# EUR-Lex - 52013SC0043 - EN

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# 52013SC0043

**COMMISSION STAFF WORKING DOCUMENT Investing in Health Accompanying the document COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS Towards Social Investment for Growth and Cohesion - including implementing the European Social Fund 2014-2020 /* SWD/2013/043 final */**

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Introduction

This document complements the
Commission Communication Towards Social Investment for Growth and Cohesion
by showing how investing in health contributes to the Europe 2020 objective of
smart, sustainable and inclusive growth.[1]

In line with that Communication,
it advocates evaluating and modernising current social policies to optimise
their effectiveness and efficiency. It also highlights the need for better
targeted, individualised and integrated services and benefits. It looks at how
health is incorporated into the main themes of the Communication: making efficiency
gains in budgets, taking action throughout life, ensuring adequate livelihoods,
activating and enabling policies, optimising social dividends and using EU
funds.

It also follows on from the 2013
Annual Growth Survey (AGS)[2]
which recognises the contribution of the healthcare sector to prepare a
job-rich recovery. The AGS also acknowledges the sector’s role in promoting
social inclusion and tackling poverty and recognises the positive effect
modernising its public administration would have. It recommends reforming
health systems to ensure their cost-effectiveness and sustainability and assessing
their performance against the twin aims of providing access to high-quality
healthcare and using public resources more efficiently.

This document establishes the
role of health as part of the Europe 2020 policy framework. It strengthens
the link between European health policies and support for health system reforms
in the context of the European Semester. Investing in health helps the EU rise to
the challenges identified in its Health Strategy[3]
that have been compounded by the economic crisis: an ageing population, an
increase in chronic diseases, a greater demand for healthcare and the high cost
of technological progress.

Health is a value in itself.[4] It is also a
precondition for economic prosperity. People’s health influences economic
outcomes in terms of productivity, labour supply, human capital and public
spending.

Health expenditure is
recognised as growth-friendly expenditure. Cost-effective and efficient health
expenditure can increase the quantity and the productivity of labour by increasing
healthy life expectancy.[5]
However, the relatively large share of healthcare spending in total government
expenditure, combined with the need for budgetary consolidation across the EU, requires
more efficiency and cost-effectiveness to ensure the sustainability of current
health system models. Evidence suggests there is considerable potential for efficiency
gains in the healthcare sector.

Average levels of health have
been improving across the EU for many years. But this hides major
inequalities. Poorer and disadvantaged people die younger and suffer more often
from disability and disease.

In the following sections, ‘investing
in health’ is further developed.

1. Investing in sustainable
health systems combines innovative reforms aimed at improving
cost-efficiency and reconciling fiscal consolidation targets with the continued
provision of sufficient levels of public services.

2. Investing in people’s health as human
capital helps improve the health of
the population in general and reinforces employability, thus making active
employment policies more effective, helping to secure adequate livelihoods and contributing
to growth.

3. Investing in reducing health
inequalities contributes to social cohesion and breaks the vicious spiral
of poor health contributing to, and resulting from, poverty and exclusion.

4. Investing in health through
adequate support from EU funds.

1. 
Investing in
sustainable health systems: Reform and Innovation

Health systems in Europe are
at the core of its high level of social protection and they are a cornerstone
of the European social market economy. The healthcare sector accounts
for 8 % of the total European workforce and for 10 % of the EU’s GDP.[6] The large
share of healthcare costs in the EU raises the issue of cost-effectiveness and the
financial sustainability of health systems. The problems caused by the economic
crisis, coupled with more structural changes in demography and the types of
diseases affecting populations in Europe, reinforce the necessity to reform and
modernise those systems. The EU can help Member States do so, to improve cost-efficiency
through sound innovation and contribute to a better assessment of the
performance of health systems.

1.1.  Sustainability of health systems

Health is an important part of
public budgets.
It represents almost a third of social policy budgets. Public expenditure accounts
for almost 80 % of healthcare budgets. In 2010, public spending on
healthcare accounted for almost 15 % of all government expenditure. In the
decade before the crisis, it was one of the fastest growing spending items for
governments in almost all Member States,[7]
considerably outpacing GDP growth. Public expenditure on healthcare and long-term
care is expected to increase by one third by 2060. This is due to a number of
factors. On the demand side, it is chiefly due to population size and
structure, its health status, individual and national incomes and provisions
regulating access to healthcare goods and services. On the supply side, the
increase is driven by the availability of and distance from health services,
technological progress and the framework regulating the provision of goods and
services.[8]
The relatively large share of public healthcare spending in total government
expenditure, combined with the need to consolidate government budget balances across
the EU, underscore the need to improve the sustainability of current health
system models. Ensuring efficiency and making the provision of health services more
cost-effective and efficient is crucial if countries are to ensure universal
access to and equity in health services and their adequate and sustainable
financing.[9]
It is therefore essential to address the financial sustainability of health
systems to ensure they are sustainable in terms of continuity of service,
universal coverage and a high level of quality.

Financial sustainability may
require budgetary cuts, including cuts in healthcare budgets. Several Member States also
need to curtail health costs in the short term. As part of policy responses to
the economic crisis between 2007 and 2011,[10]
some Member States reduced their healthcare budgets: Bulgaria, Estonia,
Hungary, Ireland, Italy, Greece, Latvia, Romania, Portugal and Spain. However, sudden
significant reductions in healthcare budgets risk creating new inefficiencies,
undermining access to and the quality of care, damaging health outcomes and
ultimately jeopardising the sustainability of the health system even more by
increasing costs. A careful assessment of these measures should shed light on
what policies are effective in the short and long terms.

Evidence shows that the
relationship between healthcare expenditure and health outcomes is not linear.
If it were, any additional euro spent on healthcare would result in a
corresponding improvement in the population’s health status (measured, for
instance, in terms of healthy life expectancy). In reality, the greater the expenditure,
the lower the marginal improvement in health status as a result of its increase.[11] Countries also
vary significantly in their ability to translate a similar level of resources
into health outcomes. International comparisons show that the same amount of
per capita healthcare expenditure can be associated with very different health
outcomes even after taking into account the differences in lifestyle and
socio-economic realities among countries[12].

It is not only how much money is
spent, but also how it is spent, that determines a country’s health status. Present budget constraints
should therefore be used as an opportunity to improve the value and effectiveness
of healthcare spending.[13]
Health system reforms and improvements in the relative allocation of money can
contain public spending and could result in large savings. The OECD has valued these
savings at 2 % of GDP on average by 2017 for OECD countries.[14]

At EU level, the Council has recognised
the need to tackle these economic and budgetary difficulties by reforming
health systems, while balancing the need to provide universal healthcare[15] and take
account of their implications in all relevant fields of EU economic policy
coordination.[16]

1.2. 
 Helping Member States
design reforms and improving the efficiency of health systems

Comparative international
analysis shows that there is significant room for efficiency gains in health
systems.[17] The Council has confirmed
this, noting that in many Member States there appears to be scope to improve
the population’s health status without increasing health spending.[18] Member States should try to
reap those gains by introducing efficiency-enhancing measures as part of the
overall prioritisation and evaluation of public expenditure and in the context
of the European Semester. This would help reconcile financial consolidation
targets with the continued provision of sufficient levels of public services.

The Commission and the
Economic Policy Committee identified a number of areas where structural reforms
and efficiency gains could improve the sustainability of health systems:[19]

o 
encouraging
more cost-effective provision and use of health services through
adequate incentives; this could involve

§ 
using
financial incentives to encourage patients to register with a general practitioner
(GP) or family doctor and using a referral system[20] to define a cost-effective
path of care: from GP, to outpatient specialist, to hospital, to emergency care,
while encouraging patients to have less recourse to unnecessary care and
emergency services;

§ 
introducing
activity- and/or quality-based payment for diagnosis-related groups of cases or
for hospital financing that, for example, increases the use of day surgery instead
of in-patient surgery when this is not necessary;

o 
ensuring a
balanced mix of staff skills and anticipating staff needs due to ageing;
this could include

§ 
improving
staff motivation through non-financial aspects (working conditions, career
advancement etc.) and encouraging continuous professional development;

§ 
addressing
the uneven distribution of health staff across regions and developing human
resources planning mechanisms to address skill mix shortcomings[21] (see Section 2.1 on employment
in the health sector);

o 
reducing
the unnecessary use of specialist and hospital care while improving primary healthcare
services; improving access to primary care for certain population groups could
include increasing the number of training posts and making general practice more
attractive or developing new roles for other healthcare providers, such as
advanced practice nurses, and encouraging the relocation of general
practitioners to areas where there is a shortage of them;[22]

o 
better
health promotion and disease prevention in and outside the health sector; this could include measures
designed and implemented jointly with other sectors that have a major impact on
health, such as education, housing, environment, employment[23] (see Section 2.3 on health
promotion and Section 3 on health inequalities);

o 
improving
data collection and
using available information to underpin the improvement of the performance of
health systems; in particular the collection of health data using the European
Community Health Indicators (ECHI) and developing tools to better assess the
efficiency of health systems (see Section 1.4 on health systems performance
assessment);

o 
using
health technology assessment more systematically for decision-making processes (see Section 1.3 on health technology
assessment);

o 
ensuring
the cost-effective use of medicines; this includes increasing the use of
less expensive equivalent (generic) drugs[24] for example through pricing measures
(price limit, lower cost-sharing rate), their prescription, or facilitating
their access to the market, as well as improving the assessment of the effectiveness
and cost-effectiveness of medicines in general and better informing patients,
healthcare staff and insurers about their use and misuse;

The recommendations above from
the Commission/EPC report of 2010 are consistent with the WHO’s ‘ten leading
sources of inefficiency of health systems’[25] and the OECD’s
recommendations for health system reform.[26]

Health
system reform is also addressed:

As
  part of the European Semester, Member States have started to
  include health systems reform in their National Reform Programmes.[27] Following the 2012 Annual
  Growth Survey,[28] six country-specific recommendations
  on health [29] were issued for Austria
  (implementing reforms to improve the organisation, financing and
  efficiency of healthcare), Belgium (improving the long-term sustainability
  of public finances by curbing age-related expenditure, including health
  expenditure), Bulgaria (doing more to improve the quality of public
  spending, particularly in the education and health sectors), Cyprus (completing
  and implementing the national health system), Germany (continuing growth-friendly
  consolidation by doing more to improve the efficiency of public spending
  on healthcare and long-term care) and the Netherlands (implementing the
  planned reform of long-term care, aimed at separating the costs of medical
  care from the costs of assisted living, and complementing it with other measures
  to contain the increase in costs). The 2013 Annual Growth Survey
  recommends reforming health systems to ensure their cost-effectiveness
  and sustainability and assessing their performance against the twin aims
  of providing access to high-quality healthcare and using public resources more
  efficiently.[30]
 In
  a reflection process as a follow-up to Council conclusions of 2010,
  Member States are currently identifying effective ways of investing in
  health for modern, responsive and sustainable health systems. In this
  context, by the end of 2013, conclusions will be drawn on the following  areas
  of focus of the reflection process: health in the context of the Europe
  2020 Strategy and the European Semester; success factors for the effective
  use of Structural Funds for health investments; responses to health system
  challenges, in particular in relation to integrated care and the use of
  pharmaceuticals; measuring and monitoring the effectiveness of health
  investments.[31]

To
support these processes, the Commission is setting up a multisectoral,
independent expert panel to advise on effective ways of investing in
health[32] and commissioned a number of studies
on forecasting EU pharmaceutical expenditure,[33] external reference pricing of
medicinal products, reimbursement systems of medicinal products, the economics
of primary healthcare financing and the evaluation of public-private
partnerships in healthcare delivery.[34]

1.3. 
 Improving cost-efficiency through sound innovation

New technologies are
widely acknowledged as an important tool for boosting innovation. Technological
developments can change ways of delivering and organising the provision of
health services and goods and, under certain conditions, help increase
cost-efficiency. They can however be expensive to buy and operate and may be
used inappropriately. Innovations in medical technology are considered one of
the primary drivers of healthcare spending. The introduction of innovative
technological solutions should therefore be thoroughly assessed in terms of their
potential to improve efficiency and productivity.[35]

Health Technology Assessment (HTA) is the main tool developed to assess and
support the cost-effective use of new technologies and innovation in healthcare.[36] It is a multidisciplinary
process firmly rooted in research and the scientific method that summarises
information about the medical, social, economic and ethical issues related to
the use of a health technology in a systematic, transparent and unbiased manner.
It is an essential tool for informing decision-makers and assessing the value
of specific actions or technologies, thus reducing the risk of implementing
measures that negatively affect patient outcomes.

At EU level, the Commission has been helping
Member States exploit the full potential of HTA by fostering cooperation that
will pool expertise and prevent the duplication of work as set out in the
Directive on the application of patients’ rights in cross-border healthcare, through
the European network for health technology
assessment.[37]

Health
Technology Assessment examples

In Austria
and Norway, Health Technology Assessment was used to assess the introduction of
the HPV vaccine in national vaccination programmes. Although the two countries had
similar views on the effectiveness of the measure, other context-specific
considerations, such as different cost considerations, led to different
decisions regarding uptake.

In the UK, the
National Institute for Health and Clinical Excellence (NICE) issues recommendations
based on HTA. One such recommendation is based on the comparison of different
medicinal products used as the primary way of preventing osteoporosis. This
kind of report provides guidance on what products would be the preferred choice
in different settings, based on a cost-effectiveness analysis. It thus serves
as guidance for general practitioners in their practice, helping to avoid
unnecessary, costly treatments.

In Poland,
the Agency for Health Technology Assessment (AHTAPol) was established in 2005
as an advisory body to the Ministry of Health. It prepares recommendations on
financing all healthcare services from public funds, notably on the drug
reimbursement list (available in pharmacies); therapeutic drugs programmes (expensive,
innovative drugs) and the hospital chemotherapy drug reimbursement list; non-drug
technologies (medical devices, surgical procedures etc.); national and local government
healthcare programmes. This allows for a more holistic approach to the use of
limited public health budgets, taking the cost-effectiveness of different
treatments into account.

E-health covers the range of tools that can be used to
assist and enhance prevention, diagnosis, treatment, monitoring and management concerning
health and lifestyle. It is often perceived as substantially increasing
productivity, and therefore as an instrument to support the reform of health
systems. Examples of successful e-health developments include health
information management and networks, electronic health records, telemedicine
services, wearable and portable monitoring systems and health portals. Developing
and deploying new technologies is a long-term endeavour. European research
programmes have been supporting the development of e-health for the last 15 years.
They have established a number of best practices that could be successfully replicated,
for example e-health applications improving quality of life and reducing
hospitalisation to the benefit of citizens, their families and those involved in
providing services.[38] Support for the
interoperability of health systems within and across national boundaries will improve
the mobility and the safety of patients even more by ensuring continuity of
care and innovation.

The Commission also contributes
to e-health through a range of actions and instruments, such as the Action Plan
on e-Health[39] and the newly created EU e-Health
Network, as part of the implementation of the Directive on the application of
patients’ rights in cross-border healthcare.[40]

E-health
project example

The
delivery of e-prescriptions in Sweden is a joint initiative between each
county council and Apoteket, Sweden’s national pharmacy. Via Sjunet, the
Swedish Information and Communication Technologies (ICT) network for healthcare,
or using web-based prescriptions, 42 % of all prescriptions are electronically
transferred from the doctor to the pharmacy. E-prescriptions increased the security
and quality of prescriptions and reduced medication errors by 15 %. They also
enabled healthcare providers to save a lot of time. Patients benefited from a dedicated
drug information hotline which improved their knowledge and safety and their flexibility
to obtain their drugs in any pharmacy. The economic evaluation of the case-study
on e-prescriptions in the Stockholm region showed that this electronic service
generated an estimated annual net economic benefit of over € 95 m in
the eight years of its implementation. Five years after planning and
development began, the net benefit was approximately € 27 m. This is
impressive, given the relatively low spending on ICT of less than € 4 m
for the whole period of eight years. Healthcare provider organisations get 80 %
of the benefits, mainly from time savings and avoided costs of providing the
same timeliness, convenience and reduction in errors without e-health. Citizens
get the remaining 20 %, chiefly through more safety thanks to correctly
issued prescriptions and better adherence to treatment.[41]

1.4.  Developing tools to better assess the
efficiency of health systems

Increasing the return on health
investments requires a solid assessment of the efficiency and effectiveness
of spending. Such an assessment faces three main methodological challenges.

The first is to verify that
the evidence of efficiency gains and improvements in health obtained through
better use of healthcare budgets remains valid when different definitions of
health outcomes are used.[42] A major problem is that much
of the evidence focuses on crude measurements such as life expectancy, failing
to consider the quality of the years of life gained. This is more clearly
brought out by concepts such as Disability Adjusted Life Years (DALY), or
Healthy Life Years (HLY).

The second challenge is to
disentangle the relative influence of health systems on health outcomes from
the impact of other determinants of population health, especially living and
working conditions, income, education and the most common lifestyle-related
risk factors

The third is the time lags
between policy changes and their impact on health outcomes,[43] a problem that may involve ‘false
savings’ because they may lead to increased costs or other unintended
consequences in the long term.

Further assessment of the
efficiency of health systems therefore requires a refined analytical framework, structured along three axes:

(1) 
the
definition of sound, reliable indicator(s) of health outcomes, building on the
existing European Community Health Indicators,

(2) 
a better
understanding of the effects of health systems on health outcomes, as distinct
from the impacts on health of other factors such as health determinants and
lifestyles, and

(3) 
a better
understanding of the mechanisms, and therefore the timing, of how health
policies affect health outcomes.

The Commission will continue to
support the work of Member States by improving the knowledge and evidence
on health expenditure and health outcomes in the achievement of structural
reforms. It will do so by working towards a sustainable health monitoring
system in Europe, using the European Community Health Indicators (ECHI),[44] by developing a sound
methodology for Health System Performance Assessment and by assessing
the cost-effectiveness of health systems through Life Table Analysis. It will
also do more to provide much-needed information on the breakdown of expenditure
per disease in the EU.[45]

2. 
 Health as an
investment in human capital

Cost-effective and efficient health
spending is a productive or growth-friendly type of expenditure. It helps increase the
economy’s production assets (labour, capital and knowledge). It increases the
quantity and the productivity of labour by increasing healthy life expectancy.[46]Investing in the health of
people of working age and enabling people to remain active and in better health
for longer helps optimise the ‘social dividend’. Investing in health also helps
limit future costs related to the treatment of preventable diseases. And
finally, investing in health also means investing in an efficient health
workforce[47].

2.1.  Contributing to employability and enabling
people to remain active for longer

The health status of
individuals strongly influences their labour market participation. For example, early labour
market exit is often the result of health-related problems.[48] Depression, musculoskeletal
diseases and unhealthy lifestyle factors (e.g. obesity and physical inactivity),
are associated with reduced on-the-job productivity. Evidence suggests that
ill-health in the population of working age leads to substantial productivity
losses. Poor health leads to
absenteeism (estimated absenteeism rates range between 3 % and 6 % of
working time, representing a yearly cost of about 2.5 % of GDP[49]), job loss (10 % of the
people who were previously employed left their job mainly for health reasons),
premature retirement or premature mortality. Almost a quarter (23.5 %) of
the people currently employed suffer from a chronic condition and have their
daily activities restricted.[50]

This adverse effect of
ill-health is most significant in the later stages of life, when it
contributes to a marked decrease in participation in the workforce. In 2010,
the employment rate of people over 65 was 4.7 %, that of people aged 60-64
was 30.5 % and that of people aged 55-59 was 60.9 %.[51] Elderly people are much more
likely to suffer from multiple diseases (co-morbidity). This has significant
human and economic implications and increases the pressure on health systems
and social care structures in terms of demand for care[52].

Longer lives are not lived
without disability. Europeans are expected to live on average almost 20 years
with an activity limitation. The levels of healthy life expectancy in the EU
are at 62.2 healthy life years (HLY) for women and 61 HLY for men,[53]

It is therefore possible to
boost economic growth by improving the health status of the population and
enabling people to remain active and in better health for longer Access to
quality health care is a constituent part of the maintenance of a productive
workforce and an integral part of the flexicurity setup[54]. There is scope for creating
a cycle in which improvements in health and prosperity are mutually reinforcing.[55] Improving the population’s
health status leads to positive economic outcomes. An OECD study estimates
that for every year of increase in a population’s life expectancy GDP could go
up as much as 4 %.[56] Occupational health plays a
key role in that context.

However, the potential
benefits from health investments through increased population employability are
currently not understood well enough. The current cost of occupational
accidents and work-related diseases amounts to between 2,6-3,8% of EU GDP[57]. Poor working conditions
impact not only on the work-force employability, but also on the sustainability
of national healthcare systems. By reducing the workers' exposure to risk
factors, well-designed OSH-policies increase productivity and limit the cost of
work-related accidents and ill health.  European regulation and strategies 
have helped reduce the incidence of accidents  and have played an important
role in preventing occupational diseases. However, there is a continuous need to
improve the workplace environment by investing in prevention of accidents and
diseases caused by work.  It should also take into consideration the economic
context of the labour market in question. For example, musculoskeletal
conditions would have a greater impact on the ability to work and on employability
in the blue-collar manual jobs industry than in the white-collar service sector.

One example of a tool to
assess the effect of alternative policy outcomes on long-term social
expenditure is the social expenditure projection model (SOME[58]) developed in Finland. Explicit
consideration is given to the impact of population health and beneficial
employment effects. This way, future benefits associated with health
investments can be better understood.

Health
status of individuals and labour market participation: example of diabetes type
2

A striking
example of how prevention can increase labour market participation is the
avoidable negative effects of diabetes type 2, which currently affects 7 %
of Europeans. A French longitudinal study[59] found that diabetes type 2 patients
lost an estimated mean time of 1.1 year in the workforce between the ages of 35
and 60.

More
generally available statistical data[60] seem to show that chronic
conditions have an important impact on several dimensions of social inclusion.
Comparing to a healthy individual, the impact of diabetes type 2 for a 50-year
old single man is significant. It represents almost 3 % of career lost (in
terms of years of working life). It also has significant individual
consequences, as it shortens the lifespan by 2.3 % and increases the
chance of being at risk of poverty by more than 5 %.

Another way to enable people
to remain active and in better health for longer is to help people with chronic
conditions that do not require hospitalisation to function actively in society
and at home by empowering them to take care of their health in close
collaboration with healthcare providers. Learning to manage their own condition
should help people to remain integrated in society and the workforce.

The idea of patient
empowerment is often considered an important and promising aspect of
chronic disease management, that can help people lead more proactive and
fulfilling lives. Some evidence suggests that self-management (supported for example
by e-health applications[61]) can be effective through
behavioural change, especially for people with long-term conditions. It may improve
their health status and reduce their drug treatment costs and the time they spend
in hospital.[62] Empowerment should not
substitute professional acute care. However, various patient empowerment models
can be applied. More research needs to be done to assess the efficiency and
efficacy of these models, and find out how to reach and include specific target
groups such as vulnerable populations.

The European Innovation
Partnership (EIP) on Active and Healthy Ageing will help citizens to lead healthier, more
active and independent lives while ageing. It aims to increase the number of healthy
life years of Europeans by two years by 2020. It applies an innovative approach
to policy‐making in the EU by bringing together key stakeholders (end users,
public authorities, and industry) and providing a forum for cooperation, the
identification of potential innovation barriers and the mobilisation of funding
instruments. It aims to improve the framework conditions for the uptake of
innovation, leveraging financing and investments in innovation and improving
coordination and coherence between funding for research and innovation at
European, national and regional level in the European Union.

The EIP focuses on the
following areas throughout a person’s life: prevention, screening and early
diagnosis; care and cure; active ageing and independent living. Between now
and 2015, 261 commitments, made by over 3 000 stakeholders and grouped in six
action plans, will be implemented, focusing on the following:[63]

· 
prescription
and adherence to treatment;

· 
personal
health management, starting with an initiative to prevent old people from
falling;

· 
prevention
and early diagnosis of functional decline and frailty;

· 
replicating
and tutoring integrated care for chronic diseases, including remote monitoring;

· 
developing
interoperable independent living solutions, including guidelines for business
models; and

· 
innovating
for age-friendly buildings, cities and environments.

Example
of a project developed under the European Innovation Partnership on Active and
Healthy Ageing — Feelgood Factory Agenda

This project
helps people to monitor their health and receive advice through the television.
Results show that patients who were in and out of the hospital every week now
go to the hospital only once or twice a year.

Liverpool
Primary Care Trust (PCT) in the UK is the Feelgood Factory Agenda’s lead partner.
Much of the focus is on people who are older and have long-term conditions (143 000
in Liverpool). One hundred and fifty ‘community health champions’ have been
recruited to design packages for people with long-term conditions. The packages
include lifestyle advice, self-management advice and equipment. Voluntary
champion roles might motivate people to work in the emergency care sector, or
up-skill unemployed people. Liverpool PCT will target 50 000 members, 3 500
users of telehealth, 5 000 users of Life Enhancing Technologies (LETs) and
3 500 users of integrated LETs and social services. Financial and human
resources allocated to the initiative include a € 21 million programme, consisting
of a direct financial contribution of € 15.6 million and € 6 million in
human resources, expertise, the provision of equipment and the use of existing
services and infrastructure.

The following areas have
proved particularly important in bringing about added value in improving
cost-effectiveness and efficiency in health care and t the Commission intends
to continue to pursue action to[64]

support research into the
  effects of health investments on employability; better understanding the
  relationship between the two could facilitate the identification and
  exchange of good practice;
 contribute to the practical
  understanding of patient empowerment and support exchanges of
  experience in this field by launching a mapping of current policies and
  evidence; such a mapping would clarify the scope of patient empowerment
  and identify potential advantages and barriers.
 continue to encourage cooperation
  in the European Innovation Partnership on Active and Healthy Ageing.

2.2.  Promoting good health

Tackling the problem of chronic
diseases and addressing the main risk factors that determine population health
will help increase people’s employability and enable them to stay longer in the
workforce. The human and economic burdens of chronic diseases can be contained
by devoting resources directly or indirectly to prevention, screening,
treatment and care. It is important to do so by targeting the different age
groups throughout their lives.[65]
A large amount of health spending, including in particular disease
prevention and health promotion, is regarded as an investment that yields a
handsome rate of return.[66]
Focusing on disease prevention can reduce high long-term treatment
costs and improve health outcomes by avoiding tens of thousands of premature
deaths and chronic diseases.[67]
However, little relative importance is currently given to health promotion in
budgetary terms. Only about 3 % of current health expenditure is allocated
to public health and prevention programmes. In other words, most Member
States do not use the opportunities for substantial gains in prevention and
health promotion, particularly through the health-in-all-policies approach,
which aims to influence the environmental, economic and social determinants of
health. Given the potential to contain the burden and cost of disease in the
long term, the importance given to disease prevention and health promotion
should be reassessed.

A recent study[68] showed that
evidence-based workplace interventions to promote mental health could help save
up to € 135 billion a year by reducing absenteeism and early retirement.

There is a wide array of
health promotion and disease prevention measures authorities can and should
make use of in many different settings (at work, at school and in health
institutions). These range from public information campaigns in the media,
excise taxes on certain products such as tobacco or alcohol, bans and stricter regulation
on labelling, advertising and selling, to health education on school curricula and
financial incentives for consumers, patients and providers.[69]

The World Health Organisation
has also identified a number of ‘best buys’ in chronic non‐communicable disease
prevention: incentive fiscal measures, food product reformulation, detection
and treatment of those at high risk of a heart attack, including early
detection and treatment of high blood pressure.[70]

The Member States began a reflection
process aimed to identify innovative approaches to address chronic diseases.[71] This could
include setting up best practice mechanisms at EU level to identify, validate
and disseminate good practice and information on policies  and measures to
tackle the problem of chronic diseases, including the development of quality
control instruments. The reflection process on chronic diseases is expected to yield
conclusions by the end of 2013.[72]

2.3. 
Employment in the
health sector

Investing in health also means
investing in the health workforce. The health and social work sector[73] has in recent years been the
single largest contributor to employment, accounting today for about 10 %
of employment. The sector also generates high-skilled jobs. Almost 40 % of
workers in the health and social work sector have tertiary qualifications. This
is much higher than the 26 % average across all sectors.[74] While the European Union lost
more than two and half million jobs between 2008 and 2011, the sector generated
over 2.8 million new jobs during the same period. Population ageing is likely
to increase that trend. Assuming a constant share of labour in this area, this
would mean a regular increase of up to eight million job vacancies by 2020,[75] although the impact of health
reforms and organisational and technological changes on staff needs remains
uncertain. The 2013 Annual Growth Survey highlights the potential that can be tapped
in this sector, through a future-oriented, reliable legal framework, the
development of adequate skills and targeted, fiscally sustainable public
support.[76]

Nevertheless, as part of the
process of modernising public administration, the possible increase in
employment in the health and social work sector must be carefully balanced
against the potential increase in public expenditure on health and overall
public expenditure and must not compromise the attainment of fiscal
sustainability. Future needs related to an ageing population must be met by
exploiting the extensive margin for efficiency gain and better productivity.

The Action Plan for the EU
health workforce, which is part of the Employment
Package of Spring 2012 "Towards
a Job Rich Recovery"[77] supports cooperation to help
improve workforce planning and forecasting and the recruitment and retention of
health professionals. An EU joint action[78] on forecasting health
workforce needs for effective planning in the EU will create a partnership of
Member States and professional organisations to share good practice and develop methodologies.

3. 
Reducing inequalities
in health

Health outcomes vary
considerably within and between Member States. In 2010, the gap in life expectancy at
birth between the highest and lowest values for EU-27 Member States was 11.6
years for males and 7.9 years for females. People with a lower income and less education
die younger and their health is worse. For example, differences in life
expectancy at age 30 between those in higher education and those with basic
secondary education or less exceed 10 years in many Member States.[79]

Across the EU the level of
disability, in terms of reported restrictions on daily living activities, is
more than twice as high in the lowest income quintile as in the highest income
quintile.[80] Even larger health
inequalities exist for some vulnerable groups such as some ethnic
minorities (Roma) and some migrant groups.

These health inequalities
represent not only a waste of human potential, but also a huge potential
economic loss
— conservatively estimated at between 1.5 % and 9.5 % of GDP
according to a report written for the Commission.[81]

Reasons for these differences
include barriers in access to healthcare, which is often worse for disadvantaged
groups/ persons in vulnerable situations[82] and in less wealthy Member States,[83] as well as
poorer diets, housing, living and working conditions, and higher levels of
health-damaging behaviours. The impact of the current crisis on these factors
threatens to increase health inequalities between social groups and between
Member States.

As stated in the 2013 AGS, ‘additional
efforts are needed to ensure the effectiveness of social protection systems in
countering the effects of the crisis, to promote social inclusion and to
prevent poverty’, including by providing broad access to affordable,
high-quality health services.[84]
Investments to reduce inequalities in health should therefore also make a
positive contribution towards reaching the Europe 2020 poverty and social
exclusion target.

A multisectoral approach is
required, with a focus on achieving greater gains in less advantaged groups
than the average in order to close gaps.[85]
Key measures are to prioritise less advantaged groups in policies to improve
the quality of and access to health systems, to address the underlying risk
factors in health behaviours and to ensure adequate incomes and living and
working conditions.[86]
Such measures are underpinned by the fundamental values and commitments the EU
and its Member States have agreed on with regard to human rights, equal
opportunities, social and economic cohesion and solidarity. Specific EU action
on health inequalities is set out in the 2009 Commission Communication on
health inequalities, Solidarity in Health. A progress report on the
health inequalities situation and the actions set out in the Communication will
be published in 2013.

Data on the effects of social
transfers on the at-risk-of-poverty rate suggests that healthcare plays a
significant role in reducing the at-risk-of-poverty rate. Access to
affordable healthcare is therefore necessary for adequate livelihoods. Fiscal
consolidation measures applied to health systems should not compromise the access
of poor, vulnerable populations to high-quality healthcare.

According to a study of policy
responses to the economic crisis,[87]
several countries have increased user charges for essential services, while in
some cases also allowing more income-based exemptions.[88] Given that
vulnerable populations are already disproportionately affected by the economic
crisis and that ill health has negative outcomes on employability, possible effects
on those populations should be carefully assessed. Healthcare coverage can help reduce
poverty. Measures
such as those that increase co-payments risk aggravating the economic hardship
borne by vulnerable populations by reducing access to healthcare.[89]

Increasing
knowledge of the effects of healthcare coverage on poverty, as measured at household
level, should take the following into account.

· 
Evidence suggesting
that a large amount of total spending on healthcare during a person’s life is
concentrated in the final year(s) of life.[90] Health expenditure comparisons between
individuals would therefore ideally be based on lifetime analyses and not be
limited to a given year.

· 
The
inherent complexity of interactions among several causal factors and variables,
such as the likelihood of similarity in the socio-economic backgrounds of
spouses and feedback loops in causal pathways between health and poverty.

Good
practice example — analysis of the redistributive impact of public health
expenditure

A 2011 paper
by Spadaro et al.[91]
shows how data collected for the Eurostat Survey of Income and Living
Conditions (SILC) can be used to analyse the redistributive impact of public
health expenditure in Spain. This is done using an insurance value approach to take
account of the effect of healthcare expenditure on household budgets. The
equivalent household income complemented by public healthcare coverage is
assessed and compared with household disposable income. It is found that public
healthcare coverage is likely to keep families out of poverty. Extending the
analysis to incorporate the household income foregone due to healthcare-related
tax transfers would allow the net impact of public healthcare coverage to be
estimated in terms of the percentage of poverty avoided. This could be calculated
as the added number of covered residents that would fall below a given poverty
threshold in the hypothetical absence of healthcare coverage.

Spain
recently introduced reforms of its co-payment system for medicines.  The
reforms take into account the redistributive impact of the co-payment system by
linking it to the level of income, thus making it more progressive.

The Commission will continue
to support measures to address health inequalities within and between Member
States by implementing the 2009 Communication Solidarity in Health:
Reducing Health Inequalities in the EU.[92] It plans to increase
knowledge and evidence to facilitate the exchange of best practice and share
understanding of the effects of health investments on social exclusion and
poverty reduction. This must include tackling the methodological difficulty of
valuing benefits in kind.

4. 
     European financial
instruments for investing in health

As a follow-up to the current EU
Health Programme, and as part of the Multiannual Financial Framework
2014–20, the Commission put forward a proposal for a new Health Programme. It
strengthens the link between economic growth and a healthy population and is
geared towards measures in line with the Europe 2020 objectives. The programme has
four objectives:

· 
to contribute
to innovative and sustainable health systems;

· 
to increase
access to better and safer healthcare for all EU citizens;

· 
to promote
good health and prevent diseases by addressing the risk factors of most
diseases;

· 
to protect
people from cross-border health threats.

The EU’s Cohesion Policy
and its funds[93]
are also powerful instruments to help Member States invest in sustainable,
innovative and reformed health systems, in people’s health for employability
and in reducing health inequalities. The Member States allocated over five
billion euro on health infrastructure from 2007 to 2013. Using structural funds
for non-direct health investments such as urban regeneration, transport,
environment, employment, social inclusion and housing can also have positive
impacts on  population’s health.[94]

The Commission proposals for
the next programming period (2014–2020) provide for the support of the Cohesion
and Structural Funds to the Member States’ investments in health. Health is
also included in most of the thematic objectives of the Common Strategic
Framework.[95]
The EU Cohesion and Structural Funds should co-finance investments in health by
the Member States that follow a coherent, strategic policy approach by

· 
investing in
health infrastructure that fosters a transformational change in the health
system, in particular reinforcing the shift from a hospital-centred model to community-based
care and integrated services;

· 
improving access
to affordable, sustainable and high-quality healthcare, in particular with a
view to reducing health inequalities between regions and giving disadvantaged
groups and marginalised communities better access to healthcare;

· 
supporting
the adaptation, up-skilling and life-long learning of the health workforce;

· 
fostering active,
healthy ageing to promote employability and employment and enable people to
stay active for longer.

The
Seventh Framework Programme  and the EU programme for research and innovation
for 2014 to 2020 (Horizon 2020)[96] also provide financial opportunities to
address the societal challenge of an ageing population and harness innovation in
public health and the management of health systems.

Conclusion

Getting
more value for money through reforms and investments is crucial. Investing in health
can lead to smarter spending — not more spending — that brings savings or
secures better health outcomes. It may take different forms, such as change in the
management of care to improve efficiency while improving health outcomes,
investment in healthcare staff, training or equipment and initiatives to
promote good health and prevent diseases.. The avoidable morbidity and
mortality underlying health inequalities represent a waste of human capital that
must be reduced.

Universal
access to safe, high-quality, efficient healthcare services, better cooperation
between social and healthcare services and effective public health policies to
prevent chronic disease can make an important contribution to economic
productivity and social inclusion. Reforms complemented by the above mentioned targeted
investments should foster cost-effective innovation to achieve good health
outcomes and aim to avoid increasing disease and financial burdens in the long
term. Financial consolidation and structural reform of health systems must go
hand in hand to continue delivering on public policy goals and ensure that
efficiency gains will guarantee universal access and increase the quality of healthcare.
They should be addressed as part of the wider agenda of structural reforms
within the context of Europe 2020 and the European Semester.

[1] Commission
Communication, Europe 2020 Strategy — COM(2010) 2020, 3.3.2010.

[2] Commission Communication,
Annual Growth Survey 2013 — COM(2012) 750 final, 28.11.2012 .

[3] Commission White Paper ‘Together for Health: A Strategic Approach
for the EU 2008-2013’ COM(2007) 630 final, 23.10.2007.

[4] Council
Conclusions on Common Values and Principles in European Union Health Systems,
OJ 2006/C 146/01, 22.6.2006.

[5] Commission,
Directorate-General for Economic and Financial Affairs (2012), The Quality of
Public Expenditures in the EU, European Economy, Occasional Papers 125,
December 2012

http://ec.europa.eu/economy_finance/publications/occasional_paper/2012/pdf/ocp125_en.pdf
.

[6] Its size
varies widely between Member States: above 11 % of GDP in Austria, Denmark,
France, Germany and the Netherlands; below 7 % of GDP in Estonia, Latvia
and Romania.

[7] Health
spending grew by nearly 5 % per year in real terms in OECD countries from
2000 to 2009, but this was followed by zero growth in 2010, as several countries
started implementing budgetary cuts. In fact, health spending per capita
started declining in 2009 for countries that were hardest hit by the economic
crisis (OECD Health Data 2012). See       http://www.oecd.org/document/39/0 3746,en_21571361_44315115_50655591_1_1_1_1.00.html
.

[8]
Commission-EPC (2012), The 2012 Ageing Report: Economic and budgetary
projections for the 27 EU Member States (2010-2060). The report projects an
increase between 2010 and 2060 of 2.6 % of GDP (percentage points) for
public expenditure on healthcare and long-term care, a proportional increase of
around 29.2 % compared to the 2010 reference level of 7.9 % of GDP.
See  http://ec.europa.eu/economy_finance/publications/european_economy/2012/pdf/ee-2012-2_en.pdf.

[9]
Directorate-General for Economic and Financial Affairs (2012) The Quality of
Public Expenditures in the EU, European Economy, Occasional Papers 125,
December 2012

http://ec.europa.eu/economy_finance/publications/occasional_paper/2012/pdf/ocp125_en.pdf.

[10] WHO (2012)
Health policy responses to the financial crisis in Europe, WHO Policy Summary 5
http://www.euro.who.int/__data/assets/pdf_file/0009/170865/e96643.pdf.

[11] See for
instance Joumard et al. ‘Health Care Systems: Efficiency and Policy
Settings’, OECD, 2010.
http://search.oecd.org/officialdocuments/displaydocumentpdf/?cote=eco/wkp(2010)25&doclanguage=en

[12] See for instance Joumard I., Andre, C. and C, Nicq, ‘Health care
systems - efficiency and institutions’, OECD, 2010, Working Paper No. 769. http://www.oecd.org/eco/economicsdepartmentworkingpapers.htm

[13] Better
implementation of policies could also result in large savings, as fraud and
avoidable errors are estimated to represent an annual loss of 5.6 % for
healthcare budgets. See European Healthcare Fraud and Corruption Network (2009) ‘The financial
cost of Healthcare fraud’ http://www.ehfcn.org/media/documents/The-Financial-Cost-of-Healthcare-Fraud---Final-(2).pdf.
Please note that the savings achieved through better implementation are not
additional to the figure on potential savings given below.

[14] OECD,
Economics Department IMF conference, 21 June 2011 ‘Public Health Care Reforms:
Challenges and Lessons for Advanced and Emerging Europe. See: http://www.imf.org/external/np/seminars/eng/2011/paris/pdf/Joumard.pdf.

[15] Council Conclusions on the Joint Report on Health Systems in the
EU, 3054th Council meeting, Economic and Financial affairs, 7.12.2010.

[16] Council Conclusions on the sustainability of public finances in the
light of ageing populations, 3167 Council Meeting, Economic and Financial
Affairs, 15.5.2012.

[17] Commission, Directorate-General for Economic and Financial Affairs
(2012) The Quality of Public Expenditures in the EU, European Economy,
Occasional Papers 125, December 2012.

[18] Council Conclusions on the Joint Report on Health Systems in the
EU, 3054th Council meeting, Economic and Financial Affairs, 7.12.2010.

[19] Joint Report on health systems prepared by the European Commission
and the Economic Policy Committee, European Economy. Occasional Papers. 74.
December 2010; and 3054th Council meeting Economic and Financial Affairs
Brussels, 7.12.2010.

[20] It is
generally accepted, especially in recent years, that strengthening primary
healthcare can help improve the equity, efficiency, effectiveness, and
responsiveness of health systems. Most studies analysing the transfer of some
services from secondary to primary care showed that primary care was more
cost-effective. Evidence suggests (Fujisawa R. and Lafortune G., 2008, OECD)
that in most countries the remuneration of specialists is higher than that of
GPs. The share of GPs as a percentage of all practising physicians varies
considerably across the EU, from 49 % in France to 7 % in Greece and
Poland, with an EU average of 29 % in 2006–07 and nine Member States where
GPs constitute less than 20 % of all doctors (Bulgaria, the Czech
Republic, Greece, Latvia, Lithuania, Poland, Portugal, Slovakia and Sweden).
This may be relevant for countries wishing to implement a primary care-led
system with a referral system from primary to specialist and hospital care.

[21] Most
countries with a relatively low number or uneven distribution of GPs have
recognised the problem and increased the number of GPs in the last two decades.
Despite an increase in the number of practising nurses in almost all Member
States, except Lithuania and Slovakia, the ratio of nurses to physicians still
varies widely, from four or more nurses per physician in Denmark, Finland,
Ireland, the Netherlands and Luxembourg to less than one in Italy or Greece.
Commission-OECD, Health at a glance: Europe 2012; http://ec.europa.eu/health/reports/docs/health_glance_2012_en.pdf.

[22] Ibid.

[23] For an economic valuation of the health impact of social welfare
spending and mortality, see D. Stuckler, S. Basu. M. McKee; Budget Crisis,
Health and Social Welfare Programmes; BMJ 2010, 340.

[24] A recent
study on forecasting EU pharmaceutical expenditure shows a consistent reduction
(between 2 % and 10 % depending on the country) in pharmaceutical
expenditure in six (France, Germany, Greece, Hungary, Portugal and the United Kingdom)
out of seven countries studied (with the exception of Poland). The study
concludes that the best ways of reducing pharmaceutical budgets are reducing
generic prices, distributing biosimilars through the hospital chain and increasing
the number of generic medicines.

[25] WHO, The
World Health Report — Health systems financing: the path to universal coverage
(2010). http://www.who.int/whr/2010/whr10_en.pdf.

[26] The OECD has
identified several system-level reforms: providing comparative performance
indication, reforming provider payment mechanisms, improving the patient’s
choice and provider competition, giving guidelines on good practice and target,
audit and inspection systems. OECD, Achieving better value for money in
healthcare (2009) and health ministerial meeting, 7-8 October 2010. See
also Smith Peter C. What is the scope for health system efficiency gains to
be achieved?, Eurohealth incorporating Euro Observer — vol.18, No 3 (2012).

[27] http://ec.europa.eu/economy_finance/economic_governance/sgp/convergence/programmes/2012_en.htm.

[28] Commission
Communication, Annual Growth Survey 2012 — COM(2011) 815 final, 23.11.2011. http://ec.europa.eu/europe2020/pdf/ags2012_en.pdf.

[29] http://ec.europa.eu/europe2020/making-it-happen/country-specific-recommendations/index_en.htm.

[30] Commission
Communication, Annual Growth Survey 2013 — COM(2012) 750 final, 28.11.2012, and
thematic summary on health and healthcare systems relevant for the Europe 2020
Strategy: http://ec.europa.eu/europe2020/making-it-happen/key-areas/index_en.htm.

[31] Council
Conclusions: Towards modern, responsive and sustainable health systems, 3095
Employment, Social Policy, Health and Consumer Affairs Council meeting,
Luxembourg, 6. 6.2011. This process started in 2011 under the auspices of the
Working Party on Public Health at Senior Level and is expected to end at the
end of 2013.

[32] Commission
Decision 2012/C 198/06 of 5 July 2012 on setting up a multisectoral and
independent expert panel to provide advice on effective ways of investing in
health.

[33]
Creativ-Ceutical (2012), EU Pharmaceutical expenditure forecast, final report
26 November 2012.

http://ec.europa.eu/health/healthcare/docs/creativ_ceutical_eu_pharmaceutical_expenditure_forecast.pdf.

[34] As envisaged
in the 2013 work plan of the Health Programme, Commission
implementing decision of 28 November 2012 concerning the adoption of the 2013
work plan (2012/C — 378/07). The results of these studies financed by the EU
Health programme are expected to become available in the course of 2014.

[35] EC-EPC
(2012), The 2012 Ageing Report: Economic and budgetary projections for the 27
EU Member States (2010-2060).

[36] Health
technology means a medicinal product, a medical device or medical and surgical
procedures as well as measures for disease prevention, diagnosis or treatment
used in healthcare.

[37] Directive
2011/24/EU of 9 March 2011 on the application of patients’ rights in
cross-border healthcare — in particular Article 15. This is mainly realised
through the European network for health technology assessment. See http://ec.europa.eu/health/technology_assessment/policy/index_en.htm

[38] See in particular Lluch, M. (2012), Evidence consolidation — Report
on best practices and key drivers of success, SIMPHS2, Luxembourg, JRC
(European Commission).  http://is.jrc.ec.europa.eu/pages/TFS/documents/SIMPHS2D4.1FinalReportonEvidenceConsolidationrev2acc.pdf.

[39] See http://ec.europa.eu/information_society/activities/health/policy/index_en.htm.

[40] Directive
2011/24/EU of 9 March 2011 on the application of patients’ rights in
cross-border healthcare.

[41] E-health is
Worth it. The economic benefits of implemented e-health solutions at ten
European sites. Karl A. Stroetmann, Tom Jones, Alexander Dobrev, Veli N.
Stroetmann, 2006.

[42] OECD (2008).
‘Health Status Determinants: Lifestyle, Environment, HealthCare Resources and
Efficiency,’ OECD Economics Department Working Papers 627.

[43] See Philipa
Mladovsky, Divya Srivastava, Jonathan Cylus, Marina Karanikolos, Tamás
Evetovits, Sarah Thomson, Martin McKee, Health policy responses to the
financial crisis in Europe, WHO Policy Summary 5
http://www.euro.who.int/__data/assets/pdf_file/0009/170865/e96643.pdf.

[44] A shortlist
of 88 European Community Health Indicators (ECHI) has been developed under
different EU Health Programmes and now provides a health monitoring system at
EU level. It covers all aspects of health: health status, health determinants,
healthcare services, health promotion, demography and socio-economic situation.

[45] Actions to
be undertaken with the financial support of the Health Programme, Commission
implementing decision of 28 November 2012 concerning the adoption of the 2013
work plan (2012/C — 378/07).

[46] Commission, Directorate-General
for Economic and Financial Affairs (2012), The Quality of Public Expenditures
in the EU, European Economy, Occasional Papers 125, December 2012.

[47] Key issues pertaining to the future health workforce are covered in:
"Towards a job rich recovery", COM(2012) 173 final, notably  in the
"Action Plan for the EU Health Workforce", SWD(2012) 93 final.

[48] See for
instance various findings from the large-scale Health and Retirement Study
project collecting personal data in longitudinal follow-up.        http://hrsonline.isr.umich.edu/sitedocs/databook/HRS_Text_WEB_Ch1.pdf.

[49] EUROFOUND
(2010), Absence from work report.

http://www.eurofound.europa.eu/ewco/studies/tn0911039s/tn0911039s_5.htm.

[50] The average
percentage of productivity loss at work among workers with cardiovascular
diseases is estimated at 7 %, compared with 15 % on average for
workers with depression and 34 % among workers with upper extremity
disorders, Oortwijn et al. (2011),
Health of people of working age Report.

http://ec.europa.eu/health/social_determinants/docs/final_full_ecorys_web.pdf.

[51] While
several factors such as pension systems and age-management at work influence
employment rates, people’s health status also affects their ability to continue
working. Commission (2012) data.

http://epp.eurostat.ec.europa.eu/cache/ITY_PUBLIC/3-13012012-BP/EN/3-13012012-BP-EN.PDF.

[52] For more
details, and notably on the need for long-term care, see the Staff Working
Document on "Long-term care in ageing societies – Challenges and policy
options" adopted as part of this package.

[53]
Commission-OECD (2012), Health at a Glance: Europe 2012, OECD
Publishing. http://dx.doi.org/10.1787/9789264183896-en.

[54]       See "Towards a job rich recovery", COM(2012) 173
final, notably "Open, dynamic and inclusive labour markets",
SWD(2012) 97 final.

[55] Martin McKee
and Marc Suhrcke (2010), Investing in Health: A Contribution to the Achievement
of the Lisbon Agenda, European Review/Volume 18/Issue 01/February 2010.

http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=6906144.

[56] Bloom,
Canning, Sevilla (2004), The Effect of Health on Economic Growth: a production
function approach, World Development, Vol. 32, No 1 (http://qcpages.qc.cuny.edu/~redwards/GC-Econ71100/bloom-etal-wd04.pdf).
The WHO 2010 Global Report on Non-Communicable Diseases recognises that each 10 %
rise in NCDs is associated with 0.5 % lower rates of annual economic
growth (http://whqlibdoc.who.int/publications/2011/9789240686458_eng.pdf).

[57] https://osha.europa.eu/en/safety-health-in-figures

[58] Ministry of
Social Affairs and Health, Finland Social expenditure scenarios — effects of
health promotion and a presentation of the analysis model, Reports of the
Ministry of Social Affairs and Health 2009:7, 13 February 2009.

[59] See http://www.hal.inserm.fr/docs/00/59/35/06/PDF/Diabetes_Care_May_2011.pdf.

[60] Sources: Commission
data for Poverty Rates, Life Expectancy, Population, GDP, labour market,
healthcare expenditure. International Diabetes Federation (IDF) for Diabetes
Type 2 epidemiology and direct medical cost, peer-reviewed journal publications
for Quality of Life (QoL).

[61] See Lluch,
M. (2012), Evidence consolidation — Report on best practices and key drivers of
success, SIMPHS2, Luxembourg JRC (European Commission).              Available
at          http://is.jrc.ec.europa.eu/pages/TFS/documents/SIMPHS2D4.1FinalReportonEvidenceConsolidationrev2acc.pdf.

[62] See Rijken,
M., M. Jones, et al. (2008), Supporting self-management. Caring for people with
chronic conditions: A health system perspective, E. Nolte and M. McKee,
Maidenhead, Open University press (in cooperation with World Health Organisation
2008 on behalf of the European Observatory on Health Systems and Policies).

[63] Commission
Communication, Taking forward the Strategic Implementation Plan of the European
Innovation Partnership on Active and Healthy Ageing — COM(2012) 83 final.

[64] Through
financing from the Health Programme, Commission implementing decision of 28 November
2012 concerning the adoption of the 2013 Health Programme work plan (2012/C —
378/07).

[65] Council
Conclusions on Healthy Ageing across the Lifecycle, 7.12.2012.

[66] World
Economic Forum, Harvard School of Public Health (2011), The Global Economic
Burden of Non-Communicable Diseases.

[67] OECD (2010),
‘Obesity and the economics of prevention: Fit not fat’.

[68] Matrix
Insight (2012), ‘Economic analysis of workplace mental health promotion and
mental disorder prevention programmes and of their potential contributions to
EU health, social and economic policy objectives — final report’. See also OECD
(2011), ‘Sick on the Job. Myths and Realities about Mental Health and Work’ and
Knapp, McDaid, Parsonage (2011), ‘Mental health promotion and mental disorder
prevention. The economic case’.

[69] Joint Report
on health systems prepared by the European Commission and the Economic Policy
Committee, European Economy, Occasional Papers 74, December 2010.

[70] World Health
Organisation (2011), ‘Global status report on non communicable diseases’, http://whqlibdoc.who.int/publications/2011/9789240686458_eng.pdf.

[71] Council
Conclusions on ‘Innovative approaches for chronic diseases in public health and
healthcare systems’ Brussels, 7.12.2010.

[72] As foreseen
in the 2013 work plan of the Health Programme , this process will be supported
by a joint action on chronic diseases that will address preventing and delaying
the onset of chronic diseases throughout the life cycle and aspects of the secondary
prevention, screening, early diagnosis, and treatment of diabetes type 2, and
develop innovative, cost-efficient and patient-centred approaches for the
management of patients with multiple chronic conditions.

[73] The ‘Health
and social work’ sector includes three sub-sectors: ‘human health’, ‘residential
care’, and ‘non-residential social work’. For some statistics no breakdown is
available; in order to present comparable data it is therefore necessary to
present the aggregate value for the whole sector.

[74] Commission
services estimate.

[75] The last
CEDEFOP skills forecast expects employment to increase by one million between
2010 and 2020. Increasing healthcare needs and the ageing of healthcare
professionals should result in seven million vacancies due to replacement
needs. Therefore, together with net employment change, around eight million job
vacancies in total are projected. See CEDEFOP (2010), Skills supply and demand
in Europe Medium-term forecast up to 2020 and http://www.cedefop.europa.eu/EN/about-cedefop/projects/forecasting-skill-demand-and-supply/skills-forecasts.aspx.

[76] Commission
Communication, Annual Growth Survey 2013 — COM(2012) 750 final, 28.11.2012.

[77] Commission
Staff Working Document on an Action Plan for the EU Health Workforce —
SWD(2012) 93 final attached to the Commission Communication, Towards a Job Rich
Recovery — COM(2012) 173 final, April 2012.

[78] To be
financed by the EU Health programme, see Commission Implementing Decision of 28
November 2012 on the Health programme work plan for 2013 (2011/C/ 358/06).

[79] Eurostat statistics in
focus 24/2010.

[80] EU Statistics on Income
and Living Conditions.

[81] Economic
implications of socio-economic inequalities in health in the European Union,
Mackenbach J, Meerding W, Kunst A., Directorate-General for Health and
Consumers 2007.

[82] Devaux M, de Looper M,
Income-related inequalities in health service utilisation in 19 OECD countries
2008-2009, OECD Health working papers 58, 2012.

[83] Citizens
from central and eastern Europe, as shown by the FP7 Research Project ASSPRO
CEE 2007 (http://www.assprocee2007.com/), are often
confronted with informal patient payments for healthcare services. These range
from the ex-ante cash payment to the ex-post gift in kind. The causes of
informal payments need to be tackled for these reforms to be successful and to
guarantee equal access to healthcare. Vulnerable groups or households with a
chronically ill member are less protected against informal payments and are
most likely to forego treatment or to experience catastrophic, impoverishing
effects due to formal and informal out-of-pocket payments.

[84] Commission
Communication — Annual Growth Survey 2013 — COM(2012) 750 final, 28.11.2012.

[85] Two
documents accompanying this package address in particular children, as
investments in prevention during early childhood are likely to bring
substantial benefits over the whole lifespan, and homelessness, as health
problems are both a triggering factor and a consequence of homelessness. See
the Commission Recommendation on "Investing in children: breaking the
cycle of disadvantage", and the Commission Staff Working Document on "Confronting
Homelessness in the European Union" adopted as part of this package..

[86] On the
importance of access to quality services, and notably health services, as part
of an active inclusion strategy, see the Commission Staff Working Document on "the
Follow-up on the implementation by Member States of the 2008 European
Commission recommendation on active inclusion of people excluded from the
labour market" adopted as part of this package.

[87] Philipa
Mladovsky et al. (2012), Health policy responses to the financial crisis in
Europe, WHO Policy Summary 5. http://www.euro.who.int/__data/assets/pdf_file/0009/170865/e96643.pdf.

[88] This is however
unlikely to lead to substantial savings in budgets as health spending is
concentrated on a section of the population that does not necessarily overlap
with the poorest section (lowest income quintile), and protects against
catastrophic health expenditure (the inability of individuals to pay for healthcare
services — in itself not necessarily synonymous with high healthcare costs).
This suggests that income-based exemptions should be coupled with co-payment
ceilings.

[89] HOPE, the
European Hospital and Healthcare Federation reports a marked increase in
emergency services activities and longer waiting time and waiting lists. http://www.hope.be/05eventsandpublications/docpublications/86_crisis/86_HOPE-The_Crisis_Hospitals_Healthcare_April_2011.pdf.

[90] Commission,
2009 Ageing report, Economic and budgetary projections for the EU-27 Member
States 2008-2060. http://ec.europa.eu/economy_finance/publications/publication14992_en.pdf.

[91] http://www.ief.es/documentos/investigacion/seminarios/economia_publica/2011_18MayoPPT.pdf.

[92] COM(2009)
567 final. The Communication is implemented in particular through a Joint
Action supported by the Health Programme: http://ec.europa.eu/eahc/projects/database.html?prjno=20102203.
A progress report on the implementation of the Communication is to be published
in 2013.

[93] For the
specific role of the European Social Fund, see European Commission Staff
Working Document - Social investment through the European Social
Fund,
SWD(2013) 44, adopted as part of this package.

[94] For more
information on health gains through structural funds see  http://www.healthgain.eu/

[95] Commission
proposal for a regulation laying down common provisions and creating a common
strategic framework, in particular Annex IV — COM(2011) 615 final/2, 2011/0276
(COD).

[96] Proposal for
a Regulation of the European Parliament and Council establishing Horizon 2020 —
the Framework Programme for Research and Innovation (2014–20), COM(2011) 809
final.