Opinion of the Economic and Social Committee on the "Proposal for a Decision of the European Parliament and of the Council adopting a programme of Community action in the field of public health (2001-2006)"
Date: 2000-11-29
Institutions: European Economic and Social Committee
Subjects: EU programme, action programme, public health

20.4.2001

EN

Official Journal of the European Communities

C 116/75

Opinion of the Economic and Social Committee on the ‘Proposal for a Decision of the European
Parliament and of the Council adopting a programme of Community action in the field of public
health (2001-2006)’

(2001/C 116/18)

On 12 July 2000 the Council decided to consult the Economic and Social Committee, under Article 152
of the Treaty establishing the European Community, on the above-mentioned proposal.

The Section for Employment, Social Affairs and Citizenship, which was responsible for preparing the
Committee’s work on the subject, adopted its opinion on 14 November 2000. The rapporteur was
Mr Fuchs.

At its 377th plenary session of 29 and 30 November 2000 (meeting of 29 November), the Economic and
Social Committee adopted the following opinion with 108 votes in favour and 4 abstentions.

1. Gist of the proposal

1.1.
The Commission has issued a Communication to the
Council, the European Parliament, the Economic and Social
Committee and the Committee of the Regions on the health
strategy of the European Community, accompanied by a
Proposal for a Decision of the European Parliament and of the
Council adopting a programme of Community action in the
field of public health (2001-2006). In putting forward this
strategy, the Commission is seeking to enter a new phase in
health policy development in order to add value to Member
States’ actions in this area and to play fully its part on the
health front.

The European Community’s new health strategy is
1.2.
designed to meet the expectations of the people of Europe and
the challenge arising from longer life expectancy, technical
progress, increased migration within the Union, enlargement
of the Community and the Amsterdam Treaty’s new public
health provisions.

1.3.
This health strategy follows on directly from the
reorganisation of EU public health policy launched in the
1998 Commission Communication on the development of
public health policy in the European Community (1). The
strategy described in the communication and set out in the
decision document highlights two main prongs of EU health
policy:

1.3.1.
Firstly, individual Member States are to be supported
in their health-related activities by an action programme which
focuses on three priorities: (i) improving health information
and knowledge, (ii) responding more rapidly to health threats
and (iii) addressing health determinants.

1.3.2.
And secondly, all Community policies are to be
assessed for their impact on human health, in line with the
requirement laid down in Article 152 of the Amsterdam
Treaty.

1.4.
The substantive link between these two main aims is
provided by a framework for action which is to coordinate
existing schemes, draft guidelines and directives and rec-
ommendations. A coherent Community approach to health
objectives is intended to boost the efficiency of the resources
used.

1.5.
The proposal for a European Parliament and Council
decision adopting a programme of Community action in the
field of public health establishes the legislative basis required
to implement the European Community health strategy set
out in the Commission communication. It also provides a
framework for the allocation of financial resources to develop
the action programmes over a total six-year period. The overall
budget is EUR 300 million.

1.6.
The resources may be used for contracts from the
Commission and to subsidise projects. The idea is that the
resources may be used flexibly (i.e. they can be switched
between the priority areas).

(1) Cf. 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, COM(1998) 230 final.

The Commission has thus submitted formal proposals
1.7.
for a Community health policy, as announced in its preceding
communication.

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2.

Previous ESC opinions on Community public health
policy

2.1.
In this context, it is worth bearing in mind previous
Committee opinions (1) as they have had an influence on the
broad lines of Community public health policy.

2.2.
The Committee gave its views on the subject most
recently in its 1998 opinion on the Commission communi-
cation on the development of public health policy in the
European Community (2).
the Committee
repeatedly called for consideration to be given to the following
points:

In this opinion,

— Limited resources: The Committee has always considered
that the financial allocation for each of the different
programmes was insufficient to achieve their objectives.

(1) 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; Communi-
cation on a programme of Community action on health pro-
motion,
information, education and training, OJ C 102,
24.4.1995; Action programme on the prevention of drug depen-
dence, OJ C 110, 2.5.1995; Programme of Community action on
the prevention of AIDS and certain 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 (own-
initiative opinion), OJ C 295, 7.10.1996; Network for the
epidemiological surveillance and control of communicable dis-
eases, OJ C 30, 30.1.1997; Communication from the Commission
to the Council and the European Parliament on the present and
proposed Community role in combating tobacco consumption,
OJ C 296, 29.9.1997; 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; Proposal for a European Parliament
and Council Regulation (EC) on orphan medicinal products, OJ
C 101, 12.4.1999; Asbestos (own-initiative opinion), OJ C 138,
18.5.1999; Proposal for a Council Directive on the protection of
workers from the risks related to exposure of carcinogens at work
(Sixth individual Directive within the meaning of Article 16 (1) of
Directive 89/391/EEC), OJ C 368, 20.12.1999; Proposal for a
European Parliament and Council Directive on the Community
code relating to medicinal products for human use (codified
version), OJ C 368, 20.12.1999; Proposal for a Directive of the
European Parliament and of the Council on the approximation of
the laws, regulations and administrative provisions of the Member
States concerning the manufacture, presentation and sale of
tobacco products, ‘recast version’, OJ C 140, 18.5.2000.

(2) Cf. Opinion of the Economic and Social Committee on the
Communication from the Commission to the Council, the Euro-
pean Parliament, the Economic and Social Committee and the
Committee of the Regions on the development of public health
policy in the European Community, OJ C 407, 28.12.1998.

— Consistency and complementarity: The Committee con-
siders it essential to guarantee consistency and comp-
lementarity between relevant Community actions and
programmes in the field of public health, in order to
avoid any duplication of work and achieve efficient
interaction between them. The Committee welcomes the
steps taken so far to reorganise the European Com-
mission, not least the banding-together of health and
consumer protection issues. The present proposal
is
geared much more towards achieving a coherent
approach than earlier action programmes and will — if
the ideas set out in the paper are properly implemented
— generate greater synergy between individual Union
policies.

— Comitology: The Committee feels that a Commission
committee should be established to assist the Commission
both on the criteria and procedures for selecting and
financing projects under the programme and on the
evaluation procedure. Member States should consider
the views of the various socio-economic partners and
interests involved in public health policy. The policy
strategy now on the table provides for the establishment
both of a Commission advisory committee and a civil
forum.

2.3.
The Community’s new health strategy takes up the
Economic and Social Committee’s repeated call for a more
horizontal approach in the field of health protection; this is to
carried out on the basis of the new Article 152 of the
Amsterdam Treaty. In addition to the direct obligation to
assess all Union policies for their impact on health, the aim is
to coordinate existing schemes for establishing networks
and observatories and drawing up guidelines, directives and
recommendations. New measures are to be taken in the
veterinary and phytosanitary fields which will help improve
health-related environmental protection and food quality.

2.4.
In its 1998 opinion on the development of public
health policy, the Committee proposed, among other things,
that a health strategy should include:

— specific, age-related issues (e.g. young and old groups)
and particularly vulnerable categories (e.g. immigrant and
other under-privileged sectors of the population);

— the link between health policy and the socio-economic

dimension (e.g. employment);

— the ‘horizontality’ of public health, which goes beyond
social policy and should cover other areas such as the
environment.

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3. General comments

The Economic and Social Committee feels it is right to
3.1.
develop a strategic approach — if only because of the expiry
of the previous programmes — and to submit a proposal to
that effect. This is also a vital necessity following ratification
of the Amsterdam Treaty. The ESC welcomes the proposal for
a Decision of the European Parliament and of the Council
adopting a programme of Community action in the field of
public health.

The Committee notes that the 1998 proposal has been
3.2.
reworked and built upon following broad discussions between
the Commission and the other Union institutions and bodies.
The strategic approach has a twofold objective: (i) to support
Member States’ efforts on the health front and (ii) to gear all
EU policies more closely to the requirements and protection
of public health. It thus reflects the spirit of the Amsterdam
Treaty. This approach also takes account of the legitimate calls
voiced by the European public over the past few years for
enhanced cross-border health protection within the EU.

It

is important

3.3.2.
to promote the convergence of
national health systems, so as both to defend the interests of
patients in the individual Member States for whom the
conditions of access to pharmaceuticals differ, and to eliminate
the outstanding unfair privileges in the system that jeopardise
the objective of improved public health by preventing sufficient
resources from being channelled towards R&D; this funding is
essential in order to secure a competitive backdrop for the
genuinely innovative companies in this sector in the EU.

In its 1998 opinion,

3.4.
the Committee called for a
strengthening of Community public health policy; this is now
reflected in the proposal for a decision. The communication
which precedes the proposed decision sets out the Com-
mission’s reasons for this course of action, i.e. the challenge
facing Member States’ health systems and its impact on public
health across the Community. The Commission notes the
increasing strain placed on Member States’ health systems by
longer life expectancy, rapid innovations in medical science
and technology, increased migration and the emergence of
new (or the resurgence of old) infectious diseases.

3.3.
The Economic and Social Committee endorses the
outcome of the debate at the European Conference on health
determinants in the European Union held in Evora on 15 and
16 March 2000. The EU Council’s view in this regard is,
among other things, that ‘the increasing differences in health
status and health outcomes between and within Member States
call
the national
and Community level.’ The conclusions of the European
Conference on medicinal products and public health held in
Lisbon on 11 and 12 April 2000 also refer to the new public
health strategy. The Council particularly urges the Commission
‘to promote cooperation and exchange of experience between
Member States, using the full range of possibilities for action’.

for renewed and coordinated efforts at

3.5.
Public expectations of high-quality, universally access-
ible health care have also increased, placing further strain on
Member States. The Commission argues that Community or
cross-border problems are best resolved at Community level,
and, while respecting the responsibilities of Member States,
sees itself playing a coordinating and/or support role. The
strategic new departure in EU public health policy goes beyond
the predominantly single-issue approach of earlier Community
schemes and sets out an integrated approach to European
public health.

The Lisbon conference was convened specifically to
3.3.1.
analyse the new context
for health policy arising from
Article 152 of the Amsterdam Treaty. The ESC therefore
welcomes the indication given in point 4 of the Commission
document — ‘achieving an integrated health strategy’ — that
the programme will support all areas of pharmaceutical policy.
It believes that this support is necessary in order to make up
lost ground on aligning the various regulatory systems in force
in the individual Member States, so as to counter the negative
impact on the free movement of medicines in the EU.

3.6.
The EU’s new health strategy thus represents a radical
move away from an issue- and programme-driven public
health policy towards a system-based approach. The downside,
however, is also a loss of focus on ongoing problems. At
least
issues (such as
cardiovascular diseases, cancer, dementia, drug addiction or
communicable diseases) are to be switched from operationally
oriented schemes to a comparative system-based approach.

the priorities in tackling individual

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3.7.
On the one hand, this switch in the pattern of public
health policy is logical and reflects the desire for coherence
and efficiency. On the other, it involves considerable impon-
derables, since, particularly in terms of health information
systems and addressing health determinants, the new methods
to be introduced are still to some extent at the experimental
stage (health technology assessments, schemes for measuring
cost effectiveness and cost efficiency, medical guidelines and
management, benchmarking), with no experience to draw on
for their use on a broad scale.

3.8.
The various types of traditional health monitoring
practised in the Member States are once again the focus of
attention as the result of an Icelandic scheme for both the
establishment and commercial utilisation of a new electronic
database containing individual health data and genetic infor-
mation. On this front, therefore, it would make sense to work
out guidelines for the ethically and scientifically justified use
of individual health data in order to provide effective protection
for citizens of the Member States.

tion, organs and substances of human origin and blood and
blood derivatives are to be linked and tailored towards the
common achievement of public health objectives.

3.12.
The new tasks in the veterinary and phytosanitary
fields are fully consistent with this approach. The Committee
also welcomes the proposal already on the table for the
establishment of a food safety authority with a remit covering,
among other things, the preparation of scientific opinions,
the operation of rapid alert systems, communication with
consumers and networking with national agencies and scien-
tific bodies. Plant protection in particular should not only be
considered in terms of safe food production, but should also
be seen — and put into practice — as part of a health-related
environment strategy. Linking the health strategy to other
fields of Community action, e.g. telecommunications and IT
programmes and statistics, will be useful in helping improve
public health protection and in furthering the coordination of
social protection systems.

3.9.
Although the rationale behind these methods — which
are all designed to give a more economic slant to medical
practice — is understandable, past experience has also shown
that approaches of this kind have not necessarily fostered
developments in medicine, particularly medical equipment.
The broad, uncritical adoption of such approaches may
hamper the development of potential new treatments and
impact badly on the medical equipment and pharmaceuticals
industry.

3.13.
In contrast to those sections of the action programme
which have already been the subject of broad discussion and
the coherent thrust of the other health-related policies which
are to come under this framework for action, little is being done
about monitoring or evaluating other Community policies or
assessing their impact on human health. The Commission
communication states that, from 2001, legislative proposals
are to include an explanation of how health requirements have
been addressed. The proposed decision, however, provides for
no formal action to that effect.

3.10.
To make the action programme more acceptable,
the Economic and Social Committee recommends action to
encourage the appropriate official bodies in the Member States,
and the regional/local authorities, to engage in international
cooperation and benchmarking on a voluntary basis. Merely
juxtaposing figures in the form of mandatory performance
comparisons or even ranking systems would simply demotiv-
ate participants. The Commission could clearly state that
taking part
in
giving the various heath care sectors access to evidence-based
knowledge and examples of best practice, and thus in making
better use of ever-expanding medical knowledge.

in the action programme can be helpful

3.11.
The measures set out in the framework for action for
bringing together various facets of public health policy are
vital. The various networks, rules and bodies dealing with
issues such as communicable diseases, prevention of drug
dependency, smoking and the fight against tobacco consump-

The Committee also notes that

3.14.
the Commission
evidently feels able to tackle the issue of addressing health
requirements in all EU policies both without external evalu-
ation and consultation, and without specifically designated
staff. The Committee feels that this is somewhat unrealistic
given the scale of the task, which touches on all Community
policies.

3.15.
The Economic and Social Committee welcomes the
extension of the schemes both to the applicant states and also
to associated and other countries. However, the practical
methods for tackling the three priorities identified in the
strands of action (particularly the benchmarking exercise) may
generate a feeling among individual Member States, applicant
states or associated countries that they are being pilloried
rather than given support.
the
schemes focus rigorously on achieving health objectives. Any
processing of material must also have a strictly practical,
scientific purpose.

It is thus important that

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3.16.
It is unclear whether the priority is to protect health
or to push through market principles. This issue in particular
will be of relevance in the ongoing development of national
social and health system policies and should be discussed
openly by the Commission. The fear is that both social
protection and the ‘humanitarian’ face of health care and social
systems will quickly fall by the wayside if health issues are
judged strictly in terms of their economic viability and social
protection measures are assessed for their consistency with
market rules. A more discriminating assessment of the interac-
tion between the market and social systems in the European
Community and a clear statement from the Commission on
the need to protect health and social systems — from, inter
alia, the market forces — would help boost public confidence.
These difficulties are particularly in evidence in the pharmaceu-
ticals sector. Mutual health insurance schemes, which operate
according to the solidarity principle, are particularly concerned
with and play an active role in these developments. The ESC
backs solutions geared strictly to achieving a high level of
health protection.

4.

Specific comments

4.1. Overall aim and general objectives (Article 2)

The new strategy set out in the European Parliament decision
is designed: (a) to improve health-related information and
knowledge; (b) to facilitate a rapid and coordinated response
to threats to health and (c) to take preventive action to
minimise or eliminate health threats. The Economic and Social
Committee regrets the failure to take up its suggestion that
there be a fourth objective, namely the integration of health
protection requirements into other Community policies and
actions.

4.2. Community actions (Article 3 and the annex: Specific objec-

tives and actions)

4.2.1. I m p r o v i n g
k n o w l e d g e

h e a l t h

i n f o r m a t i o n

a n d

4.2.1.1. Developing and operating a health monitoring

system

The provision of

information on the health
4.2.1.1.1.
situation in the Member States and — thus the Community in
general — hinges on the availability of comparable data. In
fact, such data hardly exist. Some organisations such as the
OECD or the WHO do draw up comparative studies, but they
usually do not use the same methods for collecting and
interpreting data.

4.2.1.1.2. Moreover, the data used to analyse health services
are invariably estimates; there is thus a margin of error which
as a rule makes correlation difficult or completely impossible.

This difficulty is exacerbated by the fact that the procedures
for drawing up the assorted estimates vary, and also the study
parameters in the different countries rarely match. It thus
makes sense to adopt a common European approach, which
can do much to improve data availability and — in particular
— data comparability. For the success of this venture, it will
be important always to make clear what the health monitoring
objective is, in order to ensure collection of the data required
to develop health protection. Any expansion of health moni-
toring should incorporate existing classifications and statistics.

4.2.1.1.3.
To prevent a loss of public confidence in the
Community as a result of the collection of health data, the
Commission should strive to ensure that, under these schemes,
no identifiable personal data are stored with government
authorities or with bodies to which such authorities have
access. Otherwise, there would be a danger of political misuse
or direct intervention management and the involvement of
health professionals would also be called into question.
However, this is not an argument against the systematic
approach proposed here, which can be fully implemented
without individual data, using only aggregated anonymous
information.

4.2.1.1.4.
It is in itself a major challenge to reach agreement
on a common set of indicators and then to undertake a
comparison of health monitoring data relating to health
traits. The data
systems which very much bear national
collected in this way are to be made available to the general
public, health professionals and other stakeholders (via inven-
tories and directories) and also to national, regional and
local health authorities. Although this is a very ambitious
programme, unique in the world, the question of its actual
benefits remains, for the moment, theoretical.

4.2.1.1.5.
Although the programme does make arrange-
ments for monitoring how studies are carried out and for
effective programme implementation, the question of actual
impact on health care can only be answered on the basis of
the indicators laid down in the particular study itself.

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4.2.1.1.6.
There is the risk that such indicator-based com-
parative schemes will result in Member States focusing public
health activities on areas evaluated with the help of indicators,
while neglecting other, unassessed fields (‘window dressing’).
Collateral effects such as a deterioration of care in other areas
(not covered by indicators) or a slow-down — damaging in
the long term — in the development of medical equipment
cannot be measured using the approach set out above. New
demands are thus placed on a broad-based quality assurance.

and its opinion of 13 April 2000 on the role of the local and
regional authorities in the reform of European public health
systems (2).

4.2.2. R e s p o n d i n g r a p i d l y t o h e a l t h t h r e a t s

4.2.1.2. Developing and using mechanisms for analysis,

advice, reporting, information and consultation

4.2.2.1. Enhancing the capacity to tackle communicable
diseases Strengthening the capacity to tackle other
health threats

4.2.1.2.1.
One of the ESC’s earlier recommendations was
for the establishment of an independent Commission advisory
committee. The Commission’s plan on that score is, among
to set up a European Health Forum as a
other things,
consultative mechanism. The purpose of the forum is to give
organisations representing patients, health professionals and
other stakeholders the chance to make inputs into health
policy and priority setting. It will provide a platform for
consultations and discussions on a wide range of topics.

The Commission intends to launch a consul-
4.2.1.2.2.
tation later this year on the detailed functioning, organisation
and composition of the forum.

4.2.1.2.3.
The Commission will have to ask itself how it
intends to establish such a forum as a real policy-building
mechanism which does not contravene democratic principles
or give rise to the suspicion that it is an inexpensive tool of
‘policy entrepreneurship’. The Economic and Social Committee
regrets the Commission’s lack of precision on this issue.

4.2.1.2.4.
Against the backdrop of the work programme
launched by the Commission with a view to a white paper on
European governance, the Economic and Social Committee
endorses the view expressed by the Commission in the
discussion of the opinion that the forum is to be given no
formal status. It is not a matter of calling the authority,
representativity and legitimacy of the Economic and Social
Committee and the Committee of the Regions into question.
The ESC is prepared to advise the Commission on the
composition and structure of the forum as part of a formal
consultation process. In this context, the ESC would also refer
to the Committee of the Regions’ opinion on the same issue (1)

4.2.2.1.1.
So far, there has been insufficient coordination
of national alert systems at Community level, as the events
surrounding the food poisoning and food contamination cases
of recent years have shown in particular. It is thus vital to set
in place rapid response mechanisms for major health threats
and to establish a rapid alert system.

It makes sense to link these and other specific
4.2.2.1.2.
policy areas such as ensuring the safety and quality of blood,
organs and substances of human origin and strengthening the
surveillance and control of communicable diseases; as the
Commission proposes in the communication, such linkage
should be extended to include health threats such as drug
abuse, physical
impacts on health and the prevention of
accidents and injuries. Health professionals have a particular
role to play here. They must be better able to tackle health
requirements and health threats resulting from mobility, and
in particular the cross-border movement of goods. The
appropriate national bodies should take account of this aspect
in the requirements for health professionals’ initial, further and
ongoing training.

However,

the Committee has serious doubts
4.2.2.1.3.
about the need to establish a ‘Community incident investi-
gation team’. Such a team could not have the expertise to
cover all possible outbreaks of disease; it would not have the
right to take drastic action and would be impossible to keep
usefully occupied. A more sensible option would be to set in
place rapid advisory and support mechanisms in the form of
‘networks of expertise’. Moreover, the cooperation generated
by such an approach would also benefit ‘normal’ care.

(1) Cf. Opinion of the Committee of the Regions on the Communi-
cation on the health strategy of the European Community —
Proposal for a programme of Community action in the field of
public health (2001-2006) (COM(2000) 285 final).

(2) Cf. Opinion of the Committee of the Regions of 13 April 2000
on the role of the local and regional authorities in the reform of
European public health systems — CdR 416/99 fin.

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4.2.2.1.4.
The Committee confirms the need to link the
public health strategy with other existing actions and fields
(network for the surveillance and control of communicable
diseases, European Monitoring Centre for Drugs and Drug
Addiction, smoking and tobacco control, organs and sub-
stances of human origin, blood and blood derivatives and
veterinary and phytosanitary measures).

4.2.3.2.2.
The same is true of the link-up (called for by the
Committee in the same opinion) between health policy and
the socio-economic dimension (e.g. employment). Here too,
the proposed programme may fall short of what is required,
since, although it identifies and documents health problems
and their link to socio-economic factors, the programme will
probably not intervene by regulating how both these aspects
interact.

4.2.3. A d d r e s s i n g h e a l t h d e t e r m i n a n t s

4.2.3.1. Developing strategies and measures on lifestyle-

related health determinants

The third strand of action addresses underlying
4.2.3.1.1.
health factors. These include in particular both positive and
negative lifestyle factors, such as physical activity, a proper
diet, stress, smoking, excessive alcohol consumption and drug
abuse (including doping in sport), as well as major socio-
economic factors.

4.2.3.1.2.
The fact that the Commission communication
targets action on young people is based on the belief that health
behaviour is learnt primarily in childhood and adolescence.
it should not be forgotten that adults can also
However,
change their behaviour and lifestyle. Health promotion is
directed at everyone. The media and health professionals have
a particular role to play. They must be continuously prepared
for their tasks in health promotion and disease prevention.

4.2.3.2. Developing strategies and measures on socio-econ-

omic health determinants

4.2.3.2.1.
In an earlier opinion, the Economic and Social
Committee called for consideration to be given to specific,
age-related issues (e.g. young and old groups) and particularly
vulnerable categories (e.g. immigrant and other under-privi-
leged sectors of the population). These factors may be classed
as ‘socio-economic determinants’. However, the strategy set
out here deals more with systematic observation and data
collection than the development of dedicated health advance-
ment and promotion schemes in these areas.

Demands for health system convergence have
4.2.3.2.3.
grown markedly as a result of the increased migration of EU
citizens as workers or tourists and fully open borders for the
free movement of goods, services and capital. The ESC made
known its views on this issue in its opinion of 27 January
2000 on the Proposal for a Council Regulation (EC) on
coordination of social security systems(1).

4.2.3.2.4. With regard to cross-border health care delivery
(cf. also ECJ judgements in the Kohll and Decker cases)(2), the
Community should make arrangements which clearly reinforce
people’s rights, particularly vis-à-vis health insurers or other
financing agencies such as (state) health administrations.
Action is of course also needed in the fields of cross-border
quality assurance (including quality of access) and cross-border
service delivery and payment.

4.2.3.2.5.
The Community could do much to gain public
confidence here by demonstrating that citizens have a right to
treatment abroad (and also to have it paid for by their home-
country insurer), but also by ensuring that no-one is forced for
economic reasons to travel to another country for treatment.
Given this changed environment, health system convergence,
but not harmonisation, must be stepped up considerably. The
Economic and Social Committee would like to see the
Commission give greater consideration to this ongoing devel-
opment.

(1) Cf. Opinion of the Economic and Social Committee on the
Proposal for a Council Regulation (EC) on coordination of social
security systems — OJ C 75, 15.3.2000.

(2) 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 refuses 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’). Cf. 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’).

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4.2.3.3. Developing strategies and measures on health deter-

minants related to the environment

4.5. Funding (Article 7)

The inclusion of horizontal aspects of public health is in line
with ESC recommendations (1). The proposal, however, gives
no indication of what specific changes are to be made to
cooperation by the Member States and the work of the
Commission.

4.2.4. C a r r y i n g o u t t h e a c t i o n s

The Commission recommends that provision be made both
for the issuing of contracts (full financing) and the granting of
subsidies.

The Economic and Social Committee is pleased that the
the public health
Commission will strive to ensure that
programme is efficiently and effectively implemented and that,
to this end,
independent, external mid-term and ex post
evaluations of the programme are submitted on the basis of
indicators and work programmes. In this way, the Commission
intends to assess the impact and efficiency of the resources
used and to fine-tune the management of the programme. The
issue of indicator-based assessment was addressed critically
above.

4.3.

Joint actions (Article 4)

the measures of

The Economic and Social Committee is pleased to note that ‘as
part of the effort to ensure a high level of health protection in
the definition and implementation of all Community policies
the programme may be
and activities,
implemented as joint actions with related Community pro-
grammes and actions’. The Committee would point out,
however, that this does not replace the requirement under
Article 152 of the EC Treaty which states that ‘a high level of
human health protection shall be ensured in the definition and
implementation of all Community policies and activities’.

4.4. Consistency and complementarity (Article 6)

The Committee assumes that the committee referred to in
Article 8(1) will also discuss proposals which do not stem
directly from the public health sphere but which are of
relevance to the objectives and actions of the programme.

(1) Cf. Opinion of the Economic and Social Committee on the
Communication from the Commission to the Council, the Euro-
pean Parliament, the Economic and Social Committee and the
Committee of the Regions on the development of public health
policy in the European Community, OJ C 407, 28.12.1998.

The financial framework for the six years the programme is to
run is set at EUR 300 million. This averages EUR 50 million a
year. The Economic and Social Committee welcomes the
funding rise. In contrast to earlier programmes, whose budgets
were inflexible, the framework for action provides for the
ongoing re-deployment of resources between the various
strands. The Committee feels that dedicated funding is needed
to ensure that all Community policies are geared to a high
level of health protection. The Commission evidently also
believes that it can tackle the work involved without specifically
designated staff; the fear here is that, given their complexity,
the tasks at hand will remain undone.

4.6. Participation of

the associated
the EFTA/EEA countries,
central and eastern European countries, Cyprus, Malta and
Turkey (Article 9)

the inclusion of non-EU countries,
The provisions about
especially the applicant states,
remain vague, and these
countries are not mentioned specifically in the financial
statement.

4.7.

International cooperation (Article 10)

This point addresses the issue of cooperation with international
organisations (such as the OECD and the WHO). Such
cooperation is to be stepped up — a welcome move to avoid
duplication of work and the resultant waste of resources.

5.

Summary

5.1.
To sum up, while the Economic and Social Committee
broadly welcomes the proposal, it would make the following
points:

5.2.
For the Commission, the communication on the health
strategy of the European Community represents a change in
policy direction, with a move away from priority-led, single-
issue approaches towards a comprehensive, coherent strategy
with two main strands: (i) to support national efforts on the
health front; (ii) to coordinate other individual Union measures
more closely and to assess other policies for their relevance to
health.

The European Community’s new health strategy is
5.3.
largely based on comparing health data. The Committee would
propose that the appropriate bodies in the Member States and
the regions cooperate on a voluntary basis in order to further
such comparisons and promote health system development. It
would be unfortunate if a ranking system were to have a
demotivating effect.

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C 116/83

5.4.
The Economic and Social Committee therefore wel-
comes the Commission’s efforts to provide comparable health
data. This is a valuable contribution towards greater equality
in health — and medical care.

The Committee hopes that Member States’ health planning
will be greatly assisted by taking account of care requirements.

5.5.
The Economic and Social Committee regrets that there
is no fourth strand in the action programme — and no formal
proposals and resources — dealing with the Community
analysis of health issues and their relevance for other policy
areas.

5.6.
The Commission is seeking to establish a European
Health Forum as a consultative mechanism. It does not specify
the profile such a body is to have and leaves open the issue of its
composition. In its place, the Economic and Social Committee
recommends that the official bodies responsible for health
services, regional/local government and social stakeholders
should be given adequate say and the chance to help frame the
relevant schemes.

5.7.
If all policy areas are in future to be assessed for their
relevance to health, the Commission should make this a
priority recommendation in the Proposal for a Decision of the
European Parliament and of the Council adopting a pro-
gramme of Community action in the field of public health
(2001-2006).

Brussels, 29 November 2000.

The President

of the Economic and Social Committee

Göke FRERICHS