Opinion of the European Economic and Social Committee on the White Paper — Together for Health: A Strategic Approach for the EU 2008-2013 COM(2007) 630 final
Date: 2008-09-18
Institutions: European Economic and Social Committee
Subjects: ESC opinion, cooperation policy, equal treatment, health policy, home care, local authority, public health, regional authority

C 77/96

EN

Official Journal of the European Union

31.3.2009

Opinion of the European Economic and Social Committee on the ‘White Paper — Together for
Health: A Strategic Approach for the EU 2008-2013’

COM(2007) 630 final

(2009/C 77/23)

On 23 October 2007 the European Commission decided to consult the European Economic and Social
Committee, under Article 262 of the Treaty establishing the European Community, on the

White Paper — Together for Health: A Strategic Approach for the EU 2008-2013.

The Section for Employment, Social Affairs and Citizenship, which was responsible for preparing the
Committee's work on the subject, adopted its opinion on 18 July 2008. The rapporteur was Ms Cser.

At its 447 plenary session, held on 17 and 18 September 2008 (meeting of 18 September 2008), the
European Economic and Social Committee adopted the following opinion by 114 votes to four with seven
abstentions.

1. Conclusions and recommendations.

1.1
The EESC welcomes the Commission's White Paper
entitled ‘Together for health’, given that the EESC also empha-
sises the correlation between health, economic prosperity and
competitiveness, while recognising the rights of citizens to be
empowered in their mental and physical health and to the provi-
sion of high-quality healthcare.

1.2
The EESC approves the Council's recognition of funda-
mental and shared health values, universality, access to good
quality care, equity and solidarity (1). The EESC hopes that devel-
opments in the field of public health will be based on these
fundamental principles; it also expects to see the principle of
‘health in all policies’ applied. Therefore it
trade,
competition and economic policies in the Single Market must
be coordinated and harnessed in order to achieve the EU's poli-
tical objective of ensuring a high level of public health and thus
promoting, preserving and improving human health.

feels that

1.3
The EESC agrees with and supports the Commission in
its view that active European citizenship only makes sense if
underpinned by fundamental rights; among other things, this
means emphasising, promoting awareness of and ensuring
patients' rights, and providing the requisite information. Failing
this, a Community-level health policy is unthinkable.

1.4
The EESC agrees with the Commission's priorities in par-
ticular to combat the major cross-border health scourges and
health threats, measures to monitor and give early warning of
disasters, and measures to combat tobacco and alcohol abuse
and protect public health.

1.5
Continuous and coordinated input by specific EU-oper-
ated agencies (2) play an important role in securing acceptance
for the strategy and implementing it.

(1) Council Conclusions on Common Values and Principles in European

Union Health Systems (C 2006 146/01).

(2) The Fundamental Rights Agency in Vienna, the Bilbao Agency, the

European Centre for Disease Prevention and Control, etc.

1.6
The EESC is in favour of launching more targeted compi-
lation and joint evaluation of data at Community level to ensure
successful implementation of the strategy. Besides creating real
and comparable indicators, efforts must be made to update data-
bases and develop methods to check the accuracy of data.
However, it would point out that personal data must be strictly
protected.

1.6.1
The EESC believes that those patients requiring cross-
border healthcare should receive information about their rights
to quality care. Member States should also ensure that the free
provision of services does not result in social dumping in this
field, which would be damaging to healthcare workers, their
professionalism, and ultimately to patients.

1.7
The EESC welcomes the Commission's declaration on
reducing the serious inequalities that exist between and within
Member States. However, it would warn the Commission that
support for patients' rights to mobility and greater mobility
among
such
inequalities.

healthcare workers must

exacerbate

not

1.8
The EESC supports the Commission in its intention to
strengthen and promote prevention, and welcomes its efforts to
promote health awareness programmes targeted at different age
groups. Public-service TV and radio should have an important
role to play; these should be targeted at the poor, who represent
a large proportion of the EU's population, especially children
and young people, who often lack any other means of accessing
objective and useful information and knowledge.

The EESC suggests

1.9
launching a ‘Healthy European
Citizen’ long-term campaign, to last for the entire five years of
the strategy, with annual rolling planning and feedback enabling
continuous evaluation of the strategy and appropriate adjust-
ments. The EESC recommends that the Commission extend the
duration of both the strategy and the programme/long-term
campaign
promote more
in
health-conscious behaviour among European citizens.

ten years,

order

to

to

31.3.2009

EN

Official Journal of the European Union

C 77/97

in disseminating knowledge about

The EESC emphasises the importance of broad stake-
1.10
holder
the
involvement
strategy, stimulating discussion about it and implementing it,
thus ensuring, through transparency and cooperation, accep-
tance of
the strategy and implementation of participatory
democracy.

1.11
The EESC would remind the Commission of the key
role played by health and safety at work and would urge that,
with the involvement of the social partners and Member States,
coordinated cooperation be stepped up in EU policies, and
prevention and protection be strengthened.

The EESC suggests that specialists in various policy
1.12
areas and representatives of
the social partners, professional
organisations and civil society set up forums at European,
national, regional and local levels. These forums, which would
involve cooperation on multiple levels, could form a network to
help promote the exchange of information, and would be an
appropriate means of presenting various points of view, deli-
neating between national and EU policies, and ensuring the
acceptance of such policies. Educating members of the public in
how to behave individually and collectively in the event of a
serious health crisis should be one of the subjects covered by
such forums involving a wide audience, and would enable effec-
in the interests of all concerned during
tive management
periods of difficulty.

The EESC recommends that

1.13
the EU set up similar
forums in its international policy with the participation of those
concerned and in cooperation with international organisations
to enable debate on policy issues and ensure formulation and
implementation of strategies.

The EESC supports

1.14
innovation in Member States'
healthcare systems and welcomes the development of e-health
technology; however, further research and proposals for solu-
tions are needed here, in view of the need to comply with the
subsidiarity principle and ensure patients' rights.

The EESC is disappointed that a strategy which
1.15
concerns all EU citizens has not been given a budget of its own.
The EESC recommends that, to ensure effective implementation
of the new strategy, an overall review of the EU's budget (3) be
carried out to identify projects impacting on public health; these
should be monitored and evaluated, and subsequently harmo-
nised. Throughout the duration of the strategy, efforts must be
made to ensure that,
in addition to project-type funding,
budget-type support is available in the post-2013 period for
new tasks which become ongoing.

(3) See EESC opinion of 12.3.2008 on EU budget reform and future financing,

rapporteur: Ms Florio (OJ C 204, 9 August 2008).

2. General comments

Health and high-quality-healthcare

the
2.1
European social model, built on essential values such as soli-
darity, and should be actively developed (4).

is part of

2.2
Right to be empowered in mental and physical health
and access to mental and physical healthcare, is a fundamental
right for European citizens and is one of the main pillars of
active European citizenship.

The focus must be on citizens, with joint efforts to

2.3
develop a Community culture of health and safety.

2.4
In the EU, it is vital to combat poverty and ensure access
to high-quality healthcare for all, as a fundamental performance
indicator not only of healthcare provision but also of efforts to
promote competitiveness (5).

3. Content of the White Paper

3.1
The European Commission has held two consultations
on health. Consultation revealed general support for a new
health policy strategy in Europe, and a desire for closer coopera-
tion between the European Commission and EU Member States
on further improvements in health protection in the EU.

Several major

3.2
consultation:

issues were

raised by

the public

— combating health risks,

— disadvantages in terms of health including gender-related

inequalities,

— the importance of information and awareness-raising for the

public,

— the quality and safety of cross-border healthcare,

— identification of key lifestyle-related health factors such as

diet, exercise, drinking, smoking and mental health,

— the need to improve the European information system in

order to develop the European health strategy.

3.3
The Lisbon Treaty signed on 13 December 2007 expands
and clarifies Article 152 of the Treaty establishing the European
Community by introducing the concept of ‘physical and mental
health’ to replace ‘human health’. The Lisbon Treaty also adds
monitoring, early warning of and combating serious cross-
border threats to health to the content of the Treaty.

(4) See EESC opinion of 6.7.2006 on Social cohesion: fleshing out a European
social model (own-initiative opinion), rapporteur: Mr Ehnmark (OJ C 309
of 16 December 2006).

(5) See EESC opinion on Implementation of the Lisbon Strategy.

C 77/98

EN

Official Journal of the European Union

31.3.2009

The White Paper emphasises common values such as the
3.4
right
to high-quality treatment, equality and solidarity. The
Commission has developed its common strategy on the basis of
four fundamental principles:

civil society organisations including patients' associations and
consumer organisations) both in identifying and solving
problems and in promoting health-conscious behaviour.

— Common Values in the Field of Health

— ‘Health is the Greatest Wealth’

— Health in All Policies, and

— Strengthening the EU's Voice in Global Health.

Based on this, the strategy identifies three main objectives

3.5
for the coming years:

— fostering good health in an ageing Europe,

from civil

The EESC is disappointed that the social partners, stake-
4.4
holders
society, professional organisations and
patients' associations were not involved. It suggests that coop-
eration with public authorities — at local, regional, national and
European level — in the context of social partnership should
take place, whilst effective use of financial resources is essential
conditions for implementation of the health strategy and EU
economic success.

— protecting citizens from health threats, and

5. The health of European citizens

— supporting dynamic health systems and new technologies.

The Commission is proposing 18 measures to achieve these
objectives.

4. Specific comments

4.1
The EESC agrees with the fundamental principles set out
in the White Paper, and therefore welcomes the principle of
Health in All Policies (HIAP), which will require much closer
cooperation between the Commission, the social partners, civil
to
society organisations, academia and the media in order
promote and implement the strategy.

4.2
The EESC recognises that public health around the world
is facing three main challenges: firstly, the struggle against the
constantly changing microbial world, secondly, the struggle to
change human habits and behaviour, and thirdly, the struggle
for attention and resources (6). It is also aware of the challenges
facing the EU and the resources available to meet them:

— demographic ageing is posing a growing challenge in terms

of diagnosis, treatment and care;

— health threats

such as epidemics caused by infectious
diseases and bioterrorism are increasingly serious problems;

— climate change and the hidden dangers of globalisation;

— at the same time, the rapid development of new technolo-
gies may result
for
in dynamic changes
promoting health, as well as the prevention and treatment
of illnesses.

in methods

4.3
The EESC emphasises the importance of a significant
active role for stakeholders (public authorities, social partners,

(6) Speech by Dr Margaret Chan, secretary-general to the WHO: Address
to the Regional Committee for Europe, 18 September 2007, Belgrade,
Serbia: see:
http://www.who.int/dg/speeches/2007/20070918_belgrade/en/index.
html.

The EESC agrees with the Commission that,

5.1
in imple-
menting the Citizens' Agenda, civic and patients' rights should
be the key starting points for Community health policy, and
that solidarity, as the key value underpinning the European
social model,
in the interests of
everyone's health (7).

should be strengthened,

5.2
The EESC is in favour of active European citizenship,
which only makes sense if underpinned by health-conscious
behaviour. Despite EU and national efforts to achieve this, there
are still big differences between citizens in terms of health (8),
access to healthy lifestyles and equal opportunities; this particu-
larly applies to gender equality (9) and especially vulnerable
disadvantaged groups. The EESC urges the Commission to
ensure that, once the disadvantages faced by particular groups
have been identified, specific solutions and support systems are
developed, while promoting cooperation between Member
States; moreover, promoting specific programmes to evaluate
and maintain the health of elderly people would benefit society
as a whole, and would enable population trends to be taken
into account.

5.3
In view of the inequalities within and between Member
States, the EESC supports the common objective whereby health
policies should support the strategies to reduce and eliminate
poverty. Although health costs are constantly growing this must
not result
in individuals and households (both within and
outside the EU) becoming worse off or being driven into
poverty. Both equality and affordability, as well as local avail-
ability, must therefore be ensured in the provision of the appro-
priate range of public healthcare services and social services. It
is vital to avoid further widening the gap between rich and poor
in our societies.

(7) See EESC opinion of 2.6.9.2007 on Patients' rights (own-initiative

opinion), rapporteur: Mr Bouis (OJ C 10 of 15 January 2008).

(8) See impact assessment: for example, in Italy, men live in good health for

71 years; the corresponding figure for Hungary is only 53.

(9) See EESC opinion of 13.9.2006 on the Communication from the
Commission to the Council, the European Parliament, the European
Economic and Social Committee and the Committee of the Regions on
A Roadmap for equality between women and men 2006-2010, rapporteur:
Ms Attard (OJ C 318 of 23 December 2006).

31.3.2009

EN

Official Journal of the European Union

C 77/99

The EESC believes all European citizens

5.4
should be
empowered in their mental and physical health and enjoy equal
rights to physical and mental healthcare. This can only be
achieved if particular attention is paid to disadvantaged groups
such as persons
living in long-term poverty, marginalised
groups, and groups excluded on religious grounds. Develop-
ments in the field of public health must take mental health, in
particular
into
account (10).

that of high-risk

groups, more

closely

5.5
The EESC suggests that the Member States should further
promote intercultural dialogue with a view to supporting the
work of the EU and individual citizens, particularly in terms of
providing and using healthcare
services. Recognition and
support of cultural diversity and multiculturalism can substan-
tially help to secure legitimacy and acceptance for health aware-
ness and encourage mutual help (11), as well as ensuring timely
prevention and recourse to healthcare services and treatment.

The EESC urges the Commission to formulate proposals
5.6
to develop health-
to ensure mainstreaming of proposals
conscious behaviour into all policies, with a view to ensuring
access to independent
information on mental and physical
health, including for citizens without Internet access and disad-
vantaged persons, whose numbers are — unfortunately —
increasing. One option should be cooperation with public-
service radio and TV channels to disseminate information about
public and individual health (for example on prevention) and
provide information enabling timely access to medical facilities.
This could also be done using communication tools such as
internet, accessible to patients and health workers.

5.9 While the EESC supports the free movement of labour
and acknowledges patients' rights, it would remind the Commis-
sion that mobility among patients and healthcare workers must
not exacerbate the inequalities which already exist in the field of
healthcare; indeed, it is important to overcome these (13).

The EESC notes

5.10
that adequate, high-quality public
healthcare and social services are a prerequisite for the supply of
sufficiently skilled labour in sufficient numbers. In view of this,
workers in these fields must be better paid and be given greater
social recognition and prestige, to ensure that work in this
sector becomes more attractive for young people. The EESC is
concerned about the health of ageing healthcare and social care
workers, who are threatened by burn-out and stress; that there
is a need to highlight the value of the work done in the health-
care and social services sector and to stress that professionals in
this sector do valuable work to promote health in the whole of
society.

5.11
A conscious effort must be made at national level to
establish a strong health policy, and this can only be achieved if
funding from social
adequate budgetary resources and/or
security systems are earmarked. The Member States must effec-
tively invest not only in the prosperity of their populations but
also in the well-being of their citizens and subjects.

6. Cross-border and global issues

5.7
The EESC emphasises that anti-smoking campaigns, the
development of common standards in the area of food labelling,
pharmaceutical research, and the development and promotion
of health online are areas which offer added value. In many
areas, the exchange of best practices and performance evaluation
can play a key role in making efficient and effective use of
limited funding.

6.1
The EESC agrees that, with regard to globalisation and
health, the EU can play a key role within and beyond its borders
in resolving global health problems, and in developing Com-
munity-level responses to disasters, pandemics and new chal-
lenges arising from climate change; it can also offer added value
in dealing with a global shortage of healthcare workers through
the compensation fund (14) and improving international access
to medicines.

The EESC feels that policies to support

5.8
families are
important, together with appropriate training and support for
for women
the development of health awareness; support
during pregnancy could be a good starting point
for such
efforts (12). Hence, to promote European citizenship, the EESC
recommends launching a long-term ‘Healthy European Citizen’
campaign.

(10) EESC opinion of 17.5.2006 on the Green Paper ‘Improving the mental
health of the population — Towards a strategy on mental health of the Euro-
pean Union’, rapporteur: Mr Bedossa (OJ C 195 of 18 August 2006).
(11) See EESC opinion of 20/4/2006 on the Proposal for a decision of the
European Parliament and of the Council concerning the European Year of
Intercultural Dialogue (2008), rapporteur: Ms Cser (OJ C 185 of
8 August 2006).

(12) E.g. the Hungarian nurses' network, which provides support for chil-

dren and families from conception up to the age of 18.

6.2
Existing and new threats to health (HIV/AIDS) which
transcend borders mean an increasingly strong role for the EU
in offering added value, given that Member States are incapable
of resolving such problems on their own (lack of access to
tritherapies). This particularly applies to the reinforcing of
screening and protection and coordinating the prevention of
infectious diseases.

(13) EESC opinion of 27.10.2004 on the Communication from the Commis-
sion: Follow-up to the high level reflection process on patient mobility and
healthcare developments in the European Union, rapporteur: Mr Bedossa
(OJ C 120 of 20 May 2005).

(14) EESC opinion of 11.7.2007 on Health and Migrations (exploratory
opinion), rapporteurs: Ms Cser and Mr Sharma (OJ C 256 of
27 October 2007).

C 77/100

EN

Official Journal of the European Union

31.3.2009

6.3
The EESC is disappointed at the lack of specific proposals
by the Commission to deal with problems concerning health-
care workers, who have a key role to play in ensuring the
success of the EU's health strategy. There is a very clear correla-
tion between the lack of healthcare workers and problems
connected with shortcomings in the provision of healthcare
services or the absence of such services.

Provided that they adopt and comply with collective agreements,
SMEs, which employ over 80 % of workers, require special
they are at an immense disadvantage
support, given that
financial
compared to multinational companies in terms of
resources and possibilities. The EESC deplores the fact
that
self-employed are not protected at work.

rights

The EESC would emphasise the importance of an ethical
6.4
approach to patients'
in relations between doctors,
patients and all other healthcare workers. In a developing and
changing world, with rapidly advancing medical technologies,
greater emphasis must be placed on ethics and the protection of
personal data; training and further training should therefore pay
particular attention to these aspects.

6.5
The EESC points out that there is a growing shortage of
healthcare workers and that those currently working in the
sector are ageing; an ethical approach is therefore needed to
recruitment, with specific policies on integration, skills and pay
for employees recruited from both within the EU and from third
countries. Options should be considered to promote the return
of trained healthcare migrants, thus contributing to the develop-
ment of healthcare systems in their countries of origin. With
regard to the migration of healthcare professionals within the
EU, Member States should also ensure that the free provision of
services does not result in social dumping in this field, which
would be damaging to healthcare workers, their professionalism,
and ultimately to patients.

7. Adoption and implementation of the strategy

The EESC is disappointed by the lack of adequate,
7.1
genuine, analysable and comparable information or data on the
health of European citizens, and of monitoring systems to
enable comparisons between Member States or regions. There
are also major discrepancies and gaps in terms of information
on health and safety at work (15). Certain EU agencies have an
important role to play here.

The EESC recommends that further efforts be made at
in compiling relevant

7.2
regional, national and European level
statistics and defining indicators.

7.3
The success of the renewed Lisbon strategy is closely
dependent on the health and safety of employees at work.
Working conditions are especially important for health, given
that adults spend one-third of
the workplace.
Hazardous and unhealthy conditions at work cost 3-5 % of
GNP. Prevention is the most important way of promoting health
and safety at work and ensuring it on a permanent basis.

their lives at

(15) EESC opinion of 29.5.2008 on the Communication from the Commission
to the European Parliament, the Council, the European Economic and Social
Committee and the Committee of the Regions — Improving quality and
productivity at work: Community strategy 2007-2012 on health and safety
at work, rapporteur: Ms Cser (OJ C 224 of 30 August 2008).

7.4
The EESC supports changes to Member State healthcare
systems improve the standards of service. In order to overcome
inequalities within and between Member States, the role of
regions should be analysed together with that of Member States;
however, this must not result in a transfer of responsibilities
from the national level. In this connection, the EESC is deeply
perturbed by the reforms to public social insurance and health-
care systems that are taking place in some Member States and
which seek to curb public health insurance systems and privatise
public healthcare on a massive scale.

it

The EESC supports

the Commission's objective to
7.5
promote and strengthen prevention;
the
Commission intends to work towards improved health for the
elderly, children and young people. Making this happen will
closely depend on proposals concerning tobacco, nutrition,
alcohol, mental health (including Alzheimer's disease) and
cancer screening, which are also of particular relevance to the
groups targeted by the strategy (16).

is pleased that

7.6
The EESC welcomes the results of technological develop-
ment, but does not feel that the proposal to use e-health as a
solution would ensure that requirements are met in terms of
equal opportunities, given that the views of the professionals on
this issue are not known. The reference to cost-cutting and
more citizen-centred services is justified; however, measures to
ensure patients' rights and Member States' responsibilities with
regard to developing and overseeing healthcare have not been
explained in sufficient detail.

7.7
The EESC supports increased cooperation and new initia-
tives with international organisations; given that the EU plays a
key role in the provision of international aid, the Committee is
in favour of closer cooperation with the WHO.

7.8
The EU can help to achieve the objectives of the WHO
for the 21st century if it cooperates with Member States, UN
bodies, the WHO, the ILO, and other international bodies such
as the International Organisation for Migration. Contacts must
also be stepped up with international financial institutions such
as the IMF and the World Bank. Efforts must be made to
promote forums at international level involving the social part-
ners, professional and civil society organisations,
in particular
patients' associations and consumer organisations.

(16) EESC opinion of 30.5.2007 on the Communication from the Commission
to the Council, the European Parliament, the European Economic and Social
Committee and the Committee of the Regions — An EU strategy to support
Member States in reducing alcohol-related harm, rapporteurs: Ms Van
Turnhout and Mr Janson (OJ C 175 of 27 July 2007) and EESC
opinion of 28.9.2005 on ‘Obesity in Europe — the Role and responsi-
bilities of civil society partners’ (own-initiative opinion), rapporteur:
Ms Sharma (OJ C 24 of 30 January 2006).

31.3.2009

EN

Official Journal of the European Union

C 77/101

7.9
The EESC recommends that, as part of the stronger role
to be played by the EU at international level, the EESC could
take on within the remit of its competence, a more active role
in international debates on specific subjects such as the new
challenges arising from climate change and their implications
for human health.

The health strategy must feature permanently on the
7.10
agenda of European neighbourhood and international policies,
in particular in order to ensure joint action to combat new
health threats and pandemics, the effects of disasters and new
health problems arising from climate change or other factors.

8. Financial instruments and resources

8.1
The EESC stresses that it is vital to ensure that the health
strategy is taken into account in all EU policy areas. Adequate
funding must be ensured, given that the White Paper does not
envisage that any additional funding will be available from the
budget. Therefore, the EESC has doubts whether Community-
level checking and proposals to strengthen mechanisms for
surveillance and response to health threats will succeed without
appropriate financing being foreseen. In order to ensure effective
funding for projects and in view of the ongoing nature of EU
policies,
in place continuous
specific budgetary funding for each task (17).

it would be advisable to put

Brussels, 18 September 2008.

The President

of the European Economic and Social Committee

Dimitris DIMITRIADIS

(17) EESC opinion of 5.7.2006 on the Proposal for a Council decision on the
system of the European Communities' own resources (//EC, Euratom), rappor-
teur: Ms Cser (OJ C 309 of 16 December 2006).