Summary of the impact

Durham University's Centre for Public Policy and Health (CPPH) has worked closely with the World Health Organisation's (WHO) Regional Office for Europe to help design the European Action Plan for Strengthening Public Health Capacities and Services. The European Action Plan (EAP) draws extensively on three major CPPH research projects on the nature and governance of the public health system in England. The EAP, endorsed by all 53 WHO Member States in September 2012, is a main pillar for the implementation of the WHO's policy framework — Health 2020 — also endorsed by Member States.

Underpinning research

Underpinning research is contained in three CPPH projects (2006-11) funded by the National Institute for Health Research Health Services & Delivery Research programme on (1) the public health system, (2) public health partnerships, and (3) public health governance. These studies were conducted by CPPH teams led by the Centre's Director — Hunter (Professor of Health Policy & Management, 1999-) and Marks (Senior Research Fellow, 2001-).

A book based on the findings of the first study (Section 3, Ref 1), a commissioned scoping study on the development of public health policy and practice, provided the underpinning context for a programme of public health research, including the other two studies described below (Section 3, Refs 2-5). The research employed a complex systems approach, not previously applied to the topic, to identify the particular nature of, and challenges facing, public health policy and practice and to provide a conceptual framework for understanding and exploring possible ways of meeting these. The framework is generic and may be applied to public health systems in different countries.

The second study found that partnerships in public health were more complex than those in health and social care services, that they had multiple sets of boundaries, and comprised a broader range of partner agencies. The study was the first to investigate public health partnerships in this depth. Collective leadership emerged as vital, and within complex partnerships relationships were more important than structures. The study contributed to new ways of thinking about partnerships in complex settings and challenged prevailing assumptions about their value, purpose and impact. It also identified the skills and competencies required to make partnerships more effective. The study's originality and contribution to knowledge lay in bringing these findings together within a framework derived from systems thinking which had not been previously been applied to public health (Section 3, Refs 2-3).

The third study focused on the relationships between governance, commissioning and public health. It developed the concept of `public health governance' and was the first study to explore the impact of different dimensions of governance on commissioning for health and wellbeing at a local level (Ref 4). It considered underlying principles of governance, governance arrangements (such as targets, audit and the use of incentives) and decision-making approaches and analysed how each of these influenced local strategies and priorities. The study demonstrated the complexity of the governance landscape for public health, the leadership qualities required to negotiate it, and contributed to understanding the processes involved in addressing a governance deficit in public health.

The research underpinning the three studies was collated to provide the theoretical and conceptual framework adopted by WHO in the design and development of the EAP and to frame the avenues for action which comprised the Plan (Section 3, Ref 6).

References to the research

Details of the impact

The approach from WHO Europe in mid-2010 was initiated by Professor Richard Alderslade, a senior advisor to the WHO Regional Director (RD), following publication of The Public Health System in England by Hunter, Marks and Smith (Ref 1, Section 3 above). The book's emphasis on complex systems applied to public health resonated with the RD's ambition to restore a public health focus in WHO Europe's programme of work. Central to the RD's purpose was a new policy framework and health strategy, Health 2020, to be accompanied by an action plan, the European Action Plan for Strengthening Public Health Capacities and Services. The EAP draws directly on, and is underpinned by, the 3 research studies described in sections 2 and 3. WHO describes the EAP as constituting `one of the main pillars of Health 2020' (Source 3), which aims to support action across government and society to `significantly improve the health and well-being of populations, reduce health inequalities, strengthen public health and ensure people-centred health systems that are universal, equitable, sustainable and of high quality' (Source 4). The Plan is structured around 10 avenues for action. Each avenue incorporates an overview of key themes, and support and development activities to be provided by all 53 WHO Member States, the WHO Regional Office for Europe Secretariat and its partners.

The EAP represented a departure for WHO since previous health strategies had not been accompanied by an action plan. Implementation and delivery were viewed as critical and achieving agreement over actions given the complexity of public health systems across a diverse range of countries all at different stages of development posed a major challenge. The research from Durham conceptualising public health systems was therefore seen to be both timely and highly relevant to WHO's purposes and informed their thinking. At the outset, Hunter was invited to co-facilitate a high level internal meeting of senior public health officials at WHO's Regional Office for Europe in Copenhagen (November 2010). The terms of reference were `to review concepts, definitions, boundaries and activities and to advise WHO accordingly' in the context of the key public health and health policy challenges in Europe, `including particularly that to strengthen key public health capacity and services'. The meeting led to an agreed programme of work with Hunter and Marks from 2010-12. The first output was a framework for action document which was approved by Member States at the 61^st Regional Committee in September 2011 (Sources 1 and 2). The framework served as the basis for subsequent work on developing the EAP. Working closely with senior WHO officials and advisers, Hunter and Marks had a decisive impact on the overall shape, structure and content of the EAP as borne out by the testimonies received.

International Public Health Expert and WHO Programme Manager for Public Health Services at the time said:

`It was exactly at this conceptual phase that Prof Hunter's and Linda Marks' research and input had an impact on the further production of the European Action Plan. They developed a draft concept paper which was debated in an expert working group workshop at the end of November 2010 and, after some revisions, became the solid theoretical basis for developing the first drafts of the future Action Plan.'

Hunter was invited to join the newly established Public Health Expert Reference group at WHO to advise officials on the EAP. Its members included academics and senior government health advisers from the UK, Israel, Hungary, and Sweden. At the same time, both Hunter and Marks were appointed as Special Advisors with WHO Europe and commissioned to work with their staff to produce the EAP for wish Member States reaffirmed their support at the 61^st Regional Committee in September 2011. Hunter and Marks led on the drafting of the Plan for final adoption by the Regional Committee at its 62^nd session in 2012.

The Programme Manager for Public Health Services at WHO at the time confirmed: `They, as a team, were the main writers throughout the whole process which evolved in two states:

Stage 1: development and endorsement of a policy document, e.g. the Framework, and
Stage 2: development, consultation and revisions of the European Action Plan itself.

They were not only writers but they were facilitators in the long consultation process, thus, helping to convince our end-beneficiaries on one side, and supporting WHO Europe to better understand and incorporate the various views, opinions and standpoints.' Senior Advisor Health Policy WHO Regional Office for Europe said:

`Their (Hunter and Marks') work had a profound influence. They provided a robust philosophical and scientific basis for conceptualizing public health, as well as a practical vision for how public health services might be delivered and strengthened.'

Hunter and Marks' principal contribution was to develop a series of avenues to action (which drew directly on the research reported in section 3) and a number of mid-term actions for Member States and WHO based on the concept of complex public health systems which informed the research projects described in section 2. The avenues parallel 10 Essential Public Health Operations (EPHOs) which take the form of a checklist. While the EPHOs represent the end points of the EAP, the avenues for action represent the means by which these end points will be attained through detailing the actions to be taken by Member States and WHO.

Following several iterations over a period of 18 months, the EAP (Source 3) was finalised after a consultation process with Member States and feedback from discussions at the European High Level Policy Forum meetings in Andorra (March 2011), Israel (November 2011) and Brussels (April 2012), and two sub-regional technical consultations in Helsinki (January 2012) and Brussels (March 2012). Hunter attended and participated in all of these meetings. The EAP was endorsed in September 2012 by all 53 Member States (Source 5).

WHO will monitor the progress and impact of the EAP, offering assistance to Member States in its implementation. To help advance these tasks in collaboration with WHO, and in recognition of the relevance of its research to the development and implementation of the EAP, the CPPH has been invited to become a WHO Collaborating Centre on Complex Health Systems Research, Knowledge and Action led by Hunter and Marks. The importance of the Centre's research has led to Hunter being made a member of the WHO Europe Steering Group on the EAP established to progress the implementation of the EAP and to reporting on this to Member States at the Regional Committee at its 66^th session in 2016. In addition, Hunter is chairing the WHO working group on advancing public health research to inform policy and practice (avenue for action 10, and EPHO 10). He is also taking part in a closed meeting of selected WHO public health experts in Tallinn, Estonia to agree a road map for the EAP's implementation.

Sources to corroborate the impact

1. WHO Europe Working Document, Baku, 2011: EUR/RC61/10 Strengthening public health capacities and services in Europe: a framework for action. http://www.euro.who.int/__data/assets/pdf_file/0008/147914/wd10E_StrengtheningPublicHealt h_111348.pdf
2. WHO Europe Resolution, Baku, 2011: EUR/RC61/2 Strengthening public health capacities and services in Europe: a framework for action, http://www.euro.who.int/en/who-we- are/governance/regional-committee-for-europe/past-sessions/sixty-first- session/documentation/resolutions/eurrc612-strengthening-public-health-capacities-and- services-in-europe-a-framework-for-action
3. European Action Plan for Strengthening Public Health Capacities and Services http://www.euro.who.int/en/what-we-do/health-topics/Health-systems/public-health- services/publications2/2012/european-action-plan-for-strengthening-public-health-capacities- and-services
4. Health 2020: a European policy framework supporting action across government and society for health and well-being. http://www.euro.who.int/__data/assets/pdf_file/0009/169803/RC62wd09-Eng.pdf
5. WHO Europe Resolution, Malta, 2012: EUR/RC62/R5 European action plan for strengthening public health capacities and services. http://www.euro.who.int/__data/assets/pdf_file/0006/173616/RC62rs05-EAP-ENG.pdf

WHO Regional Office for Europe — testimonials

6. Programme Manager, Public Health Services, Division of Health Systems and Public Health, WHO Regional Office for Europe
7. Senior Advisor Health Policy WHO Regional Office for Europe