In October 2007, the European Commission published its Health Strategy1 for the period 2008–13, to provide ‘an overarching strategic framework spanning core issues in health as well as health in all policies and global health issues’. What is the background? How does it relate to other European health activities? Where is it going?
The legal base for health activities by the European Union is established in the 1997 Treaty of Amsterdam: ‘a high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities’. The European Commission created an administrative Unit for public health, and subsequently upgraded this to a full Directorate—now Directorate General (DG) Health and Consumers. The first health activities consolidated the existing work on serious diseases, and developed some new fields including regulations on blood and human tissues, and improving national health reporting. Pharmaceuticals, professional accreditation, electronics and research were managed by other parts of the Commission. While Member States sought to retain national sovereignty over health services, the Bovine Spongiform Encephalopathy epidemic in the 1990s led to establishing a major new European agency on food safety, and raised the profile of health at a political level.
After wide consultation, DG Health in 2002 presented the first full public health programme, with three fields: (i) health information and knowledge—‘for policy makers, health professionals and the general public’; (ii) health threats—both communicable diseases and bioterrorism protection; and (iii) health determinants—health promotion and disease prevention. There was specific legislation for food safety and human tissue control; a new European Health Forum for greater public engagement; and improved coordination on ‘health in all policies’ through other Commission directorates (including internal market, social affairs, research, environment and trade and development). An annual round of calls for project support was developed, using peer review, and programme administration was formally established through a new Public Health Executive Agency (now called Executive Agency for Health and Consumers). This part of DG Health's work has the most impact on health professionals at local level, who find partners across countries and develop proposals in new areas of health protection. With 200 proposals submitted and around 30% accepted each year,2 an increasing proportion of financial support has gone to European-level cooperative groups, rather than directly back to Member State governments, and in a more transparent way.
The year 2005 also saw the major European developments, including enlargement from 15 to 25 (now 27) Member States, new Commissioners, new Parliament and a new budget. DG Health proposed that its budget (noted at the time to be only 15 cents per European citizen) should be doubled. But neither the European Parliament nor the European Council agreed, and funding per capita for the period 2007–13 was actually slightly reduced. DG Health therefore had to prioritize its objectives within the constrained new budget, and the new Health Strategy1 (also described as a White Paper, a term used by national governments to set out policy commitments) was published in October 2007, along with an excellent Working Document3 which contains extensive reference material on the conceptual approach, the legal basis and the links within the Commission and externally for ‘health in all policies’.
The health strategy
The new Health Strategy is structured as ‘four principles’ and ‘three objectives’ (Box 1). The objectives are, in reality, very similar to the three of the first (2002–06) health strategy, although medical care and health systems are now clearly included as well as health promotion and protection.
Shared values—indicates broad EU concerns including universality, access to good quality care, equity and solidarity and also health issues including an action orientation using best scientific evidence.
Health and wealth—seeing health protection as supporting economic productivity and the health system as important both as employment and valued consumption.
Health in all policies—continuing recognition of cross-sectoral approaches to health.
Global health—working in international settings on international issues—including development, global warming, tobacco control.
Fostering good health in an ageing Europe—recognizing the contributions of both health promotion and effective medical care.
Protecting citizens from health threats—developing this theme from terrorism to wider risks including environmental, accidents and violence and patient safety.
Supporting dynamic health systems and new technologies—concern for the organization of healthcare and public health, innovation and e-health.
The Strategy proposes two main dimensions for implementation: first, structured cooperation between Member States (including regional and local involvement) and second finance, including funds directly for DG Health and those available within other Commission programmes such as regional funds. Notably, the Strategy emphasizes that Member States must themselves contribute to achieving health objectives—it cannot be achieved through European coordination alone. And a range of instruments may be used: legislation through a European Directive would be a strong approach, but difficult to achieve, while ‘softer’ instruments include recommendations and guidelines, advisory committees and workshops.
Apart from direct funds to DG Health, the Health Strategy also addressed a second set of EU resources available through other Commission directorates, especially the regional funds, drawing on the Treaty requirement that ‘health protection shall be ensured in … all Community policies and activities’. The regional funds are a rising proportion of the total EU budget: PHARE funding assisted Eastern European countries in transition from communist economies, and for the 12 new accession countries, Common Agricultural Policy funds and regional funds together have been oriented particularly towards rural economies. The regional funds are managed by each country, without international collaboration, but are directed by each country's ministry of finance. Thus, to gain from this resource, ministries of health need to put their case to the ministry of finance. This has been a strong motive for promoting ‘Health is Wealth’, the second Principle of the Health Strategy, since economic improvement means much more to finance ministers than health improvement.
Health services directive
Yet, while these existing strands of health policy have become embodied within the Strategy, a new theme—health services—has become politically important. The Treaty says the EU ‘should fully respect the responsibilities of the Member States for the organisation and delivery of health services and medical care’. But the right of individuals to chose where they receive treatment, across national borders, has been supported by the European Court of Justice; and at the same time, there is pressure from the World Trade Organization to ‘liberalise’ (i.e. encourage competitive markets) in all services, including health services. In July 2008, DG Health issued a Communication4 to establish rules on free movement in the field of health care. It covers three areas. First, patients’ rights for choice of country for their health care, and compensatory reimbursement. Second, each Member State should define standards for quality and safety of care. Third, there should be cooperation between Member States about health knowledge, including health technology, telemedicine, prescription data and specialized centres.
However, the objectives and content of the Communication are contentious. While it is presented as a legal framework for existing uncertainties of cross-border healthcare and a strengthening of patients’ rights, Member States regard health care differently from other traded services. Member States are both the main regulator of quality of services (with professional bodies) and often the main funder of health care (particularly children, the sick and the aged, who are not wage-earners). While industry and some healthcare providers may support greater freedom to establish their services, an alliance of dissenting Member States and of non-governmental organizations could seriously damage the progress of the Communication, and also be a worry to the Commissioner. But the proposal will also be constrained by organizational limits: both the Commission and the Parliament change at the end of 2009, and politics will be slow in the months before that.
The field of Health-in-All-Policies has been directly addressed in the new strategy. The Commission has listed the 27 other Directorates where policies can overlap with health, and joint working has been developing. For example, the approach of DG Health in the fields of nutrition and obesity has been to invite stakeholders to present their policies from their own perspectives, and then to ask each to consider how they can also contribute to the health of European citizens. This may create new synergies and perhaps unlock positions that have built up through the health ‘setting’ the agenda alone. But there is much work yet to be done. Fields such as environment, research, international aid, and especially agriculture, require a lot more ‘joint’ agenda-setting for health policies to become embedded in cross-EU action.
A second feature of the Strategy will be to organize better collaboration between Member States. The Commission's health budget is a tiny proportion (0.05%) of EU spending, and the EU itself spends only 1% of total European GNP: so there is much that can be done at Member State level (and below), as well as at the European level. Equity and ‘health and wealth’ both feature strongly in the Strategy, but are mainly aspirations for the general good: these are areas where Member State policies are crucial, since reduction of inequalities (for example) cannot be ‘legislated’ from the European Union. The 2005 expansion of the Union arguably led to greater inequalities—certainly between nations. On the other hand, many areas are open to coordination support by the Health Directorate: for example, sharing expertise has been well demonstrated in preparations for bird flu, and local health promotion activities have been beneficially supported by the Public Health programme where Member States were slow in developing these services to citizens themselves. Much more could be achieved through technology sharing in public health between Member States and at regional and local levels.
Leadership is important for European public health, because many of the objectives cannot be achieved through legislation and directives. Commissioner Byrne, who led DG Health from 1997 to 2005, took a high profile position on tobacco, which finally challenged the entrenched interests of national governments (especially the United Kingdom and Germany, where the tobacco industry are at their strongest), and importantly contributed to the WHO Framework Convention of Tobacco Control. Byrne's home country, Ireland, also led the international movement to control smoking in public places. The Health Strategy has provided a broad platform for Byrne's successors, Mr Kyprianou and Mrs Vassiliou, both from Cyprus, but no big theme for leadership has emerged. And, as health remains a small part of Europe's responsibilities, there are some doubts whether a separate directorate for health will survive in the new Commission after 2009.
In developing its Health Strategy, the Commission has actively sought stakeholders and promoted consultation. For example, in 2003 the Commission established the European Health Policy Forum, a body of about 50 formal members in four broad ‘constituencies’: non-governmental organizations in the public health field and patients’ organizations; organizations representing health professionals (including EUPHA) and trade unions; health service providers and health insurance; and industry with a particular health interest. The Forum meets two or three times a year, and also conducts business through smaller working groups. Some thematic papers produced by these working groups have contributed well to shaping debate, and indeed to evolution of the health strategy. A recent example, to which EUPHA contributed, is a commentary on the character and balance of all EU funding in the future:5 the Forum recommended widening financial incentives from supporting industry towards promoting social justice.
EUPHA seeks to promote scientific knowledge—through the annual conferences, the Journal, the developing activities of the (topic-area) Sections and international collaborations such as SPHERE.6 But also, EUPHA members must understand that knowledge for policy and practice can be built by linking ‘harder’ science to ‘softer’ political perspectives. EUPHA's own new Strategy proposes a greater engagement in both research and policy at European level. Several other Europe-wide organizations are using the public health programme to fund their activities, for example, the European Public Health Alliance, linking national health NGOs, and EuroHealthNet, linking national health promotion agencies. And successful European networks have created by earlier funding from DG Health, including ‘HealthBasket’, ‘Simpatie’ and ‘Healthinequalities.net’. EUPHA member national public health associations should actively engage in collaboration, to seek and use new knowledge across national boundaries for policy and practice.
The ultimate test of the Health Strategy will be how far, from the perspective of 2013, progress was made on the issues identified in 2007. This will depend on us all—it cannot be achieved alone by the Commission. Public health associations can contribute at national level, through developing understanding of European public health issues and support by their national ministry of health, while ministries will need to develop better dialogue with national organizations, to discuss what evidence-based policies should be. Then, it will be necessary to demonstrate how national policies link across the European member states. The Health Services directive proposes new areas for coordination and cooperation: perhaps these may develop even if the political process for the directive is not finalized. Certainly, the previous ‘open method of coordination’, in which targets were set and indicators measured, lacked an important component—it did not necessarily encompass any national action.
The Commission's Health Strategy sees national and local organizations, beyond ministries of health, as important contributors. The national public health associations that are members of EUPHA can have an important role. Instead of looking to Europe for ‘them’ to do something, can we show that we can deliver coordinated change and health improvement, by working both with our governments and with the European Commission?