EN Official Journal of the European Union C 232/1

Opinion of the Committee of the Regions on Solidarity in Health: reducing health inequalities in the EU

(2010/C 232/01)

I. POLICY RECOMMENDATIONS

THE COMMITTEE OF THE REGIONS

Introduction

1. welcomes the Commission's determination to support and complement the efforts of Member States and local and regional authorities to tackle health inequalities in the European Union. The recognition of the scale of the challenge presented by the health inequalities gaps between member states and within member states is significant. The Commission's view that health inequalities present a challenge to the EU's commitment to solidarity, social and economic cohesion, human rights and equality of opportunity is well made and endorsed. However, a stronger emphasis could have been put by the Commission on the objective of ‘territorial cohesion’ newly introduced in the Lisbon Treaty.

2. recognises and uses as its own, the WHO definition of health, ‘health is a complete state of mental and physical wellbeing and not merely the absence of infirmity or disease’.

3. reminds the Commission that the Lisbon treaty now requires the institutions under article 3, to promote the wellbeing of European citizens.

4. draws the Commission's attention to the work undertaken by WHO, Sir Michael Marmot entitled ‘Closing the Gap in a Generation – Health Equity through action on the social determinants of health’. The CoR believes that this should be a key resource for the EU in addressing health inequalities.

5. accepts the Commission's assessment that the problem of health inequalities is highly complex and that the way the situation develops depends on a plethora of factors, in particular: the recognition that inequalities can be seen at all levels, from European to neighbourhood; the role of the social gradient and the close connection between health and wealth; the health consequences of disadvantage for vulnerable and socially excluded groups; and the differing effects of social policy decisions in the provision of healthcare and social support.

6. welcomes the balance which the paper has to a large extent struck between European cooperation and subsidiarity in compliance with article 168 of the Treaty on the Functioning of the European Union (TFEU); would however point out in this connection that reducing inequalities in health within Member States is, also under the Lisbon Treaty, a responsibility for national health policies.

EU Policy contributions to reducing health inequalities

7. acknowledges the contribution that can be made by EU flanking policies generally in accordance with the objective set in article 168 TFEU as well as in article 35 of the EU Charter on Fundamental Rights that ‘a high level of human health protection (…) be ensured in the definition and implementation of all Union policies and activities’.

8. recalls that the ‘right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices’ is enshrined in Article 35 of the EU Charter on Fundamental Rights.

9. welcomes the overarching goals of the EU Health Strategy which supports access to healthcare and disease prevention and promotion of healthy living.

10. urges the Commission to provide the Committee of the Regions with reassurance that the Proposal for a Directive on the application of patients’ rights in cross border healthcare will give full and complete consideration to the impact on health inequalities were this proposal to be implemented.

11. considering the emphasis put in Article 168 TFUE on the improvement of health services in cross-border areas, the Committee of the Regions calls for support to contiguous regions in different member states to develop voluntary arrangements to reduce health inequalities across borders. The Committee of the Regions emphasises in this regard the opportunities offered by the instrument of the European Grouping on Territorial Cooperation (EGTC) already actioned by several groups. But the Committee of the Regions is clear that arrangements for cross-border healthcare more widely must be carefully assessed to ensure that movement of patients across borders does not advantage groups who already benefit from healthcare to the disadvantage of others, thereby exacerbating health inequalities. A clear commitment should be made to all regions that cross-border arrangements will give fair access to promoting the health outcomes of vulnerable and low performing groups, where the rights of those groups are in competition for healthcare resources. Access to cross border health should be available only with prior authorisation so that individuals on low incomes have equal access to services.

12. welcomes the recognition of the role of the Common Agricultural Policy in relation to health issues and acknowledges the contribution of programmes such as the School Milk, Food for Most Deprived Persons, and School Fruit schemes in supporting nutrition and healthy living. Food provided in public facilities such as schools and hospitals should be primarily based on providing healthy, nutritious, locally-sourced food wherever possible. We also welcome the recognition of the impact the CAP and other policies can have on health in rural areas through action relevant to the social determinants of health. The CoR recognises that rural areas have specific health challenges: inadequate access to healthcare in rural areas can result in health inequalities in some member states; and the link between the agricultural economy and migration can result in communities with particular health needs and health inequalities. In both of these cases, the CAP can have a role in improving living conditions and is therefore significant.

13. does not agree that it is sufficient to say that EU environment policy and the market policies under the Common Agricultural Policy support a range of initiatives which can contribute to improving health. Though there is potential within the CAP to make a contribution, fundamentally the CAP is not structured to give priority to health outcomes or health inequalities and it is legitimate to consider the negative impact on health outcomes that can result from an imbalanced approach to dairy and meat production compared to fruit and vegetables. There is an opportunity to review these imbalances in the reform of the CAP and the importance of supporting good and equitable health outcomes should be asserted at every stage of the reform process.

Health inequalities and economic issues

14. regrets the failure of the Commission to fully address the issue of excessive use of alcohol and other drugs in creating ill health and underpinning health inequalities. Concerning alcohol, the CoR recognises the particular challenge it poses for policy makers who must also consider the impact, both public and private, the problem has on the local and regional economy. In this context it is appropriate to recognise that regulating consumption poses difficulties, but that is not a reason to ignore its impact on health nor to reduce efforts against the abuse of alcohol and other mind-altering substances.

15. recognises that member states across the EU are facing a severe financial and economic crisis and that this will inevitably have an impact upon the health and wellbeing of its citizens. While it is true that the economic situation may result in the gaps in health outcomes widening, this situation should not be an excuse for not adapting policies in a way to better address inequalities. The failure of financial institutions globally obliges member states, regions and localities to review their approach to building sustainable communities. Policies too heavily focused on economic prosperity can result in health inequality. While economic difficulties may result in reduced economic prosperity, it is not a barrier to giving greater priority to reducing economic, social and health, inequality. The Commission has the opportunity now in the context of FP7 and budgetary planning to review the priorities and place greater emphasis upon the measures to tackle inequality.

16. suggests that the current economic difficulties mean that the economic dimension of healthcare services and the economic impact of a healthy population are increasingly important. Healthcare services are significant employers and generate economic prosperity through associated sectors such as health research and innovation, with particular opportunities arising in the emerging economies. At the same time, the loss of elements of the workforce as a consequence of premature death and disablement represents a reduction in productivity and an increase in pressure on social support systems.

17. endorses the recognition of the importance of better health for all population groups in the context of an ageing population. Social protection systems are already feeling the effects of a changed population demographic. While longer lives are to be welcomed, if social protection systems are to remain at the level Europeans have come to expect, more must be done to manage demand for services. Increasing the healthy years of life for those with the worst prospects is therefore a priority. Considering the magnitude of the socio-economic changes an ageing population in the EU will bring about, the CoR wishes to stress the importance of research and development targeted at improving elderly healthcare.

EU Cohesion policy contribution to health inequalities

18. endorses the assertion that EU Cohesion policy is central to achieving the EU2020 objectives of economic and social cohesion and can be a powerful tool to address health inequalities. There is an important opportunity in 2010 with the development and agreement of the EU 2020 strategy to consider earmarking of structural funds as of 2013. The Committee expects the EU 2020 strategy to be strongly focused on fighting exclusion, which would in turn provide a clear connection to health inequalities.

19. believes that EU structural funds could be used to expand local health care as part of a regional development strategy. This is because all European citizens do not have access to equal opportunities, including health related opportunities, which is one of the fundamental aims of EU cohesion policy and structural funds.

20. acknowledges the Commission's identification of three areas of improvement that could be made: knowledge of the opportunity to use funds in this area; coordination between national policy departments and technical capacity to develop investments in this field. However, it is not necessarily the case that these are the areas of greatest priority for improvement. In particular, coordination between regional and local agencies, where these have responsibility for direct delivery of services, may have greater impact. Also, technical capacity may exist at national level but not in health agencies at regional or local level, and therefore interventions should be directed to the appropriate level to achieve desired outcomes.

Data collection, monitoring and analysis

21. supports the suggestion that the measure of progress towards the EU2020 agenda could be further developed to reflect the importance of reducing health inequalities. The healthy life years indicator provides one measure of health outcomes, but should be supplemented with measures that reflect the importance of narrowing the gap between the most healthy and the least healthy.

22. accepts the assessment of the variations between member states in collecting and analysing data. The development of health related indicators by EUROSTAT is helpful. In addition, it considers that the mutual support of the member states, through transfers of know-how on improving public health care, is an effective way of reducing inequalities between the member states.

23. urges the Commission to recognise the particular challenges in monitoring health outcomes for migrants and migrant communities. Transient or migrating populations are less likely to have good health outcomes and can encounter specific obstacles in accessing social support. The communication identifies migrants as a vulnerable group. In achieving effective data monitoring, there should be regard given to the specific challenges of monitoring health outcomes when population groups are migratory or in transit.

24. urges the Commission to acknowledge gender-based inequalities in health and to support the collection, monitoring and analysis of sex-disaggregated health data and gender statistics. Particular attention should be given to women's and men's right to access to preventive healthcare, with a view to effectively addressing disparities amongst and within Member States.

The role of regional and local authorities

25. welcomes the recognition of the role of regional and local authorities, both in delivering health outcomes and in delivering the services which address the social determinants of health.

26. suggests that greater emphasis is put on the importance of local action to promote healthy lifestyles and prevent the conditions that lead to ill health. Some regions have already developed their own strategies, in which goals that are set out in the communication are pursued and a framework for an overall health promotion policy is laid down. The Committee underlines that educational programmes in schools are vital to promote healthy eating and healthy living. There are many agencies that are in a position to contribute to stronger preventative action, but in many cases effective prevention will require very local activity tailored to the needs of particular communities. While the nature of the problems leading to ill health may be common across member states, delivering the messages about healthy living often requires small scale interventions built on local knowledge. These interventions may be effective in localities spread across many member states – geographically separate areas may share similar challenges, such as high unemployment from the closure of heavy industry. Future action should seek to connect small communities across the EU who are facing similar challenges that may not be shared with their closer regional neighbours. Collaboration at national level may be ineffective at drawing out the learning about approaches effective in particular small communities.

27. strongly endorses the Commission's view that improving the exchange of information and coordination of policies between different levels of government and different sectors can create more effective action and achieve a larger and more consistent impact. The Committee would suggest that this view could be more strongly put: not only that such coordination and exchange can achieve more effective and impactful action, but that it is an important precondition for the reduction of health inequalities. Commitment to reducing health inequalities offers an important opportunity for member states to consider the level of cooperation within borders and to learn from member states who have been most successful in devising partnerships between levels of government and different sectors.

EU level cooperation structures

28. reinforces the interest previously shown by the Committee of the Regions to build a focus on health inequalities into regional cooperation on health. The Committee of the Regions is committed to the principle of a structured interaction led by Committee members. The Committee is also interested in using such a structured interaction to engage collaboratively with DG SANCO and its work on health inequalities.

29. believes that structured interaction from the Committee of the Regions should be supplemented with its representation in EU health related committees and working parties dealing with health. While it is recognised that member states have discretion to appoint representatives to attend these working parties, it would be beneficial to review the progress made at local and regional level in relation to fighting health inequalities.

Vulnerable groups

30. welcomes the recognition of the needs of vulnerable groups, and the particular attention that needs to be given to people in poverty, disadvantaged migrant and ethnic minority groups, people with disabilities, elderly people and children living in poverty.

31. requests that consideration be given to the needs of other vulnerable groups, particularly where health inequalities may be emerging over time. Understanding the changing nature of society and the inequalities that emerge as a result is critical to addressing avoidable inequality. This may include the needs of adults isolated as the result of family break up, people deprived of their liberty, people in care, or people living in rural areas with a declining economic base. Consideration should also be given to the importance of understanding the social and cultural influences prevalent in different community groups because of the significance this can have on individual behaviour.

32. emphasises that action to support vulnerable groups should recognise the ambiguity in identifying ‘migrants’. For the purposes of health inequalities, any movement of population, regardless of whether people have moved from within the EU or from outside the EU, can result in social disadvantages, poor access to social support and therefore health inequalities. Population groups who have moved within the EU have unequal access to services such as housing and can become homeless. Homelessness can have acute impact on health. Specific action should be taken to consider the health outcomes of populations moving within the EU.

Regional and local role in funding and service provision

33. believes that where existing funding streams are targeted to health, local and regional authorities should be entitled to a flexibility on whether to put the focus on developing skills, knowledge, and capacity in delivery agencies or on developing healthcare infrastructure. While investment in health infrastructure may be a priority in some member states and some regions or localities where infrastructure is underdeveloped, in other areas with significant health inequalities, health infrastructure is well developed. In these areas investment may need to be directed at a very local level to develop skills, knowledge and capacity in both health agencies and the local population.

34. suggests that, whilst recognising that national implementation of Community legislation on Health and Safety at Work contributes to national health inequalities by protecting workers’ health, regional and local authorities can also have a role in modelling best practice in employment. This is relevant to authorities both as significant employers in their regions and localities, and also through authorities’ ability to influence the employment practice of other organisations and stakeholders in their regions and localities.

35. recalls its request for greater legal certainty for the providers of social services of general interest in relation to EU competition rules and expects the Commission to take up this proposal in its 2010 work programme. Notes in this regard the commitment by the President of the European Commission to elaborate a quality framework for public services.

Recommendations

The Committee of the Regions recommends:

36. Greater recognition within the EU2020 strategy of health and well being as being key to fighting exclusion.

37. The possible use of structural funds to help tackle health inequalities.

38. The inclusion of indicators beyond healthy life years in the monitoring of the Lisbon agenda, specifically indicators that reflect the gap in health outcomes between different groups.

39. Recognition that the current financial crisis will exacerbate further the health inequalities of those EU citizens who find themselves unemployed, homeless or in poverty. Instead it urges greater investment in funding programmes such as FP7 and PROGRESS to help local and regional authorities tackle health inequalities both in the short term during the exit from the current programmes and longer term to tackle the widening gap in health.

40. EU recognition and dissemination of the WHO Commission on Social Determinants of health, as well as national government responses to the WHO Commission.

41. Commitment to the open method of coordination as a tool to share best practice and bench- marking to tackle health inequalities across member states without undermining the efforts already undertaken at the local and regional level.