EN Official Journal of the European Union C 126/26

Opinion of the Committee of the Regions — Health inequalities in the European Union

2014/C 126/07

I. POLICY RECOMMENDATIONS

THE COMMITTEE OF THE REGIONS

Introduction

1. welcomes the Report (1), a progress update on the implementation of the 2009 communication (2) which presented a schedule of actions to address health inequalities; acknowledges the thorough and interim nature of the Report but considers that there would be value in highlighting the degree of success of particular actions and in prioritising those to be continued and completed;

2. believes that health and wellbeing of individuals and of the population is their greatest resource; notwithstanding Article 35 of the EU Charter of Fundamental Rights considers that the extent of health inequalities between and within Member States is a challenge to the EU’s commitment to solidarity, social, economic and territorial cohesion, human rights and equality of opportunity;

3. recognises that determinants of health status include a very broad range of personal, social, economic and environmental factors where the interrelationships between these factors determine individual and population health. Health inequalities largely arise from socio-economic disadvantage, in addition health and wellbeing are also directly affected by policy decisions taken by authorities at all levels, the individual choices people make about how they live, participate in their communities, by biological factors and by geographical considerations;

4. emphasises that, given the diversity of influencing factors, inequalities in health cannot be reduced by the health sector alone, they require action by all those whose work promotes health and wellbeing through integrated and coordinated whole-of-governance plans, the Health in All Policies Approach (HiAP) and through the wider engagement of society; underlines that political and organisational leadership committed to strategically addressing health inequalities is a prerequisite to help drive and implement this;

5. while recognising the diversity of health systems across the EU, underlines that regional and local authorities play key roles in the provision of public health services, in health promotion and disease prevention; equally, policies such as employment, housing, transport, planning, environment and public safety are some other functions of local and regional authorities ensuring that they are key actors in promoting public health and in reducing health inequalities; believes that it is often at the local and regional level that the intersectoral approaches that are crucial to reducing health inequalities can be developed and implemented in a more targeted and efficient manner and results demonstrated;

6. is concerned that the current economic climate poses a significant threat as health budget cuts add to the well-documented demographic ageing challenges to make the funding of health services even more challenging. Reducing health inequalities must be seen as an essential step as many authorities within Member States face reform of their health systems to make them more effective and more sustainable;

7. notes that as the Report simply states that ‘some health inequalities are related to differences that exist in the quality and effectiveness of health services across the EU’ (3); considers that the simultaneous publication of the Marmot Report on health inequalities in the EU (4) may have reinforced this statement and possibly helped to focus the Report's conclusions;

Health inequalities: some facts and figures

8. regrets that the Report confirms the persistence of significant and unacceptably large health inequalities between and within Member States. Over recent years, the level of inequality has improved for a small number of indicators, with no change for others and a deterioration for a few; draws attention in particular to the very high differentials in healthy life years between Member States at almost 19 years, thus while life expectancy may be increasing, people are living longer with chronic illness;

9. welcomes the fact that mortality rates have decreased and life expectancy has risen. However, these improvements are at risk with increases in adverse trends related to obesity, diabetes and physical inactivity; the projected growth in incidence of chronic diseases promises an unhealthy and costly future unless tackled;

10. barriers to accessing health services (including cost, distance and waiting time) are very high in some Member States, moreover the type and quality of medical treatment received is often a function of the services available where a person lives; draws attention to the societal benefits of incentivising medical practitioners and services to establish in disadvantaged and isolated areas;

11. given the social gradient that exists with health status, considers that a key requirement in addressing health inequalities is that the concept of levelling up be applied rather than a statistical levelling out so as to improve the health of all sections of the population to that experienced by the healthier in society;

Progress in implementing Solidarity in Health

12. welcomes the 2011-2014 Joint Action on Health Inequalities with participation from 15 Member States; supports extending this initiative with greater engagement and focus given the need for continuity in prioritising the issue and to build on successes achieved; also encourages consideration of more flexible co-financing mechanisms for Joint Action engagement;

13. encourages at the appropriate levels of governance, the introduction and implementation of appropriately resourced overarching intersectoral strategies as reducing health inequality will necessarily require commitments from many Ministries and levels of governance who often compete for resources and are often compartmentalised in their perspective; national-level strategies can inform the development of regional and local level strategies and vice-versa;

Improving the data and knowledge base

14. supports ongoing programmes for knowledge dissemination from successful projects to bridge the gap between research, policy and practice and to encourage take up of similar projects; however given the information overload facing policymakers and practitioners supports a focus on presentation in an accessible and concise way; in particular, calls for more succinct messages backed up by successful examples; moreover recommends developing and promoting a key portal to access information;

15. welcomes the significant collaborative engagements between the European Commission and international agencies and public stakeholders and recommends the highest level of partnership with WHO Europe in coordinating policies, in sharing resources and in promoting initiatives, such as Healthy Cities, the WHO's Regions for Health Network and the global network of Age-Friendly Cities and Communities; supports also, enhanced collaboration through the work programmes of relevant EU agencies;

16. without requisite data it is extremely difficult to gauge progress, therefore urges all authorities to continue working towards standardised European Core Health Indicators (ECHI), which should be developed in close consultation with local and regional representatives; insofar as possible, this should facilitate sub-national efforts to tackle health inequalities; underlines that there is a need to avoid duplicating administrative burdens for data collection given the various obligations for national and international reporting;

17. welcomes the EU programme of research on health inequalities and proposes that themes suitable for future research include: the effectiveness of interventions to reduce health inequalities; factors surrounding healthy life years differentials; greater analysis of longitudinal studies to gain better understanding of what is impacting health inequalities; indicators for mental health; and why some regions with relatively low GDP have good health indicators and vice versa;

Building commitment across society

18. reiterates that achieving the goals of Europe 2020 are fundamental to addressing health inequalities and underlines the link between healthy populations and productive, sustainable economies; equally underlines that top-level targets must be translated into tangible and measurable achievements at local and regional level;

19. stresses that getting people back to work and ensuring healthy workplaces are critical to population health; underlines that as a prerequisite to tackling health inequalities, reducing long-term and youth unemployment are overriding priorities; is concerned at the current and long-term impacts on health and mental health of those feeling excluded from contributing to society;

20. stresses the need for strong social support networks as support from families, friends and local communities is linked to better health including better mental health, this is particularly so for the elderly with isolation, mobility and communication concerns;

21. as advertising budgets for consumer goods and services crowd out health messages and as improving health requires the input of wider society, considers it imperative to involve the private sector whether through Corporate Social Responsibility initiatives or through legislative or fiscal measures, so as to encourage healthier societal outcomes e.g. reducing fresh food waste, clearer labelling, energy pricing etc.;

22. supports analysis of how fiscal measures can be used to discourage tobacco consumption, the misuse of alcohol and the excess of saturated fats, sugar and salt in some processed foods so that their costs on public health and on other public services is better reflected. Equally, supports equivalent measures to incentivise healthier foods and healthier lifestyles to encourage behavioural change;

23. considers that relevant governance policies should move towards health-proofing through Health Impact Assessments to ensure that the net effect of public policy is to improve the health and wellbeing of the population while at the same time reducing health inequalities;

Meeting the needs of vulnerable groups

24. believes that giving children the best start is crucial, as the most effective time to intervene in reducing inequalities and improving health outcomes is before birth and in early childhood. Recommends that the health of children be afforded special attention in programmes to reduce inequalities and underlines the importance of the availability of quality childcare; such measures provide a greater rate of return than later interventions;

25. draws attention to the successful impacts of evidence-based and cost-effective positive parenting programmes (5) to give parents practical strategies to help them manage their and their children’s behaviour, and encourages making such programmes more widely available, particularly to at-risk children and parents;

26. considers that childhood obesity is now amongst the greatest challenges. With socio-economic division apparent at an early age, childhood weight tracks strongly to adulthood and drives the development and worsens the outcome of chronic diseases, as crippling for health economics as for personal health; looks forward to the proposed European Commission Action Plan to address this;

27. as the WHO has attributed nearly 60% of the disease burden in Europe to seven leading risk factors (6); considers that tackling these risk factors and raising health expectations, particularly through education is key to reducing health inequalities and advocates increased targeting of groups through ICT and social media and via role models so that information on health and healthy lifestyles is presented in an accessible, credible form as longer-term health consequences may not be an immediate priority for some;

28. calls on the Commission to foster the pooling of experience with regard to health education and healthy lifestyle promotion; and in the prevention, early diagnosis and treatment in relation to drinking, smoking, diet, obesity and drugs; moreover, calls on authorities within Member States to promote physical activity, healthy lifestyles and essential life skills programmes (health literacy, basic science, ability to screen information, numeracy for budgeting etc.) with particular focus on young people and vulnerable groups;

29. as a confluence of factors can affect older people including lower incomes, chronic health conditions, isolation and mobility problems and with people living longer; emphasises the importance of achieving the targets of the European Innovation Partnership on Active and Health Ageing and supports wide implementation of its Action Plans; moreover wishes to promote the Dublin Declaration on Age-Friendly Cities and Communities in Europe 2013 (7);

30. stresses that public health programmes that reduce health inequalities can be cost effective — e.g. the screening, detection and treatment of risk groups where inherited conditions increase the probability of developing certain illnesses; the case can be made to give priority to such programmes (e.g. improving access to cervical cancer screening for low income women) on efficiency grounds;

31. underlines the necessity of addressing health inequalities through authorities and services at local level and through active community development organisations that are best placed both to understand the needs of vulnerable groups locally and to get most beneficial engagement in programmes;

Developing the contribution of EU policies

32. while authorities within Member States are responsible for the organisation and delivery of health services, the Report and Commission actions to support and coordinate the efforts of Member States can be considered to accord with the application of the subsidiarity and proportionality principles; appreciates that various EU policies and funding programmes including social affairs, research & innovation, education, energy, rural development and regional policy have the potential to impact on health and health determinants and contribute to reducing health inequalities;

33. welcomes the Commission’s set of Thematic Objectives as a means of focussing expenditure and the inclusion of reducing health inequalities as an ERDF investment priority; believes that the inclusion of health-related aspects across diverse EU programmes and funding streams is a further spur for high-level intersectoral strategies; endorses the relevant ex-ante conditionalities under the Common Provisions Regulation and considers that any consequential strategic policy framework must apply at the appropriate operational level to achieve the desired impacts;

34. is concerned at the stated lack of capacity of health systems to bring forward investments to address health inequalities (8); stresses that capacity building to successfully attract and invest EU funds needs to be prioritised; as an aid to this, supports wider promotion of resources such as Equity Action’s Applying EU Structural Funds and re-iterates the need for well-promoted contact points within Member States;

35. stresses that facilitating the engagement of local and regional health systems and authorities is critical in all phases of the ESI funds programming cycle to ensure that health improvements receive appropriate prioritisation, particularly in the application of discretionary elements of operational programmes as, within all regions, there are often localised pockets of deprivation;

36. is disappointed that reducing health inequalities is not a specific objective under Health for Growth; more widely, encourages a balance between investment in infrastructure and in preventive healthcare measures; encourages a balance within infrastructure investment between large-scale hospital development (where eligible) and more accessible, integrated community-based care; underlines also the need for assessment of EU spending with a focus on effect, sustainability and return on investment;

37. encourages uptake of the European Grouping of Territorial Cooperation (EGTC) facility by authorities and bodies in developing partnerships to facilitate cross-border projects to reduce health inequalities, for instance with respect to infrastructure and access to state-of-the-art medical equipment;

Conclusions

38. with increasing demographic and budgetary pressures, welcomes wider EU initiatives to assist authorities within Member States to develop sustainable and effective health systems in particular by investing in preventive healthcare so as to reduce future longer-term costs and to restructure healthcare systems to provide equitable access to high-quality healthcare;

39. welcomes progress on the Commission’s actions to address health inequalities and underlines that more needs to be done at all levels of governance; for instance, through the European Semester process there are opportunities to highlight health inequality issues within Member States; equally, local and regional authorities have the capacity to introduce and implement strategies to reduce inequalities at sub-national levels through evidence-based, cost-effective actions with resources concentrated on the most vulnerable;

40. given the responsibilities of local and regional authorities, the CoR wishes to participate in relevant European Commission initiatives and would like to make its resources available in this regard; would welcome a further progress report from the European Commission within the next three years to update on progress;

Brussels, 31 January 2014. The President of the Committee of the Regions Ramón Luis VALCÁRCEL SISO

(1) Report on Health Inequalities in the European Union SWD(2013) 328.

(2) Solidarity in Health: Reducing Health Inequalities in the EU COM(2009) 567.

(3) SWD(2013) 328 p. 20.

(4) Report on Health Inequalities in the EU, M. Marmot et al — European Commission (in press).

(5) For example, http://www.triplep.net/glo-en/home.

(6) Hypertension, tobacco use, alcohol misuse, high cholesterol, being overweight, low fruit and vegetable intake and physical inactivity: Mortality and burden of disease attributable to selected major health risks — WHO Global Health Risks (2009).

(7) http://www.ahaconference2013.ie/dublin_declaration/dublin_declaration_text.

(8) SWD(2013) page 16.