Opinion of the Committee of the Regions on the 'Communication from the Commission on the development of public health policy in the European Community` (1999/C 51/09)

THE COMMITTEE OF THE REGIONS,

having regard to the Commission's Communication on the development of public health policy in the European Community (COM(98)230 final);

having regard to the decision taken by the Commission on 17 April 1998 to consult it, in accordance with Articles 129 and 198C, first paragraph, of the Treaty establishing the European Community;

having regard to the decision of its Bureau on 13th May to charge Commission 5 (social policy, public health, consumer protection, research, tourism) with the preparation of this opinion;

having regard to its Opinion on the Proposal for a European Parliament and Council Decision adopting an action plan 1995-1999 to combat cancer within the framework for action in the field of public health (CdR 183/94) (); its Opinion on the Communication from the Commission and a Proposal for a European Parliament and Council Decision on a programme of Community action on health promotion, information, education and training within the framework for action in the field of public health (CdR 246/96) (); its Opinion on the programme of Community action on the prevention of AIDS and certain other communicable diseases within the framework for action in the field of public health (CdR 144/95) (); its Opinion on the Communication from the Commission to the Council and the European Parliament on a European Union Action Plan to Combat Drugs (1995-1999) (CdR 147/95) (); its Opinion on the Communication from the Commission concerning a Community action programme on health monitoring in the context of the framework for action in the field of public health and the Proposal for a European Parliament and Council Decision adopting a programme of Community action on health monitoring in the context of the framework for action in the field of public health (CdR 25/96) (); its Opinion on the Commission Communication concerning communicable disease surveillance networks in the European Community and the Proposal for a European Parliament and Council Decision creating a network for the epidemiological surveillance and control of communicable diseases in the European Community (CdR 157/96 fin) (); its Opinion on the Communication from the Commission accompanied by a proposal for a European Parliament and Council Decision adopting a programme of Community action 1999-2003 on pollution-related diseases in the context of the framework for action in the field of public health (CdR 287/97) ();

having regard to the Draft Opinion (CdR 156/98 rev. 2) adopted by Commission 5 on 29 September 1998 (rapporteur: Mr Ian Hudghton),

adopted the following opinion at its 26th plenary session held on 18 and 19 November (meeting of 19 November).

1. Introduction

1.1. The Committee of the Regions welcomes the Communication and the review of public health policy in the light of experience gained since the public health competence was extended in Article 129 of the Treaty on European Union. The COR feels that an examination of EC public health policy is also necessary in view of the extension to the competence in the draft Treaty of Amsterdam.

1.2. Eight public health programmes have originated from Article 129 and many of these programmes will come to an end by the year 2000. The COR believes that this makes an evaluation of the present programmes necessary. The COR expresses concern that three of the programmes still have to be agreed.

1.3. The European Commission is proposing three strands of action. These are:

- improving information for the development of public health;

- reacting rapidly to threats to health;

- tackling health determinants through health promotion and disease prevention.

Issues relating to enlargement and to the integration of health requirements in Community policies would be dealt with across all three strands and this is an important consideration in the communication.

1.4. While generally supporting these actions, the Committee of the Regions feels that the EC should respect subsidiarity and act where there are clear advantages in operating at the European level. The added value of pilot projects, networks and the exchange of good practice should be stressed. The COR believes that careful consideration should be given to EC intervention in each strand so that the EC complements national actions but does not duplicate them. These strands are inter-related and this inter-relationship should be born in mind when developing the EC public health competence.

2. Present activities in EU public health policy

2.1. In the Treaty of Maastricht, Article 129 covered the public health competence and the major responsibilities are as follows:

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

- Community action on health protection should be focused on the prevention of diseases.

- Community activities in the field of public health should concentrate particularly on the major health 'scourges`, including drug dependency.

2.2. There are currently eight action programmes associated with public health. These are:

- AIDS and other communicable diseases;

- cancer;

- drug dependence which is linked to other measures including the establishment of the European Monitoring Centre for Drugs and Drug Addiction. An action plan to combat drugs has also been agreed with Member States;

- health promotion;

- health monitoring;

- pollution-related diseases;

- injury prevention;

- rare diseases.

2.3. The programmes on pollution-related diseases, injury prevention and rare diseases still have to be agreed between the Council and the Parliament. The COR believes that it is important that the two institutions agree the programmes as quickly as possible.

2.4. The EC has taken action in a number of other areas including:

- guidelines and practical recommendations in cancer screening, osteoporosis, healthy diet and youth drinking;

- combating tobacco consumption and reducing tobacco advertising;

- a strategy for blood safety and self-sufficiency;

- a comprehensive review of non-iodising radiation.

2.5. The Committee of the Regions welcomes the important public health element in the Fifth Framework for Research and Technological Development (1998-2002) and this includes research into the relationship between health, environment and food: the control of viral diseases and research into the problems of the ageing population.

3. The extension of the Treaty competence for public health and the problems with the current approach

3.1. The Committee of the Regions agrees with the Communication's assessment of the problems associated with the administration of the current eight programmes. In particular, each programme has a small budget, its own independent strategy and workplan plus an individual committee structure with complex rules. This causes a considerable administrative burden and makes it more difficult for the EC to develop an integrated public health strategy.

3.2. The COR agrees that the current approach needs a more streamlined structure with fewer programmes and more co-ordination between the programmes.

3.3. The communication states that 'greater impact might have been achieved if fewer, large-scale, sustainable actions had been supported` and that 'the reliance on organizations submitting projects reflecting what they wish to do makes it difficult to ensure that programmes' policy aims, and those of national strategies, are attained`. While it may seem administratively convenient to move to larger projects, the COR believes that innovative or pilot projects remain an important part of these programmes and these types of projects are extremely effective at the regional or local level. Similarly, exchange of experience projects can be effectively developed with a small number of transnational partners who are skilled in innovative techniques.

3.4. The Communication argues that the challenges faced by public health, health promotion and disease prevention has changed since the first Community strategy was published in 1993 - and a number of these changes are outlined. They include demographic factors and an ageing population: new technologies and techniques and greater public expectation in terms of health. Changing employment patterns and changes in health care systems are also important further considerations.

3.5. The communication highlights food safety as a particular concern. There have been examples when diseases such as BSE and E-coli have caused widespread concern in public health terms. The communication states that EC public health policy must take into account the impact of modern food preparation and farming practices. The Committee of the Regions would agree with this view and would emphasize the need to develop linkages between the EC public health policy and other European policies such as the Common Agricultural Policy and food safety policy. The Committee of the Regions would also emphasize that BSE and E-coli have been a concern for different levels of government and that the fight against these diseases needs to involve all levels of government in a co-ordinated attempt to eradicate the diseases. The link with aspects relating to animal husbandry, animal feeding and antibiotics in feeding stuffs should also be heeded.

3.6. These changes have greatly affected public health policy and will remain the work of the European Community. Consequently, the Treaty of Amsterdam gave the European Union greater powers in public health.

3.7. Article 152 of the Treaty of Amsterdam deals with public health in the new Treaty and some substantive changes have been made:

- The provisions on the health impact of other policies stress that a high level of health protection should be an important factor in all Community policies and activities.

- Community actions have been extended beyond those directed at 'preventing human illness` and 'obviating sources of danger to human health` to include actions 'directed towards improving public health`.

- Actions in anti-drugs policy will focus on 'reducing drugs related health damage`.

- The Community can now adopt 'measures setting high standards of quality and safety of organs and substances of human origin, blood derivatives` but these measures 'shall not affect national provision on the donating or medical use of organs and blood.`

3.8. The effects of enlargement and the international commitments with organizations such as the World Health Organization have to be included in the development of a public health policy. The Committee of the Regions agrees that the work of international organizations needs to be taken into account when developing the EC public health policy and it is important that EC actions compliment rather than duplicate WHO actions. In terms of enlargement, there is lower spending on health per capita, lower life expectancy and lower health status indicators. There is also an issue with the free circulation of products (particularly pharmaceuticals, blood products and medical devices) which raise questions about safety and quality control. The international dimension deals with the global threat to health, particularly communicable diseases.

4. A future Community public health policy

4.1. In view of these changes, the European Commission is suggesting a Community public health policy with three strands:

- improving information for the development of public health;

- reacting rapidly to threats to health;

- tackling health determinants through health promotion and disease prevention.

Strand One: Improving information for the development of public health

4.2. The Communication emphasizes the importance of adequate health information systems to inform policy analysis and consequently improve the Community's ability to carry out effective actions in the public health field. While the Committee of the Regions agrees that the development of information systems is a key factor in the development of public health policy, the Communication lists information areas which are within the competence of Member States and not the European Community. For instance, Article 4.7 mentions 'trends in health systems` costs and financing, 'including the role of state and private insurance` and 'priorities in health, including priority-setting mechanisms, as well as public attitudes and concerns about health and the effectiveness of health systems`. This might take the European Commission into areas not specified in Article 152 of the draft Amsterdam Treaty.

4.3. While information and comparative data in these type of policy areas would be useful for Member States, the work of the European Commission should not contain recommendations or binding decisions. The priority in information gathering by the European Commission must be in areas where it has a competence. This is particularly important given the budgetary environment in which the EC public health policy will develop. In its information gathering the EC should compliment the data collection of Member States and of international organizations like the WHO and the OECD.

4.4. The dissemination of information from EC commissioned research and data collection is very important. The methods of dissemination need to be carefully thought out so that the European Community works in partnership with Member States and local and regional government. There needs to be a debate between these spheres of government about the EC's research and information programme in public health.

4.5. Research and the collection of information in many areas of public health should reinforce debate, but decisions that stem from the research remain the responsibility of Member States unless specifically allocated to the EC in European treaties.

Strand Two: Reacting rapidly to threats to health

4.6. This strand emphasizes the need for rapid reaction to communicable and rare diseases and it lists plague, haemorrhogic fevers and Asian flu as examples. The European Commission would like to add health requirements in food safety issues, sanitary and veterinary matters, zoonoses, blood and organ safety, environmental hazards, risks to health from chemical substances and poisoning and the adverse effects of medical products and devices. The COR welcomes these proposals because cooperation between Member States is an important consideration in combating threats to public health by communicable diseases. The threat posed by these diseases is increasing due to the increased mobility in the European Union caused by business and tourist visits and the European Community has role to play in the exchange of information and best practice. There is already a very effective warning and information system for food and product safety that includes all the Member States and the Commission. New information systems for related public health areas should be compatible with this system as far as possible.

4.7. Community action would include co-ordinated mechanisms at the European level and include surveillance, swift analysis, site visits and the swift analysis and investigation of specific problems. The Committee of the Regions would, in principle, support activities of this nature, as it is important that the EC supports cooperation between Member States.

Strand Three: Tackling health determinants through health promotion and disease prevention

4.8. This strand is composed of actions which strengthen individuals' skills and capabilities in health promotion and prevention. Action will be directed at changing social, economic and environmental factors so that they are conducive to individual and public health. The strand includes six of the eight public health programmes in the present strategy as these programmes deal with the prevention of disease and eradication of health problems. The COR welcomes the rest of the proposal.

4.9. The Communication states that actions could include vaccination, safety precautions, screening and testing of target populations. However, the COR feels these actions should be left to Member States with the EC funding concentrating on the creation of networks, the definition of quality standards and exchanges of best practice, focusing on projects which enhance social, economic and environmental conditions and on making health action more person-centered.

4.10. The European Commission seeks guidance on its priorities in this strand. It asks whether it should concentrate more on addressing ageing diseases such as Alzheimers' Disease; strengthen the work on nutrition and obesity; devote more attention to cardio-vascular disease; measures to reduce drugs-related health damage; focus on the health of specific population groups such as the socially excluded, e.g. single people, children or women; ensure access to health information and health advisory services for EU citizens who move for work, study and leisure; and the adaptation of strategies to take the specific problems of accession countries into account.

4.11. The COR thinks that the European Commission has introduced a long list of actions and, in view of the limited budget, it will need to prioritise these actions carefully in keeping with real public health needs. Greater emphasis thus needs to be made on health promotion measures, concentrating especially on the weakest of the target groups.

4.12. The COR believes that the European Commission needs to establish the areas in which European intervention will really add value and where the creation of networks and the exchange of experience will prove to be effective.

4.13. Section 4.1 of the Communication outlines the challenges that enlargement will present in terms of public health. It states that the applicant countries 'face potentially serious problems with communicable diseases` and that 'the free circulation of products, notably pharmaceuticals, blood products and medical devices, raises issues relating to safety and quality control as well as pricing`. In addition, the problem of drugs misuse in a number of applicant countries and the growing problem of drug taking in EU Member States means that measures to reduce drugs-related health damage will be a high priority. In view of these problems, the EC will need to review its strategies in the light of an enlarged European Union and this is a matter which needs to be considered urgently.

4.14. Access to health information and health advisory services for EU citizens working and living in other Member States is another important issue for the European Community.

4.15. Although programmes will be combined in this strand, it would appear that there will not be significant amounts of money available. With this consideration in mind, the COR suggests that the activities need to be pitched at specific target groups and health professionals rather than the general public. Pursuing this argument, projects should be developed through open calls for proposals and innovative activities which are region or locally based should be targeted.

4.16. The Committee of the Regions agrees that there is little benefit in splitting promotion and prevention programmes and a more streamlined approach is needed. A single framework for this strand could make better use of resources.

5. The way forward

5.1. The European Commission has made some initial suggestions on the proposed methods of handling public health policy in the future. The Commission considers that there must be debate both on the content of future policy and on the implementation of this policy. A central issue is the nature of the legal mechanisms to be used to ensure that the policy effectively combines incentive and legislative measures provided for in the new Treaty. The proposed network on the surveillance and control of communicable diseases will have its own legal basis.

5.2. There are two possible ways to formalise the new policy. One would be to adopt a single 'framework instrument` providing for the subsequent adoption of separate ones for each strand. This would have the advantage of creating a single financial envelope and of apportioning funding between the strands, but the disadvantage of requiring two layers of decision-making and administrative structures. The other option would be to adopt a separate legal instrument for each strand with no overall instrument. This would need an implicit consensus on the funds to be allocated to each strand. The COR believes that the three action strands are inter-related and that there are strong arguments for a single framework if negotiations to agree the framework between the institutions of the EU can be carried out quickly and effectively.

5.3. A health promotion programme would be valuable provided that clear-cut priorities are established in different areas (e.g. tobacco). The thrust of the programme should be to reduce health discrepancies and the focus should therefore be on specific social groups and health policy.

5.4. The possible extension of the EC's role to 'evidence based` medicine, quality control, implementation, health technology assessment and the dissemination of results is natural and relevant in the case of public health programmes, where there is a need to promote cooperation and good practice amongst Member States.

5.5. The use of research and the compilation of information are useful in many public health areas where Member States have responsibility but it must be remembered that research and information is used to develop an informed debate. Responsibility for the development of health and medical systems, including cost control and finding schemes, will remain a national responsibility.

5.6. The approach that public health aspects are a productive factor in society as reflected in the World Banks 'Investing in Health` initiative, is to be welcomed. Public health priorities need to be established, especially in the light of the overall goal of alleviating health discrepancies between different groups, regions and countries.

6. Main conclusions

6.1. The Communication is to be welcomed as it provides a full analysis of the issues facing the development of the EC's public health policy. Due to the growth of the EC's public health competence in the Maastricht and Amsterdam Treaties, an evaluation of public health programmes is welcome.

6.2. While generally supporting the three strands of action outlined in the Communication, the Committee of the Regions feels that the EC should respect subsidiarity and demonstrate where there are clear advantages in operating at the European level.

6.3. The present implementation of eight public health programmes with relatively restricted budgets means that there is a great deal of unnecessary administration and the COR welcomes the European Commission's attempts to streamline these programmes.

6.4. The COR emphasises the link between public health policy and other EC policies such as the Common Agricultural Policy and food safety policy.

6.5. Despite this streamlining, the amounts of money in the budget will not allow for extensive activities and the rapporteur feels that, in many areas, the programmes should concentrate on innovative local or regional projects and the exchange of experience.

6.6. It is also important that the three public health programmes still to be established are agreed by the Council and the Parliament as soon as possible.

6.7. In Strand One, the COR agrees that the European Commission should collect information to assist in the delivery of the EC public health policy, but notes that it proposes to collect information in policy areas which is the competence of Member States. The EC also needs to consider information collected by other international organizations like the WHO and the OECD. The COR feels that great care should be exercised in this area and it should not contain recommendations and binding decisions.

6.8. The COR welcomes the actions in Strand Two which is an important part of the European Commission's work, and emphasizes the EC's co-ordination role in this strand so that it encourages cooperation between Member States.

6.9. The COR welcomes the inclusion of six of the eight present public health programmes in this strand in an attempt to create a more streamlined and effective approach. However, in view of budgetary constraints, careful thought is needed in defining new or extended activity in this strand. The COR would like to emphasize the changes need in strategies due to enlargement and the growing scourge of drug-related disease in the EU.

6.10. In view of the limited budget, the COR would like to remind the Commission of the importance and effectiveness of innovative local or regionally based projects. The creation of networks and the exchange of experience also adds value at the European level.

6.11. The COR would favour a single legal framework because the three strands of action are closely inter-related.

Brussels, 19 November 1998.

The President of the Committee of the Regions

Manfred DAMMEYER

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