Special Report No 2/2009#The European Union’s Public Health Programme (2003-2007): an effective way to improve health?
Date: 2009-03-05
Institutions: European Court of Auditors
Subjects: EU programme, cooperation policy, health care, health costs, health policy, opinion of the Court of Auditors, public health

EUROPEAN COURT 
OF AUDITORS

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THE EUROPEAN UNION’S PUBLIC 
HEALTH PROGRAMME (2003–07): 
AN EFFECTIVE WAY 
TO IMPROVE HEALTH?

EN

 
 
 
 
Special Report No 2  

 2009

THE EUROPEAN UNION’S 
PUBLIC HEALTH PROGRAMME 
(2003–07): AN EFFECTIVE WAY 
TO IMPROVE HEALTH?

(pursuant to Article 248(4), second subparagraph, EC)

EUROPEAN COURT OF AUDITORS

2

EUROPEAN COURT OF AUDITORS
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Special Report No 2  

 2009

More information on the European Union is available on the Internet (http://europa.eu).

Cataloguing data can be found at the end of this publication.

Luxembourg: Office for Official Publications of the European Communities, 2009

ISBN 978-92-9207-227-8

© European Communities, 2009

Reproduction is authorised provided the source is acknowledged.

Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?

Printed in Belgium

CONTENTS

3

Paragraph

I–VI 

1–9 

ABBREVIATIONS

EXECUTIVE SUMMARY

INTRODUCTION

10–12 

AUDIT SCOPE AND APPROACH

13–82 

13–33 
14–18 
19–21 
22–28 
29–33 

34–65 
35–38 
39–49 

50–54 
55–65 

66–82 
67–69 
70–73 
74–78 
79–82 

AUDIT OBSERVATIONS

PROGRAMME DESIGN
INTERVENTION LOGIC NOT MADE EXPLICIT
PROGRAMME OBJECTIVES NEITHER SPECIFIC, NOR MEASURABLE OR TIME-DEPENDENT
ABSENCE OF STRATEGIC PLANNING AND LACK OF PRIORITY SETTING
INDICATORS AT PROGRAMME LEVEL INADEQUATE TO MONITOR ACHIEVEMENTS

PROGRAMME IMPLEMENTATION: FROM PROJECT DESIGN TO RESULTS
PROJECT OBJECTIVES NOT SPECIFIC, VERIFIABLE AND QUANTIFIABLE
 DEFINITION OF EXPECTED PROJECT RESULTS, IDENTIFICATION OF TARGET GROUPS AND PLANNING 
FOR SUSTAINABILITY THE EXCEPTION RATHER THAN THE RULE
COMPLEMENTARITY OF PROJECTS AND CONSISTENCY OF PROJECT PORTFOLIO NOT ADEQUATELY MONITORED
LIMITED EUROPEAN ADDED VALUE

PROJECT MANAGEMENT
PARTNERSHIP FUNCTIONED WELL
PROJECT MONITORING BY COMMISSION AD HOC RATHER THAN SYSTEMATIC
OUTPUTS DELIVERED, BUT NOT ACTIVELY DISSEMINATED
PROJECT EVALUATION NOT YET COMMON PRACTICE

83–92 

CONCLUSIONS AND RECOMMENDATIONS

ANNEX I:  PHP 2003–07 (‘HEALTH DETERMINANTS’ STRAND) — FUNDED PROJECTS BY TOPIC

ANNEX II:  PHP (‘HEALTH DETERMINANTS’ STRAND) — ANALYSIS OF SIX POLICY AREAS

ANNEX III:   PHP (‘HEALTH DETERMINANTS’ STRAND) — APPLICATION OF THE SMART CRITERIA TO THE PROJECT 

OBJECTIVES STATED IN THE GRANT AGREEMENTS OF THE 36 AUDITED PROJECTS

REPLY OF THE COMMISSION

Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?

 
 
 
 
 
Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?

ABBREVIATIONS

5

ABM: Activity-based management

AWP: Annual work plan

DG  JLS:  The  European  Commission’s  Directorate-General  for  Justice,  Freedom  and 
Security

DG RTD: The European Commission’s Directorate-General for Research

DG SANCO: The European Commission’s Directorate-General for Health and Consumers

DG TREN: The European Commission’s Directorate-General for Transport and Energy

EAV: European added value

EC: European Community

ECDC: European Centre for Disease Prevention and Control

EMCDDA: European Monitoring Centre for Drugs and Drug Addiction

EU: European Union

NGO: Non-governmental organisation

PHEA: Public Health Executive Agency, renamed Executive Agency for Health and  Consumers 
(EAHC) in July 2008

PHP: Public Health Programme (2003–08)

PHP 2: Second Programme of Community Action in the Field of Health 2008–13

RDI cycle: Research – development – implementation cycle

RTD: Research and technical development

WHO: World Health Organisation

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EXECUTIVE 
REPLY OF THE 
SUMMARY
COMMISSION

I.
T h e   P u b l i c   H e a l t h   P r o g r a m m e   ( P H P )   f o r 
2003–07 aimed at complementing the meas-
ures taken by Member States to protect and 
i m p r o v e   p u b l i c   h e a l t h .   I t   w a s   s t r u c t u r e d 
a r o u n d   t h r e e   p r o g r a m m e   s t r a n d s :   ‘ h e a l t h 
i n f o r m a t i o n ’ ,   r a p i d   r e a c t i o n   t o   ‘ h e a l t h 
t h r e a t s ’   a n d   h e a l t h   p r o m o t i o n   t h r o u g h 
addressing ‘health determinants’.

II.
During this period the programme awarded 
grants to consortia of organisations for the 
i m p l e m e n t a t i o n   o f   s o m e   3 5 2   p r o j e c t s ,   t h e 
total Community contribution being approxi -
mately 232 million euro.

III.
T h e   C o u r t ’ s   a u d i t   a s k e d   w h e t h e r   t h e   r i g h t 
conditions were set for the projects financed 
from the EU budget to contribute effectively 
t o   i m p r o v i n g   t h e   h e a l t h   o f   E u r o p e a n   c i t i -
z e n s ,   a s   a   c o m p l e m e n t   t o   m e a s u r e s   t a k e n 
b y   M e m b e r   S t a t e s .   I n   p a r t i c u l a r ,   t h e   C o u r t 
examined whether:

(a) 

the design of the PHP provided a suitable 
f r a m e w o r k   f o r   t h e   e f f e c t i v e   i m p l e m e n -
t a t i o n   a n d   m o n i t o r i n g   o f   C o m m u n i t y -
funded health promotion actions;

(b) 

t h e   C o m m i s s i o n   e n s u r e d ,   a t   t h e   p r o -
g r a m m e   i m p l e m e n t a t i o n   a n d   p r o j e c t 
s e l e c t i o n   s t a g e ,   t h a t   p r o j e c t s   f u n d e d 
under  the  ‘health  determinants’  strand 
of the PHP were likely to achieve sustain-
a b l e   r e s u l t s ,   w e r e   c o m p l e m e n t a r y   a n d 
provided EU added value; and

(c) 

t h e   C o m m i s s i o n   a n d   p r o j e c t   c o o r d i n a -
tors ensured that projects were managed 
effectively.

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7

EXECUTIVE 
REPLY OF THE 
SUMMARY
COMMISSION

V.
In view of its findings, the Court recommends 
t h a t   t h e   p r o g r a m m e   l o g i c   s h o u l d   b e   m a d e 
e x p l i c i t   i n   a n y   s i m i l a r   f u t u r e   l e g i s l a t i o n . 
Where the current programme is concerned, 
t h e   C o m m i s s i o n   s h o u l d   u n d e r t a k e   a   m a p -
ping exercise to gain an overview of actions 
a l r e a d y   i m p l e m e n t e d   a n d   t h u s   t o   i d e n t i f y 
any  remaining  gaps.  The  number  of  annual 
p r i o r i t i e s   s h o u l d   b e   s i g n i f i c a n t l y   r e d u c e d , 
and they should be focused on strategic top-
ics and activities with an obvious European 
a d d e d   v a l u e .   T h e   C o m m i s s i o n   s h o u l d   a l s o 
address the weaknesses identified in project 
design and implementation.

VI.
M o r e   f u n d a m e n t a l l y ,   f o r   t h e   p e r i o d   a f t e r 
2013 the Commission and the Member States 
a r e   i n v i t e d   t o   r e c o n s i d e r   t h e   E U ’ s   f u n d i n g 
approach in the field of public health. Other 
cooperation  mechanisms  which  exist,  such 
as the ‘open method of coordination’, could 
be further developed.

IV.
T h e   C o u r t ’ s   f i n d i n g s   a n d   c o n c l u s i o n s   w e r e 
as follows:

(a) 

(b) 

T h e   P H P   w a s   s e t   v e r y   b r o a d   a n d   a m b i -
tious objectives that contrasted sharply 
with the limited means at its disposal. In 
such a situation it is essential to focus on 
what can actually be achieved. However, 
t h e   i n t e r v e n t i o n   l o g i c   w a s   a t   n o   p o i n t 
made explicit, which was not conducive 
t o   s e t t i n g   c l e a r ,   m e a n i n g f u l   a n d   l o g i -
c a l l y   l i n k e d   o b j e c t i v e s   a n d   s p e c i f y i n g 
appropriate  performance  indicators.  As 
a result, the PHP lacked strategic focus. 
T h e   p r o g r a m m e ’ s   ‘ a c t i o n   a r e a s ’   e s t a b -
lished in the annual work plans outnum-
b e r e d   t h e   p r o j e c t s   f u n d e d   t o   a d d r e s s 
t h e m .   S i n c e   p r o j e c t   p r o p o s e r s   w e r e 
invited to apply for funding under often 
very  general  headings,  the  multiplicity 
and diversity of project topics and target 
g r o u p s   c a u s e d   i n p u t   t o   b e   d i l u t e d   a n d 
led to fragmented results.

P r o j e c t   e f f e c t i v e n e s s   w a s   h i n d e r e d   b y 
d e s i g n   w e a k n e s s e s   a n d   i m p l e m e n t a -
t i o n   p r o b l e m s .   W i t h   f e w   e x c e p t i o n s , 
p r o j e c t s   d i d   n o t   d e f i n e   w h a t   r e s u l t s 
t h e y   i n t e n d e d   t o   a c h i e v e ,   a n d   t h e r e -
f o r e   w e r e   u n a b l e   t o   d e m o n s t r a t e   t h a t 
t h e y   h a d   h a d   a n y   e f f e c t .   S u s t a i n a b i l i t y 
w a s   o f t e n   u n d e r s t o o d   b y   p a r t i c i p a n t s 
a s   t h e   c o n t i n u a t i o n   o f   p r o j e c t   a c t i v i -
ties  and  was  therefore  heavily  depend-
e n t   o n   c o n t i n u e d   C o m m u n i t y   f u n d i n g . 
There  was  no  systematic  monitoring  of 
actions already undertaken in the differ-
ent priority areas, which sometimes led 
to duplication of work.

(c) 

O n   t h e   p o s i t i v e   s i d e ,   t h e   p r o g r a m m e 
b r o u g h t   s t a k e h o l d e r s   f r o m   d i f f e r e n t 
c o u n t r i e s   t o g e t h e r .   P r o j e c t s   g e n e r a l l y 
had a European dimension and, in many 
cases,  facilitated  the  sharing  of  experi-
e n c e s   a n d   m u t u a l   l e a r n i n g .   N e t w o r k s 
were the clearest providers of European 
added value.

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INTRODUCTION

8

1. 

2. 

3. 

4. 

Article 152 of the EC Treaty sets out the Communities’ role in the field of 
public health, stating that Community activities are directed towards 
‘improving  public  health,  preventing  human  illness  and  diseases,  and 
obviating sources of danger to human health’. These Community actions 
a r e   t o   c o m p l e m e n t   m e a s u r e s   t a k e n   a t   n a t i o n a l   l e v e l   a n d   n e e d   t o 
respect the Member States’ responsibilities for the organisation and 
delivery of health services and medical care.

The European Commission’s main role in the area of public health is 
to  facilitate  cooperation  between  Member  State  authorities,  and  to 
implement  incentive  measures.  Apart  from  specific  competence  for 
the safety standards of organs, substances of human origin and blood, 
the EU’s legislative power in this area is limited to incentive measures 
t h a t   e x c l u d e   a n y   h a r m o n i s a t i o n   o f   t h e   l a w s   a n d   r e g u l a t i o n s   o f   t h e 
Member States.

The first Public Health Programme (PHP) was adopted for the 2003–08 
period by Decision No 1786/2002/EC of the European Parliament and 
o f   t h e   C o u n c i l 1  a n d   r e p l a c e d   e i g h t   a c t i o n   p r o g r a m m e s   o n   s p e c i f i c 
health topics 2. The PHP addressed three general objectives:

1  OJ L 271, 9.10.2002, p. 1.

2  These were the programmes 

of Community action on 

cancer, rare diseases, pollution-

related diseases, AIDS and 

other communicable diseases, 

injury prevention, prevention 

of drug dependence, health 

monitoring, and health promotion, 

information, education and 

training.

3  The Programme Committee acts 

as the management committee 

referred to in Articles 4 and 7 of 

Council Decision 1999/468/EC

(OJ L 184, 17.7.1999, p. 23) for 

the annual plan of work for 

implementing the programme. 

It oversees the arrangements, 

criteria and procedures for 

selecting and financing 

programme actions, arrangements 

for implementing joint strategies 

(a) 

t o   i m p r o v e   i n f o r m a t i o n   a n d   k n o w l e d g e   f o r   t h e   d e v e l o p m e n t   o f 
public health (‘health information’ strand);

and actions and evaluating 

the programme, and certain 

(b) 

to  enhance  the  capability  of  responding  rapidly  and  in  a  coordi-
nated fashion to threats to health (‘health threats’ strand);

(c) 

to promote health and prevent disease through addressing health 
determinants  across  all  policies  and  activities  (‘health  determi-
nants’ strand).

measures in connection with the 

coordination of health monitoring 

and rapid reaction to health 

threats. Other measures linked to 

the implementation of the PHP 

are adopted through the advisory 

procedure referred to in Articles 3 

and 7 of Decision 1999/468/EC.

To achieve these objectives, the Commission awarded grants to consortia 
of organisations (governmental, non-governmental, academia) imple-
menting  projects  which  addressed  the  priority  public  health  issues 
defined in annual work plans (AWPs) established by the Commission 
and a committee of Member States’ representatives 3.

Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?

 
 
 
 
9

5. 

The PHP covered the years 2003 to 2007. Some 352 projects were funded 
d u r i n g   t h i s   p e r i o d ,   w i t h   t h e   E C   c o n t r i b u t i o n   t o t a l l i n g   2 3 1 , 7   m i l -
lion euro in commitments 4 (see Figure 1). The ‘health determinants’ 
strand  was  the  largest  of  the  three  in  budgetary  terms,  with  a  Com-
munity  contribution  of  90,8  million  euro  corresponding  to  40  %  of 
the total amount committed for projects.

4  Figures for the 2007 call for 

proposals are based on the list of 

accepted proposals. Negotiations 

for several contracts were still 

ongoing as of October 2008.

F I G U R E   1

TOTAL COMMUNITY CONTRIBUTION (COMMITMENTS IN MILLION EURO 
AS A PERCENTAGE OF THE TOTAL BUDGET) AND NUMBER OF PROJECTS 
PER PROGRAMME STRAND

Health threats
58,8 million euro (25 %)
68 projects

Health information
82,1 million euro (35 %)
135 projects

Health determinants
90,8 million euro (40 %)
149 projects

6. 

Under the PHP, grant agreements were concluded with project coordina-
tors,  who  received  co-financing  of  up  to  60  %  (in  exceptional  cases 
up to 80 %) of the costs incurred for carrying out project activities. In 
addition to grants for projects, a minor part (about 3 %) of the PHP’s 
operational budget was used for service contracts through tendering 
procedures.

Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?

 
 
 
 
 
10

7. 

Projects funded from the PHP were very diverse in terms of size, approach 
a n d   t a r g e t   g r o u p   ( s e e   B o x   1 ) .   C o n s o r t i a   v a r i e d   i n   s i z e   f r o m   t h r e e 
to  60  partners,  the  Community  contribution  ranged  from  45  000  to 
2,5 million euro, and types of project activities differed widely.

5  Decision No 1350/2007/EC of 

the European Parliament and of 

the Council (OJ L 301, 20.11.2007, 

p. 3).

8.  On 1 January 2008 the Second Programme of Community Action in the 
F i e l d   o f   H e a l t h   2 0 0 8 – 1 3   ( P H P 2 )   c a m e   i n t o   f o r c e 5.   T h e   C o m m i s s i o n 
h a d   o r i g i n a l l y   p r o p o s e d   t o   m e r g e   t h e   p u b l i c   h e a l t h   a n d   c o n s u m e r 
protection programmes 6. It had also proposed increasing the budget 
by  around  270  %  (804  million  euro  for  health  for  2008–13),  arguing 
that  the  PHP  budget  for  health  actions  was  insufficient  to  respond 
to the Treaty obligation of countering threats to health 7.

9. 

However, following the interinstitutional agreement of 17 May 2006 on 
the  2007–13  financial  framework,  neither  the  merger  of  the  health 
and consumer protection programmes nor the increased budget was 
accepted by the European Parliament and the Council. The outcome 
of the legislative process was a second health programme with similar 
objectives and activities to the PHP, but a reduced budget of 322 mil-
l i o n   e u r o ,   a b o u t   9   %   p e r   a n n u m   l e s s   t h a n   t h a t   o f   t h e   p r e d e c e s s o r 
programme (see Box 2).

6  COM(2005) 115 final.

7 

‘Le maintien du budget actuel 

ne permet pas une mise en oeuvre 

optimale des obligations du Traité, 

ni de répondre à la volonté politique 

d’en faire plus pour les citoyens en 

matière de santé et en matière de 

protection des consommateurs. 

En effet, les ressources financières 

existantes ne permettent pas à la 

Communauté d’assurer de façon 

exhaustive les actions nécessaires 

notamment en ce qui concerne 

la lutte contre les grands fléaux 

ou maladies importantes et la 

coopération entre les États membres 

en matière de santé.’ (Impact 

assessment SEC(2005) 0425, p. 29).

B O X   1

PHP (‘HEALTH DETERMINANTS’ STRAND) — EXAMPLES OF PROJECT ACTIVITIES

• 

Collecting data on falsified prescriptions as an indicator of drug abuse.

• 

Organising a scientific symposium on the medical side-effects of doping.

• 

Preparing a report on compliance with alcohol marketing regulations.

• 

Producing and disseminating information material for migrant sex workers.

• 

Organising a competition to promote smoke-free school classes.

• 

Developing national and regional breastfeeding policy and plans.

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B O X   2

COMPARISON PHP (2003–07) VS PHP2 (2008–13)

Legal basis

Objectives

PHP (2003–07)

PHP2 (2008–13)

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 fi eld of public 
health (2003–08)

Decision No 1350/2007/EC of the 
European Parliament and of the Council 
of 23 October 2007 establishing a 
second programme of Community 
action in the fi eld of health (2008–13)

•   to improve information and knowledge 
for the development of public health
•   to enhance the capability of responding 
rapidly and in a coordinated fashion to 
threats to health

•   to promote health and prevent disease 

through addressing health determinants 
across all policies and activities

•   to generate and disseminate health 

information and knowledge

•   to improve citizens’ health security
•   to promote health, including the 
reduction of health inequalities

Budget according to 
programme decision

354 million euro (for 2003–08)8
i.e. 59 million euro p.a. over 6 years

322 million euro (for 2008–13)
i.e. 53,7 million euro p.a. over 6 years

Funding mechanisms

Grants for actions
Tenders (service contracts)9

Grants for actions
Operating grants
Conferences
Joint actions
Tenders (service contracts)

Programme 
implementation

DG SANCO10

Fully managed by the PHEA11

Impact assessment

Not done

Extended impact assessment (2005)12

8  There are two main reasons for the diff erence between the indicative PHP budget given in the programme decision and the 
fi gure of 231,7 million euro mentioned in paragraph 5 as committed for projects in 2003–07: the indicative budget included about 
58 million euro for 2008 (which was then covered by PHP2), and it also covered expenditure for the Executive Agency.

9  A ceiling of 10 % of the operational budget was set in the AWPs for calls for tenders. This ceiling was increased to 20 % in PHP2.

10 From 2005, grant management and the organisation of calls for proposals were gradually transferred to the Public Health Executive 
Agency (PHEA) (fully operational since 1 January 2007).

11 Commission Decision 2004/858/EC (OJ L 369, 16.12.2004, p. 73). In 2008 the PHEA was renamed the Executive Agency for Health and 
Consumers (EAHC).

12 SEC(2005) 0425, annex to the health and consumer protection strategy and programme proposal (COM(2005) 115 fi nal).

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AUDIT SCOPE AND APPROACH

12

10. 

Health promotion actions can be defined as ‘actions which support people 
to  adopt  and  maintain  healthy  lifestyles,  and  which  create  supportive 
living conditions (environments) for health’ 13. Actions of this type were 
largely  covered  by  the  ‘health  determinants’  strand  of  the  PHP.  The 
a u d i t   a n a l y s e d   w h e t h e r   t h e   r i g h t   c o n d i t i o n s   w e r e   s e t   b y   t h e   E u r o -
p e a n   P a r l i a m e n t ,   t h e   C o u n c i l   a n d   t h e   C o m m i s s i o n   w h e n   d e s i g n i n g 
the programme, and by the Commission and the project coordinators 
when  implementing  it,  for  projects  to  contribute  effectively  to  the 
capacity of European citizens to improve their health.

11. 

The Court examined whether:

(a) 

the design of the PHP provided a suitable framework for the effect-
ive implementation and monitoring of Community-funded health 
p r o m o t i o n   a c t i o n s   c o m p l e m e n t i n g   m e a s u r e s   t a k e n   b y   M e m b e r 
States;

(b) 

the Commission ensured, at the programme implementation and 
p r o j e c t   s e l e c t i o n   s t a g e ,   t h a t   p r o j e c t s   u n d e r   t h e   ‘ h e a l t h   d e t e r -
m i n a n t s ’   s t r a n d   o f   t h e   P H P   w e r e   l i k e l y   t o   a c h i e v e   s u s t a i n a b l e 
results, were complementary and provided EU added value; and

(c) 

the  Commission  and  project  coordinators  ensured  that  projects 
were managed effectively.

12. 

The audit involved:

(a) 

a n   a n a l y s i s   o f   t h e   p r o g r a m m e ’ s   l e g a l   b a s e   a n d   a   r e v i e w   o f   p r o -
gramme evaluations and other relevant documentation;

(b) 

a n   a n a l y s i s   o f   C o m m u n i t y   a c t i o n s   a n d   p o l i c y   d e v e l o p m e n t   i n 
s e l e c t e d   a r e a s   o f   t h e   ‘ h e a l t h   d e t e r m i n a n t s ’   s t r a n d :   d r u g s ,   a l c o -
hol, tobacco, sexual and reproductive health, mental health, and 
nutrition  and  physical  activity 14.  The  analysis  included  a  review 
of Commission policy papers, WHO policy papers, initiatives and 
programmes  in  the  Member  States  and  third  countries,  and  aca-
demic and scientific literature;

(c) 

an  assessment  of  a  sample  of  36  (out  of  a  total  of  149)  projects 
funded from the ‘health determinants’ strand, i.e. one of the three 
s t r a n d s   o f   t h e   P H P   ( 2 0 0 3 – 0 7 ) .   T h e   s a m p l e   c o v e r e d   a l l   p r o j e c t s 
in  the  six  selected  areas  which  had  reached  a  sufficient  level  of 
project maturity at the time of the audit 15. The assessment included 
a   r e v i e w   o f   t h e   p r o j e c t   d o c u m e n t a t i o n ,   i n t e r v i e w s   w i t h   a l l   t h e 
project coordinators and an online survey of project partners 16;

13  Don Nutbeam et al., The Evidence 

of Health Promotion Effectiveness — 

Shaping Public Health in a New 

Europe, International Union for 

Health Promotion and Education 

(IUHPE), 1999, p. 3.

14  The selected policy areas 

comprised all six lifestyle-related 

priority areas of the ‘health 

determinants’ strand. In all these 

areas projects were selected for 

funding in each of the years 2003 
to 2007 (see Annex I).

15  The sample included all projects 

which were either completed 

or had submitted at least a first 

interim technical report in the 

six ‘lifestyle health determinants’ 

policy areas: alcohol, tobacco, 

drugs, nutrition and physical 

activity, sexual and reproductive 

health and mental health.

16  The survey was conducted 

to obtain the other project 

participants’ views on the 

partnerships and the management 

of health promotion projects, 

and ran from 11 March to 

4 April 2008. The questionnaire 

used by the Court was based 

on previous surveys in this field 

(see El Ansari W., ‘Educational 

Partnerships for Health: Do 

Stakeholders Perceive Similar 

Outcomes?’ in Journal of Public 

Health Management and Practice, 

Vol. 9(2), 2003, pp. 136–156). 

Some 505 participants in the 

sampled projects were surveyed, 

242 of whom completed the 

questionnaire in full — a response 

rate of 47,9 %. A further 

19 participants responded to some 

but not all of the survey questions.

Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?

 
 
 
13

(d) 

interviews with staff from DG SANCO and the PHEA;

(e) 

a  quantitative  analysis  of  proposals  submitted,  projects  funded 
and project budgets;

(f) 

consultation of stakeholders at national ministries of health and 
public  health  institutes,  Member  States’  representatives  on  the 
Programme  Committee  and  national  focal  points  in  eight  Mem-
b e r   S t a t e s   ( B e l g i u m ,   E s t o n i a ,   F i n l a n d ,   F r a n c e ,   G e r m a n y ,   L a t v i a , 
 Sweden, United Kingdom); and

(g) 

a   d i s c u s s i o n   o f   r e l e v a n t   i s s u e s   w i t h   a   g r o u p   o f   e x p e r t s   i n   t h e 
field of health promotion and disease prevention at several stages 
d u r i n g   t h e   a u d i t .   T h e   e x p e r t s ’   m a i n   i n p u t   w a s   t o   c o n t r i b u t e   t o 
the  Court’s  analysis,  for  example  by  suggesting  the  RDI  cycle  as 
a  framework  for  analysis  (see  Box  10),  and  to  endorse  the  audit 
observations set out in this report.

Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?

AUDIT OBSERVATIONS

14

PROGRAMME DESIGN

13. 

Programmes are more effective if they are properly designed and the intended 
results are clearly set out. This is more likely to be the case if:

17  European Commission, 

DG Budget, ‘Evaluating EU 

(a) 

t h e   u n d e r l y i n g   l o g i c   o f   t h e   i n t e r v e n t i o n   i s   m a d e   e x p l i c i t   i n   t h e 
programme decision (or its accompanying documentation);

activities: a practical guide for the 

Commission services’, July 2004, 

p. 87.

(b) 

programme objectives are defined which are specific, measurable, 
achievable, relevant, and time-dependent (SMART);

18  COM(2000) 285 final.

(c) 

priorities are set in accordance with the organisation’s strategy; and

the PHP predated the introduction, 

19  The Commission’s proposal for 

(d) 

performance and achievements can be monitored based on robust 
and meaningful indicators.

14. 

15. 

16. 

INTERVENTION LOGIC NOT MADE EXPLICIT

A key element of programme design is defining the intervention logic — 
the hypothetical cause and effect linkages that describe how an inter-
vention is expected to attain its global objectives. In the EU context, 
t h e s e   o v e r a l l   o b j e c t i v e s   o f   p o l i c i e s   a n d   p r o g r a m m e s   a r e   g e n e r a l l y 
d e f i n e d   b y   t h e   T r e a t y .   I n t e r v e n t i o n   l o g i c   p r o v i d e s   t h e   c o n c e p t u a l 
l i n k   f r o m   a n   i n t e r v e n t i o n ’ s   i n p u t s   t o   t h e   p r o d u c t i o n   o f   i t s   o u t p u t s 
and,  subsequently,  to  its  impacts  on  society  in  terms  of  results  and 
outcomes 17. Making explicit the logic of a planned intervention allows 
the  construction  of  a  hierarchy  of  objectives  and  the  identification 
of key indicators for monitoring and evaluation.

Logic models showing how inputs into the various activities will lead to 
t h e   e x p e c t e d   r e s u l t s   a r e   t h e   m o s t   a p p r o p r i a t e   w a y   o f   s h o w i n g   t h e 
intervention logic. Neither the Commission’s legislative proposal for 
t h e   p r o g r a m m e 1 8  n o r   t h e   l e g a l   b a s i s   f o r   t h e   P H P   o r   a n y   o t h e r   r e l -
evant  documents  (such  as  impact  assessments 19  or  AWPs)  explicitly 
described  the  programme’s  intervention  logic  in  this  way.  The  situ-
ation is unchanged for PHP2.

Logic models are used in other areas of EU policy, such as external actions, 
and are common practice in the public health field in other parts of 
the  world  (United  States,  Canada).  For  example,  logic  models  were 
u s e d   f o r   p r o g r a m m e   p l a n n i n g ,   i m p l e m e n t a t i o n   a n d   e v a l u a t i o n   i n 
the Southern Arizona Border Health Careers Opportunity Program 20, 
the Health Improvement Initiative funded by the California Wellness 
Foundation 21 and the Calgary Cross-Cultural Mental Health Consulta-
tion Project 22.

in 2002, of mandatory impact 

assessments and consequently 

was only subject to a limited 

cost-effectiveness analysis. 

By contrast, there has been an 

extended impact assessment for 

PHP2 (see European Commission, 

SEC(2005) 0425; IA for the 

proposed combined health and 

consumer protection strategy and 

programme).

20  ‘How Using a Logic Model 

Refined Our Program to Ensure 

Success’, M. Page, S. H. Parker and 

R. Renger, in: Health Promotion 

Practice OnlineFirst, published on 

28 August 2007.

21  ‘Evaluating the California 

Wellness Foundation’s Health 

Improvement Initiative: A Logic 

Model Approach’, A. Cheadle, 

W. L. Beery, H. P. Greenwald, 

G. D. Nelson, D. Pearson and 

S. Senter, in: Health Promotion 

Practice, April 2003; vol. 4: 

pp. 146–156.

22  ‘Evaluability Assessment: 

A Catalyst for Program Change 

and Improvement’, W. E. Thurston, 

J. Graham and J. Hatfield, 

in: Evaluation and the Health 

Professions, June 2003; vol. 26: 

pp. 206–221.

Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?

 
 
 
 
15

17. 

18. 

In their report on the mid-term evaluation of the PHP 23, the external 
evaluators recommended developing such a systematic and reasoned 
evidence-based  description  of  the  links  between  inputs,  activities, 
outputs and outcomes (see Box 3). The Court has recommended the 
u s e   o f   i n t e r v e n t i o n   l o g i c   f o r   p r o g r a m m e   d e s i g n ,   o b j e c t i v e - s e t t i n g 
and performance measurement for other budgetary areas 24.

In the Court’s view, the definition of SMART programme objectives ( see 
paragraphs 19 to 21) and the setting of robust indicators for an effec-
tive  monitoring  of  the  programme  implementation  (see  paragraphs 
70 to 73) is more difficult to achieve in the absence of a conceptual 
framework.

23  Wija J. Oortwijn et al, Interim 

evaluation of the Public Health 

Programme 2003–08. Final Report, 

RAND Europe technical report, 

2007, p. 6.

24  See Special Report No 9/2007, 

‘Evaluating the RTD framework 

programmes — could the 

Commission approach be 

improved?’(OJ C 26, 30.1.2008), 

paragraphs 34 to 36, and Special 

Report No 7/2008, ‘Intelligent 

energy (2003–06)’ (OJ C 279, 

1.11.2008), paragraphs 18 and 21.

B O X   3

RECOMMENDATIONS OF THE INTERIM EVALUATION OF THE PUBLIC HEALTH 
PROGRAMME 2003–08

‘[The PHP] is, at this interim stage, delivering the programme of work identified in its annual work plans. 
However, this is a good time for building on these achievements by:

• 

• 

• 

developing sharper priorities that are driven by stakeholder expectations and citizens’ needs as well 
as meeting policy goals and high standards of probity;

monitoring its activities against not only the aims of each project but also the overall aims of the 
programme decision;

communicating its priorities and actions more crisply to stakeholders, and targeting tailored mes-
sages to members of the wider public health community.

Understanding what is required to deliver this would be facilitated by developing a logic model capable 
of tracing the precise causal relationships that are anticipated to connect the programme activities 
to its intended outcomes.’

(Wija J. Oortwijn et al, Interim evaluation of the Public Health Programme 2003–08. Final Report, RAND Europe technical report, 
2007, p. 6).

Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?

 
 
16

PROGRAMME OBJECTIVES NEITHER SPECIFIC, 
NOR MEASURABLE OR TIME-DEPENDENT

19.  Objectives are defined, in the Commission’s activity-based management 
(ABM) system, as the desired effects of an activity. They should not be 
a description of the activity itself, but rather illustrate the change to 
be achieved by that activity 25. The setting of SMART objectives for all 
sectors  of  EU  activity  covered  by  the  budget  is  an  obligation  under 
the Financial Regulation 26.

20.  Without an explicit intervention logic it is difficult to set coherent pro-
gramme objectives. In fact, as illustrated by the ‘health determinants’ 
strand, the PHP programme decision listed the possible activities in 
very broad and general terms. The global policy objective, ‘to promote 
h e a l t h   a n d   p r e v e n t   d i s e a s e   t h r o u g h   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 
across  all  policies  and  activities’,  was  not  broken  down  into  specific, 
measurable and time-dependent targets (see Box 4).

21. 

22. 

23. 

It is not obvious from the programme decision how these activities are 
expected  to  contribute  to  the  broad  policy  objective  of  promoting 
h e a l t h   a n d   p r e v e n t i n g   d i s e a s e ,   o r   h o w   a c h i e v e m e n t   o f   t h i s   g l o b a l 
objective could be assessed.

ABSENCE OF STRATEGIC PLANNING AND LACK 
OF PRIORITY-SETTING

If spending programmes are to have any measurable impact, they need to 
be concentrated on selected activities that are identified through stra-
tegic planning according to a rigorous set of priorities. The number of 
priorities should be commensurate with the available budget, as hav-
ing  too  many  priorities  will  reduce  the  chances  of  achieving  impact 
in any individual area.

Each year the EU Member States spend an average of 1 400 euro per 
capita on health 27. While this expenditure includes health promotion 
and  health  information  measures,  the  bulk  of  it  is  related  to  deliv-
ery  of  health  services  and  medical  care,  which  the  Treaty  makes  the 
exclusive remit of Member States.

25  European Commission, SPP/ABM 

guide, second edition, October 

2004, p. 25.

26  Article 27(3) of Council 

Regulation (EC, Euratom) 

No 1605/2002 of 25 June 2002 on 

the Financial Regulation applicable 

to the general budget of the 

European Communities (OJ L 248, 

16.9.2002, p. 1).

27  WHO Regional Office for Europe, 

Copenhagen, ‘Public expenditure 

on health, purchasing power parity 

euro per capita, WHO estimates for 

2003–05’, Health for All database 

(HFA-DB), (http://www.euro.who.

int/hfadb), October 2008.

Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?

 
 
 
 
 
17

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Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?

1

2

3

4

B O X   4

D
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S

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28  These nine topics were alcohol, 

tobacco, drugs, nutrition and 

physical activity, sexual and 

reproductive health and HIV, 

mental health, socioeconomic 

determinants of health, 

environmental determinants, and 

disease and injury prevention. 

In 2003 and 2004, additional 

topics were training in public 

health (later changed to capacity 

building) and health promotion 

in particular settings. In 2005, the 

latter topic was discontinued and 

genetic determinants of health 

was added.

18

24. 

25. 

26. 

27. 

28. 

The  PHP  budget  of  approximately  59  million  euro  per  year  assigned 
t o   h e a l t h   p r o m o t i o n   a n d   i n f o r m a t i o n   m e a s u r e s ,   a n d   t o   c o u n t e r i n g 
health threats, amounts to 13 cents for each European citizen. In this 
situation,  an  appropriate  response  by  the  EU  would  be  to  target  its 
relatively  small  budget  on  a  few  selected  priority  activities  in  areas 
o f   c l e a r   E u r o p e a n   a d d e d   v a l u e   —   t h o s e   i s s u e s   w h i c h   c a n   b e   m o s t 
effectively addressed at international level.

The priorities to be addressed in the field of public health are set out 
in  AWPs,  which  provide  a  source  of  guidance  for  project  proposers. 
T h e   A W P s   f o r   2 0 0 3 – 0 7   c o n t a i n e d   e x t e n s i v e   l i s t s   o f   t o p i c s   f o r   e a c h 
programme strand, covering a broad range of issues. Each year, nine 
s u c h   t o p i c s   w e r e   p r o p o s e d   u n d e r   t h e   ‘ h e a l t h   d e t e r m i n a n t s ’   s t r a n d 
(with an annual budget of approximately 18 million euro). A further 
three areas were funded in some but not all years 28 (see Annex I).

Between one and seven annual areas for potential action were set, rang-
ing from specific to general, for each of these nine topics (see exam-
ples  in  Box  5).  These  annual  ‘action  areas’  were  defined  in  terms  of 
a c t i v i t i e s   f o r   w h i c h   p r o j e c t   p r o p o s a l s   c o u l d   b e   s u b m i t t e d ,   n o t   a s 
objectives towards which progress could be assessed.

As a result, the AWPs for 2003–07 set a total of 154 ‘action areas’ for the 
‘health determinants’ strand alone. During the same period, only 149 
projects  were  funded  under  that  programme  strand,  meaning  that, 
even  under  optimum  circumstances,  not  all  of  these  areas  could  be 
tackled through a project. In reality, coverage of priorities was even 
l o w e r   b e c a u s e   s e v e r a l   p r o j e c t s   a d d r e s s e d   t h e   s a m e   ‘ a c t i o n   a r e a s ’ . 
M o r e o v e r ,   b r o a d   h e a l t h   t o p i c s   l i k e   n u t r i t i o n ,   a l c o h o l   a n d   m e n t a l 
health  were  often  only  addressed  by  one  or  two  projects  in  a  given 
year (see Annex I).

Since organisations and consortia were invited to apply for funding 
under often very general headings (see examples in Box 5), proposals 
submitted to the Commission very often lacked strategic focus. This 
is  a  problem  in  particular  in  areas  where  projects  were  expected  to 
provide background studies or otherwise contribute to policy devel-
opment. In these areas, tendering (and the use of service contracts) 
allows for a more precise definition of the expected deliverables. This 
was  however  limited  to  a  maximum  of  10  %  of  the  PHP  budget.  This 
ceiling has been increased to 20 % under PHP2 (see Box 2).

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B O X   5

ANNUAL ‘ACTION AREAS’ FOR THE PHP ‘HEALTH DETERMINANTS’ STRAND

Topic

Tobacco

Alcohol

Drugs

Nutrition and physical 
activity

Mental health

Sexual and reproductive 
health

Injury prevention

Environmental 
determinants

Socioeconomic 
determinants

Annual ‘action areas’ defi ned in AWPs (examples)
(Source: AWPs for the implementation of the PHP, 2003–07)

‘Promote strategies to ‘de-normalise’ smoking, including strategies and 
measures to reduce the prevalence of smoking.’ (2004)

‘To assess the enforcement of national laws and self-regulation on the 
advertising and marketing of alcoholic beverages.’ (2004)

‘Priority will be given to proposals on:
•   treatment and reinsertion activities covering all Member States and including 

both misuse/abuse of legal/illegal drugs;

•   best practice on improving the availability of prevention and harm reduction 
services and giving priority to HIV/AIDS and other blood-borne infections.’ 
(2005)

‘Develop innovative measures to improve dietary habits and physical activity 
habits in all population groups.’ (2003)

‘Building on the review of existing best practices, develop strategies for 
implementation of interventions in relevant settings aiming at promoting 
mental health and preventing depression, suicide and related disorders.’ (2003)

‘Taking account of information from the health monitoring system, develop 
health promotion strategies and defi ne best practices to address sexual 
education (teenage pregnancy, family planning) and prevention of sexually 
transmitted diseases such as HIV/AIDS, including consideration of approaches in 
school settings and those targeting specifi c groups.’ (2004)

‘Support will be given to exchanging best practice on child safety for all Member 
States, EEA and candidate countries and to promoting child safety through a 
European conference. Special attention will be paid to tackling physical violence 
and danger awareness by organising hands-on injury-prevention activities.’ 
(2006)

‘Priority will be given in 2004 to actions which support the development 
of health and environment policies and strategies, and the integration of 
health and environment concerns in other Community policies. A specifi c 
focus will be on the provision of advice and expertise to develop activities, 
including legislative work and other initiatives on health aspects related to 
the environment, particularly in relation to air pollution (including indoor air 
pollution) and electromagnetic fi elds.’

‘Tackling socioeconomic determinants will continue to be a key priority for the 
programme. In 2004, work will be supported on:
1.  identifying eff ective strategies to address inequalities in health and the health 
impact of socioeconomic determinants in specifi c settings and for population 
groups which are particularly aff ected, in particular in socially excluded, 
minority and migrant populations;

2.  developing strategies to address the health eff ects of unemployment and 

precarious employment conditions.’

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29. 

30. 

31. 

INDICATORS AT PROGRAMME LEVEL INADEQUATE 
TO MONITOR ACHIEVEMENTS

Under ABM, the Commission DGs are required to define clear, meaning-
ful and logically linked objectives for their activities, and to identify 
a p p r o p r i a t e   p e r f o r m a n c e   i n d i c a t o r s   f o r   m o n i t o r i n g   a c h i e v e m e n t . 
I n d i c a t o r s   s h o u l d   b e   d e f i n e d   b o t h   f o r   i m p a c t   ( d i f f e r e n c e   m a d e   t o 
the  target  group)  and  output  (means  through  which  the  difference 
will be brought about) 29.

29  European Commission, 

Secretariat General: SPP/ABM 

guide, second edition, October 

2004, p. 26 ff.

The absence from the PHP decision or the AWPs of an explicit inter-
v e n t i o n   l o g i c   a n d   s p e c i f i c ,   m e a s u r a b l e   a n d   t i m e - d e p e n d e n t   o b j e c -
tives impeded the development of such performance indicators. For 
example, DG SANCO’s annual management plans did not include any 
impact  indicator  for  the  ‘health  determinants’  objective  until  2006. 
T h e   i m p a c t   i n d i c a t o r   H e a l t h y   L i f e   Y e a r s   ( m e a s u r i n g   t h e   n u m b e r   o f 
y e a r s   t h a t   a   p e r s o n   o f   a   c e r t a i n   a g e   c a n   e x p e c t   t o   l i v e   w i t h o u t   i l l 
health) was the outcome of a project co-financed by the Commission 
and was specified as a Lisbon structural indicator in 2005.

However, even the impact indicator subsequently developed was still 
t o o   g e n e r a l   t o   b e   u s e d   f o r   m o n i t o r i n g   o r   e v a l u a t i o n   a n d   w a s   n o t 
linked to any quantified target. As the example illustrates, the impact 
indicator  was  framed  as  an  objective  rather  than  a  way  to  measure 
achievements (see Box 6).

B O X   6

IMPACT INDICATOR FOR PHP ‘HEALTH DETERMINANTS’ STRAND IN THE 2006 AMP

‘Increase awareness and response from stakeholders and public policy, with regard to lifestyle-
related health determinants, particularly concerning nutrition and physical activity, alcohol and 
diseases with a key public health relevance.’

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32. 

33. 

The situation has improved recently, in that the activity statements for 
the  2009  preliminary  draft  budget  set  impact  indicators  and  quan-
t i f i e d   t a r g e t s   i n   r e l a t i o n   t o   t h e   p u b l i c   a w a r e n e s s   o f   c e r t a i n   h e a l t h 
determinants (see Box 7).

However, at the time of this report the Commission had not yet used 
these indicators to assess the effectiveness of the PHP as a whole or 
of  individual  projects.  In  fact,  the  audit  found  that  the  Commission 
h a d   n o t   s e t   u p   a n   a d e q u a t e   m o n i t o r i n g   s y s t e m   a t   a n y   s t a g e   w h i c h 
would have enabled it to carry out such a performance measurement 
(see paragraphs 70 to 73).

B O X   7

SELECTED INDICATORS FOR THE OBJECTIVE OF ‘FOSTERING GOOD HEALTH 
IN AN AGEING EUROPE’ IN THE 2009 AMP

• 

‘
Level of public awareness of unhealthy behaviours and lifestyle-related health risks and health deter-
minants, in particular on nutrition, physical activity and alcohol’ to be raised from 66 % to 80 %;

•  Share of citizens who have their blood pressure measured each year’ to be raised from 59 % to 

‘
80 %;

•  Share of population aware of the health risks of tobacco smoke for non-smokers’ raised from 75 % 

‘
to 80 %.

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PROGRAMME IMPLEMENTATION: FROM PROJECT DESIGN 
TO RESULTS

34. 

For  a  programme  to  be  effective,  its  projects  need  to  achieve  posi-
tive  results.  This  is  more  likely  to  be  the  case  if,  before  a  project  is 
l a u n c h e d ,   i t s   o b j e c t i v e s ,   t a r g e t   g r o u p s   a n d   i n t e n d e d   r e s u l t s   h a v e 
been defined and it has been identified how the results will produce 
the intended impacts.

30  ‘Rules, criteria and procedures 

for the selection and funding of 

actions under the public health 

programme’ (OJ C 62, 15.3.2003).

In this policy area, effective implementation also requires from the Com-
mission, as programme manager, that

(a) 

i t   h a s   a n   a d e q u a t e   o v e r v i e w   o f   i t s   p r o j e c t   p o r t f o l i o   t o   e n s u r e 
coherence and consistency; and

(b) 

the  projects  funded  clearly  demonstrate  European  added  value 
(EAV).

PROJECT OBJECTIVES NOT SPECIFIC, VERIFIABLE 
AND QUANTIFIABLE

Projects should be designed in a way that makes it likely they will be 
effective. As at programme level, an important part of project design 
i s   t o   s e t   S M A R T   o b j e c t i v e s ;   t h e s e   s h o u l d   b e   l o g i c a l l y   d e r i v e d   f r o m 
the policy objectives as defined in the programme decision. The PHP 
award criteria required proposers to define ‘specific and realistic objec-
tives … The project must set verifiable and quantifiable objectives’ 30.

The Court’s analysis of the grant agreements for the audited projects 
s h o w e d   t h a t   p r o m o t e r s   p r e s e n t e d   a   m i x t u r e   o f   a c t i v i t i e s   a n d   o u t -
puts  rather  than  objectives  when  submitting  their  proposals.  Typi-
cal  project  ‘objectives’  were  the  exchange  of  information  between 
o r g a n i s a t i o n s   i n   t h e   f i e l d ,   c a p a c i t y - b u i l d i n g   a n d   t h e   p r o m o t i o n   o f 
‘good  practices’  (see  Box  8).  However,  the  Commission  took  no  cor-
rective measure to address this shortcoming before entering into the 
grant agreement.

35. 

36. 

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37. 

The Court’s detailed analysis of whether the project objectives stated in 
the grant agreements were to qualify as being SMART is presented in 
Annex  III.  It  concludes  that  not  one  sampled  project  had  objectives 
that  were  fully  SMART.  Objectives  were  not  stated  in  a  measurable 
and time-dependent format, and it was unclear to what degree they 
were attainable. They were not expressed in terms of targets towards 
which progress could be monitored at a later stage. However, where 
projects did define a specific target group, the stated objectives were 
generally relevant to the target group (see paragraph 40).

B O X   8

PHP (‘HEALTH DETERMINANTS’ STRAND) — EXAMPLES OF PROJECT OBJECTIVES 
FROM GRANT AGREEMENTS

A & M (‘European Centre AIDS and Mobility’):

•  To stimulate collaboration and networking between European Member States and applicant coun-

‘
tries on the issue of (young) migrants’

•  To assess and document best practice with respect to prevention, care and support in Europe in the 

‘
field of HIV/AIDS and migrant, mobile and young people’

CHOB (‘Children, obesity and associated avoidable chronic diseases’):

•  To measure and analyse the impact of food marketing to children and young people’

‘

•  To determine and consider policy options aimed at addressing obesity in children’

‘

ELSA  (‘Enforcement  of  National  Laws  and  Self-Regulation  on  Advertising  and  Marketing 
of Alcohol’):

‘
•  To create an expert network of partners from 28 European countries, to train the partners in the 
assessment of national laws and self-regulation and to convene three meetings of the network’

•  To prepare a report on the existing national laws, structures and regulation and self-regulation 

‘
mechanisms on the advertising and marketing of alcoholic beverages’

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38. 

39. 

However, this does not imply that it is impossible to set SMART objec-
t i v e s   i n   t h i s   f i e l d .   W i t h i n   t h e   s a m p l e   a u d i t e d ,   t h e   a u d i t   a l s o   f o u n d 
a n   e x a m p l e   o f   a   p r o j e c t   w i t h   s p e c i f i c   o b j e c t i v e s   w h i c h   c o u l d   h a v e 
a c h i e v e d   f u l l   c o m p l i a n c e   w i t h   t h e   S M A R T   c r i t e r i a   a f t e r   o n l y   m i n o r 
adjustments (see Box 9).

31  ‘Rules, criteria and procedures 

for the selection and funding of 

actions under the public health 

programme’ (OJ C 62, 15.3.2003).

DEFINITION OF EXPECTED PROJECT RESULTS, IDENTIFICATION 
OF TARGET GROUPS AND PLANNING FOR SUSTAINABILITY 
THE EXCEPTION RATHER THAN THE RULE

The PHP award criteria required project proposers to aim at ‘… producing 
lasting  results  conducive  to  the  realisation  of  the  programme’s  objec-
tives’ 31.  Projects  were  thus  expected  to  specify  the  intended  target 
group  and  to  define  what  results  they  intended  to  achieve  and  how 
those results would be sustained beyond the project term.

B O X   9

PHP (‘HEALTH DETERMINANTS’ STRAND) — ‘PEER DRIVE CLEAN! PROJECT’ — 
EXAMPLE OF SMART OBJECTIVES NEARLY ACHIEVED

‘The global objective is to sensitise young adults between 18 and 24 years to the dangers of alcohol 
and drug use and to achieve a modification of the eventual high risk drug use of the target group at an 
early stage.(...) The target group should be convinced through face-to-face actions of PEER educators 
to abandon the consumption of intoxicating substances while driving a motorised vehicle.’

Is the formulation of the objectives SMART?

• 

Specific

: yes (target group and what should be changed is clear)

• 

Measurable

: no (‘to sensitise’, ‘to convince’)

• 

Achievable

: yes

• 

Relevant

: yes (young drivers have a higher risk of drink-driving accidents)

• 

Time-dependent

: no

This project’s objectives meet the SMART criteria in all except the measurable and time-dependent 
aspects. These two dimensions could have been satisfied by setting a target for awareness (e.g. ‘by 
the end of the project, X % of the students taking the driving exam in the participating driving schools 
should be able to name X dangers of alcohol and drug use’) or, better still, for behavioural change 
(e.g. ‘none of the participants to be caught drink-driving in the first year after obtaining their driving 
licence’).

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TARGET GROUP NOT SPECIFIED IN A MAJORITY OF CASES

40.  Only  16  of  the  grant  agreements  for  the  sampled  health  promotion 
projects clearly specified a target group in the grant agreements. Of 
these, only nine specified what changes the project intended to bring 
to that target group. Typically, PHP projects do not directly address 
European  citizens  as  the  ultimate  target  group  of  health  promotion 
actions (e.g. people living with HIV, overweight young people, drug 
users, people at risk of becoming alcohol addicts) but work through 
‘intermediate’ groups of health professionals or policymakers. How-
e v e r ,   n i n e   o u t   o f   t h e   3 6   p r o j e c t s   a u d i t e d   b y   t h e   C o u r t   w e r e   s e t   u p 
f r o m   t h e   o u t s e t   t o   h a v e   a   d i r e c t   h e a l t h   i m p a c t   o n   t h e   p o p u l a t i o n . 
They  represented  more  than  half  of  the  projects  (56  %)  specifying  a 
target group.

41. 

42. 

EXPECTED RESULTS NOT LINKED TO INTENDED IMPACTS

Grant agreements stated each project’s ‘expected results’ under a sepa-
r a t e   h e a d i n g .   H o w e v e r ,   t h e   C o u r t ’ s   a u d i t   o f   a   s a m p l e   o f   p r o j e c t s 
f o u n d   t h a t   t h i s   a m o u n t e d   t o   a   l i s t   o f   p r o j e c t   o u t p u t s ,   d e l i v e r a b l e s 
and activities (e.g. ‘a meeting will be held’, ‘a training manual will be 
developed’), with no explanation how these activities would achieve 
c h a n g e   f o r   t h e   d i r e c t   a d d r e s s e e s .   T h e   p o o r   d e f i n i t i o n   o f   e x p e c t e d 
results and the absence of indicators meant that achievements could 
be neither demonstrated nor disproved.

The  Court  also  found  that  proposals  did  not  clarify  the  logical  links 
between projects and their possible social benefits; nor was the exist-
ence of such links ascertained by the Commission or the project coor-
d i n a t o r s   d u r i n g   t h e   s e l e c t i o n   p r o c e s s   o r   p r i o r   t o   t h e   s i g n a t u r e   o f 
grant  agreements.  The  underlying  assumption  seems  to  have  been 
t h a t   p o s i t i v e   e f f e c t s   w o u l d   f o l l o w   f r o m   p l a c i n g   t h e   h e a l t h   p r o m o -
tion issue on the political agenda, building networks and exchanging 
information. However, at no stage was it explained how project activi-
t i e s   m i g h t   h a v e   a   t r i c k l e - d o w n   e f f e c t   t h a t   w o u l d   a c t u a l l y   i m p r o v e 
people’s  capacity  to  choose  healthy  lifestyles.  This  also  underlines 
the importance of having an intervention logic in place.

PLANNING FOR SUSTAINABILITY OF RESULTS IN VERY FEW CASES

43.  When assessing health promotion projects, the different stages of the 
cycle can be classified as: study and research projects, development 
p r o j e c t s ,   i m p l e m e n t a t i o n   p r o j e c t s   a n d   ‘ g o i n g - t o - s c a l e ’   p r o j e c t s , 
known as the RDI cycle (see Box 10).

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44. 

45. 

PHP projects, with their limited duration (two to three years in most 
cases) and limited resources, are not designed to cover the full cycle 
o f   h e a l t h   p r o m o t i o n   a c t i o n s   f r o m   s e t t i n g   u p   a n   e v i d e n c e   b a s e   t o 
d e v e l o p i n g   a n d   i m p l e m e n t i n g   p u b l i c   i n t e r v e n t i o n   a n d   c r e a t i n g   a 
l a s t i n g   h e a l t h   i m p a c t .   T h e y   c a n   o n l y   a d d r e s s   p a r t   o f   t h i s   p r o c e s s . 
Nonetheless,  there  should  be  an  indicative  plan  of  how  the  results 
of a project can be taken up at the next step in the cycle.

None of the audited projects had a plan for the take-up of their results by 
the next level in the RDI cycle or how their results could be sustained 
over time. The project coordinators interviewed usually understood 
sustainability  to  mean  the  continuation  of  project  activities  rather 
than  the  effective  use  of  results  after  the  project  term.  In  all  cases 
audited, the outputs created during the project, such as websites or 
databases, were not updated after project closure.

46.  With a few exceptions, it was found that projects did not even contain 
a plan for sustainability and take-up of their results beyond the end 
of the project funding period. They focused on obtaining a follow-up 
grant  from  the  Commission  so  that  project  activities  could  be  con-
tinued. The most common attitude was that project results could be 
sustained  only  if  the  partners  could  continue  to  secure  Community 
funding.

B O X   1 0

THE RDI CYCLE

The research–development–implementation (RDI) cycle is a concept describing the sequence of 
steps in public health programme development, from fact-finding and creating an evidence base 
to developing a strategy or work plan, pilot testing and finally full-scale implementation.

Projects covering only one of these steps can be considered sustainable if their results are taken 
up and used by the next step in the cycle. For instance, research projects should ensure that results 
will be taken to the development stage, and projects developing an intervention should use the 
evidence base previously established by research projects and plan for (pilot) implementation.

The following project categories were used for this audit:

• 

Study and research projects (e.g. collection of data);

• 

Development projects (e.g. policy, guidelines or programme development);

• 

Implementation projects (e.g. piloting, training and capacity building); and

• 

‘Going-to-scale’ projects (e.g.dissemination, implementation on a wider scale).

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47. 

48. 

CONTINUOUS FUNDING OF NETWORKS FOR MORE THAN 10 YEARS

Networks of health professionals and organisations from different Mem-
ber States provide platforms for pooling experience and exchanging 
best  practices;  they  are  thus  a  tool  for  achieving  certain  results  but 
not strictly a result in themselves. Due to their nature, they cannot be 
classified neatly as belonging to any one stage of the RDI cycle. The 
sample of projects audited contained 13 networks. When interviewed, 
coordinators stated that building the network was the essential pur-
pose and outcome of their respective projects.

Networks were particularly dependent on continuous Community fund-
ing. Some networks had received funding under the PHP and its pred-
ecessor programmes for more than 10 years (see Figure 2). When no 
follow-up grant was awarded by the Commission, the network activi-
ties ceased and the network dissolved.

F I G U R E   2

PHP (‘HEALTH DETERMINANTS’ STRAND) — EXAMPLES OF RECURRENT 
NETWORKING PROJECTS

(Europe against AIDS
action plan 1991–94)
Pre-1996

8 action programmes 1996–2002
(Action programme on AIDS 
and communicable diseases:
Action programme on cancer)

(2003–07)
PHP

(2008–13)
PHP2

AIDS and mobility
(since 1991) 

TAMPEP
(since 1993) 

17 years (ongoing)

15 years (ongoing)

ENSP
(1996–2008) 

13 years

ENYPAT
(1996–2006) 

10 years

1991

1996

2003

2008

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49. 

50. 

51. 

It should also be noted that none of the PHP funding mechanisms lent 
themselves to continuous financing of the operating expenditure of 
networks. The PHP calls for proposals offered grants for actions (Art–
icle 108(1)(a) of the Financial Regulation), but not operating grants. 
As a consequence, networks had to be designated as one or the other 
type of project and grant agreements had to include project activities 
through which operating expenditure could be covered. Networks also 
had to respond to calls for proposals and submit to the same selection 
procedures  as  other  projects.  This  situation  placed  an  unnecessary 
administrative burden on both the participants and the Commission. 
Under PHP2, networks can now be funded via a dedicated operating 
grant mechanism (see Box 2).

COMPLEMENTARITY OF PROJECTS AND CONSISTENCY 
OF PROJECT PORTFOLIO NOT ADEQUATELY MONITORED

Effective programme implementation requires the programme manager 
(i.e. the Commission or the executive agency) to have an accurate and 
up-to-date overview of the project portfolio. This enables overlap and 
duplication of effort to be avoided, synergies to be created between 
the  actions  undertaken,  and  programme  planning,  implementation 
and follow-up to be executed in a coherent and consistent manner.

NO MONITORING OF PROJECT PORTFOLIO

At the time of the audit, neither DG SANCO nor the PHEA could refer to a 
monitoring tool which provided an overview of projects undertaken, 
in terms of the priorities they addressed, the activities they encom-
passed and the results they achieved (see paragraphs 70 to 73). This 
created  an  obstacle  to  ensuring  consistency  over  time  in  the  imple-
m e n t a t i o n   o f   t h e   p r o g r a m m e .   I n   t h e   a b s e n c e   o f   s u c h   c o n s o l i d a t e d 
i n f o r m a t i o n ,   t h e   C o m m i s s i o n   m a d e   d e c i s i o n s   o n   i t s   A W P   p r i o r i t i e s 
without  knowing  which  projects  already  existed  in  each  policy  area 
or which activities were covered.

FRAGMENTATION, OVERLAP OF PROJECTS AND PARALLEL 
IMPLEMENTATION OF SIMILAR ACTIONS

52.  With a view to obtaining a conclusion on complementarity in the absence 
of such an overview, the Court analysed all projects addressing one of 
the six lifestyle-related health determinants (alcohol, tobacco, drugs, 
nutrition and physical activity, sexual and reproductive health, mental 
health)  (see  Annex  II).  This  detailed  analysis  was  complemented  by 
a  quantitative  analysis,  stakeholder  interviews  and  consultation  of 
experts.

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53. 

The analysis showed that complementarity between projects and consist-
ency within the overall project portolio were lacking because of:

(a) 

f r a g m e n t a t i o n
:  i n   t h e   ‘ d r u g s ’   p o l i c y   a r e a ,   p r o j e c t s   f u n d e d   f r o m 
the PHP were few in number and addressed very diverse aspects 
o f   t h e   d r u g s   p r o b l e m ,   r a n g i n g   f r o m   d o p i n g   i n   l e i s u r e   s p o r t s   t o 
falsified prescriptions as an indicator for the abuse of legal drugs, 
and  to  drug  prevention  in  prisons.  A  similar  situation  was  found 
i n   t h e   ‘ n u t r i t i o n   a n d   p h y s i c a l   a c t i v i t y ’   p o l i c y   a r e a ,   w h e r e   t h e 
few  PHP  projects  were  very  dissimilar  in  terms  of  objectives  and 
activities;

(b) 

a c t i v i t y   o v e r l a p   a n d   t h e   d u p l i c a t i o n   o f   w o r k
:  PHP  p r o j e c t s   i n   t h e 
‘alcohol’  policy  area  were  characterised  by  a  great  deal  of  over-
lap  in  the  partners  involved  and  the  information  produced,  not 
only  between  the  projects  in  the  sample  but  also  with  regard  to 
a   p r o j e c t   f u n d e d   f r o m   t h e   p r e d e c e s s o r   C o m m u n i t y   A c t i o n   P r o -
g r a m m e   o n   H e a l t h   P r o m o t i o n   a n d   a   r e p o r t   p r o d u c e d   f o l l o w i n g 
an  earlier  call  for  tender.  In  the  ‘mental  health’  policy  area,  two 
projects with identical activities were funded under consecutive 
calls for proposals;

(c) 

: in the ‘tobacco’ policy 
parallel implementation of similar actions
area, the main projects financed from the PHP were two large net-
works established to combat smoking, one targeting the general 
population  and  the  other  young  people  only.  In  the  ‘sexual  and 
reproductive health’ policy area, the PHP funded many networks 
whose objective was to strengthen the capacity of the participat-
ing NGOs. They found their ‘niche’ by focusing on different direct 
and  indirect  addressees:  NGOs  in  central  European  countries,  or 
NGOs working with migrants, migrant sex workers, local sex work-
ers, injection-drug users or people living with HIV/AIDS.

54. 

In all these areas there are already other mechanisms which could take 
the place of the PHP: platforms, working groups, agencies (EMCDDA, 
ECDC),  WHO  and  other  EU  programmes  such  as  the  RTD  framework 
p r o g r a m m e s   o r   t h e   D r u g s   P r e v e n t i o n   a n d   I n f o r m a t i o n   P r o g r a m m e 
(see paragraph 64 and Box 12).

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LIMITED EUROPEAN ADDED VALUE

In accordance with the principles of subsidiarity and proportionality 
set out in the Treaty, Community action on matters which do not fall 
w i t h i n   t h e   e x c l u s i v e   c o m p e t e n c e   o f   t h e   C o m m u n i t y ,   s u c h   a s   p u b -
lic  health,  should  be  undertaken  only  if  and  in  so  far  as,  by  reason 
o f   i t s   s c a l e   o r   e f f e c t s ,   i t s   o b j e c t i v e   c a n   b e   b e t t e r   a c h i e v e d   b y   t h e 
Community 32.

32  See Articles 2 and 5 of the Treaty 

on European Union, together 

with paragraph 5 of the Protocol 

(No 30) on the application of the 

principles of subsidiarity and 

proportionality.

EAV BY PROGRAMME STRAND: ‘HEALTH DETERMINANTS’ STRAND LEAST 
LIKELY TO PROVIDE EAV

A key ramification of the subsidiarity principle is that EU health policy 
s h o u l d   c o n s i s t   o n l y   o f   a c t i o n s   d e l i v e r i n g   o u t p u t   w h i c h   c a n n o t   b e 
achieved by Member States acting individually, or which deliver econ-
omies of scale. The ‘health threats’ strand deals with the surveillance 
of  communicable  diseases,  and  the  ‘health  information’  strand  with 
the  collection  of  comparable  data  and  the  development  of  common 
indicators. These two strands thus focus on issues which clearly can-
not  be  managed  by  Member  States  acting  individually.  However,  in 
the Court’s view other mechanisms for cooperation between Member 
States could equally play this role (see paragraphs 64 and 65).

In contrast, tackling health determinants to promote health and pre-
v e n t   d i s e a s e   i s   n o t   a   c r o s s - b o r d e r   t a s k   p e r   s e .   I n   p a r t i c u l a r ,   d i r e c t 
health promotion — health education and influencing lifestyles — is 
a culture-specific activity which needs to take account of the specifi-
cities  of  the  national  public  health  system  and  local  characteristics 
and needs. Therefore, when comparing the three strands of the PHP, 
the ‘health determinants’ strand appears to have the least potential 
for providing EAV.

EAV BY PROJECT TYPE: NETWORKS MOST LIKELY TO PROVIDE EAV

At the level of health promotion projects under the ‘health determinants’ 
s t r a n d ,   t h e   C o u r t   h a s   a s s e s s e d   E A V   b y   t a k i n g   i n t o   c o n s i d e r a t i o n   a 
range  of  arguments  why  a  measure  could  only  be  taken  —  or  would 
b e   b e t t e r   t a k e n   —   a t   E u r o p e a n   l e v e l .   T h e   a n a l y s i s   t o o k   a c c o u n t   o f 
the four project categories defined by the RDI cycle framework, while 
networks were considered separately (see Box 10).

55. 

56. 

57. 

58. 

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33  During the period 2003–06, 

‘Life sciences, genomics and 

biotechnology for health’ is one 

of seven major thematic research 

priorities of the European Union’s 

sixth framework programme 

(FP6) aiming at the generation of 

new knowledge and translating 

it into applications that enhance 

human health. To this end 

research organisations carrying 

out both fundamental and applied 

research were supported with an 

indicative budget of 2 514 million 

euro. Such funding opportunities 

existed in the fields of genomic 

approaches to health and disease, 

biotechnology, cancer, HIV/AIDS, 

malaria and tuberculosis. Similar 

funding opportunities existed 

under the FP5 and the current FP7.

59. 

There is a requirement for all projects to involve partners from several 
European countries. A a result of their cross-border nature, networks 
are most likely to exhibit EAV through sharing of expertise, consen-
sus-building and exchange of ‘good practices’ across countries.

60. 

The EAV of the other project types is less obvious.

(a) 

:  EAV  lay  mainly  in  the  fact  that  data 
Study  and  research  projects
were collected from several countries and subject to a compara-
tive analysis. These projects sought to develop a common termin-
ology, set common standards and ensure the comparability of data 
and methods between Member States. However, there was some 
overlap with activities carried out under the ‘health information’ 
s t r a n d ,   a s   w e l l   a s   u n d e r   o t h e r   E U   p r o g r a m m e s   s u c h   a s   t h e   R T D 
framework programmes 33 or the Drugs Prevention and Information 
Programme (see paragraph 54 and Annex II).

(b) 

D e v e l o p m e n t   p r o j e c t s
:   t h e s e   p r o j e c t s ’   E A V   w a s   t h e i r   l i n k   t o   t h e 
d e v e l o p m e n t   o f   E U   p o l i c y .   T h e y   s o u g h t   t o   f u r t h e r   t h e   d e v e l o p -
ment  of  their  respective  priority  areas  at  European  level  and  to 
contribute to agenda-setting across Europe.

(c) 

I m p l e m e n t a t i o n   a n d   ‘ g o i n g - t o - s c a l e ’   p r o j e c t s
:   t h e   E A V   o f   t h e s e 
projects was least apparent. This is because, by their very nature, 
the related activities (such as piloting, training and capacity build-
ing, dissemination and implementation on a wider scale) have to 
happen on the ground, i.e. not at European level but in a particu-
l a r   r e g i o n   o r   c o u n t r y .   F o r   t h i s   c a t e g o r y   o f   p r o j e c t s ,   i t   c o u l d   b e 
argued that activities should be funded by the region or country 
w h e r e   t h e y   t a k e   p l a c e .   F o r   s o m e   p r o j e c t s   t h i s   w a s   i n d e e d   t h e 
case: Community funding was used only for ‘European activities’ 
(e.g. meetings between national coordinators) and not for actual 
interventions or daily country-based activities. However, in other 
c a s e s   f u n d i n g   f r o m   t h e   P H P   w a s   u s e d   f o r   n a t i o n a l   o r   r e g i o n a l 
activities.

61. 

The Court considers that all types of projects under the ‘health determin-
a n t s ’   s t r a n d   h a v e   t h e   p o t e n t i a l   t o   d e l i v e r   E A V   t o   s o m e   d e g r e e ,   b y 
bringing together partners from different EU Member States. However, 
applying  the  criteria  used  by  the  Court,  the  most  obvious  providers 
of EAV in the sample were networks.

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B O X   1 1

SURVEY OF PROJECT PARTNERS

‘The project’s objectives could only be realised by participating 
in the European Public Health Programme.’

0 %

10 %

20 %

30 %

40 %

50 %

60 %

strongly agree

agree

32 %

36 %

neither agree nor disagree

15 %

disagree

9 %

strongly disagree

2 %

don’t know

5 %

‘Participating in the European Public Health Programme is more effective 
than participating in a national health project.’

0 %

10 %

20 %

30 %

40 %

50 %

60 %

strongly agree

31 %

agree

neither agree nor disagree

29 %

26 %

disagree

6 %

strongly disagree

2 %

don’t know

6 %

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62. 

63. 

STAKEHOLDERS POSITIVE ABOUT THEIR PARTICIPATION 
IN THE PROGRAMME

Participants widely affirmed the European dimension of their projects. 
A large majority (68 %) of project partners responding to the Court’s 
survey agreed or strongly agreed that their project objectives could 
only  be  realised  by  participating  in  the  PHP.  Some  60  %  considered 
p a r t i c i p a t i o n   i n   t h e   P H P   t o   b e   m o r e   e f f e c t i v e   t h a n   p a r t i c i p a t i o n   i n 
national projects (see Box 11).

34  Wija J. Oortwijn et al., Interim 

evaluation of the Public Health 

Programme 2003–08. Final Report. 

RAND Europe technical report, 

2007, p. 63.

Stakeholders  in  the  Member  States  found  that  the  programme  as  a 
whole was also a source of EAV in that it provided an opportunity to 
pool  knowledge  and  share  ‘good  practices’.  The  representatives  of 
national  authorities  who  were  interviewed  in  the  framework  of  the 
a u d i t   ( P r o g r a m m e   C o m m i t t e e   m e m b e r s   a n d   n a t i o n a l   f o c a l   p o i n t s ) 
agreed that the PHP addressed the need for Member States to cooper-
ate by exchanging information, experience and guidelines on public 
h e a l t h   p r o b l e m s   o f   c o n c e r n   t o   a l l .   T h e   m i d - t e r m   e v a l u a t i o n   o f   t h e 
PHP concluded that the rationale for European intervention in public 
health is widely accepted and supported 34.

B O X   1 2

EXAMPLES OF EXISTING COORDINATION MECHANISMS (see Annex II for details)

• 

European Monitoring Centre for Drugs and Drugs Addiction (EMCDDA)

• 

European Alcohol and Health Forum

• 

EU Platform on Diet, Physical Activity and Health

• 

European Centre for Disease Prevention and Control (ECDC)

• 

Think Tank on HIV/AIDS

• 

HIV/AIDS Civil Society Forum

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64. 

65. 

However, the exchange of information and cooperation among Member 
States  in  the  field  of  public  health  is  not  limited  to  the  PHP.  Other 
m e c h a n i s m s   e x i s t   w h i c h   c a n   d e l i v e r   t h i s   E A V .   T h e r e   a r e   a   n u m b e r 
o f   f o r a ,   w o r k i n g   g r o u p s   a n d   p l a t f o r m s   i n   m o s t   p u b l i c   h e a l t h   p o l -
icy  areas  that  address  not  only  health  determinants  but  also  health 
information and health threats. They facilitate consultation between 
stakeholders — especially governmental organisations, but also civil 
society,  industry,  etc.  —  and  provide  a  ‘meeting  place’  where  com-
mon approaches can be developed and coordinated (see paragraphs 
5 4   a n d   6 0 ( a ) ) .   T h e   e x i s t e n c e   o f   a l t e r n a t i v e   m e c h a n i s m s   r a i s e s   t h e 
question  whether  such  activities  should  continue  to  be  carried  out 
under the PHP.

35  European Commission, White 

Paper, ‘Together for health: 

A strategic approach for the EU 

2008–13’, COM(2007) 630 final, 

p. 10.

In its current EU health strategy published in October 2007 the Commis-
sion  has  proposed  setting  up  a  ‘structured  cooperation  mechanism’ 
to identify and promote the necessary coordination activities among 
the  Member  States 35.  A  dedicated  ‘Council  Working  Party  on  Public 
H e a l t h   a t   S e n i o r   L e v e l ’   w a s   s e t   u p   i n   D e c e m b e r   2 0 0 8   t o   a s s i s t   t h e 
Commission in identifying priorities, defining indicators, producing 
guidelines and recommendations, fostering exchange of good prac-
tice and measuring progress.

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PROJECT MANAGEMENT

66. 

Project design is crucial, but projects must also be managed in a way that 
increases  their  chances  of  being  effective.  A  project  can  ultimately 
contribute to progress towards the overall goal if the intended results 
are achieved and are used by the target group. This is more likely to 
be the case if:

(a) 

the partnership works well;

(b) 

p r o j e c t s   a r e   a d e q u a t e l y   m o n i t o r e d   d u r i n g   i m p l e m e n t a t i o n , 
e n  a b l i n g   t h e   C o m m i s s i o n   t o   b e   i n f o r m e d   a b o u t   p r o j e c t   a c t i v i -
t i e s ,   o u t p u t s ,   p o t e n t i a l   o v e r l a p   a n d   o p p o r t u n i t i e s   f o r   s y n e r -
g i e s   b e t w e e n   p r o j e c t s ,   a n d   t o   p r o v i d e   f e e d b a c k   t o   t h e   p r o j e c t 
coordinators;

(c) 

the  expected  outputs  are  produced  and  disseminated  appropri-
ately; and

(d) 

projects  are  ultimately  evaluated,  allowing  the  Commission  and 
other project promoters to learn from experience.

67. 

68. 

69. 

PARTNERSHIP FUNCTIONED WELL

The functioning of the partnership is an important factor in the effective-
ness of any project implemented by several actors. All projects in the 
sample were implemented by a number of organisations in different 
Member States and, sometimes, candidate countries. Typically, they 
consisted  of  a  main  project  coordinator  and,  on  average,  12  associ-
ated partners from different countries.

In most cases, responsibilities were clearly assigned among coordinator 
a n d   p a r t n e r s .   I n   n i n e   o u t   o f   t h e   3 6   c a s e s   a u d i t e d ,   h o w e v e r ,   i t   w a s 
f o u n d   t h a t   t h e   p a r t n e r s h i p   w a s   v e r y   i m b a l a n c e d ,   w i t h   t h e   p r o j e c t 
c o o r d i n a t o r   a n d / o r   o n e   o t h e r   p a r t n e r   c a r r y i n g   o u t   t h e   b u l k   o f   t h e 
project activities and limited involvement by the other partners.

The majority of project coordinators and partners gave a very positive 
a s s e s s m e n t   o f   c o o p e r a t i o n   i n   t h e   p a r t n e r s h i p   ( s e e   B o x   1 3 ) .   M a n y 
r e s p o n d e n t s   t o   t h e   s u r v e y   s t r e s s e d   t h e   p a r t n e r s h i p   a s   o n e   o f   t h e 
most  important  aspects  of  the  project  because  of  the  possibility  of 
making contacts, exchanging ideas and sharing experience and ‘good 
practices’.

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B O X   1 3

SURVEY OF PROJECT PARTNERS

‘I am satisfied with how the project partners cooperate(d).’

0 %

10 %

20 %

30 %

40 %

50 %

60 %

strongly agree

32 %

agree

48 %

neither agree nor disagree

13 %

disagree

5 %

strongly disagree

1 %

don’t know

1 %

‘The project coordinator involves all partners in the work.’

0 %

10 %

20 %

30 %

40 %

50 %

60 %

strongly agree

agree

41 %

43 %

neither agree nor disagree

10 %

disagree

3 %

strongly disagree

0 %

don’t know

3 %

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PROJECT MONITORING BY COMMISSION ‘AD HOC’ 
RATHER THAN SYSTEMATIC

70. 

Neither DG SANCO nor the PHEA has written guidelines for monitoring 
projects or documenting the monitoring process 36 (see paragraph 51). 
C o n s e q u e n t l y ,   w h a t   w a s   d o n e   d e p e n d e d   o n   t h e   i n d i v i d u a l   p r o j e c t 
officer.  In  general,  monitoring  consisted  of  using  the  coordinator’s 
interim and final reports to verify whether the contract requirements 
had been met, giving the financial officer the green light to proceed 
with payment. As a rule, the Commission gave the project coordinator 
n o   w r i t t e n   f e e d b a c k   o n   t h e   c o n t e n t   a n d   t h e   a c h i e v e m e n t s   o f   t h e i r 
projects.

36  For most of the projects in the 

audit sample, technical monitoring 

was still the responsibility of the 

DG SANCO project officers; for 

12 projects selected following the 

2005 call for proposals monitoring 

responsibility had been transferred 

to the newly created Public Health 

Executive Agency (PHEA) after 

contract signature.

71.  Many  project  coordinators  were  dissatisfied  with  the  Commission’s 
project monitoring, particularly in the case of projects contributing 
to policy development. Seventeen of the 32 coordinators interviewed 
reported never having discussed the technical aspects of their project 
with representatives of the Commission during the project term. Most 
coordinators had invited the Commission’s project officer to project 
meetings, but such invitations were rarely taken up.

72. 

73. 

DG SANCO officers confirmed that project monitoring was a very minor 
p a r t   o f   t h e i r   a c t i v i t y   a n d   t h a t   n o r m a l l y   t h e y   h a d   n o   t i m e   t o   f o l l o w 
projects closely. Moreover, due to staff turnover, in some cases three 
or four different project officers were assigned to a project during its 
lifetime, and projects were left for several months with no designated 
project officer.

The Commission’s monitoring of the technical aspects of ongoing projects 
was  ad  hoc  rather  than  systematic,  not  based  on  common  minimum 
r e q u i r e m e n t s   a n d   n o t   p r o v i d i n g   f o r m a l   f e e d b a c k   t o   p a r t i c i p a n t s . 
T h i s   s h o u l d   a l s o   b e   c o n s i d e r e d   a l o n g s i d e   t h e   l a c k   o f   a n   o v e r v i e w 
of  projects  undertaken,  which  would  have  enabled  the  Commission 
to  avoid  duplication  of  work  and  to  ensure  that  potential  synergies 
between projects were fully exploited (see paragraphs 50 and 51).

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37  It should be noted that it lay 

outside the scope of this audit to 

determine the effects on target 

groups of the dissemination of 

project outputs — for example, to 

investigate whether a newsletter 

was read and appreciated or a 

database was consulted by health 

professionals.

38

OUTPUTS DELIVERED, BUT NOT ACTIVELY DISSEMINATED

74.  Outputs, or deliverables, are defined as that which is produced with the 
resources allocated to an intervention. In general, the contractually 
agreed  outputs  of  the  audited  health  promotion  projects  were  pro-
duced. Common output categories included reports on specific issues, 
training  courses,  databases,  websites,  newsletters  and  information 
material such as leaflets.

75. 

Projects mostly used the Internet for dissemination. Almost all projects 
uploaded their outputs to a website — either the project coordinator’s 
home website or a dedicated project site. This led to the simultane-
ous creation of a number of similar websites in each field, making it 
harder for any interested party to find pertinent information.

76.  Other dissemination channels included conferences, newsletters, con-
tributions  to  scientific  journals  and  press  releases.  Project  partners 
played a significant role in dissemination, as they were familiar with 
national and regional conditions and possibly already had an estab-
lished network of contacts in their country or region.

77.  While the audit found that outputs were produced and disseminated, 
project  coordinators  could  not  demonstrate  ‘take-up’  by  the  target 
group  for  any  of  the  projects  audited.  Projects  did  not  even  collect 
information of this sort 37. Neither was dissemination sustainable, as 
websites and databases were generally not updated after the end of 
the funding period (see paragraph 45).

78.  Moreover, the representatives of national ministries and health institutes 
interviewed were often not aware what projects had been undertaken, 
still  less  of  the  results  obtained.  Most  of  the  national  stakeholders 
interviewed expressed criticism of the dissemination of project results 
and considered that too little information on the outcomes of projects 
(whether ongoing or completed) was available to them.

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39

38  ‘Health promotion evaluation: 

Recommendations to policy-

makers.’ Report of the WHO 

European Working Group on 

Health Promotion Evaluation, p. 4.

39  ‘Rules, criteria and procedures 

for the selection and funding of 

actions under the public health 

programme’ (OJ C 62, 15.3.2003).

40  ECA Audit Guidelines on 

Evaluation, November 2005, p. 7.

PROJECT EVALUATION NOT YET COMMON PRACTICE

79.  Without robust evaluation the effectiveness of projects cannot be dem-
o n s t r a t e d .   A c c o r d i n g   t o   W H O ,   h e a l t h   p r o m o t i o n   i n i t i a t i v e s   s h o u l d 
b e   e v a l u a t e d   i n   t e r m s   o f   p r o c e s s e s   a s   w e l l   a s   o u t c o m e s 3 8.   P r o j e c t 
evaluation was however not a legal requirement under the PHP.

80. 

81. 

Nevertheless, the Commission announced as early as 2003, in its first 
c a l l   f o r   p r o p o s a l s ,   t h a t   i t   w o u l d   g i v e   p r i o r i t y   t o   p r o j e c t s   w h i c h 
‘devote[d]  appropriate  attention  to  the  [self-]  evaluation  of  the  proc-
ess  and  results’ 39.  From  the  2005  call  for  proposals  onwards,  a  work 
package entitled ‘Evaluation of the project’ was a compulsory section 
of grant agreements, but project coordinators were given no further 
instructions as to what this should entail.

The Court examined whether evaluations of the audited health promo-
tion projects had been carried out that met the criteria of usefulness, 
coherence, robustness, impartiality, clarity and cost-effectiveness 40. 
This analysis showed:

 —

 —

Of the 24 projects in the sample which were selected before 2005, 
three  had  conducted  a  comprehensive  self-evaluation.  Of  these 
only one met all the criteria specified above;

Nine of the 12 projects selected following the 2005 call for propos-
als included plans for limited self-evaluations, such as collection 
by  the  coordinator  of  feedback  from  the  project  partners,  in  the 
form  of  survey  sheets,  on  project  meetings  or  workshops.  In  the 
other three cases, there were plans for evaluations to be carried 
out by an external evaluator.

82.  While the Commission has encouraged and, more recently, required health 
promotion projects to conduct a comprehensive self-evaluation, this 
has  not  yet  become  common  practice  among  participants  —  owing 
partly  to  the  lack  of  Commission  guidance  for  project  coordinators 
a n d   t h e   a b s e n c e   o f   f o l l o w - u p   b y   t h e   C o m m i s s i o n   o r   t h e   P H E A   ( s e e 
paragraphs 70 to 73).

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CONCLUSIONS AND 
RECOMMENDATIONS

40

83. 

84. 

PROGRAMME DESIGN

The Court considers that the design of the PHP did not provide a suit-
able  framework  for  an  effective  implementation  and  monitoring  of 
Community-funded health promotion actions. The fact that the under-
l y i n g   i n t e r v e n t i o n   l o g i c   o f   t h e   P H P   w a s   n o t   m a d e   e x p l i c i t   w a s   n o t 
conducive  to  setting  specific,  measurable  and  time-dependent  pro-
gramme objectives and specifying appropriate indicators to measure 
achievements.

The audit also found weaknesses in the Commission’s strategic plan-
n i n g   a n d   a   l a c k   o f   p r i o r i t y   s e t t i n g .   T h e   d i v e r s i t y   o f   t o p i c s   a n d   t h e 
multiplicity  of  annual  ‘action  areas’  caused  input  to  be  diluted  and 
led to fragmented results, particularly in view of the limited budget 
available. The programme followed many different paths and lacked 
strategic focus.The Court finds that the PHP (2003–07) did not make 
a major contribution to health promotion in the European Union.

R E C O M M E N D A T I O N   1

I n   o r d e r   t o   a d d r e s s   t h e   c u r r e n t   i m b a l a n c e   b e t w e e n   o b j e c t i v e s   a n d 
means, any successor programme should be assigned better-targeted 
p r o g r a m m e   o b j e c t i v e s   w h i c h   a r e   m o r e   i n   l i n e   w i t h   i t s   b u d g e t a r y 
means.

F o r   a n y   f u t u r e   g e n e r a t i o n   o f   p r o g r a m m e s ,   t h e   u n d e r l y i n g   i n t e r v e n -
tion logic should be stated in an explicit manner, setting out specific, 
m e a s u r a b l e ,   a c h i e v a b l e ,   r e l e v a n t   a n d   t i m e - d e p e n d e n t   o b j e c t i v e s   a t 
policy  and  programme  level,  illustrating  the  links  between  them  and 
defining indicators to measure their achievement.

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41

85. 

86. 

87. 

88. 

PROGRAMME IMPLEMENTATION: FROM PROJECT 
DESIGN TO RESULTS

The Court finds that the Commission’s project selection and programme 
implementation  did  not  ensure  complementarity  between  projects, 
the  overall  consistency  of  the  portfolio  of  projects  undertaken  and 
the  funding  of  the  type  of  projects  that  provided  the  highest  likeli-
hood of EAV.

Project objectives (as proposed by promoters) were neither logically 
d e r i v e d   f r o m   t h e   p r o g r a m m e   o b j e c t i v e s ,   n o r   i n   c o m p l i a n c e   w i t h 
t h e   S M A R T   r e q u i r e m e n t   s p e c i f i e d   b y   t h e   F i n a n c i a l   R e g u l a t i o n .   T h e 
Commission took no corrective measure to address this shortcoming 
before entering into the grant agreements audited.

Expected project results were not defined as impacts on target groups 
and the sustainability of the results is considered to be low. Projects 
g e n e r a l l y   p r o d u c e d   t h e   p l a n n e d   o u t p u t s ,   b u t   t h e   a u d i t   f o u n d   n o 
d e m o n s t r a b l e   t a k e - u p   o f   p r o j e c t   r e s u l t s .   V e r y   o f t e n   t h e   r e l e v a n c e 
o f   t h e s e   o u t p u t s   f o r   t h e   t a r g e t   g r o u p   a n d   t h e i r   t a k e - u p   b y   a c t o r s 
‘ d o w n s t r e a m ’   w a s   u n c l e a r   f r o m   t h e   b e g i n n i n g .   S u s t a i n a b i l i t y   w a s 
often understood by participants as the continuation of project activi-
ties  and  was  therefore  heavily  dependent  on  continued  Community 
funding.

The Court recognises that the programme brought stakeholders from 
d i f f e r e n t   c o u n t r i e s   t o g e t h e r .   P r o j e c t s   g e n e r a l l y   h a d   a   E u r o p e a n 
dimension and, in many cases, facilitated the sharing of experiences 
a n d   m u t u a l   l e a r n i n g .   H o w e v e r ,   A r t i c l e   1 5 2   o f   t h e   E C   T r e a t y   g i v e s 
the EU only limited competence for public health policy. The Lisbon 
Treaty (currently under ratification) would not substantially alter this. 
A c c o r d i n g l y ,   t h e   a d d e d   v a l u e   o f   E U   a c t i v i t i e s   i n   t h e   f i e l d   o f   h e a l t h 
promotion, including those carried out under the PHP, lies above all in 
facilitating cooperation between the stakeholders in different Member 
States. Of the types of projects carried out under the PHP, networks 
provide  the  highest  likelihood  of  EAV  and  most  clearly  address  the 
need of actors in the field to share ‘good practice’, develop common 
standards and guidelines and exchange knowledge.

89. 

However, the main implementation mechanism of the PHP (i.e. grants for 
actions  awarded  through  calls  for  proposals)  is  not  the  most  appro-
priate mechanism for funding such networks. This is also the case for 
activities that are supposed to contribute to the Commission’s policy 
development.

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PROJECT MANAGEMENT

90.  With regard to project management, the Court found that partnerships 
g e n e r a l l y   w o r k e d   w e l l .   T h e   C o m m i s s i o n ’ s   m o n i t o r i n g   o f   o n g o i n g 
p r o j e c t s   w a s   h o w e v e r   a d   h o c   r a t h e r   t h a n   s y s t e m a t i c   a n d   d i d   n o t 
p r o v i d e   f o r m a l   f e e d b a c k   t o   p a r t i c i p a n t s .   P r o j e c t s   d i d   p r o d u c e   t h e 
d e l i v e r a b l e s   s e t   o u t   i n   t h e   g r a n t   a g r e e m e n t ,   b u t   p r o m o t e r s   r a r e l y 
disseminated  results  actively.The  ex  post  evaluation  of  projects  has 
not yet become common practice among participants.

R E C O M M E N D A T I O N   2

Where the current PHP (2008–13) is concerned, the Commission should 
undertake a mapping exercise in order to gain an overview of projects 
undertaken and their results to identify the existing overlaps and any 
remaining gaps in its project portfolio.

The  number  of  annual  ‘action  areas’  should  be  significantly  reduced, 
and they should be focused on strategic priorities.

The Commission should also address weaknesses in project design and 
implementation by:

• 

• 

• 

bringing project objectives into line with programme objectives and 
the refocused ‘annual priorities’ recommended above. In addition, 
grant agreements should establish not only which activities are to 
be undertaken, but also the desired results of those activities, the 
t a r g e t   g r o u p s   a n d   h o w   t h e   r e s u l t s   w i l l   b e   u s e d   i n   a   s u s t a i n a b l e 
manner after project completion; 

s e t t i n g   q u a n t i f i e d   t a r g e t s   a n d   p e r f o r m a n c e   i n d i c a t o r s   w h e r e v e r 
possible  in  order  to  facilitate  the  monitoring  of  progress  towards 
objectives;

ex post in order to improve the design of forth-
evaluating projects 
coming projects (and putative successor programmes) by applying 
‘lessons learnt’.

Finally, the Commission should fully exploit the existing PHP (2008–13) 
funding mechanisms for networks (ie. operating grants) in the current 
programming  period,  since  they  are  more  suitable  for  such  activities 
than grants for actions. For service contracts, the Commission should 
make use of the increased ceiling (20 % rather than 10 % of the avail-
a b l e   b u d g e t )   t o   c a r r y   o u t   a c t i v i t i e s   c o n t r i b u t i n g   t o   p o l i c y   d e v e l o p -
ment.  However,  this  will  require  a  more  rigorous  definition  of  terms 
of reference than in calls for proposals.

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43

91. 

92. 

OVERALL CONCLUSION

The PHP was set very broad and ambitious objectives that contrasted 
s h a r p l y   w i t h   t h e   l i m i t e d   m e a n s   a t   i t s   d i s p o s a l .   T h i s   i m b a l a n c e   h a s 
widened further since the current PHP (2008–13) was launched.

The Court calls into question the utility of certain components of Euro-
pean public health programmes such as the PHP. The audit suggests 
that it is difficult for such programmes to have a demonstrable impact 
on citizens’ health. Where there is ‘European added value’, it lies pri-
marily in enabling intermediaries to network and to exchange ‘good 
p r a c t i c e ’   w i t h   a   v i e w   t o   c o m p l e m e n t i n g   n a t i o n a l   p r o g r a m m e s   a n d 
a c t i v i t i e s .   M o r e o v e r ,   t h e   C o u r t   n o t e s   t h e   e x i s t e n c e   o f   c o o p e r a t i o n 
mechanisms such as the ‘open method of coordination’ which permits 
such networking and exchanges.

41  This is a method of cooperation 

based on the principle of voluntary 

intergovernmental cooperation. 

It relies in particular on mutual 

learning, benchmarking and the 

sharing of best practice.

R E C O M M E N D A T I O N   3

For the period after 2013, the European Parliament, the Council and the 
Commission  should  reconsider  the  scope  for  EU  public  health  activi-
ties and the approach to EU funding in this area. This should be done 
bearing  in  mind  the  budgetary  means  available  and  the  existence  of 
other cooperation mechanisms (such as the ‘open method of coordina-
tion’ 41)  as  a  means  of  facilitating  collaboration  and  the  exchange  of 
information among stakeholders throughout Europe.

The current budget review provides a first occasion for this reflection 
process.

This report was adopted by the Court of Auditors in Luxembourg at its 
meeting of 5 March 2009.

ud to s
For the Court of Auditors

o t e Cou t o

Vítor Manuel da Silva Caldeira
President

Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?

 
 
 
 
44

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45

A N N E X   I I

PHP (‘HEALTH DETERMINANTS’ STRAND) — ANALYSIS OF SIX POLICY AREAS

1. 

2. 

3. 

DRUGS

In December 2004 the European Council endorsed the EU drugs strategy 
(2005–12), a framework for two consecutive four-year action plans on 
drugs. The strategy’s two general aims cover public health (prevention 
of drug use, harm reduction and treatment) and security (enforcement 
of laws prohibiting drug production and trafficking). DG SANCO is a 
minor  player  in  drugs  policy  at  EU  level.  Policy  development  is  led 
by DG JLS, and the bulk of project funding goes to research projects 
managed by DG RTD and DG TREN. A Drugs Prevention and Informa-
tion Programme has been set up for 2007–13 and is managed by DG 
JLS  (budget  21  million  euro).  This  has  similar  objectives  and  target 
participants to the PHP.

The European Monitoring Centre for Drugs and Drugs Addiction (EMCDDA) 
provides  the  EU  and  its  Member  States  with  a  common  information 
framework on drugs. The EMCDDA collects information on all aspects 
of drug use based on a network of national monitoring centres. It has 
also set up a database of best practices in drug prevention.

The drugs projects funded from the PHP were few in number and covered 
a wide range of aspects and contexts of the drugs problem. However, 
they  shared  a  common  focus  on  research/collection  of  information 
a n d   t h e   e x c h a n g e   o f   b e s t   p r a c t i c e s .   T h e   C o u r t   n o t e d   t h a t   s o m e   o f 
their  objectives  and  activities,  for  example  data  collection  and  set-
ting up a database of best practices, overlapped with the EMCDDA’s 
field of activity. They could be carried out more cost/time-efficiently 
b y   t h e   E M C D D A .   I n   v i e w   o f   t h e   e x i s t e n c e   o f   t h e   E M C D D A   a n d   t h e 
dedicated  Drugs  Prevention  and  Information  Programme,  the  value 
of including drugs projects in the EU’s health programmes should be 
reconsidered.

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A N N E X   I I

ALCOHOL

4. 

5. 

6. 

Alcohol is more difficult to tackle as a health topic than other addiction-
r e l a t e d   h e a l t h   d e t e r m i n a n t s ,   b e c a u s e   i t   i s   s o c i a l l y   a c c e p t a b l e   a n d 
does not pose a health risk as such if consumed moderately. However, 
harmful alcohol consumption is estimated to be responsible for about 
10  %  of  the  total  disease  burden,  as  well  as  creating  or  aggravating 
other  social  or  economic  problems  such  as  accidents  and  violence. 
T h e   m o s t   ( c o s t - ) e f f e c t i v e   a l c o h o l   c o n t r o l   p o l i c i e s   a r e   l e g a l   r e s t r i c -
tions, which come under the remit of Member States (higher purchase 
tax,  reduced  availability  and  measures  to  combat  drink-driving  and 
underage drinking).

In response to conclusions published in 2001 by the Council, in Octo-
ber 2006 the Commission produced a strategy for reducing alcohol-
related harm. The strategy offers support for harm-reduction projects, 
data  collection  and  the  development  of  information  and  education 
m e a s u r e s   i n   c o o p e r a t i o n   w i t h   M e m b e r   S t a t e s .   W h e r e   i n d u s t r y   i s 
c o n c e r n e d ,   t h e   E C   a l c o h o l   s t r a t e g y   r e l i e s   o n   v o l u n t a r y   c o d e s   a n d 
s e l f - r e g u l a t i o n   r a t h e r   t h a n   l e g a l   r e s t r i c t i o n s .   I n   J u n e   2 0 0 7   t h e   E C 
s e t   u p   a   E u r o p e a n   A l c o h o l   a n d   H e a l t h   F o r u m   w i t h   r e p r e s e n t a t i v e s 
from the business sector (alcohol producers, the advertising industry, 
the media, retailers and caterers) and public health and civil society 
organisations. Forum members are invited to commit to stepping up 
a c t i o n s   t o   r e d u c e   a l c o h o l - r e l a t e d   h a r m ,   f o r   e x a m p l e   b y   p r o m o t i n g 
responsible commercial communications.

The PHP projects addressing alcohol were characterised by a great deal 
o f   o v e r l a p   i n   t h e   p a r t n e r s   i n v o l v e d   a n d   t h e   i n f o r m a t i o n   p r o d u c e d . 
Three of the five projects in the sample collected data and produced 
r e p o r t s   o n   t h e   a l c o h o l   p o l i c y   s i t u a t i o n   i n   e a c h   E U   M e m b e r   S t a t e . 
Meanwhile, a major comprehensive report on ‘Alcohol in Europe’ was 
produced  for  the  Commission,  as  well  as  a  report  entitled  ‘Alcohol 
policies in EU Member States and Norway’, which was produced using 
f u n d i n g   f r o m   t h e   f o r m e r   C o m m u n i t y   A c t i o n   P r o g r a m m e   o n   H e a l t h 
P r o m o t i o n .   T h i s   o v e r l a p   c a n   b e   e x p l a i n e d   b y   t h e   a b s e n c e   o f   a n   E U 
alcohol strategy to orientate priorities in the years before 2006 and 
the lack of a mapping exercise of previous activities in this field.

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A N N E X   I I

TOBACCO

7. 

8. 

9. 

According to WHO, tobacco use is a leading cause of preventable pre-
m a t u r e   d e a t h   i n   t h e   w o r l d   t o d a y .   T h e   m o s t   ( c o s t - ) e f f e c t i v e   h e a l t h 
promotion measure in connection with tobacco is legislation (higher 
purchase  tax,  restrictions  on  smoking  in  the  workplace,  advertising 
bans), which should be combined with consumer education through 
health warnings and campaigns.

Community support for anti-tobacco organisations began as early as 1987 
with the Europe Against Cancer programme. The EU has also adopted 
legislative  measures  on  tobacco  control.  They  are  based  on  the  EU’s 
competence in the internal market as laid down in Article 95 of the EC 
Treaty.  In  particular,  two  major  directives  were  adopted  in  2001  and 
2003 on tobacco products and advertising respectively. More recently, 
the  Green  Paper  ‘Towards  a  Europe  free  from  tobacco  smoke:  policy 
options at EU level’ was published at the beginning of 2007.

This  legislative  action  has  been  accompanied  by  Community  support 
for  Europe-wide  prevention  and  cessation  actions,  in  which  the  PHP 
projects are a minor budgetary player. More important programmes are 
public  anti-smoking  campaigns  financed  by  the  Community  Tobacco 
Fund, which derives its resources from a levy on subsidies awarded to 
the  EU’s  tobacco  producers.  To  date  the  Tobacco  Fund  has  financed 
two large awareness-raising campaigns. The latest campaign, ‘HELP — 
For  a  life  without  tobacco’,  was  launched  in  2005  with  a  budget  of 
72 million euro over four years. It was devised for the Commission by 
a  consortium  of  health  experts  and  PR  professionals,  and  includes  a 
roadshow and TV spots broadcast in all EU Member States.

10. 

The tobacco projects financed from the PHP consisted mainly of two 
large networks which had already been receiving funding since 1996 
under  the  predecessor  action  programmes.  One  dealt  with  smoking 
p r e v e n t i o n   i n   g e n e r a l ,   b u t   w i t h   a   s t r o n g   f o c u s   o n   t o b a c c o - c o n t r o l 
advocacy  and  lobbying,  and  the  other  focused  on  young  people.  As 
these  networks  were  not  officially  eligible  for  financing,  they  were 
turned into ‘framework projects’ coordinating several sub-projects. In 
2005 this structure was abandoned, and some sub-projects continued 
as stand-alones.

11.  While  the  effect  of  the  PHP  projects  is  not  measurable,  the  Commu-
nity funding indirectly enabled the general network and its member 
organisations  to  conduct  successful  tobacco-control  advocacy  and 
l o b b y i n g   a c t i v i t i e s   a t   b o t h   E U   a n d   n a t i o n a l   l e v e l .   O n e   e x a m p l e   i s 
recent legislation in several Member States banning smoking in public 
places.

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A N N E X   I I

12. 

13. 

14. 

NUTRITION AND PHYSICAL ACTIVITY

Rising public concern about the increasing obesity rate, especially among 
children, has been reflected in several Commission actions in recent 
y e a r s .   I n   2 0 0 6   t h e   C o m m i s s i o n   p u b l i s h e d   t h e   W h i t e   P a p e r   ‘ A   s t r a t -
egy  for  Europe  on  nutrition,  overweight  and  obesity-related  health 
issues’. A key tool for implementing this strategy is the EU Platform 
on Diet, Physical Activity and Health, which was established in 2005 
as  a  forum  for  stakeholders  from  civil  society  and  industry  who  are 
willing  to  commit  themselves  to  taking  steps  that  can  reduce  obes-
ity. Member State authorities are linked in the European Network on 
Nutrition and Physical Activity. To further the exchange of policy ideas 
and practices between Member States, in 2007 the Commission also 
set up a high-level group focused on nutrition and physical activity-
related health issues.

1 

It is mentioned only once: 

‘The Commission will continue to 

support the monitoring function 

through its projects under the Public 

Health Programme, which support 

networking actions and sharing 

of information in the area of good 

practice in nutrition and physical 

activity, and obesity prevention.’ 

(White Paper, p. 9).

Apart from these platforms, the strategy emphasises EU activities in 
r e l a t e d   p o l i c y   a r e a s   s u c h   a s   c o n s u m e r   p o l i c y   ( l a b e l l i n g ) ,   a g r i c u l -
ture  (distribution  of  fruit  in  schools)  and  urban  transport  (stimulat-
ing  physical  activity).  The  PHP  plays  only  a  very  limited  role  in  the 
strategy 1.

There are not many PHP projects in the area of nutrition and physical 
activity,  and  they  have  very  diverse  objectives  and  activities,  which 
gives a fragmented picture. Several individual projects audited either 
were unable to demonstrate achievement of results or delivered low 
EAV. For example, one project was funded with the purpose of find-
ing partners for a follow-up project, a proposal for which was never 
submitted. Another project, a study on the impact of food marketing 
to  children,  was  found  by  the  auditors  to  partly  duplicate  a  similar 
W H O   s t u d y .   A   t h i r d   p r o j e c t   f i n a n c e d   a c t i v i t i e s   w h i c h   w e r e   i m p l e -
mented individually by the project partners, in a number of schools, 
a r o u n d   t h e   t h e m e s   o f   n u t r i t i o n   a n d   p h y s i c a l   a c t i v i t y .   T h e s e   l o c a l 
activities  were  devised  by  the  children  themselves  to  increase  their 
commitment and could be anything from organising a sports festival 
in the park to decorating the school walls with pictures of fruit. While 
t h i s   m i g h t   h a v e   s o m e   h e a l t h   i m p a c t   i n   t h e   p a r t i c i p a t i n g   s c h o o l s , 
t h e   E A V   a n d   t h e   n e e d   f o r   E U   f u n d i n g   f o r   t h e s e   l o c a l   a c t i v i t i e s   a r e 
questionable.

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2  Since its emergence in the 

1980s, HIV/AIDS has caused more 

than 25 million deaths worldwide. 

In the 1990s its spread was 

temporarily halted in Europe. 

The situation changed in the new 

century, when WHO reported 

that HIV was spreading rapidly in 

eastern Europe and was on the rise 

again in western Europe.

49

A N N E X   I I

SEXUAL AND REPRODUCTIVE HEALTH

15. 

16. 

17. 

18. 

T h e   P H P   m a r k e d   a   b r e a k   f r o m   t h e   C o m m i s s i o n ’ s   ‘ d i s e a s e - s p e c i f i c ’ 
approach (which had characterised its 1996–2002 AIDS/communica-
ble diseases programme). The sexual and reproductive health policy 
area has become broader. However, HIV/AIDS is still the focus of most 
projects in this area 2.

In 2005 the Commission adopted its Communication on combating HIV/
AIDS within the EU and in the neighbouring countries, 2006–09. This 
provided an action plan, an essential document which identified exist-
ing needs and necessary actions. The Commission has also launched 
several  initiatives  to  consult  relevant  stakeholders  in  the  field.  The 
Think Tank on HIV/AIDS is a forum in which the Commission, the Mem-
ber States and candidate and EEA countries can exchange information. 
The HIV/AIDS Civil Society Forum (CSF) is an informal advisory body 
that  was  established  in  2005  to  facilitate  the  participation  of  NGOs 
and networks.

The European Centre for Disease Prevention and Control (ECDC) was set 
u p   i n   2 0 0 5   a s   a   C o m m u n i t y   a g e n c y   f o r   m o n i t o r i n g   c o m m u n i c a b l e 
diseases. Its action extends to HIV, and it runs a programme on HIV, 
sexually transmitted infections (STIs) and blood-borne viruses.

PHP projects in the area of sexual and reproductive health were the 
largest  group  in  the  audit  sample.  Most  of  these  projects  were  net-
works with the shared objective of strengthening the capacity of the 
participating NGOs. They found their niche by focusing on different 
direct and indirect addressees: NGOs in central European countries, 
or NGOs working with migrants, migrant sex workers, local sex work-
ers, injection-drug users or people living with HIV/AIDS.

19. 

Some of the networks collected data and monitored prevalence or other 
aspects of HIV/AIDS among their target groups. In future, these activi-
ties could be taken over by the ECDC.

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3  Article 152 of the EC Treaty: 

‘Community action, which shall 

complement national policies, shall 

be directed towards improving 

public health, preventing human 

illness and diseases, and obviating 

sources of danger to human 

health’. Article 168 of the Lisbon 

Treaty: ‘Union action, which shall 

complement national policies, shall 

be directed towards improving 

public health, preventing physical 

and mental illness and diseases, 

and obviating sources of danger to 

physical and mental health’.

A N N E X   I I

MENTAL HEALTH

20.  Mental health has been increasingly recognised as a public health issue 
i n   r e c e n t   y e a r s .   U n l i k e   t h e   c u r r e n t   E C   T r e a t y ,   t h e   T r e a t y   o f   L i s b o n 
explicitly mentions mental health as an area for EU action 3. However, 
s u c c e s s i v e   p a s t   p u b l i c   h e a l t h   p r o g r a m m e s   h a v e   a l r e a d y   c o - f u n d e d 
projects  in  the  fields  of  mental  health  promotion  and  prevention  of 
mental disorders.

21. 

22. 

23. 

In September 2005, following the WHO European Ministerial Conference 
on Mental Health, the Commission published a Green Paper on mental 
health  (‘Promoting  the  mental  health  of  the  population:  Towards  a 
s t r a t e g y   o n   m e n t a l   h e a l t h   f o r   t h e   E U ’ )   w h i c h   l a u n c h e d   a   c o n s u l t a -
tion  on  possible  actions  to  be  included  in  a  planned  mental  health 
strategy.  However,  the  Member  States  were  unable  to  agree  on  the 
s t r a t e g y   a n d   i t   h a d   t o   b e   a b a n d o n e d .   F o r   t h i s   r e a s o n ,   t h e   p l a n n e d 
EU platform on mental health also failed to take shape. After several 
a t t e m p t s   t o   t a k e   t h e   i s s u e   f u r t h e r ,   i n   J u n e   2 0 0 8   t h e   C o m m i s s i o n 
organised a high-level conference which agreed on a European Pact 
on Mental Health and Well-being.

In the absence of a mental health strategy to orientate EU action, and 
given the broad nature of the mental health priorities set in the AWPs 
and  the  lack  of  an  overview  of  existing  activities,  three  of  the  four 
sampled projects in the mental health area overlapped significantly. 
Two projects funded under consecutive calls for proposals conducted 
identical activities, with a focus on policy development and data col-
lection. There was also partial duplication of work with other actors. 
Several  databases  of  mental  health  programmes  have  been  created 
in parallel (e.g. the EU Agency for Health and Safety at Work in Bilbao 
has a database on stress), but they are not well interlinked.

Another project, funded to support the Commission in the development 
o f   t h e   m e n t a l   h e a l t h   s t r a t e g y ,   n e v e r   m a t e r i a l i s e d .   T h e   p r o j e c t   w a s 
then reorientated and given the task of coordinating the other mental 
health  projects  and  helping  to  disseminate  their  outputs  —  in  this 
role it overlaps with another, RTD-funded project.

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PHP (‘HEALTH DETERMINANTS’ STRAND) — APPLICATION OF THE SMART 
CRITERIA TO THE PROJECT OBJECTIVES STATED IN THE GRANT AGREEMENTS 
OF THE 36 AUDITED PROJECTS

SMART criteria4

Analysis of project objectives

Specifi c (Do they specify the target 
group and the factors that need 
to change?)

Few grant agreements clearly specifi ed the target group in terms of direct 
and indirect addressees and the changes which the project intended to 
bring. Often, while the objectives did not mention the target group, it could 
be inferred from the project activities (implicit target group).

Measurable (Are they written in a 
measurable format, e.g. magnitude 
of eff ects, numbers to be reached?)

Achievable (Are they feasible given 
the available time, money, staffi  ng?)

Relevant (Are they relevant for the 
target group/s?)

Time-dependent (Do they state 
the time frame within which the 
objectives must be reached?)

None of the projects gave measurable objectives. Where performance 
indicators were defi ned in quantitative terms, they related to outputs to 
be produced, not objectives (typically, they referred to ‘X copies of a report 
to be printed’, never e.g. ‘share of school children reporting they have 
performed some physical activity over the last 7 days to be raised to X %’).

For most projects it was unclear whether the objectives had been achieved. 
Performance indicators complementing the objectives were largely absent; 
progress towards achieving them was usually not monitored. On the other 
hand, it could be argued that objectives such as ‘exchange of information’, 
‘increase knowledge’, ‘promote cooperation’ are almost impossible not to 
achieve.

It lay outside the scope of the audit to verify this question for all projects 
down to the ultimate target group. However, direct addressees such as 
NGOs and health professionals were often involved as project partners. In 
the survey of project partners, 88 % of respondents said that the project 
objectives were relevant for their country or region and 86 % said they were 
relevant for their organisation.

Timescales were almost never applied to objectives, but only to outputs 
(e.g. a report to be produced by month X).

4  Auxiliary questions in brackets are taken from Kok, H., Bollars,C., Molleman, G. and Van den Broucke, S., The European Quality 
Instrument for Health Promotion (EQUIHP), 2005.

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EXECUTIVE SUMMARY

IV.
A s   r e g a r d s   t h e   C o u r t ’ s   f i n d i n g s   a n d 
conclusions,

(a)
In accordance with Article 152 of the Treaty, 
all actions of the Commission in the domain 
of  public  health  aim  at  complementing  the 
m e a s u r e s   t a k e n   b y   M e m b e r   S t a t e s   t o   p r o -
tect  and  improve  health.  The  Public  Health 
Programme (PHP) 2003–07 is only one of the 
instruments used in this context.

The Commission agrees that a higher budget 
would achieve more, but the implementation 
of  the  PHP  2003–07  reflects  the  budgetary 
means granted by the European Parliament 
a n d   t h e   C o u n c i l   a s   w e l l   a s   t h e   p r i o r i t i e s 
a n d   o b j e c t i v e s   b o t h   i n s t i t u t i o n s   a p p r o v e d 
for it.

The underlying logic of PHP 2003–07 is based 
o n   t h e   h e a l t h   s t r a t e g y   a d o p t e d   i n   2 0 0 0   b y 
the Commission (COM(2000) 285 final), and 
t a k e s   i n t o   a c c o u n t   t h e   s u b s i d i a r i t y   p r i n c i -
p l e   s p e c i f i e d   i n   t h e   T r e a t y .   S p e c i f i c   p r i o r i -
ties  are  set  in  the  annex  to  the  programme 
decision.  The  programme  primarily  aims  at 
the achievement of intermediate indicators, 
such as the identification and dissemination 
of ‘good practice’, the networking of EU pub-
lic health expertise and the mapping of the 
European  public  health  realities  to  prepare 
common approaches.

T h e   p r i o r i t i e s   f o r   t h e   P H P   a s   s e t   o u t   i n 
Decision  No  1786/2002/EC  of  the  European 
P a r l i a m e n t   a n d   o f   t h e   C o u n c i l   a d o p t i n g   a 
programme of Community action in the field 
of public health for 2003–08 were defined in 
line with the requirements of Article 152 of 
the Treaty and in accordance with the health 
strategy approved in 2000.

T h e   C o m m i s s i o n   a c c e p t s   t h a t   f u r t h e r 
progress  is  needed  to  specify  in  the  AWP  a 
number of such priority areas and areas for 
potential action which is commensurate with 
the available budgetary appropriations.

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(b)
Audited projects were selected in the initial 
p h a s e   o f   t h e   P H P   ( 2 0 0 3 – 0 7 ) .   T h e   s i t u a t i o n 
changed  significantly  in  the  last  two  years 
of the programme audited, and this change 
has been maintained under the current PHP 
(2008–13). Since 2006, the ‘guide for appli-
c a n t s ’   u s e d   f o r   t h e   c a l l s   f o r   p r o p o s a l s   h a s 
contained detailed instructions to applicants 
to  use  the  latest  generally  accepted  princi-
ples for project management for developing 
t h e i r   a p p l i c a t i o n .   T h e   n e g o t i a t i o n   p r o c e s s 
ensures that these are actually fixed as such 
in the grant agreement, and the PHEA, now 
EAHC, ensures their application throughout 
the project duration. Since 2007 the execu-
tive  agency  carries  out  an  annual  mapping 
exercise.

(c)
The Commission welcomes the audit finding 
that  stakeholders  confirmed  the  ‘European 
added value’ (EAV) and usefulness of the PHP. 
It should also be noted that the existence of 
E A V   h a s   b e e n   a n   a w a r d   c r i t e r i a   f o r   g r a n t s 
since the start of the PHP (2003–07).

V.
In the EU context, the Commission’s legisla-
tive proposals are generally accompanied by 
an  ex-ante  impact  assessment  which  analy-
ses the economic, social and environmental 
i m p a c t s   o f   p o s s i b l e   p o l i c y   o p t i o n s .   T h i s   i s 
where the Commission intends to set out the 
programme  logic  of  any  putative  successor 
programmes to the current PHP (2008–13).

T h e   i n t e r i m   e v a l u a t i o n   o f   t h e   P H P   ( 2 0 0 3 –
0 7 )   p e r f o r m e d   i n   2 0 0 7   i d e n t i f i e d   a   c e r t a i n 
n u m b e r   o f   a r e a s   f o r   i m p r o v e m e n t .   S e v e r a l 
of these measures have been implemented, 
or  are  being  implemented,  in  the  manage-
ment of the Public Health Programme (2008–
1 3 ) ,   i n c l u d i n g   t h e   r e c o m m e n d e d   m a p p i n g 
exercise.

Since 2006, and in particular for the current 
PHP (2008–13) the guide for applicants used 
for the calls for proposals contains detailed 
instructions  to  applicants  to  use  the  latest 
g e n e r a l l y   a c c e p t e d   p r i n c i p l e s   f o r   p r o j e c t 
m a n a g e m e n t   f o r   d e v e l o p i n g   t h e i r   a p p l i -
c a t i o n .   T h e   n e g o t i a t i o n   p r o c e s s   e n s u r e s 
that  these  are  actually  fixed  as  such  in  the 
grant agreement, and the PHEA, now EAHC, 
e n s u r e s   t h e i r   a p p l i c a t i o n   t h r o u g h o u t   t h e 
project duration.

VI.
The Commission agrees with the Court that 
t h e   l i m i t e d   f u n d i n g   a v a i l a b l e   a t   E U   l e v e l 
needs to be focused on strategic topics and 
activities  with  an  obvious  European  added 
value.

T h e   C o m m i s s i o n   a l s o   s h a r e s   t h e   C o u r t ’ s 
v i e w   t h a t   t h e   o p e n   m e t h o d   o f   c o o r d i n a -
tion  and  other  forums  and  platforms  in  the 
h e a l t h   f i e l d   t h a t   f a c i l i t a t e   c o l l a b o r a t i o n 
a n d   t h e   e x c h a n g e   o f   i n f o r m a t i o n   b e t w e e n 
M e m b e r   S t a t e s   a n d   s t a k e h o l d e r s   t h r o u g h -
o u t   t h e   E u r o p e a n   U n i o n   c o u l d   b e   f u r t h e r 
developed.

H o w e v e r ,   t h e   C o m m i s s i o n   c o n s i d e r s   t h a t 
s u c h   c o o p e r a t i o n   m e c h a n i s m s   c a n   ( a n d 
s h o u l d )   n o t   r e p l a c e   a   d e d i c a t e d   E u r o p e a n 
f u n d i n g   p r o g r a m m e   i n   t h e   a r e a   o f   p u b l i c 
h e a l t h .   W h i l e   s u c h   i n s t r u m e n t s   f a c i l i t a t e 
c o l l a b o r a t i o n   a n d   t h e   e x c h a n g e   o f   i n f o r -
mation,  they  do  not  provide  the  necessary 
f u n d i n g   f o r   E U - w i d e   p u b l i c   h e a l t h   i n i t i a -
tives (e.g. for the start-up and maintenance 
of networks).

In addition, the PHP provides the Commission 
with the necessary means to initiate actions 
to support and underpin policy development 
in key areas of public health policy through 
successive call for proposals.

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Moreover, the PHP (2003–07) as adopted in 
Decision No 1786/2002/EC reflects the views 
expressed  by  the  European  Parliament  and 
the Council in terms of priorities and objec-
tives during the approval process.

See also replies to paragraphs 10, 21, 40 and 
60(c).

T h e   C o m m i s s i o n   a c c e p t s   h o w e v e r   t h a t   t h e 
i n t e r v e n t i o n   l o g i c   o f   t h e   P H P   ( 2 0 0 3 – 0 7 ) 
h a s   n o t   b e e n   m a d e   f u l l y   e x p l i c i t   i n   t h e 
p r o g r a m m e   d e c i s i o n .   I t   s h o u l d   b e   n o t e d , 
havener, that this programme was designed 
in  1999–2000  and  approved  in  2002,  i.e.  in 
a   p e r i o d   w h e n   t h e   C o m m i s s i o n ´ s   c u r r e n t 
p r o g r a m m i n g ,   m o n i t o r i n g   a n d   e v a l u a t i o n 
methods were not yet fully deployed.

15.
The benefits of a logic model approach will 
become increasingly apparent now that the 
P H P   h a s   b e c o m e   m o r e   e s t a b l i s h e d   a n d   i t s 
o u t p u t s   c l e a r e r .   A s   s u g g e s t e d   i n   t h e   2 0 0 7 
interim evaluation report, a first attempt at 
modelling the potential benefits of the PHP 
for  European  citizens  could  be  made  in  the 
ex post evaluation [to be carried out in 2010] 
(Wija J. Oortwijn et al, Interim evaluation of 
the Public Health Programme 2003–08. Final 
Report, RAND Europe technical report, 2007, 
section 2, p. 100).

16.
I n   t h e   C o m m i s s i o n ’ s   v i e w ,   p u b l i c   h e a l t h 
c a n n o t   d i r e c t l y   b e   c o m p a r e d   t o   o t h e r   E U 
p o l i c y   a r e a s   d u e   t o   t h e   l i m i t e d   s c o p e   o f 
c o m p e t e n c e s   o f   C o m m u n i t y   a c t i o n   u n d e r 
t h e   T r e a t y .   E q u a l l y ,   C o m m i s s i o n   i n t e r v e n -
tions in public health cannot be compared to 
those of institutions quoted by the Court. It 
is obvious that The California Wellness Foun-
dation (which is a private foundation) has a 
more specific mandate and a direct access to 
final beneficiaries of its actions (Californian 
c i t i z e n s )   a n d   c a n   o n l y   b e   c o m p a r e d   w i t h 
regional bodies in Member States.

AUDIT SCOPE AND APPROACH

10.
A r t i c l e   1 5 2   s t i p u l a t e s   t h a t   ‘ C o m m u n i t y 
action  shall  complement  national  policies, 
[ a n d ]   s h a l l   b e   d i r e c t e d   t o w a r d s   i m p r o v i n g 
public health’ thereby making a distinction 
between the responsibility of Member States 
t o   i m p l e m e n t   t h e i r   h e a l t h   p r o m o t i o n   p r o -
grammes and the responsibility of the Com-
munity to complement their action.

I n   t h i s   s e n s e ,   t h e   C o m m i s s i o n   u n d e r l i n e s 
that  the  PHP  primarily  aims  to  target  inter-
mediaries — Member States, key stakehold-
ers  and  actors  —  network  them  at  EU  level 
a n d   h e l p   t o   i d e n t i f y   a n d   t e s t   ‘ g o o d   p r a c -
tice’ in order to underpin and support public 
health policy development.

See also replies to paragraphs 14, 21, 40 and 
60(c).

AUDIT OBSERVATIONS

14.
The  intervention  logic  which  underlies  the 
P H P   i s   b a s e d   o n   A r t i c l e   1 5 2   o f   t h e   T r e a t y , 
w h i c h   c l e a r l y   s t i p u l a t e s   t h a t   ‘ C o m m u n i t y 
action  shall  complement  national  policies, 
[ a n d ]   s h a l l   b e   d i r e c t e d   t o w a r d s   i m p r o v i n g 
public health’, thereby making a distinction 
between the responsibility of Member States 
t o   i m p l e m e n t   t h e i r   h e a l t h   p r o m o t i o n   p r o -
grammes and the responsibility of the Com-
munity to complement their action.

T h e   P H P   t h e r e f o r e   a i m s   t o   t a r g e t   i n t e r -
mediaries — Member States, key stakehold-
ers  and  actors  —  network  them  at  EU  level 
a n d   h e l p   t o   i d e n t i f y   a n d   t e s t   ‘ g o o d   p r a c -
tice’ in order to underpin and support pub-
l i c   h e a l t h   n a t i o n a l   p o l i c y   d e v e l o p m e n t .   I n 
t h i s   c o n t e x t ,   i t   s h o u l d   a l s o   b e   n o t e d   t h a t 
the practical guide ‘Evaluating EU activities’ 
was  published  in  2004  and  could  therefore 
not have been used in 1999–2000 when the 
PHP (2003–07) was designed.

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17.
T h e   a c t i o n   p l a n   d e f i n e d   a f t e r   t h e   2 0 0 7 
interim evaluation of the PHP (2003–07) has 
confirmed that logical models are to be used 
in the evaluation of the PHP.

See also reply to paragraph 15.

In addition, the application forms for projects 
require  since  2006  that  project  design  fol-
l o w s   a   l o g i c a l   m o d e l .   S i n c e   t h e   P H E A ,   n o w 
EAHC, was created, this has been reinforced 
and ensured in project negotiation and fol-
l o w   u p ,   a s   d o c u m e n t e d   b y   t h e   a g e n c y ’ s 
negotiation guidelines.

18.
The  Commission  agrees  to  the  necessity  of 
establishing indicators for an effective pro-
g r a m m e   m o n i t o r i n g .   T h e   d e v e l o p m e n t   o f 
a d e q u a t e   i n d i c a t o r s   a t   p o l i c y ,   p r o g r a m m e 
and project levels, together with the collec-
tion  of  data,  is  one  of  the  objectives  of  the 
‘health information’ strand of the PHP.

See also replies to paragraphs 30 and 31.

19.
PHP  (2003–07)  was  designed  in  1999–2000 
and approved in 2002, i.e. in a period when 
t h e   C o m m i s s i o n ´ s   c u r r e n t   p r o g r a m m i n g , 
m o n i t o r i n g   a n d   e v a l u a t i o n   m e t h o d s   w e r e 
not yet fully deployed.

I t   s h o u l d   a l s o   b e   n o t e d   t h a t   t h e   S P P / A B M 
g u i d e   r e f e r r e d   t o   w a s   o n l y   p u b l i s h e d   i n 
2004.

At the level of projects, the setting of SMART 
o b j e c t i v e s   h a s   b e e n   g r a d u a l l y   e n f o r c e d   i n 
the two last years of the PHP (2003–07) and 
its current successor programme. Since 2006, 
t h e   g u i d e   f o r   a p p l i c a n t s   u s e d   f o r   t h e   c a l l s 
f o r   p r o p o s a l s   i n s t r u c t s   a p p l i c a n t s   t o   u s e 
the latest generally accepted principles for 
project management. The PHEA, now EAHC, 
e n s u r e s   t h e i r   a p p l i c a t i o n   t h r o u g h o u t   t h e 
project duration.

See also reply to paragraph 86.

20.
A s   a   m a t t e r   o f   p r i n c i p l e   t h e   C o m m i s s i o n 
considers that the intervention logic of the 
P H P   c a n n o t   e a s i l y   b e   m a d e   a s   e x p l i c i t   a s 
t h e   i n t e r v e n t i o n   l o g i c   f o r   a   h e a l t h   p r o m o -
tion programme within a Member State or a 
third country. This is due to the fact that the 
PHP  is  not  intended  to  be  a  health  promo-
tion programme targeted to citizens. This is 
also the reason why the global policy objec-
tives cannot easily be broken down into spe-
cific targets at the level of programmes and 
projects.

See also replies to paragraphs 14 to 16.

21.
The activities of the PHP flow from the 2000 
health strategy adopted by the Commission 
( C O M ( 2 0 0 0 )   2 8 5 )   w h i c h   s e t s   t h e   l i n k   w i t h 
the activities of other actors (such as Mem-
ber  States).  The  PHP  therefore  aims  to  tar-
get  intermediaries  like  Member  States,  key 
stakeholders and actors, to network them at 
EU level and to help identify and test ‘good 
practice’  in  order  to  underpin  and  support 
public health policy development.

M o r e o v e r ,   t h e   P H P   ( 2 0 0 3 – 0 7 )   a s   a d o p t e d 
i n   D e c i s i o n   N o   1 7 8 6 / 2 0 0 2 / E C   r e f l e c t s   t h e 
views expressed by the European Parliament 
a n d   t h e   C o u n c i l   i n   t e r m s   o f   p r i o r i t i e s   a n d 
objectives.

See also replies to paragraphs 10, 14, 40 and 
60(c).

22.
The  Commission  has  made  major  efforts  to 
set out its priorities in a precise and detailed 
way in the AWP.

23.
The  Commission’s  financial  intervention  in 
p u b l i c   h e a l t h   c a n n o t   b e   e a s i l y   c o m p a r e d 
to  that  of  Member  States  as  the  respective 
domains of competence differ in shape and 
coverage.

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28.
In many cases the creation of links between 
a c t o r s   i n   d i f f e r e n t   a r e a s   o f   p u b l i c   h e a l t h 
policy  and  the  development  of  networking 
s t r u c t u r e s   a c r o s s   M e m b e r   S t a t e s   a r e   a l s o 
to  be  considered  to  be  the  principal  objec-
t i v e s   o f   m o s t   p r o j e c t s   c o - f i n a n c e d   b y   t h e 
PHP. Such activities are mainly implemented 
t h r o u g h   g r a n t s   a w a r d e d   t h r o u g h   ‘ c a l l s   f o r 
proposals’ procedures.

The use of tendering is often difficult, in par-
ticular in those domains where the number 
o f   p o t e n t i a l   b i d d e r s   f o r   s u c h   s e r v i c e   c o n -
tracts is limited.

30.
PHP 2003–07 was designed in 1999–2000 and 
approved in 2002, in a period when the Com-
mission’s current programming, monitoring 
a n d   e v a l u a t i o n   m e t h o d s ,   s u c h   a s   a c t i v i t y -
based  management,  had  not  yet  been  fully 
deployed.

T h e   P H P   w a s   t h e   f i r s t   p r o g r a m m e   t o   p r o -
v i d e   f o r   t h e   d e f i n i t i o n ,   t h r o u g h   i t s   ‘ h e a l t h 
information’ strand, of strong and common 
i n d i c a t o r s   a n d   f o r   t h e   c o l l e c t i o n   o f   p e r t i -
n e n t   d a t a   i n   a l l   M e m b e r   S t a t e s .   I t   s h o u l d 
also be noted that the Commission’s Healthy 
Life Years indicator is the first and only glo-
b a l   p u b l i c   h e a l t h   i n d i c a t o r   a v a i l a b l e   a t   E U 
level.

31.
The  Commission  considers  that  the  setting 
up of indicators for an effective programme 
monitoring strongly depends on availability 
of  pertinent  data  at  project  level.  Develop-
ing  appropriate  indicators  and  data  collec-
tion methods is one of the objectives of the 
PHP`s ‘health information’ strand.

See also reply to paragraph 18.

24.
The Commission agrees that a higher budget 
would achieve more, but the implementation 
of  the  PHP  2003–07  reflects  the  budgetary 
means granted by the European Parliament 
a n d   t h e   M e m b e r   S t a t e s   a n d   t h e   p r i o r i t i e s 
a n d   o b j e c t i v e s   b o t h   i n s t i t u t i o n s   a p p r o v e d 
for it.

T h e   P H P   i s   a   c a t a l y s a t o r   f o r   c r e a t i n g   t h e 
conditions for the development of improved 
health  promotion  activities.  Calculating  an 
average per European citizen is not particu-
larly  relevant  for  a  programme  such  as  the 
PHP.

25.
The  Commission  has  made  constant  efforts 
to set out funding priorities in a precise and 
detailed  way  in  the  AWP  in  order  to  clarify 
the kind of work required, the policy link and 
the  link  to  previous  work.  The  selection  of 
t o p i c s   i s   i n f l u e n c e d   b y   M e m b e r   S t a t e   r e p -
r e s e n t a t i v e s   i n   t h e   P r o g r a m m e   C o m m i t t e e 
which agrees the annual work programme.

See also reply to paragraph 78.

26.
I n   e s t a b l i s h i n g   t h e   A W P ,   u n d e r   e a c h   t o p i c 
the  Commission  has  detailed  specific  areas 
illustrating  where  actions  would  be  of  par-
ticular relevance.

27.
T h e   C o m m i s s i o n   a c c e p t s   t h a t   f u r t h e r 
progress  is  needed  to  specify  in  the  AWP  a 
number of such topics and areas for poten-
tial action which is commensurate with the 
available budgetary appropriations.

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36.
T h e   p r o j e c t s   a u d i t e d   b y   t h e   C o u r t   w e r e 
s e l e c t e d   i n   t h e   s t a r t i n g   p h a s e   o f   t h e   P H P 
( 2 0 0 3 – 0 7 ) .   T h e   C o m m i s s i o n   n o t e s   t h a t   i t 
took applicants time to get used to require-
m e n t s   t o   s p e c i f y   o b j e c t i v e s ,   a c t i v i t i e s   a n d 
actions in more detail. In the Commission’s 
v i e w ,   t h e   s i t u a t i o n   i s   h o w e v e r   c o n s t a n t l y 
improving.

The  guide  for  applicants  used  for  the  calls 
for proposals since 2006 instructs applicants 
t o   u s e   t h e   l a t e s t   g e n e r a l l y   a c c e p t e d   p r i n -
c i p l e s   f o r   p r o j e c t   m a n a g e m e n t   ( i n c l u d i n g 
definition of objectives) for developing their 
application. The negotiation process ensures 
that  these  are  actually  fixed  as  such  in  the 
grant agreement, and the project officers of 
the  PHEA,  now  EAHC,  ensure  their  applica-
tion throughout the project duration.

38.
See also replies to paragraphs 19 and 86.

40.
The PHP primarily aims to target intermedi-
aries — Member States, key stakeholders and 
actors  —  and  to  network  them  at  EU  level. 
It also helps to identify and test ‘good prac-
tice’ in order to underpin and support public 
health national policy development.

See  also  replies  to  paragraph  10,  14,  21,  36 
and 60(c).

41.
This only applies to the 2003, 2004 and 2005 
projects  and  has  since  been  corrected  with 
t h e   i s s u a n c e   o f   a   m o r e   d i r e c t i v e   g u i d e   f o r 
applicants as of 2006.

See also reply to paragraph 36.

32.
New  AMP  indicators  (such  as  ‘level  of  pub-
lic  awareness  of  unhealthy  behaviours  and 
lifestyle-related health risks’, ‘share of citi-
z e n s   t h a t   h a v e   t h e i r   b l o o d   p r e s s u r e   m e a s -
ured  each  year’,  ‘share  of  population  being 
aware  of  the  health  risks  of  tobacco  smoke 
for non-smokers’, ‘share of population know-
ing that balanced diet means eating a variety 
of  different  foods’)  were  developed  during 
preparation of the 2009 activity statement in 
the framework of the 2009 preliminary draft 
b u d g e t ,   a n d   t h e y   w e r e   r e c o g n i s e d   b y   t h e 
Council  Budget  Committee  as  a  significant 
improvement  (Council  document  13895/08 
FIN362 dated 7 October 2008 — p. 23, ‘COM-
BUD assessment report of the PDB 2009 activ-
ity statements — note d’introduction’).

I n   a d d i t i o n ,   t h e   C o m m i s s i o n   h a s   s e t   u p   a 
working  group  for  the  further  definition  of 
indicators to be used in the frame of APS and 
AMP with a view to systematising the collec-
tion of the related pertinent data on a more 
regular basis for APS and AMP exercises from 
the year 2010.

33.
During the period audited by the Court, the 
C o m m i s s i o n   h a s   p r o v i d e d   f o r m a l   f e e d b a c k 
to participants on a case-by-case basis at the 
interim  and  final  reporting  stages,  both  on 
operational and financial considerations.

Since  the  creation  of  the  PHEA,  now  EAHC, 
t h e   m o n i t o r i n g   o f   p r o j e c t s   h a s   f u r t h e r 
improved.

S e e   a l s o   r e p l i e s   t o   p a r a g r a p h s   5 1 ,   5 3   a n d 
70 to 73.

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42.
In  selecting  projects,  relevance  to  EU  poli-
cies is a main criterion for funding. Projects 
have an impact on the policies cycle in sev-
eral ways, for example by:

 —

 —

 —

 —

feeding outcomes into technical bodies 
of Member States and stakeholders;
p r o m o t i n g   s u s t a i n a b l e   n e t w o r k s   o f 
expertise;
p r o v i d i n g   t h e   b a c k g r o u n d   f o r   r e c o m -
mendations on good practice.

The impact on people’s lifestyle is achieved 
indirectly.

45.
T h e   R D I   c y c l e   i s   n o t   f u l l y   a p p l i c a b l e   a s 
projects could only be targeted towards the 
intermediate level. The action was therefore 
limited to research followed by development 
a n d   i n   s o m e   c a s e s   p i l o t   p r o j e c t s   b u t   t h e 
C o m m i s s i o n   i s   i n   n o   p o s i t i o n   t o   r e a c h   t h e 
stage of full-scale implementation.

 —

The Commission can point to several exam-
p l e s   o f   a   s u c c e s s f u l   u p t a k e   o f   r e s u l t s   o f 
projects financed under the PHP (2003–07), 
such as the following:

 —

 —

W o r k   o n   t h e   i m p a c t   o f   a d v e r t i s i n g   o n 
y o u n g   p e o p l e   ( c h i l d r e n , o b e s i t y   a n d 
a s s o c i a t e d   a v o i d a b l e   c h r o n i c   d i s e a s e s ) 
fed into the Commission’s round table on 
advertising  self-regulation  (from  2005) 
w h i c h   p r o d u c e d   a   c o d e   o f   c o n d u c t   f o r 
self-regulation in the EU advertising Sec-
tor. It also contributed to the concept of 
the EU Platform on Diet, Physical Activ-
ity and Health where the European Heart 
Network is still an active member.

 —

The Shape-up project contributed to the 
d e v e l o p m e n t   o f   i n n o v a t i v e   e x a m p l e s 
o f   g o o d   p r a c t i c e s   t o   p r o m o t e   h e a l t h y 
b e h a v i o u r s   i n   s c h o o l   s e t t i n g s   a n d   o f 
p u b l i c – p r i v a t e   p a r t n e r s h i p   a p p r o a c h e s 
t h a t   a r e   p r o m o t e d   i n   t h e   S t r a t e g y   f o r 
E u r o p e   o n   N u t r i t i o n ,   O v e r w e i g h t   a n d 
Obesity-related health issues adopted by 
the Commission in 2007. Shape-up lead-
ers are currently part of a group of actors 
convened by the Commission for the pro-
m o t i o n   o f   g o o d   p r a c t i c e   e x a m p l e s   a n d 
of  community-based  approaches  based 
on public–private partnerships.
Good  practice  and  policy  recommenda-
t i o n s   o n   s e x u a l   e d u c a t i o n   a n d   s e x u a l 
h e a l t h   d e v e l o p e d   b y   t h e   S A F E   p r o j e c t 
w e r e   p r e s e n t e d   t o   t h e   H I V / A I D S   T h i n k 
T a n k   a n d   t h e   C i v i l   S o c i e t y   F o r u m .   K e y 
e l e m e n t s   o f   t h e i r   c o n c l u s i o n s   w e r e 
t a k e n   u p   i n   t h e   d i s c u s s i o n   d o c u m e n t 
d e v e l o p e d   b y   t h e   s e x u a l   h e a l t h   r o u n d 
t a b l e   o n   p o t e n t i a l   f u t u r e   E U   a c t i o n   i n 
t h i s   a r e a   a n d   d i s c u s s e d   i n   a   w o r k s h o p 
in May 2008.
O n   d r u g s   i n   p r i s o n s ,   E N D I P P   p r o v i d e d 
b a c k g r o u n d   i n f o r m a t i o n   f o r   f o l l o w - o n 
w o r k   w h i c h   i n   t u r n   l e d   t o   t h e   p r e p a r a -
t i o n   o f   c o u n t r y   r e p o r t s   o n   p r e v e n t i o n , 
treatment, and harm reduction services 
i n   p r i s o n ,   o n   r e i n t e g r a t i o n   s e r v i c e s   o n 
r e l e a s e   f r o m   p r i s o n   a n d   o n   m e t h o d s 
t o   m o n i t o r / a n a l y s e   d r u g   u s e   a m o n g 
p r i s o n e r s ,   a n d   f e d   i n t o   p r e p a r a t o r y 
w o r k   t o w a r d s   a   p r o p o s a l   f o r   a   C o u n c i l 
recommendation.
SUPPORT has been reoriented to en able 
m o r e   t r a n s p a r e n c y   a n d   s y n e r g i e s 
between mental health projects and help 
using  and  disseminating  their  outputs. 
S U P P O R T   p r o v i d e d   i n p u t   t o   t h e   p r e p a -
r a t i o n   o f   t h e   E u r o p e a n   P a c t   f o r   M e n t a l 
Health and Well-being and into the June 
2 0 0 8   h i g h - l e v e l   c o n f e r e n c e   a n d   o r g a n -
ised related workshops.

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46.
Generally national funding sources are avail-
a b l e   o n l y   f o r   n a t i o n a l   c o m p o n e n t s   o f   n e t -
w o r k i n g   a c t i v i t i e s   a c r o s s   M e m b e r   S t a t e s . 
This  explains  the  need  for  a  European  PHP 
to finance such activities, which are clearly 
in the overall EU interest.

See also replies to paragraphs 56 and 64.

U n d e r   t h e   f i r s t   P H P   ( 2 0 0 3 – 0 7 )   f u n d i n g 
m e c h a n i s m s   w e r e   n o t   a d a p t e d   t o   p r o v i d e 
l o n g e r - t e r m   f i n a n c i a l   s u p p o r t .   U n d e r   t h e 
c u r r e n t   P H P   ( 2 0 0 8 – 1 3 )   o t h e r ,   m o r e   a p p r o -
priate,  tools  and  financing  mechanisms  are 
available, mainly operating grants and joint 
actions financing.

48.
See reply to paragraph 46.

51.
T h e   C o m m i s s i o n   c o n s i d e r s   t h a t   i t s   m o n i -
t o r i n g   o f   p r o j e c t s   u n d e r t a k e n   h a s   s i g n i f i -
c a n t l y   i m p r o v e d   s i n c e   t h e   p e r i o d   c o v e r e d 
by  the  audit.  Nevertheless,  information  on 
previously funded projects has always been 
a v a i l a b l e .   I n   p a r t i c u l a r ,   l i s t s   o f   p r e v i o u s l y 
f u n d e d   p r o j e c t s   w i t h   l i n k s   t o   t h e i r   r e p o r t s 
were made public either on the DG SANCO or 
the  PHEA,  now  PHEA,  websites.  Since  2008, 
such monitoring information is also encoded 
in a comprehensive database.

This  tool  will  further  enhance  the  Commis-
sion’s monitoring of its project portfolio.

S e e   a l s o   r e p l i e s   t o   p a r a g r a p h s   3 3 ,   5 2   a n d 
70 to 73.

 —

 —

‘ E u r o c a r e   —   C l o s i n g   t h e   g a p ’   c o n t r i b -
u t e d   t o   c r e a t i n g   a   l e v e l   p l a y i n g   f i e l d 
f o r   d i s c u s s i o n s   o n   a l c o h o l   p o l i c y   w i t h 
stakeholders, as it allowed non-industry 
p l a y e r s   t o   d e v e l o p   c o m m o n   p o s i t i o n s 
a n d   t a k e   t h e s e   f o r w a r d   i n   d i s c u s s i o n s 
involving economic operators organised 
by the Commission. The project allowed 
the public health community to provide 
substantial  structured  and  coordinated 
i n p u t   i n t o   t h e   C o m m u n i t y ’ s   a l c o h o l 
strategy, which was adopted in October 
2006, and its implementation.
Input was provided to the Commission’s 
Green Paper ‘Towards a Europe free from 
tobacco smoke’ (through various projects 
funded by DG SANCO and referenced in 
t h e   G r e e n   P a p e r ) .   I n p u t   w a s   a l s o   p r o -
vided  to  the  Framework  Convention  on 
Tobacco Control (FCTC) through a posi-
tion paper of the Framework Convention 
A l l i a n c e   ( a n   i n t e r n a t i o n a l   n e t w o r k   o f 
more than 200 non-governmental organ-
isations) drafted under ENSP — the Euro-
pean Network for Smoking Prevention.

The  creation  of  the  ECDC  in  Stockholm  has 
been pushed forward and its work priorities 
developed on the basis of projects on com-
m u n i c a b l e   d i s e a s e   s u r v e i l l a n c e   s u p p o r t e d 
under the ‘health threats’ strand.

M o r e   b r o a d l y ,   t h e   H e a l t h y   L i f e   Y e a r s   i n d i -
cator  in  the  Lisbon  strategy  —  which  is  an 
i m p o r t a n t   r e f e r e n c e   f o r   i n t e r v e n t i o n   o n 
health determinants — has been developed 
on the basis of projects on health indicators 
under the health information strand, and is 
still calculated and being further developed 
o n   t h e   b a s i s   o f   s u c h   p r o j e c t s ,   a s   a r e   o t h e r 
key benchmark indicators of health at Com-
m u n i t y   l e v e l   i n   t h e   E u r o p e a n   C o m m u n i t y 
Health  Indicators  (ECHI)  list.  The  relevance 
of  these  at  national  level  is  clear,  with  the 
Healthy  Life  Years  indicator  being  adopted 
as the key benchmark for the national health 
s t r a t e g y   i n   E s t o n i a ,   f o r   e x a m p l e ,   a n d   t h e 
N e t h e r l a n d s   u s i n g   t h e   m o r e   d e t a i l e d   E C H I 
l i s t   t o   b e n c h m a r k   i t s   n a t i o n a l   p o l i c i e s   i n   a 
specific publication ‘Dare to Compare’.

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I n   t h e   f i e l d   o f   t h e   r e d u c t i o n   o f   a l c o h o l -
r e l a t e d   h a r m ,   t h e r e   w e r e   o n l y   a   l i m i t e d 
n u m b e r   o f   o r g a n i s a t i o n s   o p e r a t i n g   a t 
E u r o p e a n   l e v e l ,   a n d / o r   c a p a b l e   o f   l e a d i n g 
projects with a European dimension. It is to 
be noted that the different country reports 
on the situation regarding alcohol policy in 
the EU Member States on the one hand, and 
the ‘Alcohol in Europe’ report on the other, 
served different purposes, and are different 
in content (see Annex II, point 6).

53
(c)
T h e   C o m m i s s i o n   c o n s i d e r s   t h a t   t h e   t w o 
tobacco  networks  clearly  addressed  differ-
ent target groups.

In the ‘sexual and reproductive health’ area 
t h e   C o m m i s s i o n   h a s   a   d e d i c a t e d   p o l i c y   o n 
HIV/AIDS, including an action plan which is 
partially implemented through PHP funding. 
S u c h   f u n d i n g   r e s u l t s   i n   i m p r o v e d   p r e v e n -
tion of HIV transmission across Europe (see 
Annex II, point 15).

The advisory bodies referred to by the Court 
play an important role in the coordination of 
EU policy on HIV/AIDS, but have no financing 
capacity (see Annex II, point 16).

In  the  Commission’s  view  it  is  important  to 
support and to strengthen specialised NGOs 
a n d   n e t w o r k s   a c t i n g   o n   t h e   g r o u n d   o r   o n 
p o l i t i c a l   l e v e l s ,   a n d   s u p p o r t i n g   P L W H A   o r 
working  towards  the  prevention  of  new  HIV 
infections.  NGOs  or  networks  have  to  reach 
their counterparts — be they patients, people 
belonging  to  risk  groups,  local  or  national 
authorities,  or  politicians.  A  specialisation, 
or,  as  the  report  states,  a  ‘niche’,  is  conse-
quently  an  asset  for  an  NGO  working  in  the 
f i e l d   o f   H I V / A I D S .   T a k i n g   i n t o   a c c o u n t ,   f o r 
example, the costs for a lifelong antiretrovi-
ral  treatment  in  the  EU  at  an  average  price 
of  10  000  euro  per  person  per  year  (only  for 
medication), an investment in specialised and 
professional  NGOs  reaching  people  who  are 
most at risk of attracting HIV is justified and 
reasonable (see Annex II, point 18).

52.
A s   r e g a r d s   t h e   c o m p l e m e n t a r i t y   b e t w e e n 
p r o j e c t s ,   t h e   C o m m i s s i o n   h a s   r e q u i r e d 
project proponents to put their project into 
t h e   c o n t e x t   o f   e x i s t i n g   p r o j e c t s   a n d   b u i l d 
o n   r e s u l t s   a l r e a d y   a c h i e v e d .   T h i s   h a s   a l s o 
been  specified  as  one  of  the  award  criteria 
for grants.

I n   c e r t a i n   c a s e s ,   t h e   C o m m i s s i o n   r e q u i r e d 
proponents to cooperate with other projects 
a n d   t o   m a k e   d o c u m e n t a t i o n   o n   p r e v i o u s l y 
funded work publicly available.

In  addition,  as  a  general  procedure,  lists  of 
selected projects for funding are submitted 
to  the  Commission-wide  interdepartmental 
consultation procedure.

See also reply to paragraph 51.

53
(a)
It should be noted that the scope for actions 
w h e n   c o n s i d e r i n g   ‘ h e a l t h   d e t e r m i n a n t s ’   i s 
l a r g e .   T h e   P H P   a i m e d   a t   p i o n e e r i n g   d i f f e r -
e n t   a p p r o a c h e s   w h i l e   a v o i d i n g   o v e r l a p s . 
The Commission considers that the fact that 
p r o j e c t s   w e r e   d i v e r s e   a n d   c o v e r e d   d i f f e r -
ent  aspects  of  the  ‘drugs’  or  ‘nutrition  and 
physical activity’ areas shows that efforts to 
avoid overlap were successful.

P r o j e c t s   l i k e   ‘ S h a p e   u p ’   o r   ‘ E P O D E ’   f u n d e d 
under the PHP fed into the 2007 White Paper 
on nutrition, overweight and obesity-related 
health issues. The EU drugs strategy calls for 
a multidisciplinary approach (EU drugs strat-
e g y   2 0 0 5 – 1 2   C o u n c i l   d o c u m e n t   1 5 0 7 4 / 0 4 
dated 22 November 2004).

53
(b)
All projects audited fulfilled the PHP selec-
t i o n   a n d   a w a r d   c r i t e r i a .   W h i l e   d i f f e r e n t 
projects may have dealt with similar issues, 
they did so from different perspectives and 
with different methodologies.

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The European Centre for Disease Prevention 
a n d   C o n t r o l   ( E C D C )   i n   S t o c k h o l m   b e c a m e 
f u l l y   o p e r a t i o n a l   w i t h   r e s p e c t   t o   H I V / A I D S 
e p i d e m i o l o g y   a s   f r o m   2 0 0 8   o n w a r d s   ( s e e 
Annex II, point 19).

54.
Only the RTD framework programme and the 
drugs programme, and the ECDC as concerns 
c o m m u n i c a b l e   d i s e a s e s   s u r v e i l l a n c e ,   p r o -
v i d e   f u n d i n g   f o r   c o o p e r a t i o n   a t   E u r o p e a n 
level. In these cases the Commission has put 
in place mechanisms to ensure coordination 
and to avoid overlap with the PHP.

T h r o u g h   t h e   P H P ,   t h e   C o m m i s s i o n   h a s   i n i -
t i a t e d   a c t i o n s   i n   s e v e r a l   d o m a i n s   w h i c h 
s u p p o r t e d   a n d   u n d e r p i n n e d   p o l i c y   d e v e l -
o p m e n t   i n   k e y   a r e a s   o f   E u r o p e a n   p u b l i c 
h e a l t h   p o l i c y .   T h i s   h a s   b e e n   d o n e   b e a r i n g 
in  mind  the  existence  of  other  cooperation 
mechanisms.

The  ECDC  was  created  based  on  the  results 
of PHP (2003–07) projects. Furthermore the 
Commission  funds  PHP  projects  with  inter-
n a t i o n a l   o r g a n i s a t i o n s   l i k e   t h e   W H O   ( s u c h 
a s   2 0 0 7 W H O 0 2   ‘ N u t r i t i o n   a n d   p h y s i c a l 
a c t i v i t y   s u r v e i l l a n c e ’ )   a n d   t h e   O E C D   ( s u c h 
as 2006OECD02 ‘Health workforce and inter-
national migration’).

See also reply to paragraph 45.

56.
T h e   e x i s t e n c e   o f   ‘ E u r o p e a n   a d d e d   v a l u e ’ 
( E A V )   h a s   a l w a y s   b e e n   a   k e y   c r i t e r i o n   f o r 
making award decisions for PHP projects.

The  existence  of  other  cooperation  mecha-
n i s m s   ( s u c h   a s   t h e   o p e n   m e t h o d   o f   c o o r -
dination)  for  facilitating  collaboration  and 
exchange of information among stake holders 
throughout Europe does not exclude action 
by the PHP. Most of these other mechanisms 
do not provide financing necessary for start-
u p   a n d   m a i n t e n a n c e   o f   i n i t i a t i v e s   a t   E u r o -
pean level.

See also replies to paragraphs 46 and 64.

57.
T h e   v a s t   m a j o r i t y   o f   p r o j e c t s   c o n s i s t e d   o f 
n e t w o r k s ,   a s   o n e   o f   t h e   a w a r d   c r i t e r i a   w a s 
the  involvement  of  partners  from  different 
European countries.

58.
See reply to paragraph 45.

60.
(a)
See reply to paragraph 52.

60.
(c)
The PHP does not in general fund going-to-
s c a l e   i m p l e m e n t a t i o n   p r o j e c t s .   T h i s   i s   t h e 
responsibility of Member States.

See replies to paragraphs 10, 14 and 40.

62.
The Commission welcomes this confirmation 
of the ‘European added value’ (EAV) and the 
usefulness of the PHP.

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78.
M e m b e r   S t a t e s   a r e   o f f i c i a l l y   i n f o r m e d   o f 
the  list  of  selected  projects  (see  for  exam-
p l e   C ( 2 0 0 8 )   6 1 8 0   f o r   t h e   y e a r   2 0 0 8 )   a f t e r 
e v a l u a t i o n   o f   t h e   p r o p o s a l s   t h r o u g h   t h e i r 
representatives in the PHP Committee. This 
list  is  formally  reviewed  by  the  programme 
c o m m i t t e e   b e f o r e   s u b m i s s i o n   t o   t h e   E u r o -
p e a n   P a r l i a m e n t   f o r   s c r u t i n y   a n d   t h e n   t o 
Commission for formal approval.

See also reply to paragraph 25.

CONCLUSIONS AND 
RECOMMENDATIONS

Programme design

83.
A r t i c l e   1 5 2   o f   t h e   T r e a t y   s t i p u l a t e s   t h a t 
‘ C o m m u n i t y   a c t i o n   s h a l l   c o m p l e m e n t 
n a t i o n a l   p o l i c i e s ,   a n d   s h a l l   b e   d i r e c t e d 
t o w a r d s   i m p r o v i n g   p u b l i c   h e a l t h ’   t h e r e b y 
c l e a r l y   m a k i n g   a   d i s t i n c t i o n   b e t w e e n   t h e 
r e s p o n s i b i l i t y   o f   M e m b e r   S t a t e s   t o   i m p l e -
m e n t   t h e i r   h e a l t h   p r o m o t i o n   p r o g r a m m e s 
and the responsibility of the Community to 
complement their action.

T h e   P H P   w a s   d e s i g n e d   i n   a c c o r d a n c e   w i t h 
the  health  strategy  adopted  in  2000  by  the 
C o m m i s s i o n   ( s e e   C O M ( 2 0 0 0 )   2 8 5 )   a n d   t a k -
ing  into  account  the  limited  scope  of  com-
p e t e n c e s   o f   C o m m u n i t y   a c t i o n   u n d e r   t h e 
Treaty.

T h e   P H P   p r i m a r i l y   a i m s   t o   t a r g e t   i n t e r m e -
diaries  —  Member  States,  key  stakeholders 
and actors — and network them at EU level. 
It also helps to identify and test ‘good prac-
tice’ in order to underpin and support public 
health national policy development.

64.
Other  existing  mechanisms  of  cooperation, 
i n   p a r t i c u l a r   w i t h   M e m b e r   S t a t e s ,   c a n n o t 
r e p l a c e   t h e   P H P ’ s   a c t i o n   i n   u n d e r p i n n i n g 
and supporting policy development in some 
domains or activities for which actual finan-
cial support is crucial.

See also replies to paragraphs 46, 54 and 56.

65.
T h e   a c t i v i t i e s   r e s u l t i n g   f r o m   t h i s   C o u n c i l 
working party are to be funded through the 
current PHP (2008–13).

69.
The  Commission  shares  the  view  that  part-
nerships generally worked well.

It particularly welcomes the positive assess-
ment by project coordinators of large-scale 
networks  to  bring  together  knowledge  and 
expertise at the EU level.

70–73.
During the period audited by the Court, the 
C o m m i s s i o n   h a s   p r o v i d e d   f o r m a l   f e e d b a c k 
t o   p a r t i c i p a n t s   o n   a   c a s e - b y - c a s e   b a s i s   a t 
the interim and final reporting stages, both 
o n   o p e r a t i o n a l   a n d   f i n a n c i a l   c o n s i d e r a -
t i o n s .   W h e r e   n e c e s s a r y ,   c o r r e c t i v e   a c t i o n s 
on reports were taken through withholding 
payment  for  a  period  pending  provision  of 
complementary information.

The Commission considers that since the cre-
ation of the PHEA, now EAHC, the monitoring 
of projects has been further improved.

See also replies to paragraphs 33, 51 and 52.

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T h e   f i n a l   e v a l u a t i o n   o f   t h e   P H P   ( 2 0 0 3 – 0 7 ) 
will be available in 2010 — when the major-
ity of the projects will be finished — and will 
allow overall conclusions to be drawn on the 
effectiveness of the programme in reaching 
its objectives.

See replies to paragraphs 22, 25 and 27.

Recommendation 1

While  the  Commission  has  the  right  of  ini-
t i a t i v e ,   i t   i s   t h e   E u r o p e a n   P a r l i a m e n t   a n d 
t h e   C o u n c i l   w h i c h   a d o p t   t h e   p r o g r a m m e 
d e c i s i o n ,   i n c l u d i n g   t h e   o b j e c t i v e s   t o   b e 
achieved and the budgetary appropriations 
t o   b e   m a d e   a v a i l a b l e   f o r   a c h i e v i n g   t h e s e 
objectives.

S i n c e   2 0 0 2 ,   t h e   C o m m i s s i o n ’ s   l e g i s l a t i v e 
proposals are generally accompanied by an 
e x   a n t e   i m p a c t   a s s e s s m e n t   w h i c h   a n a l y s e s 
t h e   e c o n o m i c ,   s o c i a l   a n d   e n v i r o n m e n t a l 
impacts of possible policy options.

T h i s   i s   w h e r e   t h e   C o m m i s s i o n   i n t e n d s   t o 
s e t   o u t   t h e   p r o g r a m m e   l o g i c   o f   a n y   p u t a -
t i v e   s u c c e s s o r   p r o g r a m m e s   t o   t h e   c u r r e n t 
PHP (2008–13).

See reply to paragraph 15.

85.
It should be noted that the scope for actions 
w h e n   c o n s i d e r i n g   ‘ h e a l t h   d e t e r m i n a n t s ’   i s 
large. The PHP aimed at pioneering different 
approaches while avoiding overlaps.

All projects audited fulfilled all the selection 
and award criteria. While different projects 
may have dealt with similar issues, they did 
so from different perspectives and with dif-
f e r e n t   m e t h o d o l o g i e s ,   t h u s   i n c r e a s i n g   t h e 
significance of the results produced.

The  Commission  accepts  that  the  interven-
tion logic of the PHP (2003–07) has not been 
m a d e   e x p l i c i t   i n   t h e   p r o g r a m m e   d e c i s i o n . 
It  should  be  noted,  however,  that  this  pro-
g r a m m e   w a s   d e s i g n e d   i n   1 9 9 9 – 2 0 0 0   a n d 
approved  in  2002,  i.e.  in  a  period  when  the 
Commission´s  current  programming,  moni-
toring and evaluation methods were not yet 
fully deployed.

The benefits of a logic model approach will 
become increasingly apparent now that the 
P H P   h a s   b e c o m e   m o r e   e s t a b l i s h e d   a n d   i t s 
o u t p u t s   c l e a r e r .   A s   s u g g e s t e d   i n   t h e   2 0 0 7 
interim evaluation report, a first attempt at 
modelling the potential benefits of the PHP 
for European citizens will be done.

See replies to paragraphs 10, 14, 15, 19, 21, 
40 and 60(c).

Developing appropriate indicators and data 
collection methods is one of the objectives 
o f   t h e   P H P ` s   ‘ h e a l t h   i n f o r m a t i o n ’   s t r a n d . 
T h e   C o m m i s s i o n   c o n s i d e r s   t h a t   s e t t i n g   u p 
o f   i n d i c a t o r s   f o r   a n   e f f e c t i v e   p r o g r a m m e 
monitoring strongly depends on availability 
of pertinent data at project level.

New indicators were developed in the frame 
of the 2009 preliminary draft budget. In addi-
tion,  the  Commission  has  set  up  a  working 
group for the further definition of indicators 
to be used in the frame of APS and AMP for 
the year 2010.

See replies to paragraphs 31 and 32.

84.
The  Commission  has  made  major  efforts  to 
set out its priorities in a precise and detailed 
way in the AWP. The Commission accepts that 
further progress is needed to specify in the 
AWP  a  number  of  such  topics  and  areas  for 
potential action which is commensurate with 
the available budgetary appropriations.

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The Commission considers that the fact that 
projects were diverse and covered different 
aspects in a given area shows that efforts to 
avoid overlap were successful.

A s   r e g a r d s   t h e   c o m p l e m e n t a r i t y   b e t w e e n 
p r o j e c t s ,   t h e   C o m m i s s i o n   h a s   r e q u i r e d 
project proponents to put their project into 
t h e   c o n t e x t   o f   e x i s t i n g   p r o j e c t s   a n d   b u i l d 
on results already achieved before. This has 
also been specified as one of the award cri-
teria for grants.

I n   a d d i t i o n ,   t h e   C o m m i s s i o n   r e f e r s   t o   i t s 
general interdepartmental consultation pro-
cedure which was applied to the PHP.

E n s u r i n g   c o m p l e m e n t a r i t y   w i l l   b e   m a d e 
e a s i e r   w i t h   t h e   c r e a t i o n   o f   a   c o m p r e -
h e n s i v e   d a t a b a s e   f o r   p r o j e c t   m o n i t o r i n g 
information.

T h e   e x i s t e n c e   o f   ‘ E u r o p e a n   a d d e d   v a l u e ’ 
( E A V )   h a s   a l w a y s   b e e n   a   k e y   c r i t e r i o n   f o r 
m a k i n g   s e l e c t i o n   a n d   a w a r d   d e c i s i o n s   f o r 
PHP projects.

See replies to paragraphs 46, 51, 52, 53 and 
56.

86–87.
PHP 2003–07 was designed in 1999–2000 and 
approved  in  2002,  i.e.  in  a  period  when  the 
Commission’s  current  programming,  moni-
toring  and  evaluation  methods  had  not  yet 
been fully deployed.

T h e   p r o j e c t s   a u d i t e d   b y   t h e   C o u r t   w e r e 
selected from the starting phase of the PHP 
(2003–07).

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T h e   C o m m i s s i o n   n o t e s   t h a t   i t   t o o k   a p p l i -
c a n t s   t i m e   t o   g e t   u s e d   t o   r e q u i r e m e n t s   t o 
specify  objectives,  activities  and  actions  in 
more  detail.  In  the  Commission’s  view,  the 
situation  is  however  constantly  improving. 
The  guide  for  applicants  used  for  the  calls 
for proposals since 2006 instructs applicants 
t o   u s e   t h e   l a t e s t   g e n e r a l l y   a c c e p t e d   p r i n -
c i p l e s   f o r   p r o j e c t   m a n a g e m e n t   ( i n c l u d i n g 
definition of objectives) for developing their 
application. The negotiation process ensures 
that  these  are  actually  fixed  as  such  in  the 
grant agreement, and the project officers of 
the  PHEA,  now  EAHC,  ensure  their  applica-
tion throughout the project duration.

See replies to paragraphs 19 and 36.

88.
The Commission welcomes this confirmation 
of  the  ‘European  added  value’  (EAV)  and  of 
the  usefulness  of  the  PHP.  The  existence  of 
EAV has always been a key criterion for mak-
ing award decisions for PHP projects.

T h e   v a s t   m a j o r i t y   o f   p r o j e c t s   c o n s i s t e d   o f 
n e t w o r k s ,   a s   o n e   o f   t h e   a w a r d   c r i t e r i a   w a s 
the  involvement  of  partners  from  different 
European countries.

See replies to paragraphs 56 and 57.

89.
The Commission accepts that under the first 
PHP (2003–07) funding mechanisms were not 
a d a p t e d   t o   p r o v i d e   l o n g e r - t e r m   f i n a n c i a l 
s u p p o r t .   U n d e r   t h e   c u r r e n t   P H P   ( 2 0 0 8 – 1 3 ) 
other, more appropriate, tools and financing 
mechanisms are available, mainly operating 
g r a n t s   a n d   j o i n t   a c t i o n s   f i n a n c i n g .   G e n e r -
ally  national  funding  sources  are  available 
o n l y   f o r   n a t i o n a l   c o m p o n e n t s   o f   n e t w o r k -
i n g   a c t i v i t i e s   a c r o s s   M e m b e r   S t a t e s .   T h i s 
e x p l a i n s   t h e   n e e d   f o r   a   E u r o p e a n   P H P   t o 
finance  such  activities  which  are  clearly  in 
the overall EU interest.

See replies to paragraphs 46, 56 and 64.

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90.
The  Commission  shares  the  view  that  part-
n e r s h i p s   g e n e r a l l y   w o r k e d   w e l l .   I t   p a r t i c u -
l a r l y   w e l c o m e s   t h e   p o s i t i v e   a s s e s s m e n t   b y 
project coordinators of large-scale networks 
to  bring  together  knowledge  and  expertise 
at the EU level.

During the period audited by the Court, the 
C o m m i s s i o n   h a s   p r o v i d e d   f o r m a l   f e e d b a c k 
t o   p a r t i c i p a n t s   o n   a   c a s e - b y - c a s e   b a s i s   a t 
the interim and final reporting stages, both 
on operational and financial considerations. 
Since  the  creation  of  the  PHEA,  now  EAHC, 
the monitoring of projects has been further 
improved.

M e m b e r   S t a t e s   a r e   o f f i c i a l l y   i n f o r m e d   o f 
t h e   l i s t   o f   s e l e c t e d   p r o j e c t s   a f t e r   e v a l u a -
t i o n   o f   t h e   p r o p o s a l s   t h r o u g h   t h e i r   r e p r e -
sentatives in the PHP Committee. This list is 
formally approved by the Committee before 
submission  to  the  European  Parliament  for 
scrutiny and then to Commission for formal 
approval.

T h e   C o m m i s s i o n   i n t e n d s   t o   i m p l e m e n t   t h e 
r e c o m m e n d a t i o n   o f   t h e   C o u r t   t o   r e i n f o r c e 
dissemination activities for projects funded 
under the PHP.

See replies to paragraphs 33, 51, 69, 70 and 78.

Recommendation 2

Reply to the first subrecommendation
T h e   i n t e r i m   e v a l u a t i o n   o f   t h e   P H P   ( 2 0 0 3 –
0 7 )   p e r f o r m e d   i n   2 0 0 7   i d e n t i f i e d   a   c e r t a i n 
n u m b e r   o f   a r e a s   f o r   i m p r o v e m e n t ,   i n c l u d -
ing the mapping exercise recommended by 
t h e   C o u r t   o f   A u d i t o r s   f o r   t h e   c u r r e n t   P H P 
(2008–13).

See reply to paragraph 51.

The Commission intends to carry out such a 
m a p p i n g   e x e r c i s e   a n n u a l l y   f o r   t h e   c u r r e n t 
PHP  (2008–13).  This  will  complement  those 
c a r r i e d   o u t   i n   2 0 0 7   a n d   2 0 0 8   f o r   p r o j e c t s 
undertaken under PHP (2003–07).

Reply to the second subrecommendation
The Commission accepts that further progress 
is needed to specify in the AWP a number of 
topics and areas for potential action which is 
commensurate with the available budgetary 
appropriations.

See reply to paragraph 27.

Reply to the third subrecommendation
Since  the  creation  of  the  PHEA,  now  EAHC, 
the design and monitoring of projects under-
taken  has  improved.  The  new  funding  pos-
s i b i l i t i e s   f o r   n e t w o r k s   w i l l   b e   c o n s i s t e n t l y 
used.

See replies to paragraphs 33 and 46.

Overall conclusion

91.
The Commission agrees that a higher budget 
w o u l d   h a v e   a l l o w e d   m o r e   t o   b e   a c h i e v e d , 
but the PHP 2003–07 reflects the budgetary 
means granted by the European Parliament 
and the Council and its priorities and objec-
tives for this programme.

92.
The impact on citizens’ health of any health 
p r o m o t i o n   i n i t i a t i v e   c a n   o n l y   b e   a s s e s s e d 
t h r o u g h   c h a n g e s   i n   c i t i z e n s ’   b e h a v i o u r , 
w h i c h   c a n   o n l y   b e   a s s e s s e d   o v e r   t h e   l o n g 
term. The Commission considers that current 
and  previous  PHPs  made  a  significant  con-
t r i b u t i o n   t o   f o s t e r   a   m o d e r n ,   p a r t i c i p a t i v e 
public health policy at EU level.

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Recommendation 3

Reply to the first subrecommendation
Through  the  PHP  the  Commission  has  been 
able  to  initiate  actions  in  several  key  areas 
of public health which supported and under-
p i n n e d   p o l i c y   d e v e l o p m e n t .   T h i s   i s   b e i n g 
done bearing in mind the budgetary means 
available and the existence of other cooper-
ation mechanisms (such as the open method 
of coordination) which, although facilitating 
collaboration  and  exchange  of  information 
among stakeholders throughout Europe, do 
not provide financing necessary for start-up 
and maintenance of networks.

Reply to the second subrecommendation
T h e   C o m m i s s i o n   c o n s i d e r s   t h a t   t h e   b e s t 
opportunity to review the current health pro-
g r a m m e   w i l l   b e   p r o v i d e d   w h e n   t h e   r e s u l t s 
of  the  evaluation  of  the  PHP  (2003–07)  are 
available, in 2010.

For any putative successor programme to the 
current PHP (2008–13) after 2014, the Com-
mission, in accordance with its procedures, 
i s   t o   c a r r y   o u t   a n   e x   a n t e   i m p a c t   a s s e s s -
ment which will analyse the different policy 
options and their respective impacts.

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European Court of Auditors

Special Report No 2/2009

The European Union’s Public Health Programme (2003–07): an effective way to improve health?

Luxembourg: Office for Official Publications of the European Communities

2009 — 66 pp. — 21 x 29.7 cm

ISBN 978-92-9207-227-8

Special Report No 2/2009 — The European Union’s Public Health Programme (2003–07): an effective way to improve health?

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IN THIS  REPORT, THE  EUROPEAN  COURT  OF  AUDITORS  ANALYSES 

T H E   E U R O P E A N   U N I O N’S   P U B L I C   H E A LT H   P R O G R A M M E   ( P H P ) 

FOR  2003–07.  THE  COUR T ’S  AUDIT  ASKED  WHE THER  THE  RIGHT 

CONDITIONS  WERE  SE T  FOR  PROJEC TS  FINANCED  FROM  THE  EU 

BUDGET TO COMPLEMENT THE MEASURES TAKEN BY MEMBER STATES 

TO PROTEC T AND IMPROVE PUBLIC HEALTH. THE REPORT DETAILS 

CONCLUSIONS AND RECOMMENDATIONS IN PROGRAMME DESIGN, 

IMPLEMENTATION AND MANAGEMENT. IN VIEW OF ITS FINDINGS, THE 

COURT CALLS INTO QUESTION THE UTILITY OF CERTAIN COMPONENTS 

OF EUROPEAN PUBLIC HEALTH PROGRAMMES SUCH AS THE PHP. THE 

COMMISSION AND THE MEMBER STATES ARE INVITED TO RECONSIDER 

THE EU’S FUNDING APPROACH IN THE FIELD OF PUBLIC HEALTH.

EUROPEAN COURT OF AUDITORS

ISBN 978-92-9207-227-8