EN    EN EN 
 
EN    EN  COMMISSION OF THE E UROPEAN COMMUNITIES 
Brussels, 20.10.2009 
SEC(2009) 1397 final 
COMMISSION STAFF WORKING DOCUMENT 
EXECUTIVE SUMMARY OF THE IMPACT ASSESSMENT  
 
 
Accompanying the 
  
COMMUNICATION FROM THE CO MMISSION TO THE EUROPEAN 
PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL 
COMMITTEE AND THE COMMI TTEE OF THE REGIONS 
 
Solidarity in health: Reducing he alth inequalities in the EU 
  
{COM(2009) 567 final} 
{SEC(2009) 1396} 
 
EN 2   EN 1. INTRODUCTION  
This document summarises the impact assessment which considers policy options for an EU 
initiative "Solidarity in Health: Reducing H ealth Inequalities in the EU". The Commission 
identified the need for action in the EU Health Strategy1 and announced an EU initiative on 
health inequalities in th e 2008 Renewed Social Agenda2. This document incorporates 
comments from the Impact Assessment Board in  relation to the objectives, the use of the 
terms inequalities and inequities, proportionality, subsidiarity and costs. The report commits 
only the Commission's services involved in its  preparation and does not prejudge the final 
Commission decision. 
Principle responsibility for addressing health in equalities rests with Me mber States, but EU 
policies can have an indirect impact on health  and can help overcome current obstacles to 
action. The report appraises EU action to support and compleme nt the efforts of Member 
States and stakeholders and to  mobilise EU policies towards reducing health inequalities, in 
full respect of subsidiarity.  
EU action should support improvements in th e health of the whol e population, but with 
emphasis on reducing avoidable a nd unfair gradients in health between social groups and EU 
regions – i.e. a 'levelling-up' approach.  
A number of relevant actions are already taken at both the EU and nati onal levels. Current 
actions are however limited by the level of awareness and priority  given, lack of stakeholder 
involvement, gaps in information and knowledge , insufficient exchange of good practice and 
difficulties in creating an inter-sectoral policy approach. This document therefore considers measures to address these issues.  
2. P
ROBLEM DEFINITION  
There is currently an 8 year gap in life expe ctancy at birth for women between EU Member 
States and a 14-year gap for men. There are also  large differences in death, disability and 
disease between Member States an d EU regions. In some countri es the health gap to the EU 
average and the best performers has widened in the last two decades. 
There are large differences in health between social groups defined on the basis of income, 
occupation, educational level or ethnic group in all Member States3. People with lower 
education, income or occupation live shorter li ves and spend more time in poorer health. 
Differences in life expectancy at birth betw een socio-economic groups range from 4 to 10 
years for men and 2 to 6 years for women. This pattern is re flected in many measures of 
physical and mental health. In some countries the gap has widened in the last decades.  
Inequalities in health are related to inequali ties in social determinants of health including 
living conditions (housing, environment), health -related behaviour (diet, smoking, exercise), 
                                                 
1 COM(2007) 630. 
2 COM(2008) 412. 
3 Health Status & Living Conditions. Monitoring Report prepared by the European Observatory on the 
Social Situation . European Commission 2008.  
 
EN 3   EN employment and working conditions, educati on, access to social protection including access 
to quality health care. A substantial proport ion of health inequalit ies are avoidable and 
amenable to policies which can be influenced by EU policy. 
Three areas are identified where weaknesses are observed which pose obstacles to taking 
effective action to address hea lth inequalities. These are area s where the EU can support and 
complement Member States actions:  
Lack of awareness and insufficient policy prio rity and commitment by Member States and 
other stakeholders 
Absence of comparable and regular data, mon itoring and reporting. L ack of knowledge on the 
determinants and the effective policies to implement 
Insufficient concerted EU approach to health inequalities (lack of mainstreaming at the EU 
level) 
Member States are implementing some policies but comprehensive strategies are lacking. 
Over half of the Member States do not place any policy emphasis on reducing health 
inequalities. In addition, policies lack evaluation and dissemination.  
While robust evidence exists, more information is required on the effect (causality) and 
importance of some health determinants in or der for Member States to implement effective 
action in relation to particul ar population groups and determ inants. Comparable, routinely 
available EU wide data on health outcomes and determinants of health inequalities broken 
down by socio-economic group is also needed.  
Lack of EU data and research knowledge is an obstacle to policy development. Better and 
shared evidence and a rationale for action can provide the commitment cu rrently lacking from 
a range of stakeholders. 
At EU level health inequalities have received higher policy priority and there are a number of 
EU policies which are having a positive impact. However, this is difficult to quantify and 
there has not been significant mainstreaming of  health inequalities across all relevant EU 
policies.  
3. OBJECTIVES  
EU action regarding health inequalities aims  to support and complement the actions of 
Member States and other stakeholders and to en sure that EU policies and activities provide a 
high level of health protection as set out in the Treaty. As far as possible, the health protection 
provided by EU policies should extend to all citi zens irrespective of where they live or their 
social background. In fulfilling these aims EU  action can make a contribution towards a 
reduction in health inequalities in the EU.  
3.1. General Objectives 
The general objective of this initiative is to support and complement the efforts of Member 
States and stakeholders and mobilise EU po licies towards reducing health inequalities. 
 
EN 4   EN 3.2. Specific Objectives  
Specific objectives are to: 
Raise awareness, promote information, best-p ractice exchange and policy coordination and 
advocate the tackling of health inequalities as a policy priority; both at Community and Member States level and by other stakeholders. 
Improve data availability and the mechanisms to measure, monitor and report on inequalities 
in health across the EU and im prove the knowledge base on the causes of health inequalities 
and the evidence base for action. 
Develop the contribution of relevant EU polic ies towards reducing inequalities in health, 
including better support of Me mber States and stakeholders ' efforts to tackle health 
inequalities and a specific focus on vulnerable groups and third countries. 
4. A
NALYSIS OF SUBSIDIARITY : IS AN EU ROLE JUSTIFIED ?  
Although the main responsibility fo r addressing health inequalities rests with Member States, 
the problem is of policy concern for the EU for a number of reasons.  
Firstly, the pervasiveness and persistence of  health inequalities suggests a discrepancy 
between the existing situation and some of the overarching goals of the EU such as 
strengthening of economic and social cohesion, ensuring equa l opportunities, promoting the 
reduction of inequalities, and the promotion of equality between men and women and the 
solidarity among Member States (Art. 2 of th e EU Treaty and Art. 2 of EC Treaty).  
Secondly, high levels of poor health in sec tions of the EU population imply substantial 
opportunity costs for the Uni on and provide an economic r eason for promoting action to 
address them. High levels of population health are important in the context of an ageing 
population to allow longer working lives and support higher productivity, competitiveness and employment levels. Avoidable ill-health also  leads to large costs for health systems and 
puts unnecessary pressure on public budgets. Reducing unnecessary losses due to ill health and premature death can make a contribution to meeting th e Lisbon goals and achieving 
Europe's full potential for prosperity.  
There is a legal basis for action under several articles of the EC Treat y including: arts. 12 and 
13 (on anti-discrimination), art. 125 (promo ting employment and a skilled, trained and 
adaptable workforce), arts. 136 and 137 (improvi ng living and working c onditions and social 
protection and combating of exclus ion), art. 152 (ensuring a high level of health protection of 
all Community policies), arts. 158 and 159 (str engthening economic a nd social cohesion). 
These articles form the basis for the Community  to support and complement Member States' 
actions. 
The necessity of EU action can be found: 1) in the need for EU-wide data collection and 
monitoring, as the EU is better placed then indi vidual Member States to ensure reliable and 
comparable data and 2) in Cohesion policy through which the EU provides financial support 
to Member States, especially less well-off regions,  that can be invested in key determinants of 
health inequalities such as living conditions, tr aining and employment services, and healthcare 
(promotion, prevention and treatment). The EU can also provide added value
 by raising 
 
EN 5   EN awareness and reinforcing a focus on health inequalities, improving monitoring mechanisms, 
enhancing research and knowledge gathering, provi ding visibility of relevant actions through 
improving the sharing of experiences and good practices and capacity building, and improving the linkages between EU policies. Thes e have been suggested  in the consultation 
responses and in other research reviews.  
5. P
OLICY OPTIONS  
Three options are analysed to achieve the objec tives. Option I is the continuation of current 
activities ("business as usual"). Option II "Curre nt plus" builds on existing work which can be 
taken forward in a short time frame without further or fundamental changes to current 
Community instruments, and formulated in  a Communication. Option III "Far Reaching" 
requires a longer time frame, involves changes in existing EU instruments, and includes a 
Council Recommendation. The options are cumula tive (option III builds on option II which 
builds on option I - see table). 
5.1. Option I: Business as usual  
In Option I, work to support th e reduction of health  inequalities continues under the social 
OMC and the Health Strategy. Equity in health is a guiding principle of the Health Strategy 
and reducing inequities in access to health care and health outcomes is a common objective 
under the social OMC. Through the exchange of e xperience, the EU assists Member States to 
translate this objective into national strategies. Mechanisms include National Strategy Reports 
and the Joint Report on Social Protection and Social Inclusion, peer  reviews and Social 
Protection Committee meetings, as  well as meetings of the EU Expert Group on Social 
Determinants of Health and Health Inequalities and the C ouncil Working Party on Public 
Health at Senior Level. There is financ ial support through PR OGRESS and the Health 
Programme 2008-2013. Likewise, C ohesion Policy, the Common Ag riculture Policy and the 
Agricultural and rural Development funds suppor t some activities regarding key determinants 
of health. Other EU actions would continue  though not focusing on health inequalities. 
5.2. Option II: Current plus  
In Option II, the Commission adopts a Communication raising awareness on health 
inequalities and highlighting their economic, political and ethical magnitude. Option II 
confirms the reduction of health  inequalities as a policy prio rity, increases dialogue with 
stakeholders and strives towards a better use of existing information and exchange 
mechanisms and existing financial support. It supports actions to build knowledge for 
effective action and strives to improve the measurement system on health inequalities 
between Member States, EU Regions and social  groups. It encourages a first reflection by 
relevant policy areas on their potential for action in this fi eld (as proposed by some national 
authorities in the consultation). It announces a nu mber of specific actions aiming to strengthen 
activities, without requir ing significant new policy developmen t. It remains the responsibility 
of Member States to develop concrete policies. 
5.3. Option III: Far reaching.  
In Option III the Commission proposes in ad dition: a Council recommendation on health 
inequalities; targets to reduce health inequaliti es across the EU as a whole; a high level inter-
institutional advisory committ ee; a review of a number of policy areas to include the 
 
EN 6   EN reduction of health inequalities as an explicit pr iority whereby resources would be reallocated 
or added accordingly for the period beyond  2013; a review of community measures 
contributing to ensuring access to basic needs for health (health care,  shelter, food, water 
education); and an larger international initi ative to address global health inequalities. 
6. ANALYSIS OF IMPACTS  
This is a non-legislative initiative aiming to strengthen action to support and complement the 
efforts of Member States and other stakehol ders to reduce health inequalities. Actions 
proposed in options I, II and III imply: 1) increasing efforts to improve co-ordination and facilitation of the issues at EU level and 2) increasing efforts to raise awareness among 
Member States and other stakeholders of the im portance to consider hea lth and social issues 
notably in the present economic crisis. The extent to which the activities assist action by 
Member States and other stakeholders to reduce health inequalities is the main determinant of 
the impact of the proposals.  
6.1. Social Impacts 
The actions in the three options  are expected to have positive social impacts and none is 
expected to have a negative so cial impact. Compared to Option I,  Options II and III are likely 
to have a greater positive social impact 
An important issue is that the present economic crisis can increase health  inequalities through 
a deterioration of some determinants of hea lth. Option II and III, through stronger awareness 
raising activities could help to ensure that, at  a time of prioritisation, Member States do not 
neglect this policy area and incur negative fu ture economic and social consequences.  
6.2. Economic impacts 
Indirect economic costs of larg e health inequalities are poten tially considerable. They cannot 
be estimated with precision. One study has es timated the potential economic gain from 
bringing the health of the whol e population up to the level of those with higher education to 
be between 1.2% and 9% of GDP.  
It is difficult to identify the costs of actions to improve data availability and comparability, 
notably by socio-economic status.  
Overall, progress on the determinants of health  and health inequalities would likely have a 
positive economic impact. In the long run gains in  health and reductions in loss of healthy life 
years may be cost neutral or of overall economic benefit.  
7. A
PPRAISAL OF THE OPTIONS  
All three options would help to achieve the gene ral objectives with Option III likely to have 
the largest effect. However, Option III involves additional costs and faces some 
implementation barriers. Based on feasibility (not ably the ability to act  in relation to the 
current crisis) and the costs involved Option II is the preferred Option. Option II can be seen 
as a stepping stone to further EU level work  on health inequalities and fully respects the 
principle of subsidiarity.  
 
EN 7   EN 8. MONITORING AND EVALUATION  
Actions assessed include proposals to improve  information, monitoring and reporting on 
progress on health inequalities and their determ inants which can be used for monitoring and 
evaluation. The Commission will al so use expert support for re gular analyses of EU policy 
developments through the European Observatory on the Social Situation and the Observatory 
on Health Systems and Policies. An additiona l monitoring mechanism is a Commission report 
in 2012 on the implementation of this initiative and the progre ss it has had on addressing 
health inequalities, with fu rther reports envisaged.  
 
EN 8   EN Option I  
– Business as usual  Option II  
– Current  plus Option III  
– Far reaching  
 
EN 9   EN