[pic] | COMMISSION OF THE EUROPEAN COMMUNITIES |

Brussels, 23.10.2007

SEC(2007) 1376

COMMISSION STAFF WORKING DOCUMENT Document accompanying the WHITE PAPER

Together for Health: A Strategic Approach for the EU 2008-2013 {COM(2007) 630 final}{SEC(2007) 1374}{SEC(2007) 1375}

INTRODUCTION

This paper has been prepared to support and provide background on the White Paper "Together for Health: A Strategic Approach for the EU 2008-2013" (COM(2007) 630) of the European Commission. The Health Strategy aims to be a cohesive framework document, giving clear direction to Community activities in the field of health for the coming years in order to further improve and protect health in the EU and beyond its borders. It reinforces the importance of health within key EC[1] policies such as the Lisbon Strategy for Growth and Jobs, in terms of the links between health and economic prosperity, and the Citizens' Agenda, in terms of people's right to be empowered in their health and healthcare. The Strategy is a framework which goes across sectors, recognising the contributions to health of a wide range of other policy areas.

The Strategy puts forward an overall approach, based on four fundamental principles and three strategic objectives , selected with the aim of tackling areas in which strong European added value can be achieved. This Staff Working Paper aims to provide background on the principles and strategic objectives of the Strategy and to provide more detail on the actions identified in the White Paper. Priority actions where the aim is to make specific proposals within the next 2 years are set out in the White Paper and elaborated in this document, while further actions will be proposed throughout the life of the Strategy. The Commission will work with Member States to develop more specific operational objectives within these strategic objectives.

One of the major differences between this Health Strategy and previous strategic documents on health is that it proposes key cooperation mechanisms together with the Member States and stakeholders to implement the Strategy and to reach concrete results as well as a strengthened approach to Health in All Policies . Annexes 1-6 therefore aim to provide an overview on what is done on health at European level, not only in health policy, but also in other policy areas. Annex 1 lists the main Community public health legislation. Annex 2 sets out how different Commission departments contribute to health policy, and Annex 3 gives an overview of financial Community instruments that are used to finance health related actions. Community agencies working in health are listed in Annex 4, and international commitments in health are provided in Annex 5. Annex 6 provides text from the Treaty showing examples of articles where health is mentioned.

FUNDAMENTAL PRINCIPLES FOR EC ACTION ON HEALTH

PRINCIPLE 1: A STRATEGY BASED ON SHARED HEALTH VALUES

Shared Values

The European Union is "founded on the principles of liberty, democracy, respect for human rights and fundamental freedoms, and the rule of law, principles which are common to the Member States"[2].

The EC aims not only to provide a well functioning internal market for goods, capital and services, it also supports social justice and respect for human dignity, and therefore its internal and external actions should strive to support these values. This is particularly important in the field of health, which is a key element in individual and social well being.

Community actions to support the objectives of the Health Strategy should therefore be built on fundamental rights relating to health and health as a global public good. In addition, they should make concrete common values such as equity, participation and empowerment of citizens, and transparency.

Equity and Solidarity

Although today's Europeans are healthier, wealthier and can expect to live longer than their predecessors, there are still major differences in health between and within EU Member States and regions in terms of life expectancy, health status and access to high quality health services. Health inequities (which can be defined as inequalities in health that are avoidable and unfair) is a term which has been used widely to refer to a broad range of issues – to differences in health outcomes, differences in access to treatment and care, and differences in health between different groups within countries, such as between rich and poor, or between male and female. It also refers to differences between countries and the need to work towards a situation where all European citizens have an equal opportunity to enjoy a high level of healthcare regardless of where they live or their social status.

In the last 25 years, life expectancy at birth has increased by an average of over 4.5 years in the EU Member States. But this general trend masks major differences between countries. Some Member States experienced a decline in life expectancy during the mid-1990s and in Latvia and Lithuania life expectancy at birth has dropped significantly in the latest available figures (2005)[3]. Life expectancy is a key summary indicator of health but it is based entirely on death rates. Healthy Life Years (HLY) is a concept which allows us to consider how much time people are spending in good health, which can be expected to correlate better than life expectancy with the level of active participation in society and with the strain placed on health systems by a population in poor health. Healthy life expectancy in the EU has not increased consistently year on year and there are major differences between Member States which are related to factors influencing good health during life, rather than life expectancy.

Huge differences in health also exist within Member States between people living in different parts of the same country and between people in the best and worst socio-economic situations. There is a clear link between income and child mortality. Poverty, unemployment, low levels of education, differences in gender, genetic risks, membership of some minority ethnic groups, and disability are some of the factors that are often associated with poorer health. Typical differences in life expectancy between groups of people with highest and lowest educational levels or highest and lowest income groups within an EU country are in the region of 4 to 5 years[4].

Reducing these health gaps is essential not only because health is important in its own right, but because they contribute to undesirable pressure on the social and economic development of the EU as whole and hinder its integration and competitiveness.

Tackling inequalities in the economic, social, environmental, genetic and behavioural determinants of health as well as in the quantity and quality of health services is a major challenge which requires coordinated action both at national and European level, and a new focus is needed in this area to review existing policies and mechanisms for doing so, on the basis of solid data and information on developments. Working across different sectors is also vital in reducing health inequalities. In particular, mainstreaming of gender issues in relation to health policy must be undertaken with the aim of reducing health inequities related to gender[5] The Commission is committed to improving quality and comparability of gender-specific health data[6]. Technologies can also support the full participation of citizens in their healthcare, in particular the elderly and those with disabilities, including through new developments such as e-health and e-inclusion (supporting social integration)[7].

EC regional policy can help play a role in closing gaps in health inequalities between countries and regions, both through the health benefits of appropriate economic development and through specifically targeted investments in the health sector. In the programming period 2000-2006, 3% of the Structural Funds budget was planned to fund actions on social infrastructure and health in the EU Member States (including EU cross-border cooperation). For the period 2007-13, indications are that expenditure in the category 'health infrastructure' will constitute around 1.5% of the Structural Funds' budget. Further health-related interventions beyond this percentage include health-related research infrastructures and support, support to SMEs in the health sector and labour market and training activities in the health sector. Cooperation on the development of intersectoral policies to tackle inequities in health should be part of strategic cooperation with Member States and Regions. The potential for Regional Policy to contribute to the health sector and help improve the population's health should be maximised. This includes not only direct investments in health infrastructure, health-related research and innovation and training, but also facilitating exchange of good practices and experiences between and within Member States, including through the Regions for Economic Change initiative[8].

The large and growing inequities in access to healthcare at global level also call for EU joint action on global health. At present, the level of public funding for health in the EU is on average some 100 times higher than the level of spending in sub-Saharan Africa. There is a need to expand the concepts of equity and solidarity beyond the EU's borders and to progress towards universal access to basic healthcare. The EC’s external relations should priorities health inequities and act in coherence with internal health policies.

Citizens' Empowerment

Individuals must play a role in taking care of their own health, and therefore citizens' and patients' participation and empowerment need to be regarded as core values in all health-related work at EC level. A recent Eurobarometer survey showed that healthcare was one of the main concerns of EU citizens[9]. Health policy should provide mechanisms and support for citizens to acquire the necessary knowledge and competences to enable them to act effectively in the interests of their own health and that of their families and communities, both in their everyday lives at home, work and school as well as when they are using the healthcare system.

Information and Communication Technology (ICT) is a key instrument for supporting empowerment of citizens and patients in health. E-health applications make health information widely available so that people are becoming more knowledgeable about health and want to be actively involved in decisions affecting their health and wellbeing. Reflecting this, healthcare is becoming increasingly patient-centred. Building on the work on the Citizens’ Agenda[10], Community health policy must take citizens' and patients' rights as a key starting point. This includes the ability to participate in and influence decision-making as well as to gain competences, through education, to maintain their wellbeing, in line with the European Framework of Key Competences for lifelong learning[11]. Community health policy should also support better access to individualised health information, prevention tools and healthcare. The EC has a role in sharing good practice on innovative e-health solutions and on encouraging more access for citizens to better information about healthcare.

Citizens' empowerment can also be supported by civil society and NGOs, including patients' groups and disease support and advocacy networks. This principle also applies to the global dimension, and relates to the need to ensure "grassroots" ownership of development policies in respect of the Paris Declaration on Aid Effectiveness[12], which states that citizens and governments should play an active role in policy making.

The diversity of information about health is also stimulating requests from the public for reliable and comparable EU health data, for a stronger evidence-basis for policy decisions and enhanced transparency. A comparable European Health Information and Knowledge System is crucial for supporting decision-making at the health systems’ strategic, control and operational levels, monitoring their implementation and evaluating their impact. It aims to create a harmonised and methodologically agreed system for health monitoring and surveillance in the EU sharing common mechanisms for collection of health data.

To support the transparency of health policy and to underline its link to scientific evidence, information on how the results of health-related research are used as a basis for health policy also needs to be actively and widely disseminated. Contacts between health experts are also crucial for enabling information sharing, finding partners for projects and development and testing of new ideas. Opportunities and mechanisms for contacts and networking should be enhanced across the EU and more broadly, for example by using web-based technology and building on the experience of the Health Portal[13].

Actions Adoption of a Statement on fundamental health values (Commission, Member States) Following the statement of the Council on common values and principles in EU Health systems, adopted in June 2006[14], further values will be elucidated for all EC action on health in agreement with Member States. These will relate both to individual citizens and patients and society, covering health policy in the EU and in its external relations, as a reference for actions. System of European Community Health Indicators with common mechanisms for collection of comparable health data at all levels, including a Communication on the exchange of health-related information (Commission) To improve the collection, comparability and compatibility of health data, current work on developing a comparable European system of health indicators needs to be continued, based on common mechanisms for collecting comparable health data (for example, the European Health Survey System including a European Health Examination Survey, the EU Hospital Information System and the System of Health Accounts), including at the regional level. The statistical element of this system will be further developed within the context of the Community Statistical Programme in general and the forthcoming legislative framework for Community health statistics[15] in particular. In relation to this action, a Communication will be developed on the European Union Health Information, Knowledge and eHealth System covering the future organisation and responsibilities for health information in the EU between the different stakeholders participating in the health information generation process. Further work on how to reduce inequities in health This Communication will set out measures to be taken by the Commission to support the efforts of Member States and other organizations to reduce inequities in health. Promotion of health literacy programmes for different age groups (Commission) To help citizens make sound judgements about their health based on reliable and up-to-date information and data, health literacy needs to be improved within the EU. Initiatives within this package will explore the use of approaches including school education systems, programmes for children, extra curricular activities and peer education for young people, web-based education modules for adults, and health education in the workplace. |

- PRINCIPLE 2: "HEALTH IS THE GREATEST WEALTH" [16]

There is growing evidence showing how health contributes to wealth and how investment in health contributes to long term growth and sustainability of economies[17]. Health policymakers have long argued that ‘ health means wealth’; that a healthy population is necessary for economic productivity and prosperity, and that wealth, particularly in the form of effective investment, also supports better health. Despite clear evidence supporting the link between health and economic prosperity, it is not always adequately taken into account. In 2005, the Healthy Life Years (HLY) indicator was included as a Lisbon Structural Indicator, recognising that the population's life expectancy in good health was an important measure in understanding and supporting economic growth. The use of the HLY indicator at all levels still needs to be encouraged and increased. The Commission pointed out, in its report to the 2006 Spring European Council, that Member States need to reduce the high numbers of people who are inactive because of their ill-health[18] and that Europe cannot afford to have people drop out of the labour market when they are in their fifties[19]. This report urged action; rather than just seeing health as a negative cost, it recognised that policy in many sectors has a role in improving health for the benefit of the wider economy.

Spending in the health sector is an important and rising cost for national administrations and social security schemes - healthcare spending around the world is generally rising at a faster rate than economic growth[20]. Furthermore, alongside the rising costs of running health systems and services, the cost of ill-health is in itself a significant burden to the economy. Despite the problems in measuring these costs, it is clear that the impact of illness on the economy is huge. Poor health is an important factor in early retirement and worker absenteeism. Studies have shown that in Germany, the probability of leaving the workforce at the earliest possible age is 4 times higher for men with disabilities, and in Ireland, the proportion of labour participation is 61% lower for men with chronic diseases[21]. People who continue to work despite health problems are also likely to be less productive than healthy people[22].

Costs associated with health are significant, but effective investment in health can lead to more efficient health systems and social security schemes, more people avoiding illness, and therefore to greater future financial sustainability. As well as healthcare treatment, effective prevention programmes can have substantial effects on reducing major and chronic diseases. For example, the largest single factor contributing to the decline in cardiovascular disease occurring in the EU over the last 20 years has been the decrease in tobacco smoking owing to a combination of tobacco control measures and support to individuals to quit. Investment in this kind of prevention can be much more cost effective than that required to treat or cure diseases which could have otherwise been prevented. There is growing evidence that an increase in investment in preventative measures could reduce the expected growth in healthcare costs. Data from the Organisation for Economic Cooperation and Development (OECD) show that their Member States spend on average only 2.9% of their overall budget for health on prevention, health promotion and public health[23], and there is therefore potential for the EC to work to encourage Member States to develop and share best practice in investment in these areas. The understanding of economic factors relating to health and illness and the economic impact of health improvement both in the EU and globally must be improved including through developing information and analysis in the Commission as well as working with partners such as the OECD and the European Observatory on Health Systems and Policies.

Furthermore, the health sector itself can contribute to economic growth. Health represents a high-innovation, high-technology industry, with a growing market and potential high multiplier effects, i.e. many people using similar services. Healthcare industries constitute a strong and growing sector of the EU's economy. The main industries include pharmaceuticals and biotechnology, medical devices and e-health with the latter currently growing at the fastest rate[24]. Health systems themselves employ vast numbers of people and contribute significantly to national economies, but the broader health sector can be understood to include not only hospitals, clinics and insurance providers, but also laboratories, pharmacies, research, training and education organisations, safety and health at work institutions, pharmaceutical and medical device companies e-health industries, and even spas, sport and fitness centres and health foods which are on the increase as people become increasingly concerned about their own health and wellbeing and want to take responsibility for it. According to data from the Eurostat Labour Force Survey (LFS) the number of people employed in the area of Health and Social Work in the EU-15 has grown steadily, from 13 to 15 million in total between 1995 and 2000, and rising to around 20.1 million in 2005 in the EU-27. In Germany, despite an economic slow-down, 1.1 million new jobs were created in the health and social sector between 1996 and 2005, and several Länder have developed plans specifically for expanding the health industry[25]. Similar patterns are observed for most other EU countries in the same period, e.g. 800 000 in the UK, and 600 000 in Spain.

For individuals too, health and socio-economic factors are linked. People in poorer areas and those with lower social, economic and educational status suffer more illness and die younger than those better off. The wealthy have access to better quality health care than other groups – good health in turn enables people to work longer and more productively, thus ensuring their income.

The link between health and economic growth is just as relevant globally where the impact of a disease such as HIV/AIDS can have a devastating effect on the whole economic and social fabric of poorer countries. For example, the SARS outbreak in 2003 which ultimately killed about 800 people, led, despite the well-organised international response, to a total cost for the East and Southeast Asian economies as a whole of about US $18 billion[26]. Without this effective international action, the human and financial cost would have been much higher. The global relevance to the ‘health is wealth’ principle is also clear in the fact that developing countries face the greatest challenges in providing adequate health financing. There is a critical need to address the issue of enabling public financing of basic healthcare for all.

Actions Development of a programme of analytical studies of the economic relationships between health status, health investment and economic growth and development (Commission, Member States) The Commission, working with partners, will develop a programme of analytic studies of the links between economic growth and investments and innovation in the health and life sciences sectors, including ICT for health. This will aim to inform the Member States through synthesising the most up-to-date knowledge and experience on cost-effective health policies and actions, Including, for example, evaluating the relative weight to the economies of different EU Member States of compensation paid for various forms of ill-health (occupational diseases and/or accidents) contracted during work, analysing the economic impact of different investments in health and different kinds of health interventions (including prevention measures as opposed to treatment), and analysing economic pressures on health systems including the impact of technologies, or demographic and social change, and of mobility of patients and health professionals. |

- PRINCIPLE 3: HEALTH IN ALL POLICIES

Health in All Policies (HIAP) is a concept that underpins work on health at the European level. Under article 152 of the Treaty, the EC is required to make sure that a high level of health protection is ensured in ‘the definition and implementation of all Community Policies and Activities’. Health is also mentioned in other articles throughout the Treaty. For example, Article 137(1)(a) which requires the European Community to support and complement the activities of the Member States in the field of health and safety and work[27]. A list of other references in the Treaty is included in Annex 6.

There are many other fields which have an impact on health, such as regional policy, external policy, trade, agriculture, transport, environment, energy, research, economic policy, and social policy. Policy partnerships are ongoing in many of these fields, and important work to integrate health into other policies has been undertaken at Community level. Examples throughout this document relate not only to policy in the health sector but policy across many different sectors at Community level. This Strategy sets out a number of actions in the field of health, many of which are in areas with clear cross-sectoral links, and which will involve the participation of different sectors to achieve them. Methodologies such as Health Impact Assessment (HIA) and Health Systems Impact Assessment (HSIA) have been developed. In addition, a number of European Agencies are doing important health-related work (see Annex 4). However, systems for supporting health-related work in non-health policy areas need to be strengthened and made more systematic at all levels of government.

Taking action on health within the health field alone is not sufficient and can even have negative consequences: that the health benefits of actions in other areas are not fully recognised; that the impact of other policies on health and health systems is not sufficiently taken into consideration by the health sector; that the possibilities for sharing knowledge and expertise are not exploited, and that full potential for health improvement and protection is not achieved. A multi-sectoral approach needs to be supported and strengthened at EC, national, regional and local levels to contribute to more efficient actions on health. This approach should include recognition of the importance of a solid evidence base to demonstrate impacts on health. The EU has a role in working with Member States to share best practice on increasing capacity for cross-sectoral working in the field of health.

A HIAP approach also needs to permeate external policies, building on existing international commitments[28]. These should complement internal Community actions, in the same way as the Community should build on its internal experience when participating in global negotiations.

Actions Strengthening integration of health concerns into all policies at Community, Member State and regional levels, including use of Impact Assessment and evaluation tools (Commission, Member States) HIAP approaches will be encouraged and promoted at all levels, including through giving Member States new opportunities to network, share experience and best practice, with the aim of supporting increased intersectoral cooperation in the field of health. The use of HIA and HSIA, which are already recognised as part of the Commission’s Impact Assessment mechanism, will be encouraged. The online Health Systems Impact Assessment Tool, which offers a methodology and background information on key policy areas in relation to their interaction with and impact on health systems, will be further developed. This will include adding further assessments of policy areas and disseminating the Tool at EC, national, regional and local levels to make it available to people assessing new initiatives which may have an impact on health systems. Opportunities for using post-hoc evaluation to support the integration of health into other policies will be explored. |

- PRINCIPLE 4: STRENGTHENING THE EU'S VOICE IN GLOBAL HEALTH

The EC has a Treaty obligation in Article 152 to 'foster cooperation with third countries and the competent international organisations in the sphere of public health.'

Global health refers to health issues which transcend EU and national borders and individual governments. It includes those health problems affecting citizens inside and outside the EU which need to be addressed through actions at global level.

Globalisation has increased cross-border flows of people and products. Huge inequities in access to basic healthcare and exposure to the determinants of ill-health are a significant destabilizing factor. This results in an increased global spread of both communicable and life-style related disease, which causes human suffering for both EU and non-EU citizens. In relation to communicable disease, global HIV/AIDS deaths are projected to rise from 2.8 million in 2002 to 6.5 million in 2030. There is also an important burden of disease and premature deaths by respiratory conditions during childhood, and non-communicable diseases are gradually becoming more important. The global proportion of deaths due to non-communicable diseases is projected to rise from 59% in 2002 to 69% in 2030 and total tobacco-attributable deaths are foreseen to rise from 5.4 million in 2005 to 8.3 million in 2030[29].

The EC is already active in global health. The EU as a whole is the world's largest development and humanitarian aid donor, and health is an important component in the EC's assistance to world-wide efforts to combat poverty, to work towards the Millennium Development Goals and European Consensus on Development Cooperation, and to preserve the lives of people affected by humanitarian crisis. The EU also contributes significantly to the Global Fund to fight AIDS, Tuberculosis and Malaria. Development aid will work towards alignment with the Paris principles[30], improving its coordination and predictability. This will require greater in-depth analysis and dialogue between national and global health policies. The European programme for action to tackle the critical shortage of health workers in developing countries is an example of an important EU activity in global health, linking internal and external actions in health.

Extensive collaborative working with international organisations already takes place. The EU played a key role in negotiations on the World Health Organization (WHO) Framework Convention on Tobacco Control and on the International Health Regulations, and is currently actively involved within the WHO debate on public health, innovation and intellectual property. Another recent example of work with the WHO includes involvement with the WHO Commission on Social Determinants of Health, and joint action on communicable and non communicable diseases.

The EU's contribution to global health requires interaction of policy areas such as health, development cooperation, external action, research and trade. New actors are also emerging in the global health arena and new forms of interactions are taking place. For instance, public-private-partnerships have gained importance and foundations are playing a significant role in financing of global health. This new nature of global health governance is presenting challenges in coordination, as well as raising questions about accountability and visibility, and the roles and responsibilities of different actors.

However, activities in the field of global health should be strengthened to give the EU a stronger voice in global health and to create better health outcomes for EU citizens and for others. The Community can add value in its contributions to global health by sharing common European values, as well as its experience in implementing health policy that reduces health inequalities, strengthens the health systems and promotes health. International collaborative research should continue to be supported through EC Framework Programmes for Research in areas of mutual interest and benefit, and the EU must also respond to health threats in third countries and to save and preserve life in emergency and immediate post-emergency situations.

Actions Enhance the Community's status in international organisations and strengthen cooperation on health with strategic partners and countries (Commission) Building on existing cooperation with international organisations active in health, action will be taken to enhance the EC’s status in international organisations (such as the WHO, the International Labour Organisation, other United Nations agencies, the OECD, the Council of Europe and the Observatory on Health Systems and Policies), recognising the substantial contribution of the EU in financial and other support to third countries. Cooperation with other strategic partners will also be strengthened, including private and public partnerships in health such as the Global Fund to fight AIDS, Tuberculosis and Malaria, and with third countries, with a particular emphasis on the regional dimension and on candidate, potential candidate and European Policy Neighbourhood countries. In line with the priorities agreed with third countries and with the policy dialogue and sectoral approaches developed for external assistance, ensure an adequate inclusion of health in the EU's external assistance and promote the implementation of international health agreements, in particular FCTC and IHR (Commission) The principles of international health agreements should be reflected in the Community's external instruments. This would mean in particular supporting full implementation of the International Health Regulations (IHR) and the Framework Convention on Tobacco Control (FCTC) as well as contributing to further development of the FCTC. IHR and FCTC commitments should be properly addressed in bilateral and regional relations and financial programmes. |

STRATEGIC OBJECTIVES

- OBJECTIVE 1: FOSTERING GOOD HEALTH IN AN AGEING EUROPE

The predicted trend towards demographic ageing, resulting from low birth rates, increasing longevity, and the ageing of the 'baby boom' generation is now well established on political agendas across Europe.

By 2050 the percentage of people aged 65+ is expected to increase by 70%, and the percentage of people aged 80+ by 170% in the EU-25[31]. Commission projections support the prediction that population ageing will pose major economic, budgetary and social challenges which are expected to have a significant impact on growth and lead to significant pressures to increase public spending, making it difficult for Member States to maintain sound and sustainable public finances in the long-term[32]. However, if the population ages in good health and remains active this is positive both for the individual and for the wider economy. If healthy life expectancy evolves broadly in line with change in age-specific life expectancy, then the projected increase in spending on healthcare due to ageing would be halved[33].

In order to maximise the healthy life years and to achieve healthy ageing, it is important to promote health and prevent disease throughout the lifespan, including by tackling health determinants such as nutrition, physical activity, alcohol, drugs and tobacco consumption, environment and socioeconomic factors. Improving the health of children, adults of working age and older adults will help to create a healthy, productive population and support a healthy older population now and in the future. This involves redesigning health policies and actions to target different age groups.

The health of children and young people is a particular concern. Poor health in early life can lead to long term impacts. Threats to health such as falling levels of physical activity and rising levels of obesity, harmful alcohol use, drug abuse and mental stress pose risks to the health of young people now and in future. Inter-sectoral collaboration should be enhanced to promote children and young people’s health, building on and contributing to existing action on rights of the child, combating poverty and social exclusion, and promoting participation of young people, as well as on EC youth-oriented public health activities on tobacco, alcohol, drugs, environment, nutrition, obesity, safe sex and mental health. The EC and Member States need to engage with a broad range of stakeholders, including youth and business organizations to protect and improve the health of young people, including using settings such as schools.

The health of the working age population is a key factor for economic sustainability, and Community policy initiatives in this area, including the Safety and Health at Work Strategy 2007-2012, can help to promote health and to reduce losses to the labour force due to physical and mental ill health. The health of migrants should have a particular focus. It would be beneficial to integrate EC action in public health with action on employment, social protection and safety and health at work, and strengthen mechanisms for information exchange and cooperation on this issue between Member States, the Commission and the business community.

Given the increasing numbers of older people, a new focus on their specific health needs is required. The European Union Labour Force Survey 1995 showed that illness or disability, although very variable across the Member States, accounts for up to 25% of retirements of males in the EU-15. As the population grows older, older people will need to remain at work for longer and stay active longer, and will therefore need to be more empowered to take control of their own health. At the same time, health and social care services will need to adapt to support the older population, through for example training health professionals and providing more preventive interventions and care closer to home. The widespread use of new technologies would provide more accessible products and services that meet the needs of older people, particularly home healthcare, telemedicine, continuity of care, chronic disease management etc. More can also be done to promote the development of geriatric medicine with a focus on individualised care, and to tackle diseases that are particularly prevalent in this age-group, such as neurodegenerative diseases and Alzheimer's, and to increase the effective use of vaccination including the influenza vaccine.

Community policies should also help people of all ages to live healthier lives. A major part of the burden of disease comes from conditions related to lifestyle, environmental conditions, and socio-economic factors.

In the EU, 25% of people aged between 15 and 24 are daily smokers[34], while studies have shown that the majority of smokers want to stop smoking[35]. Smoking has been proven to have a causal relationship with many serious and life-threatening diseases. It is estimated that in 2006 there were almost 335,000 deaths for lung cancer in Europe[36]. Recently, the risks of environmental tobacco smoke have been more clearly recognised with several European Member States banning smoking in the workplace. More than 1 out of every 4 deaths among young men (aged 15 – 29 years)[37] in the EU is due to the consequences of harmful alcohol use, thus making it the 3rd biggest cause of early death and illness in the EU[38]. Sexual health promotion should be strengthened, including through the follow-up to the review of the implementation of current policy on HIV/AIDS[39]. Accidents and injuries are the main cause of death in children and young people.

The worrying rise in obesity is leading to a rapid increase in Type II diabetes and obesity is also an important risk factor for cardiovascular diseases. Three quarters of type 2 diabetes, a third of ischaemic heart disease, half of hypertensive disease, a third of ischaemic strokes and about a quarter of osteoarthritis can be attributed to excess weight gain. Studies from the UK and the USA already show that obesity reduces life expectancy[40],[41], and the impact may become greater in future given the increase in childhood obesity. The need to promote physical activity will be part of the Commission's considerations in producing a Green Paper on Urban Transport in 2007 and guidelines on sustainable urban transport plans. The implementation of a White Paper on sport will also be relevant to the physical activity agenda through joint actions to encourage increased participation and improved opportunities particularly for young people.

The EC therefore has a role to play in supporting healthy ageing through improving healthy lifestyles through initiatives to support Member States to tackle health determinants. Moreover, it also has a role in coordinating responses to disease.

Supporting healthy ageing at Community level is also achieved through initiatives in relation to specific diseases, in relation to prevention, diagnosis, treatment, genetic testing (70% of the disease burden are complex genetic diseases[42]), information and telemedicine. Priorities for work on diseases vary according to different perspectives (citizens, patients, healthcare providers, others). The EC needs to explore ways to prioritise its work by means of a quantitative assessment of the relative impacts of diseases and strategies to tackle those diseases. A European Network of Disease Registers with agreed procedures for designation should be set up to accredit EU-wide disease registers. Further actions in the field of blood, tissues and cells, and the quality, safety and availability of organs should also be taken, following the Commission Communication on organ donation and transplantation[43].

Community priorities may be set to tackle diseases which cause the greatest burden such as cardiovascular disease and cancer, but the Community also has a key role in tackling rare diseases. Rare diseases, including those of genetic origin, are life-threatening or chronically debilitating diseases which are of such low prevalence that special combined efforts are needed to address them to prevent significant morbidity, perinatal or early mortality or a considerable reduction in an individual's quality of life or socio-economic potential. The EC is well placed to coordinate action to improve knowledge, facilitate access to information and create reference networks for these diseases.

Actions Measures to promote the health of older people and the workforce and actions on children's and young people's health (Commission) A Communication on the health of the workforce will be launched to integrate EU action in public health with action on employment and social protection and to strengthen mechanisms for information exchange and cooperation on this issue between Member States, the Commission, and the business community. A Communication on healthy ageing will be put forward by the Commission. A series of initiatives on the health of children and young people will also be launched. These will be developed with the input of young people and other stakeholders and will build on and contribute to existing action on the rights of the child, combating poverty and social exclusion and promoting participation of young people, as well as on EU youth-oriented public health strategies on alcohol, drugs, environment, nutrition, obesity, safe sex, oral health and mental health. Development and delivery of actions on tobacco, nutrition, alcohol, mental health and other health determinants (Commission, Member States) To promote healthy lifestyles and to address the burden of disease, the Commission will build upon the current work on addressing key health determinants. This will include taking forward strategies and actions that have recently been developed, including the EC strategy on nutrition, overweight and obesity, including strengthening the EC Platform on Diet, Physical Activity and Health and facilitating an EC salt campaign; the EC strategy on reducing alcohol related harm, the Green Paper on smoke free environments, the outcome of the recent consultation on tobacco taxation[44], actions on mental health, and the Council recommendation on injury prevention and safety promotion in Member States. The Commission will continue to use the full potential of its instruments to combat tobacco consumption. New Guidelines on Cancer screening and a Communication on European Action in the Field of Rare Diseases (Commission) The Commission will follow up on the actions from the programme Europe Against Cancer[45] by adopting a Commission Communication on Cancer including new guidelines on cancer prevention, early diagnosis, control, workplace exposure and access to treatment and information, as well as a new version of the European Code Against Cancer. Premature death and disability from cardiovascular diseases should also be combated and the European Heart Health Charter taken forward. Further EC-coordinated initiatives on specific diseases will be introduced where these can offer clear added value to actions in Member States. These may include initiatives in relation to diabetes and to neuro-degenerative diseases such as Alzheimer’s and dementias, as well as rare diseases, for which a Commission Communication and a Council Recommendation will be adopted. Follow up of the Communication on organ donation and transplantation[46] (Commission) Following the conclusions of the Communication, the Commission will develop in the coming years an EU legal framework on quality and safety for organ donation and transplantation. This legal instrument will be complemented with an action plan to strengthened cooperation between Member States in this field. Through this plan the Commission will promote cooperation and assist Member States to share experience and best practices with a view to increasing organ availability, enhancing the efficiency and accessibility of transplantation systems and complementing the legal instrument on quality and safety. |

- OBJECTIVE 2: PROTECTING CITIZENS FROM HEALTH THREATS

Protecting citizens against health threats such as communicable and non-communicable diseases and the health effects of climate change are ongoing health challenges where work at Community level provides clear added value, because these are issues which cross boundaries and cannot be tackled effectively by individual Member States. Protection of human health has been specifically set out in the Treaty[47], and security is also one the broad strategic objectives of the Commission.

Work in this area has included actions to improve preparedness and response to epidemics or deliberate acts such as bioterrorism, to support Member States in addressing communicable disease threats such as HIV/AIDS and tuberculosis, patient safety issues, medical devices, road safety and action to tackle environmental threats such as water and air pollution, and the body of EC legislation on health products including pharmaceuticals, quality and safety of blood, tissues and cells. Work on health threats also links closely to the health of animals, and coordination must be ensured on issues such as animal diseases which can be transferred to humans[48], and on ensuring food safety.

The European Centre for Disease Control (ECDC) was established in 2004 to identify, assess and communicate current and emerging threats to human health posed by infectious diseases. Recent work has included validating scientific recommendations regarding the best use of seasonal flu vaccination, and advice on improving comparability of childhood immunisation approaches in the Member States, in particular to take account of increased cross-border mobility. The review of the ECDC’s remit in 2008 will aim to strengthen further the response to disease threats.

Much has therefore been done, but some challenges have not yet been adequately tackled. Poor environmental quality is a significant cause of avoidable ill health. Recent estimates of the impact of air pollution made in the 'Clean air for Europe' (CAFE) programme found that in the EU about 350 000 people died prematurely in 2000 due to outdoor air pollution caused by fine particulate matter (PM2.5) alone. According to the WHO[49], 11.5% of children suffer from asthmatic symptoms in Europe. Indoor air pollution is also a significant problem. Lead intake from water and food is a major cause of brain damage - particularly in children from poorer backgrounds. WHO has estimated that in the WHO European region environmental lead pollution causes around 4% of the healthy life years lost. To improve indoor air quality and mitigate health risks, activities related to information, research and addressing key indoor pollutants should be brought together, building on the EC Environment and Health Action Plan (2004-2010).

Climate change has the potential to have a major impact on health, including on patterns of disease. It may reduce the predictability of communicable disease threats such as pandemics, and worsen their consequences, with gene-environment interactions playing a part. In extremes of heat there are increased cases of food poisoning, and an increased likelihood of malaria and tick-borne diseases, as well as the longer term implications of an increase in skin cancers. There is a risk of more water shortages, with reduced availability of clean water and an increase in water-borne diseases. In recent years, extreme weather conditions have proved harmful and fatal particularly among the elderly and other vulnerable groups, for example, France suffered an estimated 15,000 deaths in one month due to a heat-wave in 2003. Floods and severe cold are also threats to vulnerable groups, and extreme conditions leading to loss of electrical power can cause significant problems very quickly, particularly for health infrastructure. A number of reports on Climate Change have been carried out recently[50] and the EC can build on these in its work to add value to Member States' actions in this area, which will include health issues as well as other issues.

Patient safety is a further area of concern. Adverse events due to healthcare processes are wide in range, from healthcare acquired infections (HCAIs) to those stemming from unsafe devices, from prescribing errors to contaminated blood, and many more. The UK Department of Health, in its 2000 report, An organisation with a memory[51], estimated that adverse events occur in around 10% of hospital admissions or about 850 000 adverse events a year in the UK. The UK National Audit Office estimated that around 50% of these incidents could have been avoided if lessons from previous incidents had been learned[52]. In the Netherlands, research has shown that around 800,000 Dutch people over the age of 18 have been subject, in their own perception, to errors based on the inadequate transfer of medical information[53]. The economic costs of adverse events in health systems can also be huge. For example, in the UK, it is estimated that adverse events cost approximately €3 billion a year in additional hospital stays alone, while litigation represents a further cost[54]. ICT can be a useful tool to support patient safety through, for example, systems for pre-screening patients to support optimal diagnoses, and incident reporting systems. The Community can add value in relation to patient safety and a proposal is planned for 2008, which will include proposals to combat HCAIs.

The human and economic cost of accidents is also high. Road accidents killed 39000 people in the EU in 2006, and the direct cost to society has been estimated at €45 billion/year[55]. Strengthened efforts are needed to reduce the burden of traffic accidents in the EU. Approaches may include education of drivers, technological advances such as safety features in vehicles and road infrastructure, and judicial measures.

In terms of the global aspect of health threats, the EC should continue to provide humanitarian aid to save and preserve life, reduce or prevent suffering and safeguard the integrity and dignity of third country populations affected by humanitarian crises. More specifically, this should aim to support access to basic curative and preventive health services in crisis situations with an emphasis on the most vulnerable groups, and rapid and appropriate reactions to the emergence of life-threatening epidemics and health hazards.

Actions Strengthen EC mechanisms for surveillance and response to health threats, including review of the remit of the ECDC. (Commission) To enhance protection of the health and safety of European citizens, European mechanisms for surveillance and response to health threats, including newly emerging and re-emerging threats, will be strengthened. This will include streamlining current structures, such as reconsidering the remit of the European Centre for Disease Prevention and Control (ECDC) and the work of the network for the epidemiological surveillance and control of communicable diseases in the Community, the Health Security Committee and the International Health Regulations. To enhance real time data-gathering on illnesses, epidemics and environmentally related health problems and to aid rapid response, possibilities for developing an EU-wide virtual medical mapping system will be explored. Health aspects on adaptation to climate change (Commission) The Commission will produce a report on Climate Change covering a range of areas of concern including health. The most up-to-date scientific information on health effects from extreme weather and events relating to climate change will be gathered and analysed to support effective responses in preventing and responding to them. The implementation of surveillance systems for the main effects of climate change such as heat-waves and flooding will be examined. The capacity of EU health systems and infrastructure to cope with different levels of climate-related health threats will be estimated, with the aim of supporting contingency planning for hypothetically dangerous situations as necessary. |

- OBJECTIVE 3: SUPPORTING DYNAMIC HEALTH SYSTEMS AND NEW TECHNOLOGIES

Health systems throughout the EU are under pressure to respond to challenges such as the increasing mobility of patients and professionals as well as migration in general, citizens’ rising expectations, population ageing and changing disease patterns. They need to constantly adapt in order to meet their objectives. Innovation and the development of new technologies are key issues that affect EU health systems in today’s quickly changing world.

Ensuring sufficient capacity in the field of healthcare and public health is a crucial issue, particularly in the new Member States, and this is closely linked to the issue of health professional mobility, as well as the increasing challenges of new technologies and population ageing. More investment in capacity building for health professionals and workforce planning, including in public health and healthcare management training and evaluation, is necessary to improve the efficiency of health systems, to raise the level of European public health expertise and to strengthen Europe's place in the global health market. At EU and international level, issues of brain-drain and ethical recruitment are emerging: some places are suffering from a lack of qualified personnel, whereas others are facing an influx of healthcare professionals from other countries. To improve the quality and availability of education and training for health professionals, the potential for Regional Policy programmes and other tools such as the Lifelong Learning Programme and possibilities for networking should be fully exploited.

Health systems have to deal with a wide range of issues that have a cross-border impact, from pharmaceuticals and medical devices to organ donation and transplantation, mobility of patients and health professionals, to the availability of a single European emergency phone number. The new framework for health services[56] will help to identify and support further areas where EC action can add value, such as developing of European networks of centres of reference ensuring that patients can have access to highly specialised care requiring a particular concentration of resources or expertise that is beyond the capacity of every Member State to provide; creating a network for assessment of new health technologies to share results quickly between health systems and to avoid unnecessary duplication of efforts; or cooperation in border regions where the nearest appropriate healthcare provider may be across the border in another Member State. Efficient provision of care may be then best achieved through cooperation between providers serving populations across borders throughout their local region.

The new framework will also clarify the application of Community Law to health services and healthcare. It will set out clearly the common principles for healthcare in the EU, identify which Member State will be responsible for ensuring compliance with those principles and what those responsibilities include, in order to ensure that there is clarity and confidence with regard to which authorities are setting and monitoring healthcare standards throughout the EU.

The Community can support health systems by providing information and analytical support, reporting on developments and good practice in different health systems, supporting, facilitating and encouraging the use of targeted research, and facilitating dialogue and peer-to-peer cooperation. Close collaboration with Member States and international organisations such as the WHO, the World Bank, the ILO, the OECD and the European Observatory on Health Systems and Policies[57] is valuable in identifying key issues facing health systems and responding appropriately, and will be enhanced. The Commission will also explore the possibility of becoming a member of the Observatory.

Health is a sector that strongly and directly benefits from research and technological development, but also one that triggers it, an example of a 'business driving technology'. For example, the growing use of life sciences and biotechnology for the development of drugs, vaccines, genome-based diagnostics and innovative therapies, as well as the applications of "nanomedicine", represent a huge potential of innovation and growth[58]. The health sector must take advantage of innovation and technology where this can contribute to greater efficiency and health improvements. In the future, greater attention to innovation in the fields of major and chronic diseases, such as cancer, diabetes and cardiovascular disease could over time substantially reduce the burden on care services. Evidence shows that effective eHealth investments improve quality productivity, which in turn liberates capacity and enables better access to care[59]. Technologies can support a shift from reliance on hospital care to more prevention and primary care which is important for future sustainability of healthcare given population ageing, and can support better health outcomes. A balance must, however, be struck in terms of cost-effectiveness, and health systems must consider on a case by case basis what kind of investment in technology is the most cost-effective. Moreover, new and unfamiliar technologies can also give rise to ethical concerns, and issues of citizen's trust and confidence must be properly addressed. Health Technology Assessment (HTA) is one tool where current work is being taken forward by the Community in partnership with Member States to support the evaluation of new technologies and the exchange of best practice. The assessment of new technologies benefits from EU-level cooperation to gather evidence and share best practice.

E-Health is already an important tool for making substantial productivity gains, and in the future it is likely to be a key instrument to achieve restructured, citizen-centred health systems. There are many examples of successful e-Health developments including health information management and networks, electronic health records, telemedicine services, wearable and portable monitoring systems, and health portals. Today, at least four out of five European doctors have an Internet connection, and a quarter of all Europeans use the Internet for health information. European Community research programmes have been supporting e-Health for the last fifteen years. Technical work to develop electronic health records is also being supported by the EC. This is necessarily a long-term project but there is scope for this type of action to support cross-border healthcare if developed as a web-based system. More broadly, supporting the interoperability of health systems within and across national boundaries will support mobility and the safety of patients by ensuring continuity of care. Member States have shown that they are keen to take the e-Health agenda forward, drawing on best practice and experience from across the EU. This should enable a move towards a “European e-Health Area"[60].

In support of these kinds of forward-looking solutions, international standardization initiatives have potential to increase interoperability, innovation and productivity in the field of health. The EC therefore has a role to encourage and monitor the development, adoption and use of technical standards, namely on ICT; common vocabularies, classifications, nomenclatures and thesaurus; guidelines and best practices; and stable working and legal frameworks in the health domain, and especially for eHealth and transborder services.

Facing these challenges and in particular their cross-border dimension calls for adequate support to national systems at European level, while respecting the subsidiarity principle.

Actions Implementation of Community framework for safe, high quality and efficient health services (Commission) To reinforce cooperation between the Member States on issues relating to health services and in particular to cross-border healthcare, and to provide certainty over the application of Community law to health services and healthcare, the Commission will propose a Community framework for safe, high quality and efficient health services. Support Member States and Regions in managing innovation in health systems (Commission). The Commission will develop work under to support Member States in identifying, assessing and providing guidance on innovation in healthcare. This will look at mechanisms that Member States use within their healthcare systems, and identify existing structures and tools for support at European level, such as the European health technology assessment network, the Innovative Medicines Initiative (IMI), and the 7th Research Framework Programme (2007-2013), in particular the Health Theme under the specific programme 'Cooperation' and the Competitiveness and Innovation Programme. The potential for a new structure for making and disseminating technical recommendations at European level will be explored. In particular, the important and emerging areas of genomics and nanotechnology will be addressed. Support implementation and interoperability of e-health solutions in health systems (Commission) The Commission will develop work to support the effective use of e-health solutions in health systems, including issues of interoperability between different systems both within and between countries. The Commission will continue to support ehealth as a Lead Market within the Lead Market Initiative. The Commission will also develop and implement a protected web platform for multimedia content and communication, capable of extracting and sending relevant information to and from a range of sources, building on the experience of recent successful internet projects such as the UK's MyHealthSpace. |

TOGETHER FOR HEALTH: IMPLEMENTATION OF THE STRATEGY

- 4.1. IMPLEMENTATION MECHANISMS

The EC has a clear requirement in the Treaty to improve and protect health. Fostering coordination and cooperation with the Member States is also enshrined in the EC Treaty, and seems likely to be further strengthened in a future Reform Treaty. The objectives and principles of the Strategy need to be supported by an appropriate practical mechanism in order to create real improvements in health in the EU. The key component of the implementation mechanisms of the Strategy will be a new Structured Cooperation mechanism to advise the Commission and to promote coordination between the Member States. (see Action below).

The Commission will work to strengthen further the involvement of key stakeholders in contributing to the development and implementation of actions to protect and improve the health of European citizens. Building on the progress made through structures such as the EC Platform on diet, physical activity and health, the European Alcohol and Health Forum, the e-Health stakeholders' group and the Health Policy Forum, the Commission will work closely with stakeholder groups, and with regional and local level bodies with a view to optimising their contribution to the implementation of the Strategy.

The European regions are key actors in delivering healthcare but often lack crucial resources and effective communication channels. Regional cooperation in healthcare could be enhanced through better sharing of knowledge and expertise and more efficient transfer and integration of health innovation. Community support, in complementarity with Regional Policy, needs to be provided to regions willing to set up mechanisms to foster regional cooperation on key health themes, such as health inequities, high quality health services, health professionals and healthy lifestyles. The participation of the regions in the implementation of the Strategy will be ensured.

In implementing the Strategy, the Commission will work across sectors in accordance with the HIAP principle, and will make use of a full range of instruments at its disposal: legislation, communications, recommendations, guidelines and networks as well policy instruments such as strategies on tobacco, nutrition and physical activity, safety and health at work, emerging technologies, alcohol and mental health. In a number of areas clear objectives for action already exist, for example following the recently adopted strategy on nutrition, overweight and obesity related issues[61]. The new implementation mechanism will build on those areas and refer to those objectives as part of the broader implementation of the Strategy.

Regular overviews and reports on health issues in the EU and of progress in tackling them will be undertaken to ensure the visibility of the Strategy and enable its progress to be followed. This White Paper sets out the first stage of the Strategy to 2013, when a review will take place to support the definition of further work towards the Strategy's objectives.

Actions The Commission will put forward a Structured Cooperation implementation mechanism (Commission) To ensure strategic cooperation, the Commission will propose a new mechanism for the implementation of the strategy with the Member States. This would include a Committee with Member States to identify priorities, define indicators, produce guidelines and recommendations, foster exchange of good practice, measure progress. This would include a structure for working with Member States, replacing some existing committees, which the new mechanism would make redundant. It will also ensure consistency with the work of the other existing bodies which deal with health related issues (such as the Administrative Commission, and the Social Protection Committee). |

- 4.2. FINANCIAL INSTRUMENTS

The actions set out in this Strategy will be supported by existing financial mechanisms until the end of current financial framework (2013), without additional budgetary consequences.

Key mechanisms include the health programmes. To ensure that the actions under the current Public Health Programme (2003-2008) and the new Second Programme of Community Action in the Field of Health (2008-2013) support the objectives of the Strategy, clearly defined priorities will be set by identifying specific objectives and deliverables on an annual basis.

The new Safety and Health at Work Strategy 2007-2012 will also have a major role in financing health-related actions.In addition, a number of other Community instruments provide funding relevant to health, e.g. the 7th Framework Programme on Research, Regional Policy, the European Action Plan for 'Ageing Well in the Information Society' and the Development Cooperation Instrument and Pre-accession Instrument. For a more comprehensive list see Annex 3.

ANNEX 1:

KEY EC PUBLIC HEALTH ACQUIS[62]

HEALTH - HORIZONTAL MEASURES |

Legislation | Description |

COM(2000)285 | Commission Communication on EU Health Strategy 2000 |

Commission Decision (2004/210/EC) | Commission Decision of 3 March 2004 setting up Scientific Committees in the field of consumer safety, public health and the environment |

Decision No 1786/2002/EC | Decision No 1786/2002/EC of the European Parliament and of the Council of 23 September 2002 adopting a programme of Community action in the field of public health (2003-2008) |

COM(2006)234 | Proposal for a Programme for Community Action in the field of Health 2007-2013 |

Decision 2004/858/EC | Commission Decision of 15 December 2004 setting up an executive agency, the 'Executive Agency for the Public Health Programme', for the management of Community action in the field of public health - pursuant to Council Regulation (EC) No 58/2003 (2004/858/EC) |

HEALTH - VERTICAL MEASURES |

Communicable diseases |

Decision No 2119/98/EC | Decision No 2119/98/EC of the European Parliament and of the Council of 24 September 1998 setting up a network for the epidemiological surveillance and control of communicable diseases in the Community |

Decision 2000/57/EC | Commission Decision of 22 December 1999 on the early warning and response system for the prevention and control of communicable diseases under Decision No 2119/98/EC of the European Parliament and of the Council |

Decision 2000/96/EC | Commission Decision of 22 December 1999 on the communicable diseases to be progressively covered by the Community network under Decision No 2119/98/EC of the European Parliament and of the Council |

Decision 2002/253/EC | Commission Decision of 19 March 2002 laying down case definitions for reporting communicable diseases to the Community network under Decision No 2119/98/EC of the European Parliament and of the Council |

Decision 2003/542/EC | Commission Decision of 17 July 2003 amending Decision 2000/96/EC as regards the operation of dedicated surveillance networks and Corrigendum (OJ L 185 of 24.7.2003) |

Decision 2003/534/EC | Commission Decision of 17 July 2003 amending Decision No 2119/98/EC of the European Parliament and of the Council and Decision 2000/96/EC as regards communicable diseases listed in those decisions and amending Decision 2002/253/EC as regards the case definitions for communicable diseases |

Regulation (EC) No 851/2004 | Regulation (EC) No 851/2004 of the European Parliament and of the Council of 21 April 2004 establishing a European Centre for disease prevention and control |

Council Recommendation 2002/77/EC | Council Recommendation of 15 November 2001 on the prudent use of antimicrobial agents in human medicine |

Treaty Establishing the European Atomic Energy Community (Euratom) | Chapter 3 (conferring competences to the Community for the protection of the health of workers and the general public against the dangers arising from ionising radiations). |

Blood, tissues, cells and organs |

Directive 2002/98/EC | Directive 2002/98/EC of the European Parliament and of the Council of 27 January 2003 setting standards of quality and safety for the collection, testing, processing, storage and distribution of human blood and blood components and amending Directive 2001/83/EC |

Directive 2004/23/EC | Directive 2004/23/EC of the European Parliament and of the Council of 31 March 2004 on setting standards of quality and safety for the donation, procurement, testing, processing, preservation, storage and distribution of human tissues and cells. |

Directive 2004/33/EC | Commission Directive 2004/33/EC of 22 March 2004 implementing Directive 2002/98/EC of the European Parliament and of the Council as regards certain technical requirements for blood and blood components. |

Directive 2005/61/EC | Commission Directive 2005/61/EC of 30 September 2005 implementing Directive 2002/98/EC of the European Parliament and of the Council as regards traceability requirements and notification of serious adverse reactions and events. |

Directive 2005/62/EC | Commission Directive 2005/62/EC of 30 September 2005 implementing Directive 2002/98/EC of the European Parliament and of the Council as regards Community standards and specifications relating to a quality system for blood establishments. |

Directive 2006/17/EC | Commission Directive 2006/17/EC implementing Directive 2004/23/EC of the European Parliament and of the Council as regards certain technical requirements for the donation, procurement and testing of human tissues and cells |

Council Recommendation (98/463/EC) | Council Recommendation on the suitability of blood and plasma donors and the screening of donated blood in the European Community |

COM(2007)275 | Commission Communication on Organ Donation and Transplantation: Policy Actions at EU Level |

Mental health |

Council Conclusions 2-3 June 2003 | Council meeting - Employment, Social policy, Health and Consumers affairs on 2-3 June 2003: Conclusions on Mental health |

Council Resolution (2000/C 86/01) | Council Resolution of 18 November 1999 on the promotion of mental health |

Council Conclusions (2002/C 6/01) | Council conclusions of 15 November 2001 on combating stress and depression-related problems |

Council Conclusions (2003/C 141/01) | Council Conclusions of 2 June 2003 on combating stigma and discrimination in relation to mental illness |

Council Conclusions 9805/05 | Council Conclusions on Community mental health action, 6 June 2005 |

Healthy lifestyles; socio-economic determinants |

Council Conclusions (2004/C 22/01) | Council Conclusions of 2 December 2003 on healthy lifestyles: education, information and communication |

Council Resolution (2000/C 218/03) | Council Resolution of 29 June 2000 on action on health determinants |

Nutrition |

Council Conclusions 9803/05 | Council Conclusions of 6 June 2005 on Obesity, nutrition and physical activity |

COM(2007)279 | White Paper on a Strategy for Europe on Nutrition, Overweight and Obesity related health issues. |

Directive 2002/178/EC | Directive laying down the general principles and requirements of food law, establishing the European Food Safety Authority and laying down procedures in matters of food safety. [63] |

Directive 89/398/EEC | Directive on the approximation of the laws of Member States relating to foodstuffs intended for particular nutritional uses |

Directive 90/496/EEC | Directive on nutritional labelling of foodstuffs |

Regulation 1924/2006 | Regulation on nutritional and health claims made on foods |

Regulation 1925/2006 | Regulation on the addition of vitamins and minerals and of certain other substances to foods |

Directive 2002/46/EC | Directive relating to food supplements |

Tobacco |

Directive 2001/37/EC | Directive 2001/37/EC of the European Parliament and of the Council on the approximation of the laws, regulations and administrative provisions of the Member States concerning the manufacture, presentation and sale of tobacco products |

Directive 2003/33/EC | Directive 2003/33/EC of the European Parliament and of the Council on the approximation of the laws, regulations and administrative provisions of the Member States relating to the advertising and sponsorship of tobacco products |

Decision 2003/641/EC | Commission Decision 2003/641/EC on the use of colour photographs or other illustrations as health warnings on tobacco packages |

Decision C(2005) 1452 | Commission Decision C(2005) 1452 on the library of selected source documents containing colour photographs or other illustrations for each of the additional warnings listed in annex 1 to Directive 2001/37/EC of the European Parliament and of the Council |

Decision C (2006) 1502 | Commission Decision C (2006) 1502 amending Commission Decision C(2005) 1452 of 26 May 2005 on the library of selected source documents containing colour photographs or other illustrations for each of the additional warnings listed in Annex 1 to Directive 2001/37/EC of the European Parliament and of the Council |

Decision 2004/513/EC | Council Decision 2004/513/EC concerning the conclusion of the WHO Framework Convention on Tobacco Control |

Council Recommendation (2003/54/EC) | Council Recommendation of 2 December 2002 on the prevention of smoking and on initiatives to improve tobacco control |

Council Resolution (96/C 374/04) | Council Resolution of 26 November 1996 on the reduction of smoking in the European Community |

Council Resolution (89/C 189/01) | Resolution of the Council and the Minister of Health of the Member States of 18 July 1989 on banning smoking in places open to the public |

Regulation (EC) No 2182/2002 | Commission Regulation (EC) No 2182/2002 of 6 December 2002 laying down detailed rules for the application of Council Regulation (EEC) No 2075/92 with regard to the Community Tobacco Fund |

Council Conclusions (2000/C 86/03) | Council Conclusions of 18 November 1999 on combating tobacco consumption |

Green Paper of January 2007 | Towards a Europe free from tobacco smoke: policy options at EU level |

Alcohol |

Council Conclusions (2001/C 175/01) | Council Conclusions of 5 June 2001 on a Community strategy to reduce alcohol-related harm |

Council Recommendation 2001/458/EC) | Council Recommendation of 5 June 2001 on the drinking of alcohol by young people, in particular children and adolescents |

Council Conclusions on Alcohol and young people 2004/ /EC | Council Conclusions of 2 June 2004 reiterated Council Conclusions of 5 June 2001 on a Community strategy to reduce alcohol-related harm |

COM(2006)625 | Commission Communication on an EU strategy to support Member States in reducing alcohol related harm |

Drugs |

Council Recommendation (2003/488/EC) | Council Recommendation of 18 June 2003 on the prevention and reduction of health-related harm associated with drug dependence |

Safety and Health at Work[64] |

Directive 89/391/EEC | Council Directive 89/391/EEC of 12 June 1989 on the introduction of measures to encourage improvements in the safety and health of workers at work As of September 2006, 19 Directives exist under this framework Directive on issues including work equipment, exposure to substances, pregnant workers and workers in specific industries like mining or fishing. |

Directive 2003/88/EC | Directive 2003/88/EC of the European Parliament and of the Council of 4 November 2003 concerning certain aspects of the organisation of working time |

Directive 94/33/EC | Council Directive 94/33/EC of 22 June 1994 on the protection of young people at work |

Directive 91/322/EEC | Commission Directive 91/322/EEC of 29 May 1991 on establishing indicative limit values by implementing Council Directive 80/1107/EEC on the protection of workers from the risks related to exposure to chemical, physical and biological agents at work |

Regulation (EC) N° 2062/94 | Council Regulation (EC) No 2062/94 of 18 July 1994 establishing a European Agency for Safety and Health at Work |

Council Resolution of 3 June 2002 on a new Community strategy on health and safety at work (2002-2006) |

Commission Recommendation of 19 September 2003 concerning the European schedule of occupational diseases |

Veterinary and Phytosanitary Legislation[65] |

Regulation (EC) 999/2001 | Laying down rules for the prevention, control and eradication of certain transmissible spongiform encephalopathies |

Regulation 396/2005 | On maximum residue levels of pesticides in or on food and feed of plant and animal origin and amending Council Directive 91/414/EEC (Not yet fully applicable. Treaty base under Article 37 and Article 152) |

Specific Health Topics |

Cancer |

Council Recommendation (2003/878/EC) | Council Recommendation of 2 December 2003 on cancer screening |

Cardiovasular Diseases |

Council Conclusions | Council Conclusions of 2 June 2004 on promoting heart health |

Accidents and injuries |

COM(2006)329 | Proposal for a Council Recommendation on the prevention of injury and the promotion of safety |

8344/07 | Council Recommendation On The Prevention Of Injury And The Promotion Of Safety |

Women's Health |

97/C 394/01 | Council Resolution of 4 December 1997 concerning the report on the state of women's health in the European Community |

External Action |

COM(2005)179 | A European Programme for Action to Confront HIV/AIDS, Malaria and Tuberculosis through External Action (2007-2011) |

COM(2006) 870 | A European Programme for Action to tackle the critical shortage of health workers in developing countries (2007 – 2013) |

ANNEX 2:

HEALTH ACROSS THE EUROPEAN COMMISSION

DG | Key Health Links |

AGRI | Nutritional aspects in promotional campaigns for EU agricultural products, information campaigns on smoking (funded up to 2008) |

BEPA | Investing in youth |

COMP | Competition rules in health markets |

EAC | Education on healthy lifestyles; Lifelong learning; Young people and health, Promotion of sport |

ECFIN | Economic projections re: demographic change, healthcare spending |

EMPL | Safety and Health at work; coordination of Social security schemes including the EHIC card; access of people with disabilities to social and health services; European Social Fund; Open Method of Coordination on Healthcare and Long Term Care |

ENTR | Pharmaceuticals; Medical Devices; Biotechnology; Safety of Cosmetics; Chemicals; Innovation |

ENV | Environmental health e.g. air quality, water quality, noise; 'European Environment and Health Strategy', COM(2003)338, and 'European Environment and Health Action Plan 2004-2010', COM(2004)416 |

EUROSTAT | Data collection in field of health and safety |

INFSO | Development and deployment of e-Health tools and services[66]. |

JLS | Illegal Drugs; Immigration policy and integration, protection of personal data concerning health |

JRC | Scientific and Technical Support in areas which may have an impact on health directly or indirectly (chemicals, air pollution, deteriorated water quality, food, genetically-modified organisms, nanotechnology, consumer products) |

MARKT | Benefits of Internal market to patients and healthcare providers; recognition of professional qualifications; Intellectual property rights and access to medicines; legal framework for public private partnership |

REGIO | Regional Policy actions to support health policy, including through 'Regions for Economic Change' |

RTD | Research framework programmes FP6, FP7 |

SANCO | Public health, consumer policy, food safety, animal health |

SG | Coordination policy on Biotech and sustainable development |

TAXUD | Policy on enforcement to combat introduction of products with a health risk |

TREN | Road safety, Energy, Ionising radiation, Working and Driving Hours |

AIDCO | External aid for health |

DEV | Health in EC and EU development policy, ACP country and regional programmes, and thematic programmes for all regions |

ECHO | Humanitarian aid operations. Access to healthcare in crisis situations and rapid response to life-threatening epidemics and other health hazards. |

ELARG | Assisting EU accession countries to put in place the health acquis |

RELEX | Relations with third countries, including European Neighbourhood countries on health |

TRADE | Trade negotiations re: Health and social services and services of health professionals |

OLAF | Illicit trade in tobacco products |

ANNEX 3:

FINANCIAL COMMUNITY INSTRUMENTS RELEVANT FOR HEALTH

DG | Financial instrument |

AGRI | Nutrition aspects of promotion campaigns under CAP; Tobacco Fund information campaigns (ending 2008) |

EAC | Lifelong Learning Programme (2007-2013) Youth programme |

EMPL | European Social Fund (2007-2013), projects/actions under the Safety and Health at Work Strategy 2007-2012 |

ENTR | Competitiveness and Innovation Framework Programme (CIP) (2007-13) |

ENV | LIFE (supporting environmental and nature conservation projects) |

EUROSTAT | Statistical Programme |

INFSO | eTEN Programme[67], Competitiveness and Innovation Programme, Ambient Assisted Living Programme[68] |

JLS | Programme Security and Safeguarding Liberties Framework programme on Solidarity and the management of migration flows Drugs Prevention and Information Programme (Council Common Position July 2007) Daphne III (combating violence against women, young people and children) |

REGIO | Regional Policy programmes co-financed with the European Regional Development Fund (2007-2013) |

RTD | Research Framework Programmes FP6, FP7 ( research on health and treatment including public health and health systems, food safety, eHealth, Innovative Medicines Initiative, actions related to global health, road safety) |

SANCO | Programme of Community Action in the field of Public Health (2003-2008) Programme for Community Action in the field of Health (2008-2013) Programme of Community action in the field of consumer policy (2007-2013) Council Decision of 26 June 1990 on expenditure in the veterinary field (90/424/EEC) |

TREN | Intelligent Energy Europe, actions under the Euratom Framework Programmes (radiation protection) |

DEV | Development cooperation instrument, European development fund |

ECHO | Humanitarian aid operations |

ELARG | Instrument for Pre-accession Assistance – IPA Technical Assistance and Information Exchange Instrument - TAIEX |

RELEX | European Neighbourhood and Partnership Instrument including TAIEX, Development and Cooperation Instrument (DCI), Stability Instrument (SI), Humanitarian Assistance Instrument, and other thematic instruments including 'Investing in People', 'Cooperation with Non-State Actors', etc. |

OLAF | Hercules programme |

ANNEX 4:

COMMUNITY AGENCIES DIRECTLY RELEVANT TO HEALTH

Abbreviation | Agency | Mission/Role |

EU-OSHA | European Agency for Safety and Health at Work (Bilbao, Spain) | To make Europe's workplaces safer, healthier and more productive by bringing together and sharing knowledge and information, and by promoting a culture of risk prevention. |

ECDC | European Centre for Disease Prevention and Control (Stockholm, Sweden) | To identify, assess and communicate current and emerging threats to human health posed by infectious diseases. |

ECHA | European Chemicals Agency (Helsinki, Finland) | To manage and carry out technical, scientific and administrative aspects of REACH (an EC regulation on the safe use of chemicals, No 1907/2006) and to ensure consistency at Community level in relation to these aspects To provide the Member States and the institutions of the Community with the best possible scientific and technical advice on questions relating to chemicals which fall under REACH To manage IT based guidance documents, tools and data bases To support national helpdesk and run a helpdesk for registrants To make information on chemicals publicly accessible |

EEA | European Environment Agency (Copenhagen, Denmark) | To support sustainable development and to help achieve significant and measurable improvement in Europe's environment through the provision of timely, targeted, relevant and reliable information to policy making agents and the public. |

EFSA | European Food Safety Authority (Parma, Italy) | To provide objective scientific advice on all matters with a direct or indirect impact on food and feed safety, contribute to a high level of protection of human life and health through taking account of animal health and welfare, plant health and the environment, in the context of the operation of the internal market. |

EMEA | European Medicines Agency (London, UK) | To foster scientific excellence in the evaluation and supervision of medicines, for the benefit of public and animal health. |

EMCDDA | European Monitoring Centre for Drugs and Drug Addiction (Lisbon, Portugal) | To provide the Community and its Member States with objective, reliable and comparable information at European level concerning drugs and drug addiction and their consequences. |

EUROFOUND | European Foundation for the Improvement of Living and Working Conditions (Dublin, Ireland) | To provide information, advice and expertise – on living and working conditions, industrial relations and managing change in Europe – for key actors in the field of EC social policy on the basis of comparative information, research and analysis. |

FRA | European Union Agency for Fundamental Rights | To collect information and data, provide advice to the European Union and its Member States, and promote dialogue with civil society to raise public awareness of fundamental rights. Article 35 of the Charter of Fundamental Rights enshrines the right to healthcare. |

ESA | European Space Agency | To ensure that investment in space continues to deliver benefits to the citizens of Europe and the world, including satellite technology which can help to provide the information needed to manage the environment, understand and mitigate the effects of climate change, and ensure civil security for Europe. |

ANNEX 5:

INTERNATIONAL COMMITMENTS ON HEALTH (CAPITA SELECTA)

I. BINDING INSTRUMENTS

- WHO Framework Convention on Tobacco Control, 2003

- WHO International Health Regulations (IHR), 2005

- Convention on Human Rights and Biomedicine of the Council of Europe, 1997

II. GLOBAL COMMITMENTS

- United Nations Millennium Declaration adopted by the General Assembly resolution, 2000

- Paris Declaration on Aid Effectiveness, adopted at the High level Forum, Paris, 2005

- Global Strategy on Diet, Physical Activity and Health, endorsed by the WHA within the WHO, 2004

- Global health strategy for the prevention and control of noncommunicable diseases, adopted by the WHA, 2007

- Resolution on public health problems caused by harmful use of alcohol, adopted by the WHA, 2005

III. EUROPEAN COMMITMENTS ON HEALTH

- European Charter on Counteracting Obesity, adopted at the WHO European Ministerial Conference in Istanbul, 2006

- Children's environment and health action plan for Europe and the Ministerial Declaration on environment and health, endorsed by the WHO RC, 2004

- Council of Europe guide to the preparation, use and quality assurance of blood components, 2007

- Council of Europe Guide to safety and quality assurance for organs,tissues and cells, 2006

- Mental health Declaration for Europe launching the Mental Health Action Plan for Europe, endorsed by the WHO RC, 2005

- Gaining health: the European strategy for the prevention and control of noncommunicable diseases, adopted by the WHO RC, 2006

- Framework for alcohol policy in the WHO European Region, endorsed by the WHO RC, 2005

- European Strategy for Tobacco Control and the Declaration for a Tobacco-free Europe, adopted by the WHO Regional Committee for Europe (RC), 2002

- European Consensus on Development Cooperation, Joint Declaration of the Council and Member States, Official Journal C 46/01 of 24 February 2006

ANNEX 6:

HEALTH IN THE TREATY ESTABLISHING THE EUROPEAN COMMUNITY

The Treaty clearly states that the activities of the Community shall include ' a contribution to the attainment of a high level of health protection ' Article 3 (1) (p)

EU action on health is also explicitly provided for in Treaty Article 152:[69]

Article 152

1. A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities.

Community action, which shall complement national policies, shall be directed towards improving public health, preventing human illness and diseases, and obviating sources of danger to human health. Such action shall cover the fight against the major health scourges, by promoting research into their causes, their transmission and their prevention, as well as health information and education.

The Community shall complement the Member States' action in reducing drugs-related health damage, including information and prevention.

2. The Community shall encourage cooperation between the Member States in the areas referred to in this Article and, if necessary, lend support to their action.

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 organisations in the sphere of public health.

4. The Council, acting in accordance with the procedure referred to in Article 251 and after consulting the Economic and Social Committee and the Committee of the Regions, shall contribute to the achievement of the objectives referred to in this article through adopting:

(a) | measures setting high standards of quality and safety of organs and substances of human origin, blood and blood derivatives; these measures shall not prevent any Member State from maintaining or introducing more stringent protective measures; |

(b) | by way of derogation from Article 37, measures in the veterinary and phytosanitary fields which have as their direct objective the protection of public health; |

(c) | incentive measures designed to protect and improve human health, excluding any harmonisation of the laws and regulations of the Member States. |

The Council, acting by a qualified majority on a proposal from the Commission, may also adopt recommendations for the purposes set out in this article.

5. Community action in the field of public health shall fully respect the responsibilities of the Member States for the organisation and delivery of health services and medical care. In particular, measures referred to in paragraph 4(a) shall not affect national provisions on the donation or medical use of organs and blood.

Health is also mentioned in other articles throughout the Treaty. For example,

Article 95 (3), (6) and (8) concerning health in relation to the internal market

Article 133 (6) concerning common commercial policy , stating that health services "…shall fall within the shared competence of the Community and its Member States…".

Article 137 (1) (a) "1.'The Community shall support and complement the activities of the Member States in the following fields: a) improvement in particular of the working environment to protect workers' health and safety "

Article 153 "The Community shall contribute to protecting the health, safety and economic interests of consumers "

Article 174 (1 ) "Community policy on the environment shall contribute to pursuit of the following objectives: (…)- protecting human health.

Article 163 concerning the objective to promote 'all the research activities deemed necessary by virtue of other chapters of this Treaty'.

Article 177 on development cooperation includes a requirement to ' contribute to the general objective of…respecting human rights and fundamental freedoms'

[1] European Community.

[2] Article 6 TEU (http://europa.eu.int/eur-lex/lex/en/treaties/dat/12002M/pdf/12002M_EN.pdf).

[3] Source: Eurostat.

[4] Health Inequalities: Europe in Profile. Mackenbach J. 2006 (http://ec.europa.eu/health/ph_determinants/socio_economics/keydo_socioeco_en.htm)

[5] In June 2006 the Council invited the commission to take into account and integrate the gender dimension (Council Conclusions on Women's Health 2006/C146/02). The Commission roadmap for equality between women and men recognises the gender dimension in health - COM(2006) 192.

[6] Council resolution of 4 December 1997

[7] See COM(2007) 332 "Ageing Well in the Information Society, an i2010 initiative, Action Plan on Information and Communication Technologies and Ageing".

[8] COM(2006) 675 and SEC(2006) 1432 of 8.11.2006 include in the list of priority themes for modernisation several themes of relevance to the proposed health strategy, including 'Making healthy communities', 'Promoting a healthy workforce in healthy workplaces' and 'Meeting the demographic challenge'.

[9] https://www.eurobarometer-conference.eu/pdf/eb65/eb65_first_en.pdf

[10] COM(2006) 211.

[11] http://eur-lex.europa.eu/LexUriServ/site/en/oj/2006/l_394/l_39420061230en00100018.pdf

[12] Adopted at the High Level Forum, Paris 2005.

[13] www.health.europa.eu

[14] Reference number 2006/C 146/01.

[15] COM(2007) 46.

[16] Virgil (70-19 BC).

[17] Cf. in particular ‘The contribution of health to the economy in the European Union’. M. Suhrcke, M. McKee, R. Sauto Arce, S. Tsolova, J. Mortensen, Luxembourg, August 2005 (study carried out with a grant from the European Commission, Directorate General for Health and Consumer Protection).

[18] Annex to COM(2006) 30, 25.1.2006 (www.adb.org/documents/books/ado/2003/update/sars.pdf).

[19] 2006 Commission Communication to the Spring European Council - COM(2006) 30, 25.1.2006.

[20] Snapshots: Health Care Spending in the United States and OECD Countries Jan 2007 (http://www.kff.org/insurance/snapshot/chcm010307oth.cfm)

[21] The contribution of health to the economy in the EU, European Commission, 2005.

[22] The contribution of health to the economy in the EU, European Commission, 2005, p. 20-22.

[23] OECD Health Data 2006, Statistics and Indicators for 30 Countries. CDROM, Paris 2006.

[24] Esko Aho, Creating an Innovative Europe: Report of the Independent Expert Group on R+D and Innovation Appointed Following the Hampton Court Summit, available at: http://ec.europa.eu/invest-in-research/pdf/download_en/aho_report.pdf

[25] Kickbusch I. Innovation in health policy: responding to the health society. Gac Sanit. 2007;21(4):338-42.

[26] Assessing the Impact of SARS in Developing Asia, Asian Development Outlook 2003 Update (www.adb.org/documents/books/ado/2003/update/sars.pdf)

[27] Article 137(1)(a).

[28] See Annex 5 of the Impact Assessment accompanying the White Paper for key commitments.

[29] Mathers CD, Loncar D (2006) Projections of global mortality and burden of disease from 2002-2030.

[30] Paris Declaration 2005.

[31] The impact of ageing on public expenditure: projections for the EU25 Member States on pensions, health care, long term care, education and unemployment transfers (2004-2050) Economic Policy Committee and European Commission (DG ECFIN), 2006, European Economy. Special Report no.1/2006.

[32] 'The long-term sustainability of public finances in the EU', EUROPEAN ECONOMY. No. 4. , European Commission (DG ECFIN) 2006, Annex to the Commission's Communication on 'The long-term sustainability of public finances in the EU' - COM(2006) 574, SEC(2006) 1247.

[33] The impact of ageing on public expenditure: projections for the EU25 Member States on pensions, health care, long term care, education and unemployment transfers (2004-2050) Economic Policy Committee and European Commission (DG ECFIN), 2006, European Economy. Special Report No 1/2006,

[34] Eurostat, Health Interview Surveys 2004 (NewCronos Database).

[35] Fong et al, The near-universal experience of regret among smokers in four countries: findings from the International Tobacco Control Policy Evaluation Survey. Nicotine Tob Res. 2004 Dec;6 Suppl 3:S341-51.

[36] Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P. Estimates of the cancer incidence and mortality in Europe in 2006. Ann Oncol. 2007 Mar;18(3):581-92.

[37] Anderson P, Baumberg B (2006) Alcohol and Europe, London Institute of Alcohol Studies.

[38] The WHO Global Burden of Disease Study (Rehm et al 2004).

[39] Set out in the Commission Communication to combat HIV/AIDS within the European Union and in the neighbouring countries 2006-2009 - COM(2005) 654.

[40] Peeters A et al. Obesity in adulthood and its consequences for life expectancy: a life-table analysis. Annals of Internal Medicine, 2003, 138:24-32.