EuroHealthNet Draft Response to the European Commission consultation on an EU strategy

Context

EuroHealthNet welcomes the initiative of the European Commission to bring forward a strategic Communication in 2007, although it regrets that this was not achieved before the proposal for a pending Action Programme 2007-13. That clearly is the prime delivery mechanism for addressing core issues in addition to limited possible legislative measures, and should operate in close synergy with other programmes and measures.

Therefore EuroHealthNet urges the EU institutions to sensibly co-ordinate its strategic approach in future, by ensuring that a review of the strategy reaches conclusions before subsequent action programmes in relevant fields are proposed.

That will require a concise, focussed inter-institutional debate in 2007 to allow the strategy to be implemented and reviewed in sufficient time before overall EU strategic and budget decisions are made for the period beyond 2013.

With that proviso, EuroHealthNet concurs with suggestions that the schedule for the strategy could be ten years with a mid point review. EuroHealthNet also calls on the EC to liaise closely with the UN Millennium Development Goal process to ensure synergies.

Specific Questions - Elements

1. How should we prioritise between and within all the potential areas of work to focus on those which add real value at EU level?

EuroHealthNet welcomes the stated intention to establish three broad elements of the strategy, addressing core issues, mainstreaming health, and global health.

We welcome in general the concentration and focus of priorities. There has been too much diversity in the annual work programmes, diluting outcomes. With the WHO actively collaborating with member states in Europe, and working much more effectively with the Commission than hitherto in a number of aspects (such

EuroHealthNet response to EC consultation on a future EU health strategy 1 as counteracting obesity and communicable diseases), it is important to avoid duplication and to agree what can be best achieved by the different actors and stakeholders.

The strategy should overcome this by defining limited clear priorities with measurable objectives, and only diverting from them on the evidence of urgently changed needs such as a pandemic crisis, not short term political pressures.

In that sense the new “baton exchange” approach of successive Presidencies with commonly agreed objectives is very much to be welcomed, for example on counteracting obesity, and should be continued.

Role of member states in prioritisation

The member states have declined to provide greater resources for health during the process to determine the EU budgets 2007-13, despite a clear initial request from the Commission. It is therefore their responsibility to define realistically the ways in which they feel the provisions of Article 152 of the Treaty can now be achieved, not to use Presidencies and other mechanisms to seek unrealistic actions by the Commission, and to ensure policy coherence from relevant non- health Councils.

Role of NGOs and other stakeholders

The role of civil society and economic operators is also important, and in many cases is crucial in delivering processes and services without which objectives cannot be achieved. But capacity is a major problem in most cases, and efforts should be made to provide suitable support for their involvement at an earlier consultative stage. The innovative work of DG SANCO towards stakeholder involvement – peer review and improved policy impact assessments is very welcome and should be implemented by other directorates.

The other side of that coin is that stakeholders should appreciate the democratic process. Civil society organisations and economic operators can be guilty of not seeing wider pictures beyond their own interests when objective decisions are needed, but it will be important for most if not all to feel some ownership of the strategy objectives and to contribute to their promotion and explanation to citizens.

The Policy Forum is a useful initiative that is not functioning as effectively as it could. It could become a helpful collaborative body within the strategy by becoming an early consultation channel. It is not valuable to organisations to discuss policies after publication to the institutions: it is added value to be involved in consultations across the policy range.

Once the priorities are set, for example three priority work objectives in each of the three elements, horizontal task groups can be applied to identify, stimulate, monitor and advise on concrete progress, as was suggested in the case of mental

EuroHealthNet response to EC consultation on a future EU health strategy 2 health by the Consultative Platform Report (see DG SANCO website). These may be established within the EC as well as on a multi stakeholder basis.

1.1 What kind of objectives could be set?

Foremost, it is important that objectives are reachable, concrete and thus possible to monitor systematically. Also, they should be framed within the competence of the European Union in relation to the member states.

So in our field, for example we welcome the intention to include action on health inequalities (or more proactively action for ), arguably in all three elements. Not all member states have strategies in place, and objectives could be set to include, for example: - an action plan in place in all states after 5 years and evaluation of effectiveness against indicators by ten years, agreed as a cooperative measure; - a Commission strategic communication to include a comprehensive approach to social and economic determinants which are clearly within competences (a specific strategic approach within the legislative framework); - specific attention in the Lisbon review (a political initiative); - attention to inter-service mechanisms to enhance inequalities impact assessments, possibly driven by a Commissioner led task group (a delivery mechanism); - improved collaboration within the OMC processes for social inclusion and cohesion, health care and others (a non-legislative benchmarking approach) - FP7 research and evaluation, including cost-effectiveness (an evaluation process). - better cross directorate use of the portal and EC websites (promotion and information tools)

The question remains concerning accountability. If inequalities continue to grow between and within states, it is a sensitive political matter. It would be desirable to introduce an EU wide target to reduce gradients in social status and health inequality within the specified strategic period, for which indicators are clear.

Without the ability to set targets and initiate sanctions or significant support programmes, which are understood to be resisted by member states, both the EC and WHO cannot be responsible for one of the greatest health “scourges” of the current age, as described in Article 152.

That is not a reason for inaction, and part of the purpose of the EU, as with , demographic change and other difficult cross cutting issues, is to provide interdependent leadership.

1.2 What criteria should be used to set objectives?

Content wise, we can agree with proposed direction of goals and have the opinion that the prevalence and burden of diseases by DALYS provides a useful tool for prioritization. However, the approach should be firmly oriented to improvement of

EuroHealthNet response to EC consultation on a future EU health strategy 3 public and population health, not just protection. That needs to be instilled in key CAP and internal market measures, for example in nutrition.

Added value must be a vital criteria: for certain conditions there is relatively little the EU dimension can add despite strong advocacy. “No” is often the most difficult word in policy making, but the EC must resist being burdened with too much

As the specific public health programme is largely pre-defined, special attention should now be given to mechanisms to proactively develop the health in all policies approach recently agreed by the Council. An important criterion to prioritise, and for example to select project proposals, is therefore the involvement of, and partnership with other policy sectors.

Other important criteria include age and gender sensitivity, which is often missing and need to be mentioned at an early stage of programme development.

1.3 Is the Healthy Life Years structural indicator in the Lisbon agenda a key criterion?

Agency views vary on this issue. EuroHealthNet does draw attention to the fact that this indicator varies from the DALYS model used more frequently, and urges the EC and member states to ensure that data and analyses are compatible and comparable throughout to support evidence based policy making.

Moreover, EuroHealthNet calls on the EC and member states to initiate a major element of the Lisbon Review in 2010 on the importance of health in all policies as a driver to achieve Lisbon objectives, with a focus on socio-economic determinants, mobility and demographic changes.

Health in all policies is an approach for all member states, not just community policies, and the role of national and European parliaments is crucial in applying and monitoring this approach.

Indicators for determinants should be applied (for example the 36 developed in Sweden related to the 11 objectives in the national public health strategy). A high priority is a unitary health information system. Implementation of ECHI II is a strong necessity in all countries, making a strong basis for health/disease information, prioritisation, intervention, monitoring, comparisons, analysis and evaluation, discussion.

Some network agencies consider that health care systems reform can be a lower priority for the EU, taking into account that in almost all of the countries the insurance health system is functioning, including newer member states which had to transform their health systems firstly due to external economic and financial forces, and the sensitive competence. This is clearly the subject of parallel consultation and debate.

EuroHealthNet response to EC consultation on a future EU health strategy 4 2. What should we realistically aim to achieve in practice?

To ensure that health needs of EU citizens are taken into account fairly in all policy making, competences and activities associated with the EU institutions and its member states. That means attention to the rights of citizens set out in the Treaty and the Charter of Fundamental Rights, to empower citizens to exercise choices about their health, and access to fair and accurate information to support those decisions.

The provisions of Article 152 should be applied in full: Member States have formally agreed them.

As a principle, progress can only be ensured if health has a high priority in the EU in relation to other priorities. This has been proven to be an important factor for failure or success when health has met conflicting objectives with other policy areas, for example the Common Agricultural Policy, which not only drives and maintain high prices on healthy food but also subsidise fatty dairy products to a population where overweight and obesity is stated as a 'heavy' public health problem.

There is a need for much more coherent policymaking if the idea of HIAP and the respect of Article 152 should have an impact. Just introducing the method of HIA does not solve the problem of conflicting goals, if there is no real chance to change according to outcomes. Health is an important goal itself and as a driver for development should impact other policies (and not the other way around).

Agencies have commented that it is not realistic, either strategically or within programmes, for the enlarged number of states to seek or achieve common objectives in a short timescale. Differential objectives depending on situations could be operated.

2.1 What objectives should be set for the short and long term?

To build up efficient delivery mechanisms: capacity building within most member states is essential to deliver health improvements.

Benchmarks may be sensitive if it comes to compare between MS, but can be useful topic wise, together with good policy and contextual analysis, so that achievements can be understood.

It is suggested that a number of objectives could be set for time frames of five or ten years in the field of workplace health, for example accident reduction.

3. Are there issues where legislation would be appropriate?

When it comes to different "tools" such as legislation, OMC, recommendations, platforms and forums, such options must rest on evaluated knowledge and experiences on how efficient these different methods have been so far. There is a

EuroHealthNet response to EC consultation on a future EU health strategy 5 severe lack of evaluation on what works, and does not, in former EU public health programmes.

In terms of disease burden within EU, the time has come to learn the lessons from tobacco and transfer them to the field of alcohol in terms of marketing, taxes and warning labels.

Agencies have strongly pointed out that legislation to decrease alcohol beverage availability has proven to be a very strong and effective way to keep down damage from harmful drinking when it comes to access to alcohol with clear age limits and retail monopoly.

3.1 What other non-legislative instruments should be used, including impact assessments?

Our opinion is that HIA has by far not yet been utilized to its potential and should be extended effectively, for example to the CAP reforms and proposals affecting older people.

3.2 Will it be useful to introduce processes such as the Open Method of Coordination in health fields?

Only if the intention is absolutely serious and the aim completely transparent. Many health bodies are not properly involved in national consultative processes in existing OMC provisions, and evidence of resulting improvements is limited. Strengthening existing networks or Ec working groups can also offer exchanges: what is needed is commitment to implementation of transferable approaches, and not just European reporting exercises.

4. How can different approaches be used and combined?

Integrated approaches to health aim to improve public health through the collaboration or ‘joining up’ of several policy sectors. However, it should be noted that the integration of policy measures or interventions is more than merely a (often ad hoc) combination of initiatives. Integration also implies bringing together policy measures and interventions in existing structures so that its results are more sustainable.

Integrated health strategies operate via coordinated policy planning, advocacy and generating support, inter-sectoral cooperation, community participation and health impact assessment.

Integration of lifestyle-related health determinants Integrated approaches to health can also be defined at a level of lifestyle-related health determinants only. Traditionally, interventions are directed towards single topics, such as tackling tobacco use, drugs, alcohol, nutrition, sexual health, mental health or physical activity. However, studies have shown that the most effective disease prevention and health promotion strategies are made through a combination of actions that address several determinants of health at the

EuroHealthNet response to EC consultation on a future EU health strategy 6 same time. Findings from a German general population study (TACOS, Schumann et al. 2001) show, for example, that tobacco smoking is related to additional unhealthy behaviours. Smokers are more likely to consume unhealthy foods, report less physical activity and exhibit more hazardous alcohol drinking. The data support the demand for interventions targeting unhealthy behaviours in an integrated way.

Further research is needed to determine whether simultaneous or sequential interventions of health behaviours should be implemented, in which settings combined interventions are applicable and how individuals could be motivated to change a number of health behaviours without being overwhelmed.

Specific Questions - Implementation

5. How can progress be ensured and objectives are met?

Comments from agencies included: - Build up capacity at national and community levels for development, implementation and evaluation of integrated prevention programs. - Promote research on issues related to prevention and management. - Tackle issues outside the health sector which influence control of diseases. - Assess the impact of social and economic development on the burden of the major diseases. - Design those programs with an ongoing monitoring system to ensure that all the requirements and objectives are met.

5.1 Should indicators and milestones be used?

Milestones can be used in terms of resources allocated, capacity building and infrastructures for public health, but also for regulations like smoke-free restaurants and how big proportion of the concerned population that are covered by targeted health promotion and disease prevention programmes.

5.2 What could indicate short term change in the first five years?

- Improved capacity and infra-structure of the public health and health promotion sector in all EU member states. - Improved collaboration with other policy sectors at the European level, national and regional level. - Policy development, concrete initiatives like banning smoking in restaurants, drinking and driving - Improved health information system, indicators being the most feasible source of information.

EuroHealthNet response to EC consultation on a future EU health strategy 7 6. How can it be ensured that the strategy adds value to action at member state level?

The new Strategy must involve all the Ministries of Health which will have to ensure the infrastructure and organizational capacities in order to meet the activities and the objectives of the Strategy.

The strategy should also incorporate clear support mechanisms that allow in-dept exchange and consultation between different Member States, such as twinning, staff exchange, clustering member states for specific actions etc. EU wide projects that include all 27 EU States are not in all cases the best way forward.

Of course, maintaining diversity in a non-homogenous EU is important. Not all states face the same problems at the same time, so flexibility must be factored.

6.1 How can responsibility for implementation be shared between member states and the EU?

The tests of clear added value must be applied.

The key roles of the EU have been fostering democratic stability and socio- economic cohesion. That is what individual states and non-legislative international institutions can not achieve alone, and is where the EU can best play a key part in core, mainstream and global approaches.

7. How could measures for involving stakeholders be improved or innovated?

Engaging stakeholders and creating partnerships must be a continuous developing task as a number of "new" MS still may lack the possibilities to take part in EU consultations and projects due to demanding co-financing of projects, and may also not have, what is an important prerequisite for sustainability, organisations involved that are publicly accountable. Our experience is that networking, provided it has sufficient resources to maintain a 'secretariat function' and facilitate exchange has proven to be productive.

7.1 How can innovative partnerships be formed?

By bottom up growth rather than imposition.

Stakeholder perception audit could be performed in order to improve and develop partnerships- research studies.

Through creating a national strategic partnership forum, voluntary, community and public sector will be helped to work to deliver better health, social care services, contributing to the development of the civil society.

EuroHealthNet response to EC consultation on a future EU health strategy 8 8. Further comments This is a very complex process, and time will be needed to run it in a way that is both inclusive and responsive.

Clive Needle EuroHealthNet

EuroHealthNet response to EC consultation on a future EU health strategy 9 This paper represents the views of its author on the subject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of the Commission's or Health & Consumer Protection DG's views. The European Commission does not guarantee the accuracy of the data included in this paper, nor does it accept responsibility for any use made thereof.