Opinion on the Commission Communication on the framework for action in the field of public health (94/C 388/02)

On 3 December 1993 the Commission decided to consult the Economic and Social Committee, under Article 129 of the Treaty establishing the European Economic Community, on the abovementioned Communication.

The Section for Protection of the Environment, Public Health and Consumer Affairs, which was responsible for preparing the Committee`s work on the subject, adopted its Opinion on 7 June 1994. The Rapporteur was Mr Ataíde Ferreira.

At its 317th Plenary Session (meeting of 6 July 1994), the Economic and Social Committee adopted the following Opinion by a large majority with 1 vote against and 3 abstentions.

1. Introduction

1.1. In view of the importance of public health in terms of both its economic and social repercussions and its possible positive or negative impact on generating solidarity in Europe and in developing European citizenship (), a Communication on the subject warrants analysis by the ESC; for the Opinion to be clear and unambiguous, an analysis of the Communication`s premises and technical/legal framework () is necessary.

1.2. This is not a legislative Opinion in the strict sense of the term, since referral to the Committee is part of the preparatory process for special intervention, where action will be rooted in a complex web of areas of responsibility, some pertaining to the Commission and others falling within the remit of the Member States, and which according to the case in hand come into contact in cooperation and coordination processes. The ESC therefore intends to clarify its views on how Article 129 of the Treaty can and should be interpreted. The Communication will have to be analyzed on the basis of its objectives and premises.

1.3. Before analysing the Communication itself, let us raise the preliminary question of how to interpret Article 129 of the Treaty against the background of the major social, economic and political issues affecting the everyday life of men and women living in the European Union, on whose behalf the ESC speaks.

2. The preliminary question - the Community and public health

2.1. One of the significant innovations contained in the new text of the Treaty of Rome, as inserted by Article G(38) of the European Union Treaty, is Title X, which deals with public health; Article 129 stipulates that:

'1. The Community shall contribute towards ensuring a high level of human health protection by encouraging cooperation between the Member States and, if necessary, lending support to their action.

Community action shall be directed towards the prevention of diseases, in particular the major health scourges, including drug dependence, by promoting research into their causes and their transmission, as well as health information and education.

Health protection requirements shall form a constituent part of the Community`s other policies.

2. Member States shall, in liaison with the Commission, coordinate among themselves their policies and programmes in the areas referred to in paragraph 1. The Commission may, in close contact with the Member States, take any useful initiative to promote such coordination.

3. The Community and the Member States shall foster cooperation with third countries and the competent international organizations in the sphere of public health.

4. In order to contribute to the achievement of the objectives referred to in this Article, the Council:

- acting in accordance with the procedure referred to in Article 189b, after consulting the Economic and Social Committee and the Committee of the Regions, shall adopt incentive measures, excluding any harmonization of the laws and regulations of the Member States;

- acting by a qualified majority on a proposal from the Commission, shall adopt recommendations.`

2.2. The Commission is thus empowered to submit to the Council (i) proposals for recommendations to be made to the Member States and (ii) incentive measures to encourage cooperation between Member States so as to help secure a high degree of health protection.

Health is not yet an area dealt with in a Community policy, but it is an area of common concern particularly as regards disease prevention and drug addiction.

In accordance with the provision quoted above, the new legal basis does not jeopardize those interconnections and measures in the health field, resulting from the various Treaty provisions, which have allowed the Community to take important initiatives in this area supported by the ESC.

2.3. Indeed, the concept of public health as defined by Member States in the international organizations to which they belong, includes, in addition to disease prevention, health promotion for individuals and specific age and social categories in particular, and in specific environments (school, workplace, etc.). Under these circumstances, the Article 129 norm has to be interpreted in the light of Member States` prior experience and the various actions and programmes already undertaken and implemented by the Community, the legal basis for which consists of other provisions in the same Treaty.

2.4. The second paragraph of Article 129(1) should - hopefully - be interpreted by the Council and of course the Court of Justice in the light of the common history of Member States and the Community itself, and should be understood as being merely indicative because only in this way does it make sense. If interpreted literally (i) it would make no sense, (ii) it would mean that current programmes would be halted, (e.g. bio-medical research, which includes programmes going far beyond mere disease prevention), (iii) the AIDS and cancer programmes would be called into question, and (iv) drug addiction would automatically be classified as a disease.

3. General comments

3.1. The Commission`s promptness in drafting this Communication on the framework for action in the field of public health is to be welcomed, coinciding as it does with the entry into force of the Maastricht revision of the treaty; this means that the importance of a health policy for Europe has clearly been recognized, as a guarantee for a rise in 'the standard of living and quality of life` () for European citizens.

3.2. Despite the difficulties in interpretation, the Commission has done good work in looking into specific aspects of disease prevention in depth and in trying to set the question in a broader framework.

3.3. The document attempts to consolidate successive analyses, discussions and studies by the various institutions, including work by the ESC.

To recap, the Opinions referred to in point 46 of the Commission`s Communication are identified below in more detail:

- Information Report on public health - 11. 2. 1986 - CES 539/86 - ENVI/169;

- Opinion on the proposal for a Council Resolution on a programme of action of the European Communities on cancer prevention - OJ No C 101, 28. 4. 1986, p. 22;

- Opinion on the prevention of environmental pollution by asbestos - OJ No C 207, 18. 8. 1986;

- Opinion on the transparency of medicinal product prices - OJ No C 319, 30. 11. 1987;

- Opinion on the proposal for a Council Regulation relating to a research and development coordination programme of the European Economic Community in the field of medical and health research (1987-1989) OJ No C 105, 21. 4. 1987, p. 7, and Opinion on the 'Europe against Cancer` programme concerning the information of the public and the training of members of the health professions - OJ No C 105, 21. 4. 1987, p. 18;

- Opinion on the proposal for a Council Regulation on a Community action in the field of information technology and telecommunications applied to health care AIM (Advanced Informatics in Medicine in Europe) pilot phase - OJ No C 356, 31. 12. 1987, p. 8;

- Opinion on the specific research programme in the field of health-predictive medicine: human genome analysis 1989-1991 - OJ No C 5, 6. 3. 1989, p. 47;

- Opinion on the labelling of medicinal products for human use and on package leaflets - OJ No C 225, 10. 9. 1990;

- Opinion on the five proposals for Council Decisions concerning the conclusion of cooperation agreements between European Economic Community and the Republic of Austria, Kingdom of Norway, the Swiss Confederation, the Republic of Finland and the Kingdom of Sweden in the field of medical and health research - OJ No C 56, 7. 3. 1990, p. 11;

- Opinion on the legal status for the supply of medicinal products for human use - OJ No C 225, 10. 9. 1990;

- Opinion on the draft Council Resolution on improving the prevention and treatment of acute human poisoning - OJ No C 124, 21. 5. 1990, p. 1;

- Opinion on the proposal for a Council Directive on advertising of medicinal products for human use - OJ No C 60, 8. 3. 1991, p. 40;

- Opinion on the proposal for a Council Decision adopting a specific research and technological development programme in the field of biomedicine and health (1990-1994) - CES 1372/90 in OJ No C 41, 18. 2. 1991;

- Opinion on the Community procedures for the authorization and supervision of medical products for human use and establishing a European agency for the evaluation of medicinal products of 4 July 1991 - CES 882/91 - OJ No C 269, 14. 10. 1991;

- Opinion on the wholesale distribution of medicinal products for human use - OJ No C 225, 10. 9. 1990;

- Opinion on the Community`s system of information on accidents involving consumer products - OJ No C 62, 12. 3. 1990;

- Opinion on the proposal for a Decision of the Council and the Ministers of Health for the Member States adopting a plan of action in the framework of the 1991-1993 Europe against AIDS programme - CES 700/91 in OJ No C 191, 22. 7. 1991 and 1994 CES 1237/93 (not published);

- Opinion on the proposal for a Council Regulation (EEC) on the establishment of a European drugs monitoring centre and a European information network on drugs and drug addiction (REITOX) - CES 635/92 in OJ No C 223, 31. 8. 1992;

- Own-initiative Opinion on health/safety at the workplace - training - OJ No C 249, 13. 9. 1993, p. 12;

- Opinion on the proposal for a Council Decision concerning the inclusion of a cooperation agreement between the European Economic Community and the Republic of Turkey in the field of medical and health research - CES 864/91 in OJ No C 269, 14. 10. 1991;

- Opinion on occupational medicine - OJ No C 307, 19. 11. 1984;

- Opinions on dangerous substances and operations.

This Communication is important for the future of European public health; it is preceded by an executive summary which provides a brief outline of the content of the Communication for the members of those Institutions to which the Communication is sent, and urges them to examine the subject in depth.

3.4. The main challenges in the public health field are clearly identified in the Commission Communication (from point 4 onwards).

3.5. The matter of the costs and financing of health spending must be looked into later; here the ESC will be able to make a contribution.

3.6. As a result of the difficulties encountered in interpreting the text, the chapter on 'Health status and trends in the Member States` (Part A - II, point 14 onwards) does not, in our opinion, give an analysis from a truly European perspective and for this reason it is incomplete, for it should be noted that achievements in public health at national level, be they major or minor, are not only the result of Community action in this area but are also rooted in the experience and knowledge accumulated and tested over decades by Member State organizations, with support from international organizations whose role here should not be forgotten, such as their contribution to the current concept of 'health promotion` () and the Environment and Health Charter ().

The Commission should also mention significant events in the recent history of public health in Europe. This would help to improve our understanding of the contribution which the proposed public health policy represents.

Member States` past achievements are just as important as the future.

3.7. As regards the more specific area of disease prevention and the priorities indicated in point 122 of the Communication (), the ESC agrees with the Commission`s conclusions, notwithstanding a number of general reservations, about its stance on public health.

3.8. The ESC feels that a public health policy cannot be viewed in a restrictive sense (disease and drug addiction prevention), but should be viewed as health promotion based on a horizontal, interdisciplinary approach, involving cooperation between the various disciplines.

3.9. The Commission Communication contains imprecise terminology which creates difficulties in interpreting the text as regards the real aims pursued.

A policy for public health will only be such if organized on a horizontal basis. Health promotion has to deal with all aspects of the living environment, including disease prevention, but it should not be limited to the latter alone.

3.10. The fact that the information given in Annex I (Member States` preventive policies) does not follow a uniform, orderly pattern, has meant that there are shortcomings in the identification of priorities and definition of strategy in this document, as referred to above.

3.11. To avoid over-hasty reactions, it should be made clear that the proposed definition of a global, horizontal model for a health policy for the European Union in no way clashes with the responsibilities of the various Commission Directorates-General or services, nor does it clash with the various levels of Member State government (national, vertical or horizontal). This is merely a matter of managing synergies, avoiding ineffective action caused by a lack of communication or compatibility with other action and, essentially, of better management for ensuring a higher economic and social return.

4. Specific comments

4.1. The chapters entitled 'Health status and trends` () and 'The European Community approach` () identify the Commission`s main strategic options. Here lies the core of the approach to the subject, which the ESC intends to debate fully in keeping with its responsibilities set out in the Treaty and in response to the Council of Ministers` referral of the subject to the Committee.

4.2. The ESC feels that the Council should not limit itself to a literal interpretation of the sphere of public health, as defined in Article 129 of the Treaty.

4.2.1. This interpretation would involve restricting the sphere of public health as it is understood by the various Member States (), and would clearly go against the development of the concepts of public health which are commonly accepted by scientific circles and by Member States.

4.2.2. The Commission itself seems to want a broader interpretation of this article in that it is proposed to take other health initiatives. Moreover, the Commission is proposing a policy for developing countries, based on an integrated, global approach ().

4.2.3. This interpretation advocated by the ESC has the following advantages:

- it does not go against current trends in the public health thinking of most Member States, thereby avoiding greater fragmentation in practice;

- it makes it easier to link up and coordinate the Commission`s European policy with Member States` policies, as well as those of other international organizations;

- it makes it easier to link up and coordinate public health policy with European socio-economic policies and options for developing health systems;

- it allows better management of the resources invested and will lead to a better cost/benefit ratio;

- it reconciles the wording of Article 129 of the Treaty with the spirit and overall objectives of the Community and the Union.

4.3.

A new approach

4.3.1. The ESC feels it will be necessary to define more clearly, major areas of public health action, which are not fully understood by means of a disease-by-disease approach, i.e.:

a)

Age groups

An up-to-date European public health policy should at least make a reference to the health problems faced by younger people (alcohol, violence, drugs, smoking) and the elderly (dependence, exclusion, health care), not forgetting those faced by mothers (and women in general), children and the least-privileged population categories in Europe.

b)

Vulnerable groups

Consideration must also be given to the health of the immigrant population, the unemployed and the victims of the most acute forms of exclusion () (particularly the homeless).

c)

Specific environments

Health at school and in the workplace should be given a prominent place in any public health policy. This also applies to unhealthy elements in the physical environment, such as air pollution, urban noise and pollution of waterways.

4.3.2. The process which every community - be it national, regional, local - or the European Union as a whole will have to go through to attain its health objectives, will involve the same challenges, irrespective of the nature of these objectives:

- how and by whom are those decisions taken which most affect citizens` health;

- what Community and health service infrastructures support or implement public health actions;

- and finally, how are public health actions to be financed?

4.3.3. Since Article 129 stipulates that in health protection the Community`s role is not to set standards or align rules, but is more to provide impetus for, facilitate and support Member States` action, it would be particularly important for the Commission`s analysis to set out more clearly the link between public health policy and social (), farming, consumer, environmental and sport and leisure policy. Thus it is hoped that the Commission and finally the Council will be able to mesh all the different ways of improving quality of life ().

4.3.4. In Member States, particularly at local level, there are hundreds of organizations made up of men and women, which have made significant contributions to public health, particularly in health education and information in the strict sense of the term but also linking these issues with consumer, food and environmental questions in particular. At Community level also there are bodies with considerable action capabilities whose merits should not be underestimated which should in fact be assessed by the Commission, so that at national and European Union level it might be possible to involve all interested parties, including administrative bodies, in implementing a health policy.

4.3.5. Finally, it is to be hoped that even in the limited scope of a Communication designed to promote disease prevention, the document under analysis would mention ways of guaranteeing a suitable link with national and European scientific circles. In this way, Community action will be assured a more solid scientific basis.

5. Conclusions and recommendations

5.1. A public health policy which responds to the requirements and concerns of European citizens has to (a) provide a bold response to the desire for improvements in quality of life, including health promotion and (b) take on board a series of horizontal and vertical actions, which in some cases will be the Community`s responsibility and, in others, will be up to the Member States at national, regional or local level depending on the circumstances and each Member State`s legal system within a specific framework for cooperation and coordination, depending on the case and circumstances involved.

5.2. The Communication as it stands is geared to and based on prevention and information, although it also indicates an accurate list of public health priorities, and thus does not constitute an adequate response to the Committee`s expectations in this field.

5.3. The ESC therefore calls on the Council to adopt an overall coherent stance for public health policy, interpreting Article 129 of the Treaty in accordance with Article 2 of the same Treaty, since this is the fundamental, ordaining principle and thinking behind the establishment of the Community of States and Citizens.

5.4. To this end, the ESC also calls on the Council to give the Commission a mandate to supplement this timely, important Communication by making a global, horizontal analysis of public health, thus overcoming the limitations which have created shortcomings in the present analysis of public health policy.

5.5. To this end, the document should, as mentioned above, take account of the following:

a)

the specific circumstances of various categories, i.e. in addition to diseases and drug addiction: age groups, vulnerable groups and specific environments;

b)

an analysis of which proposed actions and initiatives fall or can fall within the Community`s responsibilities, independently of Article 129, in line with its own powers and in accordance with the Treaty, and which ones could likewise be dealt with through cooperation and coordination;

c)

such an analysis must take account of the vital link between public health policy and health care policy, particularly in terms of facilities, human resources, (management and technical work) and finance, without jeopardizing the specific nature, character and objectives of each of these policies;

d)

it is recommended that a suitable link be made between health policy, as already indicated in the present Communication, and the socio-economic dimension, in terms of solidarity, competitiveness and employment, in the framework of a 'social Europe` and the 'Citizens` Europe`, particularly by stepping up the horizontal approach to the subject (work, employment (), urban living environment, housing, farming policy, consumption, environment, etc.) (). Full account must be taken of the freedom of the individual, of his or her particular lifestyle and of European diversity;

e)

public health issues should be taken into consideration in the priorities for Structural Fund action, particularly Social Fund action, withdrawing all those which could jeopardize public health issues.

Done at Brussels, 6 July 1994.

The President

of the Economic and Social Committee

Susanne TIEMANN

() OJ No C 295, 22. 10. 1994, p. 47.

() Cf. 'Investing in Health` World Development Report 1993 - World Bank - Oxford University Press 1993, pp. 7 and 14.

() The Citizens` Europe, OJ No C 313, 30. 11. 1992.

() Quality and impact of ESC Opinions - CES 592/92 rev.

() Article 2 of the EC Treaty.

() See glossary: Health promotion - International Conference on Health Promotion - Bonn, 17-19 December 1990, p. 21.

() European Charter on Environment and Health adopted by the European Ministers of the Environment and Health, Frankfurt, 7/8 December 1989.

() Cf. p. 34 of the Communication.

() See p. 6.

() See p. 15.

() For example:

a) The United Kingdom for England - 'Health of the Nation` (1993) - quoted in the Commission Communication - A series of health objectives linked up to the mechanisms for achieving these objectives, either through health services or initiatives centred on the community and supported by genuine intersectoral cooperation (education, transport, social services);

b) The Netherlands - 'Health Strategy of the Netherlands` (1993) - an equally broad and comprehensive series of health objectives;

c) France - A Public Health Strategy elaborated by the High Committee on Public Health (1993 preliminary) - quoted in the Commission Communication, which proposes a comprehensive health policy.

() COM(94) 77 final, 24. 3. 1994.

() COM(92) 542 final - Communication entitled 'Towards a Europe of Solidarity`, point III.3.

() Green Paper on European Social Policy, COM(93) 551 final, pp. 43-49 and 66-68.

() Article 3(o) of the Treaty.