# EUR-Lex - 52014DC0215 - EN

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# 52014DC0215

**COMMUNICATION FROM THE COMMISSION On effective, accessible and resilient health systems /* COM/2014/0215 final */**

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1. Introduction

Health systems[1] play a
central role in modern societies in helping people maintain and improve their
health. Health systems should be able to add more years to life, but also to
add more life to years.

Health systems in
EU Member States are varied, reflecting different societal choices. However,
despite organisational and financial differences, they are built on common
values, as recognised by the Council of Health Ministers in 2006:[2]
universality, access to good quality care, equity and solidarity.

EU health systems increasingly interact with each other. The entry
into force of Directive 2011/24[3]
was a key step in increasing this interaction. Strengthening cooperation
between health systems should help them function better when faced with the increasing
mobility of patients and healthcare professionals.

Over the last
decade, European health systems have faced growing common challenges:
increasing cost of healthcare, population ageing associated with a rise of
chronic diseases and multi-morbidity leading to growing demand for healthcare,
shortages and uneven distribution of health professionals, health inequalities
and inequities in access to healthcare.

Moreover, in
recent years, the economic crisis has limited the financial resources available
and thus aggravated Member States’ difficulties in ensuring their health systems’
sustainability.[4]
In turn, this jeopardises Member States’ ability to provide universal access to
good quality healthcare. Health systems need to be resilient: they must be able
to adapt effectively to changing environments, tackling significant challenges
with limited resources.

Increasing
interdependence and common challenges call for closer cooperation. In 2006, Member
States agreed upon common objectives on the accessibility, quality and
financial sustainability of health care in the context of the Open Method of
Coordination for social protection and social inclusion[5]. In 2011,
the Council of Health Ministers established an EU-level reflection process to
help Member States provide modern, responsive and sustainable health systems.[6] It
recognised that ‘whilst ensuring equitable access to high quality health
care services in circumstances of scarce economic and other resources has
always been a key question, at present it is the scale and urgency of the
situation that is changing and, if unaddressed, it could become a crucial
factor in the future economic and social landscape of the EU’.

In December
2013, the Council of Health Ministers endorsed the progress made and called for
further work in this area, in its conclusions on the ‘reflection process on
modern, responsive and sustainable health systems’.[7]

In the 2014 Annual
Growth Survey[8]
(AGS) “the top priority now is to build growth and competitiveness” in order to
build a lasting recovery. With this goal in mind, the AGS emphasises the need
to improve the efficiency and financial sustainability of healthcare systems,
while enhancing their effectiveness and ability to meet social needs and ensure
essential social safety nets. It also acknowledges the importance of the
healthcare sector in tackling the social consequences of the economic crisis,
stressing that healthcare services are an area that will generate significant
job opportunities in the years to come. It recommended that active social
inclusion strategies should be developed, including broad access to affordable
and high-quality health services.

This had
previously been stressed in 2013, when eleven Member States[9] received
a recommendation for reform in their health systems as part of the European
Semester. Most of these recommendations focused on the sustainability and
cost-effectiveness of health systems, calling for reforms in the hospital
sector, in the pricing of health services, out-patient care and primary care.
Three recommendations also called for maintaining or improving access to
healthcare.

Besides being a value in itself, health is also a precondition for
economic prosperity, as recognised in the Commission staff working document ‘Investing
in health’, which is part of the Social Investment Package.[10] People’s
health influences economic outcomes in terms of productivity, labour supply,
human capital and public spending. The healthcare sector is strongly driven by
innovation, and has major economic significance: it represents  10% of the EU’s GDP. Moreover,
it is a highly labour intensive activity and one of the largest sectors in the
EU: the healthcare workforce accounted for 8% of all jobs in the EU in 2010.[11]

Capitalising on
experience and work carried out over recent years, and with a view to further
developing approaches at EU level, this Communication focuses on actions to:

1. 
Strengthen the effectiveness of health systems

2. 
Increase the accessibility of healthcare

3. 
Improve the resilience of health systems

2. Strengthening the effectiveness of health systems

Effectiveness,
safety and patient experience are key components of healthcare quality, an
important element of health systems’ performance. Work on patient safety is
ongoing at EU level,[12]
while patient experience is a key area which will require further attention in
the future.

This
Communication focuses on effectiveness: health systems’ ability to produce
positive health outcomes, i.e. to improve the health of the population.

Measuring the effectiveness
of health systems will become increasingly important, especially as health
systems are not the only factor in improving our health. Although large
variations in life expectancy still persist between Member States, overall we
are living longer and in better health than previous generations. This is not
least because of the significant achievements made in public health and from
outside the health system. Future improvements are also to be expected, for
example from fewer people smoking, lower alcohol consumption, better nutrition,
and greater uptake of physical activity. There is a general consensus that the healthcare
sector’s contribution to a healthy population has increased dramatically in the
last fifty to sixty years.

Gathering
information on the comparative effectiveness of health systems is still at an
early stage. The examples presented below show areas where the contribution of
health systems to the improvement of health is most evident, backed by
available EU-wide indicators (i.e. perinatal mortality, amenable mortality,
incidence of vaccine-preventable diseases and cancer screening). This
comparison reveals large variations between EU Member States.

Perinatal mortality

Perinatal mortality is calculated as the sum of late foetal
mortality (after 28 weeks’ gestation) and early neonatal mortality (within seven
days after delivery). Compared to infant mortality,[13] it is less strongly associated with socioeconomic factors and hence
a more reliable indicator of health system effectiveness.

Figure 1: perinatal mortality rates per 1 000
total births (2011 or most recent data)

Data source: Eurostat database,
Europeristat project (developed by Commission staff)

The perinatal
mortality rate declined in the last five years in the majority of Member
States, although some countries saw the rate increase during this period.

Amenable mortality

Amenable
mortality is defined as premature deaths that should not occur if timely and
effective healthcare is provided. It is a fundamental
indicator used to explore the contribution of health systems to health outcomes.[14] Amenable mortality combines the standardised
mortality rates for a selected set of diseases on which healthcare is estimated
to have a direct impact.

Figure
2: amenable mortality, standardised
death rates per 100 000 inhabitants — 2010

Data source: Eurostat (data for Greece not available)

Virtually all
Member States have been able to reduce the rate of amenable mortality between
2000 and 2010, though the rates of decrease vary considerably among them.

Communicable diseases

The incidence of
particular communicable diseases is directly affected by the provision of
appropriate healthcare services: immunisation campaigns have dramatically
reduced the incidence of vaccine-preventable diseases (even though in some
countries there are worrying signs of falling vaccination rates).

Figure 3: incidence of vaccine-preventable diseases —
confirmed cases per 100 000 inhabitants — 2011

Data source: ECDC Annual
epidemiological report 2012

Even focusing on
a small set of vaccine-preventable diseases (meningococcal disease, hepatitis
B, mumps, and measles), incidence rates across Member States shows a significant
difference.

Cancer screening

Early diagnosis
of colorectal, cervical, and breast cancer through organised population-based
screening programmes is a useful proxy for the effectiveness of the healthcare
system in addressing sectors at risk. The Council recommended implementing such
programmes in accordance with European quality assurance guidelines.[15]

Breast cancer is
the area where most progress has been made. National screening programmes
generally meet EU guidelines in defining target age-groups (women aged 50-69)
and on recommended time intervals between mammography screenings. However, while
European guidelines identify a desirable target screening rate of at least 75 %
of eligible women (and an acceptable level of 70 %), only a few Member
States reached this rate in 2010.

Figure 4: breast cancer screening — % of women 50-69
screened

Data source: OECD health at a glance
Europe 2012, national statistics

Main findings

Some initial
observations can be made in relation to these specific indicators, although
they are not representative enough to support a broad evaluation of health
systems. They illustrate large variations between EU Member States. They also
show that health outcomes are multidimensional and difficult to define. In
general, assessing the effectiveness of health systems is a complex process:
healthcare measures may only show their effects after long periods, and
comparability and reliability of data is a challenge. However, work to improve
this is being carried out.

The Commission
has supported the development of the European health core indicators (ECHI), a
set of indicators to monitor the health of the population and the performance
of health systems. Several reports have also been issued, assessing European
health systems. Particularly valuable examples are the joint EPC-European
Commission report on health systems, published in 2010, and the ‘Health at a
glance Europe’ series, published by OECD and the Commission.

Another important step has been undertaken in 2013: the
Social Protection Committee developed a joint assessment framework on health,
intended to act as a first-step screening device to detect possible issues in
Member States’ health systems. It constitutes a key contribution to the
comparative assessment of health systems’ performance, taking into account the availability
of data at EU level. Finally, the framework programmes
for research and for technological development funded several projects to
develop indicators and methodologies to assess the performance of health
systems.[16]

3. Increasing the accessibility of health systems

Health systems must
be accessible. This is one of the principles stated in the European Social
Charter,[17]which
emphasises the importance of transparent criteria for access to medical
treatment, and the obligation for States to have an adequate healthcare system
which does not exclude parts of the population from receiving healthcare
services.

However, access
to healthcare is difficult to measure and there is no EU wide detailed
methodology to monitor it and promote best practice. This would be an important
step to reduce health inequalities.[18]

A commonly used
indicator is the variance across the EU in the percentage of residents
reporting difficulties in accessing medical care for reasons related[19] to the
accessibility of health systems: waiting time, travelling distance and cost
sharing. However, these findings derive from self-reported needs and may
therefore suffer from cultural bias when compared across countries.

Figure 5: Self-declared unmet needs for medical
examination by reason, proportion of population (%)

Source: Eurostat, Statistics on Income and Living
Conditions 2012 (2011 data for AT and IE)

Access to
healthcare is the result of interaction between different factors, including health
system coverage (i.e. who is entitled to healthcare),  depth of coverage (i.e.
what are citizens entitled to), affordability and availability of healthcare
services. Healthcare access is also directly affected by the organisation and
management models used in health systems. Patients may find healthcare more
difficult to access if health systems are complex and lack transparency.

Population coverage

Health services
are mostly financed from public sources in virtually all EU Member States.
Healthcare coverage is universal or almost universal in all Member States;
however, some people from disadvantaged backgrounds are still excluded from
adequate health coverage.

Depth of
coverage

Publicly
financed healthcare treatments differ between national health systems. For
example, dental care, eye care services and some state-of-the-art treatments
are covered only in some Member States. In several Member States there is no
explicit definition of publicly financed treatments. This complicates
comparison and analysis which could contribute to a consensus on minimum or
optimal levels of care provision.

Affordability

People are often
asked to contribute financially towards the service they require, in the form
of cost-sharing or co-payment. This can help ensure that health services are
used responsibly; at the same time, however, this co-payment should not
represent an obstacle or a deterrent to people getting the healthcare they
need. Cost-containment measures in health systems, meant to promote more
rational use of healthcare, should not unduly reduce access to high-quality
healthcare.

Availability
(health workforce, distance from point of care, waiting times)

Patients should
have reasonable access to healthcare services: they should not have to travel
too far or wait too long to access the service they need. This is a
particularly serious challenge in rural and remote areas.

Problems relating
to distance could be overcome through more integrated models of care, which
improve contact between patients and the health system, and through wider
uptake of eHealth solutions.

There is no EU-wide
definition of how to measure waiting times, even though this is a significant
concept in Regulation 883/04[20]
and Directive 2011/24. This might change as Directive 2011/24 improves health
system accountability for access to care, through increased transparency on the
concept of ‘undue delay’ when waiting for treatment.

Ageing
population and the rise in multiple chronic diseases require different skills
mixes, with implications for the content of medical training programmes. The
separation between professions is likely to become less rigid through the
creation of multidisciplinary teams. Demand for skills and competences in the
healthcare sector is changing constantly and roles and professions are likely
to evolve in order to meet population needs. For instance, given the high rates
of physical inactivity in the EU and the associated health risk factors, health
professionals have a key role to counsel patients on the importance of physical
activity, working with other sectors such as the sports sector.[21]

In order to be
ahead of these developments, medical training planning systems have to be
smarter, respond more quickly and be in a better position to attract students
to the specialities that are needed most.

In addition,
evidence shows that attention should be paid to medicines, as the share of
private expenditure in medicines is markedly higher than for other types of
publicly covered healthcare.

National
decisions on pricing and reimbursement have direct and indirect impacts on the
accessibility to medicines across the EU: innovative products are not always
made available at the same time in all Member States, and in some countries
they may not be available at all.

A first step to
improving this was made through the process on corporate responsibility in the
pharmaceutical field, which encouraged discussion between competent authorities
responsible for pricing and reimbursement and other interested stakeholders,
and supported the transparent exchange of information on how to achieve better
access to medicines.

4. Improving the resilience of health systems

Modern health
systems need to remain accessible and effective while pursuing long-term
sustainability. To do this, they have to remain fiscally sustainable. The
Commission supports Member States in this work, providing analysis and
forecasts, and recommending reforms as part of the European Semester process.

Health systems
should also look at non-fiscal factors. They must be able to adapt effectively
to changing environments and identify and apply innovative solutions to tackle
significant challenges  — shortages of expertise/resources in specific areas,
unexpected surges in demand (e.g. owing to epidemics), etc. — with limited
resources. In other words, they need to build and maintain resilience.

EU health
systems have not coped equally well with the economic crisis and some have had
to implement major and sometimes painful reforms in a very short time. Building
on experience of recent reforms, the Commission has identified the following resilience
factors that helped some health systems safeguard accessible and effective
healthcare services for their population.

Stable funding mechanisms

Stable funding
allows effective investment planning and smooth continuity of services in
organising and managing care delivery. Health systems whose financing is based
on less stable sources of revenue are more prone to suffer from external
shocks: e.g. systems relying mostly on employment-based contributions for
funding are more exposed to the consequences of a rise in unemployment.
Reserves or other countercyclical formulas for government budget transfer may
help ensure stability of funds.

Sound risk
adjustment methods

A consistent
system of risk adjustment and risk pooling is a key tool to ensure that
resources are spent according to needs. For example, when several social health
insurance companies collect social contributions or insurance premiums, a
risk-adjustment/risk-equalisation mechanism is used to take into account the
size, age-gender structure and a proxy of the morbidity patterns of the
individuals insured in each fund. This is to avoid patient selection,
discrimination and ensure funding is adjusted to need.

Good
governance

Governance is
about well-defined responsibilities in running the health system and its main
components, together with strong leadership, sound accountability mechanisms
and a clear organisational structure. This enables systems to adapt quickly to
new objectives and priorities and enhances their ability to respond to major
challenges by identifying and putting in place the measures necessary to
support smart investment decisions.

Information flows in the system

A sound
knowledge of strengths and weaknesses and the ability to monitor information,
including at the level of individual patients or healthcare providers, enable
health systems managers to make tailored, evidence-based decisions in specific
sub-sectors.

EHealth-based
information systems facilitate and support the strengthening of information
knowledge systems. Furthermore, eHealth can deliver more personalised
healthcare, which is more targeted, effective and efficient and helps to reduce
error and to minimise the length of hospitalisations.

Adequate
costing of health services

It is essential for
understanding the complexity of the processes leading from costs to outcomes:
how costs correspond to human and physical resources, how resources contribute
to activities (e.g. surgical interventions, diagnostic tests), how activities
group into care interventions, and finally how care interventions impact on
health.

Health
technology assessment is key for ensuring a common method for evaluating
efficacy of interventions and proper costing of services and hence to allow
decision makers to allocate resources in the most efficient way.

The ability to
cost healthcare services accurately is not only necessary for controlling
expenditure, but also a prerequisite for effective decisions on investment and
prioritisation.

A health
workforce of adequate capacity and with the right skills

A highly
qualified and motivated health workforce of adequate capacity and with the
right skills is essential for finding innovative solutions through
organisational and technological change. Having an effective structure of
incentives is vital to improving the performance of health professionals and
ensuring the focus is on direct provision of healthcare.

5. An EU agenda for effective, accessible and resilient
health systems

The primary
responsibility for health systems rests with the Member States. The EU has
taken a number of actions that can support Member States', in particular by
providing guidelines and as monitoring or evaluation tools.

The Commission
has set up an independent expert panel to provide advice in relation to
investing in health.[22]
This panel will provide analyses and recommendations to the Commission on a
number of the issues discussed.

Supporting the strengthening of the
effectiveness of health systems

Health systems performance assessment
(HSPA)

The Council of
Health Ministers invited Member States to use HSPA for policy-making,
accountability and transparency, and invited the Commission to support Member
States in using HSPA.

In response to
this invitation, collaborative work on HSPA will provide Member States with
tools and methodologies, including:

capitalising
  on EU-funded research on performance assessment measures and indicators; 
 defining
  criteria and procedures for selecting priority areas for HSPA at national
  and EU level; 
 developing a
  tailored reporting system; and 
 intensifying
  cooperation with international organisations, in particular the OECD and
  the World Health Organisation.

This
collaborative work may also allow more targeted work at EU level to reduce
inequalities by providing support to Member States that are performing below
the EU average to help improve their situation. It could also prove
instrumental in helping Member States meet requirements under Directive 2011/24
for information on quality and safety.

Quality of care, including patient
safety

In spring 2014,
the Commission intends to present its second report on the implementation of
the Council recommendation on patient safety.[23]
On the basis of the findings of this report, the Commission intends to discuss
action to further improve patient safety and to reduce unwarranted variation
between and within Member States.

The findings of
the recent public consultation on patient safety and quality of care show that
there is a high interest in developing a broader EU agenda to address the
issues that impact on quality in healthcare. The Commission intends to follow
up appropriately.

Integration
of care

Integration of
care should take place both between different levels of healthcare (primary
care, hospital care, etc.) and between health and social care, particularly
with regard to elderly people or people with chronic illnesses.

Member States’
reforms, to reduce the reliance of their health systems on hospital-based care
through better integration of care, provide an opportunity to exchange learning
experiences in key areas and to answer the following questions:

Which patients
  can be treated better or equally well outside hospital? 
 How can
  avoidable hospitalisations be successfully reduced?

The expert panel
on investing in health has published a report on primary care and integration
of care, on which the Commission has launched a public consultation to identify
new areas for reflection.

Increasing
the accessibility of healthcare

The EU health
workforce

Significant gaps
have been identified in Member States’ capacity to plan for future health workforce
resource requirements, relating to both overall volume and required skills mixes,
in order to meet expected healthcare needs efficiently.

The outcomes of
the action plan on the health workforce[24]
will help to better predict future skills needs and provide important insights to
train future generations of healthcare professionals with the right skills.
Improving available data to enhance national planning systems can also help address
the challenges posed by health workforce mobility and find solutions that take
into account the right to move freely in the EU.

Health workforce
planning efforts should develop sustainable solutions at EU level to ensure
sufficient numbers of adequately trained health professionals with the right
skills to provide care to all who need it. To avoid future shortages and skills
mismatches, the Commission intends to work further with Member States on
developing recommendations, common tools, indicators and guidelines, strengthening
EU support for Member States’ planning.

Cost-effective
use of medicines

The EU needs a
competitive pharmaceutical industry. With this background, Member States and the Commission should reflect further on how to reconcile the policy
objectives of ensuring accessible healthcare for all EU citizens with the need
for cost containment. Consideration should be given to improved cooperation on
building mechanisms for increased transparency and better coordination to
minimise any unintended effects that current national pricing systems may have
in terms of accessibility throughout the EU.

Optimal
implementation of Directive 2011/24

Directive
2011/24 broadens patient choice in healthcare and helps them avoid undue delay
in receiving the treatments they need. The Directive will improve transparency by
requiring the Member States to set up national contact points to provide
information to citizens, including on their rights and entitlements, patient
safety and quality of care standards. It also calls for a better understanding
of baskets of healthcare. Member States should ensure that all the provisions
of the Directive are properly implemented. The Commission will closely monitor
how the concept of undue delay is applied in Member States.

Reference networks
will promote cooperation among highly specialised providers across Member
States, allowing patients with low prevalence, complex or rare diseases to
access high quality care. The Commission intends to launch calls for expressions
of interest in becoming European reference network members, who could also
provide training for health professionals and support in defining common
quality assurance requirements.

Improving
resilience of health systems

There is an
urgent need for further investigation into resilience factors for health
systems and ways to build these. Member States should develop better analyses
of these factors on the basis of their national experience. This should be
complemented by EU work on sharing best practice and on designing policy
measures. The following approaches will be beneficial to improve the resilience
of health systems in the European Union.

Health
technology assessment (HTA)

HTA is a
scientific approach to evaluate the relative effect a particular health technology
has on a medical condition by answering questions like:

Is the
  technology effective? 
 For whom does
  it work? 
 What costs are
  entailed? 
 How well does
  it work compared to alternative technologies?

HTA has proved
to be an efficient tool for improving access to innovative technologies for
patients and for supporting more efficient allocation of funds.

Member States
cooperate on HTA within a network established in Directive 2011/24. The
Commission supports an ambitious goal for the HTA network, namely that jointly
produced HTA information should be re-used at national level. This will reduce
duplication of work by regulators, HTA bodies and the HTA industry, and will
lead to a shared understanding of the clinical aspects of health technologies (i.e.,
their relative safety and efficacy/effectiveness).

In future years,
a more ambitious and stable structure to support scientific cooperation on HTA
will be developed. In collaboration with the HTA network, the Commission is working
on possible proposals on this.

Health
information system

Any intervention
to increase the resilience of the health system must take account of the system
itself. Decisions on investing or disinvesting in specific sectors need to be
based on an understanding of the processes governing those sectors and the
impact of the interventions on health and economic parameters.

Member States
should therefore invest in developing their information flows to, for example,
ensure that patient-level information flows are channelled appropriately to all
necessary healthcare providers, or that more effective and sustainable
reorganisation of health systems and services are supported.[25]

The Commission
is considering supporting Member States on establishing a sustainable and
integrated EU health information system, exploring in particular the potential
of a comprehensive European research infrastructure consortium (ERIC) on health
information.

eHealth

The Commission strongly
encourages cooperation between Member States on eHealth and supports them in
developing and implementing cost-effective and interoperable eHealth solutions
to improve health systems.[26]
As required by Directive 2011/24, the Commission supports the eHealth network, which
works to deliver sustainable benefits from European eHealth systems and
services and interoperable applications. The 2012-2020 eHealth action plan also
emphasises the benefits of eHealth services for citizens, patients and
healthcare providers, and proposes specific actions to lower the barriers to deploying
these services.

Further efforts
are needed to develop effective and interoperable telemedicine services.
European reference networks will represent an ideal opportunity to introduce
and test telemedicine in the EU.

6. Conclusions

The 2013 Annual
Growth Survey recognised that “in the context of the demographic challenges and
the pressure on age-related expenditure, reforms of healthcare systems should
be undertaken to ensure cost-effectiveness and sustainability, assessing the
performance of these systems against the twin aim of a more efficient use of
public resources and access to high quality healthcare”.

Member States’
future ability to provide high quality care to all will depend on making health
systems more resilient, more capable of coping with the challenges that lie
ahead. And they must achieve this while remaining cost-effective and fiscally
sustainable.

While this is
primarily a task for the Member States, this communication highlights a number
of initiatives through which the EU can support policy makers in the Member
States. The EU will have to develop these initiatives and build on them to
ensure that citizens’ aspirations to high quality care can be met. The focus
will have to be on methods and tools that will allow Member States to achieve
greater effectiveness, accessibility and resilience of their health systems, in
line with reform recommendations addressed to Member States in the context of
the European Semester. To implement reforms identified in these
recommendations, Member States are also encouraged to use
European funding instruments.

[1] In this Communication, health systems are defined as those systems
that aim to deliver healthcare services to patients – be they preventive,
diagnostic, curative, and palliative – whose primary purpose to improve health.

[2] Council Conclusions on Common values and principles in European
Union Health Systems, OJ C 146,  22.06.2006

[3] Directive 2011/24/EU, OJ L 88, 04.04.2011.

[4] This
is also highlighted in the Council conclusions on the Economic  Policy
Committee (EPC) – European Commission Joint Report on health systems in the EU
(7 December 2010).

[5]  Joint Social
Protection Committee / Economic Policy Committee Opinion on the Commission
Communication “Working together, working better: proposals for a new framework
for the open co-ordination of social protection and inclusion" endorsed by
EPSCO on 10 March 2006.

[6] Council Conclusions: Towards modern,
responsive and sustainable health systems (6 June 2011).

[7] Council Conclusions on the Reflection
process on modern, responsive and sustainable health systems (10   December 2013).

[8] COM(2013)
800.

[9]  Austria, Bulgaria, Czech Republic, Germany, Finland, France, Malta, Poland, Romania, Slovakia and Spain.

[10] COM(2013)
83.

[11] SWD(2012) 93, accompanying COM(2012) 173.

[12] Council Recommendation of 9 June 2009 on patient
safety, including the prevention and control of healthcare associated
infections, OJ C 151, 03.07.2009.

[13] Infant mortality is the number of deaths in children within the
first year of life per 1 000 live births.

[14] Arguably, ‘amenable mortality’ comparisons need to take disease
incidence into account and not just deaths relating to the relevant diseases. However,
availability of comparable data is not ensured.

[15] Council Recommendations of 2 December 2003 on cancer screening; OJ
L 327, 16.12.2003. See also European guidelines on quality assurance in
colorectal cancer screening and diagnosis, cervical cancer screening, and
breast cancer screening and diagnosis.

[16] See for instance the ECHO (http://www.echo-health.eu),
Eurohope (http://www.eurohope.info), and
EuroREACH (http://www.euroreach.net)
projects.

[17] Revised European Social Charter, Strasbourg 3 May 1996.

[18] COM(2009) 567.

[19] Note that the ‘other reasons’ classification in this survey relates
to reasons not linked to local health systems, e.g. ‘no time’, ‘fear of doctor’,
etc.

[20] Regulation 883/2004 of 29 April 2004 on the coordination of social
security systems, OJ L 166, 30.04.2004

[21] Council Recommendation of 26 November 2013 on promoting
health-enhancing physical activity across sectors, OJ C 354, 4.12.2013.

[22] Commission
Decision of 5 July 2012 on setting up a multisectoral and independent
expert panel to provide advice on effective ways of investing in health, OJ C
198, 06.07.2012.

[23] The first report was published in 2012: COM(2012) 658.

[24] SWD(2012) 93, accompanying COM(2012) 173.

[25] See the conclusions of the e-health task force report entitled ‘Redesigning
health in Europe for 2020’, which calls upon policy makers to use the power of
data: http://ec.europa.eu/digital-agenda/en/news/eu-task-force-ehealth-redesigning-health-europe-2020.

[26] COM(2012)
736.