Enhancing evidence-informed health decision-making in Europe: preconference event to the 8th European Public Health Conference, 14–15 October 2015: meeting report

Enhancing evidence- informed health decision-making in Europe Meeting Report Preconference event to the 8th European Public Health Conference, 14–15 October 2015 Enhancing evidence-informed health decision-making in Europe ii The World Health Organization was established in 1948 as the specialized agency of the United Nations serving as the directing and coordinating authority for international health matters and public health. One of the WHO’s constitutional functions is to provide objective and reliable information and advice in the field of human health. It fulfills this responsibility in part through its publications programmes, seeking to help countries make policies that benefit public health address their most pressing public health concerns. The WHO Regional Office for Europe is one of the six regional offices throughout the world, each with its own programme geared to the particular health problems of the countries it serves. 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Enhancing evidence-informed health decision-making in Europe Preconference event to the 8th European Public Health Conference, 14–15 October 2015 Meeting Report Keywords EVIDENCE-BASED PRACTICE HEALTH POLICY RESEARCH POLICY MAKING EUROPE Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen O, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site. (http://www.euro.who.int/pubrequest). Document number: WHO/EURO:2016-6431-46197-66825 © 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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Enhancing evidence-informed health decision-making in Europe ii Enhancing evidence-informed health decision-making in Europe Preconference event to the 8th European Public Health Conference, 14–15 October 2015 Meeting Report Enhancing evidence-informed health decision-making in Europe iii Contents Acknowledgements .................................................................................................................... iii List of abbreviations ................................................................................................................... iii Executive summary .................................................................................................................... iv 1. Introduction ............................................................................................................................ 1 2. The EIP roadmap ................................................................................................................... 1 3. The state of the art in EIP....................................................................................................... 3 4. EIP in practice ........................................................................................................................ 5 5. Practical guidance for the development of the EIP Action Plan .............................................. 7 6. Reflections on the development of the Action Plan ................................................................ 9 7. Conclusions.......................................................................................................................... 11 References ............................................................................................................................... 13 Annex ....................................................................................................................................... 14 Enhancing evidence-informed health decision-making in Europe iii Acknowledgements The WHO Regional Office for Europe would like to express its sincere gratitude to its partners, Health Services Research Europe, and the European Public Health Association Sections on Health Services Research and Public Health Practice and Policy for their cooperation in the organization of this event. We particularly thank Dr Johan Hansen, Netherlands Institute for Health Services Research, Utrecht, the Netherlands, and Dr Marleen Bekker, Maastricht University, Maastricht, the Netherlands, for having organized this meeting on behalf of the partner organizations. We, in addition, thank Professor Roland Bal, Erasmus University, Rotterdam, the Netherlands, Prof Mark Leys, Vrije Universiteit, Brussels, Belgium, Mr Nick Fahy, University of Oxford, Oxford, United Kingdom, and Dr Claudia Stein, WHO Office for Europe, Copenhagen, Denmark, for their presentations and contributions to facilitating the discussions. We also kindly acknowledge and thank Dr Vesna-Kerstin Petrič, Ministry of Health, Ljubljana, Slovenia, Professor Ilmo Keskimäki, National Institute for Health and Welfare, Helsinki, Finland, and Dr Anne Karin Lindahl, Norwegian Knowledge Centre for the Health Services, Oslo, Norway, for sharing their experiences in evidence-informed policy and practice. We finally would like to thank Ms Ioana Vlad, London School of Hygiene & Tropical Medicine, London, United Kingdom, for acting as rapporteur and preparing the report of this event. List of abbreviations EVIPNet Evidence-informed Policy Network EIP Evidence-informed policy-making EUPHA European Public Health Association HSR Europe Health Services Research Association KT Knowledge translation KTP Knowledge translation platform Enhancing evidence-informed health decision-making in Europe iv Executive summary Reflecting the increasing demand and momentum for legitimate tools and processes to strengthen evidence-informed policy-making (EIP), the WHO Regional Office for Europe, together with Health Services Research Europe (HSR Europe) and the European Public Health Association (EUPHA) Sections on Health Services Research and Public Health Practice and Policy, organized a preconference event on EIP at the 8th European Public Health Conference on 14–15 October 2015. The event brought together a variety of key stakeholders for EIP across Europe to reflect on the accelerated roadmap developed by the WHO Regional Office for Europe to enhance EIP in the WHO European Region (referred to here as the EIP roadmap) and debate on means for EIP development. Proposed by the European Advisory Committee on Health Research and requested by the Member States in December 2014, the EIP roadmap is an initiative aimed at coordinating and enhancing overall capacity for EIP in the WHO European Region. Building on the EIP roadmap, an Action Plan and Resolution on enhancing EIP in the WHO European Region are under preparation. The event was an opportunity to reflect on the EIP roadmap and on how the development of the Action Plan for EIP can incorporate theoretical and practical state of the art in the field. There was awareness that striking a balance between theoretical complexity and practical applicability of EIP initiatives is challenging but indispensable. As such, there is a need to shift to a paradigm of coproduction of knowledge in EIP, renouncing an a priori separation of science and policy as separate domains. This paradigm highlights the fact that the boundaries between science and policy need to be managed: that is clearly separated as well as coordinated by neutral spaces for knowledge brokerage. Some useful tools for EIP from the perspective of coproduction are proposed through the Evidence-informed Policy Network in Europe (EVIPNet Europe). EVIPNet Europe’s methodologies include situational analyses and stakeholder consultations as key for developing buy-in for EIP. EVIPNet emphasizes that creating contacts between different stakeholders is as important as written evidence briefs for policy. In order to coordinate the utilization of these tools, EVIPNet supports the establishment of country teams, also known as knowledge translation platforms (KTPs), that are intended to function as national advisory bodies applying innovative knowledge translation (KT) tools and fostering engagement of diverse stakeholders (e.g. researchers, policy-makers, civil society) in health policy-making. EVIPNet and other WHO Regional Office for Europe initiatives supporting EIP (e.g. the European Health Information Initiative and the Health Evidence Network) are all key for the implementation of the European Health 2020 policy framework. Although the nature of EIP is complex and contested, stakeholders attending and organizing the European Public Health preconference event shared a common vision that evidence should inform policy and that tools for EIP are needed. The current event contributed to creating and strengthening informal communities for EIP across the European Region. The further development of the WHO Regional Office for Europe's Action Plan for EIP could be an important tool through which this common vision can be put into practice, by supporting structured implementation of EIP efforts. Enhancing evidence-informed health decision-making in Europe 1 1. Introduction Innovative tools and legitimate processes for EIP are increasingly important as potential responses to current problems faced by health systems globally, ranging from the need to increase accountability of decision-making to containing costs and ultimately ensuring sustainability of the system. Such issues are particularly problematic in the context of shifting models of health governance, whereby the power of central governments is increasingly delegated or shared with new categories of stakeholders at the corporate and community levels. This does not mean that governments’ role in coordinating health policy has become obsolete, but rather that their role in knowledge generation and coordination for health policy- making are even more important. As such, the need to adapt research systems in order to cater to the increasing demand for policy-relevant research and for mechanisms to link research and policy is acutely felt and hotly debated, particularly since the range of actors such changes might affect has become wider. In this context, the WHO Regional Office for Europe, together with HSR Europe, and the EUPHA Sections on Health Service Research and Public Health Practice and Policy, organized a preconference event on EIP at the 8th European Public Health Conference on 14– 15 October 2015. The aim of the event was to: 1. reflect on use of the EIP roadmap in the WHO European Region (1); 2. share experiences and openly debate on how to enhance EIP; and 3. invite participants to join efforts at national, regional and organizational levels. Participants included a variety of key stakeholders for EIP, including researchers and decision- makers across Europe. Through interactive reflection, participants and facilitators (please see the list of participants in the Annex) identified a series of different perspectives on what should be done to implement the EIP roadmap. 2. The EIP roadmap Linking health research to the promotion of evidence-informed policies to improve health systems is enshrined in the core functions of WHO. The WHO Regional Office for Europe has a major role to play in bridging the know–do gap and supporting countries in strengthening KT mechanisms for health policy development. The research–policy interface in public health is, for example, a crucial pillar for the implementation of the European Health 2020 policy framework (2), as well as for the European Health Information Initiative (3). In 2012, a new initiative, EVIPNet Europe, was launched (4). This network focuses on increasing and institutionalizing EIP capacity in countries of low and middle income in the Dr Claudia Stein, Mr Nick Fahy and Dr Vesna- Kerstin Petrič during the event © WHO Enhancing evidence-informed health decision-making in Europe 2 Region and complements the work of the Health Evidence Network (5) in providing policy- maker-centred research syntheses for decision-making. Building on its global experience, EVIPNet supports the establishment of country teams (KTPs) that are intended to function as national advisory bodies applying innovative KT tools and fostering engagement of diverse stakeholders (e.g. researchers, policy-makers, civil society) in health policy-making. While such initiatives represent a first step, EIP efforts to date have remained scattered and uncoordinated, and the overall capacity for EIP in the WHO European Region remains weak. Consequently, as proposed by the European Advisory Committee on Health Research1 and requested by the Member States in December 2014, the WHO Regional Office for Europe developed the EIP roadmap (1). The roadmap has four strategic objectives and 12 concrete actions to take these objectives forward (Fig. 1). Fig. 1 Strategic objectives of the EIP roadmap 1: develop awareness and create commitment within the Region to improve the culture for and practise of EIP Action 1: stakeholder mapping and analysis at country and regional levels Action 2: develop communication, outreach and engagement strategies Action 3: provide incentives for EIP and establish high-level commitment 2: build national EIP capacities for the implementation of Health 2020 and other national health agendas Action 4: institutionalize platforms at national level on the use of evidence to inform policies Action 5: provide locally adapted workshops and training for EIP Action 6: assess country situation and monitor progress over time 3: convene regional communities of practice and share good EIP practices Action 7: make an inventory of existing networks and subject matter experts in KT and EIP Action 8: share lessons and learn from country and institutional experiences Action 9: convene and build networks and partners 4: develop, use and evaluate tools and mechanisms to support EIP Action 10: map, adapt and develop existing EIP/KT tools Action 11: develop, pilot and use new tools for EIP/KT Action 12: monitor and evaluate existing and new tools for EIP/KT Building on the EIP roadmap, an Action Plan and Resolution on enhancing EIP in the WHO European Region are under preparation and should be submitted for deliberation and adoption at the 66th WHO Regional Office for Europe Regional Committee in 2016. The stakeholder consultation at the preconference event to the 8th European Public Health Conference on enhancing EIP in Europe was an important step to harvest feedback on the EIP roadmap. Deliberations at the meeting are presented in the following sections of this report. They refer to:  the best available evidence on EIP and reflections on the nature of EIP;  practical examples of EIP in different European countries; and  practical recommendations for the EIP Action Plan. 1 Read more details about the work of the European Advisory Committee on Health Research here. Enhancing evidence-informed health decision-making in Europe 3 3. The state of the art in EIP Dr Nick Fahy, University of Oxford, presented the current existing theoretical debates, tools and innovations on KT for EIP and highlighted gaps in research and practice that hinder adequate facilitation of EIP. Dr Fahy showed how KT does not follow a simple linear "pipeline" from research into reviews into policy, partly because policy-making functions in a different paradigm to that of research. If research has a paradigm of enquiry, policy-makers function in a paradigm of persuasion and telling persuasive stories. Consequently, EIP initiatives should draw on evidence from psychology, sociology and political science: these disciplines highlight the importance of "storytelling", by helping to identify narratives of plots and actors in policy stories. Ultimately, this focus on storytelling and persuasion could translate into an active engagement of both researchers and policy-makers in a shared process to support EIP. However, striking a balance between theoretical complexity and practical applicability of EIP initiatives proved challenging and raised two slightly contradictory sets of problems among participants:  EIP initiatives often use simplistic conceptualization of evidence use (see examples in Box 1).  the idea of EIP as persuasion or "storytelling" is problematic, as it could affect the quality of the evidence used, or is too complex, therefore impractical. Box 1. Is EIP a simplistic concept? The EIP field tends to simplify the process of evidence use in policy decisions. This can be explained by the fact that most thinking around EIP is rooted in a "two communities" logic, whereby the distinct worlds of researchers and policy-makers need to coordinate and communicate better to achieve evidence utilization. In practice, this results in simplistic approaches to EIP, such as:  defining policy-makers exclusively as politicians or high-level civil servants: this definition, often implied and not clearly stated, ignores two other important types of actor, the local policy-makers and intermediate levels of the bureaucracy and the emerging actors beyond the state (e.g. communities of practice, public–private partnerships), who are part of new models of health governance; and  defining policy problems exclusively as the remit of one academic discipline: policy questions are often multidimensional and so require multidisciplinary research questions, which would then trigger multidisciplinary answers. To avoid oversimplification, EIP efforts should acknowledge that there are interactions in both directions between evidence and policy. Practically, this means acknowledging, for example, that researchers themselves are political actors, who will want to maintain their power and legitimacy by insisting on their independence from "politics" and, therefore, oppose some EIP initiatives. The two sets of problems exemplify how finding a balance between practical tools and the complexity of EIP is challenging. This is particularly important given the shifts in the nature of policy-making, from top-down decision-making to a more generalized need for evidence across a vaster range of stakeholders beyond government. This change in governance models Enhancing evidence-informed health decision-making in Europe 4 supports the idea of evidence use as persuasion or storytelling, the latter being part of any democratic society. For example, the information that mass media presents is the archetype of storytelling influencing policy. As an agenda-setting pathway, it should be based on better evidence, for example through newsletters from researchers to journalists. As for the critiques relating to the quality of evidence, trans- and multidisciplinary research is important in raising the quality of the evidence available for use in policy. In the current policy environment, characterized by complex multifaceted problems (e.g. the legalization of cannabis), evidence is often insufficient and uncertain. In such cases, organizing platforms for policy dialogues with policy-makers and other influential stakeholders, in which both the evidence and the lack of it can be discussed, is key for a legitimate process of decision- making. Professor Roland Bal, Erasmus University, further explored the idea of EIP as a social process that includes contradictory systems of meaning by discussing the challenges to traditional EIP models stemming from the social sciences. Professor Bal argued for the need to move from the logic of the "two communities" (6) to the logic of "coproduction of knowledge" in EIP. The latter emphasizes the study of science as a social practice and renounces an a priori separation of science and policy as separate domains (7), unlike most theories of KT (8). Professor Bal presented two examples of innovative solutions and mechanisms for EIP:  the Dutch Health Council2 as an example of a formal institution that uses informal mechanisms for EIP (9); and  the Dutch "Academic Collaborative Centres for Public Health", which are long- term collaborations between (or collective infrastructures aimed to better connect) local public health policy makers, researchers and professionals (10). Following from this understanding of EIP as a process of "coproduction of knowledge" is the idea that boundaries between science and policy need to be managed: that is clearly separated as well as coordinated by neutral spaces. These neutral spaces for knowledge brokering can employ two types of mechanism for EIP:  formal mechanisms such as mandates from governments (e.g. EVIPNet KTPs currently being set-up in many countries in the WHO European Region); and  informal mechanisms such as common social/coffee spaces for policy-makers and researchers. In this sense, knowledge brokering can take many forms, on a spectrum from individuals, to instruments, to social and institutionalized settings, depending on the context where it is applied. The theoretical considerations by Dr Fahy and Professor Bal were complemented by real-life examples of knowledge brokering organizations and initiatives from across the WHO European Region. These examples are presented in section 4. 2 You can consult to website of the Dutch Health Council here. Enhancing evidence-informed health decision-making in Europe 5 4. EIP in practice Dr Vesna-Kerstin Petrič, Ministry of Health, Directorate for Public Health, Slovenia, described the real-life example of how EIP mechanisms and tools can be developed and of knowledge brokering in Slovenia. The evolution of EIP and the launch of EVIPNet in Slovenia can be summarized in three consecutive phases. Currently, demand for evidence, particularly for the development of national policies, is a major driving force for EIP in Slovenia. Building on past efforts, a more sustained collaboration between the Ministry of Health (civil service) and the Public Health Institute is taking shape and thus providing knowledge brokering. In this context, the launch and implementation of the EVIPNet Europe pilot (March 2014 to September 2015) activities served as a catalyst for EIP in Slovenia.3 The pilot activities included the development of an evidence brief for policy4 and the planning for creation of a national KTP. The latter is being informed by the findings of a situational analysis providing insights into the driving forces and barriers of EIP in Slovenia.5 The creation of KTPs and the 3 The summary of the launch event can be found here. 4 See the EVIPNet global website for definition and examples of evidence briefs for policy. 5 A summary of the situational analysis for EIP in Slovenia can be found here. 1990 2000 2010 2 1 3 In the early 1990s, selecting policy priorities was the responsibility of Ministers of Health, who would do so based mainly on epidemiological evidence and on policy examples from other high- income European countries After accession to the European Union (2007), politicians started to make more stringent requests from civil servants to base policy initiatives on evidence, particularly on evidence of cost–effectiveness. In the late 1990s and early 2000s, the main inspiration for Slovenian health policy became the WHO recommendations for health policy-making. Enhancing evidence-informed health decision-making in Europe 6 development of evidence briefs for policy lie at the core of EVIPNet Europe’s methodology for fostering EIP at country level.6 Lessons learnt from the process of piloting EVIPNet.  The situational analysis is a useful albeit demanding process. The situation analysis revealed that, while a range of successful evidence-to-policy activities exist in the country, a KTP is required to systematize and coordinate these efforts.  The stakeholder consultation, at which the findings of the situation analysis were presented, deliberated and validated, was key for buy-in from different actors.  Creating contacts between different stakeholders proved as important as the written evidence briefs for policy.  Networking abroad and nationally has been central for KT, to be coordinated by the future KTP. As health policy problems are becoming increasingly complex and uncertainty abounds, international collaboration and networking through mechanisms such as EVIPNet Europe are key to successfully bridging the gap between research and policy in countries such as Slovenia. Real-life experience of EIP in practice, including challenges and driving factors, was also illustrated by knowledge brokering organizations and initiatives from Finland (Box 2) and Norway (Box 3). Box 2. EIP in practice: example from Finland The National Institute for Health and Welfare in Finland is a research institute advising the Ministry of Social Affairs and Health and related government bodies on public health, welfare and social policies. The Institute functions at national level and its mandate is defined by legislation. However, the historical model for EIP/policy advice in Finland is changing. There has been a reduction in funding for the Institute in favour of commissioning research from universities, think tanks or consultancies. In this context, the EIP roadmap (presented in section 2) is a good instrument for the Ministry of Social Affairs and Health in Finland as it gives a structure for EIP and could provide adequate tools to guide the development of the new model for EIP. (Provided by Professor Ilmo Keskimäki of the National Institute for Health and Welfare of Finland.) 6 For more details about its EIP methodology, please consult EVIPNet Europe’s brochure. Enhancing evidence-informed health decision-making in Europe 7 Box 3. EIP in practice: example from Norway The Norwegian Knowledge Centre for the Health Services, Oslo, has an EIP remit, which includes:  carrying out health technology assessments and systematic reviews, particularly focused on priority-setting for new, expensive technologies;  developing new methodologies to support EIP, such as patient safety indicators, effectiveness research; and  organizing policy dialogues with politicians, based on the methodology outlined in the Supporting Use of Research Evidence Tools (SUPPORT) tools (12). Challenges of EIP work at the Centre:  although policies should be evidence informed, "evidence" does not always mean systematic evidence, given the imperative time pressures on policy-makers;  the dominance of push of evidence from the Centre to policy-makers over the pull for evidence from the policy-making community;  failure to give policy-makers what they want can lead to a reduction in support for the Centre; reasons for this failure can be time constraints, policy-makers’ seeking evidence to support a decision already made or policy-makers asking questions that are not amenable to research; and  the Centre's mandate includes collaboration with the local and health services levels of policy-making, but this full mandate has yet to be met. (Provided by Dr Anne Karin Lindahl of the Norwegian Knowledge Centre for the Health Services.) 5. Practical guidance for the development of the EIP Action Plan Dr Claudia Stein, Director, and Tanja Kuchenmüller, Technical Officer at the Division of Information, Evidence, Research and Innovation, WHO Regional Office for Europe, presented the EIP roadmap aims of harnessing EIP tools and processes to strengthen health systems and public health in the Region in support of implementation of the Health 2020 policy framework (see section 2). Throughout the theoretical and practical sessions of the preconference event, participants reflected on how their own experiences of EIP could contribute to the operationalization of an EIP Action Plan for the implementation of the EIP roadmap. Four key topics emerged during the deliberations around which practical recommendations for the development of the EIP Action Plan developed. Fig. 2 outlines these recommendations for each of the four topics identified:  coproduction and stakeholder involvement  actions needed to enhance EIP  knowledge brokering  societal impact of research. Enhancing evidence-informed health decision-making in Europe 8 Fig. 2 Key recommendations for the WHO Regional Office for Europe Action Plan Enhancing evidence-informed health decision-making in Europe 9 6. Reflections on the development of the Action Plan Stakeholders attending the European Public Health preconference event saw the value of the EIP Action Plan in providing a joint framework that would lay out a foundation for cohesion and collaboration of stakeholders with a vested interest in fostering EIP. Encouraging commitment of all stakeholders is particularly important given the shifts in governance models discussed above in which the central role of the state is increasingly delegated or shared with other actors. In these new models of governance, knowledge remains one of the main sources of legitimacy for governments in coordinating health policy-making. However, politicians may agree on the values of EIP easily, but taking action on EIP is more complicated. Therefore, reinforcing commitment from WHO Regional Office for Europe Member States through the adoption of an EIP Action Plan and Resolution is a goal worth pursuing in order to capitalize on the increasing demand and momentum for EIP. The deliberations resulted in seven key recommendations to be considered when developing the Action Plan. 1. Develop individual, institutional and mixed knowledge brokerage mechanisms. (a) At individual level, researchers:  must be prepared to provide advice informed by evidence in a timely manner; for example, civil servants can prepare for the evidence needs of newly elected governments in advance, based on their election campaign ideas;  must be honest about the boundaries of available evidence;  must jointly identify what kind of evidence should be prioritized and generated for use in policy-making; and  must be prepared to identify when evidence is appropriate for influencing decisions and when it is not (e.g. in settings where evidence is not valued as an important input); a fertile ground for EIP needs to be supported first. (b) At institutional level, knowledge brokerage spaces need to be developed that provide neutral institutional pathways for the use of evidence and supporting trans- and multidisciplinary, participatory research (e.g. KTPs promoted by EVIPNet). (c) Mixed model of knowledge brokerage combines both formal and informal elements, such as communities of practice, some of which being created and sustained solely through their members’ interest (e.g. Alcohol Policy Network) and others being project-based initiatives (e.g. EURO Healthy). One caveat of project- based funding is that it often does not succeed in becoming sustainable, which raises issues around the lack of efficiency of the allocation of public money. In this context, it is important to ask how project-based initiatives can be translated to sustainable institutional structures, beyond such outputs as evidence repositories for example. In contrast, it is important to avoid building fixed institutions with vested interests that become inert to innovation and change. Enhancing evidence-informed health decision-making in Europe 10 2. Consider alternative levels of policy-making and develop EIP models for local decision-making and for alternative governance mechanisms (e.g. associational, network, corporate or community governance). (a) Such model should include channels for knowledge, research and monitoring systems already in use (e.g. health information, public health monitoring data). (b) Further, it should consider how central "policies" translate at different governance levels (e.g. the development of local public health targets, particularly in devolved or federal countries). 3. Include considerations on how to create links between existing evidence utilization tools. (a) Examples include health impact assessment, health technology assessment, health reporting (e.g. journalists), health systems performance assessments or existing scientific advisory bodies. Despite the fact that these tools might have varying degrees of embeddedness in policy-making, they do have common elements with EIP. (b) Coordination between such tools is needed for EIP to become generalized at different policy levels. For example, EVIPNet Europe, which aims to coordinate EIP at country level, could take on such an effort. 4. Build capacity for EIP at academic level. (a) Map the programmes that include EIP in their curricula (at bachelor, masters and doctorate levels). (b) Promote and develop multi- and transdisciplinary research within academic institutions. (c) Put in place internships to teach young professionals about how policy-making happens, such as the Masters in Public Health Capstone Project.7 (d) Integrate social sciences such as public administration, policy analysis, multilevel governance or political science. (e) Develop a repository of trainers in EIP at European level (EVIPNet has begun this process). 5. Consider the needed reforms of research-incentive structures in order for societal relevance to acquire primary importance in funding decisions. (a) Decisions about which types of research are being produced are important. For example, local evidence, the type that might be most useful for EIP, is often not well financed and not academically rewarded or rewarding to researchers. In contrast, international evidence might be unusable or irrelevant but be allocated more funding. (b) "Traditional" rules of publishing and incentives structures create barriers (e.g. released data cannot be published). 7 The Capstone Project is run by the Johns Hopkins Bloomberg School of Public Health (see here for more details). Enhancing evidence-informed health decision-making in Europe 11 (c) Striving to create policy-relevant research despite existing barriers is the only way to determine increase in funding for this kind of research. This can contradict opinions by policy-makers that researchers’ work cannot be used, as well as contribute to the increase of evidence use conceptually (i.e. evidence utilization slowly becoming a formal or an informal rule of decision-making). 6. Consider policymakers’ incentive structures. (a) Capacity building for higher science literacy of individual policy-makers was seen as helpful. However, it was agreed that policy-makers do, in fact, use evidence frequently. In many cases, the issue is not the lack of individual capacity but the difference in paradigms and systems of meaning. (b) Creating institutional structures and other pathways for evidence to be used in policy-making (e.g. links between ministries of health and public health institutes) is as important as capacity development for individuals. However, institutional pathways are key in ensuring sustainability of EIP initiatives and mitigating effects of staff turnover. 7. The Action Plan needs to be accompanied by an implementation plan that clarifies the difference between actions that are short, medium and long termed. In conclusion, given the complex and sometime contradictory nature of EIP, it was agreed that successful knowledge brokering and other EIP initiatives should aim to "coproduce knowledge" by bringing together different systems of meaning. 7. Conclusions The development of EIP is both a theoretical and a practical challenge. There was agreement that evidence use in policy refers to a complex reality that should not be oversimplified as a liner process of linking "two communities". However, applying a paradigm shift to conceptualize EIP as a process of "coproduction of knowledge" was seen as challenging. Consequently, the deliberations gave equal importance to conceptual debates related to the development of EIP, as well as to practical steps towards advancing the field. The common theme referred to the importance of considering complexity at the same time as being practical. In this context, the EIP roadmap and future Action Plan/Resolution were seen as key tools in advancing the field in the WHO European Region. Participants confirmed that the tools were particularly relevant given the need to structure and offer guidance on EIP work across their respective countries. The deliberations built on the discussions on theoretical debates and the innovative practices for EIP, resulting in a series of key recommendations for the development of the WHO Regional Office for Europe Action Plan (presented in Box 4). Enhancing evidence-informed health decision-making in Europe 12 Box 4. Key recommendations for the development of the Action Plan For researchers and decision-makers at all levels 1. Develop models for evidence use according to new health governance models (targeting corporate and community level actors, as well as local decision- makers). 2. Support institutional, individual and mixed models of knowledge brokerage. Brokerage is not only about formal mechanisms but also about building trust and informal contacts. For national level policy-makers, including funders of research 3. Support institutional knowledge brokerage. 4. Coordinate new and existing evidence utilization tools. 5. Consider incentive structures for researchers and policy-makers and how they hinder or support EIP. 6. Build capacity for EIP at academic level, including undergraduate and graduate education in social sciences. For international organizations, such as the WHO 7. Support international mechanisms and networks in order to foster sharing knowledge and sustained momentum for EIP across countries. Although the EIP terminology is complex and potentially misleading, it was clear that both the participants and the organizers shared a common vision that evidence should inform policy and that tools are needed. The current event was important in creating and strengthening informal communities for EIP across the European Region. The further development of the WHO Regional Office for Europe's Action Plan for EIP could be an important tool through which this common vision can be put into practice, by supporting structured implementation of EIP efforts. Enhancing evidence-informed health decision-making in Europe 13 References 1. WHO Regional Office for Europe. Towards an accelerated roadmap for strengthening evidence-informed policy-making in the European Region Copenhagen: WHO Regional Office for Europe; 2015 (Report of the First Technical Expert Meeting; http://www.euro.who.int/__data/assets/pdf_file/0019/291061/EIP-Report-1st-Technical- Expert-Meeting-en.pdf, accessed 6 April 2016). 2. WHO Regional Office for Europe. Health 2020: a European policy framework supporting action across government and society for health and well-being. 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Enhancing evidence-informed health decision-making in Europe 14 Annex List of participants Belgium Mark Leys Vrije Universiteit, Brussels Canada Maureen Dobbins McMaster University Denmark Leena Eklund Karlsson University of Southern Denmark Finland Maire Kolimaa Ministry of Social Affairs and Health Ilmo Keskimäki National Institute for Health and Welfare France Anthony Lacouture École des hautes études en santé publique Germany Rainer Fehr Bielefeld University Nicole Rosenkötter NRW Centre for Health - Health Information Thomas Ziese Robert Koch Institut Angela Fehr Robert Koch Institut Kerstina Horch Robert Koch Institut Sabrina Hense Robert Koch Institut Freia Debock Univerität Heidelberg Israel Laura Rosen Tel Aviv University Italy Adriana Valente National Research Council Lithuania Jelena Talackiene Ministry of Health Malta Paula Vassallo Superintendence of Public Health Netherlands Alexandra Ziemann Acute Zorg Euregio Roland Bal Erasmus University Rotterdam Joanne Vincenten Maastricht University Medical Centre Johan Hansen Netherlands Institute for Health Services Research Judith de Jong Netherlands Institute for Health Services Research Marleen Bekker Radboud University Norway Espen Moseidjord Aust-/Vest-Agder Fylkeskommune Anne Karin Lindahl Norwegian Knowledge Centre for the Health Services Poland Miroslaw Wysocki National Institute of Public Health Enhancing evidence-informed health decision-making in Europe 15 Portugal Angela Freitas CEGOT,University of Coimbra Iwona Stefanik University of Coimbra Paula Santana University of Coimbra Romania Petru Sandu Babes-Bolyai University Russia Ekaterina Zimina Federal Research Institute of Public Health Tatiana Kaygorodova Federal Research Institute of Public Health Vasiliy Vlassov State Research University Higher School of Economics Slovakia Martin Smatana Ministry of Health Slovenia Tit Albreht National Institute of Public Health Sweden Patrik Nylander Public Health Agency of Sweden Switzerland Marie Annick Le Pogam Institut Universitaire de Médecine Sociale et Préventive (IUMSP) de Lausanne Isabelle Peytremann Bridevaux Institute of Social and Preventive Medicine Bernard Burnand Lausanne University Hospital Mohammed Al-Khaldi Swiss Tropical and Public Health Institute Taiwan, Province of China Chingyi Shih Ministry of Health and Welfare Shu-Li Chia Ministry of Health and Welfare Yu-Hsuan Lin Ministry of Health and Welfare United Kingdom Ioana Vlad London School of Hygiene & Tropical Medicine Mark Mccann MRC/CSO Social and Public Health Sciences Unit Nick Fahy University of Oxford, United Kingdom WHO Regional Office for Europe Claudia Stein Director, Division of Information, Evidence, Research and Innovation Tanja Kuchenmüller Evidence and Information for Policy, Division of Information, Evidence, Research and Innovation Tim Nguyen Evidence and Information for Policy, Division of Information, Evidence Research and Innovation Ryoko Takahashi Evidence and Information for Policy, Division of Information, Evidence Research and Innovation