Opinion of the Committee of the Regions on:

- 'the communication from the Commission concerning a Community action programme on health monitoring in the context of the framework for action in the field of public health`, and - 'the proposal for a European Parliament and Council Decision adopting a programme of Community action on health monitoring in the context of the framework for action in the field of public health` (96/C 129/11)

On 18 July 1995, the Committee of the Regions decided, under Article 198c of the Treaty establishing the European Community, to draw up an Opinion on the above-mentioned communication and proposal.

Commission 8 for Economic and Social Cohesion, Social Policy and Public Health was responsible for preparing the Committee's work on the subject. The Rapporteur was Mr Bengt Mollstedt.

At its 11th Plenary Session of 17 and 18 January 1996 (meeting of 18 January 1996), the Committee of the Regions adopted the following Opinion.

1. Introduction

The Committee of the Regions has with great interest studied the Community action programme on health monitoring, which is aimed at the collection of health data at Community level and the development of Community health indicators building a capacity for analysis of data obtained dissemination of information on health and its determinants to enable the Community as well as the Member States to establish priorities, review policies and actions, and assist them in deciding on allocation of resources.

Health information is identified in Article 129 as a specific area of Community action and is a fundamental instrument in the Community policy-making process. Health data and indicators are an essential part of a health monitoring system, which will serve the purpose of monitoring health and health determinants throughout the Community and permit comparisons with third countries, to facilitate planning, monitoring, implementation and evaluation of Community programmes and actions, and finally to provide Member States with high quality, comparative indicators and information which support and add value to their national health monitoring systems and contribute to the development of national health policies.

According to the Commission, the system should build on readily available European data and indicators, any unnecessary duplication of work should be avoided, the system should not impose unnecessary burdens on Member States which already transmit health data to a number of international organizations, available options for developing the various parts of the system should be carefully assessed, and the system should be designed to have as much flexibility as possible.

The Commission foresees three strands of action: the establishment of Community health indicators, the development of a Community-wide network for data collection and dissemination and the capacity for and conduct of analyses. This is suggested to be initiated by a five-year Community action programme.

2. General comments

2.1. The Commission has paid interest to the field of public health and stressed the importance of monitoring health with different indicators. Since public health is very close to every citizen, every local community and every region, the topic is of great concern to the Committee of the Regions. The Communication and the Proposal from the Commission underline the importance of subsidiarity but does not take into consideration that this principle involves active participation of local and regional authorities. The Committee of the Regions sees the principle of subsidiarity as a tool to get involvement of the individual citizen, especially concerning health. Thus, activities to promote health must stay primarily with the local and regional authorities. The national level should be involved only in special cases. However, when health data are to be collected, it is necessary to work with large populations, such as regions or bigger cities.

2.2. The Committee of the Regions insists that when the report and the proposed five-year plan are implemented, the Committee of the Regions and the local and regional authorities are given a significant involvement in the procedure. The Committee of the Regions will see the programme as a start for more intense activity of the Community concerning public health, with due respect for the present responsibilities of local and regional authorities.

2.3. The communication and proposal concern two different aspects, the political and technical involvement. The political aspects concern the impact of public health on the future of the Union and the need for improvements concerning the health of the total population. The report describes the importance of possibilities to compare public health in different areas, regions and Member States, mainly to give possibilities to improve health. There are also descriptions of how data could be used for analysis of causes and effects, all in order to give a background for better health of the European population.

2.4. The Committee of the Regions has no objections to the political objectives stated in the report. However, it is important to give regions, big cities etc. the opportunity to use the material broken down to a level which will also suit administrations smaller than Member States.

2.5. The Committee of the Regions feels that this programme could be used for setting up minimum standards of health in all member Countries in the future.

2.6. The technical aspects concern collection and dissemination of data to and from Member States. Indicators of health are given as examples and the set of indicators should be decided on as soon as possible in co-operation with the WHO, schools of public health and other experts. The Commission should consider including local and regional expertise in this work, for example local and/or regional Environmental Health Officers. Finally the semantics should be mentioned. Health aspects concern the individual citizen living without illness, handicaps etc. The aggregation of data about the individual citizens will give an illustration of public health. When a sick person gets care, treatment, etc., the term medical care is suitable. However, medical care and health care are not synonymous and must be separated in the intellectual process.

3. Specific comments on the communication

3.1. Paragraphs 1-3

The Committee of the Regions agrees with the general principles, but underlines (in paragraph 2) that also local authorities and regions with outstanding results could be set as targets.

The Committee of the Regions stresses that the health indicators shall give added value also to local and regional authorities.

3.2. Paragraph 5

The term 'subsidiarity` must be seen in its widest sense, i.e. to delegate to local and regional authorities their proper tasks concerning public health.

3.3. Paragraph 9

The Committee of the Regions notices with interest that the system should 'support the community and Member States in health policy and evaluation`. It is important that the monitoring system is dynamic and involved in day-to-day activities, and that the system does not live its own isolated life.

3.4. Paragraph 15

The Committee of the Regions shares the view that the monitoring system should collaborate with WHO. It must however be noticed that some WHO programmes, for example 'Healthy Cities`, are based on collaboration between local authorities and not between nations. Such a system could be used as an example.

3.5. Paragraph 26

The Commission mentions 'medical practices`. This is not in accordance with the principle that medical care will be handled by the individual member states. However, this could be accepted if 'medical practices` will be defined as 'involvement of the medical care sector and medical knowledge in the field of public health`.

3.6. Paragraph 30

This paragraph concerns factors with impact on public health, such as education, physical environment, occupation and social policy. Here we find one of the key reasons why the Community should have an overall interest in public health matters. However, the responsibility for many practical activities in these fields stays with the local and/or regional authorities, and the principle of subsidiarity must once again be stressed.

3.7. Paragraph 40

The Committee of the Regions notices with satisfaction that the Commission recognizes the need to safeguard the individual citizen and his/her integrity, and underlines that this is an important part of the programme.

3.8. Paragraph 43

The Committee of the Regions think it is necessary to add to the important list of purposes:

'- to analyze cause-effect connections in the field of public health especially when aggregated data from many Member States are needed for conclusions`.

3.9. Paragraph 46

The list of indicators given in Annex A is an important example which must be analyzed in greater detail. The Committee of the Regions suggests that the assisting Committee, referred to in Article 5 of the proposal, should examine this list in cooperation with technical experts from the field of public health. However, the Committee of the Regions finds the distinction between cause and background factors essential.

3.10. Paragraphs 62-63

The Committee of the Regions feels that the system must be able to change over time but must also be consistent in order to measure long term changes. Thus the discussion about harmonization could be limited.

3.11. Paragraph 74

The Committee of the Regions agrees that measuring the status of public health is only a background for improvement of the public health policy. The Community and its members, including concerned local and regional authorities, must use them for a continuous discussion and improvement.

3.12. Paragraph 77

The Committee of the Regions observes that this is the first time in the text where regions and population sub-groups are mentioned. The Committee of the Regions would prefer to have this fact stated at an earlier state in the communication.

3.13. Paragraph 90

The Committee of the Regions accepts that a report is published annually but will note that good examples could also be found in different local, regional and national reports, and that these could be used as inspiration for the Commission's annual reports.

3.14. Paragraph 97

The programme for evaluation is acceptable but the Committee of the Regions demands to be consulted or included in an evaluation group.

3.15. Annex A

The Committee of the Regions would like to point to the following areas that ought to be included among the health indicators illustrated in Annex A:

- asthma/allergy;

- food hygiene (monitoring of restaurants and institutional kitchens);

- overuse of antibiotics, both as medical remedies and in meet production.

4. Specific comments on the proposal

4.1. Article 2.1

The Committee of the Regions insists that cooperation should take place not only with Member States but also with representatives of local and regional authorities. These should be informed and involved in the work in good time.

4.2. Article 2.2

The Committee of the Regions suggests that organizations such as the WHO, the OECD and Eurostat are mentioned in the text.

4.3. Article 3

The Committee of the Regions feels that the allocated budget, 13,8 mecu, might not be sufficient considering the necessary cooperation with other agencies, local and regional authorities etc.

4.4. Article 5.1

The suggested Committee will have many members. The Committee of the Regions suggests that the Committee be composed of only one member representing each Member State (national level) and additional Committee members from regional bodies such as the Committee of the Regions, the Nomesko (the Nordic Committee for Medical Statistics) and others.

4.5. Article 6.2

The Committee of the Regions underlines the importance of including associated countries in the programme.

5. Conclusions

The Committee of the Regions supports the proposed system on health monitoring and underlines:

- that the system should use existing national and international data;

- that the system should disseminate information and analyzes to authorities concerned as soon as possible;

- that the local and regional authorities should have possibilities to take part in the system;

- that measuring the status of health is only a support and background for improvement of the public health policy;

- that the suggested monitoring system is a start for a more intense activity of the European Union in the field of public health, albeit within the framework of the present Article 129 in the EU-Treaty.

Done at Brussels, 18 January 1996.

The Chairman of the Committee of the Regions

Jacques BLANC