Opinion of the Economic and Social Committee on the 'Communication from the Commission to the Council, the European Parliament, the Economic and Social Committee and the Committee of the Regions on the development of public health policy in the European Community` (98/C 407/04)

On 21 April 1998 the Commission decided to consult the Economic and Social Committee, under Article 198 of the Treaty establishing the European Community, on the above-mentioned communication.

The Section for Protection of the Environment, Public Health and Consumer Affairs, which was responsible for preparing the Committee's work on the subject, adopted its opinion on 7 July 1998. The rapporteur was Mr Lemmetty.

At its 357th plenary session (meeting of 9 September 1998), the Economic and Social Committee adopted the following opinion by 101 votes to 2 with 1 abstention.

Gist of the Commission communication

1.1. The Commission has submitted a communication to the Council, the European Parliament, the Economic and Social Committee and the Committee of the Regions on the development of public health policy in the European Community. A previous communication was published on 24 November 1993 and the Commission feels there is now a need to consider how far the existing framework remains satisfactory and is able to respond to a number of important developments.

1.2. The need for change arises from persistent health threats but more importantly from the growing pressure on health systems, combined with the increase in life span of the population as well as the enlargement of the Community and the new public health provisions in the Treaty of Amsterdam.

1.3. The Commission has come to the conclusion that the priorities, structures, and methods of action are all in need of fundamental review and reformulation. This conclusion has been reached by evaluating current public health programmes and the experience gained from them.

1.4. The communication deals briefly with the state of health in the European Union, the public health challenges facing the Member States, the challenges of enlargement and the international dimension. The Community's role in public health is examined, particularly in the light of the Maastricht Treaty, and there is a discussion of future Community public health policy.

1.5. The communication proposes basing future Community public health policy on three strands of action:

- improving information for the development of public health;

- reacting rapidly to threats to health;

- tackling health determinants through health promotion and disease prevention.

1.5.1. The Commission intends that these strands of action should also tackle the challenges of enlargement and the question of health requirements in other policy areas.

1.6. The Communication does not make formal proposals for the Community's new public health policy, but seeks to stimulate a broad debate on the direction of Community public health policy in the next millennium. Following the debate, the Commission intends to present concrete proposals for the new policy once the Treaty of Amsterdam has been ratified.

2. Previous ESC opinions on Community public health policy

2.1. In this context it is worth bearing in mind previous Committee opinions (), as they have had an influence on the broad lines of Community public health policy which now appear in the Commission communication, especially in Sections 5 and 6, and elsewhere.

2.2. With regard to the action programmes drawn up by the Commission, the Committee made the following points:

- limited resources: The Committee has always considered that the financial allocation for each of the different programmes was insufficient to achieve their objectives;

- consistency and complementarity: The Committee estimates that it is essential to guarantee consistency and complementarity between relevant Community actions and programmes in the field of public health, in order to avoid any duplication or overlap of work and achieve efficient interaction between them;

- comitology: The Committee feels that the views of the various socio-economic partners and interests involved in public health policy should be considered by Member States when making nominations for the Advisory Committees that are to assist the Commission on both the criteria and procedures for selecting and financing projects under the different programmes, and the evaluation procedure.

2.2.1. Having analysed the action programmes, the Commission has now made similar observations: the programmes are not sufficiently flexible and have brought with them a considerable administrative burden, tying up precious resources.

2.3. The Committee's opinions have also stressed the importance of reinforcing the horizontal approach in health protection. This approach has now been taken on board, being forcefully expressed in the new Article 152 of the Amsterdam Treaty. There is also a new paragraph 4(b) on 'measures in the veterinary and phytosanitary fields`.

2.3.1. The provisions of the Amsterdam Treaty are dealt with further in point 3.8.

2.4. On the subject of future Community public health policy, particular mention should be made of the Committee's opinion on the previous Commission communication on the 'Framework for action in the field of public health`, adopted on 6 July 1994 ().

2.4.1. This opinion highlighted the following points:

- the specific problematic of age (e.g. young and old groups) and vulnerable categories (e.g. immigrant and other least-privileged populations);

- the link between health policy and the socio-economic dimension (e.g. employment);

- the 'horizontality` of public health beyond social policy to include specific media (e.g. the environment).

3. General comments

3.1. The Economic and Social Committee recognizes the importance of the Commission communication and the discussion contained therein. This discussion is now particularly topical as many problems have reached a stage where it is possible to make general observations. External challenges have also grown and preparations must be made to comply with the new Treaty.

3.2. Public health is improving throughout the Community but there is a great potential for further improvement both at Member State and Community level. The Committee therefore agrees that there is an urgent need to strengthen Community public health policy.

3.3. In its analysis of the state of public health and the challenges facing Member States, the Commission has presented noteworthy and incontrovertible facts. However, the Committee notes that, in contrast with the very detailed consideration of the public health challenges facing the Member States, the communication does not yet include many concrete proposals for action. In this context, the Committee stresses that citizens have greater expectations but also concerns about the future of health care.

3.4. The Committee feels that there are many unsolved questions beside those tackled in the communication. Health care spending in the Community has increased, but the consequences of new developments in economic policy and of the completion of the single market have not been taken into account. Other issues to consider are crossborder health care and socio-economic development.

3.5. The challenge of enlargement and the international dimension

3.5.1. Enlargement and the international dimension could have been dealt with in more detail. These questions should be examined more closely and the Committee suggests further action, especially on the subject of applicant countries.

3.5.2. Given that the development of public health policy will be a major task when the Community enlarges to Central and Eastern Europe, applicant countries should be given every possible assistance. This does not mean through legislation alone, but also by integrating these countries into existing health action programmes and the overall EU's public health policy at the earliest possible stage.

3.5.3. The Committee, therefore, asks the Commission to draft a report evaluating the state of health in applicant countries, in a similar way as has been done in the communication on 'Environment and enlargement`, as a means of identifying possible areas for cooperation and technical support (e.g. the exchange of information, expert assistance to existing programmes, etc.). Furthermore, the Committee stresses the need to collaborate with WHO in assessing the state of health in applicant countries.

3.5.3.1. In the context of enlargement, the Committee underlines the important role of Phare projects and does not accept any reductions of support in the health sector.

3.5.4. Contacts with international bodies promoting public health in their own spheres are well established, so it is enough here merely to mention the need for cooperation and the avoidance of unnecessary duplication of work. In particular, health-related activities within the European Economic Area and the G7 framework as well as Euro-Mediterranean co-operation are of great importance. The Committee would, therefore, like to emphasize the need for the Commission to continue close cooperation with WHO, OECD and the Council of Europe.

3.6. The Community's role in public health

3.6.1. The Commission has analysed the present role of the Community in the field of public health in a rather self-critical way and, in making its new proposals, has acknowledged the problems and shortcomings which have emerged. But many of the problems are of the kind which the Committee and others warned about beforehand, such as limited resources and the inflexibility of programmes.

3.6.2. Certain unexpected events, such as the BSE crisis, prompted citizens to demand action and reaction on public health from the Community. This has resulted in, among other things, a reorganization of the Commission and an increase in resources. The Committee feels that now, the beginning of a new century, is the right time to analyse and continue to develop the Community's role in public health. There does not have to be a crisis to bring this about. In this context, the media are responsible for highlighting certain more 'saleable` diseases and problems (Creutzfeldt-Jakob-disease - CJD -, anti-impotence pills, etc.), while some more important public health issues and risks may be underestimated. The Committee is currently preparing an own-initiative opinion on 'Resistance to antibiotics as a threat to public health`, just to mention one important issue.

3.6.3. The Committee recognizes the need to reorganize public health programmes at Community level and their management. However, it stresses the extreme importance of evaluating very carefully both the experiences gained and the possible consequences of new ways of organisation and management prior to creating any new organisational or managerial structures. This evaluation should take into account the results of the implementation of existing programmes, and the viewpoints of the Commission and the Member States as well as of the experts involved in the implementation of the programmes.

3.7. Relationship between the Community and the Member States regarding health care systems

3.7.1. The Committee would like to point out the fact that, even though health care systems are entirely the responsibility of the Member States, health care and health professionals share common problems and these are likely to become more 'visible` at the Community level as a result of the 'free movement of people` (see below) and the enlargement (see above).

3.7.2. In this context, Section 6 of the Communication is rather relevant for national systems. The Committee, as stated in many earlier occasions, attaches great importance to cooperation with and between Member States, and stresses the principle of subsidiarity. Therefore, it feels that the Community's role in health protection should continue to emphasise health promotion and disease prevention, and the exchange of information which best supports public health and health protection both in the Community and the Member States.

3.7.3. The judgements of the European Court of Justice (ECJ) () in the Kohll and Decker cases have shown that the ECJ, in applying the principles of 'free movement of goods, services and capital` enshrined in the Treaty, has adopted rulings which have a direct impact on the Member States' health systems. The jurisprudence of the ECJ thus has a major influence on national health care systems.

3.7.4. These ECJ judgements are primarily based on Treaty provisions concerning economic cooperation. Social protection provisions in the Treaties are limited and hence, social protection is regulated at Community level only to a rather limited extent. In this connection, the Committee estimates that the consequences of 'free movement` cannot be tackled solely in terms of market considerations, and that market rules should not adversely affect the health systems in the Member States. Furthermore, it feels that there is a need to consider health systems and services as part of the quality of life of European citizens.

3.8. Public health provisions of the new Treaty of Amsterdam

3.8.1. The new Article 152 on public health in the Amsterdam Treaty deserves special attention because it will form the basis of all future development. The Committee has on many occasions welcomed the increasingly important role of public health at Community level.

3.8.2. It is particularly significant that the provision stating that 'A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities` has been moved to the beginning of Article 152. This consideration should be of paramount importance when formulating the new public health policy and the strands of action.

3.8.3. The new provisions cover action which is 'directed towards improving public health, preventing human illness and diseases, and obviating sources of danger to human health.`

3.8.4. The Committee feels that these general principles are such that the entire future of public health policy can be built upon them. The tasks involved, demanding as they are, make it possible to insist on adequate funding at Community level.

3.8.5. The Committee also feels that the provisions of the new Treaty should encourage the Commission to reorganise its public health sector, and that they allow a better allocation of resources. The future of Community public health policy depends on resource availability, and hence existing resources should be prioritized and rationed in a fair manner, evaluating, on a case by case basis, the costs and benefits of the application of the 'precautionary principle`.

3.8.5.1. Furthermore, the Committee considers that the public health sector within DG V needs to have more staff overall, and, in particular, more high quality public health expertise at its disposal. In addition, coordination with other DGs should be guaranteed.

3.8.6. The Committee urges the Commission to clarify these essential preconditions in the next step of the process. In addition, it feels that the role of public health could be further strengthened if there was one Commissioner specifically in charge of public health at Community level.

3.9. A future Community public health policy

3.9.1. As far as the future of Community public health policy is concerned, the proposed strands of action go only part of the way to meeting the objectives put forward and the challenges being faced. The Committee would like to see the proposed objectives prioritized. In addition, the Committee doubts that the proposed three strands of action deal adequately with major issues such as the enlargement and the impact of other Community policies on health.

3.9.2. In this connection, the Committee would like to point out the Commission's social action programme for 1998-2000 and the preparation of the Fifth RTD Framework Programme.

3.9.3. Finally, in the conclusions of the communication, the Commission promises to come forward with concrete proposals for the new policy in due course, once the Treaty of Amsterdam has been ratified. In this context, the Committee considers it necessary to have a comprehensive outline for action in the field of public health.

4. Specific comments

4.1. The Commission proposes three strands of action for future public health policy. In so doing it assumes that the principles and positions expressed in the 1993 communication are still topical, while in actual fact these require a thorough reworking.

4.1.1. Future Community action should pay particular attention to health promotion and disease prevention, but at the same time other actions should be carried out which support the development of public health and health care in the Member States. Regarding the latter, the Committee feels that efforts should be concentrated on information exchange and the development of guidelines based on common understanding of best practices. Priority should be given to topics deemed particularly important for the health of citizens, for improving health care, and for those on which Community action can provide considerable added value. When carrying out such work due regard must be given to the Treaties which define and restrict the Community's scope for action.

4.2. Strand 1: Improving information for the development of public health

4.2.1. In Strand 1 the Commission stresses the need to establish a reliable health information system. Information is needed on health status, on health determinants, and on health-care systems. In each case, the Commission suggests possible areas to be dealt with. The points mentioned are very general.

4.2.2. The Committee would have welcomed a more comprehensive statement mentioning other important priorities, such as functional ability and disability, including work capacity and work disability, as well as the health and functional ability of both the ageing work force and the elderly.

4.2.3. In view of the Treaties, the Committee feels that the Community could, under Strand 1, give the highest priority to subjects concerning health promotion and disease prevention, but it should also promote activities which support the development of public health and health care as a whole.

4.2.4. The Committee also feels that the Commission should ensure that future Strand 1 activities directly serve and support the development of public health and health systems in the Member States.

4.3. Strand 2: Reacting rapidly to threats to health

4.3.1. Strand 2 seeks primarily to emphasize the cooperation and support of the authorities in the Member States, and the communication refers to recent examples of different kinds of epidemic.

4.3.2. This strand would make it possible to develop Community-level surveillance and an early-warning system, as well as creating the capacity to react quickly. In April 1998, the Council adopted a common position on the 'Action programme on rare diseases` and, in May 1998, an agreement was reached through the conciliation procedure on the 'Network for the epidemiological surveillance and control of communicable disease`.

4.3.3. The Committee is in favour of expanding the Community's capacity to react to health threats to cover, in addition to communicable diseases, other acute threats and health hazards. Furthermore, it considers that this strand could also include health requirements such as those to do with food safety and the environment.

4.4. Strand 3: Tackling health determinants through health promotion and disease prevention

4.4.1. Strand 3 deals with tackling health determinants through health promotion and disease prevention. The Commission wishes to modify its current programme-based method of operation. Mention is also made of the need to redistribute resources. On this point, the Commission sets out to promote discussion of the priorities by itself posing the questions to be considered.

4.4.2. The Commission intends to evaluate and assess particular measures and actions influencing public health knowledge, attitudes and behaviour within this strand ('health determinants`) giving examples of developments relating to tobacco, alcohol, drugs and nutrition.

4.4.3. The Committee considers that it would be helpful to extend the list of examples to include healthy lifestyles, physical activity, factors influencing allergies and asthma, social behaviour and mental health. All too often the importance is of these issues is overlooked and undervalued. On the other hand, it would not be justified to include advertising because it is only one way of communication and it is not unique.

4.4.4. The Committee feels that the document's approach to disease prevention is too limited, and that it should be extended to comprise all relevant factors, i.e. measures directed to the physical and the social environment, to total populations, to high risk groups, and to individuals.

4.5. The impact of Community policies on health and the need for a 'horizontal approach`

4.5.1. Apart from the three strands of action, the communication deals with the impact of other Community policies on health. The Commission has submitted a third report on the integration of health-protection requirements in Community policies (1996) () and an additional document relating to it. However, in the light of the new Treaty, which aims at 'ensuring a high level of human health protection in the definition and implementation of all Community policies and activities`, the Committee estimates that reporting alone is not sufficient, because being exclusively a record of the past (in this case, representing the situation as it was 2 years ago) it fails to make any recommendations for future action.

4.5.2. The Committee feels that one way of ensuring a high level of human health protection in other policies and activities would be to establish a fourth strand of action dealing with the integration of health requirements in all Community action. If the Commission is not willing to do so, it should at least present a way to ensure that health aspects are always given the (sufficient) consideration they deserve.

4.5.3. The Committee stresses the need for an horizontal approach and it is not satisfied with the 'mainstreaming` outlined in the communication. In addition, in order to increase human health protection in the definition of Community policies, the Committee suggests that in every Commission proposal there should be an evaluation of its effects on public health, and that this should be one of the new approaches of future Community policy.

4.5.4. In this connection, the Committee welcomes the Council's () invitation to the Commission to include sections on public health impact in its annual reports on the implementation of the previous year's overall work programme, and to indicate in its annual forward work programme all proposals which may have an impact on health protection.

5. Conclusions

5.1. The Committee welcomes the Commission communication considering that the new approach comprising three strands of action is acceptable. However, in the Committee's view the communication's consideration of a 'future Community public health policy` is too general and actions within the proposed strands are not prioritised. The Commission document should contain detailed proposals specifying the way in which the Commission aims at achieving the actions proposed under each strand. In this context, the Commission should consider the effects on public health policy of new developments in economic and employment policies and of single market issues (e.g. ECJ judgements).

5.2. Furthermore, the Committee also considers that the communication:

- does not take full advantage of the provisions of the new Treaty of Amsterdam, in particular the requirement to 'ensuring a high level of human health protection in the definition and implementation of all Community policies and activities`;

- should set up a fourth strand of action dealing with the integration of health requirements in other policies and activities or, alternatively, present another practical way to ensure that health aspects are taken into account;

- should also include a deeper analysis of the enlargement, and of its effects and risks for Community public health policy. The Committee asks the Commission to draft an 'evaluation report` on 'Health and enlargement` as a means of identifying possible areas for cooperation and technical support for applicant countries.

5.3. The Committee, therefore, urges the Commission to take these recommendations into account at the next stage which, in the Committee's view, should be to draw up a comprehensive outline for action in the field of public health.

5.4. Finally, the Committee considers it essential to reorganize and strengthen the Commission services acting in the field of public health, and recommends the establishment of one Commissioner specifically in charge of public health at Community level.

Brussels, 9 September 1998.

The President of the Economic and Social Committee

Tom JENKINS

() Cf. ESC Opinions on: Communication on the framework for action in the field of public health, OJ C 388, 31.12.1994; Action Programme to combat cancer, OJ C 393, 31.12.1994; Communication on health promotion, information, education and training, OJ C 102, 24.4.1995; Action Programme on the prevention of drug dependence, OJ C 110, 2.5.1995; Action Programme on AIDS and other communicable diseases, OJ C 133, 31.5.1995; Action Programme on health monitoring, OJ C 174, 17.6.1996; The Bovine Spongiform Encephalopathy (BSE) crisis and its wide-ranging consequences for the EU, OJ C 295, 7.10.1996; Network for the epidemiological surveillance and control of communicable diseases, OJ C 30, 30.1.1997; Action Programme on injury prevention, OJ C 19, 21.1.1998; Action Programme on rare diseases, OJ C 19, 21.1.1998; Action Programme on pollution-related diseases, OJ C 19, 21.1.1998; Communication on consumer health and food safety, OJ C 19, 21.1.1998.

() Cf. ESC Opinion on the 'Communication on the framework for action in the field of public health`, OJ C 388, 31.12.1994.

() Cf. Judgement of the European Court of Justice no C-120/95 (28.4.1998), where Articles 30 and 36 of the EC Treaty preclude national rules under which a social security institution of a Member State refuse to reimburse to an insured person on a flat-rate basis the cost of a pair of spectacles with corrective lenses purchased from an optician established in another Member State, on the grounds that prior authorisation is required for the purchase of any medical products abroad ('free movement of goods`).

Judgement of the European Court of Justice no C-158/96 (28.4.1998), where Articles 59 and 60 of the EC Treaty preclude national rules under which reimbursement, in accordance with the scale of the State of insurance, of the cost of dental treatment provided by an orthodontist established in another Member State is subject to authorisation by the insured person's social security institution ('free movement of services`).

() Cf. COM(98) 34 final, third Report from the Commission to the Council, the European Parliament, the Economic and Social Committee and the Committee of the Regions on the integration of health protection requirements in Community policies (1996).

() Cf. OJ C 169, 4.6.1998.