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
Date: 1998-04-15
Institutions: Directorate-General for Employment, Social Affairs and Inclusion, European Commission
Subjects: action programme, disease prevention, health care system, public health

COMMISSION  OF THE EUROPEAN  COMMUNITIES 

Brussels,  15.04.1998 
COM(1998) 230  final 

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 

Executive  Summary 

The  Commission  set  out  a  framework  for  action  in  the  field  of  public  health  in  its 
communication  of 24 November  1993. This  described  the  strategy  to be pursued  and 
measures to be put forward  by the Commission to give effect  to Article  129 of the EC 
Treaty.  Eight  public  health  programmes  have  been  proposed  in  the  context  of  this 
framework.  Five  are  in  the  course  of  implementation  and  the  others  are  being 
considered  by  the  European  Parliament  and  the  Council  under  the  co-decision 
procedure.  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,  such  as 
emerging  health  threats  and  increasing  pressures  on  health  systems,  as  Well  as  the 
enlargement of the Community  and the new public health provisions  in the Treaty  of 
Amsterdam.  Moreover,  such  a  review  is  particularly  urgent  as  most  of  the  existing 
programmes  will  be  coming  to  an  end  in  or  about  the  year  2000  and  proposals  will 
have to be put forward  in the near  future. 

This  communication  first  considers  a  number  of  developments  in  health  status  and 
health  systems  in  the  Community,  as  well  as principles  and  pre-requisites  of  public 
health  action  at  Community  level.  These  considerations  lead  to  the  conclusion  that, 
although the principles and underlying philosophy  of the  1993 communication  on the 
framework  for  action  in the  field  of  public  health  remain  valid,  priorities,  structures 
and  methods  are  all  in  need  of  fundamental  review  and  reformulation.  Finally,  the 
communication  outlines a possible new Community public health policy, based  upon 
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. 

Issues  related  to  enlargement,  and  to  the  integration  of  health  requirements  in 
Community policies, would be dealt with by all three strands. 

The Commission  intends to come forward  with concrete proposals  on the new policy 
once the Treaty  of Amsterdam has been ratified.  In the meantime  it is hoped that  the 
ideas  presented  in  this  communication  will  stimulate  a  broad  debate  on  the  future 
Community public health policy. 

%^ 

Table of contents 

Introduction^.Purpose and Scope 

The State of Health in the European Union 

The Public Health Challenges facing the Member States 
3.1 Health care costs 
3.2 Demographic Trends 
3.3 Technological and other supply-driven  developments 
3.4 Changes in health systems 
3.5 Citizens' expectations and concerns 
3.6  Employment 

The Challenge of Enlargement and the International  Dimension 
4.1 Enlargement 
4.2 The international  dimension 

The Community's Role in Public Health 
5.1 The existing legal base 
5.2 The Community's role 
5.3 The development of Community public health activities since Maastricht 
5.4 Experience with the implementation of the  1993 framework  of action 
5.5 New developments at Community level 

A Future Community Public Health Policy 
6.1 Improving information  for the development of public health 
6.2 Reacting rapidly to threats to health 
6.3 Tackling health determinants through health promotion and disease 

prevention 

6.4 The impact of Community policies on health 

The Way Forward 

Conclusions 

1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

44 

1.  Introduction  -  Purpose  and  Scope 

1.  A  comprehensive  Community  strategy  on  public  health  has  been  in  place  since 
November  1993. This  followed "the ratification  of  the'Maastricht  Treaty  which  gave 
the  Community  an  explicit  competence  in this  field.  There  are  a number  of  reasons 
why this strategy is in need of fundamental  revision: 

• 

• 

• 

• 

• 

• 

first,  the  experience  gained  in  implementing  the  existing  public  health  strategy 
which has indicated some drawbacks with the current approach; 

second,  new  developments  in  health  status  and  health  systems  which  have 
emerged and which could not have been anticipated in  1993; 

third,  the  clear  requests  to  the  Commission  from  both  the  Council  and  the 
European  Parliament,  as  well  as  major  actors  in  the  health  field,  to  present 
proposals for a new public health policy able to respond to the new challenges; 

fourth, the Commission's own commitment to give health policy a higher priority; 

fifth,  the new health challenges posed by the enlargement process; and 

finally, the strengthening of public health provisions in the Treaty of Amsterdam. 

2. The development of a new policy has become particularly urgent. In order to be in a 
position  to  come  forward  with  concrete  proposals  for  new  measures  as  soon  as 
possible  after  ratification  of  the  Amsterdam  Treaty,  it  is  necessary  now  to  set  the 
terms  of reference  for  a debate  on the  overall  direction  of policy.  Moreover,  most  of 
the existing  public health programmes  will  be  coming  to  an  end  in or  about  the  year 
2000.  This  means  that  new  proposals  need  to  be  ready  in  time  so  that  there  is  no 
vacuum in Community policy in this important  field. 

3. In order to launch the debate, this communication  sets out the results of a review of 
the  existing  framework  and  presents  a  new  policy  orientation  in  the  field  of  public 
health, which puts emphasis on the improvement of health and the need to concentrate 
on  a  limited  number  of  priorities,  while  being  sufficiently  flexible  to  respond 
promptly to new health threats and developments. 

2.  The  State  of  Health  in  the  European  Union 

People  in  the  EU  are  now  living  longer  and  leading  healthier  lifestyles  than  ever 
before.  A  range  of  indicators  ranging  from  life  expectancy,  infant  mortality  and 
maternal mortality  confirm  this trend. This must not lead to any complacency.  One in 
five  citizens  still  dies  prematurely,  often  due  to  preventable  diseases.  New  risks  to 
health,  especially  communicable  diseases,  are  emerging.  There  are  disturbing 
inequalities in health status between social classes. And longer life expectancy  is itself 
creating  its  own  problems  such  as  a  sharp  rise  in  age-related  diseases  such  as 
Alzheimer's'. 

^C 

4. In general terms, the health of the Community population is better than ever  before. 
Year  by  year,  Community  citizens  are  living  longer.  Since  1970,  life  expectancy  at 
birth for  women  in the Community has risen by  5 1/2  years and for  men, by almost 5 
years. A  girl  born  in ,1995..can  expect to  live well over  80 years, a boy  to  nearly  74. 
From  1970 to  1992, the Community's  infant  mortality  more than halved, to under  10 
per  1000  live  births  and  the  differences  between  Member  States  decreased.  In  the 
same period, maternal mortality fell  sharply to 7 per  100,000 live births. 

5. The main killer  diseases  of the last century, such as smallpox, cholera and  measles 
are no  longer the threat they  were. The development  and  widespread  use  of  vaccines 
and  antibiotics  have  contributed  to  this  success,  as  have  improved  hygiene, 
environmental  and  social  conditions.  Nevertheless,  it  would  be  wrong  to  conclude 
from these achievements that no serious health problems remain in the Community. 

6.  First,  levels  of premature  mortality,  i.e.  death  before  the  age  of  65, are  still  high, 
accounting for  one fifth  of all deaths. More than 600,000 people aged between 35 and 
64 die every year, particularly  from  lifestyle-related  diseases: four  in ten from  cancer, 
three  in  ten  from  cardiovascular  diseases  and  nearly  one  in  ten  from  accidents  and 
suicides.  Behaviour  patterns  developed  in  childhood  and  adolescence,  such  as 
smoking, limited exercise, poor nutrition, etc., are major  risk factors  for these diseases 
in adulthood. Moreover, an estimated 22 million people aged  16 and over report being 
severely  hampered  in  their  daily  activities  by  a  'chronic  physical  or  mental  health 
problem'. 

7. Second, new risks to health  are emerging, for  example, from  new diseases  such as 
new variant Creutzfeldt-Jacob Disease (CJD), avian flu and Ebola haemorrhagic fever, 
the spread of food-borne  infections,  the resurgence  of old infectious  diseases, notably 
tuberculosis,  and  the  growing  problem  of  resistance  to  antibiotics.  AIDS  is  a 
continuing  concern.  The  increase  in travel  and  in population  mobility  will  aggravate 
these problems. 

8.  Third,  there  are  wide  variations  and  inequalities  in  health  status  both  among 
Member  States'  populations  and  among  the  different  population  groups  in  each 
country.  A striking  example related to age and  gender  is that within the  15 to  34 age 
group, the mortality  rate from  traffic  accidents  is three times higher  for  men than  for 
women.  Possibly  the  most  important  health  inequality  relates  to  socio-economic 
position.  People  in  lower  socio-economic  classes  have  significantly  increased  health 
risks  throughout  their  lives.  The  result  is  that  mortality  and  morbidity  rates  are 
significantly  higher  for  people  in the  lowest  socio-economic  classes.  In  the  UK,  for 
example,  a baby  born  today  to  parents  of one  of  the  highest  socio-economic  classes 
can expect to live five years longer than a baby in a lower class. 

9. Fourth, a consequence  of the lengthening  life  expectancy  in the Community  is the 
increase in the number of persons suffering  from  diseases and conditions related to old 
age,  in  particular  cancers,  cardiovascular  diseases,  physical  disabilities  and  mental 
disorders,  such  as Alzheimer's  disease  and other  neuro-degenerative  disorders.  It  has 
been  estimated  that  by  the  year  2000,  8  million  people  in  the  Community  will  be 
affected  by  Alzheimer's.  Increases  in  the  numbers  affected  by  diseases  such  as  this 
will have important consequences for social and health care and treatment services. 

3. 

The Public Health  Challenges facing  the Member  States 

Health care systems  in the Member  States are subject  to conflicting  pressures.  Rising 
costs due to demographic factors^ new technologies  and increased  public  expectations 
are  pulling  in  one  direction.  System  reforms,  greater  efficiencies  and  increased 
competition  are  pulling  in  another.  Member  States  must  manage  these  conflicting 
pressures  without  losing  sight  of the  importance  of health  to  people's  wellbeing  and 
the economic importance of the health systems. 

3.1  Health care costs 

10.  Over  the  last  three  decades, health  care  spending  in the  Community  has  roughly 
doubled as a proportion of GDP and now ranges from  5% to  10% in different  Member 
States.  This  is  considerably  less  than  in  the  United  States  (over  14%). In  response, 
Member  States  have  been  undertaking  a  wide  range  of  structural  reforms  and  cost 
containment  measures  to  improve  the  efficiency  and  effectiveness  of  their  health 
systems.  The  need  to  contain  rising  healthcare  spending  and  to  optimise  cost-
effectiveness  in  this  sector  has  been  underlined  by  the  general  constraints  on  public 
expenditure.  Several  factors,  affecting  both  the  supply  of  and  the  demand  for  health 
services,  have  contributed  to  the  rise  in  health  expenditure.  The  main  ones  are 
discussed below. 

3.2 Demographic  Trends 

11.  As  a  result  of  the  falling  birth-rates  and  lengthening  life  expectancy,  the 
Community  population  is ageing.  By 2020, there will be 40% more people  aged  75 
and above than in  1990. This is likely to increase demand  for health  services and will 
also necessitate changes to their organisation and structure. 

12. With more people living into their 80s and 90s, there will be increased pressure on 
health care and particularly  on social care. It has been estimated that, over the next 30 
years,  health  care  expenditure  will  rise  by  at  least  1-3%  of  GDP  as  a  result  of 
demographic  changes  alone1. The problem  will  be made more  serious  by the  decline 
in family  size and the increasing number of small and single parent households, which 
is likely  to  reduce the contribution  traditionally  made by family  members  to the  care 
of the elderly.  Health  and  social  services will need to respond  to these  changes.  The 
question of how to pay for the increasing costs is made more difficult  because the total 
dependency  ratio (the ratio of dependants to workers)  is likely to rise from  its current 
levels. 

3.3 Technological and other supply-driven developments 

13.  Supply  management  factors  are  at  least  as  important  in  determining  overall 
healthcare  costs  as  demand  factors.  In  recent  decades,  new  medical  developments 
have  been  introduced  at  unprecedented  rates,  and  their  impact  is  a  major  factor  in 
rising costs. Innovative  medicinal products, for  example, generally  cost  far  more  than 

Franco, T. Munzi, Ageing and fiscal policies in the EU, European Economy  1997:4 

existing  drugs.  Yet, many  current  therapies  have  not  been  proven  to  be  beneficial  to 
health and cost-effective.  This points to the need for greater emphasis on evaluation of 
health 
including  healthcare 
Computerisation  and  networking, 
telematics, may help-reduce health costs particularly  in relation to the management  of 
health care. 

interventions. 

3.4 Changes in health systems 

14.  Member  States  face  a  number  of  common  problems  related  to  the  financing, 
organisation  and management  of their health  systems. There is an increasing  concern 
to raise overall standards, while at the same time to control health costs and secure the 
best value for  money. In parallel, health systems, like other areas of the economy, are 
affected  by the globalisation of trade and industry and the pressures of competition, as 
well as the development  of the Community  internal market. The various  initiatives  in 
the  field  of  managed  care  and  the  growth  of  evidence-based  medicine,  quality 
assurance and health technology assessment are all responses to these developments. 

3.5 Citizens' expectations and concerns 

15. Health  services have to reflect  present  and projected  national  and  local needs  and 
respond  to  popular  demands, priorities  and  concerns.  In  this  context  an  encouraging 
trend  in  Member  States  is  the  growing  attention  being  paid  to  public  opinion  in  the 
planning  and  provision  of  services.  Besides  being  able  to  express  their  views  on 
service developments, citizens are also increasingly involved in priority  setting. 

16.  Although  the  legitimate  aspirations  of  the  public  have  to  be  respected  and 
addressed  by  governments  and  health  authorities,  growing  public  involvement  can 
produce  further  pressure  on services  and budgets, since people  are reluctant  to  accept 
any rationing of services or cuts in their levels. A recent Eurobarometer  survey  showed 
that only  5% of the Community  population  are ready to  see lower public  spending  on 
health  care.  By  contrast  50%  wanted  higher  spending.2  In  general,  satisfaction  with 
health systems is linked with the level of expenditure. 

17.  One  further,  significant  development  which  policy  must  take  into  account  is  the 
impact  of  modern  food  preparation  and  farming  practices.  The  introduction  of  new 
techniques,  such as genetically  modified  foods  and  food  irradiation, problems  related 
to  'natural'  foods  and  the  increased  availability  of  'fast'  foods  give  rise  to  public 
concern and to demands for policy responses. 

3.6  Employment 

18.  The  relationship  between  employment  and  health  goes  beyond  the  impact  of 
unemployment on health status. The health sector is an important employer,  consumer 
of  goods  and  a  leading  player  in  research  and  development.  It  thus  makes  a  key 
contribution  to  socio-economic  development.  According  to  the  1996  Labour  Force 
Survey,  more  than  10% of those  in  employment  were  employed  in  health.  Health  is 
one of the fastest  growing sectors in the  1990s, expanding on average at just under 3% 

Eurobarometer 44.3 carried out early in  1996. 

a  year.  A  further  issue  is  that  unemployment  reduces  the  total  funds  available  for 
health care. This is because in many countries a significant  proportion  of the  finances 
for health and social protection  systems is linked to income-related  contributions. It is 
therefore  important  when  considering  health  system  reforms  and  cost  containment 
measures, to take into account the possible effects  on health and  safety  issues  as well 
as on the broader economy. 

4.  The  Challenge  of  Enlargement  and  the  International  Dimension 

The  health  situation  in  the  countries  of  central  and  eastern  Europe  compares  poorly 
with  the  situation  in  the  existing  EU.  In  general,  there  is  lower  life  expectancy  and 
poorer  health  status  in  these  countries.  They  have  fewer  resources  to  improve  this 
situation.  Enlargement  will  also  have  implications  for  the  health  systems  in  the 
existing  Member  States,  especially  due  to  free  movement.  There  will  be  a  need  to 
assist the applicant countries to adapt to Community policy  in this field. Co-operation 
on health  issues with  international  organisations, such as the WHO, is also  necessary 
to address threats to health at the global level. 

4.1  Enlargement 

19. The development of public health policy has to take into account the  consequences 
of the enlargement of the Community towards Central and Eastern Europe. The health 
problems  of  these  countries  are  substantially  different  from,  and  often  more 
intractable  than, those  of existing  Member  States. Their  main health  status  indicators 
compare poorly  with  Member  States'. As  is normal  for  lower-income  countries  with 
less-developed  health  systems,  they  also  face  potentially  serious  problems  with 
communicable  diseases.  In  addition,  the  candidate  countries,  with  the  exception  of 
Cyprus, have  fewer  resources to  spend  on health. Their health  systems  are  in need  of 
significant  reform to improve their overall effectiveness,  as well as requiring a number 
of specific  changes to bring them in line with the relevant Community  legislation. The 
future  policy  must  tackle  the  problems  and  priorities  of  the  candidate  countries  and 
find ways of providing Community  support. 

20  A  further  issue  is the  possible  consequences  of  enlargement  for  the  health  status 
and  systems  of  the  existing  Member  States.  In  particular,  the  free  circulation  of 
products,  notably  certain  pharmaceuticals  and  blood  products  and  medical  devices, 
raises issues relating to safety  and quality control as well as pricing. 

21. The Commission is already giving support to the candidate countries to ensure that 
they  are  in  a  position  to  implement  the  European  Community's  health-related 
legislation  (the  acquis),  using  mechanisms  such  as  the  PHARE  programme  and 
structural  instruments.  In  addition,  the  Community's  public  health  programmes  are 
being opened for the participation of candidate countries which will assist them  in the 
process  of  adaptation  to  the  Community  policy  in  this  field.  Information  will  be 
needed  about  the  trends  in health  and  health  determinants  in the  candidate  countries 
and  about  the  possible  effects  of  accession  on  their  and  existing  Member  States' 
health systems. 

4.2 The International  Dimension 

22.  Public  health  policy  and  actions  must  respond  to  changes  in  the  international 
dimension.  Health  issues,play  an  important  role  in  the  Community's  relations  with 
third  countries,  its  development  co-operation  and  humanitarian  aid  activities.  Health 
problems  in  third  countries,  can  have  an  effect  on  the  health  of  the  Community 
population.  It  is  therefore  necessary  to  strengthen  the  initiatives  aiming  at  global 
epidemiological  surveillance  and mechanisms to respond rapidly to health threats  and 
to help developing  countries  to  improve their  health  systems. Currently,  a number  of 
health-related  activities  are  taking  place,  for  example,  within  the  context  of  the 
Agreement  on  the  European  Economic  Area,  Euro-Mediterranean  Co-operation  and 
within  the  G7  framework.  Moreover*-co-operation  on  global  surveillance  of  and 
response  to  communicable  diseases  is  being  considered  by  the  EU-US  Task  Force. 
Their results will feed  into the Community's public health policy. 

23. Furthermore, in many areas under consideration here, international  bodies, notably 
the World Health Organization, the World Bank, the United Nations Population  Fund 
(UNFPA), the Council of Europe and the Organisation for Economic Co-operation and 
Development  (OECD)  are  active  within  their  respective  remits.  There  are  several 
important  areas where co-operation with WHO is taking place, for  example, on health 
information  and  health  monitoring  systems  and  on  communicable  diseases.  WHO  is 
currently  updating  its  International  Health  Regulations  and  Health  For  All  objectives 
which  should be ready by the year 2000. These are likely to influence  Member  States' 
health agendas, and will be taken into account in Community policy. The World  Bank 
has an important role in supporting  health  service development  in Central  and  Eastern 
Europe. There is also increasing co-operation with UNFPA in implementing the action 
programme  of the International  Conference  on Population Development  (Cairo  1994). 
OECD has produced  documentation  and a database on health care and on health costs. 
The  Council  of  Europe  is carrying  out  work  in  several  areas  related  to  public  health, 
including pharmaceuticals, drugs and bio-ethical issues. 

5.  The  Community's  Role  in  Public  Health 

The  Community's  role  in  public  health  has  increased  over  time  and  especially  with 
the  ratification  of  the  Maastricht  Treaty.  It  gave  the  Community  a  particular  role  in 
promoting health protection and disease prevention. Eight distinct health  programmes 
and a range of other activities have been developed  in response. These  activities  vary 
from  programmes on cancer, on AIDS  and on combating drug dependence, to reports 
on the state of health in the EU and to recommendations  on blood  safety.  In  addition, 
many  other  Community  policies  also  impact  on health.  Developments  in the  last two 
years,  such  as  the  emergence  of  new  communicable  diseases,  have  contributed  to  a 
new and greater awareness of the importance of health policy at Community level. 

5.1 The existing legal base 

24.  The  European  Community  has  dealt  with  health  issues  for  four  decades.  Both  the 
Treaty on the European, Coal, and, Steel Community and the Euratom  Treaty referred  to 
health  and  contained  several  provisions,  for  example,  relating  to  restricting  free 
movement  of  goods  on  health  grounds  and  to  the  health  and  safety  of  workers.  The 
Single  European  Act  introduced  further  areas  of  health-related  work  such  as  a  large-
scale research programme and the development of health and safety  at work  legislation. 
However, it was only with the Maastricht  Treaty, with its new public health provisions, 
that  the  Community  had  the  opportunity  to  develop  a  coherent  public  health  strategy. 
Article  3(o),  gave  the  Community  a  new  objective  of  making  'a  contribution  to  the 
attainment  of  a high  level  of health  protection'  which  is  applicable  to  all  Community 
policies.  Article  129  of  the  Treaty  then  sets  out  a  framework  for  Community  public 
health activities in pursuit of this objective. 

25. The Article's main provisions are as follows: 

•  The  Community  shall  contribute  towards  ensuring  a  high  level  of  human  health 
protection by encouraging co-operation between the Member States and, if necessary, 
lending support to their action. 

•  Community  action  on  health  protection  should  be  focused  on  the  prevention  of 

diseases. 

•  Community  activities in the field of public health should  concentrate particularly  on 

the major health 'scourges', including drug dependence. 

•  In these areas, the Community is to co-operate with other organisations active in the 

field. 

26.  The  Article  provides  for  the  adoption  of  incentive  measures,  excluding  any 
harmonisation  of  Member  States'  legislation,  and  recommendations.  Finally,  it 
stipulates  that  health  protection  requirements  shall  form  a  constituent  part  of  other 
Community policies. 

27.  In  addition  to  Article  129, there  are  several  other  health-related  Treaty  Articles 
(e.g. Articles  39  and  43 -  agricultural  policy, Article  75c -  transport  safety,  Articles 
100  and  100a  -  approximation  of  laws  related  to  the  single  market,  Article  129a  -
consumer  protection,  Article  13Of -  research,  Article  13Or -  environment,  etc.).  The 
Court  of Justice has  confirmed3  that the objective  set for  the  Community  in Article 3 
(o)  of  the  Treaty  to  contribute  to  attaining  a  high  level  of  human  health  protection 
applies to all areas of Community policy which have an impact on health. 

28.  Just  after  the  Maastricht  Treaty  came  into  force,  the  Commission  presented  a 
communication  on  the  framework  for  action  in  the  field  of  public  health.  This 
described  current  health  challenges,  health  status  and  trends  within  the  Member 
States.  It  stressed  tackling  the  determinants  of  health  and  the  underlying  causes  of 
disease,  and  outlined  criteria  for  deciding  the  priorities  for  Community  action.  The 
philosophy of this communication  and the arguments expressed remain valid today. 

Cf.  Case C-180/96R, United Kingdom  v. Commission, ECR  1996,1-3903 

5.2 The  Community's  role 

29.  The  1993  communication  set  out  some  criteria  to  ensure  that  Community  public 
health  actions  , fully,  respect.  the:  principles  of  subsidiarity,  proportionality  and 
transparency  and  that  the  work  undertaken  provides  added  value  to  Member  States' 
activities.  It  is  essential  that  these  criteria  continue  to  be  met  in  the  definition  and 
implementation of actions. 

5.3  The development  of Community  public  health  activities since  Maastricht 

Action  programmes 

30. On the basis of the analysis in the  1993 communication, the Commission proposed 
the  development  of eight public  health  action programmes.  Of these,  five  have  been 
adopted.  The action programmes  on AIDS and other  communicable  diseases,  cancer, 
drug  dependence  and  health  promotion4  have  been  underway  since  1996;  the  fifth 
programme,  on  health  monitoring  was  adopted  in  June  19975. The  drug  dependence 
programme  is  linked  with  other  political  and  legislative  measures,  including  the 
establishment  of the  European  Monitoring  Centre  for  Drugs  and  Drug  Addiction.  A 
co-ordinated  approach to combating  demand  for  and supply  of drugs has been  agreed 
with the Member  States and  is laid down  in a European Union action plan to  combat 
drugs.6.  For  the  remaining  three  programmes,  on  pollution-related  diseases,  injury 
prevention  and rare diseases,7 the Commission put forward  proposals during  1997 for 
decisions  of  the  European  Parliament  and  the  Council.  These  are  still  under 
discussion. 

31.  These  programmes  support  many  projects  which  cover  inter  alia  the  following 
areas: the exchange of information  and personnel, training, pilot projects,  information 
campaigns,  networking  of  organisations  and  experts.  In  addition  work  is  being 
undertaken  on developing  guidelines  and practical  recommendations  in several  areas, 
including  cancer  screening,  osteoporosis,  healthy  diet  and  youth  drinking.  The 
programmes  aim to provide  Community  added value by undertaking  activities  which 
cannot  be  undertaken  satisfactorily  by  individual  Member  States,  or  where  joint 
implementation has advantages, or which complement their activities. 

Initiatives  in other areas 

32.  In  addition  to  the  action  programmes,  work  has  been  carried  out  in  other  areas 
related to the  1993 framework.  First, the Commission has proposed  the  establishment 
of a European  Community  network  for  the control  and surveillance  of  communicable 
diseases8.  Second,  new  initiatives  have  been  taken  on  smoking,  such  as  a 
communication  on  the  present  and  proposed  Community  role  in  combating  tobacco 

OJ L 95 of  16.4.96, p  16, OJ L 95 of  16.4.96, p. 9, OJ L 19 of 22.1.97, p. 25, OJ L95 of 
16.4.96, p. 1 
OJL193 of 22.7.97,  pi 
COM (94) 234 final of 23.6.1994 
COM (97) 266  final  of 4.6.97, COM(97)178 final of  14.5.97, COM(97) 225 final of 26.5.97 
COM (96) 78 final of 7.3.96 

consumption,9 and the adoption of a Council common position on tobacco  advertising. 
Third,  a  strategy  has  been  agreed  on  blood  safety  and  self-sufficiency,  including  a 
Commission  proposal  for  a  Council  recommendation  on  the  suitability  of  donors  of 
blood  and plasma, and the testing  of.donations.10 Fourth,  a comprehensive  review  has 
been  undertaken  on  non-ionising  radiation,  and  Commission  proposals  for  Council 
recommendations  are  being  prepared.  Fifth,  a  number  of  reports  are  produced 
regularly,  notably  on  health  status  in  the  Community,"  and  on  TSEs,  including 
information  on  reported  cases  of  CJD  in  the  Community.  Annual  reports  are  being 
prepared  on  health  requirements  in  other  policies12.  A  wide  range  of  Community 
policies  have  an  impact  on  health  and  even  have  a  health-related  Treaty  objective. 
These  reports  provide  an  overview  of the  actions  being  undertaken  in the  context  of 
these  policies.  For  example,  the  Commission  has  presented  a  second  modified 
proposal  for  a  5th  Framework  Programme  for  Research  and  Technological 
Development  (1998  -  2002).  One  of  the  priorities  of  this  proposal  is  to  focus 
Community  research  policy  on  specific  themes  such  as,  in  the  area  of  health,  the 
relationship  between  health,  environment  and  food,  the  control  of  viral  diseases,  and 
the  ageing population.  Equally,  the  Commission's  Joint  Research  Centre  contributes 
to the fight  against cancer. 

5.4 Experience  with the implementation of the 1993 framework  of action 

33.  From  the  outset  the  Commission  envisaged  that  the  public  health  framework 
would  need  to  be  reviewed  in  the  light  of  experience  and  trends  in  health  in  the 
Community.  This  review  should  not  merely  be  in  terms  of  how  well  the  action 
programmes  have  worked,  but  should  also consider  how far  they  have  contributed  to 
the  Treaty  objective.  Other  issues  for  assessment  are whether  the priorities,  structure 
and balance of the framework  have proved effective  and whether they  are  appropriate 
for the  future. 

34.  In  1993,  the  Commission  decided  against  proposing  one  overall  public  health 
programme.  One  reason  for  this  was  concern  that  this  would  risk  serious  delays  in 
implementing  the new legal provisions  arising  from  differences  between the  Member 
States  over  the  priorities  to  be  addressed.  Instead  the  Commission  decided  to  put 
forward  proposals  for  eight  separate  action  programmes.  While  this  approach  has 
avoided  some  of  the  pitfalls  anticipated  with  one  programme,  it  has  given  rise  to 
unforeseen  problems: 

•  It  has  led  to  a  considerable  administrative  burden  owing  to  the  fact  that  each 

programme has its own 'mixed'  committee and complex rules and structure; 

•  It has  limited  flexibility,  making  it difficult  to respond to developments  which  are 
not  covered  by  the  present  programmes  or  to  changes  in  the  Community's  or 
Member  States' priorities; 

COM (96) 609 final  of  18.12.96 
COM (97) 605 final of  17.11.97 
COM (95) 357 final of  19.7.95 and COM (97) 224 final of 22.5.97. 
COM (95)  196 final of 29.5.95, COM (96) 407 final of 4.9.96 and COM (98) 34 final of 
27.1.98. 

•  The  available  budget  for  each  programme  is  relatively  small,  raising  concerns 

about whether potential Community added value is being maximised ; 

•  Since  each  programme  develops  its  own  independent  strategy  and  workplan,  co 
ordination between the programmes  is difficult  to achieve in practice and there is a 
risk of duplication and overlap of activities. 

35.  Another  problem  related to the  implementation  of the programmes  is their  focus 
on  projects  submitted  for  consideration  by  organisations  in  the  field.  This  has  two 
consequences:  first,  funds  have been  spread  among  a substantial  number  of  projects, 
some not of relevance to all Member  States. Greater impact might have been achieved 
if fewer,  larger-scale, sustainable  actions had been  supported.  Second, the reliance  on 
organisations  submitting  projects  reflecting  what they wish to do makes  it difficult  to 
ensure that the programmes' policy aims, and those of national strategies, are attained. 

5.5 New developments at Community Level 

36. In the last two years, several developments have contributed to a new awareness of 
the importance of health policy at Community level and to a rethinking of its activities 
in the field  of health.  During this period, there has  been  growing  interest  in  Member 
States  in  developing  joint  activities  at  Community  level  to  support  them  in  coping 
with the health challenges they face, which were outlined above. 

37.  The  BSE  crisis  has  demonstrated  the  need  for  a  more  integrated  approach  to 
health-related  policy.  To  improve  its  capacity  to  respond  to  the  various  issues  raised 
by  the  crisis,  the  Commission  decided  to  re-organise  and  strengthen  its  services 
dealing  with  consumer  policy  and health protection  and to  establish  a new  system  of 
scientific  committees.  A  central  aim  of  this  restructuring  was  to  separate  the 
procurement  of  scientific  advice, and  the  function  of  inspection,  from  the process  of 
preparing  legislative  instruments.13 As part of their remit, the new committees  will  be 
able to provide expert advice on matters related to public health. 

38. The extension  of the legal basis of the Community's public health activities in the 
Amsterdam  Treaty  reflects  the  evolving  consensus  on the  importance  of  Community 
action  in this field.  Although  the new Treaty has not yet been  ratified,  it  is  necessary 
to  refer  briefly  to  its  public  health  provisions  here,  since  they  revise  Article  129 
(which  becomes  Article  152  in the  new  Treaty).  It  is the  Commission's  intention  to 
make  maximum  use  of  the  possibilities  offered  by  the  new  Treaty.  However,  their 
precise effect  will require detailed consideration. 

39. The main changes are as follows. 

•  The  provisions  on  the  health  impact  of  other  policies  have  been  moved  to  the 
beginning of the Article and they stress that a high level of human health protection 
shall  be  ensured  in  the  definition  and  implementation  of  all  Community  policies 
and activities. 

•  Some  changes  have  been  introduced  into  the  section  dealing  with  the  aims  of 
Community  actions, which encompass  actions "directed  towards  improving  public 

cf.  Commission  communication  on consumer health and food  safety, COM(97)183 of 30.4.97 

10 

health",  as  well  as  actions  directed  at  "preventing  human  illness"  and  "obviating 
sources of danger to human health". 

Actions in the drugs field  are to focus on "reducing drugs-related health damage". 

Two additions are made to Paragraph 4, dealing with decision-making: 

-  Paragraph  4(a)  states  that  the  Community  can  adopt  "measures  setting  high 
standards  of  quality  and  safety  of  organs  and  substances  of  human  origin, 
blood  and  blood  derivatives".  This  should  be  read  in  connection  with  the 
second  sentence  of  paragraph  5,  which  says  that  these  measures  "shall  not 
affect  national  provisions  on  the  donation  or  medical  use  of  organs  and 
blood".  Paragraph  4(a)  also  stresses  that  Member  States  can  adopt  or 
maintain more stringent protective measures if they wish. 

-  Paragraph  4(b)  brings  into  the  scope  of  this  Article  (and  therefore  the  co-
decision  procedure)  "measures  in  the  veterinary  and  phytosanitary  fields 
which have as their direct objective the protection of public health". 

Paragraph 4(c) preserves the existing wording regarding  incentive measures, i.e. it 
excludes "any harmonisation of the laws and regulations of the Member States". 

6.  A  Future  Community  Public  Health  Policy 

The  Community's  role  in  public  health  has  to  evolve  to  deal  with  new  challenges, 
changed  circumstances  and  the  greater  role  envisaged  for  public  health  in  the  draft 
Amsterdam  Treaty.  Drawing  from  these  factors  and  the  experience  of  the  existing 
framework,  the  Commission  considers  that  future  policy  should  comprise  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. 

These  three  strands  would  also  enable  the  Community  to  respond  effectively  to  the 
challenges of enlargement, and to the issues of health requirements in other policies. 

40.  A  number  of  events,  such  as  the  outbreaks  of  certain  infectious  diseases,  have 
raised the profile  of public health at Community  level, but a new public health policy 
cannot  be based  on  short-term  considerations  and one-off  events, however  important. 
Instead,  it  should  have  a  long-term  perspective,  with  a  set  of  clear  priorities  and 
appropriate implementation  instruments. 

41. No formal  policy proposals can be made before the ratification  of the new Treaty, 
but  it  is  appropriate  to  consider  at this  stage  what  the  main  strands  of  a  Community 
health policy  could  be and how they  might  build  upon  current  Community  action.  In 
doing  so, the  Commission  is aware  of the need  for  an extensive  debate  in which  the 
other  Institutions  and  other  interested  parties  can  join.  It  intends  to  present  its 

11 

proposals  in the light of the results  of this debate as soon as possible  after  the  Treaty 
of Amsterdam comes into force. 

and philosophy  of the  1993  communication 
42.  As  emphasise^abovea-the,p^ 
on  public  health,  remain  valid.  However  the  developments  outlined  above  require  a 
substantial  rethinking  of  the  present  approach.  A  Community  public  health  policy 
should  have  several  characteristics.  It  should  make  the  best  use  of  the  limited 
resources  available  at  Community  level.  It  should  emphasise  the  improvement  of 
health and health  gain and concentrate  on a limited number  of priorities. It should  be 
sufficiently  flexible  to  respond  promptly  to  new  health  threats  and  developments. 
Most  importantly, the policy  should take up the concerns  of Community  citizens  and 
be credible  and convincing  so that they are aware that  effective  arrangements  exist.at 
Community level to attain a high level of health protection. 

43.  On  the  basis  of the  above  analysis, the  Commission  considers  that  future  policy 
should comprise 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. 

These  three  strands  would  enable  the  Community  to  respond  effectively  to  the 
challenges of enlargement, and to the issues of health requirements in other policies. 

6.1: 

Strand  1: Improving  information for  the development of public  health 

AA. In  order  to  improve  the  Community's  ability  to  carry  out  effective  and  durable 
actions  in  the  field  of  public  health,  a  sound  health  information  system  and 
infrastructure  for policy analysis and development is essential. The Community  action 
programme  on  health  monitoring  represents  a first  step  by  defining  common  health-
related 
indicators;  collecting  and  exchanging  data  by  means  of  electronic 
communications developed in the Interchange of Data between Administrations (IDA) 
scheme14; and  a capability  for  undertaking  inquiries  and  analyses. This will  also  lead 
to  a  better-validated  database  and  an  improved  analytical  capacity  to  inform  public 
health policy development at Community and Member State level. 

45.  Building  on  the  activities  and  outputs  of  this  programme,  a  structured  and 
comprehensive  Community  system  for  collecting,  analysing  and  disseminating 
information  should be developed.  The system would  also be used  for  evaluations  and 
appraisals,  to  make  comparisons  between  Member  States,  with  accession  countries 
and  other  countries,  and  develop  future  scenarios  and  a  forecasting  capacity.  This 
strand would have two complementary  focuses: first, trends in health status and health 
determinants; and second, developments concerning health systems. 

Health  Status 

46. Areas to be dealt with could include: 

Council Decision 95/468/EC; OJ L269,  11.11.95, p.23 

12 

Trends  and  patterns  of  demography,  morbidity  and mortality,  and  of major  health 
determinants.  Analyses  could  cover  different  conditions,  including  physical  and 
mental  illness, specific  population  groups, such as children  and the  elderly,  trends 
in healuVrelated,knowledges-attitudes and behaviour, and gender-specific  issues. 

Inequalities  in  health,  covering  variations  between  population  groups  of  the 
determinants of health, morbidity and mortality, and assessment of interventions to 
reduce  them.  Analyses  would  also  cover  issues  of  access  to  health  services,  their 
use and health outcomes. 

• 

Other  topics  would  be  the  interaction  between  health  status  and  socio-economic 
factors  such  as  social  exclusion,  migration  and  employment,  and  between  health 
status and environment. 

Health Systems 

47. The following  areas could be covered: 

•  The impact of trends in health status and health determinants on health services and 
interventions  and  health  expenditure,  such  as  changes  in  patterns  of  prescribing 
pharmaceuticals,  and the consequences  of demographic  trends, notably  the  ageing 
of the population. 

•  Developments  in  health  systems,  including  reforms,  distribution  of  resources  and 
cost  containment  measures  and  their  consequences,  including  their  impact  on 
health status. 

•  Trends  in  health  systems'  costs  and  financing,  including  the  role  of  state  and 

private insurance. 

•  The  health  sector  as  a  productive  factor  in  society,  including  its  role  as  a  major 
employer.  Studies  might  be  made  e.g.  on  the  impact  of  market  mechanisms, 
measurement  of needs  for  services; costs  and  expenditure  calculation  and  control; 
competition between private and public provision and trends in managed care. 

•  Priorities  in  health,  including  priority-setting  mechanisms,  as  well  as  public 

attitudes and concerns about health and the effectiveness  of health systems. 

48.  A major  emphasis  within  the  information  strand  covering  both  health  status  and 
health  systems  would  be  placed  on  best  practice  in  health  care,  i.e.  the  current  best 
evidence  as  regards  the  safety,  efficacy,  effectiveness  and  cost-effectiveness  of 
different  approaches  to  health  promotion,  prevention,  diagnosis  and  treatment;  for 
instance 
the  cost-effectiveness  of  screening  programmes,  health  education 
programmes,  emergency  services  and new pharmaceutical  products. The work  would 
aim  to  promote  and  bring  together  activities  in  the  Member  States  in  the  fields  of 
evidence-based  medicine,  quality  assurance  and  improvement,  appropriateness  of 
interventions, and health technology  assessment. Co-ordination of work in these  fields 
would  be  supported  and  set  on  a formal  footing  in order  to  pool  the  expertise  of  the 
centres  in  the  Member  States,  to  gather  and  exchange  information,  stimulate 
international  studies, and improve the dissemination of findings. 

49.  Another  cross-cutting  theme  would  be  the  impact  of  developments  in  the 
Community  and  of  Community  policies  and  actions,  including  social  protection  of 

13 

migrant workers and people moving within the Community; the utilisation of research 
findings;  the  application  of  technology,  the  use  made  of  structural  funds;  the 
completion  of  the  single  market  and  the  introduction  of  a  single  currency;  and  the 
consequences  of  the  application  of  other  Community  legislation,  in  areas  such  as 
health  and  safety,  pharmaceuticals  and  medical  devices,  free  movement  of  health 
professionals  and competition.  Moreover,  specific  attention would have to be paid to 
obtaining 
the 
enlargement process. 

information  and  providing  analysis  and  guidance  relevant  for 

50.  To  be  fully  effective  such  a  Community  system  and  its  components  should 
ultimately  be  based  on  appropriate  networks  to  which  Member  States  would  be 
committed  to  contribute  in respect  of  the  collection,  processing  and  transmission  of 
data, and in relation to taking into account the results of the analyses and  evaluations. 
Moreover,  reporting  on the follow-up  to  any recommendations  that might  be  adopted 
would be essential. 

51. A Community  system of this kind would offer  several major  advantages: the data 
collected  would  be  comparable,  comprehensive,  up-to-date  and  of  high  quality;  the 
information  would be validated; and the outputs of the system would be linked to the 
development  and  implementation  of policy.  It  would  therefore  be  different  from  the 
various  information  and  reporting  systems  that  now  exist,  such  as  those  created  by 
WHO and OECD. 

6.2: 

Strand 2: Reacting rapidly to threats to health 

52.  A  second  strand  should  be  the  creation  of  a  Community  surveillance,  early 
warning, and rapid reaction capability. There have been recent examples  of  outbreaks 
of  disease  such  as  plague,  haemorrhagic  fevers  and  avian  flu  which  have  required 
urgent  consultations  and  action  at  Community  level.  This  strand  of  action  would 
involve having a capability which would be available to deal with future  outbreaks. It 
would  enable  quick  and  appropriate  responses  to  be  given to  threats  to  health  which 
might arise at any time. This would involve co-ordination mechanisms  at  Community 
level.  Actions  to  be  undertaken  would  include  surveillance,  swift  analysis  and 
investigation  of  specific  problems  or  issues,  including  site  visits,  if  appropriate.  The 
aim  would  be  first  to  identify  the  hazards  and  evaluate  the  likely  consequences  in 
health  and  other  policy  terms;  and,  second,  to  determine  whether  and,  if  so,  what 
action  was  needed  to  manage  health  risks  and  to  communicate  information  to  health 
authorities and more widely, as appropriate. 

53.  In  1996,  the  Commission  put  forward  a  proposal  for  a  European  network  for 
communicable  disease  surveillance  and  control15.  It  will  provide  a framework  which 
will  enable  the  Community  and  Member  States  to  take  a  co-ordinated  approach  to 
surveillance  and control of outbreaks. For the network to function  effectively  requires 
the Member  States to make a commitment that the relevant  surveillance  and  response 
organisations and authorities in their countries will co-operate fully  in the operation of 
the  network.  The  proposal  is  currently  being  discussed  by  the  Council  and  the 
European  Parliament,  and  it  is  hoped  that  it will  be  adopted  in  the  near  future.  This 

see footnote  11 

14 

network  could  provide  a model  for  further  Community  mechanisms.  In  addition,  the 
Commission's  proposal  for  a  rare  diseases  programme,16  which  is  currently  under 
consideration,  includes  actions  on  handling  clusters  of  cases  of  rare  diseases  which 
could be carried,forwardin.this.broader  context 

54.  The  subject  matter  of  this  strand  of  action  could  be  further  extended  to  cover, 
besides  communicable  and  rare  diseases,  health  requirements  in  food  safety  issues, 
safety, 
phytosanitary  and  veterinary  matters,  zoonoses,  blood  and  organ 
environmental  hazards,  risks  to  health  from  chemical  substances  and  poisoning,  and 
adverse effects  of medicinal products and devices. In addition, there might be a role in 
helping  to  provide  a  rapid  response  to  concerns  about  the  health  claims  of  new 
products  or  procedures.  This  strand  would  also  allow  appropriate  responses  to  the 
challenges faced by the accession states. 

55. In a number of these areas, such as food  safety  issues and veterinary matters, there 
are already  Community  early warning  and rapid reaction  systems  in place.  Therefore, 
any further  work that might be developed on these areas within this strand would have 
to link up with these systems and take them fully  into account. 

56.  The  work  undertaken  should  make  use  of  the  best  advice,  including  that  of  the 
experts  working  with  the  Community  under  the  scientific  advisory  committee 
structure,  as  well  as  expertise  in  international  organisations  and  third  countries.  The 
task  is  to  provide  information  and  advice  within  a  very  short  time  scale.  Most 
important, these activities must have the full  backing and co-operation of the  relevant 
authorities in the Member States. 

6.3: 

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

the  major  health  scourges, 

57. While  Article  129 of the Maastricht  Treaty  emphasises the prevention  of  disease, 
particularly 
that 
Community  action  shall  be  directed  towards  improving  public  health,  preventing 
human  illness  and  diseases,  and  obviating  sources  of  danger  to  human  health.  In the 
light of this, policy in this strand should aim at improving health determinants through 
health promotion as well as effective  actions on disease prevention. 

the  Amsterdam  Treaty  stresses 

58.  Health  promotion  aims  at  enabling  people  to  increase  control  over  the 
determinants  of  health  and  thereby  to  improve  their  health.  It  encompasses  actions 
aimed  at  strengthening  individuals'  skills  and  capabilities  and  those  directed  at 
changing  social, economic and environmental  conditions so that they are conducive to 
individual  and  public  health.  Disease  prevention  is  equally  important.  It  includes 
many  activities,  such  as  vaccination,  safety  precautions  and  rules,  screening  and 
testing of target populations. 

59.  Reflecting  the  weight  given  to  prevention  in  Article  129, six  of  the  eight  public 
health programmes proposed are concerned with prevention of diseases and  injuries. 

COM(97)225 final of 26.5.97 

15 

60.  The  new  policy  must  make  provision  for  tackling  health  determinants,  both 
through  broad  health promotion  activities and by  specific  disease prevention  actions, 
and  should  be  underpinned  by  inter-sectoral  action  and  the  possibilities  for 
instruments offered  by the Treaty^ not only in the health field  but also in other sectors. 
The  precise  contents  of  this  strand,  such  as  the  determinants  to  be  addressed,  the 
disease-specific  actions to be taken  and the health promotion priorities, needs  further 
consideration.  The  basic  issue  is how  far  the  existing  actions  reflect  trends  in  health 
and changes in the pattern of disease. 

61. Among the questions to be considered are the  following: 

•  how  greater  emphasis  can be  given  to  addressing  conditions  which  are  becoming 
ever  more  important  as  a  result  of  the  ageing  population^  notably  Alzheimer's 
disease and other mental disorders; 

•  how work on nutrition and obesity can be strengthened; 

»  whether more stress should be put on cardiovascular diseases; 

•  how the new Treaty provision  on reducing drugs-related  health damage  should be 

implemented; 

•  whether  there  should  be  a  greater  focus  on  the  health  of  specific  population 

groups, such as the socially excluded, young people and children, or women; 

•  how  access to health  information  and  health  advisory  services  can be  assured  for 
Community  citizens  as  they  move  to  other  Member  States  for  work,  study  or 
leisure, and how to reinforce  partnerships with education and training  institutions; 
and 

•  how  strategies  should  be  adapted  to  take  the  specific  problems  of  accession 

countries into account. 

62. Leaving aside the detailed contents of this strand of action, two conclusions can be 
drawn about its structure and objectives.  First, there  seems little benefit  in  continuing 
to  split  promotion  and  prevention  actions  into  a  number  of  separate  programmes. 
Bringing actions together in a coherent manner and thoroughly evaluating them within 
a  single  framework  would  make  better  use  of  resources.  Secondly,  the  existing 
balance  between  actions  on  disease  prevention  and  on  health  promotion,  and  the 
resources devoted to them, will need to be  modified. 

63.  Consideration  must  also  be  given  to  a  number  of  questions  arising  from  the 
practical experience of implementing the existing  framework: 

•  should  activities  be  primarily  aimed  at the  general  public,  specific  target  groups, 

health professionals  or specialist  organisations? 

•  should  projects  be  mainly  solicited  through  open  calls  for  proposals,  or  by  using 

specific  calls for tender, in particular in response to policy  considerations? 

•  should the emphasis be on large-scale activities involving  all Member  States, or on 

small, region- or locally based activities? 

•  should more emphasis be given to long-term  sustainable projects  likely to result in 

the setting up of lasting  structures? 

16 

64. One conclusion already emerging  is that more weight should be placed on  actions 
that support the development  and implementation  of policy, including those related to 
devising and testing intervention strategies and methodologies. Such work would need 
to  be  informed, by. the,, results.from„the  Community  health  information  system. 
Research  findings  on  e.g.  best  practice  and  effectiveness  of  interventions,  disease 
causation  and the  impact  of determinants  on health  need  to  be  speedily  disseminated 
so that they  can feed  into this  strand.  Co-ordination  between  health  research  projects 
and promotion  and  prevention  will  thus  be required.  Similarly,  work  will  be  needed 
analysing the impact of other policy areas on health-related behaviour and attitudes. 

6.4 The impact of Community policies  on health 

65.  The  Commission  has  developed  a  set  of  procedures  in  response  to  the  Treaty 
obligation  that  'health  protection  requirements  shall  form  a  constituent  part  of  the 
Community's  other policies'. These  include measures to ensure that the  Commission 
services  in  charge  of  public  health  are  consulted  on  all  health-related  proposals;  the 
setting up of the Interservice Group on Health to provide a forum  for discussing  major 
health-related  issues  among  Directorate  Generals,  and  the  preparation  of  annual 
reports on the integration of health requirements in Community policies. 

66.  It  has  not  however  proved  easy  to  implement  the  Treaty  obligation  to  keep  a 
'health watch'  on all areas of Community policy, or to develop and apply an adequate 
methodology.  The  new  Treaty  Article  underlines  that  a  high  level  of  human  health 
protection  shall  be  ensured  in  the  definition  and  implementation  of  all  Community 
policies  and  activities.  The  action  strands  described  would  enable  the  Treaty 
requirement to be complied with more effectively  in several complementary ways: 

•  Community  policies  and  large-scale  multi-annual  programmes,  such  as  research, 
structural  funds,  education,  training  and  youth,  transport  policy,  food  policy, 
agricultural policy, competition and industrial policy, which can have a  significant 
long-term  impact  on  health  determinants,  health  status  and  health  systems  could 
utilise  the  information  base  developed  under  the  information  system.  This  could 
its  adoption.  During 
involve  an  appraisal  of  the  policy  or  action  before 
implementation,  a policy  or action  could be closely  monitored;  and  afterwards  its 
impact  could  be  the  object  of  an  in-depth  and,  if  appropriate,  independent 
evaluation. 

• 

• 

Specific  measures  and  actions relating to  fast-emerging  risks to  health  would  fall 
within  the  remit  of  the  rapid  reaction  mechanisms.  Issues  in  this  field  could 
include  legislative  instruments  on public health  aspects  of food  safety,  veterinary 
and phytosanitary  measures, etc. 

Particular  measures  and  actions  influencing  knowledge,  attitudes  and  behaviour, 
such as developments relating to tobacco, alcohol, drugs, nutrition and  advertising 
would be scrutinised and assessed within the health determinants  strand. 

67. The precise  instruments  to be created to carry out the various  activities  identified 
will require further  consideration. It may be necessary, for example, to develop sets of 
criteria  and  specific  methodologies,  such  as  appraisal  guidelines  and  checklists, 

17 

against  which  developments  in  any  health-related  policy  could  be  measured.  Such 
instruments could also be used to assess the impact of public health activities. 

7.  The  W ay  Forward 

68. The Commission considers that there must be debate both on the ideas for  a  future 
policy presented  in this document,  and on how the policy  should be put  into effect.  A 
central issue is the nature of the legal mechanisms to be used to ensure that the policy 
effectively  combines  incentive  and  legislative  measures  provided  for  in  the  new 
Treaty.  Provisions  must be made for  the transition  from  the present.programmes  and 
legal instruments to a new policy.  Several factors  make this a very complex issue: the 
existing  public  health  programmes  each have their  own  legal  decisions  and  expire  at 
different  dates;  three  draft  action  programmes  have  not  yet  been  adopted;  the 
Community  resources  available  to  public  health  actions  are  attached  to  the  existing 
action  programmes;  actions  under the  existing  and  proposed  programmes  that  would 
continue under the new policy will have to be re-grouped and allocated  funding  which 
reflects  their  relative  importance;  finally,  the  proposed  network  on  the  surveillance 
and control of communicable diseases will have its own legal basis. 

69. There are two possible ways to formalise  the new policy. One would be to adopt a 
single  'framework  instrument'  providing for the subsequent adoption of separate  ones 
for  each strand. This would have the advantage of creating a single financial  envelope 
and  of  apportioning  funding  between  the  strands,  but  the  disadvantage  of  requiring 
two  layers  of decision-making  and administrative  structures.  The  other  option  would 
be to adopt a separate legal instrument for each strand with no overall instrument. This 
would need an implicit consensus on the funds to be allocated to each. 

70. Whichever option  is chosen, there must be some flexibility  in tackling  unforeseen 
problems and in allocating resources between the strands of action. There  should  also 
be  scope  for  the  introduction  of  binding  provisions  governing,  for  example,  the 
collection  of  data,  once  the  networks  and  other  structures  envisaged  have  been 
developed and are fully  in place. Moreover, in the areas singled out by Article  152 and 
other health-related  articles  in the Treaty  of Amsterdam  for  harmonisation measures, 
the  Community  would  be  able  to  adopt  binding  instruments  regardless  of  the 
programme structure or funding  mechanism. 

71.  The work programme(s)  agreed  in the different  strands  of  action  could  vary  year 
on  year,  as  appropriate.  This  kind  of  approach  would  enable  the  overall  aims,  scope 
and  structure  of  the  Community  programmes  to  be  clearly  set  out,  within  defined 
limits, while introducing some element of flexibility  over their content. 

18 

8. Conclusion 

72. This communication  does not put forward  formal  proposals for  a new  Community 
public  health  policy.  Instead  its  aim-is* to  give  an  overview  of  issues  that  must  be 
addressed  in  determining  the  future  direction  of  the  policy.  The  Commission  has 
concluded  that  in  order  to  build  on  what  has  been  achieved,  while  taking  proper 
account  of  the  trends  in  health  and  the  changing  situation  in the  Community,  a  new 
public  health  policy  is  required.  The  Commission  intends  to  come  forward  with 
concrete proposals for the new policy in due course once the Treaty of Amsterdam has 
been  ratified.  In  the  meantime  it  is  hoped  that  the  ideas  presented 
in  this 
communication  will  stimulate  a  broad  debate  on  the  way  that  Community  public 
health policy should go forward  into the next millennium. 

19 

ISSN 0254-1475 

COM(98) 230 final 

DOCUMENTS 

EN 

05  15  04  10 

Catalogue  number  :  CB-CO-98-262-EN-C 

ISBN  92-78-35242-X 

Office  for Official  Publications of the European  Communities 

L-2985 Luxembourg