EN Official Journal of the European Union C 77/96

Opinion of the European Economic and Social Committee on the ‘White Paper — Together for Health: A Strategic Approach for the EU 2008-2013’

COM(2007) 630 final

(2009/C 77/23)

On 23 October 2007 the European Commission decided to consult the European Economic and Social Committee, under Article 262 of the Treaty establishing the European Community, on the

White Paper — Together for Health: A Strategic Approach for the EU 2008-2013.

The Section for Employment, Social Affairs and Citizenship, which was responsible for preparing the Committee's work on the subject, adopted its opinion on 18 July 2008. The rapporteur was Ms Cser.

At its 447 plenary session, held on 17 and 18 September 2008 (meeting of 18 September 2008), the European Economic and Social Committee adopted the following opinion by 114 votes to four with seven abstentions.

1. Conclusions and recommendations.

1.1 The EESC welcomes the Commission's White Paper entitled ‘Together for health’, given that the EESC also emphasises the correlation between health, economic prosperity and competitiveness, while recognising the rights of citizens to be empowered in their mental and physical health and to the provision of high-quality healthcare.

1.2 The EESC approves the Council's recognition of fundamental and shared health values, universality, access to good quality care, equity and solidarity (1). The EESC hopes that developments in the field of public health will be based on these fundamental principles; it also expects to see the principle of ‘health in all policies’ applied. Therefore it feels that trade, competition and economic policies in the Single Market must be coordinated and harnessed in order to achieve the EU's political objective of ensuring a high level of public health and thus promoting, preserving and improving human health.

1.3 The EESC agrees with and supports the Commission in its view that active European citizenship only makes sense if underpinned by fundamental rights; among other things, this means emphasising, promoting awareness of and ensuring patients' rights, and providing the requisite information. Failing this, a Community-level health policy is unthinkable.

1.4 The EESC agrees with the Commission's priorities in particular to combat the major cross-border health scourges and health threats, measures to monitor and give early warning of disasters, and measures to combat tobacco and alcohol abuse and protect public health.

1.5 Continuous and coordinated input by specific EU-operated agencies (2) play an important role in securing acceptance for the strategy and implementing it.

1.6 The EESC is in favour of launching more targeted compilation and joint evaluation of data at Community level to ensure successful implementation of the strategy. Besides creating real and comparable indicators, efforts must be made to update databases and develop methods to check the accuracy of data. However, it would point out that personal data must be strictly protected.

1.6.1 The EESC believes that those patients requiring cross-border healthcare should receive information about their rights to quality care. Member States should also ensure that the free provision of services does not result in social dumping in this field, which would be damaging to healthcare workers, their professionalism, and ultimately to patients.

1.7 The EESC welcomes the Commission's declaration on reducing the serious inequalities that exist between and within Member States. However, it would warn the Commission that support for patients' rights to mobility and greater mobility among healthcare workers must not exacerbate such inequalities.

1.8 The EESC supports the Commission in its intention to strengthen and promote prevention, and welcomes its efforts to promote health awareness programmes targeted at different age groups. Public-service TV and radio should have an important role to play; these should be targeted at the poor, who represent a large proportion of the EU's population, especially children and young people, who often lack any other means of accessing objective and useful information and knowledge.

1.9 The EESC suggests launching a ‘Healthy European Citizen’ long-term campaign, to last for the entire five years of the strategy, with annual rolling planning and feedback enabling continuous evaluation of the strategy and appropriate adjustments. The EESC recommends that the Commission extend the duration of both the strategy and the programme/long-term campaign to ten years, in order to promote more health-conscious behaviour among European citizens.

1.10 The EESC emphasises the importance of broad stakeholder involvement in disseminating knowledge about the strategy, stimulating discussion about it and implementing it, thus ensuring, through transparency and cooperation, acceptance of the strategy and implementation of participatory democracy.

1.11 The EESC would remind the Commission of the key role played by health and safety at work and would urge that, with the involvement of the social partners and Member States, coordinated cooperation be stepped up in EU policies, and prevention and protection be strengthened.

1.12 The EESC suggests that specialists in various policy areas and representatives of the social partners, professional organisations and civil society set up forums at European, national, regional and local levels. These forums, which would involve cooperation on multiple levels, could form a network to help promote the exchange of information, and would be an appropriate means of presenting various points of view, delineating between national and EU policies, and ensuring the acceptance of such policies. Educating members of the public in how to behave individually and collectively in the event of a serious health crisis should be one of the subjects covered by such forums involving a wide audience, and would enable effective management in the interests of all concerned during periods of difficulty.

1.13 The EESC recommends that the EU set up similar forums in its international policy with the participation of those concerned and in cooperation with international organisations to enable debate on policy issues and ensure formulation and implementation of strategies.

1.14 The EESC supports innovation in Member States' healthcare systems and welcomes the development of e-health technology; however, further research and proposals for solutions are needed here, in view of the need to comply with the subsidiarity principle and ensure patients' rights.

1.15 The EESC is disappointed that a strategy which concerns all EU citizens has not been given a budget of its own. The EESC recommends that, to ensure effective implementation of the new strategy, an overall review of the EU's budget (3) be carried out to identify projects impacting on public health; these should be monitored and evaluated, and subsequently harmonised. Throughout the duration of the strategy, efforts must be made to ensure that, in addition to project-type funding, budget-type support is available in the post-2013 period for new tasks which become ongoing.

2. General comments

2.1 Health and high-quality-healthcare is part of the European social model, built on essential values such as solidarity, and should be actively developed (4).

2.2 Right to be empowered in mental and physical health and access to mental and physical healthcare, is a fundamental right for European citizens and is one of the main pillars of active European citizenship.

2.3 The focus must be on citizens, with joint efforts to develop a Community culture of health and safety.

2.4 In the EU, it is vital to combat poverty and ensure access to high-quality healthcare for all, as a fundamental performance indicator not only of healthcare provision but also of efforts to promote competitiveness (5).

3. Content of the White Paper

3.1 The European Commission has held two consultations on health. Consultation revealed general support for a new health policy strategy in Europe, and a desire for closer cooperation between the European Commission and EU Member States on further improvements in health protection in the EU.

3.2 Several major issues were raised by the public consultation: — combating health risks, — disadvantages in terms of health including gender-related inequalities, — the importance of information and awareness-raising for the public, — the quality and safety of cross-border healthcare, — identification of key lifestyle-related health factors such as diet, exercise, drinking, smoking and mental health, — the need to improve the European information system in order to develop the European health strategy.

3.3 The Lisbon Treaty signed on 13 December 2007 expands and clarifies Article 152 of the Treaty establishing the European Community by introducing the concept of ‘physical and mental health’ to replace ‘human health’. The Lisbon Treaty also adds monitoring, early warning of and combating serious cross-border threats to health to the content of the Treaty.

3.4 The White Paper emphasises common values such as the right to high-quality treatment, equality and solidarity. The Commission has developed its common strategy on the basis of four fundamental principles: — Common Values in the Field of Health — ‘Health is the Greatest Wealth’ — Health in All Policies, and — Strengthening the EU's Voice in Global Health.

3.5 Based on this, the strategy identifies three main objectives for the coming years: — fostering good health in an ageing Europe, — protecting citizens from health threats, and — supporting dynamic health systems and new technologies. The Commission is proposing 18 measures to achieve these objectives.

4. Specific comments

4.1 The EESC agrees with the fundamental principles set out in the White Paper, and therefore welcomes the principle of Health in All Policies (HIAP), which will require much closer cooperation between the Commission, the social partners, civil society organisations, academia and the media in order to promote and implement the strategy.

4.2 The EESC recognises that public health around the world is facing three main challenges: firstly, the struggle against the constantly changing microbial world, secondly, the struggle to change human habits and behaviour, and thirdly, the struggle for attention and resources (6). It is also aware of the challenges facing the EU and the resources available to meet them: — demographic ageing is posing a growing challenge in terms of diagnosis, treatment and care; — health threats such as epidemics caused by infectious diseases and bioterrorism are increasingly serious problems; — climate change and the hidden dangers of globalisation; — at the same time, the rapid development of new technologies may result in dynamic changes in methods for promoting health, as well as the prevention and treatment of illnesses.

4.3 The EESC emphasises the importance of a significant active role for stakeholders (public authorities, social partners, civil society organisations including patients' associations and consumer organisations) both in identifying and solving problems and in promoting health-conscious behaviour.

4.4 The EESC is disappointed that the social partners, stakeholders from civil society, professional organisations and patients' associations were not involved. It suggests that cooperation with public authorities — at local, regional, national and European level — in the context of social partnership should take place, whilst effective use of financial resources is essential conditions for implementation of the health strategy and EU economic success.

5. The health of European citizens

5.1 The EESC agrees with the Commission that, in implementing the Citizens' Agenda, civic and patients' rights should be the key starting points for Community health policy, and that solidarity, as the key value underpinning the European social model, should be strengthened, in the interests of everyone's health (7).

5.2 The EESC is in favour of active European citizenship, which only makes sense if underpinned by health-conscious behaviour. Despite EU and national efforts to achieve this, there are still big differences between citizens in terms of health (8), access to healthy lifestyles and equal opportunities; this particularly applies to gender equality (9) and especially vulnerable disadvantaged groups. The EESC urges the Commission to ensure that, once the disadvantages faced by particular groups have been identified, specific solutions and support systems are developed, while promoting cooperation between Member States; moreover, promoting specific programmes to evaluate and maintain the health of elderly people would benefit society as a whole, and would enable population trends to be taken into account.

5.3 In view of the inequalities within and between Member States, the EESC supports the common objective whereby health policies should support the strategies to reduce and eliminate poverty. Although health costs are constantly growing this must not result in individuals and households (both within and outside the EU) becoming worse off or being driven into poverty. Both equality and affordability, as well as local availability, must therefore be ensured in the provision of the appropriate range of public healthcare services and social services. It is vital to avoid further widening the gap between rich and poor in our societies.

5.4 The EESC believes all European citizens should be empowered in their mental and physical health and enjoy equal rights to physical and mental healthcare. This can only be achieved if particular attention is paid to disadvantaged groups such as persons living in long-term poverty, marginalised groups, and groups excluded on religious grounds. Developments in the field of public health must take mental health, in particular that of high-risk groups, more closely into account (10).

5.5 The EESC suggests that the Member States should further promote intercultural dialogue with a view to supporting the work of the EU and individual citizens, particularly in terms of providing and using healthcare services. Recognition and support of cultural diversity and multiculturalism can substantially help to secure legitimacy and acceptance for health awareness and encourage mutual help (11), as well as ensuring timely prevention and recourse to healthcare services and treatment.

5.6 The EESC urges the Commission to formulate proposals to ensure mainstreaming of proposals to develop health-conscious behaviour into all policies, with a view to ensuring access to independent information on mental and physical health, including for citizens without Internet access and disadvantaged persons, whose numbers are — unfortunately — increasing. One option should be cooperation with public-service radio and TV channels to disseminate information about public and individual health (for example on prevention) and provide information enabling timely access to medical facilities. This could also be done using communication tools such as internet, accessible to patients and health workers.

5.7 The EESC emphasises that anti-smoking campaigns, the development of common standards in the area of food labelling, pharmaceutical research, and the development and promotion of health online are areas which offer added value. In many areas, the exchange of best practices and performance evaluation can play a key role in making efficient and effective use of limited funding.

5.8 The EESC feels that policies to support families are important, together with appropriate training and support for the development of health awareness; support for women during pregnancy could be a good starting point for such efforts (12). Hence, to promote European citizenship, the EESC recommends launching a long-term ‘Healthy European Citizen’ campaign.

5.9 While the EESC supports the free movement of labour and acknowledges patients' rights, it would remind the Commission that mobility among patients and healthcare workers must not exacerbate the inequalities which already exist in the field of healthcare; indeed, it is important to overcome these (13).

5.10 The EESC notes that adequate, high-quality public healthcare and social services are a prerequisite for the supply of sufficiently skilled labour in sufficient numbers. In view of this, workers in these fields must be better paid and be given greater social recognition and prestige, to ensure that work in this sector becomes more attractive for young people. The EESC is concerned about the health of ageing healthcare and social care workers, who are threatened by burn-out and stress; that there is a need to highlight the value of the work done in the healthcare and social services sector and to stress that professionals in this sector do valuable work to promote health in the whole of society.

5.11 A conscious effort must be made at national level to establish a strong health policy, and this can only be achieved if adequate budgetary resources and/or funding from social security systems are earmarked. The Member States must effectively invest not only in the prosperity of their populations but also in the well-being of their citizens and subjects.

6. Cross-border and global issues

6.1 The EESC agrees that, with regard to globalisation and health, the EU can play a key role within and beyond its borders in resolving global health problems, and in developing Community-level responses to disasters, pandemics and new challenges arising from climate change; it can also offer added value in dealing with a global shortage of healthcare workers through the compensation fund (14) and improving international access to medicines.

6.2 Existing and new threats to health (HIV/AIDS) which transcend borders mean an increasingly strong role for the EU in offering added value, given that Member States are incapable of resolving such problems on their own (lack of access to tritherapies). This particularly applies to the reinforcing of screening and protection and coordinating the prevention of infectious diseases.

6.3 The EESC is disappointed at the lack of specific proposals by the Commission to deal with problems concerning healthcare workers, who have a key role to play in ensuring the success of the EU's health strategy. There is a very clear correlation between the lack of healthcare workers and problems connected with shortcomings in the provision of healthcare services or the absence of such services.

6.4 The EESC would emphasise the importance of an ethical approach to patients' rights in relations between doctors, patients and all other healthcare workers. In a developing and changing world, with rapidly advancing medical technologies, greater emphasis must be placed on ethics and the protection of personal data; training and further training should therefore pay particular attention to these aspects.

6.5 The EESC points out that there is a growing shortage of healthcare workers and that those currently working in the sector are ageing; an ethical approach is therefore needed to recruitment, with specific policies on integration, skills and pay for employees recruited from both within the EU and from third countries. Options should be considered to promote the return of trained healthcare migrants, thus contributing to the development of healthcare systems in their countries of origin. With regard to the migration of healthcare professionals within the EU, Member States should also ensure that the free provision of services does not result in social dumping in this field, which would be damaging to healthcare workers, their professionalism, and ultimately to patients.

7. Adoption and implementation of the strategy

7.1 The EESC is disappointed by the lack of adequate, genuine, analysable and comparable information or data on the health of European citizens, and of monitoring systems to enable comparisons between Member States or regions. There are also major discrepancies and gaps in terms of information on health and safety at work (15). Certain EU agencies have an important role to play here.

7.2 The EESC recommends that further efforts be made at regional, national and European level in compiling relevant statistics and defining indicators.

7.3 The success of the renewed Lisbon strategy is closely dependent on the health and safety of employees at work. Working conditions are especially important for health, given that adults spend one-third of their lives at the workplace. Hazardous and unhealthy conditions at work cost 3-5 % of GNP. Prevention is the most important way of promoting health and safety at work and ensuring it on a permanent basis. Provided that they adopt and comply with collective agreements, SMEs, which employ over 80 % of workers, require special support, given that they are at an immense disadvantage compared to multinational companies in terms of financial resources and possibilities. The EESC deplores the fact that self-employed are not protected at work.

7.4 The EESC supports changes to Member State healthcare systems improve the standards of service. In order to overcome inequalities within and between Member States, the role of regions should be analysed together with that of Member States; however, this must not result in a transfer of responsibilities from the national level. In this connection, the EESC is deeply perturbed by the reforms to public social insurance and healthcare systems that are taking place in some Member States and which seek to curb public health insurance systems and privatise public healthcare on a massive scale.

7.5 The EESC supports the Commission's objective to promote and strengthen prevention; it is pleased that the Commission intends to work towards improved health for the elderly, children and young people. Making this happen will closely depend on proposals concerning tobacco, nutrition, alcohol, mental health (including Alzheimer's disease) and cancer screening, which are also of particular relevance to the groups targeted by the strategy (16).

7.6 The EESC welcomes the results of technological development, but does not feel that the proposal to use e-health as a solution would ensure that requirements are met in terms of equal opportunities, given that the views of the professionals on this issue are not known. The reference to cost-cutting and more citizen-centred services is justified; however, measures to ensure patients' rights and Member States' responsibilities with regard to developing and overseeing healthcare have not been explained in sufficient detail.

7.7 The EESC supports increased cooperation and new initiatives with international organisations; given that the EU plays a key role in the provision of international aid, the Committee is in favour of closer cooperation with the WHO.

7.8 The EU can help to achieve the objectives of the WHO for the 21st century if it cooperates with Member States, UN bodies, the WHO, the ILO, and other international bodies such as the International Organisation for Migration. Contacts must also be stepped up with international financial institutions such as the IMF and the World Bank. Efforts must be made to promote forums at international level involving the social partners, professional and civil society organisations, in particular patients' associations and consumer organisations.

7.9 The EESC recommends that, as part of the stronger role to be played by the EU at international level, the EESC could take on within the remit of its competence, a more active role in international debates on specific subjects such as the new challenges arising from climate change and their implications for human health.

7.10 The health strategy must feature permanently on the agenda of European neighbourhood and international policies, in particular in order to ensure joint action to combat new health threats and pandemics, the effects of disasters and new health problems arising from climate change or other factors.

8. Financial instruments and resources

8.1 The EESC stresses that it is vital to ensure that the health strategy is taken into account in all EU policy areas. Adequate funding must be ensured, given that the White Paper does not envisage that any additional funding will be available from the budget. Therefore, the EESC has doubts whether Community-level checking and proposals to strengthen mechanisms for surveillance and response to health threats will succeed without appropriate financing being foreseen. In order to ensure effective funding for projects and in view of the ongoing nature of EU policies, it would be advisable to put in place continuous specific budgetary funding for each task (17).

Brussels, 18 September 2008. The President of the European Economic and Social Committee Dimitris DIMITRIADIS

(1) Council Conclusions on Common Values and Principles in European Union Health Systems (C 2006 146/01).

(2) The Fundamental Rights Agency in Vienna, the Bilbao Agency, the European Centre for Disease Prevention and Control, etc.

(3) See EESC opinion of 12.3.2008 on EU budget reform and future financing, rapporteur: Ms Florio (OJ C 204, 9 August 2008).

(4) See EESC opinion of 6.7.2006 on Social cohesion: fleshing out a European social model (own-initiative opinion), rapporteur: Mr Ehnmark (OJ C 309 of 16 December 2006).

(5) See EESC opinion on Implementation of the Lisbon Strategy.

(6) Speech by Dr Margaret Chan, secretary-general to the WHO: Address to the Regional Committee for Europe, 18 September 2007, Belgrade, Serbia: see:

http://www.who.int/dg/speeches/2007/20070918_belgrade/en/index.html.

(7) See EESC opinion of 2.6.9.2007 on Patients' rights (own-initiative opinion), rapporteur: Mr Bouis (OJ C 10 of 15 January 2008).

(8) See impact assessment: for example, in Italy, men live in good health for 71 years; the corresponding figure for Hungary is only 53.

(9) See EESC opinion of 13.9.2006 on the Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions on A Roadmap for equality between women and men 2006-2010, rapporteur: Ms Attard (OJ C 318 of 23 December 2006).

(10) EESC opinion of 17.5.2006 on the Green Paper ‘Improving the mental health of the population — Towards a strategy on mental health of the European Union’, rapporteur: Mr Bedossa (OJ C 195 of 18 August 2006).

(11) See EESC opinion of 20/4/2006 on the Proposal for a decision of the European Parliament and of the Council concerning the European Year of Intercultural Dialogue (2008), rapporteur: Ms Cser (OJ C 185 of 8 August 2006).

(12) E.g. the Hungarian nurses' network, which provides support for children and families from conception up to the age of 18.

(13) EESC opinion of 27.10.2004 on the Communication from the Commission: Follow-up to the high level reflection process on patient mobility and healthcare developments in the European Union, rapporteur: Mr Bedossa (OJ C 120 of 20 May 2005).

(14) EESC opinion of 11.7.2007 on Health and Migrations (exploratory opinion), rapporteurs: Ms Cser and Mr Sharma (OJ C 256 of 27 October 2007).

(15) EESC opinion of 29.5.2008 on the Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions — Improving quality and productivity at work: Community strategy 2007-2012 on health and safety at work, rapporteur: Ms Cser (OJ C 224 of 30 August 2008).

(16) EESC opinion of 30.5.2007 on the Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions — An EU strategy to support Member States in reducing alcohol-related harm, rapporteurs: Ms Van Turnhout and Mr Janson (OJ C 175 of 27 July 2007) and EESC opinion of 28.9.2005 on ‘Obesity in Europe — the Role and responsibilities of civil society partners’ (own-initiative opinion), rapporteur: Ms Sharma (OJ C 24 of 30 January 2006).

(17) EESC opinion of 5.7.2006 on the Proposal for a Council decision on the system of the European Communities' own resources (//EC, Euratom), rapporteur: Ms Cser (OJ C 309 of 16 December 2006).