National Action for European Public Health Research

which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction: Research and innovation are the basis for improving health and health services. The European Union (EU) supports research through multi-annual programmes. Public Health Innovation and Research in Europe (PHIRE) investigated how European countries cooperate for action in public health research. Methods: In PHIRE, following stakeholder workshops and consultations, a national report on public health research was created for 24 of 30 European countries. The report template asked five questions, on national links to European public health research and on national research through the Structural Funds and Ministry of Health. The national reports were assessed with framework analysis, and the country actions were classified strong/partial/weak or none. There were responses to the five questions sufficient for this analysis for between 14 and 20 countries Results: Six countries had public health research aligned with the EU, while three (large) countries were reported not aligned. Only two countries expressed strong engagement in developing public health research within Horizon 2020: most Ministries of Health had no position and only had contact with EU health research through other ministries. Only two countries reported use of the 2007–13 Structural Funds for public health research. While seven Ministries of Health led research from their own funds, or linked with Ministries of Science in six, the Ministries of Health of seven countries were reported not to be involved in public health research. Conclusions: Ministries of Health and stakeholders are poorly engaged in developing public health research, with the Horizon 2020 research programme, or the Structural Funds. The European Commission should give more attention to coordination of public health research with member states if it is to give best value to European citizens. P ublic Health Innovation and Research in Europe (PHIRE), a study led by the European Public Health Association (EUPHA), has studied the uptake of public health innovations in European countries and assessed national public health research systems. This final article in a series of nine in the PHIRE Supplement of the European Journal of Public Health 1 reviews action for public health research across European countries.


Introduction
National governments are responsible for their population's health, the health care system and the health research system.The World Health Organization (WHO) provides leadership and technical strength, including for research, working through Ministries of Health. 2,3The European Union (EU) has had legal competence for public health since 1992, 4 while competence for research was gained earlier.The EU research programme, covering broad areas including life and health sciences, has grown steadily. 5he EU has a multi-annual strategy and budget. 6The European budget for research funded the Seventh Framework Research Programme 2007-13, and the eighth programme, entitled 'Horizon 2020', will run 2014-20. 7European Commission funds for public health, through the Directorate for Health and Consumers, were organized as the First (2003-7) and Second (2008-13) Health Programmes, and the new programme 'Health for Growth' will run 2014-20. 8The EU budget also has Structural Funds-one-third of all EU funds-for Member States to use in support of agreed priorities. 9esearch (with technology, innovation and entrepreneurship) and also health care were prioritized in the 2007-13 Structural Funds, 10,11 and research, innovation and improved public administration are prominent in the proposed country Partnership Agreements for Cohesion Policy in 2014-20. 12he European Commission Directorate of Health and Consumers has had a rather static annual budget since its origin in 2002, of around E50 million for health activities. 13By contrast, the Directorate for Research and Innovation annual budget rose from E5 billion in 2007 to E11 billion in 2013, and will continue to grow to 2020. 14Around E700 million of this was allocated annually for Health research, and there was also separate funding of medical research through the European Research Council.Within the EU Health research theme, biomedical and technological research (with commercial as well as scientific benefits) receive most of the funding, while population and organizational research (with social benefits but no patents) less than 5%. 15The Structural Funds allocated around E7 billion each year for research and innovation, but much of this has gone to capital projects without direction to thematic areas. 11he Horizon 2020 research programme is based on technical and policy documents developed by the European Commission, 16 followed by consultation with stakeholders, Member States and Parliament.Earlier collaborative studies SPHERE 17 and STEPS 18 have investigated public health research publications by country in Europe, 19 national health research structures 20 and engagement of civil society organisations 21 in the new EU member states.PHIRE assessed the uptake and impact of selected public health innovations funded by the EU Public Health Programme, collected national health research programmes and calls identified in 2010 and described public health research systems of 30 European countries (EU 27 plus Iceland, Norway and Switzerland). 22

Methods
Stakeholder workshops on the national position were held in 15 countries, and internal or external discussions in nine countries. 22ational reports were created, following a template, 22 for Austria, Bulgaria, Cyprus, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Ireland, Italy, Latvia, Lithuania, Malta, Norway, the Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Sweden and the UK.No information was provided by respondents for Belgium, Iceland, Hungary, Luxembourg, Spain and Switzerland.The full National Reports are presented for reference on the PHIRE web pages. 23he third section of the National Reports focused on national responses to the European public health research agenda, with a set of linked questions: (i) Is there a connection between national research and the European projects, in general?(ii) Does the Ministry of Health have a position on the content of the EU's Horizon 2020 (2014-20) Research Programme?And how does the Ministry of Health discuss this with the Ministry of Science? (iii) Does the Ministry of Health have a position on the use of the EU's Structural (Regional and Social) Funds programme for public health research in 2014-20?(iv) How does the Ministry of Health discuss this with the Ministry of Finance and/or other Ministries?(v) Does the Ministry of health provide details on the engagement in priorities and funding both at national and European level?
National reports were completed for 24 of 30 (80%) of European countries in PHIRE.Responses by question ranged from 14 to 20 countries, and were gained for 85 of a potential 120 (68%) of sections in the reports, so the totals vary by section, see Table 1.The replies were collated, assessed using framework analysis. 24The reported actions by countries were rated strong, or partial, or weak.Country actions were considered 'Strong' for 20 responses out of 85, while 32 were 'Partial' and 34 were 'Weak or None'.The response texts are summarized in Supplementary Table S1.

Connections between National and European research
The themes of the European Seventh Framework Research Programme were relevant for five countries, Czech Republic, Cyprus, Finland, Latvia and Romania, which have adapted their research strategies towards European priorities or use results for public health policies (Latvia).Eight countries described the link to European research through co-funding.France, Germany and the UK indicated that connections for public health research were weak, Ireland reported 'There is no explicit connection between national research and European projects' and links were reported absent for Greece and Malta.

Ministry of Health position on Horizon 2020
Finland welcomed the unified structure of the Horizon 2020 proposals, and the main societal challenges.The Ireland Health Research Board was 'heavily involved in the consultation process'.The Slovakian Ministry of Health had contributed to a national Preliminary Statement on Horizon 2020, and in Italy is 'working for a structured collaboration'.Ten countries reported that their Ministry of Health had no position.

National discussion on Horizon 2020
The Ireland Health Research Board discusses research interests directly to the European Commission through the Programme Board.The Slovenia Ministry of Health discusses with the Ministry of Science.In 10 countries, Ministries of Science or Education initiated national discussions involving the Ministry of Health, or discussions within a cross-ministerial committeesometimes (Malta and Sweden) formally under the prime minister, with the Ministry of Health present.Four countries reported little or no contact on Horizon 2020.

Use of the structural funds
Estonia and Lithuania described active current use of the Structural Funds for health research: both countries had established annual programmes with open calls.The Research Council in Estonia had 'negotiated intensively' with the Ministry of Social Affairs (which covers health), approving six projects, and similarly six were approved in Lithuania.Five countries showed knowledge of the research funding, with Poland also noting receiving income for research through bilateral funding (especially Germany and the USA).In four countries, there was less knowledge of the structural funds for research: for example, Slovakia commented on use of the Structural Funds for the national public health programme, rather than for research.'Old' EU member states ignored this section (the 2007-13 Structural Funds for research and innovation were directly mainly in the EU 'new member' states).

Health Ministry research funding
Seven countries gave relatively clear accounts of health research funding from their Ministries of Health.This may be related to specific concerns, for example, in Slovakia 'The Ministry of Health independently funds research and analysis on complex technical issues, and also co-finances research annually with the Slovak Research Agency'.In Italy and Ireland there are annual calls, and in Portugal 'on a non-regular basis'.Sweden's Ministry of Health directly finances the Council for Working Life and Social Research, which funds project and programme grants competitively, and in the UK the Ministry of Health controls the funds from the National Health Service for clinical and health services research.In six countries, the Ministry of Health is involved indirectly in research funding: in Austria through financing independent associations; in the Czech Republic and Latvia in supporting health research applications to the Ministry of Science; in Estonia, the Ministry of Health manages research through the National Institute for Health Development; in Finland, the Ministry has a strategic role; and in France, providing funding jointly with the Ministry of Science.In seven countries, there is no direct role except indicatively through the national health plan.

National report commentaries
The PHIRE national report template provided space, after the questions, for free text commentaries.Several reports used this area.Commentaries, shown in Supplementary Table S2  The results of this study are limited by response rates of countries, interpretation of the Report questions by the respondents and the representativeness of individuals writing the National Reports.Responses for questions were gained from half (14) to three quarters (20) of 27 EU countries.Of these responses, six countries were reported to have their public health research priorities ordered along the lines of the EU health research programmes, while three larger EU countries were reported not to be aligned.Only two countries (Finland and Ireland) were assessed with strong engagement for public health research in the development of Horizon 2020.Most Ministries of Health were said to have no position, with their contact on Horizon 2020 through the Ministry of Science, or a pan-ministry committee.Two countries, Estonia and Lithuania, gave strong examples of the Structural Funds used for public health research, and six gave partial acknowledgment.Ministries of Health lead their own health research funds in seven countries, or are directly involved in six, but in seven countries they were reported to have no involvement.
In a previous collaborative study, SPHERE (Strengthening Public Health Research in Europe), 20 out of 24 officials in EU member states regarded their national biomedical research as led from the Ministry of Science, and public health research led from the Ministry of Health. 20Yet few of the Ministry of Health respondents could identify public health research beyond their national public health institutes, and few ministries had a unit or formal contact concerned with health research commissioning.Although the PHIRE data are incomplete, the evidence of limited involvement in European and national health research by Ministries of Health should be of concern to the WHO European Region, which has included health research as a target policy area in its strategy 'Health 2020' and has re-established its Regional Advisory Board for Research. 25WHO Headquarters, working with the Council for Health Research and Development (which now includes the Global Forum for Health Research), and the Symposium on Health Systems Research, should also give attention to health research programmes of European countries. 26nother direction for public health research at European level could also be better links with the major disease-based organizations, and thematic areas for research.For example, the European Commission Joint Action 'Partnership for Action Against Cancer' includes reviewing cancer research, 27 and the ERA-NET for national environment and health research programmes (ERA-ENVHEALTH) engages 16 public research funding organizations from 10 European countries. 28lthough some EU member states have an interest in developing public health research, there is not a coherent European policy of coordination.ERA-NETs bring national funding bodies together, 29 while joint programming creates cross-national groupings of research teams. 30But these groupings remain only a small proportion of all health research across European countries.Developments that could be taken up by the EU Directorate for Health and Consumers include placing national contact points for public health research within Ministries of Health, improved organizational data including finance and comparative mapping over time of public health programmes, outcomes and impact to contribute the 'high level of human health' that is one Treaty objective of the EU.

Conclusion
Horizon 2020 will continue the rapid expansion of EU-funded research.Health remains a key Social Challenge identified by the programme. 15More attention should be given by the EU and member states to coordination of European public health research to give best value to European citizens.
DiscussionWhile a proportion of European Ministries of Health fund national health research programmes, and a few have drawn on the European Structural Funds for research, the majority of countries have limited engagement in developing public health research in relation to the EU's research programme Horizon 2020.

Table 1
Balance of country responses in PHIRE National Reports on European public health research