EUROPEAN COMMISSION Brussels, 6.11.2019 COM(2019) 565 final REPORT FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS on the implementation of the Council Recommendation on promoting health-enhancing physical activity across sectors



1.Introduction and context The Council Recommendation on promoting health-enhancing physical activity (HEPA) across sectors (‘the Council Recommendation’), adopted in November 2013, invited the Commission to report on its implementation and on its added value every 3 years. A first progress report was published in December 2016 covering the period 2014-2016. This is the second report, covering the period 2017-2019. Sport and physical activity contribute to physical, mental and social health, yet the 2018 Special Eurobarometer on Sport and Physical Activity shows that too many people in the EU do not reach the minimum levels of physical activity recommended by the World Health Organization (WHO). The objective of the Council Recommendation is to tackle this problem. Engagement in sport and physical activity varies with age, gender, level of education and socio-economic background, and between countries, suggesting that national policies and guidelines may influence behaviours. The Council Recommendation encourages the EU Member States to develop national strategies and action plans to promote physical activity involving all relevant sectors, including but not limited to sport and health. It also encourages them to cooperate closely with each other and with the Commission by regularly exchanging information and best practices. This overview of the implementation of the Council Recommendation shows positive developments, including the adoption of several new policies, improvement of cross-sector cooperation at national level and stronger cross-border cooperation. 2.Method The Council Recommendation includes in its Annex a set of 23 indicators (‘the monitoring framework’) that are used to monitor the progress made in the Member States on policies to promote HEPA and to evaluate physical activity levels. An indicator is considered implemented when a Member State has introduced a policy or programme that is tracked using the indicator. The Council Recommendation called on each Member State to appoint a national HEPA focal point to coordinate the collection at national level of information for the monitoring framework. The focal point network has met five times since the first progress report on the Council Recommendation, with the support of the Commission and the WHO. These meetings have been used as a forum for extending cross-sectoral cooperation involving other important stakeholders in the field. Physical activity promotion requires a multi-sectoral approach. Coordinated, concerted action by all relevant sectors avoids duplication and inconsistencies. For example, the meeting in October 2018 in Luxembourg was organised as a joint meeting with the High Level Group on Nutrition and Physical Activity established under the health policy. The meeting in June 2019 in Brussels involved the Member State representatives in the High Level Group on Nutrition and Physical Activity and in the Committee for the Common Organisation of the Agricultural Markets (school fruit, vegetable and milk scheme) established under the agriculture policy. Since the entry into force of the Council Recommendation, the Commission has cooperated with the WHO to support the Member States and their focal points through the Erasmus+ programme. The data used in the present report were collected by the national focal points. This progress report also reflects the contributions received from the WHO and from the Council Working Party on Sport. 3.WHO European Health Information Gateway and HEPA country factsheets All data collected through the monitoring framework are fed into the WHO European Health Information Gateway, launched by the WHO in 2016 to replace its European database on nutrition, obesity and physical activity. The Gateway is an easy way for all 53 WHO Member States in the European Region to access health data, information and resources, and helps improve the health of Europeans by improving the information that underpins policy. This interactive one-stop health information shop allows visualisation and analysis of data on over 3,500 indicators. The Commission worked closely with the WHO to compile EU Member States’ contributions to country factsheets on physical activity, which were published in September 2018. The factsheets summarise how physical inactivity is tackled at policy level. Thematic physical activity factsheets focusing on health and education have also been developed, which summarise the current status of physical activity promotion in these two sectors and present a selection of success stories, or examples of good practice, from the EU Member States. These successful policy actions can inspire the development and scaling-up of new initiatives to promote physical activity in these sectors. 4.HEPA policy development and implementation at national level All 28 EU Member States collected data on the implementation of the 23 indicators at national level. The data collected present a good overview of HEPA promotion in the EU. Since the first report, there has been a general increase in the number of countries with policies and strategies to promote physical activity in populations. Most countries reported data from national systems for monitoring and surveillance of physical activity. This is encouraging, as such data allow analysis of trends and identification of effective actions and underserved policy areas and populations. The increased number of countries with a national coordination mechanism and with dedicated funding for HEPA from several sectors is also encouraging. It shows that more countries are using a comprehensive, multi-sectoral approach to promote physical activity and that the importance of physical activity is increasingly recognised. An overall improvement in 16 indicators, 11 of which improved by more than 20% (see Figure 1) can be seen between 2015 and 2018. Direct comparisons of the data for 2015 and 2018 require caution, however, since the survey methods were slightly different, the new focal points may have collected the data differently, and more Member States responded to the survey in 2018 than in 2015 (Greece did not participate in the survey in 2015). Indicators that were met by only a few countries in 2015 (such as indicators 7 and 18, both on the use of guidelines), were still underreported. Finland is the only country that has fully addressed and implemented all 23 indicators of the monitoring framework (see Annex). An overview of the results of the monitoring framework is presented below. The details on the countries can be consulted on the European Health Information Gateway and in the country factsheets on physical activity.

National policy recommendations on HEPA have been put in place by 22 countries. In nine of these, the recommendations were based solely on the WHO’s Global recommendations on physical activity for health, while other recommendations were used in five countries. Ten countries followed other international recommendations or a combination of them. Twenty-two countries reported that they had a national coordination mechanism for the promotion of physical activity. The mechanism ranged from small working groups for coordinating the physical activity component of a national non-communicable disease action plan, to high-level ministerial councils. Allocation of specific funding for the promotion of HEPA is a strong indicator of action to promote physical activity by governments and government sectors. Twenty-six countries reported that they provided dedicated funding to promote HEPA, with the sports and health sectors providing most of the funding. All countries reported at least one national sports-for-all policy or action plan for promoting physical activity. Overall, 148 sports-for-all policies or other national HEPA policies or action plans were reported. The sports sector was most commonly involved in implementing national physical activity policies or action plans. Seven countries reported that the guidelines for ‘sports clubs for health’ were used. Such guidelines encourage sports clubs to invest in health-related sport activities and in promoting health as linked to sport activities. An additional 10 reported using similar programmes, guidelines or frameworks for sports clubs or sports federations. Twenty-four countries reported that they had programmes to promote physical activity among specific groups. Of the 148 reported policies and action plans to promote HEPA, 72 targeted specific groups. The groups most often addressed were those of low socio-economic status, elderly people and people with disabilities. Twenty countries reported specific policies, programmes or cost incentives to increase access to exercise facilities for socially disadvantaged groups, and 13 reported community programmes to promote physical activity among elderly people. Twenty-one countries had a national programme or scheme to promote counselling on physical activity by health professionals (several countries reported local or regional schemes, or projects that were not yet national). Seven reported that people who gave counselling on physical activity or prescribed exercise were reimbursed by the national health insurance scheme. Twenty-two countries reported that physical activity for health was included in the curriculum for one or more types of health professional. All countries offered this to doctors, and 18 also offered it to physiotherapists, 17 to nurses and 11 to other health professionals such as nutritionists, occupational therapists, kinesiologists and pharmacists. In the education sector, all Member States reported that physical education classes were held in schools. The number of hours provided in each country is presented in the country factsheets. The hours are mandatory for 21 countries in primary schools and 20 countries in secondary schools. Twenty-four countries reported at least one scheme that promoted physical activity in schools. The most commonly reported scheme (20 countries) was after-school programmes; 15 countries reported national initiatives for active school breaks, and 14 had schemes for active breaks during lessons. Fifteen countries reported a national programme for active travel to school. Training of physical education teachers in HEPA was reported by 21 countries. Five countries reported having implemented the European guidelines for improving infrastructure for leisure-time physical activity at national level. A number of related national schemes or programmes to improve infrastructure for leisure-time or recreational physical activity were reported. Fifteen countries reported that they had a scheme to promote physical activity at the workplace, and 19 reported schemes to encourage active travel to work. Twenty-three countries reported an established national campaign to promote physical activity, in which several types of media were used. More than one type was used in the campaign in 21 countries. Overall, 54% of the reported policies and action plans included a plan for evaluation (77% in 2015). 5.Measuring the prevalence of physical activity It is important to fully understand the reasons for high levels of physical inactivity in order to be able to guide and develop adequate and effective physical activity policies that can help boost participation and reduce barriers. Data allow analysis of trends and identification of effective actions and underserved policy areas and populations. Twenty-six countries reported at least one physical activity surveillance system in one sector (compared to 17 in 2015), and 24 reported the existence of one system in the health sector. It is difficult to compare levels of physical activity in the population between countries, since different methods and instruments are used to monitor physical activity. The first report in 2016 identified the publication of different, and sometimes contradictory, data from the different survey instruments as an issue that needed to be addressed. This situation, with a variety of survey instruments and questionnaires used to collect data across the Member States, remains unchanged. Twenty-one countries provided data on adult physical activity levels from independent national surveys. Data resulting from EU surveys were also reported (five countries reported data from the Eurobarometer on sport and physical activity and seven used the European Health Interview Survey (EHIS) results as their national data on physical activity levels). Data reported for children and adolescents came mostly from national surveys or from the Health Behaviour in School-aged Children survey. In view of this, the Member States collaboration developed within the HEPA focal points network and with the WHO has led to the Erasmus+ funded project EUPASMOS (European Union Physical Activity and Sport Monitoring System), involving 20 EU Member States. This project aims to create a harmonised sport and physical activity monitoring system by developing an integrated and shared methodological process that will provide comparable, valid and reliable physical activity and sport participation data across EU Member States. The project will deliver data and a validated methodology by mid-2020. It will also deliver recommendations to extend the EHIS, which currently includes a very limited section on physical activity. 6.European statistics on physical activity The Council Recommendation invited the Commission to examine the possibility of producing European statistics on physical activity levels based on data collected under the monitoring framework.

Data on physical activity are collected within the EU surveys, mainly the EHIS, and are available on Eurostat website, under Eurobase domains ‘Health’ and ‘Sport’. In 2018, Eurostat released a leaflet on sport-related statistics, including data on physical activity levels, coming from the EHIS, wave 2014. The European Union statistics on income and living conditions (EU-SILC) module on health, conducted in 2017, also included a few variables about physical activity. In the monitoring framework, only seven Member States used data from the EHIS to report on physical activity levels. Integrating the EHIS with existing national and regional surveys remains a challenge, due to the different priorities of the surveys and the organisations responsible for designing, validating and implementing the surveys, especially in countries where there is good monitoring of physical activity and sports participation. Under the current public health statistics Framework Regulation, the third edition of the EHIS survey is taking place in 2019. Subsequent surveys will be carried out under the upcoming Regulation on integrated European social statistics. Eurostat, other Commission services and the Member States are working together to agree on, and possibly improve, the survey instruments. 7.Cooperation on HEPA between Member States and with the Commission The Council Recommendation encourages Member States to cooperate closely among themselves and with the Commission to promote HEPA by engaging in a process of regular exchange of information and best practices. The Commission was invited to facilitate these exchanges and to support the Member States. The network of national focal points has enabled useful exchange of good practices and fostered EU collaboration. Presentations of HEPA-promoting good practices were systematically included in the meetings to facilitate exchanges of experience and lessons learned. In addition, a set of good practices was compiled in thematic factsheets on health and education (see section 3 above). The Commission supported the WHO in providing technical assistance to individual countries to help them develop evidence-based physical activity guidelines, recommendations and roadmaps for physical activity policies in different sectors. Physical activity guidelines were developed for one country. Two publications aiming to help countries develop or expand their own national physical activity guidelines were also produced. In 2017-2019, through the sport chapter of the Erasmus+ programme, the EU also co-financed a total of 33 collaborative partnerships and eight not-for-profit European sporting events aiming to encourage participation in sport and physical activity. These projects involved a variety of stakeholders from higher education, public authorities, NGOs and sports clubs in all 28 Member States. This enabled outreach to people throughout the EU in their local environments, and the targeting of various sections of the population including children, the elderly and people with disabilities. In December 2017, the Commission organised a cluster meeting on ‘Encouraging participation in sport and physical activities’, bringing together all related projects co-funded by the EU in 2014-2016 with other relevant stakeholders, in order to identify policy-relevant outcomes and their possible use beyond the lifetime of the projects. Through Horizon 2020, the EU Framework Programme for Research and Innovation (R&I), the Commission supports the Joint Programming Initiative Healthy Diet for a Healthy Life (2016-2021). This initiative gathers 26 countries from within and outside Europe to align national R&I strategies and to fund new research on the relationship between diet, physical activity and health and prevention or minimisation of lifestyle-related non-communicable diseases. With a budget of more than EUR 85 Million, more than 50 projects have been already funded, such as the knowledge hub on Determinants of Diets and Physical Activity (DEDIPAC), which brought together over 300 scientists from 13 countries. The Member States and the Commission also work together in the context of the European Week of Sport to raise awareness of the benefits of sport and physical activity, regardless of age, background and fitness level. In 2018, the European Week of Sport took place in all Erasmus+ programme countries, and was extended to the Eastern Partnership and Western Balkan regions. More than 48,000 events were organised in all the participating regions and partner organisations. Furthermore, in September 2017, Tibor Navracsics, Commissioner for Education, Culture, Youth and Sport, Vytenis Andriukaitis, Commissioner for Health and Food Safety and Phil Hogan, Commissioner for Agriculture and Rural Development, launched the Tartu call for a healthy lifestyle, to promote healthy lifestyles in Europe, in particular among children. Two years later, the first results show that the Commission is using more funds, raising more awareness and gathering more knowledge than 2 years ago to tackle unhealthy diets and physical inactivity. Finally, the Commission is committed to playing a role in helping local and regional authorities promote sport and healthy lifestyles, since they are closest to the public. For example, in 2018 the Commission launched the SHARE initiative (SportHub: Alliance for regional development in Europe) to highlight the role of sport in regional development. 8.Evaluation of the Council Recommendation’s added value The Council Recommendation provides the EU Member States with the impetus to address physical inactivity through public policy. Of the total 148 policies and action plans reported by the EU Member States across all sectors relevant for HEPA promotion (152 were reported during the first reporting period), 89 were adopted after the adoption of the Council Recommendation in November 2013. The WHO’s Physical Activity Strategy for the European Region 2016–2025 provides further incentive for the EU Member States to act. Maintaining and strengthening the HEPA focal points network is a key element of the Council Recommendation. Representatives from the EU Member States meet regularly to discuss and learn about new trends, available evidence and recent developments in HEPA. This allows them to remain well informed on how to promote HEPA in their countries, and highlight its importance. Beyond the usefulness of the focal points network for exchanging good practices (including beyond the structured framework of the meetings), the data that they collect under the monitoring framework provides a revised overview of the implementation of HEPA-related policies and actions across the EU. It is crucial to use evaluation plans to assess the impact and effectiveness of policies and action plans at national level. Despite this, only 80 of the 148 reported policies or action plans contained one. Nor was any systematic information reported on whether these evaluations were actually carried out. This should be addressed in the next monitoring round. Overall, the contributions of the focal points to the monitoring framework were very good. For future rounds of data collection, the survey instrument can be further improved to reduce the margin for interpretation, make cross-country data comparisons easier and avoid situations where changes of focal point in a country lead to different reporting methods. The structured cooperation with the WHO Regional Office for Europe in the context of the Council Recommendation has proven mutually beneficial and has included joint dissemination activities and improvement of the WHO European Health Information Gateway. In particular, the focal points found the support provided by the Commission, and the WHO Regional Office for Europe useful. The Commission received positive feedback from the Council Working Party on Sport, with the country factsheets on physical activity considered useful to very useful. The most valuable part of the exercise was the work carried out jointly by the different sectors at national level. The meetings of the focal points are also considered very useful for improving cross-sector and cross-border cooperation and for deepening discussions. The thematic factsheets on education and health were considered useful to very useful and should be repeated in the future, possibly by creating similar factsheets for other sectors such as transport, urban planning, physical activity in the workplace, social security (seniors) or tourism. Thematic meetings could be organised in sectors such as urban planning and physical activity. 9.Conclusions This review of the implementation of the Council Recommendation for 2017-2019 shows positive developments. Several new policies have been adopted. The greatest improvements were seen in the number of countries with national programmes for counselling on physical activity and exercise prescription by health professionals and with national schemes for physical activity at school and active travel to school. In addition, more countries reported programmes to increase access to exercise or recreation facilities for socially disadvantaged groups, indicating better recognition of the unequal opportunities for physical activity. The Commission encourages the EU Member States to continue strengthening the focus of their national programmes on children and young people, and to regularly provide information on their efforts.