2009
THE EUROPEAN UNION’S PUBLIC 
HEALTH PROGRAMME  (2003–07): 
AN EFFECTIVE WAY TO IMPROVE HEALTH?EUROPEAN COURT 
OF AUDITORS
Special Report  No 2
ISSN 1831-0834
EN

THE EUROPEAN UNION’S 
PUBLIC HEALTH PROGRAMME (2003–07): AN EFFECTIVE WAY TO IMPROVE HEALTH?Special Report  No 2   2009
EUROPEAN COURT OF AUDITORS(pursuant to Article 248(4), second subparagraph, EC)
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?2
EUROPEAN COURT OF AUDITORS
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E-mail: euraud@eca.europa.eu
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Special Report  No 2   2009
More information on the European Union is available on the Internet (http://europa.eu).
Cataloguing data can be found at the end of this publication.Luxembourg: Office for Official Publications of the European Communities, 2009ISBN 978-92-9207-227-8
© European Communities, 2009
Reproduction is authorised provided the source is acknowledged.
Printed in Belgium
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?3
CONTENTS
Paragraph
 ABBREVIATIONS
I–VI EXECUTIVE SUMMARY
1–9 INTRODUCTION
10–12  AUDIT SCOPE AND APPROACH
13–82  AUDIT OBSERVATIONS
13–33  PROGRAMME DESIGN
14–18 INTERVENTION LOGIC NOT MADE EXPLICIT
19–21 PROGRAMME OBJECTIVES NEITHER SPECIFIC, NOR MEASURABLE OR TIME-DEPENDENT
22–28 ABSENCE OF STRATEGIC PLANNING AND LACK OF PRIORITY SETTING29–33 INDICATORS AT PROGRAMME LEVEL INADEQUATE TO MONITOR ACHIEVEMENTS
34–65  PROGRAMME IMPLEMENTATION: FROM PROJECT DESIGN TO RESULTS
35–38 PROJECT OBJECTIVES NOT SPECIFIC, VERIFIABLE AND QUANTIFIABLE
39–49  DEFINITION OF EXPECTED PROJECT RESULTS, IDENTIFICATION OF TARGET GROUPS AND PLANNING 
FOR SUSTAINABILITY THE EXCEPTION RATHER THAN THE RULE
50–54 COMPLEMENTARITY OF PROJECTS AND CONSISTENCY OF PROJECT PORTFOLIO NOT ADEQUATELY MONITORED55–65 LIMITED EUROPEAN ADDED VALUE
66–82  PROJECT MANAGEMENT
67–69 PARTNERSHIP FUNCTIONED WELL
70–73 PROJECT MONITORING BY COMMISSION AD HOC RATHER THAN SYSTEMATIC74–78 OUTPUTS DELIVERED, BUT NOT ACTIVELY DISSEMINATED
79–82 PROJECT EVALUATION NOT YET COMMON PRACTICE
83–92  CONCLUSIONS AND RECOMMENDATIONS
 ANNEX I: PHP 2003–07 (‘HEALTH DETERMINANTS’ STRAND) — FUNDED PROJECTS BY TOPIC
 ANNEX II: PHP (‘HEALTH DETERMINANTS’ STRAND) — ANALYSIS OF SIX POLICY AREAS ANNEX III:  PHP (‘HEALTH DETERMINANTS’ STRAND) — APPLICATION OF THE SMART CRITERIA TO THE PROJECT 
OBJECTIVES STATED IN THE GRANT AGREEMENTS OF THE 36 AUDITED PROJECTS
 REPLY OF THE COMMISSION
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?5
ABBREVIATIONS
ABM : Activity-based management
AWP : Annual work plan
DG JLS : The European Commission’s Directorate-General for Justice, Freedom and 
Security
DG RTD : The European Commission’s Directorate-General for Research
DG SANCO : The European Commission’s Directorate-General for Health and Consumers
DG TREN : The European Commission’s Directorate-General for Transport and Energy
EAV : European added value
EC: European Community
ECDC : European Centre for Disease Prevention and Control
EMCDDA : European Monitoring Centre for Drugs and Drug Addiction
EU: European Union
NGO : Non-governmental organisation
PHEA : Public Health Executive Agency, renamed Executive Agency for Health and  Consumers 
(EAHC) in July 2008
PHP : Public Health Programme (2003–08)
PHP 2 : Second Programme of Community Action in the Field of Health 2008–13
RDI cycle : Research – development – implementation cycle
RTD : Research and technical development
WHO : World Health Organisation
REPLY OF THE 
COMMISSION
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?6
EXECUTIVE SUMMARY
I.
The Public Health Programme (PHP) for  
2003–07 aimed at complementing the meas-
ures taken by Member States to protect and 
improve public health. It was structured  
around three programme strands: ‘health  
information’, rapid reaction to ‘health  threats’ and health promotion through  
addressing ‘health determinants’.
II.
During this period the programme awarded grants to consortia of organisations for the 
implementation of some 352 projects, the  total Community contribution being approxi -mately 232 million euro.
III.
The Court’s audit asked whether the right  conditions were set for the projects financed 
from the EU budget to contribute effectively 
to improving the health of European citi-
zens, as a complement to measures taken  
by Member States. In particular, the Court  
examined whether:
the design of the PHP provided a suitable (a) 
framework for the effective implemen-
tation and monitoring of Community-
funded health promotion actions;
the Commission ensured, at the pro- (b) 
gramme implementation and project  
selection stage, that projects funded  
under the ‘health determinants’ strand 
of the PHP were likely to achieve sustain-able results, were complementary and  
provided EU added value; and
the Commission and project coordina- (c) 
tors ensured that projects were managed effectively.
REPLY OF THE 
COMMISSION
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?7
IV.
The Court’s findings and conclusions were  
as follows:
The PHP was set very broad and ambi- (a) 
tious objectives that contrasted sharply 
with the limited means at its disposal. In such a situation it is essential to focus on 
what can actually be achieved. However, 
the intervention logic was at no point  
made explicit, which was not conducive to setting clear, meaningful and logi-cally linked objectives and specifying  
appropriate performance indicators. As a result, the PHP lacked strategic focus. The programme’s ‘action areas’ estab-lished in the annual work plans outnum-
bered the projects funded to address  
them. Since project proposers were  invited to apply for funding under often 
very general headings, the multiplicity 
and diversity of project topics and target 
groups caused input to be diluted and  
led to fragmented results.
Project effectiveness was hindered by  (b) 
design weaknesses and implementa-
tion problems. With few exceptions,  
projects did not define what results  
they intended to achieve, and there-
fore were unable to demonstrate that  they had had any effect. Sustainability  
was often understood by participants  
as the continuation of project activi-
ties and was therefore heavily depend-
ent on continued Community funding.  
There was no systematic monitoring of 
actions already undertaken in the differ-ent priority areas, which sometimes led 
to duplication of work.
On the positive side, the programme  (c) 
brought stakeholders from different  countries together. Projects generally  
had a European dimension and, in many 
cases, facilitated the sharing of experi-
ences and mutual learning. Networks  were the clearest providers of European added value.EXECUTIVE 
SUMMARY
V.
In view of its findings, the Court recommends 
that the programme logic should be made  
explicit in any similar future legislation.  
Where the current programme is concerned, 
the Commission should undertake a map-
ping exercise to gain an overview of actions already implemented and thus to identify  
any remaining gaps. The number of annual 
priorities should be significantly reduced,  
and they should be focused on strategic top-ics and activities with an obvious European added value. The Commission should also  
address the weaknesses identified in project design and implementation.
VI.
More fundamentally, for the period after  2013 the Commission and the Member States are invited to reconsider the EU’s funding  
approach in the field of public health. Other 
cooperation mechanisms which exist, such 
as the ‘open method of coordination’, could 
be further developed.
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?8
INTRODUCTION
 1.  Article 152 of the EC Treaty sets out the Communities’ role in the field of 
public health, stating that Community activities are directed towards 
‘improving public health, preventing human illness and diseases, and  
obviating sources of danger to human health ’. These Community actions 
are to complement measures taken at national level and need to  
respect the Member States’ responsibilities for the organisation and 
delivery of health services and medical care.
 2.  The European Commission’s main role in the area of public health is 
to facilitate cooperation between Member State authorities, and to implement incentive measures. Apart from specific competence for the safety standards of organs, substances of human origin and blood, the EU’s legislative power in this area is limited to incentive measures that exclude any harmonisation of the laws and regulations of the  Member States.
 3.  The first Public Health Programme (PHP) was adopted for the 2003–08 
period by Decision No 1786/2002/EC of the European Parliament and 
of the Council1 and replaced eight action programmes on specific  
health topics2. The PHP addressed three general objectives:
to improve information and knowledge for the development of (a) 
public health (‘health information’ strand);
to enhance the capability of responding rapidly and in a coordi- (b) 
nated fashion to threats to health (‘health threats’ strand);
to promote health and prevent disease through addressing health (c) 
determinants across all policies and activities (‘health determi-nants’ strand).
 4.  To achieve these objectives, the Commission awarded grants to consortia 
of organisations (governmental, non-governmental, academia) imple-
menting projects which addressed the priority public health issues defined in annual work plans (AWPs) established by the Commission 
and a committee of Member States’ representatives
3.1 OJ L 271, 9.10.2002, p. 1.
2 These were the programmes 
of Community action on cancer, rare diseases, pollution-
related diseases, AIDS and 
other communicable diseases, 
injury prevention, prevention 
of drug dependence, health monitoring, and health promotion, 
information, education and 
training.
3 The Programme Committee acts 
as the management committee 
referred to in Articles 4 and 7 of Council Decision 1999/468/EC
(OJ L 184, 17.7.1999, p. 23) for 
the annual plan of work for 
implementing the programme. 
It oversees the arrangements, 
criteria and procedures for 
selecting and financing programme actions, arrangements 
for implementing joint strategies 
and actions and evaluating 
the programme, and certain 
measures in connection with the coordination of health monitoring 
and rapid reaction to health 
threats. Other measures linked to 
the implementation of the PHP 
are adopted through the advisory procedure referred to in Articles 3 
and 7 of Decision 1999/468/EC.
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?9
4 Figures for the 2007 call for 
proposals are based on the list of 
accepted proposals. Negotiations 
for several contracts were still ongoing as of October 2008. 5.  The PHP covered the years 2003 to 2007. Some 352 projects were funded 
during this period, with the EC contribution totalling 231,7 mil-
lion euro in commitments4 (see Figure 1 ). The ‘health determinants’ 
strand was the largest of the three in budgetary terms, with a Com-munity contribution of 90,8 million euro corresponding to 40 % of the total amount committed for projects.
TOTAL COMMUNITY CONTRIBUTION (COMMITMENTS IN MILLION EURO 
AS A PERCENTAGE OF THE TOTAL BUDGET) AND NUMBER OF PROJECTS PER PROGRAMME STRANDFIGURE 1
 6.  Under the PHP, grant agreements were concluded with project coordina-
tors, who received co-financing of up to 60 % (in exceptional cases 
up to 80 %) of the costs incurred for carrying out project activities. In 
addition to grants for projects, a minor part (about 3 %) of the PHP’s operational budget was used for service contracts through tendering 
procedures.Health threats
58,8 million euro (25 %)68 projects Health information
82,1 million euro (35 %)135 projects 
Health determinants
90,8 million euro (40 %)149 projects 
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?10
 7.  Projects funded from the PHP were very diverse in terms of size, approach 
and target group (see Box 1 ). Consortia varied in size from three  
to 60 partners, the Community contribution ranged from 45 000 to 2,5 million euro, and types of project activities differed widely.
 8.  On 1 January 2008 the Second Programme of Community Action in the 
Field of Health 2008–13 (PHP2) came into force5. The Commission  
had originally proposed to merge the public health and consumer  
protection programmes6. It had also proposed increasing the budget 
by around 270 % (804 million euro for health for 2008–13), arguing that the PHP budget for health actions was insufficient to respond to the Treaty obligation of countering threats to health
7.
 9.  However, following the interinstitutional agreement of 17 May 2006 on 
the 2007–13 financial framework, neither the merger of the health 
and consumer protection programmes nor the increased budget was 
accepted by the European Parliament and the Council. The outcome 
of the legislative process was a second health programme with similar 
objectives and activities to the PHP, but a reduced budget of 322 mil-lion euro, about 9 % per annum less than that of the predecessor  
programme (see Box 2 ).5 Decision No 1350/2007/EC of 
the European Parliament and of 
the Council (OJ L 301, 20.11.2007, 
p. 3).
6 COM(2005) 115 final.
7 ‘Le maintien du budget actuel 
ne permet pas une mise en oeuvre optimale des obligations du Traité, 
ni de répondre à la volonté politique 
d’en faire plus pour les citoyens en 
matière de santé et en matière de 
protection des consommateurs. 
En effet, les ressources financières 
existantes ne permettent pas à la Communauté d’assurer de façon 
exhaustive les actions nécessaires 
notamment en ce qui concerne 
la lutte contre les grands fléaux 
ou maladies importantes et la 
coopération entre les États membres 
en matière de santé .’ (Impact 
assessment SEC(2005) 0425, p. 29).
PHP (‘HEALTH DETERMINANTS’ STRAND) — EXAMPLES OF PROJECT ACTIVITIES
Collecting data on falsified prescriptions as an indicator of drug abuse.• 
Organising a scientific symposium on the medical side-effects of doping.• 
Preparing a report on compliance with alcohol marketing regulations.• 
Producing and disseminating information material for migrant sex workers.• 
Organising a competition to promote smoke-free school classes.• 
Developing national and regional breastfeeding policy and plans.• BOX 1
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?11
COMPARISON PHP (2003–07) VS PHP2 (2008–13)BOX 2
PHP (2003–07) PHP2 (2008–13)
Legal basis Decision No 1786/2002/EC of the 
European Parliament and of the Council of 23 September 2002 adopting a programme of Community action in the fi  eld of public 
health (2003–08)Decision No 1350/2007/EC of the 
European Parliament and of the Council of 23 October 2007 establishing a second programme of Community action in the fi  eld of health (2008–13)
Objectives •  to improve information and knowledge 
for the development of public health
•  to enhance the capability of responding 
rapidly and in a coordinated fashion to threats to health
•  to promote health and prevent disease 
through addressing health determinants across all policies and activities•  to generate and disseminate health 
information and knowledge
•  to improve citizens’ health security•  to promote health, including the 
reduction of health inequalities
Budget according to programme decision 354 million euro (for 2003–08)8
i.e. 59 million euro p.a. over 6 years322 million euro (for 2008–13)
i.e. 53,7 million euro p.a. over 6 years
Funding mechanisms Grants for actionsTenders (service contracts)
9Grants for actionsOperating grantsConferencesJoint actionsTenders (service contracts)
Programme implementation DG SANCO10Fully managed by the PHEA11
Impact assessment Not done Extended impact assessment (2005)12
8 There are two main reasons for the diff  erence between the indicative PHP budget given in the programme decision and the 
fi gure of 231,7 million euro mentioned in paragraph 5 as committed for projects in 2003–07: the indicative budget included about  
58 million euro for 2008 (which was then covered by PHP2), and it also covered expenditure for the Executive Agency.
9 A ceiling of 10 % of the operational budget was set in the AWPs for calls for tenders. This ceiling was increased to 20 % in P HP2.
10 From 2005, grant management and the organisation of calls for proposals were gradually transferred to the Public Health Execut ive 
Agency (PHEA) (fully operational since 1 January 2007).
11 Commission Decision 2004/858/EC (OJ L 369, 16.12.2004, p. 73). In 2008 the PHEA was renamed the Executive Agency for Health an d 
Consumers (EAHC).
12 SEC(2005) 0425, annex to the health and consumer protection strategy and programme proposal (COM(2005) 115 fi  nal).
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?12
AUDIT SCOPE AND APPROACH
 10.  Health promotion actions can be defined as ‘ actions which support people 
to adopt and maintain healthy lifestyles, and which create supportive  
living conditions (environments) for health ’13. Actions of this type were 
largely covered by the ‘health determinants’ strand of the PHP. The audit analysed whether the right conditions were set by the Euro-pean Parliament, the Council and the Commission when designing  the programme, and by the Commission and the project coordinators 
when implementing it, for projects to contribute effectively to the 
capacity of European citizens to improve their health.
 11.  The Court examined whether:
the design of the PHP provided a suitable framework for the effect- (a) 
ive implementation and monitoring of Community-funded health promotion actions complementing measures taken by Member  
States;
the Commission ensured, at the programme implementation and (b) 
project selection stage, that projects under the ‘health deter-
minants’ strand of the PHP were likely to achieve sustainable  
results, were complementary and provided EU added value; and
the Commission and project coordinators ensured that projects (c) 
were managed effectively.
 12.  The audit involved:
an analysis of the programme’s legal base and a review of pro- (a) 
gramme evaluations and other relevant documentation;
an analysis of Community actions and policy development in  (b) 
selected areas of the ‘health determinants’ strand: drugs, alco-
hol, tobacco, sexual and reproductive health, mental health, and 
nutrition and physical activity14. The analysis included a review 
of Commission policy papers, WHO policy papers, initiatives and 
programmes in the Member States and third countries, and aca-demic and scientific literature;
an assessment of a sample of 36 (out of a total of 149) projects (c) 
funded from the ‘health determinants’ strand, i.e. one of the three 
strands of the PHP (2003–07). The sample covered all projects  in the six selected areas which had reached a sufficient level of 
project maturity at the time of the audit
15. The assessment included 
a review of the project documentation, interviews with all the  project coordinators and an online survey of project partners
16;13 Don Nutbeam et al., The Evidence 
of Health Promotion Effectiveness — 
Shaping Public Health in a New 
Europe, International Union for 
Health Promotion and Education 
(IUHPE), 1999, p. 3.
14 The selected policy areas 
comprised all six lifestyle-related priority areas of the ‘health 
determinants’ strand. In all these 
areas projects were selected for 
funding in each of the years 2003 
to 2007 (see Annex I ).
15 The sample included all projects 
which were either completed 
or had submitted at least a first 
interim technical report in the 
six ‘lifestyle health determinants’ 
policy areas: alcohol, tobacco, 
drugs, nutrition and physical 
activity, sexual and reproductive health and mental health.
16 The survey was conducted 
to obtain the other project 
participants’ views on the partnerships and the management 
of health promotion projects, 
and ran from 11 March to 
4 April 2008. The questionnaire 
used by the Court was based 
on previous surveys in this field 
(see El Ansari W., ‘Educational 
Partnerships for Health: Do 
Stakeholders Perceive Similar 
Outcomes?’  in Journal of Public 
Health Management and Practice, 
Vol. 9(2), 2003, pp. 136–156 ). 
Some 505 participants in the 
sampled projects were surveyed, 
242 of whom completed the 
questionnaire in full — a response 
rate of 47,9 %. A further 19 participants responded to some 
but not all of the survey questions.
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?13
interviews with staff from DG SANCO and the PHEA; (d) 
a quantitative analysis of proposals submitted, projects funded (e) 
and project budgets;
consultation of stakeholders at national ministries of health and (f) 
public health institutes, Member States’ representatives on the 
Programme Committee and national focal points in eight Mem-
ber States (Belgium, Estonia, Finland, France, Germany, Latvia,   Sweden, United Kingdom); and
a discussion of relevant issues with a group of experts in the  (g) 
field of health promotion and disease prevention at several stages during the audit. The experts’ main input was to contribute to  the Court’s analysis, for example by suggesting the RDI cycle as a framework for analysis (see Box 10 ), and to endorse the audit 
observations set out in this report.
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?14
PROGRAMME DESIGN
 13.  Programmes are more effective if they are properly designed and the intended 
results are clearly set out. This is more likely to be the case if:
the underlying logic of the intervention is made explicit in the  (a) 
programme decision (or its accompanying documentation);
programme objectives are defined which are specific, measurable, (b) 
achievable, relevant, and time-dependent (SMART);
priorities are set in accordance with the organisation’s strategy; and (c) 
performance and achievements can be monitored based on robust (d) 
and meaningful indicators.
INTERVENTION LOGIC NOT MADE EXPLICIT
 14.  A key element of programme design is defining the intervention logic — 
the hypothetical cause and effect linkages that describe how an inter-
vention is expected to attain its global objectives. In the EU context, 
these overall objectives of policies and programmes are generally  
defined by the Treaty. Intervention logic provides the conceptual  
link from an intervention’s inputs to the production of its outputs  and, subsequently, to its impacts on society in terms of results and 
outcomes
17. Making explicit the logic of a planned intervention allows 
the construction of a hierarchy of objectives and the identification 
of key indicators for monitoring and evaluation.
 15.  Logic models showing how inputs into the various activities will lead to 
the expected results are the most appropriate way of showing the  
intervention logic. Neither the Commission’s legislative proposal for 
the programme18 nor the legal basis for the PHP or any other rel-
evant documents (such as impact assessments19 or AWPs) explicitly 
described the programme’s intervention logic in this way. The situ-ation is unchanged for PHP2.
 16.  Logic models are used in other areas of EU policy, such as external actions, 
and are common practice in the public health field in other parts of the world (United States, Canada). For example, logic models were used for programme planning, implementation and evaluation in  
the Southern Arizona Border Health Careers Opportunity Program
20, 
the Health Improvement Initiative funded by the California Wellness 
Foundation21 and the Calgary Cross-Cultural Mental Health Consulta-
tion Project22.AUDIT OBSERVATIONS
17 European Commission, 
DG Budget, ‘Evaluating EU 
activities: a practical guide for the 
Commission services’, July 2004, 
p. 87.
18 COM(2000) 285 final.
19 The Commission’s proposal for 
the PHP predated the introduction, 
in 2002, of mandatory impact 
assessments and consequently 
was only subject to a limited cost-effectiveness analysis. 
By contrast, there has been an 
extended impact assessment for 
PHP2 (see European Commission, 
SEC(2005) 0425; IA for the 
proposed combined health and 
consumer protection strategy and programme).
20 ‘How Using a Logic Model 
Refined Our Program to Ensure 
Success’, M. Page, S. H. Parker and R. Renger, in: Health Promotion 
Practice OnlineFirst , published on 
28 August 2007.
21 ‘Evaluating the California 
Wellness Foundation’s Health 
Improvement Initiative: A Logic Model Approach’, A. Cheadle, 
W. L. Beery, H. P. Greenwald, 
G. D. Nelson, D. Pearson and 
S. Senter, in: Health Promotion 
Practice , April 2003; vol. 4: 
pp. 146–156.
22 ‘Evaluability Assessment: 
A Catalyst for Program Change 
and Improvement’, W. E. Thurston, J. Graham and J. Hatfield, 
in: Evaluation and the Health 
Professions , June 2003; vol. 26: 
pp. 206–221.
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?15
 17.  In their report on the mid-term evaluation of the PHP23, the external 
evaluators recommended developing such a systematic and reasoned 
evidence-based description of the links between inputs, activities, outputs and outcomes (see Box 3 ). The Court has recommended the 
use of intervention logic for programme design, objective-setting  
and performance measurement for other budgetary areas
24.
 18.  In the Court’s view, the definition of SMART programme objectives ( see 
paragraphs 19 to 21) and the setting of robust indicators for an effec-tive monitoring of the programme implementation (see paragraphs 70 to 73) is more difficult to achieve in the absence of a conceptual 
framework.
RECOMMENDATIONS OF THE INTERIM EVALUATION OF THE PUBLIC HEALTH 
PROGRAMME 2003–08
‘[The PHP] is, at this interim stage, delivering the programme of work identified in its annual work plans. 
However, this is a good time for building on these achievements by:
developing sharper priorities that are driven by stakeholder expectations and citizens’ needs as well • 
as meeting policy goals and high standards of probity;monitoring its activities against not only the aims of each project but also the overall aims of the 
• 
programme decision;communicating its priorities and actions more crisply to stakeholders, and targeting tailored mes-
• 
sages to members of the wider public health community.
Understanding what is required to deliver this would be facilitated by developing a logic model capable 
of tracing the precise causal relationships that are anticipated to connect the programme activities to its intended outcomes.’
(Wija J. Oortwijn et al, Interim evaluation of the Public Health Programme 2003–08. Final Report, RAND Europe technical report,  
2007, p. 6).BOX 323 Wija J. Oortwijn et al, Interim 
evaluation of the Public Health 
Programme 2003–08. Final Report, 
RAND Europe technical report, 2007, p. 6.
24 See Special Report No 9/2007, 
‘Evaluating the RTD framework 
programmes — could the Commission approach be 
improved?’(OJ C 26, 30.1.2008), 
paragraphs 34 to 36, and Special 
Report No 7/2008, ‘Intelligent 
energy (2003–06)’ (OJ C 279, 
1.11.2008), paragraphs 18 and 21.
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?16
PROGRAMME OBJECTIVES NEITHER SPECIFIC, 
NOR MEASURABLE OR TIME-DEPENDENT
 19.  Objectives are defined, in the Commission’s activity-based management 
(ABM) system, as the desired effects of an activity. They should not be 
a description of the activity itself, but rather illustrate the change to 
be achieved by that activity25. The setting of SMART objectives for all 
sectors of EU activity covered by the budget is an obligation under the Financial Regulation
26.
 20.  Without an explicit intervention logic it is difficult to set coherent pro-
gramme objectives. In fact, as illustrated by the ‘health determinants’ 
strand, the PHP programme decision listed the possible activities in very broad and general terms. The global policy objective, ‘ to promote 
health and prevent disease through addressing health determinants  
across all policies and activities ’, was not broken down into specific, 
measurable and time-dependent targets (see Box 4 ).
 21.  It is not obvious from the programme decision how these activities are 
expected to contribute to the broad policy objective of promoting 
health and preventing disease, or how achievement of this global  
objective could be assessed.
ABSENCE OF STRATEGIC PLANNING AND LACK 
OF PRIORITY-SETTING
 22.  If spending programmes are to have any measurable impact, they need to 
be concentrated on selected activities that are identified through stra-
tegic planning according to a rigorous set of priorities. The number of 
priorities should be commensurate with the available budget, as hav-
ing too many priorities will reduce the chances of achieving impact 
in any individual area.
 23.  Each year the EU Member States spend an average of 1 400 euro per 
capita on health27. While this expenditure includes health promotion 
and health information measures, the bulk of it is related to deliv-
ery of health services and medical care, which the Treaty makes the exclusive remit of Member States.25 European Commission, SPP/ABM 
guide, second edition, October 
2004, p. 25.
26 Article 27(3) of Council 
Regulation (EC, Euratom) 
No 1605/2002 of 25 June 2002 on 
the Financial Regulation applicable 
to the general budget of the 
European Communities (OJ L 248, 
16.9.2002, p. 1).
27 WHO Regional Office for Europe, 
Copenhagen, ‘Public expenditure 
on health, purchasing power parity 
euro per capita, WHO estimates for 
2003–05’, Health for All database (HFA-DB), (http://www.euro.who.
int/hfadb), October 2008.
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?17PHP PROGRAMME OBJECTIVE, ‘HEALTH DETERMINANTS’ STRAND
Programme objectives —
‘health determinants’ strandSMART criteria
Specifi  c
(so that 
progress can 
be checked)Measurable
(need to 
report 
progress 
credibly and 
verifi  ably)Achievable RelevantTime-
dependent
(with 
deadline)
‘To promote health and prevent disease through action on health determinants across all Community policies and activities by:
No
1No2Partly3Yes No43.1. preparing and implementing strategies and measures, including those related to 
public awareness, on life-style related health determinants, such as nutrition, physical activity, tobacco, alcohol, drugs and other substances and on mental health, including measures to take in all Community policies and age- and gender-specifi  c strategies;
3.2. analysing the situation and developing strategies on social and economic health 
determinants, in order to identify and combat inequalities in health and to assess the impact of social and economic factors on health;
3.3. analysing the situation and developing strategies on health determinants related 
to the environment and contributing to the identifi  cation and assessment of the 
health consequences of environmental factors;
3.4. analysing the situation and exchanging information on genetic determinants and 
the use of genetic screening;
3.5. developing methods to evaluate quality and effi   ciency of health promotion 
strategies and measures;
3.6. encouraging relevant training activities related to the above measures.’
1 The objective does not specify what should be changed or include targets against which progress can be monitored.
2 The objective is not measurable or quantifi  able, no performance indicators are defi  ned.
3 On the basis of the ‘activities’ stated in the programme decision as ‘objectives’, it is achievable at least to some degree.
4 No time span is indicated.BOX 4
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?18
28 These nine topics were alcohol, 
tobacco, drugs, nutrition and 
physical activity, sexual and reproductive health and HIV, 
mental health, socioeconomic 
determinants of health, 
environmental determinants, and 
disease and injury prevention. 
In 2003 and 2004, additional 
topics were training in public health (later changed to capacity 
building) and health promotion 
in particular settings. In 2005, the 
latter topic was discontinued and 
genetic determinants of health 
was added. 24.  The PHP budget of approximately 59 million euro per year assigned 
to health promotion and information measures, and to countering  
health threats, amounts to 13 cents for each European citizen. In this situation, an appropriate response by the EU would be to target its 
relatively small budget on a few selected priority activities in areas 
of clear European added value — those issues which can be most  effectively addressed at international level.
 25.  The priorities to be addressed in the field of public health are set out 
in AWPs, which provide a source of guidance for project proposers. 
The AWPs for 2003–07 contained extensive lists of topics for each  
programme strand, covering a broad range of issues. Each year, nine 
such topics were proposed under the ‘health determinants’ strand  (with an annual budget of approximately 18 million euro). A further three areas were funded in some but not all years
28 (see Annex I ).
 26.  Between one and seven annual areas for potential action were set, rang-
ing from specific to general, for each of these nine topics (see exam-ples in Box 5 ). These annual ‘action areas’ were defined in terms of 
activities for which project proposals could be submitted, not as  
objectives towards which progress could be assessed.
 27.  As a result, the AWPs for 2003–07 set a total of 154 ‘action areas’ for the 
‘health determinants’ strand alone. During the same period, only 149 projects were funded under that programme strand, meaning that, even under optimum circumstances, not all of these areas could be 
tackled through a project. In reality, coverage of priorities was even 
lower because several projects addressed the same ‘action areas’.  Moreover, broad health topics like nutrition, alcohol and mental  
health were often only addressed by one or two projects in a given 
year (see Annex I ).
 28.  Since organisations and consortia were invited to apply for funding 
under often very general headings (see examples in Box 5 ), proposals 
submitted to the Commission very often lacked strategic focus. This 
is a problem in particular in areas where projects were expected to 
provide background studies or otherwise contribute to policy devel-
opment. In these areas, tendering (and the use of service contracts) allows for a more precise definition of the expected deliverables. This 
was however limited to a maximum of 10 % of the PHP budget. This 
ceiling has been increased to 20 % under PHP2 (see Box 2 ).
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?19
ANNUAL ‘ACTION AREAS’ FOR THE PHP ‘HEALTH DETERMINANTS’ STRANDBOX 5
Topic Annual ‘action areas’ defi  ned in AWPs (examples)
(Source:  AWPs for the implementation of the PHP, 2003–07)
Tobacco ‘Promote strategies to ‘de-normalise’ smoking, including strategies and 
measures to reduce the prevalence of smoking.’ (2004)
Alcohol ‘To assess the enforcement of national laws and self-regulation on the 
advertising and marketing of alcoholic beverages.’ (2004)
Drugs ‘Priority will be given to proposals on:
•  treatment and reinsertion activities covering all Member States and including 
both misuse/abuse of legal/illegal drugs;
•  best practice on improving the availability of prevention and harm reduction 
services and giving priority to HIV/AIDS and other blood-borne infections.’ (2005)
Nutrition and physical activity ‘Develop innovative measures to improve dietary habits and physical activity habits in all population groups.’ (2003)
Mental health ‘Building on the review of existing best practices, develop strategies for implementation of interventions in relevant settings aiming at promoting mental health and preventing depression, suicide and related disorders.’ (2003)
Sexual and reproductive health ‘Taking account of information from the health monitoring system, develop health promotion strategies and defi  ne best practices to address sexual 
education (teenage pregnancy, family planning) and prevention of sexually transmitted diseases such as HIV/AIDS, including consideration of approaches in school settings and those targeting specifi  c groups.’ (2004)
Injury prevention ‘Support will be given to exchanging best practice on child safety for all Member 
States, EEA and candidate countries and to promoting child safety through a European conference. Special attention will be paid to tackling physical violence and danger awareness by organising hands-on injury-prevention activities.’ (2006)
Environmental determinants ‘Priority will be given in 2004 to actions which support the development of health and environment policies and strategies, and the integration of health and environment concerns in other Community policies. A specifi  c 
focus will be on the provision of advice and expertise to develop activities, including legislative work and other initiatives on health aspects related to the environment, particularly in relation to air pollution (including indoor air pollution) and electromagnetic fi  elds.’
Socioeconomic 
determinants‘Tackling socioeconomic determinants will continue to be a key priority for the programme. In 2004, work will be supported on:1.  identifying eff  ective strategies to address inequalities in health and the health 
impact of socioeconomic determinants in specifi  c settings and for population 
groups which are particularly aff  ected, in particular in socially excluded, 
minority and migrant populations;
2.  developing strategies to address the health eff  ects of unemployment and 
precarious employment conditions.’
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?20
INDICATORS AT PROGRAMME LEVEL INADEQUATE 
TO MONITOR ACHIEVEMENTS
 29.  Under ABM, the Commission DGs are required to define clear, meaning-
ful and logically linked objectives for their activities, and to identify appropriate performance indicators for monitoring achievement.  Indicators should be defined both for impact (difference made to  
the target group) and output (means through which the difference 
will be brought about)
29.
 30.  The absence from the PHP decision or the AWPs of an explicit inter-
vention logic and specific, measurable and time-dependent objec-tives impeded the development of such performance indicators. For example, DG SANCO’s annual management plans did not include any impact indicator for the ‘health determinants’ objective until 2006. 
The impact indicator Healthy Life Years (measuring the number of  
years that a person of a certain age can expect to live without ill  
health) was the outcome of a project co-financed by the Commission 
and was specified as a Lisbon structural indicator in 2005.
 31.  However, even the impact indicator subsequently developed was still 
too general to be used for monitoring or evaluation and was not  
linked to any quantified target. As the example illustrates, the impact 
indicator was framed as an objective rather than a way to measure achievements (see Box 6 ).29 European Commission, 
Secretariat General: SPP/ABM 
guide, second edition, October 
2004, p. 26 ff.
IMPACT INDICATOR FOR PHP ‘HEALTH DETERMINANTS’ STRAND IN THE 2006 AMP
‘Increase awareness and response from stakeholders and public policy, with regard to lifestyle-
related health determinants, particularly concerning nutrition and physical activity, alcohol and diseases with a key public health relevance.’BOX 6
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?21
SELECTED INDICATORS FOR THE OBJECTIVE OF ‘FOSTERING GOOD HEALTH 
IN AN AGEING EUROPE’ IN THE 2009 AMP
‘• Level of public awareness of unhealthy behaviours and lifestyle-related health risks and health deter-
minants, in particular on nutrition, physical activity and alcohol’ to be raised from 66 % to 80 %;
‘• Share of citizens who have their blood pressure measured each year ’ to be raised from 59 % to 
80 %;
‘• Share of population aware of the health risks of tobacco smoke for non-smokers ’ raised from 75 % 
to 80 %.BOX 7 32.  The situation has improved recently, in that the activity statements for 
the 2009 preliminary draft budget set impact indicators and quan-
tified targets in relation to the public awareness of certain health  determinants (see Box 7 ).
 33.  However, at the time of this report the Commission had not yet used 
these indicators to assess the effectiveness of the PHP as a whole or 
of individual projects. In fact, the audit found that the Commission had not set up an adequate monitoring system at any stage which  
would have enabled it to carry out such a performance measurement 
(see paragraphs 70 to 73).
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?22
PROGRAMME IMPLEMENTATION: FROM PROJECT DESIGN 
TO RESULTS
 34.  For a programme to be effective, its projects need to achieve posi-
tive results. This is more likely to be the case if, before a project is launched, its objectives, target groups and intended results have  been defined and it has been identified how the results will produce 
the intended impacts.
  In this policy area, effective implementation also requires from the Com-
mission, as programme manager, that
it has an adequate overview of its project portfolio to ensure  (a) 
coherence and consistency; and
the projects funded clearly demonstrate European added value (b) 
(EAV).
PROJECT OBJECTIVES NOT SPECIFIC, VERIFIABLE 
AND QUANTIFIABLE
 35.  Projects should be designed in a way that makes it likely they will be 
effective. As at programme level, an important part of project design 
is to set SMART objectives; these should be logically derived from  
the policy objectives as defined in the programme decision. The PHP award criteria required proposers to define ‘ specific and realistic objec-
tives … The project must set verifiable and quantifiable objectives ’
30.
 36.  The Court’s analysis of the grant agreements for the audited projects 
showed that promoters presented a mixture of activities and out-
puts rather than objectives when submitting their proposals. Typi-
cal project ‘objectives’ were the exchange of information between organisations in the field, capacity-building and the promotion of  ‘good practices’ (see Box 8 ). However, the Commission took no cor-
rective measure to address this shortcoming before entering into the grant agreement.30 ‘Rules, criteria and procedures 
for the selection and funding of 
actions under the public health 
programme’ (OJ C 62, 15.3.2003).
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?23
 37.  The Court’s detailed analysis of whether the project objectives stated in 
the grant agreements were to qualify as being SMART is presented in 
Annex III . It concludes that not one sampled project had objectives 
that were fully SMART. Objectives were not stated in a measurable 
and time-dependent format, and it was unclear to what degree they 
were attainable. They were not expressed in terms of targets towards which progress could be monitored at a later stage. However, where projects did define a specific target group, the stated objectives were 
generally relevant to the target group (see paragraph 40).
PHP (‘HEALTH DETERMINANTS’ STRAND) — EXAMPLES OF PROJECT OBJECTIVES 
FROM GRANT AGREEMENTS
A & M (‘European Centre AIDS and Mobility’):
‘• To stimulate collaboration and networking between European Member States and applicant coun-
tries on the issue of (young) migrants ’
‘• To assess and document best practice with respect to prevention, care and support in Europe in the 
field of HIV/AIDS and migrant, mobile and young people ’
CHOB (‘Children, obesity and associated avoidable chronic diseases’):
‘• To measure and analyse the impact of food marketing to children and young people ’
‘• To determine and consider policy options aimed at addressing obesity in children ’
ELSA (‘Enforcement of National Laws and Self-Regulation on Advertising and Marketing 
of Alcohol’):
‘• To create an expert network of partners from 28 European countries, to train the partners in the 
assessment of national laws and self-regulation and to convene three meetings of the network ’
‘• To prepare a report on the existing national laws, structures and regulation and self-regulation 
mechanisms on the advertising and marketing of alcoholic beverages ’BOX 8
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?24
 38.  However, this does not imply that it is impossible to set SMART objec-
tives in this field. Within the sample audited, the audit also found  
an example of a project with specific objectives which could have  achieved full compliance with the SMART criteria after only minor  
adjustments (see Box 9 ).
DEFINITION OF EXPECTED PROJECT RESULTS, IDENTIFICATION 
OF TARGET GROUPS AND PLANNING FOR SUSTAINABILITY THE EXCEPTION RATHER THAN THE RULE
 39.  The PHP award criteria required project proposers to aim at ‘… producing 
lasting results conducive to the realisation of the programme’s objec-tives ’
31. Projects were thus expected to specify the intended target 
group and to define what results they intended to achieve and how those results would be sustained beyond the project term.
PHP (‘HEALTH DETERMINANTS’ STRAND) — ‘PEER DRIVE CLEAN! PROJECT’ — 
EXAMPLE OF SMART OBJECTIVES NEARLY ACHIEVED
‘The global objective is to sensitise young adults between 18 and 24 years to the dangers of alcohol 
and drug use and to achieve a modification of the eventual high risk drug use of the target group at an early stage.(...) The target group should be convinced through face-to-face actions of PEER educators to abandon the consumption of intoxicating substances while driving a motorised vehicle .’
Is the formulation of the objectives SMART?
Specific• : yes (target group and what should be changed is clear)
Measurable• : no (‘to sensitise’, ‘to convince’)
Achievable• : yes
Relevant• : yes (young drivers have a higher risk of drink-driving accidents)
Time-dependent• : no
This project’s objectives meet the SMART criteria in all except the measurable and time-dependent 
aspects. These two dimensions could have been satisfied by setting a target for awareness (e.g. ‘ by 
the end of the project, X % of the students taking the driving exam in the participating driving schools 
should be able to name X dangers of alcohol and drug use ’) or, better still, for behavioural change 
(e.g. ‘ none of the participants to be caught drink-driving in the first year after obtaining their driving 
licence ’).BOX 931 ‘Rules, criteria and procedures 
for the selection and funding of 
actions under the public health programme’ (OJ C 62, 15.3.2003).
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?25
TARGET GROUP NOT SPECIFIED IN A MAJORITY OF CASES
 40.  Only 16 of the grant agreements for the sampled health promotion 
projects clearly specified a target group in the grant agreements. Of 
these, only nine specified what changes the project intended to bring 
to that target group. Typically, PHP projects do not directly address European citizens as the ultimate target group of health promotion actions (e.g. people living with HIV, overweight young people, drug 
users, people at risk of becoming alcohol addicts) but work through 
‘intermediate’ groups of health professionals or policymakers. How-ever, nine out of the 36 projects audited by the Court were set up  
from the outset to have a direct health impact on the population.  
They represented more than half of the projects (56 %) specifying a 
target group.
EXPECTED RESULTS NOT LINKED TO INTENDED IMPACTS
 41.  Grant agreements stated each project’s ‘expected results’ under a sepa-
rate heading. However, the Court’s audit of a sample of projects  
found that this amounted to a list of project outputs, deliverables  and activities (e.g. ‘a meeting will be held’, ‘a training manual will be 
developed’), with no explanation how these activities would achieve 
change for the direct addressees. The poor definition of expected  
results and the absence of indicators meant that achievements could 
be neither demonstrated nor disproved.
 42.  The Court also found that proposals did not clarify the logical links 
between projects and their possible social benefits; nor was the exist-ence of such links ascertained by the Commission or the project coor-dinators during the selection process or prior to the signature of  grant agreements. The underlying assumption seems to have been that positive effects would follow from placing the health promo-tion issue on the political agenda, building networks and exchanging information. However, at no stage was it explained how project activi-ties might have a trickle-down effect that would actually improve  people’s capacity to choose healthy lifestyles. This also underlines the importance of having an intervention logic in place.
PLANNING FOR SUSTAINABILITY OF RESULTS IN VERY FEW CASES
 43.  When assessing health promotion projects, the different stages of the 
cycle can be classified as: study and research projects, development 
projects, implementation projects and ‘going-to-scale’ projects,  
known as the RDI cycle (see Box 10 ).
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?26
 44.  PHP projects, with their limited duration (two to three years in most 
cases) and limited resources, are not designed to cover the full cycle 
of health promotion actions from setting up an evidence base to  developing and implementing public intervention and creating a  
lasting health impact. They can only address part of this process.  
Nonetheless, there should be an indicative plan of how the results of a project can be taken up at the next step in the cycle.
 45.  None of the audited projects had a plan for the take-up of their results by 
the next level in the RDI cycle or how their results could be sustained 
over time. The project coordinators interviewed usually understood 
sustainability to mean the continuation of project activities rather 
than the effective use of results after the project term. In all cases audited, the outputs created during the project, such as websites or databases, were not updated after project closure.
 46.  With a few exceptions, it was found that projects did not even contain 
a plan for sustainability and take-up of their results beyond the end of the project funding period. They focused on obtaining a follow-up 
grant from the Commission so that project activities could be con-
tinued. The most common attitude was that project results could be 
sustained only if the partners could continue to secure Community 
funding.
THE RDI CYCLE
The research–development–implementation (RDI) cycle is a concept describing the sequence of 
steps in public health programme development, from fact-finding and creating an evidence base to developing a strategy or work plan, pilot testing and finally full-scale implementation.
Projects covering only one of these steps can be considered sustainable if their results are taken 
up and used by the next step in the cycle. For instance, research projects should ensure that results will be taken to the development stage, and projects developing an intervention should use the evidence base previously established by research projects and plan for (pilot) implementation.
The following project categories were used for this audit:
Study and research projects (e.g. collection of data);
• 
Development projects (e.g. policy, guidelines or programme development);• 
Implementation projects (e.g. piloting, training and capacity building); and• 
‘Going-to-scale’ projects (e.g.dissemination, implementation on a wider scale).• BOX 10
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?27
CONTINUOUS FUNDING OF NETWORKS FOR MORE THAN 10 YEARS
 47.  Networks of health professionals and organisations from different Mem-
ber States provide platforms for pooling experience and exchanging 
best practices; they are thus a tool for achieving certain results but 
not strictly a result in themselves. Due to their nature, they cannot be classified neatly as belonging to any one stage of the RDI cycle. The sample of projects audited contained 13 networks. When interviewed, 
coordinators stated that building the network was the essential pur-
pose and outcome of their respective projects.
 48.  Networks were particularly dependent on continuous Community fund-
ing. Some networks had received funding under the PHP and its pred-ecessor programmes for more than 10 years (see Figure 2 ). When no 
follow-up grant was awarded by the Commission, the network activi-ties ceased and the network dissolved.
PHP (‘HEALTH DETERMINANTS’ STRAND) — EXAMPLES OF RECURRENT 
NETWORKING PROJECTSFIGURE 2
1991 1996 2003 2008AIDS and mobility
(since 1991)  
TAMPEP
(since 1993)  
ENSP
(1996–2008)  
ENYPAT
(1996–2006)  17 years (ongoing)
15 years (ongoing)
13 years
10 yearsPre-1996
(Europe against AIDS
action plan 1991–94)8 action programmes 1996–2002
(Action programme on AIDS and communicable diseases:Action programme on cancer)PHP(2003–07)PHP2
(2008–13)
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?28
 49.  It should also be noted that none of the PHP funding mechanisms lent 
themselves to continuous financing of the operating expenditure of 
networks. The PHP calls for proposals offered grants for actions (Art–icle 108(1)(a) of the Financial Regulation), but not operating grants. 
As a consequence, networks had to be designated as one or the other 
type of project and grant agreements had to include project activities 
through which operating expenditure could be covered. Networks also had to respond to calls for proposals and submit to the same selection procedures as other projects. This situation placed an unnecessary administrative burden on both the participants and the Commission. 
Under PHP2, networks can now be funded via a dedicated operating 
grant mechanism (see Box 2 ).
COMPLEMENTARITY OF PROJECTS AND CONSISTENCY 
OF PROJECT PORTFOLIO NOT ADEQUATELY MONITORED
 50.  Effective programme implementation requires the programme manager 
(i.e. the Commission or the executive agency) to have an accurate and 
up-to-date overview of the project portfolio. This enables overlap and duplication of effort to be avoided, synergies to be created between 
the actions undertaken, and programme planning, implementation 
and follow-up to be executed in a coherent and consistent manner.
NO MONITORING OF PROJECT PORTFOLIO
 51.  At the time of the audit, neither DG SANCO nor the PHEA could refer to a 
monitoring tool which provided an overview of projects undertaken, 
in terms of the priorities they addressed, the activities they encom-
passed and the results they achieved (see paragraphs 70 to 73). This created an obstacle to ensuring consistency over time in the imple-
mentation of the programme. In the absence of such consolidated  
information, the Commission made decisions on its AWP priorities  
without knowing which projects already existed in each policy area 
or which activities were covered.
FRAGMENTATION, OVERLAP OF PROJECTS AND PARALLEL 
IMPLEMENTATION OF SIMILAR ACTIONS
 52.  With a view to obtaining a conclusion on complementarity in the absence 
of such an overview, the Court analysed all projects addressing one of 
the six lifestyle-related health determinants (alcohol, tobacco, drugs, 
nutrition and physical activity, sexual and reproductive health, mental 
health) (see Annex II ). This detailed analysis was complemented by 
a quantitative analysis, stakeholder interviews and consultation of experts.
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?29
 53.  The analysis showed that complementarity between projects and consist-
ency within the overall project portolio were lacking because of:
fragmentation (a) : in the ‘drugs’ policy area, projects funded from  
the PHP were few in number and addressed very diverse aspects 
of the drugs problem, ranging from doping in leisure sports to  
falsified prescriptions as an indicator for the abuse of legal drugs, and to drug prevention in prisons. A similar situation was found in the ‘nutrition and physical activity’ policy area, where the  few PHP projects were very dissimilar in terms of objectives and 
activities;
activity overlap and the duplication of work (b) : PHP projects in the  
‘alcohol’ policy area were characterised by a great deal of over-
lap in the partners involved and the information produced, not only between the projects in the sample but also with regard to 
a project funded from the predecessor Community Action Pro-
gramme on Health Promotion and a report produced following  
an earlier call for tender. In the ‘mental health’ policy area, two 
projects with identical activities were funded under consecutive 
calls for proposals;
parallel implementation of similar actions (c) : in the ‘tobacco’ policy 
area, the main projects financed from the PHP were two large net-
works established to combat smoking, one targeting the general 
population and the other young people only. In the ‘sexual and 
reproductive health’ policy area, the PHP funded many networks whose objective was to strengthen the capacity of the participat-ing NGOs. They found their ‘niche’ by focusing on different direct and indirect addressees: NGOs in central European countries, or 
NGOs working with migrants, migrant sex workers, local sex work-
ers, injection-drug users or people living with HIV/AIDS.
 54.  In all these areas there are already other mechanisms which could take 
the place of the PHP: platforms, working groups, agencies (EMCDDA, 
ECDC), WHO and other EU programmes such as the RTD framework 
programmes or the Drugs Prevention and Information Programme  
(see paragraph 64 and Box 12 ).
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?30
LIMITED EUROPEAN ADDED VALUE
 55.  In accordance with the principles of subsidiarity and proportionality 
set out in the Treaty, Community action on matters which do not fall 
within the exclusive competence of the Community, such as pub-
lic health, should be undertaken only if and in so far as, by reason of its scale or effects, its objective can be better achieved by the  Community
32.
EAV BY PROGRAMME STRAND: ‘HEALTH DETERMINANTS’ STRAND LEAST 
LIKELY TO PROVIDE EAV
 56.  A key ramification of the subsidiarity principle is that EU health policy 
should consist only of actions delivering output which cannot be  
achieved by Member States acting individually, or which deliver econ-
omies of scale. The ‘health threats’ strand deals with the surveillance 
of communicable diseases, and the ‘health information’ strand with 
the collection of comparable data and the development of common 
indicators. These two strands thus focus on issues which clearly can-not be managed by Member States acting individually. However, in 
the Court’s view other mechanisms for cooperation between Member 
States could equally play this role (see paragraphs 64 and 65).
 57.  In contrast, tackling health determinants to promote health and pre-
vent disease is not a cross-border task per se. In particular, direct  
health promotion — health education and influencing lifestyles — is 
a culture-specific activity which needs to take account of the specifi-
cities of the national public health system and local characteristics 
and needs. Therefore, when comparing the three strands of the PHP, the ‘health determinants’ strand appears to have the least potential 
for providing EAV.
EAV BY PROJECT TYPE: NETWORKS MOST LIKELY TO PROVIDE EAV
 58.  At the level of health promotion projects under the ‘health determinants’ 
strand, the Court has assessed EAV by taking into consideration a  
range of arguments why a measure could only be taken — or would 
be better taken — at European level. The analysis took account of  
the four project categories defined by the RDI cycle framework, while networks were considered separately (see Box 10 ).32 See Articles 2 and 5 of the Treaty 
on European Union, together 
with paragraph 5 of the Protocol 
(No 30) on the application of the 
principles of subsidiarity and 
proportionality.
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?31
 59.  There is a requirement for all projects to involve partners from several 
European countries. A a result of their cross-border nature, networks  
are most likely to exhibit EAV through sharing of expertise, consen-sus-building and exchange of ‘good practices’ across countries.
 60.  The EAV of the other project types is less obvious.
Study and research projects (a) : EAV lay mainly in the fact that data 
were collected from several countries and subject to a compara-
tive analysis. These projects sought to develop a common termin-
ology, set common standards and ensure the comparability of data 
and methods between Member States. However, there was some 
overlap with activities carried out under the ‘health information’ strand, as well as under other EU programmes such as the RTD  
framework programmes
33 or the Drugs Prevention and Information 
Programme (see paragraph 54 and Annex II ).
Development projects (b) : these projects’ EAV was their link to the  
development of EU policy. They sought to further the develop-
ment of their respective priority areas at European level and to contribute to agenda-setting across Europe.
Implementation and ‘going-to-scale’ projects (c) : the EAV of these  
projects was least apparent. This is because, by their very nature, 
the related activities (such as piloting, training and capacity build-ing, dissemination and implementation on a wider scale) have to happen on the ground, i.e. not at European level but in a particu-lar region or country. For this category of projects, it could be  
argued that activities should be funded by the region or country 
where they take place. For some projects this was indeed the  
case: Community funding was used only for ‘European activities’ 
(e.g. meetings between national coordinators) and not for actual interventions or daily country-based activities. However, in other 
cases funding from the PHP was used for national or regional  
activities.
 61.  The Court considers that all types of projects under the ‘health determin-
ants’ strand have the potential to deliver EAV to some degree, by  bringing together partners from different EU Member States. However, applying the criteria used by the Court, the most obvious providers of EAV in the sample were networks.33 During the period 2003–06, 
‘Life sciences, genomics and 
biotechnology for health’ is one of seven major thematic research 
priorities of the European Union’s 
sixth framework programme 
(FP6) aiming at the generation of 
new knowledge and translating 
it into applications that enhance 
human health. To this end research organisations carrying 
out both fundamental and applied 
research were supported with an 
indicative budget of 2 514 million 
euro. Such funding opportunities existed in the fields of genomic 
approaches to health and disease, 
biotechnology, cancer, HIV/AIDS, 
malaria and tuberculosis. Similar 
funding opportunities existed 
under the FP5 and the current FP7.
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?32
SURVEY OF PROJECT PARTNERS
‘The project’s objectives could only be realised by participating 
in the European Public Health Programme.’
0 % 10 % 20 % 30 % 40 % 50 % 60 %
15 %
9 %
2 %
5 %36 %32 %
neither agree nor disagree
disagree
strongly disagree
don’t knowagreestrongly agree
‘Participating in the European Public Health Programme is more effective 
than participating in a national health project.’
0 % 10 % 20 % 30 % 40 % 50 % 60 %
26 %
6 %
2 %
6 %29 %31 %
neither agree nor disagree
disagree
strongly disagree
don’t knowagreestrongly agreeBOX 11
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?33
STAKEHOLDERS POSITIVE ABOUT THEIR PARTICIPATION 
IN THE PROGRAMME
 62.  Participants widely affirmed the European dimension of their projects. 
A large majority (68 %) of project partners responding to the Court’s 
survey agreed or strongly agreed that their project objectives could 
only be realised by participating in the PHP. Some 60 % considered participation in the PHP to be more effective than participation in national projects (see Box 11 ).
 63.  Stakeholders in the Member States found that the programme as a 
whole was also a source of EAV in that it provided an opportunity to 
pool knowledge and share ‘good practices’. The representatives of national authorities who were interviewed in the framework of the 
audit (Programme Committee members and national focal points)  
agreed that the PHP addressed the need for Member States to cooper-
ate by exchanging information, experience and guidelines on public 
health problems of concern to all. The mid-term evaluation of the  
PHP concluded that the rationale for European intervention in public 
health is widely accepted and supported
34.
EXAMPLES OF EXISTING COORDINATION MECHANISMS (see Annex II  for details)
European Monitoring Centre for Drugs and Drugs Addiction (EMCDDA)• 
European Alcohol and Health Forum• 
EU Platform on Diet, Physical Activity and Health• 
European Centre for Disease Prevention and Control (ECDC)• 
Think Tank on HIV/AIDS• 
HIV/AIDS Civil Society Forum• BOX 1234 Wija J. Oortwijn et al. , Interim 
evaluation of the Public Health 
Programme 2003–08. Final Report. 
RAND Europe technical report, 
2007, p. 63.
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?34
 64.  However, the exchange of information and cooperation among Member 
States in the field of public health is not limited to the PHP. Other 
mechanisms exist which can deliver this EAV. There are a number  of fora, working groups and platforms in most public health pol-
icy areas that address not only health determinants but also health 
information and health threats. They facilitate consultation between stakeholders — especially governmental organisations, but also civil society, industry, etc. — and provide a ‘meeting place’ where com-
mon approaches can be developed and coordinated (see paragraphs 
54 and 60(a)). The existence of alternative mechanisms raises the  question whether such activities should continue to be carried out 
under the PHP.
 65.  In its current EU health strategy published in October 2007 the Commis-
sion has proposed setting up a ‘structured cooperation mechanism’ to identify and promote the necessary coordination activities among the Member States
35. A dedicated ‘Council Working Party on Public 
Health at Senior Level’ was set up in December 2008 to assist the  
Commission in identifying priorities, defining indicators, producing 
guidelines and recommendations, fostering exchange of good prac-tice and measuring progress.35 European Commission, White 
Paper, ‘Together for health: 
A strategic approach for the EU 2008–13’, COM(2007) 630 final, 
p. 10.
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?35
PROJECT MANAGEMENT
 66.  Project design is crucial, but projects must also be managed in a way that 
increases their chances of being effective. A project can ultimately 
contribute to progress towards the overall goal if the intended results are achieved and are used by the target group. This is more likely to be the case if:
the partnership works well; (a) 
projects are adequately monitored during implementation,  (b) 
en abling the Commission to be informed about project activi-
ties, outputs, potential overlap and opportunities for syner-
gies between projects, and to provide feedback to the project  coordinators;
the expected outputs are produced and disseminated appropri- (c) 
ately; and
projects are ultimately evaluated, allowing the Commission and (d) 
other project promoters to learn from experience.
PARTNERSHIP FUNCTIONED WELL
 67.  The functioning of the partnership is an important factor in the effective-
ness of any project implemented by several actors. All projects in the sample were implemented by a number of organisations in different Member States and, sometimes, candidate countries. Typically, they 
consisted of a main project coordinator and, on average, 12 associ-
ated partners from different countries.
 68.  In most cases, responsibilities were clearly assigned among coordinator 
and partners. In nine out of the 36 cases audited, however, it was  found that the partnership was very imbalanced, with the project  coordinator and/or one other partner carrying out the bulk of the  project activities and limited involvement by the other partners.
 69.  The majority of project coordinators and partners gave a very positive 
assessment of cooperation in the partnership (see Box 13 ). Many  
respondents to the survey stressed the partnership as one of the  
most important aspects of the project because of the possibility of 
making contacts, exchanging ideas and sharing experience and ‘good 
practices’.
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SURVEY OF PROJECT PARTNERS
‘I am satisfied with how the project partners cooperate(d).’
0 % 10 % 20 % 30 % 40 % 50 % 60 %
13 %
5 %
1 %
1 %48 %32 %
neither agree nor disagree
disagree
strongly disagree
don’t knowagreestrongly agree
‘The project coordinator involves all partners in the work.’
10 %
3 %
0 %
3 %43 %41 %0 % 10 % 20 % 30 % 40 % 50 % 60 %
neither agree nor disagree
disagree
strongly disagree
don’t knowagreestrongly agreeBOX 13
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?37
PROJECT MONITORING BY COMMISSION ‘AD HOC’ 
RATHER THAN SYSTEMATIC
 70.  Neither DG SANCO nor the PHEA has written guidelines for monitoring 
projects or documenting the monitoring process36 (see paragraph 51). 
Consequently, what was done depended on the individual project  officer. In general, monitoring consisted of using the coordinator’s interim and final reports to verify whether the contract requirements 
had been met, giving the financial officer the green light to proceed with payment. As a rule, the Commission gave the project coordinator 
no written feedback on the content and the achievements of their  
projects.
 71.  Many project coordinators were dissatisfied with the Commission’s 
project monitoring, particularly in the case of projects contributing 
to policy development. Seventeen of the 32 coordinators interviewed 
reported never having discussed the technical aspects of their project 
with representatives of the Commission during the project term. Most 
coordinators had invited the Commission’s project officer to project meetings, but such invitations were rarely taken up.
 72.  DG SANCO officers confirmed that project monitoring was a very minor 
part of their activity and that normally they had no time to follow  
projects closely. Moreover, due to staff turnover, in some cases three or four different project officers were assigned to a project during its 
lifetime, and projects were left for several months with no designated project officer.
 73.  The Commission’s monitoring of the technical aspects of ongoing projects 
was ad hoc rather than systematic, not based on common minimum 
requirements and not providing formal feedback to participants.  This should also be considered alongside the lack of an overview  of projects undertaken, which would have enabled the Commission to avoid duplication of work and to ensure that potential synergies 
between projects were fully exploited (see paragraphs 50 and 51).36 For most of the projects in the 
audit sample, technical monitoring 
was still the responsibility of the 
DG SANCO project officers; for 
12 projects selected following the 
2005 call for proposals monitoring responsibility had been transferred 
to the newly created Public Health 
Executive Agency (PHEA) after 
contract signature.
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OUTPUTS DELIVERED, BUT NOT ACTIVELY DISSEMINATED
 74.  Outputs, or deliverables, are defined as that which is produced with the 
resources allocated to an intervention. In general, the contractually 
agreed outputs of the audited health promotion projects were pro-duced. Common output categories included reports on specific issues, training courses, databases, websites, newsletters and information 
material such as leaflets.
 75.  Projects mostly used the Internet for dissemination. Almost all projects 
uploaded their outputs to a website — either the project coordinator’s 
home website or a dedicated project site. This led to the simultane-ous creation of a number of similar websites in each field, making it harder for any interested party to find pertinent information.
 76.  Other dissemination channels included conferences, newsletters, con-
tributions to scientific journals and press releases. Project partners played a significant role in dissemination, as they were familiar with 
national and regional conditions and possibly already had an estab-
lished network of contacts in their country or region.
 77.  While the audit found that outputs were produced and disseminated, 
project coordinators could not demonstrate ‘take-up’ by the target group for any of the projects audited. Projects did not even collect information of this sort
37. Neither was dissemination sustainable, as 
websites and databases were generally not updated after the end of 
the funding period (see paragraph 45).
 78.  Moreover, the representatives of national ministries and health institutes 
interviewed were often not aware what projects had been undertaken, still less of the results obtained. Most of the national stakeholders interviewed expressed criticism of the dissemination of project results and considered that too little information on the outcomes of projects (whether ongoing or completed) was available to them.37 It should be noted that it lay 
outside the scope of this audit to 
determine the effects on target 
groups of the dissemination of 
project outputs — for example, to 
investigate whether a newsletter 
was read and appreciated or a database was consulted by health 
professionals.
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PROJECT EVALUATION NOT YET COMMON PRACTICE
 79.  Without robust evaluation the effectiveness of projects cannot be dem-
onstrated. According to WHO, health promotion initiatives should  be evaluated in terms of processes as well as outcomes
38. Project  
evaluation was however not a legal requirement under the PHP.
 80.  Nevertheless, the Commission announced as early as 2003, in its first 
call for proposals, that it would give priority to projects which  
‘devote[d] appropriate attention to the [self-] evaluation of the proc-
ess and results ’39. From the 2005 call for proposals onwards, a work 
package entitled ‘Evaluation of the project’ was a compulsory section of grant agreements, but project coordinators were given no further 
instructions as to what this should entail.
 81.  The Court examined whether evaluations of the audited health promo-
tion projects had been carried out that met the criteria of usefulness, 
coherence, robustness, impartiality, clarity and cost-effectiveness40. 
This analysis showed:
Of the 24 projects in the sample which were selected before 2005,  —
three had conducted a comprehensive self-evaluation. Of these only one met all the criteria specified above;
Nine of the 12 projects selected following the 2005 call for propos- —
als included plans for limited self-evaluations, such as collection by the coordinator of feedback from the project partners, in the form of survey sheets, on project meetings or workshops. In the other three cases, there were plans for evaluations to be carried out by an external evaluator.
 82.  While the Commission has encouraged and, more recently, required health 
promotion projects to conduct a comprehensive self-evaluation, this 
has not yet become common practice among participants — owing 
partly to the lack of Commission guidance for project coordinators 
and the absence of follow-up by the Commission or the PHEA (see  
paragraphs 70 to 73).38 ‘Health promotion evaluation: 
Recommendations to policy-
makers.’ Report of the WHO 
European Working Group on 
Health Promotion Evaluation, p. 4.
39 ‘Rules, criteria and procedures 
for the selection and funding of 
actions under the public health 
programme’ (OJ C 62, 15.3.2003).
40 ECA Audit Guidelines on 
Evaluation, November 2005, p. 7.
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?40
PROGRAMME DESIGN
 83.  The Court considers that the design of the PHP did not provide a suit-
able framework for an effective implementation and monitoring of 
Community-funded health promotion actions. The fact that the under-lying intervention logic of the PHP was not made explicit was not  conducive to setting specific, measurable and time-dependent pro-
gramme objectives and specifying appropriate indicators to measure 
achievements.
 84.  The audit also found weaknesses in the Commission’s strategic plan-
ning and a lack of priority setting. The diversity of topics and the  multiplicity of annual ‘action areas’ caused input to be diluted and led to fragmented results, particularly in view of the limited budget available. The programme followed many different paths and lacked 
strategic focus.The Court finds that the PHP (2003–07) did not make 
a major contribution to health promotion in the European Union.
RECOMMENDATION 1
In order to address the current imbalance between objectives and  
means, any successor programme should be assigned better-targeted 
programme objectives which are more in line with its budgetary  
means.
For any future generation of programmes, the underlying interven-
tion logic should be stated in an explicit manner, setting out specific, 
measurable, achievable, relevant and time-dependent objectives at  
policy and programme level, illustrating the links between them and defining indicators to measure their achievement.CONCLUSIONS AND 
RECOMMENDATIONS
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PROGRAMME IMPLEMENTATION: FROM PROJECT 
DESIGN TO RESULTS
 85.  The Court finds that the Commission’s project selection and programme 
implementation did not ensure complementarity between projects, the overall consistency of the portfolio of projects undertaken and the funding of the type of projects that provided the highest likeli-
hood of EAV.
 86.  Project objectives (as proposed by promoters) were neither logically 
derived from the programme objectives, nor in compliance with  
the SMART requirement specified by the Financial Regulation. The  Commission took no corrective measure to address this shortcoming before entering into the grant agreements audited.
 87.  Expected project results were not defined as impacts on target groups 
and the sustainability of the results is considered to be low. Projects generally produced the planned outputs, but the audit found no  
demonstrable take-up of project results. Very often the relevance  
of these outputs for the target group and their take-up by actors  
‘downstream’ was unclear from the beginning. Sustainability was  
often understood by participants as the continuation of project activi-
ties and was therefore heavily dependent on continued Community 
funding.
 88.  The Court recognises that the programme brought stakeholders from 
different countries together. Projects generally had a European  dimension and, in many cases, facilitated the sharing of experiences 
and mutual learning. However, Article 152 of the EC Treaty gives  
the EU only limited competence for public health policy. The Lisbon 
Treaty (currently under ratification) would not substantially alter this. Accordingly, the added value of EU activities in the field of health promotion, including those carried out under the PHP, lies above all in facilitating cooperation between the stakeholders in different Member 
States. Of the types of projects carried out under the PHP, networks 
provide the highest likelihood of EAV and most clearly address the 
need of actors in the field to share ‘good practice’, develop common 
standards and guidelines and exchange knowledge.
 89.  However, the main implementation mechanism of the PHP (i.e. grants for 
actions awarded through calls for proposals) is not the most appro-
priate mechanism for funding such networks. This is also the case for 
activities that are supposed to contribute to the Commission’s policy 
development.
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PROJECT MANAGEMENT
 90.  With regard to project management, the Court found that partnerships 
generally worked well. The Commission’s monitoring of ongoing  
projects was however ad hoc rather than systematic and did not  provide formal feedback to participants. Projects did produce the  deliverables set out in the grant agreement, but promoters rarely  
disseminated results actively.The ex post  evaluation of projects has 
not yet become common practice among participants.
RECOMMENDATION 2
Where the current PHP (2008–13) is concerned, the Commission should 
undertake a mapping exercise in order to gain an overview of projects undertaken and their results to identify the existing overlaps and any 
remaining gaps in its project portfolio.
The number of annual ‘action areas’ should be significantly reduced, 
and they should be focused on strategic priorities.
The Commission should also address weaknesses in project design and 
implementation by:
bringing project objectives into line with programme objectives and 
• 
the refocused ‘annual priorities’ recommended above. In addition, 
grant agreements should establish not only which activities are to be undertaken, but also the desired results of those activities, the 
target groups and how the results will be used in a sustainable  
manner after project completion; 
setting quantified targets and performance indicators wherever  
• 
possible in order to facilitate the monitoring of progress towards 
objectives;
evaluating projects • ex post  in order to improve the design of forth-
coming projects (and putative successor programmes) by applying ‘lessons learnt’.
Finally, the Commission should fully exploit the existing PHP (2008–13) 
funding mechanisms for networks (ie. operating grants) in the current 
programming period, since they are more suitable for such activities 
than grants for actions. For service contracts, the Commission should 
make use of the increased ceiling (20 % rather than 10 % of the avail-able budget) to carry out activities contributing to policy develop-
ment. However, this will require a more rigorous definition of terms 
of reference than in calls for proposals.
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OVERALL CONCLUSION
 91.  The PHP was set very broad and ambitious objectives that contrasted 
sharply with the limited means at its disposal. This imbalance has  
widened further since the current PHP (2008–13) was launched.
 92.  The Court calls into question the utility of certain components of Euro-
pean public health programmes such as the PHP. The audit suggests that it is difficult for such programmes to have a demonstrable impact on citizens’ health. Where there is ‘European added value’, it lies pri-marily in enabling intermediaries to network and to exchange ‘good practice’ with a view to complementing national programmes and  activities. Moreover, the Court notes the existence of cooperation  mechanisms such as the ‘open method of coordination’ which permits such networking and exchanges.
RECOMMENDATION 3
For the period after 2013, the European Parliament, the Council and the 
Commission should reconsider the scope for EU public health activi-
ties and the approach to EU funding in this area. This should be done 
bearing in mind the budgetary means available and the existence of other cooperation mechanisms (such as the ‘open method of coordina-
tion’
41) as a means of facilitating collaboration and the exchange of 
information among stakeholders throughout Europe.
The current budget review provides a first occasion for this reflection 
process.
  This report was adopted by the Court of Auditors in Luxembourg at its 
meeting of 5 March 2009.
For the Court of Auditors
o t eC o u to u dt o s
Vítor Manuel da Silva Caldeira
President41 This is a method of cooperation 
based on the principle of voluntary 
intergovernmental cooperation. 
It relies in particular on mutual 
learning, benchmarking and the 
sharing of best practice.
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ANNEX I PHP 2003–07 (‘HEALTH DETERMINANTS’ STRAND) — FUNDED PROJECTS BY TOPIC
Year Topic
Tobacco
Alcohol
Drugs
Nutrition and physical
activity
Sexual and reproductive
health, HIV/AIDS
Mental health
Social determinants
of health
Environmental 
determinants of health
Health promotion 
in particular settings
Training in public
health
Disease and injury
prevention
Genetic determinants
Capacity buildingTotal
2003 Projects funded 2 1 1232 2114 19
Number of action areas 7 2 3211 3211 23
Projects funded/action area 0,29 0,50 0,33 1,00 3,00 2,00 0,67 0,50 1,00 4,00 1,33
2004 Projects funded 2 1 224132532 27
Number of action areas 7 1 131121211 21
Projects funded/action area 0,29 1,00 2,00 0,67 4,00 1,00 1,50 2,00 2,50 3,00 2,00 1,81
2005 Projects funded 5 4 222332 411 29
Number of action areas 5 4 235543 312 37
Projects funded/action area 1,00 1,00 1,00 0,67 0,40 0,60 0,75 0,67 1,33 1,00 0,50 0,81
2006 Projects funded 4 2 5545 1 1 3 4 2 45
Number of action areas 3 3 354344 2 2 33
Projects funded/action area 1,33 0,67 1,67 1,00 1,00 1,67 2,75 0,75 2,00 1,00 1,38
2007 Projects funded 10 11 4 3 1 29
Number of action areas 3 5 465344 4 2 40
Projects funded/action area 0,83 0,79 0,50 0,75 0,50 0,67
Total projects funded 149
Total number of action areas 154
Total funded projects/action areas 0,97
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ANNEX II
PHP (‘HEALTH DETERMINANTS’ STRAND) — ANALYSIS OF SIX POLICY AREAS
DRUGS
 1.  In December 2004 the European Council endorsed the EU drugs strategy 
(2005–12), a framework for two consecutive four-year action plans on 
drugs. The strategy’s two general aims cover public health (prevention of drug use, harm reduction and treatment) and security (enforcement 
of laws prohibiting drug production and trafficking). DG SANCO is a 
minor player in drugs policy at EU level. Policy development is led 
by DG JLS, and the bulk of project funding goes to research projects 
managed by DG RTD and DG TREN. A Drugs Prevention and Informa-tion Programme has been set up for 2007–13 and is managed by DG 
JLS (budget 21 million euro). This has similar objectives and target 
participants to the PHP.
 2.  The European Monitoring Centre for Drugs and Drugs Addiction (EMCDDA) 
provides the EU and its Member States with a common information 
framework on drugs. The EMCDDA collects information on all aspects 
of drug use based on a network of national monitoring centres. It has 
also set up a database of best practices in drug prevention.
 3.  The drugs projects funded from the PHP were few in number and covered 
a wide range of aspects and contexts of the drugs problem. However, they shared a common focus on research/collection of information and the exchange of best practices. The Court noted that some of  
their objectives and activities, for example data collection and set-ting up a database of best practices, overlapped with the EMCDDA’s 
field of activity. They could be carried out more cost/time-efficiently 
by the EMCDDA. In view of the existence of the EMCDDA and the  
dedicated Drugs Prevention and Information Programme, the value of including drugs projects in the EU’s health programmes should be 
reconsidered.
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ANNEX II
ALCOHOL
 4.  Alcohol is more difficult to tackle as a health topic than other addiction-
related health determinants, because it is socially acceptable and  does not pose a health risk as such if consumed moderately. However, harmful alcohol consumption is estimated to be responsible for about 
10 % of the total disease burden, as well as creating or aggravating 
other social or economic problems such as accidents and violence. The most (cost-)effective alcohol control policies are legal restric-
tions, which come under the remit of Member States (higher purchase 
tax, reduced availability and measures to combat drink-driving and 
underage drinking).
 5.  In response to conclusions published in 2001 by the Council, in Octo-
ber 2006 the Commission produced a strategy for reducing alcohol-
related harm. The strategy offers support for harm-reduction projects, 
data collection and the development of information and education 
measures in cooperation with Member States. Where industry is  concerned, the EC alcohol strategy relies on voluntary codes and  
self-regulation rather than legal restrictions. In June 2007 the EC  
set up a European Alcohol and Health Forum with representatives  
from the business sector (alcohol producers, the advertising industry, 
the media, retailers and caterers) and public health and civil society 
organisations. Forum members are invited to commit to stepping up 
actions to reduce alcohol-related harm, for example by promoting  responsible commercial communications.
 6.  The PHP projects addressing alcohol were characterised by a great deal 
of overlap in the partners involved and the information produced.  
Three of the five projects in the sample collected data and produced 
reports on the alcohol policy situation in each EU Member State.  
Meanwhile, a major comprehensive report on ‘Alcohol in Europe’ was produced for the Commission, as well as a report entitled ‘Alcohol policies in EU Member States and Norway’, which was produced using funding from the former Community Action Programme on Health  
Promotion. This overlap can be explained by the absence of an EU  
alcohol strategy to orientate priorities in the years before 2006 and 
the lack of a mapping exercise of previous activities in this field.
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ANNEX II
TOBACCO
 7.  According to WHO, tobacco use is a leading cause of preventable pre-
mature death in the world today. The most (cost-)effective health  promotion measure in connection with tobacco is legislation (higher purchase tax, restrictions on smoking in the workplace, advertising 
bans), which should be combined with consumer education through 
health warnings and campaigns.
 8.  Community support for anti-tobacco organisations began as early as 1987 
with the Europe Against Cancer programme. The EU has also adopted 
legislative measures on tobacco control. They are based on the EU’s competence in the internal market as laid down in Article 95 of the EC Treaty. In particular, two major directives were adopted in 2001 and 2003 on tobacco products and advertising respectively. More recently, 
the Green Paper ‘Towards a Europe free from tobacco smoke: policy 
options at EU level’ was published at the beginning of 2007.
 9.  This legislative action has been accompanied by Community support 
for Europe-wide prevention and cessation actions, in which the PHP 
projects are a minor budgetary player. More important programmes are 
public anti-smoking campaigns financed by the Community Tobacco 
Fund, which derives its resources from a levy on subsidies awarded to 
the EU’s tobacco producers. To date the Tobacco Fund has financed two large awareness-raising campaigns. The latest campaign, ‘HELP — 
For a life without tobacco’, was launched in 2005 with a budget of 72 million euro over four years. It was devised for the Commission by a consortium of health experts and PR professionals, and includes a 
roadshow and TV spots broadcast in all EU Member States.
 10.  The tobacco projects financed from the PHP consisted mainly of two 
large networks which had already been receiving funding since 1996 under the predecessor action programmes. One dealt with smoking prevention in general, but with a strong focus on tobacco-control  advocacy and lobbying, and the other focused on young people. As 
these networks were not officially eligible for financing, they were 
turned into ‘framework projects’ coordinating several sub-projects. In 
2005 this structure was abandoned, and some sub-projects continued 
as stand-alones.
 11.  While the effect of the PHP projects is not measurable, the Commu-
nity funding indirectly enabled the general network and its member 
organisations to conduct successful tobacco-control advocacy and 
lobbying activities at both EU and national level. One example is  
recent legislation in several Member States banning smoking in public 
places.
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ANNEX II
NUTRITION AND PHYSICAL ACTIVITY
 12.  Rising public concern about the increasing obesity rate, especially among 
children, has been reflected in several Commission actions in recent years. In 2006 the Commission published the White Paper ‘A strat-egy for Europe on nutrition, overweight and obesity-related health 
issues’. A key tool for implementing this strategy is the EU Platform 
on Diet, Physical Activity and Health, which was established in 2005 as a forum for stakeholders from civil society and industry who are 
willing to commit themselves to taking steps that can reduce obes-
ity. Member State authorities are linked in the European Network on 
Nutrition and Physical Activity. To further the exchange of policy ideas 
and practices between Member States, in 2007 the Commission also set up a high-level group focused on nutrition and physical activity-related health issues.
 13.  Apart from these platforms, the strategy emphasises EU activities in 
related policy areas such as consumer policy (labelling), agricul-ture (distribution of fruit in schools) and urban transport (stimulat-
ing physical activity). The PHP plays only a very limited role in the 
strategy
1.
 14.  There are not many PHP projects in the area of nutrition and physical 
activity, and they have very diverse objectives and activities, which gives a fragmented picture. Several individual projects audited either were unable to demonstrate achievement of results or delivered low 
EAV. For example, one project was funded with the purpose of find-
ing partners for a follow-up project, a proposal for which was never submitted. Another project, a study on the impact of food marketing 
to children, was found by the auditors to partly duplicate a similar 
WHO study. A third project financed activities which were imple-
mented individually by the project partners, in a number of schools, around the themes of nutrition and physical activity. These local  activities were devised by the children themselves to increase their commitment and could be anything from organising a sports festival 
in the park to decorating the school walls with pictures of fruit. While 
this might have some health impact in the participating schools,  
the EAV and the need for EU funding for these local activities are  
questionable.1 It is mentioned only once: 
‘The Commission will continue to 
support the monitoring function 
through its projects under the Public 
Health Programme, which support 
networking actions and sharing of information in the area of good 
practice in nutrition and physical 
activity, and obesity prevention .’ 
(White Paper, p. 9).
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ANNEX II
SEXUAL AND REPRODUCTIVE HEALTH
 15.  The PHP marked a break from the Commission’s ‘disease-specific’  
approach (which had characterised its 1996–2002 AIDS/communica-ble diseases programme). The sexual and reproductive health policy area has become broader. However, HIV/AIDS is still the focus of most 
projects in this area
2.
 16.  In 2005 the Commission adopted its Communication on combating HIV/
AIDS within the EU and in the neighbouring countries, 2006–09. This 
provided an action plan, an essential document which identified exist-ing needs and necessary actions. The Commission has also launched several initiatives to consult relevant stakeholders in the field. The Think Tank on HIV/AIDS is a forum in which the Commission, the Mem-
ber States and candidate and EEA countries can exchange information. 
The HIV/AIDS Civil Society Forum (CSF) is an informal advisory body 
that was established in 2005 to facilitate the participation of NGOs 
and networks.
 17.  The European Centre for Disease Prevention and Control (ECDC) was set 
up in 2005 as a Community agency for monitoring communicable  
diseases. Its action extends to HIV, and it runs a programme on HIV, 
sexually transmitted infections (STIs) and blood-borne viruses.
 18.  PHP projects in the area of sexual and reproductive health were the 
largest group in the audit sample. Most of these projects were net-works with the shared objective of strengthening the capacity of the 
participating NGOs. They found their niche by focusing on different 
direct and indirect addressees: NGOs in central European countries, 
or NGOs working with migrants, migrant sex workers, local sex work-ers, injection-drug users or people living with HIV/AIDS.
 19.  Some of the networks collected data and monitored prevalence or other 
aspects of HIV/AIDS among their target groups. In future, these activi-
ties could be taken over by the ECDC.2 Since its emergence in the 
1980s, HIV/AIDS has caused more 
than 25 million deaths worldwide. 
In the 1990s its spread was 
temporarily halted in Europe. 
The situation changed in the new century, when WHO reported 
that HIV was spreading rapidly in 
eastern Europe and was on the rise 
again in western Europe.
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ANNEX II
MENTAL HEALTH
 20.  Mental health has been increasingly recognised as a public health issue 
in recent years. Unlike the current EC Treaty, the Treaty of Lisbon  explicitly mentions mental health as an area for EU action
3. However, 
successive past public health programmes have already co-funded  projects in the fields of mental health promotion and prevention of mental disorders.
 21.  In September 2005, following the WHO European Ministerial Conference 
on Mental Health, the Commission published a Green Paper on mental health (‘Promoting the mental health of the population: Towards a strategy on mental health for the EU’) which launched a consulta-tion on possible actions to be included in a planned mental health 
strategy. However, the Member States were unable to agree on the 
strategy and it had to be abandoned. For this reason, the planned  
EU platform on mental health also failed to take shape. After several 
attempts to take the issue further, in June 2008 the Commission  organised a high-level conference which agreed on a European Pact 
on Mental Health and Well-being.
 22.  In the absence of a mental health strategy to orientate EU action, and 
given the broad nature of the mental health priorities set in the AWPs and the lack of an overview of existing activities, three of the four 
sampled projects in the mental health area overlapped significantly. Two projects funded under consecutive calls for proposals conducted identical activities, with a focus on policy development and data col-
lection. There was also partial duplication of work with other actors. Several databases of mental health programmes have been created 
in parallel (e.g. the EU Agency for Health and Safety at Work in Bilbao 
has a database on stress), but they are not well interlinked.
 23.  Another project, funded to support the Commission in the development 
of the mental health strategy, never materialised. The project was  
then reorientated and given the task of coordinating the other mental 
health projects and helping to disseminate their outputs — in this 
role it overlaps with another, RTD-funded project.3 Article 152 of the EC Treaty: 
‘Community action, which shall 
complement national policies, shall 
be directed towards improving 
public health, preventing human 
illness and diseases, and obviating sources of danger to human 
health ’. Article 168 of the Lisbon 
Treaty: ‘ Union action, which shall 
complement national policies, shall 
be directed towards improving 
public health, preventing physical 
and mental illness and diseases, and obviating sources of danger to 
physical and mental health ’.
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ANNEX III
PHP (‘HEALTH DETERMINANTS’ STRAND) — APPLICATION OF THE SMART 
CRITERIA TO THE PROJECT OBJECTIVES STATED IN THE GRANT AGREEMENTS OF THE 36 AUDITED PROJECTS
SMART criteria4Analysis of project objectives
Specifi  c (Do they specify the target 
group and the factors that need to change?)Few grant agreements clearly specifi  ed the target group in terms of direct 
and indirect addressees and the changes which the project intended to bring. Often, while the objectives did not mention the target group, it could be inferred from the project activities (implicit target group).
Measurable  (Are they written in a 
measurable format, e.g. magnitude of eff  ects, numbers to be reached?)None of the projects gave measurable objectives. Where performance 
indicators were defi  ned in quantitative terms, they related to outputs to 
be produced, not objectives (typically, they referred to ‘X copies of a report to be printed’, never e.g. ‘share of school children reporting they have performed some physical activity over the last 7 days to be raised to X %’).
Achievable  (Are they feasible given 
the available time, money, staffi   ng?)For most projects it was unclear whether the objectives had been achieved. 
Performance indicators complementing the objectives were largely absent; progress towards achieving them was usually not monitored. On the other hand, it could be argued that objectives such as ‘exchange of information’, ‘increase knowledge’, ‘promote cooperation’ are almost impossible not to achieve.
Relevant  (Are they relevant for the 
target group/s?)It lay outside the scope of the audit to verify this question for all projects 
down to the ultimate target group. However, direct addressees such as NGOs and health professionals were often involved as project partners. In the survey of project partners, 88 % of respondents said that the project objectives were relevant for their country or region and 86 % said they were relevant for their organisation.
Time-dependent  (Do they state 
the time frame within which the objectives must be reached?)Timescales were almost never applied to objectives, but only to outputs 
(e.g. a report to be produced by month X).
4 Auxiliary questions in brackets are taken from Kok, H., Bollars,C., Molleman, G. and Van den Broucke, S., The European Quality 
Instrument for Health Promotion (EQUIHP), 2005.
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EXECUTIVE SUMMARY
IV.
As regards the Court’s findings and  
conclusions,
(a)
In accordance with Article 152 of the Treaty, all actions of the Commission in the domain of public health aim at complementing the measures taken by Member States to pro-tect and improve health. The Public Health Programme (PHP) 2003–07 is only one of the instruments used in this context.
The Commission agrees that a higher budget 
would achieve more, but the implementation 
of the PHP 2003–07 reflects the budgetary 
means granted by the European Parliament 
and the Council as well as the priorities  
and objectives both institutions approved  
for it.
The underlying logic of PHP 2003–07 is based 
on the health strategy adopted in 2000 by 
the Commission (COM(2000) 285 final), and 
takes into account the subsidiarity princi-ple specified in the Treaty. Specific priori-
ties are set in the annex to the programme decision. The programme primarily aims at the achievement of intermediate indicators, such as the identification and dissemination of ‘good practice’, the networking of EU pub-
lic health expertise and the mapping of the European public health realities to prepare 
common approaches.
The priorities for the PHP as set out in  
Decision No 1786/2002/EC of the European Parliament and of the Council adopting a  programme of Community action in the field of public health for 2003–08 were defined in line with the requirements of Article 152 of the Treaty and in accordance with the health strategy approved in 2000.
The Commission accepts that further  
progress is needed to specify in the AWP a 
number of such priority areas and areas for 
potential action which is commensurate with 
the available budgetary appropriations.
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(b)
Audited projects were selected in the initial phase of the PHP (2003–07). The situation  
changed significantly in the last two years 
of the programme audited, and this change has been maintained under the current PHP (2008–13). Since 2006, the ‘guide for appli-
cants’ used for the calls for proposals has  
contained detailed instructions to applicants to use the latest generally accepted princi-
ples for project management for developing 
their application. The negotiation process  
ensures that these are actually fixed as such 
in the grant agreement, and the PHEA, now EAHC, ensures their application throughout the project duration. Since 2007 the execu-tive agency carries out an annual mapping 
exercise.
(c)
The Commission welcomes the audit finding that stakeholders confirmed the ‘European 
added value’ (EAV) and usefulness of the PHP. 
It should also be noted that the existence of 
EAV has been an award criteria for grants  
since the start of the PHP (2003–07).
V.
In the EU context, the Commission’s legisla-
tive proposals are generally accompanied by an ex-ante  impact assessment which analy-
ses the economic, social and environmental 
impacts of possible policy options. This is  where the Commission intends to set out the 
programme logic of any putative successor 
programmes to the current PHP (2008–13).
The interim evaluation of the PHP (2003–
07) performed in 2007 identified a certain  number of areas for improvement. Several  of these measures have been implemented, or are being implemented, in the manage-ment of the Public Health Programme (2008–13), including the recommended mapping  
exercise.Since 2006, and in particular for the current 
PHP (2008–13) the guide for applicants used 
for the calls for proposals contains detailed 
instructions to applicants to use the latest generally accepted principles for project  management for developing their appli-
cation. The negotiation process ensures  
that these are actually fixed as such in the grant agreement, and the PHEA, now EAHC, 
ensures their application throughout the  
project duration.
VI.
The Commission agrees with the Court that the limited funding available at EU level  needs to be focused on strategic topics and 
activities with an obvious European added 
value.
The Commission also shares the Court’s  
view that the open method of coordina-
tion and other forums and platforms in the 
health field that facilitate collaboration  
and the exchange of information between  
Member States and stakeholders through-
out the European Union could be further  
developed.
However, the Commission considers that  
such cooperation mechanisms can (and  should) not replace a dedicated European  funding programme in the area of public  health. While such instruments facilitate  collaboration and the exchange of infor-mation, they do not provide the necessary funding for EU-wide public health initia-tives (e.g. for the start-up and maintenance of networks).
In addition, the PHP provides the Commission 
with the necessary means to initiate actions 
to support and underpin policy development 
in key areas of public health policy through 
successive call for proposals.
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AUDIT SCOPE AND APPROACH
10.
Article 152 stipulates that ‘Community  
action shall complement national policies, 
[and] shall be directed towards improving  public health’ thereby making a distinction between the responsibility of Member States 
to implement their health promotion pro-
grammes and the responsibility of the Com-munity to complement their action.
In this sense, the Commission underlines  
that the PHP primarily aims to target inter-
mediaries — Member States, key stakehold-ers and actors — network them at EU level 
and help to identify and test ‘good prac-
tice’ in order to underpin and support public 
health policy development.
See also replies to paragraphs 14, 21, 40 and 
60(c).
AUDIT OBSERVATIONS
14.The intervention logic which underlies the PHP is based on Article 152 of the Treaty,  which clearly stipulates that ‘Community  action shall complement national policies, [and] shall be directed towards improving  
public health’, thereby making a distinction 
between the responsibility of Member States to implement their health promotion pro-
grammes and the responsibility of the Com-
munity to complement their action.
The PHP therefore aims to target inter-
mediaries — Member States, key stakehold-ers and actors — network them at EU level and help to identify and test ‘good prac-tice’ in order to underpin and support pub-lic health national policy development. In  this context, it should also be noted that  
the practical guide ‘Evaluating EU activities’ 
was published in 2004 and could therefore not have been used in 1999–2000 when the 
PHP (2003–07) was designed.Moreover, the PHP (2003–07) as adopted in 
Decision No 1786/2002/EC reflects the views 
expressed by the European Parliament and the Council in terms of priorities and objec-tives during the approval process.
See also replies to paragraphs 10, 21, 40 and 
60(c).
The Commission accepts however that the  
intervention logic of the PHP (2003–07)  
has not been made fully explicit in the  programme decision. It should be noted,  
havener, that this programme was designed 
in 1999–2000 and approved in 2002, i.e. in 
a period when the Commission´s current  
programming, monitoring and evaluation  
methods were not yet fully deployed.
15.
The benefits of a logic model approach will 
become increasingly apparent now that the 
PHP has become more established and its  
outputs clearer. As suggested in the 2007  interim evaluation report, a first attempt at 
modelling the potential benefits of the PHP for European citizens could be made in the ex post  evaluation [to be carried out in 2010] 
(Wija J. Oortwijn et al, Interim evaluation of the Public Health Programme 2003–08. Final Report, RAND Europe technical report, 2007, section 2, p. 100).
16.
In the Commission’s view, public health  cannot directly be compared to other EU  policy areas due to the limited scope of  competences of Community action under  the Treaty. Equally, Commission interven-
tions in public health cannot be compared to those of institutions quoted by the Court. It 
is obvious that The California Wellness Foun-
dation (which is a private foundation) has a 
more specific mandate and a direct access to final beneficiaries of its actions (Californian 
citizens) and can only be compared with  
regional bodies in Member States.
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17.
The action plan defined after the 2007  
interim evaluation of the PHP (2003–07) has 
confirmed that logical models are to be used in the evaluation of the PHP.
See also reply to paragraph 15.
In addition, the application forms for projects 
require since 2006 that project design fol-
lows a logical model. Since the PHEA, now 
EAHC, was created, this has been reinforced 
and ensured in project negotiation and fol-low up, as documented by the agency’s  
negotiation guidelines.
18.
The Commission agrees to the necessity of 
establishing indicators for an effective pro-
gramme monitoring. The development of  adequate indicators at policy, programme  
and project levels, together with the collec-
tion of data, is one of the objectives of the 
‘health information’ strand of the PHP.
See also replies to paragraphs 30 and 31.
19.
PHP (2003–07) was designed in 1999–2000 and approved in 2002, i.e. in a period when the Commission´s current programming,  
monitoring and evaluation methods were  not yet fully deployed.
It should also be noted that the SPP/ABM  
guide referred to was only published in  2004.
At the level of projects, the setting of SMART 
objectives has been gradually enforced in  
the two last years of the PHP (2003–07) and its current successor programme. Since 2006, 
the guide for applicants used for the calls  
for proposals instructs applicants to use  
the latest generally accepted principles for project management. The PHEA, now EAHC, 
ensures their application throughout the  
project duration.
See also reply to paragraph 86.20.
As a matter of principle the Commission  
considers that the intervention logic of the 
PHP cannot easily be made as explicit as  the intervention logic for a health promo-tion programme within a Member State or a 
third country. This is due to the fact that the 
PHP is not intended to be a health promo-tion programme targeted to citizens. This is 
also the reason why the global policy objec-
tives cannot easily be broken down into spe-
cific targets at the level of programmes and 
projects.
See also replies to paragraphs 14 to 16.21.
The activities of the PHP flow from the 2000 
health strategy adopted by the Commission 
(COM(2000) 285) which sets the link with  the activities of other actors (such as Mem-
ber States). The PHP therefore aims to tar-
get intermediaries like Member States, key 
stakeholders and actors, to network them at 
EU level and to help identify and test ‘good practice’ in order to underpin and support 
public health policy development.
Moreover, the PHP (2003–07) as adopted  
in Decision No 1786/2002/EC reflects the  views expressed by the European Parliament and the Council in terms of priorities and  objectives.
See also replies to paragraphs 10, 14, 40 and 
60(c).
22.
The Commission has made major efforts to set out its priorities in a precise and detailed way in the AWP.
23.
The Commission’s financial intervention in public health cannot be easily compared  
to that of Member States as the respective 
domains of competence differ in shape and 
coverage.
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24.
The Commission agrees that a higher budget would achieve more, but the implementation of the PHP 2003–07 reflects the budgetary means granted by the European Parliament and the Member States and the priorities  and objectives both institutions approved  for it.
The PHP is a catalysator for creating the  
conditions for the development of improved 
health promotion activities. Calculating an 
average per European citizen is not particu-larly relevant for a programme such as the PHP.
25.
The Commission has made constant efforts 
to set out funding priorities in a precise and 
detailed way in the AWP in order to clarify 
the kind of work required, the policy link and 
the link to previous work. The selection of topics is influenced by Member State rep-
resentatives in the Programme Committee  
which agrees the annual work programme.
See also reply to paragraph 78.26.
In establishing the AWP, under each topic  
the Commission has detailed specific areas 
illustrating where actions would be of par-
ticular relevance.
27.
The Commission accepts that further  progress is needed to specify in the AWP a number of such topics and areas for poten-
tial action which is commensurate with the 
available budgetary appropriations.28.
In many cases the creation of links between actors in different areas of public health  policy and the development of networking structures across Member States are also  to be considered to be the principal objec-tives of most projects co-financed by the  PHP. Such activities are mainly implemented through grants awarded through ‘calls for  proposals’ procedures.
The use of tendering is often difficult, in par-
ticular in those domains where the number of potential bidders for such service con-tracts is limited.
30.
PHP 2003–07 was designed in 1999–2000 and 
approved in 2002, in a period when the Com-
mission’s current programming, monitoring 
and evaluation methods, such as activity-
based management, had not yet been fully deployed.
The PHP was the first programme to pro-
vide for the definition, through its ‘health  information’ strand, of strong and common 
indicators and for the collection of perti-
nent data in all Member States. It should  
also be noted that the Commission’s Healthy 
Life Years indicator is the first and only glo-
bal public health indicator available at EU  
level.
31.
The Commission considers that the setting up of indicators for an effective programme monitoring strongly depends on availability 
of pertinent data at project level. Develop-
ing appropriate indicators and data collec-
tion methods is one of the objectives of the PHP`s ‘health information’ strand.
See also reply to paragraph 18.
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32.
New AMP indicators (such as ‘level of pub-lic awareness of unhealthy behaviours and lifestyle-related health risks’, ‘share of citi-zens that have their blood pressure meas-ured each year’, ‘share of population being aware of the health risks of tobacco smoke for non-smokers’, ‘share of population know-ing that balanced diet means eating a variety of different foods’) were developed during preparation of the 2009 activity statement in the framework of the 2009 preliminary draft budget, and they were recognised by the  Council Budget Committee as a significant improvement (Council document 13895/08 FIN362 dated 7 October 2008 — p. 23, ‘COM-BUD assessment report of the PDB 2009 activ-ity statements — note d’introduction’).
In addition, the Commission has set up a  
working group for the further definition of 
indicators to be used in the frame of APS and AMP with a view to systematising the collec-
tion of the related pertinent data on a more 
regular basis for APS and AMP exercises from 
the year 2010.
33.
During the period audited by the Court, the 
Commission has provided formal feedback  
to participants on a case-by-case basis at the 
interim and final reporting stages, both on 
operational and financial considerations.
Since the creation of the PHEA, now EAHC, 
the monitoring of projects has further  improved.
See also replies to paragraphs 51, 53 and  
70 to 73.36.
The projects audited by the Court were  selected in the starting phase of the PHP  (2003–07). The Commission notes that it  took applicants time to get used to require-ments to specify objectives, activities and  actions in more detail. In the Commission’s view, the situation is however constantly  improving.
The guide for applicants used for the calls 
for proposals since 2006 instructs applicants 
to use the latest generally accepted prin-ciples for project management (including  definition of objectives) for developing their application. The negotiation process ensures that these are actually fixed as such in the grant agreement, and the project officers of 
the PHEA, now EAHC, ensure their applica-
tion throughout the project duration.
38.
See also replies to paragraphs 19 and 86.
40.
The PHP primarily aims to target intermedi-aries — Member States, key stakeholders and 
actors — and to network them at EU level. 
It also helps to identify and test ‘good prac-
tice’ in order to underpin and support public 
health national policy development.
See also replies to paragraph 10, 14, 21, 36 
and 60(c).
41.
This only applies to the 2003, 2004 and 2005 projects and has since been corrected with the issuance of a more directive guide for  applicants as of 2006.
See also reply to paragraph 36.
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42.
In selecting projects, relevance to EU poli-cies is a main criterion for funding. Projects have an impact on the policies cycle in sev-eral ways, for example by:
feeding outcomes into technical bodies  —
of Member States and stakeholders;
promoting sustainable networks of   —
expertise;providing the background for recom- —
mendations on good practice.
The impact on people’s lifestyle is achieved 
indirectly.
45.
The RDI cycle is not fully applicable as  
projects could only be targeted towards the 
intermediate level. The action was therefore 
limited to research followed by development 
and in some cases pilot projects but the  Commission is in no position to reach the  
stage of full-scale implementation.
The Commission can point to several exam-
ples of a successful uptake of results of  projects financed under the PHP (2003–07), 
such as the following:
Work on the impact of advertising on   —
young people (children,obesity and  
associated avoidable chronic diseases)  
fed into the Commission’s round table on advertising self-regulation (from 2005) 
which produced a code of conduct for  self-regulation in the EU advertising Sec-tor. It also contributed to the concept of 
the EU Platform on Diet, Physical Activ-
ity and Health where the European Heart 
Network is still an active member.The Shape-up project contributed to the  —
development of innovative examples  of good practices to promote healthy  behaviours in school settings and of  public–private partnership approaches  that are promoted in the Strategy for  Europe on Nutrition, Overweight and  Obesity-related health issues adopted by the Commission in 2007. Shape-up lead-ers are currently part of a group of actors convened by the Commission for the pro-motion of good practice examples and  of community-based approaches based on public–private partnerships.Good practice and policy recommenda- —
tions on sexual education and sexual  health developed by the SAFE project  were presented to the HIV/AIDS Think  
Tank and the Civil Society Forum. Key  
elements of their conclusions were  
taken up in the discussion document  developed by the sexual health round  
table on potential future EU action in  
this area and discussed in a workshop  
in May 2008.On drugs in prisons, ENDIPP provided   —
background information for follow-on  
work which in turn led to the prepara-
tion of country reports on prevention,  
treatment, and harm reduction services 
in prison, on reintegration services on  
release from prison and on methods  
to monitor/analyse drug use among  prisoners, and fed into preparatory  
work towards a proposal for a Council  recommendation.SUPPORT has been reoriented to en able  —
more transparency and synergies  
between mental health projects and help 
using and disseminating their outputs. SUPPORT provided input to the prepa-
ration of the European Pact for Mental  Health and Well-being and into the June 2008 high-level conference and organ-ised related workshops.
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‘Eurocare — Closing the gap’ contrib- —
uted to creating a level playing field  for discussions on alcohol policy with  stakeholders, as it allowed non-industry players to develop common positions  and take these forward in discussions  involving economic operators organised by the Commission. The project allowed the public health community to provide substantial structured and coordinated input into the Community’s alcohol  strategy, which was adopted in October 2006, and its implementation.Input was provided to the Commission’s  —
Green Paper ‘Towards a Europe free from tobacco smoke’ (through various projects funded by DG SANCO and referenced in 
the Green Paper). Input was also pro-
vided to the Framework Convention on 
Tobacco Control (FCTC) through a posi-
tion paper of the Framework Convention Alliance (an international network of  
more than 200 non-governmental organ-
isations) drafted under ENSP — the Euro-
pean Network for Smoking Prevention.
The creation of the ECDC in Stockholm has 
been pushed forward and its work priorities 
developed on the basis of projects on com-
municable disease surveillance supported  
under the ‘health threats’ strand.
More broadly, the Healthy Life Years indi-
cator in the Lisbon strategy — which is an important reference for intervention on  health determinants — has been developed on the basis of projects on health indicators under the health information strand, and is still calculated and being further developed on the basis of such projects, as are other  key benchmark indicators of health at Com-munity level in the European Community  Health Indicators (ECHI) list. The relevance of these at national level is clear, with the Healthy Life Years indicator being adopted as the key benchmark for the national health 
strategy in Estonia, for example, and the  
Netherlands using the more detailed ECHI  
list to benchmark its national policies in a  
specific publication ‘Dare to Compare’.46.
Generally national funding sources are avail-able only for national components of net-working activities across Member States.  This explains the need for a European PHP to finance such activities, which are clearly in the overall EU interest.
See also replies to paragraphs 56 and 64.
Under the first PHP (2003–07) funding  
mechanisms were not adapted to provide  
longer-term financial support. Under the  current PHP (2008–13) other, more appro-priate, tools and financing mechanisms are available, mainly operating grants and joint actions financing.
48.
See reply to paragraph 46.
51.
The Commission considers that its moni-
toring of projects undertaken has signifi-
cantly improved since the period covered  
by the audit. Nevertheless, information on previously funded projects has always been 
available. In particular, lists of previously  
funded projects with links to their reports  
were made public either on the DG SANCO or 
the PHEA, now PHEA, websites. Since 2008, 
such monitoring information is also encoded 
in a comprehensive database.
This tool will further enhance the Commis-
sion’s monitoring of its project portfolio.
See also replies to paragraphs 33, 52 and  
70 to 73.
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52.
As regards the complementarity between  projects, the Commission has required  project proponents to put their project into the context of existing projects and build  on results already achieved. This has also  been specified as one of the award criteria for grants.
In certain cases, the Commission required  
proponents to cooperate with other projects 
and to make documentation on previously  
funded work publicly available.
In addition, as a general procedure, lists of 
selected projects for funding are submitted to the Commission-wide interdepartmental consultation procedure.
See also reply to paragraph 51.53
(a)
It should be noted that the scope for actions 
when considering ‘health determinants’ is  
large. The PHP aimed at pioneering differ-ent approaches while avoiding overlaps.  
The Commission considers that the fact that 
projects were diverse and covered differ-
ent aspects of the ‘drugs’ or ‘nutrition and 
physical activity’ areas shows that efforts to 
avoid overlap were successful.
Projects like ‘Shape up’ or ‘EPODE’ funded  
under the PHP fed into the 2007 White Paper on nutrition, overweight and obesity-related health issues. The EU drugs strategy calls for a multidisciplinary approach (EU drugs strat-egy 2005–12 Council document 15074/04  dated 22 November 2004).
53
(b)All projects audited fulfilled the PHP selec-tion and award criteria. While different  projects may have dealt with similar issues, they did so from different perspectives and 
with different methodologies.In the field of the reduction of alcohol-
related harm, there were only a limited  number of organisations operating at  European level, and/or capable of leading  projects with a European dimension. It is to be noted that the different country reports on the situation regarding alcohol policy in the EU Member States on the one hand, and the ‘Alcohol in Europe’ report on the other, served different purposes, and are different in content (see Annex II, point 6).
53
(c)The Commission considers that the two  tobacco networks clearly addressed differ-ent target groups.
In the ‘sexual and reproductive health’ area 
the Commission has a dedicated policy on  
HIV/AIDS, including an action plan which is partially implemented through PHP funding. 
Such funding results in improved preven-
tion of HIV transmission across Europe (see 
Annex II, point 15).
The advisory bodies referred to by the Court 
play an important role in the coordination of 
EU policy on HIV/AIDS, but have no financing 
capacity (see Annex II, point 16).
In the Commission’s view it is important to 
support and to strengthen specialised NGOs and networks acting on the ground or on  
political levels, and supporting PLWHA or  working towards the prevention of new HIV infections. NGOs or networks have to reach 
their counterparts — be they patients, people 
belonging to risk groups, local or national 
authorities, or politicians. A specialisation, or, as the report states, a ‘niche’, is conse-
quently an asset for an NGO working in the field of HIV/AIDS. Taking into account, for  example, the costs for a lifelong antiretrovi-ral treatment in the EU at an average price 
of 10 000 euro per person per year (only for 
medication), an investment in specialised and 
professional NGOs reaching people who are 
most at risk of attracting HIV is justified and 
reasonable (see Annex II, point 18).
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The European Centre for Disease Prevention 
and Control (ECDC) in Stockholm became  fully operational with respect to HIV/AIDS  epidemiology as from 2008 onwards (see  Annex II, point 19).
54.
Only the RTD framework programme and the 
drugs programme, and the ECDC as concerns communicable diseases surveillance, pro-
vide funding for cooperation at European  
level. In these cases the Commission has put in place mechanisms to ensure coordination and to avoid overlap with the PHP.
Through the PHP, the Commission has ini-
tiated actions in several domains which  
supported and underpinned policy devel-
opment in key areas of European public  
health policy. This has been done bearing  
in mind the existence of other cooperation mechanisms.
The ECDC was created based on the results 
of PHP (2003–07) projects. Furthermore the Commission funds PHP projects with inter-
national organisations like the WHO (such  
as 2007WHO02 ‘Nutrition and physical  
activity surveillance’) and the OECD (such  
as 2006OECD02 ‘Health workforce and inter-
national migration’).
See also reply to paragraph 45.56.
The existence of ‘European added value’  (EAV) has always been a key criterion for  making award decisions for PHP projects.The existence of other cooperation mecha-
nisms (such as the open method of coor-dination) for facilitating collaboration and exchange of information among stake holders throughout Europe does not exclude action by the PHP. Most of these other mechanisms do not provide financing necessary for start-up and maintenance of initiatives at Euro-pean level.
See also replies to paragraphs 46 and 64.57.
The vast majority of projects consisted of  networks, as one of the award criteria was the involvement of partners from different European countries.
58.
See reply to paragraph 45.
60.
(a)
See reply to paragraph 52.
60.
(c)
The PHP does not in general fund going-to-
scale implementation projects. This is the  
responsibility of Member States.
See replies to paragraphs 10, 14 and 40.
62.
The Commission welcomes this confirmation of the ‘European added value’ (EAV) and the usefulness of the PHP.
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64.
Other existing mechanisms of cooperation, in particular with Member States, cannot  replace the PHP’s action in underpinning  and supporting policy development in some domains or activities for which actual finan-cial support is crucial.
See also replies to paragraphs 46, 54 and 56.
65.
The activities resulting from this Council  
working party are to be funded through the current PHP (2008–13).
69.
The Commission shares the view that part-nerships generally worked well.
It particularly welcomes the positive assess-
ment by project coordinators of large-scale 
networks to bring together knowledge and expertise at the EU level.
70–73.
During the period audited by the Court, the Commission has provided formal feedback  
to participants on a case-by-case basis at  
the interim and final reporting stages, both 
on operational and financial considera-
tions. Where necessary, corrective actions  
on reports were taken through withholding 
payment for a period pending provision of 
complementary information.
The Commission considers that since the cre-
ation of the PHEA, now EAHC, the monitoring of projects has been further improved.
See also replies to paragraphs 33, 51 and 52.78.
Member States are officially informed of  the list of selected projects (see for exam-ple C(2008) 6180 for the year 2008) after  evaluation of the proposals through their  representatives in the PHP Committee. This list is formally reviewed by the programme committee before submission to the Euro-pean Parliament for scrutiny and then to  Commission for formal approval.
See also reply to paragraph 25.
CONCLUSIONS AND 
RECOMMENDATIONS
Programme design
83.
Article 152 of the Treaty stipulates that  
‘Community action shall complement  national policies, and shall be directed  
towards improving public health’ thereby  
clearly making a distinction between the  
responsibility of Member States to imple-ment their health promotion programmes  
and the responsibility of the Community to 
complement their action.
The PHP was designed in accordance with  
the health strategy adopted in 2000 by the 
Commission (see COM(2000) 285) and tak-
ing into account the limited scope of com-petences of Community action under the  
Treaty.
The PHP primarily aims to target interme-
diaries — Member States, key stakeholders 
and actors — and network them at EU level. 
It also helps to identify and test ‘good prac-tice’ in order to underpin and support public 
health national policy development.
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The Commission accepts that the interven-
tion logic of the PHP (2003–07) has not been made explicit in the programme decision.  It should be noted, however, that this pro-gramme was designed in 1999–2000 and  approved in 2002, i.e. in a period when the Commission´s current programming, moni-toring and evaluation methods were not yet fully deployed.
The benefits of a logic model approach will 
become increasingly apparent now that the PHP has become more established and its  outputs clearer. As suggested in the 2007  interim evaluation report, a first attempt at modelling the potential benefits of the PHP for European citizens will be done.
See replies to paragraphs 10, 14, 15, 19, 21, 
40 and 60(c).
Developing appropriate indicators and data 
collection methods is one of the objectives 
of the PHP`s ‘health information’ strand.  
The Commission considers that setting up  of indicators for an effective programme  
monitoring strongly depends on availability 
of pertinent data at project level.
New indicators were developed in the frame 
of the 2009 preliminary draft budget. In addi-
tion, the Commission has set up a working 
group for the further definition of indicators to be used in the frame of APS and AMP for 
the year 2010.
See replies to paragraphs 31 and 32.84.
The Commission has made major efforts to set out its priorities in a precise and detailed 
way in the AWP. The Commission accepts that further progress is needed to specify in the AWP a number of such topics and areas for potential action which is commensurate with the available budgetary appropriations.The final evaluation of the PHP (2003–07)  
will be available in 2010 — when the major-ity of the projects will be finished — and will allow overall conclusions to be drawn on the effectiveness of the programme in reaching its objectives.
See replies to paragraphs 22, 25 and 27.
Recommendation 1
While the Commission has the right of ini-
tiative, it is the European Parliament and  the Council which adopt the programme  decision, including the objectives to be  achieved and the budgetary appropriations to be made available for achieving these  objectives.
Since 2002, the Commission’s legislative  
proposals are generally accompanied by an ex ante  impact assessment which analyses  
the economic, social and environmental  
impacts of possible policy options.
This is where the Commission intends to  
set out the programme logic of any puta-
tive successor programmes to the current  
PHP (2008–13).
See reply to paragraph 15.85.
It should be noted that the scope for actions when considering ‘health determinants’ is  large. The PHP aimed at pioneering different approaches while avoiding overlaps.
All projects audited fulfilled all the selection 
and award criteria. While different projects may have dealt with similar issues, they did 
so from different perspectives and with dif-ferent methodologies, thus increasing the  significance of the results produced.
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The Commission considers that the fact that 
projects were diverse and covered different aspects in a given area shows that efforts to 
avoid overlap were successful.
As regards the complementarity between  
projects, the Commission has required  project proponents to put their project into the context of existing projects and build  on results already achieved before. This has also been specified as one of the award cri-teria for grants.
In addition, the Commission refers to its  
general interdepartmental consultation pro-
cedure which was applied to the PHP.
Ensuring complementarity will be made  
easier with the creation of a compre-
hensive database for project monitoring  
information.
The existence of ‘European added value’  
(EAV) has always been a key criterion for  
making selection and award decisions for  
PHP projects.
See replies to paragraphs 46, 51, 52, 53 and 
56.
86–87.
PHP 2003–07 was designed in 1999–2000 and 
approved in 2002, i.e. in a period when the Commission’s current programming, moni-
toring and evaluation methods had not yet 
been fully deployed.
The projects audited by the Court were  
selected from the starting phase of the PHP (2003–07).The Commission notes that it took appli-
cants time to get used to requirements to  specify objectives, activities and actions in 
more detail. In the Commission’s view, the 
situation is however constantly improving. The guide for applicants used for the calls for proposals since 2006 instructs applicants 
to use the latest generally accepted prin-
ciples for project management (including  definition of objectives) for developing their 
application. The negotiation process ensures 
that these are actually fixed as such in the 
grant agreement, and the project officers of 
the PHEA, now EAHC, ensure their applica-tion throughout the project duration.
See replies to paragraphs 19 and 36.88.
The Commission welcomes this confirmation 
of the ‘European added value’ (EAV) and of the usefulness of the PHP. The existence of 
EAV has always been a key criterion for mak-
ing award decisions for PHP projects.
The vast majority of projects consisted of  
networks, as one of the award criteria was 
the involvement of partners from different European countries.
See replies to paragraphs 56 and 57.89.
The Commission accepts that under the first 
PHP (2003–07) funding mechanisms were not 
adapted to provide longer-term financial  
support. Under the current PHP (2008–13)  other, more appropriate, tools and financing mechanisms are available, mainly operating grants and joint actions financing. Gener-
ally national funding sources are available 
only for national components of network-
ing activities across Member States. This  
explains the need for a European PHP to  
finance such activities which are clearly in the overall EU interest.
See replies to paragraphs 46, 56 and 64.
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90.
The Commission shares the view that part-
nerships generally worked well. It particu-larly welcomes the positive assessment by  
project coordinators of large-scale networks 
to bring together knowledge and expertise at the EU level.
During the period audited by the Court, the 
Commission has provided formal feedback  to participants on a case-by-case basis at  
the interim and final reporting stages, both 
on operational and financial considerations. 
Since the creation of the PHEA, now EAHC, 
the monitoring of projects has been further improved.
Member States are officially informed of  
the list of selected projects after evalua-
tion of the proposals through their repre-
sentatives in the PHP Committee. This list is 
formally approved by the Committee before submission to the European Parliament for 
scrutiny and then to Commission for formal 
approval.
The Commission intends to implement the 
recommendation of the Court to reinforce  dissemination activities for projects funded under the PHP.
See replies to paragraphs 33, 51, 69, 70 and 78.
Recommendation 2
Reply to the first subrecommendation
The interim evaluation of the PHP (2003–
07) performed in 2007 identified a certain  number of areas for improvement, includ-ing the mapping exercise recommended by the Court of Auditors for the current PHP  (2008–13).
See reply to paragraph 51.The Commission intends to carry out such a 
mapping exercise annually for the current  PHP (2008–13). This will complement those 
carried out in 2007 and 2008 for projects  
undertaken under PHP (2003–07).
Reply to the second subrecommendation
The Commission accepts that further progress 
is needed to specify in the AWP a number of topics and areas for potential action which is 
commensurate with the available budgetary 
appropriations.
See reply to paragraph 27.Reply to the third subrecommendation
Since the creation of the PHEA, now EAHC, 
the design and monitoring of projects under-
taken has improved. The new funding pos-
sibilities for networks will be consistently  
used.
See replies to paragraphs 33 and 46.Overall conclusion
91.
The Commission agrees that a higher budget would have allowed more to be achieved,  but the PHP 2003–07 reflects the budgetary means granted by the European Parliament and the Council and its priorities and objec-
tives for this programme.
92.
The impact on citizens’ health of any health 
promotion initiative can only be assessed  through changes in citizens’ behaviour,  which can only be assessed over the long  term. The Commission considers that current and previous PHPs made a significant con-
tribution to foster a modern, participative  public health policy at EU level.
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Recommendation 3
Reply to the first subrecommendation
Through the PHP the Commission has been 
able to initiate actions in several key areas 
of public health which supported and under-pinned policy development. This is being  done bearing in mind the budgetary means 
available and the existence of other cooper-
ation mechanisms (such as the open method of coordination) which, although facilitating 
collaboration and exchange of information 
among stakeholders throughout Europe, do 
not provide financing necessary for start-up 
and maintenance of networks.
Reply to the second subrecommendation
The Commission considers that the best  
opportunity to review the current health pro-
gramme will be provided when the results  
of the evaluation of the PHP (2003–07) are 
available, in 2010.
For any putative successor programme to the 
current PHP (2008–13) after 2014, the Com-
mission, in accordance with its procedures, 
is to carry out an ex ante  impact assess-
ment which will analyse the different policy options and their respective impacts.
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European Court of Auditors
Special Report No 2/2009
The European Union’s Public Health Programme (2003–07): an effective way to improve health?
Luxembourg: Office for Official Publications of the European Communities2009 — 66 pp. — 21 x 29.7 cmISBN 978-92-9207-227-8

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IN THIS REPORT, THE EUROPEAN COURT OF AUDITORS ANALYSES 
THE EUROPEAN UNION’S PUBLIC HEALTH PROGRAMME (PHP) FOR 2003–07. THE COURT’S A UDIT ASKED WHETHER THE RIGHT 
CONDITIONS WERE SET FOR PROJECTS FINANCED FROM THE EU 
BUDGET TO COMPLEMENT THE MEASURES TAKEN BY MEMBER STATES TO PROTECT AND IMPROVE PUBLIC HEALTH. THE REPORT DETAILS CONCLUSIONS AND RECOMMENDATIONS IN PROGRAMME DESIGN, IMPLEMENTATION AND MANAGEMENT. IN VIEW OF ITS FINDINGS, THE COURT CALLS INTO QUESTION THE UTILITY OF CERTAIN COMPONENTS OF EUROPEAN PUBLIC HEALTH PROGRAMMES SUCH AS THE PHP . THE COMMISSION AND THE MEMBER STATES ARE INVITED TO RECONSIDER THE EU’S FUNDING APPROACH IN THE FIELD OF PUBLIC HEALTH.
EUROPEAN COURT OF AUDITORS
ISBN 978-92-9207-227-8QJ-AB-09-002-EN-C