Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions - Modernising social protection for the development of high-quality, accessible and sustainable health care and long-term care: support for the national strategies using the "open method of coordination"
Date: 2004-04-20
Institutions: European Commission
Subjects: European social policy, health care, health care system, health policy, social security

COMMISSION OF THE EUROPEAN COMMUNITIES 

Brussels, 20.4.2004 
COM(2004) 304 final 

COMMUNICATION FROM THE COMMISSION TO THE COUNCIL, THE 
EUROPEAN PARLIAMENT, THE EUROPEAN ECONOMIC AND SOCIAL 
COMMITTEE AND THE COMMITTEE OF THE REGIONS 

Modernising social protection for the development of high-quality, accessible and 
sustainable health care and long-term care: support for the national strategies using the 
“open method of coordination” 

EN 

   EN 

 
 
 
  
1. 

INTRODUCTION 

The social protection systems created in the Member States aim to ensure access for 
all to quality care. Their development has considerably reduced the risk of poverty, 
which, in the past, was often linked to ill health, old age or accident, and has made a 
significant contribution to improving the state of health of the people of Europe over 
recent decades1. They are therefore an important part of the European social model, 
and the quality of care provided in Europe is almost unrivalled in the world.  

The aim of this Communication, announced in the Spring Report 20042, is to define a 
common  framework  to  support  Member  States  in  the  reform  and  development  of 
health  care  and  long-term  care,  borne  by  the  social  protection  system,  using  the 
“open method of coordination”. The Resolution adopted by the European Parliament 
on 11 March calls for greater cooperation on health and long-term care and calls on 
the  Commission  to  present  relevant  proposals  in  the  spring  of  2004,  allowing  the 
Council  to  apply  the  “open  method  of  coordination”  in  this  field  and  to  adopt 
common objectives.  

This Communication is thus a complement to the one concerning the proposals of the 
“High-level process of reflection on patient mobility and healthcare developments in 
the  European  Union”  (hereinafter  known  as  the  "Communication  on  patient 
mobility"),  launched  at  the  initiative  of  Commissioners  David  Byrne  and  Anna 
Diamantopoulou  and  involving  representatives  of  the  health  ministries  and  the 
Commission3.  These  two  Communications,  adopted  together  by  the  Commission, 
thus  present  an  overall  strategy  for  developing  a  shared  vision  for  the  European 
health care and social protection systems.  

Social protection is a way of distributing, at the level of an entire society, costs which 
often  exceed  the  means  of  an  individual  or his/her family, ensuring  that paying  for 
healthcare  does  not  lead  to  impoverishment  and  that  even  those  on  a  low  income 
have reasonable access to care. These results have been achieved using a wide range 
of  systems  –  based  on  insurance  or  the  direct  provision  of  services  –  the  prime 
responsibility  for  which,  under  the  Treaty,  falls  to  the  Member  States.  The 
importance  of  this  responsibility  and  the  need  for  better  cooperation  at  European 
level were emphasised in the conclusions of the “High-level process of reflection”. 

to  social  cohesion  and  employment  and 

The  role  of  health  systems  in  combating  the  risk  of  poverty  and  disease,  their 
contribution 
the  consequences  of 
demographic  ageing  have  been  acknowledged  for  some  considerable  time  by  the 
Union. As early as 1992, a Council Recommendation4 called on the Member States 
to  “to  maintain  and,  where  necessary,  develop  a  high-quality  health-care  system 
geared  to  the  evolving  needs  of  the  population,  and  especially  those  arising  from 
dependence of the elderly, to the development of pathologies and therapies and the 

1 

2 
3 

4 

For example, between 1960 and 2001, life expectancy for men rose by 8.1 years and for women by 8.7 
years. 
COM (2004) 29 final – “Delivering Lisbon:Reforms for the enlarged Union” 
The conclusions of the HLPR are available at: 
http://europa.eu.int/comm/health/ph_overview/Documents/key01_mobility_en.pdf 
Council  Recommendation  of  27  July  1992  on  the  convergence  of  social  protection  objectives  and 
policies (92/442/EEC), Official Journal L 245 , 26/08/1992, p. 0049 - 0052. 

2 

 
 
  
 
                                                 
need to step up prevention”. In 1999, health care was identified by the Council as one 
of the four fields of social protection5 where closer cooperation between the Member 
States was needed. 

Following  the  Lisbon  and  Gothenburg  European  Councils,  which  highlighted  the 
need to reform and adapt social protection systems, including health care, in order to 
meet  the  challenge  of  demographic  ageing  and  ensure  social  cohesion,  the 
Commission  identified  three  principles6  that  could  serve  as  a  basis  for  this  reform. 
These principles were approved by the Barcelona European Council in March 20027:  

–  Accessibility of care for all, based on fairness and solidarity, taking into account 
the  needs  and  difficulties  of  the  most  disadvantaged  groups  and  individuals,  as 
well as those requiring costly, long-term care;  

–  High-quality care for the population, which keeps up with medical advances and 
the emerging needs associated with ageing and is based on an assessment of their 
health benefits;  

–  Measures to ensure the long-term financial sustainability of this care and aiming 

to make the system as efficient as possible. 

2. 

ACCESSIBILITY, QUALITY, FINANCIAL SUSTAINABILITY: A CHALLENGE FOR HEALTH 
CARE SYSTEMS, A KEY TO THE SUCCESS OF THE LISBON STRATEGY  

The  joint  report  of  the  Commission  and  of  the  Council  "Supporting  national 
strategies for the future of health care and care for the elderly" of 10 March 2003 
emphasised  that  technological  and  treatment  innovations,  improved  wellbeing  and 
patient  information,  and  demographic  ageing  are  raising  new  problems  in  terms  of 
the  capacity  of  the  national  systems  to  ensure  accessibility  and  high  quality  and  to 
guarantee  their  financial  sustainability  over  the  long  term.  Certain  problems  are 
common to all the systems: inequalities and ongoing access difficulties, despite the 
universal  access  guaranteed  in  principle;  insufficient  provision  of  quality  services 
compared to the needs of the population in some cases, with excessive waiting times; 
and widening financial imbalances in certain systems.  

The new Member States are set to add to this diversity and accentuate current trends 
in EU-15. Their main health indicators tend to be worse than in EU-15, particularly 
for  men,  and  they  spend  significantly  less  on  their  health  care  systems,  despite 
constant  growth  since  the  early  1990s.  Moreover,  the  ageing  of  the  health  care 
professions is more marked there than in EU-15. The Lisbon Strategy is therefore a 
coherent framework for catching up in terms of the level and quality of care, and is 
supported by a range of instruments, including the “open method of coordination”. 

5 

6 
7 

In 2000, health accounted for 27.3% of all social protection expenditure in EU-15, the second largest 
item  after  retirement  and  survivors’  pensions  (Source:  statistical  annex  to  the  draft  Joint  report  on 
social inclusion 2003, SEC (2003) 1425). 
COM (2001) 723 final 
§25:  “The  European  Council  takes  note  of  the  initial  Council  report  on  health  care  and  care  for  the 
elderly,  and  invites  the  Commission  and  the  Council  to  examine  more  thoroughly  the  questions  of 
accessibility, quality and financial sustainability in time for the spring 2003 European Council.” 

3 

 
 
  
 
                                                 
At  the  same  time,  European  integration  entails  growing  interaction  between  care 
systems:  

–  Health  care  services  have  been  recognised  by  the  Court  of  Justice  as  services 
within the meaning of the Treaty, and patients, as the recipients of these services, 
must  be  able  to  benefit  from  the  free  provision  of  services  that  the  Treaty 
guarantees8. The updated version of Regulation 1408/719 includes this dimension, 
and  its  application  is  specified  in  a  proposal  for  a  directive  presented  on  13 
January  2004  on  services  in  the  internal  market,  which  includes  a  definition  of 
hospital services10;  

–  The  citizens  of  the  Union  are  making  increasing  use  of  their  right  of  free 
movement11 to go and live in another Member State, to move there temporarily or 
to seek health care there.  

This  interaction  has  been  accompanied  by  the  development  of  policies  at  EU  level 
with  an  impact  on  health  care  systems  and,  more  generally,  on  the  health  of 
Europeans.  However,  these  trends  have  never  been  the  subject  of  a  global  strategy 
tackling  the  development  and  modernisation  of  the  supply  and  funding  of  care, 
patient and health worker mobility in an enlarged Union, cooperation between health 
care  regions  and  systems,  as  well  as  the  mainstreaming  of  the  main  objective  — 
providing a high level of human health protection — in all Community policies. The 
“Spring Report 2004” therefore calls for the coordination of national policies to be 
stepped  up  in  order  to  support  the  modernisation  and  development  efforts  in  the 
sector  undertaken  by  all  the  Member  States,  both  the  current  and  the  new  ones.  A 
global  strategy  for  health  care  systems  is  therefore  being  proposed  now  in  two 
Commission communications: 

–  This  Communication  proposes  common  objectives  for  the  development  and 
modernisation of health care provision and funding, which would allow Member 
States to define their own national strategy and benefit from the experiences and 
good practices of the other Member States. This coordination of national policies 
would  complement  the  other  three  main  areas  of  social  protection  –  pensions, 
inclusion and “Making work pay” — which have been coordinated more closely 
since 2000. 

–  A second Communication follows up the recommendations adopted by the “High-
level process of reflection”. It presents a set of concrete proposals covering many 
different areas and providing for the mainstreaming of the objective of providing a 
high  level  of  human  health  protection,  as  stated  in  the  Treaty,  in  Community 
policies. 

8 

9 

10 
11 

(EC)  on  coordination  of 

for  a  Council  Regulation 

See  Report  on  the  application  of  internal  market  rules  in  the  field  of  health  care  services  and 
implementation by the Member States of the Court’s jurisprudence (SEC (2003) 900). 
systems  
Proposal 
(COM  (1998)  779  final);  Amended  proposal  for  a  Regulation  of  the  European  Parliament  and  of  the 
Council on coordination of social security systems (COM (2003) 596 final); Communication from the 
Commission to the European Parliament pursuant to the second subparagraph of Article 251(2) of the 
EC  Treaty  concerning  the  common  position  of  the  Council  on  the  adoption  of  a  Regulation  of  the 
the  coordination  of  social  security  systems 
European  Parliament  and  of 
(COM (2004) 44 final) 
COM (2004) 2 final 
Commission's Action Plan for skills and mobility, COM (2002) 72 final. 

the  Council  on 

security 

social 

4 

 
 
  
 
                                                 
The  provision  and  funding  of  health  and  long-term  care  are  key  elements  of  the 
economic  and  social  modernisation  strategy  launched  in  Lisbon in  March  2000  for 
three complementary reasons. 

Social  cohesion  is  reinforced  by  access  to  quality  care  based  on  the  principles  of 
universal access, fairness and solidarity. Improving access to care is acknowledged to 
be  a  way  of  mobilising  the  potential  of  the  EU’s  workforce  in  the  context  of  a 
shrinking active population. Recent studies12 show that care policy should be seen as 
an  active  employment  policy  tool,  as  it  increases  the  social  and  occupational 
integration  prospects  of  jobseekers.  However,  the  draft  Joint  report  on  social 
inclusion13 shows that the most disadvantaged groups have more, and more serious, 
health  problems:  for  example,  16%  of  those  in  the  bottom  income  quintile  say  that 
they are in poor health, compared to 7% in the top quintile14. These people often find 
it more difficult to have access to care, because of long waiting times, high treatment 
costs  in  relation  to  their  income,  complex  administrative  procedures  and,  more 
generally, insufficient prevention (screening, vaccination).  

Secondly,  in  2002,  health  and  long-term  care15  represented  around  10%  of  total 
employment  in  the  Union  of  15,  and  between  4.1  and  7.1%  in  the  new  Member 
States. With 1.7 million new jobs created between 1997 and 2002 in EU-15, it is the 
second largest creator of jobs. To meet the challenges posed by demographic trends 
and  technological  progress,  it  is  vital  to  have  a  sufficient  number  of  trained 
professionals and to give them quality jobs. The ageing of the workforce will make 
itself felt here in particular. In 2002, in EU-15 and EU-25, 11% of the workforce in 
this  sector  was  aged  between  55  and  64,  and  the  proportion  was  even  higher  for 
doctors16. Above all, a large proportion of workers in this sector (27%, in both EU-15 
and EU-25) are in the age range 45 to 54, which could lead to a demographic time 
bomb in the years to come. These people will retire at a time of general ageing of the 
population,  which  means  that  the  health  and  social  services  sectors  will  have  to 
compete with other sectors to recruit new staff.  

Improving the quality of jobs will thus be essential to ward off early retirement, in 
particular  of  those  people  with  the  hardest  and  most  stressful  jobs  and  those  aged 
older  than  55,  as  well  as  to  promote  recruitment.  Improving  the  productivity  and 
effectiveness  of  care  providers  will  also  be  a  key  element  in  the  sustainable 
development of this sector. “E-health”, the development of which is promoted by the 
Plan  of  action  eEurope  200517,  has  an  essential  role  to  play  here,  in  informing, 
preventing  and  improving  care  provision  and  in  the  lifelong  training  of  health  care 
professionals18. 

12 

13 
14 

15 

16 

17 
18 

Brenner, H., "Unemployment and public health" – Final report ordered by the European Commission, 
May 2002 
COM (2003) 773 final 
In  2000.  Source:  Joint  indicators  of  poverty  and  social  exclusion,  Eurostat,  ECHP  UDB,  December 
2002 version. 
See Emploi en Europe 2003, page 37. The labour force survey includes health care, all ‘social’ services, 
including child care, and veterinary services. 
In 2001, it ranged from 11.7 % in the UK to 21.7 % in the Czech Republic and 33.2% in Denmark, for 
example. See also the Commission report on the social situation in 2003. 
Commission Communication “eEurope 2005: an information society for all”, COM (2002) 263 final. 
See  the  Commission  Communication  “e-health –  improving  the  health  care  provided  to  European 
citizens: a plan of action for a European e-health area”, COM (2004) XXX 

5 

 
 
  
 
                                                 
Demographic ageing will have two other effects on the health care and elderly care 
sector:  the  increase  in  the  number  of  people  older  than  65  years  (+  64%  between 
2002 and 2050, according to the Eurostat base scenario) and in the number of those 
aged older than 80 (from 14.8 million to 37.9 million between the same dates). These 
trends, which testify to improvements in Europeans’ state of health, will also mean 
more  age-related  illnesses  and  more  people  in  long-term  care.  The  ageing  of  the 
population is accompanied by a growing number of old people living alone, because 
of greater family mobility, and a higher female employment participation rate, even 
though women perform the lion’s share of informal care work. The response to the 
needs  of  this  population  group  will  include  developing  a  wide  range  of  services, 
including care at home, which will be chosen by ever more people, and specialised 
institutions, as well as closer coordination between care providers often working in 
isolation (intensive care, primary care and social services). 

The social protection systems need to be reformed in an integrated and coordinated 
way  to  meet  these  challenges.  The  Commission  Communication  Strengthening  the 
social dimension of the Lisbon strategy: Streamlining open coordination in the field 
of social protection19 showed that health and elderly care is one of the areas where 
coordination in the field of social protection should be streamlined. This streamlining 
will contribute to strengthening the political messages in favour of the modernisation 
of  these  systems  and  to  ensuring  that  they  are  in  line  with  the  other  coordination 
processes under the “Lisbon Strategy”. 

The results will be: 

•  Greater  consistency  with  existing  social  protection  processes  (pension  reform, 
social  inclusion),  with  which  many  areas  of  common  interest  exist20.  As  part  of 
the streamlining  of these  processes, one important task will be to identify issues 
which could constitute general objectives for all the branches of social protection, 
such as issues relating to gender, the role of health care in active ageing or the role 
of social protection systems in employment promotion measures. 

•  Closer  coordination  with  other  political  processes,  including  the  European 
Employment  Strategy,  in  particular  with  regard  to  the  challenges  of  the  ageing 
workforce in these sectors, and the broad economic policy guidelines. As a result 
of the streamlining, issues of health and long-term care should be better reflected 
in the Lisbon Strategy, in line with their importance to citizens. As provided for in 
the  Spring  Report  2004,  the  Commission  will  be  examining,  by  2005,  the 
arrangements  for  incorporating  public  health  in  the  Lisbon  Strategy,  and  its 
contribution to growth and sustainable development.  

•  In  this  context,  the  “open  method  of  coordination”  will  be  a  flexible  tool, 
respecting the diversity of  the national situations and competences and therefore 
particularly well adapted to the specific features of health care systems in all the 
branches of social protection. 

19 
20 

COM (2003) 261 final 
For example, accessibility of care is an important theme of social inclusion policy (see the draft joint 
report  2003,  op.  cit.);  ageing  has  an  impact  on  the  social  and  financial  sustainability  of  pension 
schemes. 

6 

 
 
  
 
                                                 
•  The joint objectives, one pillar of which relates to health care, will offer an overall 
policy framework for the reforms, making them more transparent and highlighting 
the issues common to care systems. 

•  The open method of coordination will contribute to involving the many actors in 
this sector, particularly the social partners, the health care professions and patient 
representatives, whose role is becoming ever more important. 

•  Exchanges  of  experience  will  improve  the  various  actors’  knowledge  of  the 

possible reforms. Joint indicators will support these exchanges. 

•  Finally,  the  “open  method  of  coordination”  will  favour  a  comprehensive, 
integrated  approach  to  the  problems  found  today  in  the  different  systems,  by 
establishing a close link with the various instruments and policies associated with 
the field. 

3. 

JOINT OBJECTIVES FOR DEVELOPING CARE SYSTEMS 

The lower risk of ill health-, accident- or old age-related poverty and the significant 
improvement  in  Europeans’  state  of  health  are  valuable  achievements  of  Europe’s 
social protection systems. They must continue to provide high-quality care based on 
the principles of universal access – i.e. covering all the population – and solidarity – 
i.e.  based  on  collective  contributions,  not  on  individual  wealth  –  and  which  is 
financially  sustainable.  Accessibility,  quality  and  financial  sustainability  are 
therefore  all  important  and  mutually  dependent.  Moreover,  a  key  to  the 
development  and  reform  of  the  systems  is  their  ability  to  implement  effective 
governance  based  on  involving  and  giving  responsibility  to  the  players 
concerned  –  including  the  social  partners,  regional  and  local  authorities, 
patients  and  civil  society  –  and  coordinating  care  providers,  financial 
organisations,  NGOs  and  the  public  authorities.  At  European  level,  it  would  be 
desirable for the sectoral social partners to make a tangible contribution to the reform 
efforts. 

On the basis of the guidelines approved in March 2002 by the Barcelona European 
Council and the Joint Report adopted by the Commission and the Council in March 
2003,  the  Commission  is  therefore  proposing  the  following  joint  objectives  to 
support the development of these systems in the enlarged Union. 

3.1. 

Ensuring access to care: universal access, fairness, solidarity 

One  real  success  of  European  care  systems  has  been  to  make  high-quality  care 
accessible  to  all.  They  must  continue  to  provide  a  safety  net  against  ill  health-, 
accident-  or  old  age-related  poverty,  for  both  the  beneficiaries  of  care  and  their 
families. Universal coverage must be based on solidarity, according to the structure 
of each system, benefiting in particular those on low incomes and those whose state 
of health requires intensive, long or expensive care, including palliative and end-of-
life  care.  However,  access  difficulties  still  exist  for  certain  groups  and  individuals, 
compromising 
integration  ability.  Moreover, 
inequalities  in  the  regional  distribution  of  care  facilities  or  inadequate  supply 
compared  to  need  can  lead  to  abnormally  long  waiting  lists.  Staff  recruitment  and 
management  difficulties  can  cause  similar  problems.  Care  systems  must  therefore 

their  social  and  occupational 

7 

 
 
  
 
develop  a  care  package  which  is  sufficient  and  well  adapted  to  the  needs  of  the 
population. 

Objectives: 

Ensuring  access  to  high-quality  care  based  on  the  principles  of  universal  access, 
fairness and solidarity. 

Providing a safety net against poverty or social exclusion associated with ill health, 
accident, disability or old age, for both the beneficiaries of care and their families. 

In  particular,  and  in  accordance  with  the  specific  nature  of  their  own  system,  the 
Member States agree to: 

•  offer  all  the  population  high-quality  care  adapted  to  their  needs.  Particular 
attention will have to be paid to persons requiring long-term or expensive care, to 
those  with  particular  difficulties  accessing  care  –  such  as  ethnic  minorities  and 
migrants – and those on low incomes;  

•  ensure  the  financial  and  physical  accessibility  of  care  systems  for  disabled 

persons; 

•  offer  specific  care  for  elderly  people,  based  in  particular  on  closer  coordination 
between  the  social  services,  primary  carers,  hospital  services  and  specialised 
institutions; 

•  promote palliative and end-of-life care; 

•  reduce, where necessary, regional inequalities in the provision of care; 

•  develop,  where  necessary,  suitable  structures  with  trained  staff  to  increase  the 
supply  of  care  and  cut  waiting  lists,  in  particular  where  these  waits  are  at  the 
expense of patients’ health and quality of life. Support could be provided for the 
development  of  infrastructure,  particularly  hospitals,  under  economic  and  social 
cohesion policy: the bodies responsible for the Structural Funds, in particular the 
ERDF and the Cohesion Fund, should look at how this support can be fully used 
in the eligible regions; 

•  promote human resources management that meets the challenges of demographic 
ageing in the health care and long-term care sector, in particularly by anticipating 
or reducing shortages of certain categories of staff, thanks to sufficient investment 
in  basic  and  continuing  training  and  an  improvement  in  the  quality  of  jobs, 
including their  health and safety  at work  aspects.  The  ESF  contribution  must  be 
used  to  the  full  in  this  area.  The  Communication  on  patient  mobility  also 
complements this objective by proposing the promotion of cross-border mobility 
for health care workers and more research into these flows;  

•  take into account in all these measures the specific problems that men and women 
can face, especially in human resources policy and the promotion of high-quality 
jobs. 

8 

 
 
  
 
3.2. 

Promoting high-quality care 

Offering  accessibility  and  high  quality  must  remain  a  fundamental  objective  of  the 
European  systems.  However,  achieving  this  objective  has  become  much  more 
difficult than it was when these systems were created, for two main reasons: 

•  The impact of technological progress is still uncertain, in particular in the context 
of an ageing society. It may indeed make systems more effective, raise healthy life 
expectancy and increase costs, particularly for new drugs. Furthermore, the high 
standard of education,  particularly for those of  the baby  boomer generation who 
are  now  reaching  retirement,  may  have  a  similar  impact,  with  more  healthy 
behaviour and greater prevention but also a growing demand for care, particularly 
innovative care. 

•  The range of care available today is richer, more varied and complex than when 
the care systems were created. Investment in health is a political choice and will 
have a positive impact on the economy in the long term. Nevertheless, given the 
limited public funds available, investment in any sector will automatically affect 
the other sectors21. The mainly public funds invested in health must therefore be 
used  as  efficiently  and  effectively  as  possible  in  order  to  improve  the  overall 
health situation.  

These trends, intensified by the ageing of the population, mean that the real quality 
and benefit for individuals and for overall health of the drugs, treatments or billing 
methods available will have to be audited more and more. This calls for a preventive 
approach in order to improve overall wellbeing and effective management of the care 
system, on the basis of closer coordination between all the players and making them 
more responsible for the management of resources and the supply of care.  

Objective: 

Promoting  high-quality  care  in  order  to  improve  people’s  state  of  health  and 
quality of life. 

In  particular,  depending  on  the  specific  nature  of  their  system,  Member  States 
should: 

•  promote practices and treatments providing real benefits for health and quality of 
life,  based  on  an  appropriate  scientific  assessment.  The  costs  and  benefits  of 
drugs,  equipment  and  treatments  must  be  evaluated,  in  accordance  with  the 
procedures  of  each  national  system  and  with  the  development  of  European 
cooperation in this area;  

•  mainstream  the  gender  dimension  in  the  development  of  prevention  and  health 
policies,  in  order  to  better  take  into  account  the  specific  problems  of  men  and 
women and make their care more effective; 

21 

According to OECD-Healthcare 1996, health spending increases by 0.5 % with every 1% increase in 
wealth. Moreover, according to a study by the EU Economic Policy Committee published in 2001, the 
‘spontaneous’ effect of demographic ageing could increase the share of public expenditure earmarked 
for health and long-term care by between 1.7 and 4 GDP points.  

9 

 
 
  
 
                                                 
•  ensure a high level of basic and continuing training of health care workers, in the 

context of lifelong learning; 

•  develop health and safety at work policies based on risk prevention and creating 
better-quality  jobs  for  all  workers,  especially  older  workers,  in  order  to  reduce 
premature death (at younger than 65 years) and raise healthy life expectancy;  

•  earmark financial and human resources to the regions, services and different types 
of care depending on actual need, in order to obtain the best possible results for 
the  health  and  quality  of  life  of  beneficiaries.  The  Communication  on  patient 
mobility complements this objective by proposing the identification of “reference 
centres” and the promotion of their networking; 

•  promote governance that encourages the systems’ adaptability to changing needs, 
in particular thanks to effective coordination between the players concerned (the 
public  purse,  insurance  funds,  health  care  professions,  hospitals,  prevention 
institutions and organisations, including educational establishments, regional and 
local authorities involved in health care systems, patients and citizens);  

•  define  the  rights  of  patients  and  their  families  and  the  arrangements  for  the 
involvement  of  organised  civil  society.  The  Communication  on  patient  mobility 
complements  this  objective  by  proposing  that  the  information  available  on 
individual rights and the European and national rules on billing for care should be 
brought together and enhanced. 

3.3. 

Guaranteeing the financial sustainability of accessible, high-quality care 

Continuing  to  offer  accessible,  high-quality  care  without  taking  funds  away  from 
other  sectors  or  political  priorities  is  a  major  challenge  for  all  the  Member  States, 
both  the  existing  and  the  new  ones.  They  are  faced  with  the  need  to  ensure  proper 
funding for their care system in order to offer quality services while adapting to new 
needs, especially those associated with ageing, and to technological progress. A large 
proportion of health and elderly care spending is paid for from public funds, which 
are  subject  to  the  requirements  of  the  Stability  and  Growth  Pact.  To  ensure  that 
sufficient  public  funds  are  available  to  meet the  needs of the care system, Member 
States  must  have  healthy  and  sustainable  budgetary  situations.  Cutting  the  public 
debt  rapidly  and  raising  employment  rates  are  important  ways  of  making  public 
funding more sustainable.  

In this context, the Member States have long been implementing measures or reforms 
designed  to  ensure  the  financial  equilibrium  of  the  systems,  based  on  various 
instruments:  reimbursement  rates,  in  order  to  encourage  responsibility  or  guide 
demand  in  a  particular  direction;  prices  and  volumes  of  treatments,  in  order  to 
control  certain  products  or  prescriptions;  the  fixing  of  budgets,  particularly  in  the 
hospital  sector;  the  development  of  steering  tools  based  on  health  objectives,  the 
results  obtained  and  the  diseases  treated,  and  on  giving  more  responsibility  for  the 
management of resources to people working in the sector and financial backers; the 
establishment of  new  ratios between  the  various financing possibilities, particularly 
to  reinforce  the  responsibility  of  the  players  concerned.  There  is  no  single  way  of 
meeting  this  challenge  —  research  into  financial  sustainability  should  therefore 
continue to be based on a combination of these instruments. 

10 

 
 
  
 
In  general,  the  Member  States  should  take  appropriate  measures  to  ensure  sound 
management of public funding for health care and long-term care, concentrating on 
the need to improve the quality and effectiveness of public expenditure. 

Objective: 

Ensuring  the  long-term  financial  sustainability  of  high-quality  care  accessible  to 
all.  

In  particular,  and  depending  on  the  specific  features  of  their  national  system, 
Member States should: 

•  develop prevention and guidance policies at treatment entry points, so as to reduce 
the need for expensive treatments, particularly hospital and intensive care, and to 
this end strengthen the coordination between the various care providers (primary 
care,  hospitals,  local  social  services).  This  objective  complements  the  work 
undertaken under the Community action programme for health22, which supports 
prevention  measures  in  order  to  improve  health  and  reduce  future  health  care 
expenditure;  

•  achieve a sustainable rate of expenditure development, using measures adapted to 
the situation and the specific features of each system, e.g. incentive measures for 
providers  and  patients  or  measures  to  promote  new  treatments  or  new  products 
that reduce costs whilst providing the same service; 

•  ensure  that  their  system  is  properly  funded,  in  order  to  meet  the  new  challenges 

posed by ageing, changes in society and technological progress; 

•  offer the most cost-effective care possible, thanks, in particular, to an audit of the 
health  benefits  of  certain  drugs,  procedures  or  types  of  billing  and  to  activity-
based and real-need-based funding; 

•  improve  the  effectiveness  of  the  system,  based  in  particular  on  decentralisation, 
involving the various players (local and regional public authorities, social security 
institutions  and  other  suppliers  of  funding,  the  health  care  professions  and 
hospitals,  patients)  in  and  making  them  responsible  for  the  management  of 
resources and the provision of care. 

4. 

THE NEXT STEPS 

Responsibility  for  the  organisation  and  funding  of  the  health  care  and  elderly  care 
sector rests primarily with the Member States, which are bound, when exercising this 
responsibility, to respect the freedoms defined and the rules laid down in the Treaty. 
The  added  value  of  the  “open  method  of  coordination”  is  therefore  in  the 
identification  of  challenges  common  to  all  and  in  support  for  the  Member  States’ 
reforms. 

22 

Decision  No  1786/2002/EC  of  the  European  Parliament  and  of  the  Council  of  23  September  2002 
adopting  a  programme  of  Community  action  in  the  field  of  public  health  (2003-2008)  -  Commission 
Statements OJ L 271 , 09.10.2002 

11 

 
 
  
 
                                                 
Pursuant to this Communication, it would be desirable to come to an agreement on 
the joint objectives in 2004. Member States, including the new ones, should present 
‘preliminary  reports’  covering  the  challenges  facing  their  systems  at  national  level, 
current  reforms  and  medium-term  policy  objectives  by  the  next  Spring  Summit  in 
March  2005.  These  reports  would  include  statistical  data  and,  where  relevant, 
quantified objectives. At this preliminary stage, they would be concise.  

They would then be analysed by the Commission, so that the views and contributions 
of  the  Member  States  can  be  taken  into  account  when  the  joint  objectives  of  the 
streamlined  social  security  process  are  established.  This  streamlining  will  lead  in 
2006  to  an  initial  series  of  “development  and  reform  strategies”  in  health  care  and 
long-term care for the period 2006-2009. The conclusions of the assessment of these 
strategies  will  be  presented  in  the  Joint  report  on  social  protection  and  social 
inclusion in 2007.  

Given the wide range of topics and issues tackled by the joint objectives, the Social 
Protection Committee and the other competent bodies (the Employment Committee, 
the  Economic  Policy  Committee,  the  future  High  Level  Group  on  Health  Services 
and  Medical  Care  created  in  parallel  by  the  Commission)  should  forge  close  links, 
including  the  establishment  of  a  work  programme  to  identify  the  topics  relevant  to 
each.  

With  regard  to  the  indicators,  the  Commission  proposes  starting  work  in  2004  to 
identify possible indicators for these objectives. The interim reports due in the spring 
of 2005 will contribute by submitting national data, facilitating the drawing up of an 
initial  comparison  table  of  the  different  national  situations  and  the  assessment  of 
progress  compared  to  the  stated  objectives.  This  work  will  have  to  be  based  on 
activities  undertaken  over  several  years  in  the  context  of  the  action  programme  on 
health monitoring23, then the action programme on health, to create a prototype for a 
future  Community  health  monitoring  system.  It  will  also  be  based  on  Eurostat’s 
health  statistics  work.  Cooperation  with  international  organisations,  such  as  the 
OECD and the WHO, will also be necessary. 

23 

Decision  No 1400/97/EC  of the  European Parliament  and  of  the  Council  of 30  June  1997  adopting a 
programme of Community action on health monitoring within the framework for action in the field of 
public health (1997 to 2001) OJ L 193 , 22.07.1997 

12