Commission staff working document - Executive - Summary of the impact assessment Accompanying the Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions Solidarity in health: Reducing health inequalities in the EU {COM(2009) 567 final} {SEC(2009) 1396}
Date: 2009-10-20
Institutions: European Commission
Subjects: health policy, impact study, public health, social inequality

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COMMISSION OF THE EUROPEAN COMMUNITIES 

Brussels, 20.10.2009 
SEC(2009) 1397 final 

COMMISSION STAFF WORKING DOCUMENT 

EXECUTIVE SUMMARY OF THE IMPACT ASSESSMENT 

Accompanying the 

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

Solidarity in health: Reducing health inequalities in the EU 

{COM(2009) 567 final} 
{SEC(2009) 1396} 

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1. 

INTRODUCTION 

This document summarises the impact assessment which considers policy options for an EU 
initiative  "Solidarity  in  Health:  Reducing  Health  Inequalities  in  the  EU".  The  Commission 
identified the need for action in the EU Health Strategy1 and announced an EU initiative on 
health  inequalities  in  the  2008  Renewed  Social  Agenda2.  This  document  incorporates 
comments  from  the  Impact  Assessment  Board  in  relation  to  the  objectives,  the  use  of  the 
terms inequalities and inequities, proportionality, subsidiarity and costs. The report commits 
only  the  Commission's  services  involved  in  its  preparation  and  does  not  prejudge  the  final 
Commission decision. 

Principle  responsibility  for  addressing  health  inequalities  rests  with  Member  States,  but  EU 
policies  can  have  an  indirect  impact  on  health  and  can  help  overcome  current  obstacles  to 
action.  The  report  appraises  EU  action  to  support  and  complement  the  efforts  of  Member 
States and stakeholders and to mobilise EU policies towards reducing health inequalities, in 
full respect of subsidiarity.  

EU  action  should  support  improvements  in  the  health  of  the  whole  population,  but  with 
emphasis on reducing avoidable and unfair gradients in health between social groups and EU 
regions – i.e. a 'levelling-up' approach.  

A  number  of  relevant  actions  are  already  taken  at  both  the  EU  and  national  levels.  Current 
actions are however limited by the level of awareness and priority given, lack of stakeholder 
involvement, gaps in information and knowledge, insufficient exchange of good practice and 
difficulties  in  creating  an  inter-sectoral  policy  approach.  This  document  therefore  considers 
measures to address these issues.  

2. 

PROBLEM DEFINITION 

There is currently an 8 year gap in life expectancy at birth for women between EU Member 
States  and  a  14-year  gap  for  men.  There  are  also  large  differences  in  death,  disability  and 
disease between Member States and EU regions. In some countries the health gap to the EU 
average and the best performers has widened in the last two decades. 

There  are  large  differences  in  health  between social  groups  defined  on  the  basis  of  income, 
occupation,  educational  level  or  ethnic  group  in  all  Member  States3.  People  with  lower 
education,  income  or  occupation  live  shorter  lives  and  spend  more  time  in  poorer  health. 
Differences  in  life  expectancy  at  birth  between  socio-economic  groups  range  from  4  to  10 
years  for  men  and  2  to  6  years  for  women.  This  pattern  is  reflected  in  many  measures  of 
physical and mental health. In some countries the gap has widened in the last decades.  

Inequalities  in  health  are  related  to  inequalities  in  social  determinants  of  health  including 
living conditions (housing, environment),  health-related behaviour (diet,  smoking, exercise), 

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COM(2007) 630. 
COM(2008) 412. 
Health  Status &  Living  Conditions.  Monitoring  Report prepared  by  the  European Observatory on  the 
Social Situation . European Commission 2008.  

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employment and working conditions, education, access to social protection including access 
to  quality  health  care.  A  substantial  proportion  of  health  inequalities  are  avoidable  and 
amenable to policies which can be influenced by EU policy. 

Three  areas  are  identified  where  weaknesses  are  observed  which  pose  obstacles  to  taking 
effective action to address health inequalities. These are areas where the EU can support and 
complement Member States actions:  

Lack  of  awareness  and  insufficient  policy  priority  and  commitment  by  Member  States  and 
other stakeholders 

Absence of comparable and regular data, monitoring and reporting. Lack of knowledge on the 
determinants and the effective policies to implement 

Insufficient  concerted  EU  approach  to  health  inequalities  (lack  of  mainstreaming  at  the  EU 
level) 

Member  States  are  implementing  some  policies  but  comprehensive  strategies  are  lacking. 
Over  half  of  the  Member  States  do  not  place  any  policy  emphasis  on  reducing  health 
inequalities. In addition, policies lack evaluation and dissemination.  

While  robust  evidence  exists,  more  information  is  required  on  the  effect  (causality)  and 
importance  of  some  health  determinants  in  order  for  Member  States  to  implement  effective 
action  in  relation  to  particular  population  groups  and  determinants.  Comparable,  routinely 
available  EU  wide  data  on  health  outcomes  and  determinants  of  health  inequalities  broken 
down by socio-economic group is also needed.  

Lack  of  EU  data  and  research  knowledge  is  an  obstacle  to  policy  development.  Better  and 
shared evidence and a rationale for action can provide the commitment currently lacking from 
a range of stakeholders. 

At EU level health inequalities have received higher policy priority and there are a number of 
EU  policies  which  are  having  a  positive  impact.  However,  this  is  difficult  to  quantify  and 
there  has  not  been  significant  mainstreaming  of  health  inequalities  across  all  relevant  EU 
policies.  

3. 

OBJECTIVES 

EU  action  regarding  health  inequalities  aims  to  support  and  complement  the  actions  of 
Member States and other stakeholders and to ensure that EU policies and activities provide a 
high level of health protection as set out in the Treaty. As far as possible, the health protection 
provided by EU policies should extend to all citizens irrespective of where they live or their 
social  background.  In  fulfilling  these  aims  EU  action  can  make  a  contribution  towards  a 
reduction in health inequalities in the EU.  

3.1. 

General Objectives 

The general objective of  this initiative  is  to support and complement the  efforts  of  Member 
States and stakeholders and mobilise EU policies towards reducing health inequalities. 

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3.2. 

Specific Objectives  

Specific objectives are to: 

Raise  awareness,  promote  information,  best-practice  exchange  and  policy  coordination  and 
advocate  the  tackling  of  health  inequalities  as  a  policy  priority;  both  at  Community  and 
Member States level and by other stakeholders. 

Improve data availability and the mechanisms to measure, monitor and report on inequalities 
in health across the EU and improve the knowledge base on the causes of health inequalities 
and the evidence base for action. 

Develop  the  contribution  of  relevant  EU  policies  towards  reducing  inequalities  in  health, 
including  better  support  of  Member  States  and  stakeholders'  efforts  to  tackle  health 
inequalities and a specific focus on vulnerable groups and third countries. 

4. 

ANALYSIS OF SUBSIDIARITY: IS AN EU ROLE JUSTIFIED?  

Although the main responsibility for addressing health inequalities rests with Member States, 
the problem is of policy concern for the EU for a number of reasons.  

Firstly,  the  pervasiveness  and  persistence  of  health  inequalities  suggests  a  discrepancy 
between  the  existing  situation  and  some  of  the  overarching  goals  of  the  EU  such  as 
strengthening  of  economic  and  social  cohesion,  ensuring  equal  opportunities,  promoting  the 
reduction  of  inequalities,  and  the  promotion  of  equality  between  men  and  women  and  the 
solidarity among Member States (Art. 2 of the EU Treaty and Art. 2 of EC Treaty).  

Secondly,  high  levels  of  poor  health  in  sections  of  the  EU  population  imply  substantial 
opportunity  costs  for  the  Union  and  provide  an  economic  reason  for  promoting  action  to 
address  them.  High  levels  of  population  health  are  important  in  the  context  of  an  ageing 
population  to  allow  longer  working  lives  and  support  higher  productivity,  competitiveness 
and employment levels. Avoidable ill-health also leads to large costs for health systems and 
puts  unnecessary  pressure  on  public  budgets.  Reducing  unnecessary  losses  due  to  ill  health 
and  premature  death  can  make  a  contribution  to  meeting  the  Lisbon  goals  and  achieving 
Europe's full potential for prosperity.  

There is a legal basis for action under several articles of the EC Treaty including: arts. 12 and 
13  (on  anti-discrimination),  art.  125  (promoting  employment  and  a  skilled,  trained  and 
adaptable workforce), arts. 136 and 137 (improving living and working conditions and social 
protection and combating of exclusion), art. 152 (ensuring a high level of health protection of 
all  Community  policies),  arts.  158  and  159  (strengthening  economic  and  social  cohesion). 
These articles form the basis for the Community to support and complement Member States' 
actions. 

The  necessity  of  EU  action  can  be  found:  1)  in  the  need  for  EU-wide  data  collection  and 
monitoring, as the EU is better placed then individual Member States to ensure reliable and 
comparable data and 2) in Cohesion policy through which the EU provides financial support 
to Member States, especially less well-off regions, that can be invested in key determinants of 
health inequalities such as living conditions, training and employment services, and healthcare 
(promotion,  prevention  and  treatment).  The  EU  can  also  provide  added  value  by  raising 

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awareness and reinforcing a focus on health inequalities, improving monitoring mechanisms, 
enhancing research and knowledge gathering, providing visibility of relevant actions through 
improving  the  sharing  of  experiences  and  good  practices  and  capacity  building,  and 
improving the linkages between EU policies. These have been suggested in the consultation 
responses and in other research reviews.  

5. 

POLICY OPTIONS 

Three options are analysed to achieve the objectives. Option I is the continuation of current 
activities ("business as usual"). Option II "Current plus" builds on existing work which can be 
taken  forward  in  a  short  time  frame  without  further  or  fundamental  changes  to  current 
Community  instruments,  and  formulated  in  a  Communication.  Option  III  "Far  Reaching" 
requires  a  longer  time  frame,  involves  changes  in  existing  EU  instruments,  and  includes  a 
Council Recommendation. The options are cumulative (option III builds on option II which 
builds on option I - see table). 

5.1. 

Option I: Business as usual  

In  Option  I,  work  to  support  the  reduction  of  health  inequalities  continues  under  the  social 
OMC and the Health Strategy. Equity in health is a guiding principle of the Health Strategy 
and reducing inequities in access to health care and health outcomes is a common objective 
under the social OMC. Through the exchange of experience, the EU assists Member States to 
translate this objective into national strategies. Mechanisms include National Strategy Reports 
and  the  Joint  Report  on  Social  Protection  and  Social  Inclusion,  peer  reviews  and  Social 
Protection  Committee  meetings,  as  well  as  meetings  of  the  EU  Expert  Group  on  Social 
Determinants  of  Health  and  Health  Inequalities  and  the  Council  Working  Party  on  Public 
Health  at  Senior  Level.  There  is  financial  support  through  PROGRESS  and  the  Health 
Programme 2008-2013. Likewise, Cohesion Policy, the Common Agriculture Policy and the 
Agricultural and rural Development funds support some activities regarding key determinants 
of health. Other EU actions would continue though not focusing on health inequalities. 

5.2. 

Option II: Current plus  

In  Option  II,  the  Commission  adopts  a  Communication  raising  awareness  on  health 
inequalities  and  highlighting  their  economic,  political  and  ethical  magnitude.  Option  II 
confirms  the  reduction  of  health  inequalities  as  a  policy  priority,  increases  dialogue  with 
stakeholders  and  strives  towards  a  better  use  of  existing  information  and  exchange 
mechanisms  and  existing  financial  support.  It  supports  actions  to  build  knowledge  for 
effective  action  and  strives  to  improve  the  measurement  system  on  health  inequalities 
between  Member  States,  EU  Regions  and  social  groups.  It  encourages  a  first  reflection  by 
relevant policy areas on their potential for action in this field (as proposed by some national 
authorities in the consultation). It announces a number of specific actions aiming to strengthen 
activities, without requiring significant new policy development. It remains the responsibility 
of Member States to develop concrete policies. 

5.3. 

Option III: Far reaching.  

In  Option  III  the  Commission  proposes  in  addition:  a  Council  recommendation  on  health 
inequalities; targets to reduce health inequalities across the EU as a whole; a high level inter-
institutional  advisory  committee;  a  review  of  a  number  of  policy  areas  to  include  the 

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reduction of health inequalities as an explicit priority whereby resources would be reallocated 
or  added  accordingly  for  the  period  beyond  2013;  a  review  of  community  measures 
contributing  to  ensuring  access  to  basic  needs  for  health  (health  care,  shelter,  food,  water 
education); and an larger international initiative to address global health inequalities. 

6. 

ANALYSIS OF IMPACTS  

This is a non-legislative initiative aiming to strengthen action to support and complement the 
efforts  of  Member  States  and  other  stakeholders  to  reduce  health  inequalities.  Actions 
proposed  in  options  I,  II  and  III  imply:  1)  increasing  efforts  to  improve  co-ordination  and 
facilitation  of  the  issues  at  EU  level  and  2)  increasing  efforts  to  raise  awareness  among 
Member States and other stakeholders of the importance to consider health and social issues 
notably  in  the  present  economic  crisis.  The  extent  to  which  the  activities  assist  action  by 
Member States and other stakeholders to reduce health inequalities is the main determinant of 
the impact of the proposals.  

6.1. 

Social Impacts 

The  actions  in  the  three  options  are  expected  to  have  positive  social  impacts  and  none  is 
expected to have a negative social impact. Compared to Option I, Options II and III are likely 
to have a greater positive social impact 

An important issue is that the present economic crisis can increase health inequalities through 
a deterioration of some determinants of health. Option II and III, through stronger awareness 
raising activities could help to ensure that, at a time of prioritisation, Member States do not 
neglect this policy area and incur negative future economic and social consequences.  

6.2. 

Economic impacts 

Indirect economic costs of large health inequalities are potentially considerable. They cannot 
be  estimated  with  precision.  One  study  has  estimated  the  potential  economic  gain  from 
bringing the health of the whole population up to the level of those with higher education to 
be between 1.2% and 9% of GDP.  

It  is  difficult  to  identify  the  costs  of  actions  to  improve  data  availability  and  comparability, 
notably by socio-economic status.  

Overall,  progress  on  the  determinants  of  health  and  health  inequalities  would  likely  have  a 
positive economic impact. In the long run gains in health and reductions in loss of healthy life 
years may be cost neutral or of overall economic benefit.  

7. 

APPRAISAL OF THE OPTIONS  

All three options would help to achieve the general objectives with Option III likely to have 
the  largest  effect.  However,  Option  III  involves  additional  costs  and  faces  some 
implementation  barriers.  Based  on  feasibility  (notably  the  ability  to  act  in  relation  to  the 
current crisis) and the costs involved Option II is the preferred Option. Option II can be seen 
as  a  stepping  stone  to  further  EU  level  work  on  health  inequalities  and  fully  respects  the 
principle of subsidiarity.  

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8. 

MONITORING AND EVALUATION 

Actions  assessed  include  proposals  to  improve  information,  monitoring  and  reporting  on 
progress on health inequalities and their determinants which can be used for monitoring and 
evaluation.  The  Commission  will  also  use  expert  support  for  regular  analyses  of  EU  policy 
developments through the European Observatory on the Social Situation and the Observatory 
on Health Systems and Policies. An additional monitoring mechanism is a Commission report 
in  2012  on  the  implementation  of  this  initiative  and  the  progress  it  has  had  on  addressing 
health inequalities, with further reports envisaged.  

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Option I  

– Business as usual 

Option II  

– Current plus 

Option III  

– Far reaching 

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