European Advisory Committee on Health Research: seventh meeting, Copenhagen, Denmark, 6–7 April 2016

European Advisory Committee on Health Research Seventh Meeting, Copenhagen, Denmark, 6–7 April 2016 ABSTRACT The European Advisory Committee on Health Research (EACHR) reports directly to the World Health Organization (WHO) Regional Director for Europe. Its purpose is to advise on formulation of policies for the development of health research, review the scientific basis of selected regional programmes, advise on new findings on priority public health issues and evidence-based strategies to address them, and facilitate exchange of information on research agendas and evidence gaps. The Committee held its seventh formal meeting in Copenhagen, Denmark, on 6–7 April 2016. Engaging actively with the Regional Director, it reviewed the implementation of previously agreed actions and the work of its subgroups on migration and evidence-informed policy-making, and updated the EACHR action plan. It reviewed and offered advice on a draft Global Action Plan on Violence, an Operational Plan for the Global Strategy for Women’s, Children’s and Adolescents’ Health, and on responses to specific assignments in preparation for the United Nations General Assembly Third High-level Meeting on Prevention and Control of Noncommunicable diseases in 2018. It also examined a range of other WHO areas of work, including key items for the meeting of the WHO Regional Committee for Europe in September 2016. Further issues identified for future consideration of the EACHR included culture and health, the developmental origins of health and disease, and the United Nations Sustainable Development Goals. Keywords: • Health research • Health management and planning • Health policy • Health status indicators • Public health administration • Strategic planning Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe United Nations City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). © World Health Organization 2016 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. 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CONTENTS ABBREVIATIONS ..................................................................................................................................................................... 1 INTRODUCTION ....................................................................................................................................................................... 1 OPENING SESSION .................................................................................................................................................................. 2 THE REGIONAL DIRECTOR'S UPDATE ............................................................................................................................. 2 GLOBAL PRIORITIES ................................................................................................................................................................................... 3 Global issue 1: Health in the Sustainable Development Agenda 2030 ............................................................................... 3 Global issue 2: Universal health coverage ....................................................................................................................................... 3 Global issue 3: Building a new WHO programme for outbreaks and emergencies such as Zika virus disease .............................................................................................................................................................................................................................. 4 REGIONAL PRIORITIES ............................................................................................................................................................................... 4 Regional issue 1: Migration and health ............................................................................................................................................ 5 Regional issue 2: Health system strengthening ............................................................................................................................. 5 EACHR DISCUSSION AND RECOMMENDATIONS ................................................................................................................................... 6 UPDATE ON PREVIOUSLY AGREED EACHR ACTIONS ................................................................................................. 6 EACHR DISCUSSION AND RECOMMENDATIONS ................................................................................................................................... 7 ACTION POINTS........................................................................................................................................................................................... 7 PUBLIC HEALTH AND MIGRATION ................................................................................................................................... 8 ACHIEVEMENTS SINCE APRIL 2015 ....................................................................................................................................................... 8 ONGOING ACTIVITIES AS OF FEBRUARY 2016 ...................................................................................................................................... 9 Maternal health ........................................................................................................................................................................................ 10 Mental health ............................................................................................................................................................................................. 10 Definitions of the term "migrant" ..................................................................................................................................................... 10 EACHR DISCUSSION AND RECOMMENDATIONS ................................................................................................................................ 10 ACTION POINTS........................................................................................................................................................................................ 11 THE CULTURAL CONTEXTS OF HEALTH AND WELL-BEING (CCH) ......................................................................12 EACHR DISCUSSION AND RECOMMENDATIONS ................................................................................................................................ 13 ACTION POINT ................................................................................................................................................................ ......................... 13 PREVENTION AND CONTROL OF NCDS .........................................................................................................................13 RESPONSES TO SPECIFIC ASSIGNMENTS IN PREPARATION FOR THE THIRD HIGH-LEVEL MEETING ON PREVENTION AND CONTROL OF NON-COMMUNICABLE DISEASES OF THE UNITED NATIONS GENERAL ASSEMBLY IN 2018 ............................. 13 EACHR DISCUSSION AND RECOMMENDATIONS ................................................................................................................................ 14 ACTION POINTS........................................................................................................................................................................................ 14 OPERATIONAL PLAN TO TAKE FORWARD THE GLOBAL STRATEGY FOR WOMEN´S, CHILDREN´S AND ADOLESCENT´S HEALTH ....................................................................................................................................................15 EACHR DISCUSSION AND RECOMMENDATIONS ................................................................................................................................ 16 ACTION POINTS........................................................................................................................................................................................ 16 DRAFT GLOBAL PLAN OF ACTION ON VIOLENCE ......................................................................................................17 EACHR DISCUSSION AND RECOMMENDATIONS ................................................................................................................................ 17 ACTION POINTS........................................................................................................................................................................................ 17 DEVELOPMENTAL ORIGINS OF HEALTH AND DISEASE AND WHO´S LIFE-COURSE APPROACH ...............18 EACHR DISCUSSION AND RECOMMENDATIONS ................................................................................................................................ 19 ACTION POINTS........................................................................................................................................................................................ 19 ISSUES FOR THE SIXTY-SIXTH REGIONAL COMMITTEE MEETING, 2016 .........................................................19 DEVELOPMENT OF ACTION PLANS FOR HEALTH SECTOR RESPONSES TO HIV AND VIRAL HEPATITIS IN THE WHO EUROPEAN REGION 2016–2021 ........................................................................................................................................................ 19 EACHR discussion and recommendations ..................................................................................................................................... 20 Action points ............................................................................................................................................................................................... 21 ZIKA VIRUS ................................................................................................................................................................ ............................... 21 DRAFT EUROPEAN FRAMEWORK FOR ACTION ON INTEGRATED HEALTH SERVICE DELIVERY ................................................... 22 EACHR discussion and recommendations ..................................................................................................................................... 22 Action points ............................................................................................................................................................................................... 23 UPDATE FROM THE EACHR SUBGROUP ON EIP ........................................................................................................23 EACHR DISCUSSION AND RECOMMENDATIONS ................................................................................................................................ 24 ACTION POINTS........................................................................................................................................................................................ 24 MEETING REFLECTIONS AND CONCLUSIONS ..............................................................................................................24 REGIONAL DIRECTOR'S REFLECTIONS ................................................................................................................................................. 24 ACTION PLAN ........................................................................................................................................................................................... 25 NEXT EACHR MEETING ................................................................................................................................................................ ........ 25 CONCLUSION AND CLOSURE................................................................................................................................................................... 25 SUMMARY OF ACTION POINTS ............................................................................................................................................................... 26 REFERENCES ...........................................................................................................................................................................28 ANNEX 1. PROGRAMME AND AGENDA ..........................................................................................................................31 ANNEX 2: LIST OF PARTICIPANTS ..................................................................................................................................33 Abbreviations CCH cultural contexts of health and well-being DOHaD developmental origins of health and disease EACHR European Advisory Committee on Health Research EHII (WHO) European Health Information Initiative EIP evidence-informed policy-making EVIPNet Evidence-informed Policy Network H&SS humanities and social sciences HEN Health Evidence Network HBSC Health Behaviour in School-aged Children (study) IHR International Health Regulations MDG Millennium Development Goal MSM men who have sex with men NCD noncommunicable disease NGO nongovernmental organization OECD Organisation for Economic Co-operation and Development SCRC Standing Committee of the WHO Regional Committee SDG Sustainable Development Goal WHO World Health Organization European Advisory Committee on Health Research Page 1 Introduction The European Advisory Committee on Health Research (EACHR) reports directly to the World Health Organization (WHO) Regional Director for Europe. Its purpose is to advise the Regional Director on formulation of policies for the development of research on health in the Region, review the scientific basis of selected WHO programmes, advise on new findings on public health priorities and evidence-based strategies to address them, and facilitate the exchange of information on research agendas and evidence gaps (Box 1). Its rotating membership comprises public health research experts with a wide variety of specialist knowledge and experience drawn from Member States of the Region and international institutions. Box 1. Terms of reference of the EACHR 1. Advise the Regional Director on formulation of policies for the development of research on health in the Region. 2. Review the scientific basis of selected programmes of the WHO Regional Office for Europe, with particular attention to their translational aspects. 3. Advise the Regional Director on new findings emerging from research on public health priorities, and effective evidence-based strategies and policies to address them. 4. Facilitate dialogue and interaction among the public health community, research bodies and funding agencies to exchange information on research agendas in the Region and address evidence gaps for priorities such as noncommunicable diseases (NCDs). 5. Facilitate the compilation and review of the results of major research programmes on public health priorities, and assess their implications for policy at the international, national and local levels. 6. Support the development of research potential and capability, nationally and regionally, with special attention to the eastern part of the Region. 7. Pursue harmonization of research activities in the Region with those in other regions and at the global level. 8. Formulate, as appropriate, ethical criteria for public health research. The Committee held its seventh formal meeting in Copenhagen, Denmark, on 6–7 April 2016. It reviewed and offered advice on a range of research topics, and agreed on a number of recommendations and action points to take forward the priorities set by the WHO Regional Committee for Europe and the European health policy framework Health 2020 (1). Engaging actively with the Regional Director, it reviewed implementation of previously agreed actions and the work of its two subgroups: on public health and migration, and on evidence-informed policy- European Advisory Committee on Health Research Page 2 making (EIP). It reviewed and offered advice on the draft global action plan on violence, an operational plan for the Global Strategy for Women’s, Children’s and Adolescents’ Health 2016– 2030, and on responses to specific assignments in preparation for the United Nations General Assembly Third High-level Meeting on Prevention and Control of Non-communicable Diseases in 2018. It also reviewed and offered advice on a range of other WHO areas of work, including key items for the Sixty-sixth Meeting of the WHO Regional Committee for Europe, to be held in Copenhagen in September 2016. The EACHR also identified issues for future consideration, including culture and health, the developmental origins of health and disease, and the United Nations Sustainable Development Goals (SDGs). Opening session Professor Tomris Türmen, EACHR Chairperson and President of the International Children's Centre, Bilkent University, Ankara, Turkey, opened the meeting and welcomed the participants. Dr Zsuzsanna Jakab, WHO Regional Director for Europe, thanked Professor Türmen and the co- chairperson Professor Rozá Ádány, and welcomed the members of the EACHR. She welcomed Professor Petros Sfikakis, Dean of the School of Medicine, University of Athens, Greece, as a new member of the EACHR and Ms Eva Falcão, Director of International Relations, Directorate- General of Health, Lisbon, Portugal, as a representative of the Standing Committee of the WHO Regional Committee for Europe (SCRC). Ms Line Matthiesen, Director General Research of the European Commission, and Mr Martin Hynes, European Research Council, sent their apologies. The Committee adopted the agenda proposed by Mr Tim Nguyen, Unit Leader, Evidence and Information for Policy, Division of Information, Evidence, Research and Innovation. Dr Mathias Bonk, independent consultant, Germany, was elected meeting rapporteur. A review of the members’ declarations of interest by the WHO Secretariat confirmed that there were no conflicts of interest with the meeting objectives. The Regional Director’s update Dr Jakab outlined the main strategic issues on the WHO global and regional agenda, and gave an update on decisions by governing bodies and major events since the sixth EACHR Meeting (2). She stated that the WHO European Region is on track to achieve the Health 2020 targets, and that many countries were now aligning their national health strategies with Health 2020. People in the WHO European Region were living longer and healthier lives than ever before, and differences in life expectancy and mortality between countries were diminishing. In contrast, unacceptable differences in health status between countries were still being observed and gains in life expectancy could be lost if rates of smoking, alcohol consumption and obesity do not decline substantially. To obtain European Advisory Committee on Health Research Page 3 adequate evidence for future policies, data collection must be strengthened and new health monitoring approaches explored. Global priorities Global issue 1: Health in the Sustainable Development Agenda 2030 The United Nations General Assembly adopted the resolution “Transforming our world: the 2030 Agenda for Sustainable Development” and the SDGs in September 2015 (3). The SDGs are seen as integrated and indivisible, and cover the economic, environmental and social pillars of sustainable development with a strong focus on equity. Development and health are inextricably linked and strong political commitment is needed with whole-of-government and whole-of-society approaches. The SDGs provide an extraordinarily important opportunity for health development. While health appears at Goal 3, “ensure healthy lives and promote well-being for all at all ages”, there are also multiple sectoral linkages with health across the other SDGs, including social, environmental and economic determinants such as education, income and urbanization. Health 2020 priorities are reinforced by the SDGs, and the WHO Regional Office for Europe supports its Member States in implementing both strategic agendas. A very important WHO Executive Board resolution on strengthening public health, including significant organizational, functional and workforce implications, was agreed at the January 2016 meeting of the Executive Board (4). The WHO Regional Office for Europe and Member States should aim to identify a public health agenda that can help to deliver both the SDGs and Health 2020, and to achieve equitable improvement in health and well-being throughout the Region using whole-of-society and health-in-all policy approaches. The EACHR has a unique opportunity to be closely involved in strengthening the public health agenda in Europe and globally. Global issue 2: Universal health coverage Universal health coverage, one of WHO’s main priorities, is an important objective within the SDGs. It combines access to health services – promotion, prevention, treatment – and the financial protection to prevent ill-health from leading on to poverty. People’s chances in life are strongly influenced by policies, environments, opportunities and norms created by society, and for which society bears responsibility. Family and social relationships, behavioural choices, social norms and opportunities, as well as historical, cultural and structural contexts, also affect individual development. While genetics partly determines health in later life, research has shown that environmental, nutritional and hormonal factors during intrauterine development have a key role in determining functional development and future disease risks. Public health action must, therefore, also focus on preconception, pregnancy and fetal development, and on the most vulnerable life stages. A life- course approach for health and well-being builds on these interactions and adopts a temporal perspective on the health of individuals, including intergenerational determinants of health. The European Advisory Committee on Health Research Page 4 life-course approach is an essential step towards implementation of the SDGs and Health 2020, as well for as the achievement of universal health coverage. The WHO European Ministerial Conference on the Life-course Approach in the Context of Health 2020 in Minsk, Belarus, on 21–22 October 2015 considered the policy implications of this understanding (5). In the Minsk Declaration, Member States committed to adopting the life-course approach across the whole of government to improve health and well-being, promote social justice, and contribute to sustainable development, inclusive growth and wealth. Global issue 3: Building a new WHO programme for outbreaks and emergencies such as Zika virus disease The establishment of one single programme for outbreaks and emergencies, including a regular budget and a clear line of authority, is one of the most important challenges within WHO’s reform process. This new programme is designed to be comprehensive, addressing all hazards flexibly, rapidly and responsively, with a principle of “no regrets”. It will work synergistically with other WHO programmes and partners to address the full cycle of health emergency preparedness, response and recovery. It will consolidate, standardize and expand the existing capacities at country, regional and headquarters levels, leverage the unique governance structure of WHO, and encourage full participation and integration of all partners, operating with clear accountability and standard performance metrics. This transformation is guided by the report and recommendations of the Ebola Interim Assessment Panel (6), the Advisory Group on Reform of WHO’s Work in Outbreaks and Emergencies, and external reports, as well as the discussions in the WHO Executive Board. The full implementation of the International Health Regulations by Member States and strengthening of health systems in many countries are essential to ensure global preparedness for public health emergencies of international concern, such as the Ebola outbreak in West Africa or the Zika virus outbreak in Latin America and the Caribbean. The risk of Zika virus transmission in Europe is extremely low but might increase in spring and summer. There is now growing evidence from observational, cohort and case–control studies indicating a high likelihood of a relationship between Zika virus infection and microcephaly and neurological disorders. Further research is needed to investigate this. The WHO Regional Office for Europe supports its Member States and is working closely with its partners in this area, particularly with the European Commission and the European Centre for Disease Control. Regional priorities Dr Jakab requested EACHR members’ guidance on several issues that were on the margins of the Sixty-sixth Regional Committee’s agenda (action plans for the health sector response to HIV and viral hepatitis in the WHO European Region, the draft of a European framework for action on integrated health service delivery, and the action plan to strengthen the use of EIP in the WHO European Region) plus the issues below. European Advisory Committee on Health Research Page 5 Regional issue 1: Migration and health The WHO Regional Office for Europe has been working with its Member States on the public health and health system impacts of the current large-scale migration in Europe, which will continue in the foreseeable future. The collective health needs of refugees and migrants and the implications of these are considerable, and have an increasing impact in today’s societies and governments. Health-care systems must be flexible enough to respond to these. WHO supports policies that provide health services to migrants and refugees, irrespective of their legal status. The WHO Regional Office for Europe is collaborating very closely with the WHO Eastern Mediterranean and African Regions to develop evidence-informed policies and interventions at the countries of transit and destination. Providing adequate standards of care for refugees and migrants is important for population health, and fundamental for protecting and promoting the human rights of both the refugees and migrants and the host communities. To assist Member States in adequately responding to these public health challenges, the WHO Regional Office for Europe established the Public Health Aspects of Migration in Europe project in 2012, and also developed and successfully piloted a unique toolkit for countries to assess their capacity to adequately cope with the public health implications of large- scale migration. It also supports Member States by providing technical and on-site assistance and policy advice on contingency planning, delivering training on public health and migration for professionals within and outside the health sector, providing medical supplies and producing relevant public information material and Health Evidence Network (HEN) synthesis reports. A high-level meeting on Refugee and Migrant Health was held in Rome, Italy, in November 2015. The meeting resulted in the outcome document Stepping up action on refugee and migrant health (7), where all European countries agreed on the urgent need to develop a European framework for collaborative action on refugee and migrant health, based on the principle of solidarity and humanity. Member States also decided that a European strategy and action plan on refugee and migrant health, accompanied by a resolution, would be developed and submitted to the next Regional Committee for Europe meeting in September 2016. Regional issue 2: Health systems strengthening Health systems strengthening is of particular importance for the European Region. The Tallinn Charter (“Health systems for health and wealth”) outlined the commitments of Member States, with a strong emphasis on enhancing solidarity, investing in health and increasing accountability. This has been reinforced within Health 2020, which outlines key policy directions in health financing, service delivery, resource generation and stewardship. Important action points include strengthening public health and health-care services with a focus on promoting coordinated, people-centred care and primary health care, and implementation of the European action plan for strengthening public health capacities and services (8) as a key pillar for implementation of the SDG framework and Health 2020. European Advisory Committee on Health Research Page 6 The agreed regional targets supporting Health 2020 are a reduction in premature mortality and inequities, increase in life expectancy, achievement of universal health coverage and enhancement of well-being. Progress in achieving these targets has been published in the European health report 2015 (9). EACHR discussion and recommendations Participants highlighted the importance of health within the SDG agenda. Some Millennium Development Goals (MDGs) have not been fulfilled and should not be forgotten. Accountability at the local, national, regional and global levels needs to be strengthened, and countries with the least resources supported to build adequate public health and research capacities. Building a sufficient evidence base for the life-course approach will be essential, as this will become a very important aspect throughout the public health agenda and within the SDG context. WHO should further support policies for and political commitment to achieving universal health coverage in the European Region. The establishment of a new WHO programme for outbreaks and emergencies has been positively received. WHO should ensure multidisciplinary research in the area of preparedness and response to outbreaks. It was emphasized that European countries are still not sufficiently prepared for the growing public health and other challenges arising from the refugee and migrant influx. The WHO Regional Office for Europe was asked to support Member States in identifying medium- and long-term solutions in this area. Lessons could be learnt from eastern European countries, which have received millions of migrants mainly from neighbouring countries within the past two decades (e.g. the Russian Federation 17 million; Kazakhstan 2 million). Participants also called for new models for financing public health research, more implementation and knowledge translation research, and the inclusion of experts from other sectors such as engineering and sociocultural sciences in the discussions. Evidence is needed from all areas for informed decision-making, and for finding affordable and sustainable innovations and interventions for health. This includes technology, such as the use of social media, which is a rapidly evolving, multidisciplinary field. Update on previously agreed EACHR actions Dr Claudia Stein, Director, Division of Information, Evidence, Research and Innovation, presented and reviewed the action points agreed at the previous EACHR meeting (in 2015). Work of the two EACHR subgroups (public health and migration, and EIP) is presented below. Mapping of national health research systems has been published in the European Journal of Public Health. The results of the mapping exercise have been integrated in the Situation analysis manual, prepared by the Evidence-informed Policy Network (EVIPNet), as well as in the draft action plan to strengthen the European Advisory Committee on Health Research Page 7 use of evidence, information and research for policy-making in the WHO European Region (10), which will be taken as a resolution to the Sixty-sixth Meeting of the Regional Committee in September 2016. Dr Stein outlined the progress for the WHO European Health Information Initiative (EHII), a multipartner network led and supported by Member States and WHO collaborating centres. It acts as an umbrella for several health information activities, projects and networks in the Region. It fosters international cooperation to exchange expertise, build capacity and harmonize data collection to support the development of a single integrated health information system for the Region. Several health information networks have been or are being established, such as EVIPNet Europe, the Central Asian Republic Information Network (CARINFONET), and the Small Countries Health Information Network (SCHIN). A south-eastern European Health Information Network and a European Burden of Disease Network are in the planning stages. The latter will initially be chaired by Public Health England and will be established with the support of the Institute for Health Metrics in Seattle, USA. Other EHII-related activities include the launch of the European Health Information Gateway and the revitalization of publications such as Country Profiles and Highlights on Health and Well-being. The WHO Regional Office for Europe is using the Health 2020 framework as a tool to strengthen the links between health and sustainable development. This will support Member States with their baseline reporting for SDG 3 and other SDG health indicators. EACHR discussion and recommendations The progress of EHII activities was received positively. Public Health Panorama, the Regional Office’s new peer-reviewed journal, could become a very important journal on health policy, and could have a more multisectoral editorial team and attract the next generation of researchers. The Organisation for Economic Co-operation and Development (OECD) is developing country health profiles in cooperation with the European Commission and the European Observatory on Health Systems and Policies; consequently, improved coordination with WHO would be useful. In the context of the planned European Burden of Disease Network, a life-course approach should be promoted and indicators for multidimensional exposures and environmental factors should be included because involuntary and preventable exposures that cause disease are being neglected. Action points  EACHR to support WHO in emphasizing the importance of health within the SDG agenda  WHO to continue coordinating with the OECD and the European Commission in areas such as the country health profiles. European Advisory Committee on Health Research Page 8 Public health and migration Professor Walter Ricciardi, Director of the Department of Public Health, Università Cattolica del Sacro Cuore, Rome, Italy, and a member of the EACHR subgroup on public health and migration, introduced the topic with Dr Santino Severoni, Coordinator, Public Health and Migration, Division of Policy and Governance for Health and Well-being, WHO European Office for Investment for Health and Development. The subgroup was formed after the fifth EACHR Meeting in 2014 to review the strategic framework for the Public Health Aspects of Migration in Europe project. The subgroup is a collaboration between two WHO divisions: the Division of Policy and Governance for Health and Well-being, and the Division of Information, Evidence, Research and Innovation (Evidence and Information for Policy Unit). The EACHR also recommended that three HEN reports be commissioned to examine the challenges facing three groups of migrants where different policy approaches might be required: undocumented migrants; labour migrants; and refugees, asylum seekers and newly arrived migrants. The reports should use existing evidence to support options for policy-makers and an evidence base for the development of a European strategy and action plan on migration and health. Achievements since April 2015 The WHO Regional Office for Europe scaled up its assistance to Member States on migration and health matters as the number of refugees and migrants increased throughout 2015 to reach over 1 million by the end of the year. In addition, more than 2 million refugees have taken shelter in Turkey. The continuing conflicts in the Middle East suggest that large influxes will continue in the coming months. These numbers suggest that the public health challenges due to migration will remain in the foreseeable future. The WHO Regional Office for Europe in collaboration with the Ministry of Health of Italy organized a High-level Meeting on Refugee and Migrant Health in November 2015, following discussions on this issue at the margins of the Regional Committee in September 2015. Fifty European, Eastern Mediterranean and African countries participated in the meeting, along with the WHO Regional Offices for Europe, Eastern Mediterranean and Africa, other United Nations agencies and international organizations. The results from the discussions are documented in Stepping up action on refugee and migrant health (7), where European Member States agreed on a framework for collaborative action. The SCRC approved the development of a European strategy and action plan on refugee and migrant health, accompanied by a resolution that will be submitted and discussed at the Regional Committee in September 2016. The collection and analysis of evidence is one of the key areas that needs immediate action in order to develop informed policies to tackle short-, medium- and long-term public health challenges related to large-scale migration in the European Region. European Advisory Committee on Health Research Page 9 Three academic institutions (Institute of Public Health of the Catholic University of the Sacred Heart, Rome, Italy; Medical University of Vienna, Austria; and Uppsala University, Sweden) were commissioned to undertake evidence syntheses from March to September 2015, with each institution focusing on a distinct migrant type. The analyses examined both the peer-reviewed academic literature and the grey literature to ensure a multidisciplinary and comprehensive approach. In September 2015, the three HEN reports were published and presented to the 53 Member during the Sixty-fifth WHO Regional Committee for Europe meeting. In addition, joint missions with national ministries in charge of health have assessed country capacity to adequately cope with the public health consequences of large-scale migration. These assessment reports have been published, including key findings and recommendations, for Bulgaria, Greece, Cyprus, Serbia, Portugal, Malta and Sicily (Italy). Other publications include the following: ● WHO/Europe policy brief on migration and health: environment and health aspects; ● WHO/Europe policy brief on migration and health: mental health care for refugees; ● Piloting toolkit for assessing health system capacity to manage large influxes of migrants in the acute phase; and ● Migration and health: key issues. Finally, the WHO Regional Office for Europe along with other United Nations agencies has developed guidance documents on public health and migration, in particular: ● General principles of vaccination of refugees, asylum seekers and migrants in the WHO European Region: joint technical guidance from WHO, United Nations High Commissioner for Refugees and United Nations Children’s Fund; and ● Mental health and psychosocial support for refugees, asylum seekers and migrants on the move in Europe: a multi-agency guidance note. Ongoing activities as of February 2016 Reports from joint health system assessment missions conducted with ministries in charge of health in Spain, Albania, Hungary and the former Yugoslav Republic of Macedonia are being finalized and will be published shortly on the website of the WHO Regional Office for Europe. The toolkit for assessing health system capacity to manage large influxes of refugees and migrants in the acute phase, which has been piloted in the 11 countries where assessment missions have been conducted, is also being finalized and will be published on the website. The initial three reports on migrant health underscored the need for additional issue-specific HEN synthesis reports, including in the areas of maternal health, mental health and the influence of definitions of migrant groups on aspects of public health. These three new reports will be published and presented at the Sixty-sixth Regional Committee meeting. European Advisory Committee on Health Research Page 10 Maternal health In the WHO European Region, evidence shows that migrant women have a higher risk of unintended pregnancies, complications of pregnancy, sexually transmitted infections, as well as sexual and domestic violence, and female genital mutilation. As their documentation status often differs from that of citizens, many migrant women find that their access to health services is restricted. This HEN report (commissioned to the International Centre for Reproductive Health, Ghent University, Belgium) will review evidence on the reduction of inequalities in accessibility and quality of maternal health care for migrants in the WHO European Region, and will formulate policy options to overcome those barriers and ultimately improve migrant women’s health status. Mental health Previous systematic reviews suggested that certain migrant groups, such as labour migrants and refugees, have higher rates of depression, anxiety, post-traumatic stress disorder and other mental illnesses. This report (commissioned to the Queen Mary University of London, United Kingdom) will provide a synthesis of evidence on policies and interventions to improve access to and delivery of mental health-care services. Definitions of the term migrant The definitions used to describe migrants and the application of these definitions differ throughout the WHO European Region. A HEN report (commissioned to the University of Limerick, Ireland) will explore how variations in these definitions influence the access to and delivery of health care for different population groups, and what policy options can be drawn from the available evidence. EACHR discussion and recommendations Participants expressed their great appreciation of the work of the subgroup. The response to the refugee and migration crisis by countries such as Greece, despite the existing austerity measures, and by civil society has been very impressive; however, the initial phase now seems to be over and plans and programmes for the next stages and in the longer term need to be developed and implemented. Local solutions also need to be identified. To achieve these ends, the health status of the refugee and migrant population needs to be much better assessed, lessons need to be learnt from past experiences with managing large migration influxes (e.g. into the Russian Federation and Israel), and the academic community needs to be mobilized in all health-related sectors. For countries to prepare and strengthen their national health systems adequately, language barriers, cultural factors, human rights issues and financial support need to be addressed. The inclusion of civil society is important in preparing for and responding to migration and health. It is also important to clarify definitions and highlight the importance of health information in populations affected by crisis and conflict. Research has shown that communicable diseases are not a health security issue with regard to migration but that other areas such as maternal health and NCDs, European Advisory Committee on Health Research Page 11 especially mental health, need more attention, and a systems-based approach is needed to improve the availability and accessibility of the necessary health-care services. WHO, the European Commission and other bodies should use their political influence to find solutions for preventing further crisis situations. In general, discussions have mainly involved ministries of internal affairs and the security sector, and inclusion of the health sector was not considered necessary. Future preparedness and response activities in the area of public health will require involvement of the health sector. WHO’s role in this field also needs to be further discussed. High-level political commitment is important, as demonstrated by Member States during the Rome meeting and the development of a European strategy and action plan on refugee and migrant health. WHO, its regional offices and Member States have to scale up their activities and cooperation in the field of migration. Human rights, dignity and solidarity need to be at the forefront of these discussions. Most health systems in the European Region have coped relatively well as the majority of migrants have been young and healthy; consequently, only a small number have needed to access health care and the financial burden for most countries has been manageable. Action points  WHO Secretariat to present the European strategy and action plan on refugee and migrant health to its Member States for resolution at the Sixty-sixth Regional Committee meeting;  WHO Secretariat to set up a knowledge hub on “migration and health” to support Member States, and exchange information and experiences between countries and institutions;  WHO Secretariat to support Member States to collect information on registration, health indicators and related aspects from the refugee and migrant population;  EACHR to mobilize academic institutions to promote research, particularly implementation research, in this area. European Advisory Committee on Health Research Page 12 The cultural contexts of health and well-being (CCH) Professor Mark Jackson, Professor of the History of Medicine, University of Exeter, United Kingdom, and Dr Nils Fietje, Research Officer, Division of Information, Evidence, Research and Innovation, WHO Regional Office for Europe, gave an update from the second meeting of the WHO CCH Expert Group. The Expert Group provides advice on how to consider the impact of culture on health and well- being, and how to communicate findings from data on well-being across the Region. By taking a multidisciplinary approach which, in addition to research from medicine and public health, also draws on the methods and approaches from the health-related humanities and social sciences (H&SS), the Expert Group hopes to make health policies more effective by identifying cultural enhancers of and obstacles to health and well-being. Research areas and methodologies need to be aligned with the implementation of Health 2020 and the SDGs. It is also essential to engage with policy-makers in Member States in a more systematic way, to advocate and raise awareness, and maintain ongoing collaborations throughout the research and policy process. A special issue of Public Health Panorama will focus on this topic and papers on the subject should be submitted to the WHO Secretariat. Dr Fietje presented the key achievements of the Expert Group in 2015, including growing support by Member States. As part of the development of guidance notes for reporting on well-being, Professor Jackson and colleagues at Exeter collaborated with the WHO Country Office in Romania to explore the effect of cultural contexts on cervical cancer incidence and mortality rates, as well as variations in tuberculosis incidence rates among certain ethnic groups. The Group members contributed to several publications (e.g. the European health report 2015, the the 2015 Women’s Health Report: Beyond the mortality advantage- Investigating women’s health in Europe, and the University College London/Lancet Commission Report on Culture and Health), and have presented on the cultural contexts of health project and related issues at a number of meetings and conferences. Funding for the upcoming three years has been secured from the Wellcome Trust, and the University of Exeter, which has applied to become a WHO collaborating centre in this area, will be supporting the work. A draft strategic framework has been developed to begin mainstreaming a systematic approach to the cultural context of health into the work of WHO Europe. The following vision has been articulated and agreed on: to enhance public health policy-making through a nuanced understanding of how cultural contexts affect health and health care. Three draft objectives have also been formulated: • to create a focus for culture and health at WHO Europe, in order to contribute to the implementation of Health 2020 and to strengthen WHO’s position in delivering on the health- related SDG targets; • to strengthen action-oriented H&SS research and policy analysis; • to promote the validity and use of an interdisciplinary evidence base for health-related policy and practice. European Advisory Committee on Health Research Page 13 EACHR discussion and recommendations Participants welcomed the achievements and plans of the CCH project and emphasized that the public health community needs to further develop these aspects in the research agenda, and promote the use of qualitative research analysis. This would also include strengthening policy analysis and an understanding of culture for planning implementation research studies. How cultural factors influence disease patterns can be seen in, for example, migrant populations with a very high prevalence of diabetes. Cultural factors also influence the use of health-care services and acceptance of professional advice. Action point  WHO Secretariat to include cultural aspects as a cross-cutting issue in the Health 2020/ life- course approach framework. Prevention and control of NCDs Responses to specific assignments in preparation for the Third High-level Meeting on Prevention and Control of Non-communicable Diseases of the United Nations General Assembly in 2018 Dr Jill Farrington, Senior Technical Officer, Integrated Prevention and Control, Division of Noncommunicable Diseases and Promoting Health through the Life-Course, WHO Regional Office for Europe, outlined the progress WHO has made since the 2011 United Nations NCD declaration and the assignments under way with regard to the General Assembly Third High-level Meeting in 2018. Referring to the report by the Director-General to the Executive Board in December 2015 (11), she focused on issues of particular interest for the European Region and on research aspects, which can be found in the Global action plan for the prevention and control of NCDs 2013–2020 (12) and the Action plan for implementation of the European strategy for the prevention and control of noncommunicable diseases 2012–2016 (13). An update to Appendix 3 of the Global action plan lists NCD policies and programmes, emphasizing cost–effective and affordable interventions for all Member States (“best buys”). From the nine global targets on NCDs to be attained by 2025 (against a 2010 baseline), there has been particular focus on a 25% relative reduction in the risk of premature mortality. The 2014 United Nations Outcome document on NCDs included a set of time- bound commitments covering four areas and 10 indicators. The report by the WHO Director- General to the Executive Board also makes reference to the SDGs and Health 2020 goals. The overall results towards the NCD goals in the European Region are promising but regional differences still exist. Some countries have a relatively large burden of avoidable diseases, and large gender gaps and health inequalities within and between countries. Regional progress towards achieving the NCD commitments in the area of monitoring and governance varies; while most countries have functioning routine systems for generating reliable cause-specific mortality data, European Advisory Committee on Health Research Page 14 many countries still do not have an operational multisectoral strategy or action plan for NCDs and risk factors, or have time-bound national targets and indicators in place. The Director-General in her report highlighted several research issues and gaps requiring additional attention by Member States and WHO. These include areas such as implementation research, monitoring and evaluation, , health systems barriers and opportunities for improving NCD outcomes. The concept of “best buys” is being updated this year. Data gaps still exist, for example, for the Global status report on noncommunicable diseases 2015 or for the Noncommunicable diseases progress monitor 2015. Evidence from surveys (e.g. STEPS) is, therefore, important to gather additional information on prevalence rates and gender disparities. EACHR discussion and recommendations Participants raised concerns regarding the “best buys” concept. More evidence for selecting interventions would be required and countries would need to have more clarity on the usefulness of these interventions. The experience gained from implementing these interventions could provide feedback on their usefulness, and either justify the implementation of new initiatives or a roll-back of existing ones that are not working or are too resource intensive. Emerging new evidence could feed into this process. This could be supported by suggestions taken from publications such as Governance for health in the 21st century (14), “The political origins of health inequity: prospects for change” (15) and the OECD report Obesity and the economics of prevention (16). The evaluation and interpretation of interventions should be considered more at the regional level as this could improve the understanding of trends and knowledge about competing factors. As prevention and control of NCDs needs to start early in life, targets and indicators covering the whole lifespan should be identified to provide long-term evidence. Whether existing indicators are appropriate or need modifying also needs to be considered, for example, body mass index in different cultural contexts or disability-adjusted life-years, which may cover only limited factors or sections of the lifespan (e.g. congenital versus later onset of a condition). Within this context, natural experiments could also be very useful. Action points  WHO Secretariat to promote research for the selection and prioritization of policies and programmes for NCD prevention and control;  WHO Secretariat to develop early childhood indicators/targets and consider life-course targets as proposed by the Minsk Declaration. European Advisory Committee on Health Research Page 15 Operational plan to take forward the Global strategy for women’s, children’s and adolescents’ health Dr Gunta Lazdane, Manager of the Sexual and Reproductive Health Programme, WHO Regional Office for Europe, presented findings from the WHO Health Behaviour in School-aged Children (HBSC) study (17), a collaborative cross-national study examining the physical and mental health of children and teenagers in the context of the social circumstances and developmental processes that influence their health. It draws attention to the effects of age, gender, socioeconomic status and geography on health, thus focusing policy on social and economic determinants. It provides information and analysis, and presents findings on patterns of health among young people aged 11, 13 and 15 years in 44 countries across the WHO European Region and North America. Key findings include a great mismatch between actual and perceived overweight in teenage girls, and marked declines in health between the ages of 11 and 15 in both girls and boys. The results of the HBSC study will be used for the development of the new action plan for sexual and reproductive health “Towards achieving the 2030 SDG agenda in Europe 2017–2021”, which will be included in the agenda of the Sixty-sixth Regional Committee meeting, if approved by the SCRC. Mrs Isabel Yordi, Technical Officer, Equity, Social Determinants, Gender and Rights, outlined the operational plan to take forward the Global strategy for women’s, children’s and adolescents’ health 2016–2030 (18), which was approved by the United Nations General Assembly in September 2015. The vision is “to create, by 2030, a world in which every woman, child and adolescent in every setting realizes their rights to physical and mental health and well-being, has social and economic opportunities, and is able to participate fully in shaping sustainable and prosperous societies”. The strategy will be closely linked with the four SDGs (3, 5, 10, 16) supporting women’s health. The operational framework to take forward the Global strategy has a five-year scope, including regular updates, and will be further discussed at the World Health Assembly in May 2016. The key objectives are to end preventable deaths, to ensure health and well-being, and to expand the enabling environment. Other important issues targeted within the Global strategy will be the steep increase in rates of caesarean section in many countries and the unmet need for modern contraceptive methods in the European Region. Further research is needed to analyse the sexual and reproductive health of vulnerable, disadvantaged and hard-to-reach groups at the national and subnational levels; analyse existing programmes and services for sexual and reproductive health, with particular attention to defining the needs and expectations of populations living in poverty and at risk of social exclusion; and evaluate the implementation of specific programmes. This Global strategy is much broader, more ambitious and more focused on equity than its predecessor. It is universal and applies to all people (including the marginalized and hard to reach), in all places (including humanitarian settings/crisis situations), and to transnational issues. In addition, a life-course approach aiming at the highest attainable standard of physical, mental and social health and well-being at every age is being integrated. Finally, the Global strategy adopts an integrated and multisectoral approach, recognizing that non-health sectors, including nutrition, European Advisory Committee on Health Research Page 16 education, water, sanitation, hygiene and infrastructure, are essential for improving health and well- being, reducing inequities, tackling new environmental challenges and achieving the SDGs. The Global strategy sets out nine action areas based on scientific evidence and practical experience gained from implementing the first Global strategy and the MDGs, on new research into effective interventions and approaches, and on new thinking about the integrated nature of health and sustainable development. Action area 8 – research and innovation – focuses on the need for investment in a wide range of research areas, prioritization of local needs and capacities, linkage from evidence to policy and practice, and on testing innovations. Further research is particularly needed to understand the determinants and barriers that continue to restrict the access of many women, children and adolescents to health services. Political and social sciences are also suited to capture evidence related to important health-related human rights and social goals, such as health equity, empowerment and eliminating discrimination. EACHR discussion and recommendations The participants emphasized the importance of promoting gender bias issues in cross-sectoral discussions and programmes. More gender-related studies using social and cultural science approaches are necessary, and the overall research agenda in this field needs to be revised. This complex task would require long-term plans and new types of research. Gender studies should include not only women’s studies, but also men, transgender and gay studies. The presented strategic plans and operational framework appear to be rather general, including a broad and fragmented agenda for gender and health research.. In addition, the relations between a woman’s life and the impact on her family should be assessed (e.g. optimal age for giving birth with regard to issues of educational level and social pressures). Other issues that should be taken into consideration for the European strategy include the societal discrimination of overweight persons, which leads to problems such as anorexia, the linkage between overweight and smoking cessation, as well as breastfeeding and long-term outcomes on women’s health (e.g. ovarian cancer). The health and research sectors also need to reflect on their internal gender issues (e.g. gender balance in committees and career challenges for female researchers such as maternity leave, unpaid care of relatives). It was noted that the composition of the EACHR could be more gender balanced. Action points  EACHR to promote additional research in the cross-sectoral field of gender bias, including social sciences research;  WHO Secretariat to present the action plan for sexual and reproductive health – “Towards achieving the 2030 SDG agenda in Europe”– at the upcoming Sixty-sixth Regional Committee meeting; European Advisory Committee on Health Research Page 17  WHO Secretariat and EACHR to identify targets and indicators to emphasize women’s health challenges covering the whole life-course (not only reproductive and maternal issues). Draft global plan of action on violence Dr Dinesh Sethi, Programme Manager, Division of NCDs and Promoting Health through the Life- Course, presented the draft global plan of action on violence, “Strengthening the role of health system in addressing interpersonal violence, in particular against women and girls, and against children" (19), which followed from a 2014 World Health Assembly resolution. The plan was developed through consultations with key stakeholders, including Member States, United Nations agencies, nongovernmental organizations (NGOs) and academia at the regional and global levels, and will be presented for adoption at the World Health Assembly in May 2016. The guiding principles overlap with key areas of Health 2020 (e.g. life-course perspective, intersectoral working, evidence-based practice, gender equality, universal health coverage) and are also closely linked to the SDG agenda. The main objectives are to strengthen health services to facilitate the intersectoral prevention of interpersonal violence and to provide services for victims of violence. The action plan focuses on interpersonal violence, particularly against women and girls, and against children. It takes a life-course perspective to address issues such as child maltreatment, bullying, youth and gang violence, violence against women and homicide. It also recognizes that violence against women ranges from forms of violence that affect girls, such as female genital mutilation and trafficking, to those that affect women beyond the reproductive age. EACHR discussion and recommendations Participants emphasized the importance of the draft global plan of action on violence and the substantial need for more evidence in this area, especially to inform policy-makers on how to improve intersectoral collaboration. The role of primary care in preventing and identifying violence, and issues of access should be emphasized, as well as violence against minority groups, particularly in times of migration crisis. More research is needed to improve understanding of the relationship between violent behaviour and neurodevelopmental changes (e.g. adverse childhood experiences, and environmental factors such as exposure to alcohol and lead). While prosecution of violators is important, the public health approach to prevention and the needs of victims, especially children, should not be neglected. The successful one-in-five campaign to stop sexual violence against children initiated by the Council of Europe is a good example for teaching children how to protect themselves. Action points  More intersectoral intervention, prevention and response studies to be undertaken;  Primary care services to be strengthened to improve prevention, case detection and support, European Advisory Committee on Health Research Page 18  More prevalence studies to be encouraged on elder maltreatment;  Standardized instruments to be developed for measuring and monitoring the prevalence of child maltreatment;  Studies to be conducted on health-harming behaviours resulting from adverse childhood experiences, as they often cause or worsen NCDs (cohort studies commencing in childhood). Developmental origins of health and disease and WHO’s life-course approach Professor Catherine Law, University College London, Institute of Child Health, London, United Kingdom, briefly introduced the developmental origins of health and disease (DOHaD) paradigm, which is defined as a multidisciplinary field that examines how “environmental factors acting during the phase of developmental plasticity interact with genotypic variation to change the capacity of the organism to cope with its environment in later life” (20). The publication Review of social determinants and the health divide in the WHO European Region (21) grouped its recommendations into four themes: life-course stages, the wider society, the macro-level broader context, and systems, which all require early and timely collaborative action. The DOHaD paradigm is intuitive, backed by a long history of research in related fields using a variety of research designs, and is aligned with a life-course approach. This area has a number of challenges, including accessing a multidisciplinary evidence base and issues of causality, effect sizes, identifying indicators of exposure and intermediate outcome, co-benefits or unintended consequences, implications for public health and health inequities, and ethical factors (e.g. interventions during pregnancies). Additional research capacity needs to be developed in many parts of the European Region and research gaps need to be identified. More evidence is available for association than for causation, and there is a dearth of intervention studies (which are particularly challenging, given the long latent periods for the outcomes). Scandinavian and other countries have utilized linked data to form cohorts for longitudinal research. Translating the evidence base between locations and time also remains difficult because of lack of research and methods for translation, and because of the long latent periods involved. Dr Gunta Lazdane presented a concise overview of the life-course approach as part of the Health 2020 policy framework. One of the four policy priority areas for Health 2020 is the investment in health through a life-course approach, which encompasses actions that are taken early, appropriately to transitions in life, and for the whole of society. Following the Minsk Declaration in 2015 (5), much related information has been provided on the website of the WHO Regional Office for Europe. WHO is currently working on a publication called “From evidence to policy and action”, which will synthesize the available evidence in this area. European Advisory Committee on Health Research Page 19 EACHR discussion and recommendations Participants agreed that the DOHaD paradigm and life-course approach are of key relevance to policy-makers. Member States need additional assistance for implementing relevant policies, including support for long-term projects (e.g. identifying and following a birth cohort) and for dissemination of existing evidence. Other issues that need to be considered for research include hidden exposures (e.g. chemicals, social factors), socioeconomic interventions and gender equality, especially in the context of parenting. As political commitment is essential for moving this agenda forward, more structured research taking the impacts into consideration needs to be widely encouraged. Action points  EACHR to promote further studies (synthesizing the evidence from available studies) within the life-course and DOHaD approaches;  The Secretariat to draft a proposal on how EACHR could focus further on DOHaD;  EACHR to contribute to some parts of the publication “From evidence to policy and action”. Issues for the Sixty-sixth Regional Committee meeting, 2016 Regional Office staff gave presentations on key issues to be discussed at the Sixty-sixth Regional Committee meeting. These were mainly for information. EACHR members were invited to comment and to offer further advice to WHO directors and programme managers in writing. Development of action plans for health sector responses to HIV and viral hepatitis in the WHO European Region, 2016–2021 Dr Nedret Emiroglu, Director of the Division of Communicable Diseases and Health Security, WHO Regional Office for Europe, outlined the development of action plans for health sector responses to HIV and viral hepatitis in the WHO European Region. The most recent surveillance data indicate that, with more than 142 000 persons diagnosed with HIV in 2014, the WHO European Region recorded the highest annual number of newly diagnosed infections ever reported in one year. While the growth of the HIV epidemic is largely in the east of the Region, where the rate of new HIV diagnoses has more than doubled since the early 2000s, HIV presents major public health challenges in all parts of the Region. Heterosexual transmission and drug injection are the main reported transmission routes in the east. In western and central Europe, men who have sex with men (MSM) account for the largest number of new HIV diagnoses, and there has been a sustained increase in new diagnoses in this population group during the past decade. European Advisory Committee on Health Research Page 20 Progress has been made in several areas since the implementation of the European Action Plan for HIV/AIDS 2012–2015 (22). In western Europe, overall rates of newly diagnosed HIV infections decreased by 10% between 2010 and 2014. The overall number of people receiving antiretroviral therapy in the European Region increased to about one million in 2015, which included an increase of 187% in the eastern part of the Region (from 112 100 in 2010 to 321 800 in 2015). Good progress has also been made towards eliminating mother-to-child transmission through integration of HIV prevention with maternal and child health services. Three Member States have successfully validated their elimination of MTCT of HIV and/or congenital syphilis based on WHO global validation criteria, with many more preparing for validation. But many challenges remain, including large numbers of people being diagnosed and treated late through lack of awareness of their HIV infection, access barriers to HIV prevention, diagnoses and treatment for key populations (e.g. people who inject drugs), high rates of coinfection with tuberculosis or hepatitis C, and a lack of evidence-based policies and a public health approach in some countries. Therefore, the European Action Plan for HIV/AIDS has now been renewed in the form of a new action plan for the health sector response to HIV in the WHO European Region, which is based on a vision of a “WHO European Region with zero new HIV infections, zero HIV-related deaths and zero AIDS-related discrimination, in a world where people with HIV are able to live long and healthy lives”. In comparison, the action plan for the health sector response to viral hepatitis in the WHO European Region is unprecedented. It is estimated that 13.3 million people are infected with hepatitis B in the European Region (with 57 600 deaths annually) and 14–15 million with hepatitis C (with 122 800 deaths annually). More than 60% of those infected live in eastern European and central Asian countries. The vision of the European action plan is for a “WHO European Region where the transmission of new hepatitis infections is minimized and where most people living with chronic hepatitis have access to care, and affordable and effective treatment”. The main goals are to reduce the transmission of viral hepatitis and to reduce the complications, morbidity and mortality it causes. An increasing number of Member States are also developing national plans for viral hepatitis, including some ambitious hepatitis C elimination plans; surveillance activities are being enhanced and access to treatment is being increasingly supported. The European action plan is based on the three dimensions of universal health coverage: interventions for impact, delivering for equity and financing for sustainability. Following a recent meeting of the Advisory Committees, the European action plan will be updated and Member States consulted before the two action plans are submitted to the Regional Committee for adoption. EACHR discussion and recommendations Participants welcomed the development of the two action plans but raised some concerns about the ambitious targets for HIV/AIDS. New options for providing effective drugs against HIV and hepatitis C are now available, and the long-term economic burden could be reduced despite the present high cost of therapy. It is recommended that increased support for developing a vaccine for the prevention of hepatitis C and promoting the use of vaccination for hepatitis B would reduce transmission rates, as mother-to-child transmission is still of great concern in some regions (e.g. European Advisory Committee on Health Research Page 21 Greenland). In countries with a high HIV prevalence, the support of NGOs is essential as the complexity of prevention measures can only be managed with NGO support. Action points  WHO Secretariat to engage civil society organizations for the implementation of action plans;  WHO to support Member States in finding solutions for reducing the prices of and increasing accessibility to new treatments;  Zika virus Dr Emiroglu also gave a brief update on the current situation regarding Zika virus. On 1 February 2016, WHO declared that the clusters of microcephaly and other neurological disorders reported in the Region of the Americas constitute a public health emergency of international concern. The Emergency Committee on International Health Regulations (IHR) recommended a standardized and enhanced surveillance for microcephaly, and increased research into the etiology of confirmed clusters of microcephaly and neurological disorders. On 8 March 2016, based on the growing strength of evidence about the Zika virus’s association with microcephaly and Guillain–Barré syndrome, as well as other neurological disorders, a second meeting of the IHR Emergency Committee was convened. The experts re-emphasized the need for further work to generate additional evidence on this association, and to understand any inconsistency in data from different countries. An organizationwide WHO Public Health Research Working Group on Zika virus disease has been established to coordinate and prioritize public health research, review and define key questions to be addressed, and support the development and implementation of protocols. In addition, a global WHO Public Health Research Advisory Group on Zika virus disease has been set up to support the working group with its activities. A causality framework was also established for assessing associations between Zika virus infection and autoimmune or congenital disorders. The causality assessment requires different study designs (e.g. case reports, ecological studies, cross-sectional studies), with evidence being accumulated over time, and with continuous and frequent real-time updates and reassessments. The current evidence supports the hypothesis of Zika virus being a component cause of neurological disorders, including congenital abnormalities such as microcephaly, and Guillain–Barré and other neurological syndromes. Specific questions in the causality framework remain unanswered and the risk of biases in individual studies and across studies needs to be assessed systematically. More epidemiological studies, including comparison groups, need to be conducted and the evidence base continuously updated. While the risk of Zika virus-infected travellers entering Europe increases, the current risk for transmission in the European Region remains extremely low. As Aedes spp. are present in the Region, this risk will increase during spring and summer. The response by the WHO Regional Office for Europe includes the establishment of a Zika Incident Management System and the European Advisory Committee on Health Research Page 22 regional assessment of capacities for surveillance, diagnosis, integrated vector management and emergency risk communication, focusing on priority countries. Draft European framework for action on integrated health service delivery Dr Hans Kluge, Director, Division of Health Systems and Public Health, WHO Regional Office for Europe, presented the draft European framework for action on integrated health services delivery, based on the 2015 Regional Committee resolution (23) as part of the Health 2020 agenda. The Regional Committee endorsed two strategic priorities for the following five years: transforming the delivery of health services to meet the challenges of the twenty-first century; and moving towards universal health coverage, aiming at a Europe free of catastrophic expenditure. To implement and operationalize these two priorities, three health systems foundations have been identified: a sustainable workforce, access to affordable quality medicines and technologies, and health information. Change management, and leading and managing innovation underpin these. The first strategic priority is now being taken forward by the draft European framework for action on integrated delivery of health services, recognizing that well-performing health services are essential for achieving health and well-being for all people in the European Region. A regional consultation with Member States, patient organizations, providers’ associations and partners is being convened in Copenhagen on 2–3 May 2016 by the Division to debate the last draft version. This is well aligned with the Global Framework for People-centred Care and the Global Strategy on Sustainable Workforce, which will both be presented for adoption at the World Health Assembly in May 2016. Integrated delivery of health services is seen as an approach to transform service delivery around the continuum of care as it does not specify different levels of care; rather, it is the provision of comprehensive services, including public health services, to promote health and prevent disease through the life-course. It should be designed according to individual needs (people-centred) and delivered by a coordinated team of providers across different levels of health care and settings, which will require a different set of competencies in the workforce. A WHO publication Lessons from transforming health services delivery: compendium of initiatives in the WHO European Region (24) is a valuable tool for Member States in this area. EACHR discussion and recommendations Participants emphasized the complexity of the transformative processes, especially task-shifting within the health workforce. Lessons in this area could be learnt from countries in the south with different primary health-care models. In addition, variables for effectiveness, efficiency and outcomes should be better defined, and benchmark examples of system innovations identified. New types of knowledge are needed, especially on interorganizational collaboration and network development (including multisectoral networks), implementation of evidence-based interventions. European Advisory Committee on Health Research Page 23 Response Dr Kluge The Division, in close collaboration with the OECD health-care quality programme, has already taken forward monitoring of this complex area of transformative and integrated health service delivery. Action points  Members to be invited to comment further in writing and provide suggestions for research in this area;  WHO to provide the publication Lessons from transforming health services delivery: compendium of initiatives in the WHO European Region to EACHR Group members. Update from the EACHR subgroup on EIP Professor Mark Leys, Vrije Universiteit Brussels, and Chair of the EIP subgroup, and Ms Tanja Kuchenmüller, Technical Officer, Evidence and Information for Policy, Division of Information, Evidence, Research and Innovation, WHO Regional Office for Europe, presented an update of the EACHR subgroup on EIP, which was established at the fifth EACHR Meeting in 2014. Throughout the past year (2015), the group continued its work on the EIP roadmap (in particular, organizing consultative processes) and developed a joint framework, including concrete actions for all stakeholders with a vested interest in EIP (25). The objectives of the EIP roadmap are to develop awareness and create commitment, build national EIP capacity, convene communities of practice to share experiences, and to develop, use and evaluate EIP tools, mechanisms and practices. Following a technical briefing at the Regional Committee meeting in 2015, Member States called for a regional action plan and resolution to be developed based on the EIP roadmap, to be submitted at the next Regional Committee for discussion and adoption. This was supported by the SCRC in September 2015. The EIP action plan, which builds on and strengthening existing EIP efforts within WHO Europe and the Region, has now been included as an agenda item for the next Regional Committee meeting in September 2016. The central purpose of the action plan is to consolidate, strengthen and promote the use of multidisciplinary and intersectoral sources of evidence for health policy-making. It emphasizes evidence as a driver of change and innovation, and is in support of Health 2020, using the EHII as an operational platform. The action plan includes four key action areas: • strengthening national health information systems, harmonizing health indicators and establishing an integrated health information system for the European Region; • establishing and promoting national health research systems to support the setting of public health priorities; • increasing country capacities for the development of evidence-informed policies (knowledge translation); and European Advisory Committee on Health Research Page 24 • mainstreaming the use of evidence, information and research in the implementation of Health 2020 and other major regional policy frameworks. EACHR discussion and recommendations The EACHR members expressed their overall support to the action plan. EACHR members emphasized the importance of continuous interaction between researchers and policy-makers to create mutual understanding about research and evidence needs. Partnerships need to be developed along the research and policy-making continuum. Interfaces between evidence and policy need to be promoted. Transparency in the use of knowledge sources and organizing interaction between stakeholders, policy-makers and the research community is considered key in the evidence–policy linkage. Building a suitable knowledge and evidence infrastructure, and highlighting the importance of knowledge translation techniques, tools and methods are important prerequisites. Concerns were expressed that one should avoid retroactively searching for evidence in order to legitimize a policy idea post hoc (e.g. the selective, non-transparent use of evidence). In addition, implementation research (taking into account the complexity of both policy interventions and context) on promoting the use of data and research evidence in decision-making, the importance of health impact assessments, the potential of big data for public health and the concept of co-benefits (e.g. carbon reduction for climate change leading to more physical activitiy) should be considered when enhancing the capacities for EIP in the countries highlighted in the action plan. Action points  WHO Secretariat to develop tools/methodologies to strengthen EIP;  WHO Secretariat to support capacity-building of Member States in EIP;  WHO Secretariat and EACHR members to support implementation research on EIP;  WHO Secretariat to identify institutions for creating a WHO collaborating centre in EIP. Meeting reflections and conclusions Regional Director’s reflections Reflecting on the meeting, the Regional Director felt that the informal, honest style of EACHR discussions was very useful; the Committee was now achieving its full potential, members were making valuable contributions and the discussions were inspiring. Dr Jakab described the rolling agenda of priority areas for the Regional Committee up to 2020. These priorities include NCDs, communicable diseases and health systems strengthening, including universal health coverage, financial protection, workforce issues and access to medicines. In addition, environmental health and the intersectoral work of education and social policies were important. In support of the work on SDGs and the implementation of Health 2020, a high-level interministerial conference on environmental health is planned in Prague for 2017, and a high-level European Advisory Committee on Health Research Page 25 conference on working together for better health and well-being will take place in Paris in July 2016 to find common areas for policy action between the health, education and social sectors. She also suggested forming a new EACHR subgroup on the SDGs, Health 2020 and the new public health approach, and appointed Professor Tomson as its chairperson. All participants welcomed this proposal and several members offered their active support to the group. Dr Jakab emphasized the necessity for the migration subgroup to continue its important work in preparation for the Regional Committee meeting in September 2016. As the emergency phase of the current refugee crisis in the European Region would soon be over, the focus of the work should now be on mid- and long-term developments. Dr Jakab acknowledged the EACHR suggestions to intensify the work on culture and integration of culture into the work of the Regional Office horizontally in the areas of gender, equity, human rights and other technical programmes. In addition, the field of implementation research should be taken forward and a session should be planned for the next EACHR meeting. It would also be beneficial to further strengthen the link between the EACHR and governing bodies and increase interaction between them. Action plan Professor Türmen asked Dr Stein to summarize the agreed recommendations of the EACHR on the different topics and to collect feedback on these from the respective presenters at the Secretariat. The completed list should then be provided to everyone for review in a meeting report. Dr Stein also emphasized the proposal of the committee to identify new EACHR members so that additional skills can be provided to the group (e.g. including in the fields of law, innovation and technologies, gender studies). Next EACHR meeting The Secretariat will circulate dates for the eighth EACHR meeting, and propose the venue and agenda items. Conclusion and closure Professor Türmen asked members to note the next steps. WHO Secretariat and programme coordinators would be asked to note the Committee’s recommendations, as outlined in this report. The action points for members and the Secretariat are summarized below. In conclusion, Professor Türmen thanked all the participants for their lively interaction. She also thanked Professor Ádány for co-chairing the meeting. The meeting had achieved its objectives and she declared it closed. European Advisory Committee on Health Research Page 26 Summary of action points Update on previously agreed EACHR actions  EACHR to support WHO in emphasizing the importance of health within the SDG agenda;  WHO to continue coordinating with the OECD and the European Commission in areas such as the country health profiles. Public health and migration  WHO Secretariat to present the European strategy and action plan on refugee and migrant health to its Member States for resolution at the Sixty-sixth Regional Committee meeting;  WHO Secretariat to develop mid- and long-term plans and programmes, and support the identification of local solutions;  WHO Secretariat to set up a knowledge hub to support Member States and to exchange information and experiences between countries and institutions;  WHO Secretariat to support Member States to collect information on registration, health indicators and related aspects from the refugee and migrant population;  EACHR to mobilize academic institutions to promote research, particularly implementation research, in this area. The cultural contexts of health and well-being  WHO Secretariat to include cultural aspects as a cross-cutting issue in the Health 2020/ life-course approach framework. Prevention and control of NCDs  WHO Secretariat to promote research for the selection and prioritization of policies and programmes for NCD prevention and control;  WHO Secretariat to develop early childhood indicators/targets and consider life-course targets as proposed by the Minsk Declaration; Operational plan to take forward the Global strategy for women’s, children’s and adolescents’ health  EACHR to promote additional research in the cross-sectoral field of gender bias, including social sciences research;  WHO Secretariat to further discuss the action plan for sexual and reproductive health – “Towards achieving the 2030 SDG agenda in Europe”, at the upcoming Sixty-sixth Regional Committee meeting;  WHO Secretariat and EACHR to identify targets and indicators to emphasize women’s European Advisory Committee on Health Research Page 27 health challenges covering the whole life-course (not only reproductive and maternal issues). Draft global plan of action on violence  More intersectoral intervention, prevention and response studies to be undertaken;  Primary care services to be strengthened to improve prevention, case detection and support;  More prevalence studies to be encouraged on elder maltreatment;  Standardized instruments to be developed for measuring and monitoring the prevalence of child maltreatment;  Studies to be conducted on health-harming behaviours resulting from adverse childhood experiences, as they often cause or worsen NCDs (cohort studies commencing in childhood). Developmental origins of health and disease and WHO’s life-course approach  EACHR to promote further studies (evidence synthesis) within the life-course and DOHaD approaches;  The Secretariat will draft a proposal on how EACHR could focus further on DOHaD;  EACHR will contribute to some parts of the publication “From evidence to policy and action”. Key items of Sixty-sixth Meeting of the WHO Regional Committee for Europe, 2016 HIV/hepatitis  WHO Secretariat to engage civil society organizations for the implementation of action plans;  WHO to support Member States in finding solutions for reducing the prices of and increasing accessibility to new treatments ;  EACHR to comment and to offer further advice in writing to WHO directors and programme managers. Draft European framework for action on integrated health services delivery  Members to be invited to comment further in writing and provide suggestions for research in this area;  WHO to provide the publication Lessons from transforming health services delivery: compendium of initiatives in the WHO European Region to EACHR Group members. Update from the EACHR subgroup on EIP  WHO Secretariat to develop tools/methodologies to strengthen EIP;  WHO Secretariat to support capacity-building of Member States in EIP;  WHO Secretariat and EACHR members to support implementation research on EIP;  WHO Secretariat to identify institutions for creating a WHO collaborating centre in EIP. European Advisory Committee on Health Research Page 28 References 1. Health 2020: the European policy for health and well-being. Copenhagen: WHO Regional Office for Europe; 2012 (http://www.euro.who.int/en/what-we-do/health-topics/health- policy/health-2020, accessed 2 June 2016). 2. Sixth Meeting of the European Advisory Committee on Health Research (EACHR): 15–16 April 2015. Copenhagen: WHO Regional Office for Europe; 2015 (http://www.euro.who.int/en/media-centre/events/events/2015/04/sixth-meeting-of-the- european-advisory-committee-on-health-research-eachr, accessed 2 June 2016). 3. 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(http://www.euro.who.int/__data/assets/pdf_file/0005/171770/RC62wd12rev1- Eng.pdf?ua=1) European Advisory Committee on Health Research Page 29 9. The European Health Report 2015: targets and beyond – reaching new frontiers in evidence. Copenhagen: WHO Regional Office for Europe; 2015 (http://www.euro.who.int/__data/assets/pdf_file/0006/288645/European-health-report-2015- full-book-en.pdf, accessed 2 June 2016). 10. Draft resolution EUR/RC66/Conf.Doc/8. Action plan to strengthen the use of evidence, information and research for policy-making in the WHO European Region 2016–2020. Copenhagen: WHO Regional Office for Europe; 2016 http://www.euro.who.int/__data/assets/pdf_file/0006/314727/66wd12e_EIPActionPlan_160 528.pdf?ua=1] 11. Prevention and control of noncommunicable diseases: responses to specific assignments in preparation for the third High-level Meeting of the United Nations General Assembly on the Prevention and Control of Non-communicable diseases in 2018. 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WHO Regional Committee for Europe resolution EUR/RC65/13 on Priorities for health systems strengthening in the WHO European Region 2015–2020: walking the talk on people-centeredness. Copenhagen: WHO Regional Office for Europe; 2015 (http://www.euro.who.int/__data/assets/pdf_file/0003/282963/65wd13e_HealthSystemsStre ngthening_150494.pdf?ua=1, accessed 2 June 2016). 24. Lessons from transforming health services delivery: compendium of initiatives in the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2016 (http://www.euro.who.int/__data/assets/pdf_file/0014/303026/Lessons-HSD-compendium- initiatives.pdf?ua=1, accessed 2 June 2016). 25. Towards an accelerated roadmap for strengthening evidence-informed policy-making in the European Region. Report of the first technical expert meeting. 29–30 January 2015, Vilnius, Lithuania. 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Programme and agenda Day 1 (Wednesday, 6 April) OPENING, WELCOME AND INTRODUCTION (CHAIR, TOMRIS TÜRMEN) INTRODUCTORY REMARKS, INCLUDING UPDATE ON GOVERNING BODIES’ DECISIONS AND MAJOR EVENTS SINCE JULY 2015 (ZSUZSANNA JAKAB, WHO Regional Director for Europe) DISCUSSION SESSION 1: REVIEW OF THE IMPLEMENTATION OF ACTIONS FROM PREVIOUS MEETINGS OF THE EACHR (CLAUDIA STEIN) Presentation by Secretariat and discussion SESSION 2: MIGRATION AND HEALTH (WALTER RICCARDI, SANTINO SEVERONI) Presentation on key issues, concepts and research implications Discussion SESSION 3: UPDATE FROM CULTURAL CONTEXT OF HEALTH AND WELL-BEING SECOND EXPERT GROUP MEETING EUROPE (MARK JACKSON, NILS FIETJE) Presentation and discussion SESSION 4: PREVENTION AND CONTROL OF NONCOMMUNICABLE DISEASES: RESPONSES TO SPECIFIC ASSIGNMENTS IN PREPARATION FOR THE THIRD HIGH-LEVEL MEETING OF THE UNITED NATIONS GENERAL ASSEMBLY 2018 (JILL FARRINGTON) Presentation on key issues, concepts and research implications, and discussion SESSION 5: OPERATIONAL PLAN TO TAKE FORWARD THE GLOBAL STRATEGY FOR WOMEN’S, CHILDREN’S AND ADOLESCENTS’ HEALTH (ISABEL YORDI, MARTIN WEBER, GUNTA LAZDANE) Presentation on key issues, concepts and research implications, and discussion DINNER (hosted by the Division of Information, Evidence, Research and Innovation) Day 2 (Thursday, 7 April) SUMMARY OF DAY 1 SESSION 6: DRAFT GLOBAL ACTION PLAN ON VIOLENCE (DINESH SETHI, ISABEL YORDI) Presentation on key issues, concepts and research implications, and discussion SESSION 7: DEVELOPMENTAL ORIGINS OF HEALTH AND DISEASE AND WHO’S LIFE-COURSE APPROACH (CATHERINE LAW, GUNTA LAZDANE) Presentation and discussion SESSION 8: UPDATE ON KEY ITEMS OF THE REGIONAL COMMITTEE FROM THE ROLLING AGENDA (NEDRET EMIROGLU, HANS KLUGE) European Advisory Committee on Health Research Page 32 SESSION 9: UPDATE FROM THE EACHR SUBWORKING GROUPS ON EVIDENCE-INFORMED POLICY- MAKING (MARK LEYS, TANJA KUCHENMÜLLER) SESSION 10: REVIEW AND REFLECTIONS BY THE REGIONAL DIRECTOR CLOSING REMARKS (CHAIR AND WHO SECRETARIAT) CLOSE OF MEETING European Advisory Committee on Health Research Page 33 Annex 2: List of participants EACHR MEMBERS Professor Rozá Ádány (Vice-Chair) Head of the Department of Preventative Medicine University of Debrecen 26 Kassai Street H-4028 Debrecen Hungary Professor Josep M. Antó Boqué Director Centre of Research in Environmental Epidemiology Dr Aiguader, 88 E-08003 Barcelona Spain Professor Helmut Brand Head of the Department of International Health Maastricht University PO Box 616 Maastricht 6200 MD The Netherlands Professor Reinhard Burger President (Retd) Robert Koch Institute Nordufer 20 PO Box 65 02 61 13353 Berlin Germany Professor Antoine Flahault Chair Louis Jeantet in Public Health Director of the Institute of Global Health University of Geneva Campus Biotech Chemin des Mines 9 1202 Geneva Switzerland Professor Philippe Grandjean Head of Research Unit Institute of Public Health University of Southern Denmark DK-5000 Odense Denmark Professor Mark Jackson Professor of the History of Medicine Department of History of Medicine University of Exeter Exeter, EX8 2HX United Kingdom Professor Maksut Kulzhanov Adviser to the Ministry of Health and Social Development Kazakhstan School of Public Health 19 a Utepov str. Astana Kazakhstan Professor Catherine Law Professor of Public Health and Epidemiology Institute of Child Health University College London London WC1 N1EH United Kingdom Professor Mark Leys Vrije Universiteit Brussels Public Health – OPIH Laarbeeklaan 103 1090 Brussels Belgium Professor Ruta Nadisauskiene Head of the Obstetrics and Gynaecology Department Lithuanian University of Health Sciences A. Mickevičiaus g. 9 LT-44307 Kaunas Lithuania European Advisory Committee on Health Research Page 34 Professor José Pereira-Miguel Institute of Preventive Medicine & Public Health Institute of Environmental Health Faculty of Medicine, University of Lisbon av. Professor Egas Moniz 1649-028 Lisbon Portugal Professor Walter Ricciardi Director of the Department of Public Health Università Cattolica del Sacro Cuore Largo Francesco Vito 1 I-00168 Rome Italy Dr Laura Rosen Chair, Department of Health Promotion Tel Aviv University School of Public Health 69978 Ramat Aviv Israel Professor Franco Sassi Head, Public Health Programme Organisation for Economic Co-operation and Development rue André Pascal 75775 Paris Cedex 16 France Professor Petros Sfikakis Dean, School of Medicine University of Athens 75 Mikras Asias Str 11527 Athens Greece Professor Göran Tomson Senior Professor International Health Systems Research Karolinska Institute Widerströmska, Tomtebodavägen 18A SE-17177 Stockholm Sweden Professor Tomris Türmen (Chair) President International Children’s Center Bilkent University, Main Campus, Library Building 06800 Ankara Turkey Professor Vasiliy Vlassov President of the Society for Evidence Based Medicine Moscow State Medical and Dental University 20/1 Delegatskaya ul. Moscow 109451 Russian Federation Professor James Whitworth Department of Infectious Disease Epidemiology London School of Hygiene & Tropical Medicine Keppel Street London WC1E 7HT United Kingdom REPRESENTATIVE OF THE SCRC Ms Eva Falcão Director of International Relations Directorate-General of Health Alameda D. Afonso Henriques, 45 Lisbon 1049-005 Portugal RAPPORTEUR Dr Mathias Bonk Global Health Consultant Germany European Advisory Committee on Health Research Page 35 WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR EUROPE Dr Zsuzsanna Jakab Regional Director Dr Roberto Bertollini Chief Scientist and WHO Representative to the European Union Office of the Regional Director Dr Nedret Emiroglu Director Division of Communicable Diseases, Health Security and Environment Dr Jill Farrington Senior Technical Officer Division of Noncommunicable Diseases and Promoting Health through the Life-Course, Integrated Prevention and Control Dr Nils Fietje Research Officer Division of Information, Evidence, Research and Innovation Dr Gauden Galea Director Division of Noncommunicable Diseases and Health Promotion Ms Mailis Jepsen Evidence and Information for Policy Division of Information, Evidence, Research and Innovation Dr Hans Kluge Director Division of Health Systems and Public Health Ms Tanja Kuchenmüller Technical Officer Evidence and Information for Policy Division of Information, Evidence, Research and Innovation Dr Gunta Lazdane Manager Sexual and Reproductive Health Programme Mr Tim Nguyen Unit Leader Evidence and Information for Policy Division of Information, Evidence, Research and Innovation Dr Piroska Ostlin Director Division of Policy and Governance for Health and Well-being Dr Dinesh Sethi Programme Manager Division of NCDs and Promoting Health through the Life-Course Dr Santino Severoni Coordinator, Public Health and Migration, Division of Policy and Governance for Health and Well-being, WHO European Office for Investment for Health and Development Ms Kalina Shtilianova Secretary Evidence and Information for Policy Division of Information, Evidence, Research and Innovation Dr Claudia Stein Director Division of Information, Evidence, Research and Innovation Ms Ryoko Takahashi Technical Officer Evidence and Information for Policy Division of Information, Evidence, Research and Innovation Mrs Isabel Yordi Technical Officer Equity, Social Determinants, Gender and Rights