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Should EUPHA publish a new journal for European health systems research?

Mark McCarthy
DOI: http://dx.doi.org/10.1093/eurpub/ckr021 141-142 First published online: 22 March 2011

During the excellent Conference on Health Services Research in Europe (http://www.healthservicesresearch.eu/), in the Hague, the Netherlands, in March 2010, a conversation with a compatriot followed the perennial topic ‘What is public health research?’ On this occasion there was a twist: ‘Is health services research also public health research?’ We agreed they are both parts of the same activity, and noted that more health services research is done in institutes of public health than in university medical schools. Yet then my colleague said, ‘But I would never publish in the European Journal of Public Health. It has the wrong title.’

Also last year was the first Global Symposium on Health Systems Research (http://www.hsr-symposium.org/). The meeting was held in Montreux, Switzerland [where 1400 participants also attended the 2006 European Public Health Association (EUPHA) annual conference, memorably hosted by the Swiss Society for Public Health], with multiple international sponsorship including World Health Organisation (WHO) Headquarters in Geneva and its daughter organization the Alliance for Health Policy and Systems Research. The Global symposium, also an excellent meeting, was very different from the Hague conference. Although held in Europe, its perspective was slanted away from experience in ‘high-income’ countries. It drew on earlier annual meetings of the Global Forum for Health Research, also WHO sponsored, and including two global ministerial meetings on health research in 2004 (Mexico) and 2008 (Mali). It had a very ‘official’ character, with most participants (and their ‘per diems’) being funded by international sponsors or governments, and few participants paying themselves.

How can we develop health services and systems research in Europe? WHO/EURO held a ministerial meeting on health systems in Tallinn in 2008 (http://www.euro.who.int/en/home/conferences/ministerial-conference-on-health-systems); and, along with some European Member State governments, supports the Observatory on Health Systems and Policies. But these are not ‘open’ arrangements for the wide constituency of academics and practitioners. Governments send their representatives to international meetings less for frank debate, and more to defend territory. There are also increasing numbers of international meetings organized for the growingly powerful health-care industry, and prestige events by national institutions and universities claiming to address health and international development.

But the only democratic framework for researchers themselves is EUPHA. It is governed by European national associations of researchers and practitioners. For its annual conference and peer-reviewed journal, EUPHA accepts submissions from individuals who may be members of these associations or not. And in contrast with most medical conferences, it has few ties with industry for sponsorship. EUPHA's sections—including the capable Section for Health Services Research—provide networks for many active researchers who wish to keep ‘in touch’, and they offer a framework for trans-national investigations and collaborations, such as the current projects Strengthening Engagement in Public Health Research (STEPS) and Public Health Innovation and Research in Europe (PHIRE) on health research itself where EUPHA is directly a member.

When my colleague said he would not publish in European Journal of Public Health because of its name, however, he identified a real difficulty. The words ‘public health’ means different things in different countries; and there is the issue of translation. In a study of usage of the words ‘public health’ in eight countries, Kaiser and Mackenbach1 suggested that ‘a large number of loosely related terms are in use’, and that more commonly used terms are ‘health sciences’ and ‘health promotion’. And there has also been concept drift. In the UK, up until the 1970s, every local authority had a Medical Officer for Health. Then—at the same time that Archie Cochrane published his seminal work ‘Effectiveness and Efficiency’—public health was brought into the UK National Health Services and re-titled ‘Community Medicine’. But while collaboration with health economics and health services management flourished, other forces demanded that Directors of Public Health need not be medically trained, as health promotion specialists considered they could do the job just as well. (Health economists who wanted higher incomes could work for the pharmaceutical industry.) For the past decade ‘public health’ in the UK (from the government's perspective) has been equated with the wider determinants of health and not with the operation of health services—even commissioning health services, which has been passed to general practitioners. So it was not surprising that my UK colleague in health services research was wary of a journal with ‘public health’ in the title.

Yet Europe has 40 or more very varied health systems, and parts of some countries—regions, or sub-national—are developing further. What can we learn from these variations in systems and services? How do social processes operate under different cultural, legal and economic conditions? What are the best characteristics of health-care systems—the role of gate-keepers, the value of league tables, the challenge of integrated care? How do governments approach policy and spending choices between prevention (e.g. wider determinants) and health care—for example, now in the growing ‘epidemics’ of obesity and dementia? What can be done to enhance patient's experiences of health care, and give them agency without being controlled by commercial forces? The list is long, and of everyday concern to ministries of health, public health practitioners and indeed everyone working in health services (including ‘public health services’). Where can you go to find authoritative, cross-European research?

European Journal of Public Health publishes good health services research, but the majority of papers in the journal are on topics of epidemiology and health promotion. It is not a lack of research itself. Researchers are ready to explore real-life situations within their own health systems, and even if national funding agencies are not putting forward much money calls, heath services research is expanding through interdisiplinary work. The European Commission funds projects through the Directorate for Health's Public Health Programme (although these are designated development rather than research), and the Directorate for Research's theme ‘Optimising the delivery of health care to European citizens’ has funded €175 million for 75 European research projects (23 designated ‘Health Systems Research’) in the 4 years from 2007 to 2010.2

Quite a bit of this health services research is presented at EUPHA's annual conference. But where is it published? The Journal of Health Services Research and Policy aims for a broad perspective but is predominantly about the UK: and several other journals are now published across European countries recording national experience. The electronic journal BMC Health Services Research is an international competitor to the European Journal of Public Health—its publishing model has lower costs and no space limitations, so able to respond to an expanding market. But its authorship is global, the papers are less relevant to European experience, and how do you get to meet and know the people who publish in that journal?

At present, European Journal of Public Health provides both a forum for discussion—such as these viewpoints—and also information on broader European trends, through EUPHA. One option would be to designate a regular section in each edition, perhaps with a designated assistant Editor. But would this signal adequately to researchers in the field, or provide sufficient concentration of reports to become the leading place for European debate? Instead, why does not EUPHA extend its activities to publishing a new journal for health systems research? (I choose ‘systems’ rather than ‘services’ to indicate cross-national as well as micro intent, and to include the apparent oxymoron of ‘public health services’.) This may challenge the unity of public health and health services research, and might lead to separate the readerships. Yet European Journal of Public Health is in profit, helped by the circulation of EUPHA's members. A new journal could build on the evident interest of over 300 Europeans attending the Hague. It would provide a forum for strengthening the discipline across Europe in close relationship with existing research communities, and bringing researchers in health economics, management, policy and indeed clinical practice into dialogue with practitioners of public health. Looks like good business for EUPHA.