Opinion of the Committee of the Regions on the 'Communication from the Commission on the development of public health policy in the European Community'
Date: 1998-11-19
Institutions: European Committee of the Regions
Subjects: European Union, disease prevention, exchange of information, health policy, public health

22.2.1999

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Official Journal of the European Communities

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Opinion of the Committee of the Regions on the ‘Communication from the Commission on
the development of public health policy in the European Community’

(1999/C 51/09)

THE COMMITTEE OF THE REGIONS,

having regard to the Commission’s Communication on the development of public health
policy in the European Community (COM(98)230 final);

having regard to the decision taken by the Commission on 17 April 1998 to consult it, in
accordance with Articles 129 and 198C, first paragraph, of the Treaty establishing the
European Community;

having regard to the decision of its Bureau on 13th May to charge Commission 5 (social
policy, public health, consumer protection, research, tourism) with the preparation of this
opinion;

having regard to its Opinion on the Proposal for a European Parliament and Council Decision
adopting an action plan 1995-1999 to combat cancer within the framework for action in the
field of public health (CdR 183/94) (1); its Opinion on the Communication from the Commission
and a Proposal for a European Parliament and Council Decision on a programme of
Community action on health promotion, information, education and training within the
framework for action in the field of public health (CdR 246/96) (2); its Opinion on the
programme of Community action on the prevention of AIDS and certain other communicable
diseases within the framework for action in the field of public health (CdR 144/95) (3); its
Opinion on the Communication from the Commission to the Council and the European
Parliament on a European Union Action Plan to Combat Drugs (1995-1999) (CdR 147/95) (4);
its Opinion on the Communication from the Commission concerning a Community action
programme on health monitoring in the context of the framework for action in the field of
public health and the Proposal for a European Parliament and Council Decision adopting a
programme of Community action on health monitoring in the context of the framework for
action in the field of public health (CdR 25/96) (5);
its Opinion on the Commission
Communication concerning communicable disease surveillance networks in the European
Community and the Proposal for a European Parliament and Council Decision creating a
network for the epidemiological surveillance and control of communicable diseases in the
European Community (CdR 157/96 fin)(6); its Opinion on the Communication from the
Commission accompanied by a proposal for a European Parliament and Council Decision
adopting a programme of Community action 1999-2003 on pollution-related diseases in the
context of the framework for action in the field of public health (CdR 287/97) (7);

having regard to the Draft Opinion (CdR 156/98 rev. 2) adopted by Commission 5 on
29 September 1998 (rapporteur: Mr Ian Hudghton),

adopted the following opinion at its 26th plenary session held on 18 and 19 November (meeting
of 19 November).

1.

Introduction

1.1.
The Committee of the Regions welcomes the
Communication and the review of public health policy
in the light of experience gained since the public health
competence was extended in Article 129 of the Treaty
on European Union. The COR feels that an examination
of EC public health policy is also necessary in view of

(1) OJ C 210, 14.8.1995, p. 55.
(2) OJ C 210, 14.8.1995, p. 81.
(3) OJ C 100, 2.4.1996, p. 28.
(4) OJ C 100, 2.4.1996, p. 38.
(5) OJ C 129, 2.5.1996, p. 50.
(6) OJ C 337, 11.11.1996, p. 67.
(7) OJ C 64, 27.2.1998, p. 91.

the extension to the competence in the draft Treaty of
Amsterdam.

1.2.
Eight public health programmes have originated
from Article 129 and many of these programmes will
come to an end by the year 2000. The COR believes that
this makes an evaluation of the present programmes
necessary. The COR expresses concern that three of the
programmes still have to be agreed.

The European Commission is proposing three

1.3.
strands of action. These are:

— improving information for the development of public

health;

— reacting rapidly to threats to health;

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— tackling health determinants through health pro-

— injury prevention;

motion and disease prevention.

— rare diseases.

Issues relating to enlargement and to the integration of
health requirements in Community policies would be
dealt with across all three strands and this is an important
consideration in the communication.

1.4. While generally supporting these actions, the
Committee of the Regions feels that the EC should
respect subsidiarity and act where there are clear
advantages in operating at the European level. The
added value of pilot projects, networks and the exchange
of good practice should be stressed. The COR believes
that careful consideration should be given to EC inter-
vention in each strand so that the EC complements
national actions but does not duplicate them. These
strands are inter-related and this inter-relationship
should be born in mind when developing the EC public
health competence.

2. Present activities in EU public health policy

2.1.
In the Treaty of Maastricht, Article 129 covered
the public health competence and the major responsi-
bilities are as follows:

— The Community shall contribute towards ensuring a
high level of human health protection by encouraging
cooperation between the Member State 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 dependency.

There are currently eight action programmes

2.2.
associated with public health. These are:

— AIDS and other communicable diseases;

— cancer;

— drug dependence which is linked to other measures
including the establishment of the European Moni-
toring Centre for Drugs and Drug Addiction. An
action plan to combat drugs has also been agreed
with Member States;

— health promotion;

— health monitoring;

— pollution-related diseases;

2.3.
The programmes on pollution-related diseases,
injury prevention and rare diseases still have to be agreed
between the Council and the Parliament. The COR
believes that it is important that the two institutions
agree the programmes as quickly as possible.

The EC has taken action in a number of other

2.4.
areas including:

— guidelines and practical recommendations in cancer
screening, osteoporosis, healthy diet and youth
drinking;

— combating tobacco consumption and reducing

tobacco advertising;

— a strategy for blood safety and self-sufficiency;

— a comprehensive review of non-iodising radiation.

2.5.
The Committee of the Regions welcomes the
important public health element in the Fifth Framework
for Research and Technological Development (1998-
2002) and this includes research into the relationship
between health, environment and food: the control of
viral diseases and research into the problems of the
ageing population.

3. The extension of the Treaty competence for public
health and the problems with the current approach

3.1.
The Committee of the Regions agrees with the
Communication’s assessment of the problems associated
with the administration of the current eight programmes.
In particular, each programme has a small budget,
its own independent strategy and workplan plus an
individual committee structure with complex rules. This
causes a considerable administrative burden and makes
it more difficult for the EC to develop an integrated
public health strategy.

3.2.
The COR agrees that the current approach needs
a more streamlined structure with fewer programmes
and more co-ordination between the programmes.

3.3.
The communication states that ‘greater impact
might have been achieved if fewer, large-scale, sus-
tainable actions had been supported’ and that ‘the
reliance on organizations submitting projects reflecting
what they wish to do makes it difficult to ensure
that programmes’ policy aims, and those of national
strategies, are attained’. While it may seem administrat-
ively convenient to move to larger projects, the COR
believes that innovative or pilot projects remain an

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important part of these programmes and these types of
projects are extremely effective at the regional or local
level. Similarly, exchange of experience projects can be
effectively developed with a small number of transna-
tional partners who are skilled in innovative techniques.

3.4.
The Communication argues that the challenges
faced by public health, health promotion and disease
prevention has changed since the first Community
strategy was published in 1993 — and a number of these
changes are outlined. They include demographic factors
and an ageing population: new technologies and tech-
niques and greater public expectation in terms of health.
Changing employment patterns and changes in health
care systems are also important further considerations.

3.5.
The communication highlights food safety as a
particular concern. There have been examples when
diseases such as BSE and E-coli have caused widespread
concern in public health terms. The communication
states that EC public health policy must take into
account the impact of modern food preparation and
farming practices. The Committee of the Regions would
agree with this view and would emphasize the need to
develop linkages between the EC public health policy
and other European policies such as the Common
Agricultural Policy and food safety policy. The Com-
mittee of the Regions would also emphasize that BSE
and E-coli have been a concern for different levels of
government and that the fight against these diseases
needs to involve all
levels of government in a co-
ordinated attempt to eradicate the diseases. The link
with aspects relating to animal husbandry, animal
feeding and antibiotics in feeding stuffs should also be
heeded.

3.6.
These changes have greatly affected public health
policy and will remain the work of the European
Community. Consequently, the Treaty of Amsterdam
gave the European Union greater powers in public
health.

— Actions in anti-drugs policy will focus on ‘reducing

drugs related health damage’.

— The Community can now adopt ‘measures setting
high standards of quality and safety of organs and
substances of human origin, blood derivatives’ but
these measures ‘shall not affect national provision
on the donating or medical use of organs and blood.’

3.8.
The effects of enlargement and the international
commitments with organizations such as the World
Health Organization have to be included in the develop-
ment of a public health policy. The Committee of
the Regions agrees that the work of international
organizations needs to be taken into account when
developing the EC public health policy and it is important
that EC actions compliment rather than duplicate WHO
actions. In terms of enlargement, there is lower spending
on health per capita, lower life expectancy and lower
health status indicators. There is also an issue with the
free circulation of products (particularly pharma-
ceuticals, blood products and medical devices) which
raise questions about safety and quality control. The
international dimension deals with the global threat to
health, particularly communicable diseases.

4. A future Community public health policy

In view of these changes, the European Com-
4.1.
mission is suggesting a Community public health policy
with three strands:

— improving information for the development of public

health;

— reacting rapidly to threats to health;

— tackling health determinants through health pro-

motion and disease prevention.

3.7.
Article 152 of the Treaty of Amsterdam deals with
public health in the new Treaty and some substantive
changes have been made:

— The provisions on the health impact of other policies
stress that a high level of health protection should
be an important factor in all Community policies
and activities.

— Community actions have been extended beyond
those directed at ‘preventing human illness’ and
‘obviating sources of danger to human health’ to
include actions ‘directed towards improving public
health’.

Strand One: Improving information for the develop-
ment of public health

4.2.
The Communication emphasizes the importance
of adequate health information systems to inform policy
analysis and consequently improve the Community’s
ability to carry out effective actions in the public health
field. While the Committee of the Regions agrees that
the development of information systems is a key factor
in the development of public health policy, the Com-
munication lists information areas which are within the
competence of Member States and not the European

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Community. For instance, Article 4.7 mentions ‘trends
in health systems’ costs and financing, ‘including the
role of state and private insurance’ and ‘priorities in
health, including priority-setting mechanisms, as well as
public attitudes and concerns about health and the
effectiveness of health systems’. This might take the
European Commission into areas not specified in
Article 152 of the draft Amsterdam Treaty.

4.3. While information and comparative data in these
type of policy areas would be useful for Member States,
the work of the European Commission should not
contain recommendations or binding decisions. The
priority in information gathering by the European
Commission must be in areas where it has a competence.
This is particularly important given the budgetary
environment in which the EC public health policy will
develop. In its information gathering the EC should
compliment the data collection of Member States and
of international organizations like the WHO and the
OECD.

The dissemination of

4.4.
information from EC
commissioned research and data collection is very
important. The methods of dissemination need to be
carefully thought out so that the European Community
works in partnership with Member States and local and
regional government. There needs to be a debate between
these spheres of government about the EC’s research
and information programme in public health.

Research and the collection of information in
4.5.
many areas of public health should reinforce debate,
but decisions that stem from the research remain
the responsibility of Member States unless specifically
allocated to the EC in European treaties.

Strand Two: Reacting rapidly to threats to health

4.6.
This strand emphasizes the need for rapid reac-
tion to communicable and rare diseases and it lists
plague, haemorrhogic fevers and Asian flu as examples.
The European Commission would like to add health
requirements in food safety issues, sanitary and vet-
erinary matters, zoonoses, blood and organ safety,
environmental hazards, risks to health from chemical
substances and poisoning and the adverse effects of
medical products and devices. The COR welcomes these
proposals because cooperation between Member States

is an important consideration in combating threats to
public health by communicable diseases. The threat
posed by these diseases is increasing due to the increased
mobility in the European Union caused by business and
tourist visits and the European Community has role to
play in the exchange of information and best practice.
There is already a very effective warning and information
system for food and product safety that includes all the
Member States and the Commission. New information
systems for related public health areas should be
compatible with this system as far as possible.

4.7.
Community action would include co-ordinated
mechanisms at the European level and include surveil-
lance, swift analysis, site visits and the swift analysis
and investigation of specific problems. The Committee
of the Regions would, in principle, support activities of
this nature, as it is important that the EC supports
cooperation between Member States.

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

4.8.
This strand is composed of actions which
strengthen individuals’ skills and capabilities in health
promotion and prevention. Action will be directed at
changing social, economic and environmental factors so
that they are conducive to individual and public health.
The strand includes six of the eight public health
programmes in the present strategy as these programmes
deal with the prevention of disease and eradication of
health problems. The COR welcomes the rest of the
proposal.

4.9.
The Communication states that actions could
include vaccination, safety precautions, screening and
testing of target populations. However, the COR feels
these actions should be left to Member States with the
EC funding concentrating on the creation of networks,
the definition of quality standards and exchanges of best
practice, focusing on projects which enhance social,
economic and environmental conditions and on making
health action more person-centered.

4.10.
The European Commission seeks guidance on
its priorities in this strand. It asks whether it should
concentrate more on addressing ageing diseases such as
Alzheimers’ Disease; strengthen the work on nutrition
and obesity; devote more attention to cardio-vascular
disease; measures to reduce drugs-related health damage;

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focus on the health of specific population groups such
as the socially excluded, e.g. single people, children or
women; ensure access to health information and health
advisory services for EU citizens who move for work,
study and leisure; and the adaptation of strategies to
take the specific problems of accession countries into
account.

4.16.
The Committee of the Regions agrees that there
is little benefit in splitting promotion and prevention
programmes and a more streamlined approach is needed.
A single framework for this strand could make better
use of resources.

4.11.
The COR thinks that the European Commission
has introduced a long list of actions and, in view of the
limited budget, it will need to prioritise these actions
carefully in keeping with real public health needs.
Greater emphasis thus needs to be made on health
promotion measures, concentrating especially on the
weakest of the target groups.

The COR believes that the European Com-
4.12.
mission needs to establish the areas in which European
intervention will really add value and where the creation
of networks and the exchange of experience will prove
to be effective.

Section 4.1 of the Communication outlines the
4.13.
challenges that enlargement will present in terms of
public health. It states that the applicant countries
‘face potentially serious problems with communicable
diseases’ and that ‘the free circulation of products,
notably pharmaceuticals, blood products and medical
devices, raises issues relating to safety and quality
control as well as pricing’. In addition, the problem of
drugs misuse in a number of applicant countries and the
growing problem of drug taking in EU Member States
means that measures to reduce drugs-related health
damage will be a high priority. In view of these problems,
the EC will need to review its strategies in the light of
an enlarged European Union and this is a matter which
needs to be considered urgently.

4.14.
Access to health information and health advis-
ory services for EU citizens working and living in other
Member States is another important issue for the
European Community.

4.15.
Although programmes will be combined in this
strand, it would appear that there will not be significant
amounts of money available. With this consideration in
mind, the COR suggests that the activities need to be
pitched at specific target groups and health professionals
rather than the general public. Pursuing this argument,
projects should be developed through open calls for
proposals and innovative activities which are region or
locally based should be targeted.

5. The way forward

5.1.
The European Commission has made some initial
suggestions on the proposed methods of handling public
health policy in the future. The Commission considers
that there must be debate both on the content of future
policy and on the implementation of this policy. 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. The proposed network on the surveillance
and control of communicable diseases will have its own
legal basis.

5.2.
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 strand.
The COR believes that the three action strands are
inter-related and that there are strong arguments for a
single framework if negotiations to agree the framework
between the institutions of the EU can be carried out
quickly and effectively.

A health promotion programme would be valu-
5.3.
able provided that clear-cut priorities are established
in different areas (e.g. tobacco). The thrust of the
programme should be to reduce health discrepancies
and the focus should therefore be on specific social
groups and health policy.

The possible extension of the EC’s role to
5.4.
‘evidence based’ medicine, quality control, implemen-
tation, health technology assessment and the dissemi-
nation of results is natural and relevant in the case of
public health programmes, where there is a need
to promote cooperation and good practice amongst
Member States.

5.5.
information are useful

The use of research and the compilation of
in many public health areas

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where Member States have responsibility but it must be
remembered that research and information is used to
develop an informed debate. Responsibility for the
development of health and medical systems, including
cost control and finding schemes, will remain a national
responsibility.

The approach that public health aspects are a
5.6.
productive factor in society as reflected in the World
Banks ‘ Investing in Health’ initiative, is to be welcomed.
Public health priorities need to be established, especially
in the light of the overall goal of alleviating health
discrepancies between different groups, regions and
countries.

6. Main conclusions

6.1.
The Communication is to be welcomed as
it provides a full analysis of the issues facing the
development of the EC’s public health policy. Due to
the growth of the EC’s public health competence in the
Maastricht and Amsterdam Treaties, an evaluation of
public health programmes is welcome.

6.2. While generally supporting the three strands of
action outlined in the Communication, the Committee
of the Regions feels that the EC should respect sub-
sidiarity and demonstrate where there are clear advan-
tages in operating at the European level.

The present implementation of eight public
6.3.
health programmes with relatively restricted budgets
means that there is a great deal of unnecessary adminis-
tration and the COR welcomes the European Com-
mission’s attempts to streamline these programmes.

6.4.
The COR emphasises the link between public
health policy and other EC policies such as the Common
Agricultural Policy and food safety policy.

6.5. Despite this streamlining, the amounts of money
in the budget will not allow for extensive activities and

Brussels, 19 November 1998.

the rapporteur feels that, in many areas, the programmes
should concentrate on innovative local or regional
projects and the exchange of experience.

6.6.
It is also important that the three public health
programmes still to be established are agreed by the
Council and the Parliament as soon as possible.

6.7.
In Strand One, the COR agrees that the European
Commission should collect information to assist in the
delivery of the EC public health policy, but notes that it
proposes to collect information in policy areas which is
the competence of Member States. The EC also needs
to consider information collected by other international
organizations like the WHO and the OECD. The COR
feels that great care should be exercised in this area and
it should not contain recommendations and binding
decisions.

6.8.
The COR welcomes the actions in Strand Two
which is an important part of the European Com-
mission’s work, and emphasizes the EC’s co-ordination
role in this strand so that it encourages cooperation
between Member States.

6.9.
The COR welcomes the inclusion of six of the
eight present public health programmes in this strand in
an attempt to create a more streamlined and effective
approach. However, in view of budgetary constraints,
careful thought is needed in defining new or extended
activity in this strand. The COR would like to emphasize
the changes need in strategies due to enlargement and
the growing scourge of drug-related disease in the EU.

6.10.
In view of the limited budget, the COR would
like to remind the Commission of the importance and
effectiveness of innovative local or regionally based
projects. The creation of networks and the exchange of
experience also adds value at the European level.

The COR would favour a single legal frame-
6.11.
work because the three strands of action are closely
inter-related.

The President

of the Committee of the Regions

Manfred DAMMEYER