partner, he paused, looked quizzical, and expressed the hope that it "would be in the future," before going on to talk about the reach, influence, and future of the organisation.

"Because our goal is to respond speedily to requests for evidence and advice on policy issues we commission most of our reports and ‘synthesise’ them in house. As a result we have established strong links (aided by a listserv) with over 300 researchers and academic centres throughout Europe and beyond including the US, Japan, Australia, New Zealand, and South Korea. Demand for out publication has grown steadily, and it’s laid the ground for the development of several European Commission programmes, including one on mental health and wellbeing." The observatory’s website, which is hosted by WHO, has been WHO’s most accessed site for the past five years, although it was recently overtaken by the one on swine flu.

Dr Figueras considers influence from another perspective. "It is not just how many people we reach but who they are and whether we influence their thinking. That’s why we hold our regular national policy dialogues with small groups of high level decision makers." Some are more successful than others, he admits disarmingly, but cites examples (in confidence) where ministers bent on one course of action have been swayed to take another after discussion of the evidence. He also refers to a recent statement from Marc Danzon, regional director of WHO Europe, in which he describes the observatory as a "fine example of a cooperative structure" which has "supported (health) reforms programmes in numerous countries." ⁴

The observatory is not without critics, however. David Hunter, professor of health policy and management at Durham University, says that "To outsiders, it appears a bit elitist and it is not clear how it works or how it sets its agenda. I also wonder how much it permeates health systems at sub-national level. Policy making, innovation, and organisational change go on at many levels and often the most interesting occur at ground level. While its publications are useful to academics, I am not sure how much impact they have on real-time policy makers and managers, or in getting research into practice."

Both Dr Figueras and Professor Mossialos acknowledge that the observatory needs to consider how to reach a broader constituency, including health professionals and the public, and it is currently in the throes of developing a new media and dissemination strategy.

Looking to the future, there are proposals to emulate the organisation’s work elsewhere. The US Agency for International Development has just asked Dr Figueras and his colleagues to assess the feasibility of setting up an African observatory on health systems and plans are also underway to set one up in Asia and possibly the Middle East.

In the face of these developments and what Professor Mossialos describes as "a spiralling demand for new reports" the observatory is grappling with the challenge of how to grow. Its staff have spent years working closely together and honing the diplomatic skills that are needed to work effectively with a wide range of politicians, academics, and different organisations. Finding the right people to engage, and in time pass the baton to, may not be easy but is arguably no harder than persuading politicians to think long term and act on sound evidence.

Cite this as: BMJ 2009;339:b3871

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Competing interests: TR was invited to and attended three days of the summer school the observatory ran earlier this year on innovation and health technology assessment.

References

1. Keep it honest. Economist 2009 Aug 22. www.economist.com/opinion/displaystory.cfm?story_id=14258877.
2. The Ljubljana Charter on Reforming Health Care. BMJ 1996;312:1664-5.[Free Full Text]
3. Richards T. WHO European region commits to new health charter. BMJ 2008;337:a621.[Free Full Text]
4. Danzon M. Report of the regional director to WHO regional committee for Europe, 59th session, 14-17 September 2009. www.euro.who.int/document/RC59/rc59_rdspeech_eng.pdf.

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