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Public Health at EU level - Historical Background

1956 – The Treaty of Rome

The original 1956 version of the Treaty contained several provisions relating to health. Article 36 allowed restrictions on the import and export of goods for the protection of human health and life, and Article 117 and 118 were concerned with health and safety in the workplace. Articles 52-58 which concern the right of establishment and Article 59 on the free movement of services have an impact on the health profession.

1956 - The Euratom Treaty

This Treaty established the European Atomic Energy Community and contained in Article 30-39 provisions for the protection of the general public and atomic industry workers for the effect of radiation. Further provisions on the health and safety of workers are contained in the 1951 Treaty of theEuropean Coal and Steel Community. Article 2 deals with the Community's duty to raise the standard of living.

1986 – The Single European Act

Amendments were made here to the above treaties. The most important health provision is found in Article 100a, in particular paragraph 3. This states that when the Community takes harmonising measures to create a single market, the Commission will take a high level of health protection as a base for its proposals in the field of health, safety, environmental protection and consumer protection.

1992 - Maastricht Treaty

Article 129 of the Maastricht Treaty gives the European Commission a degree of legal competence in the area of public health protection for the first time. Essentially, this specifies the Community role in the coordination of national health policies limited to topics of general interest: prevention of diseases, health information and education. More importantly, it specifies, “ Health protection shall form a constituent part of the Community's other policies”. 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. Such action shall cover the fight against the major health scourges, by promoting research into their transmission and their prevention, as well as health information and education. The Community shall complement the Member States' action in reducing drugs-related health damage, including information and prevention. The Community shall encourage cooperation between the Member States and, if necessary, lend support to their action. The Community and the Member States shall foster cooperation with third world countries and the competent international organizations in the sphere of public health.

The Council, acting in accordance with the procedure referred to in Article 251 and after consulting the Economic and Social Committee and the Committee of the Regions, shall contribute to the achievement of the objectives referred to in this Article through adopting:

(a) Measures setting high standards of quality and safety of organs and substances of human origin, blood and blood derivatives; these measures shall not prevent any Member State from maintaining or introducing more stringent protective measures;

(b) By way of derogation from Article 37, measures in the veterinary and phytosanitary fields which have as their direct objective the protection of public health;

(c) Incentive measures designed to protect and improve human health, excluding any harmonization of the laws and regulations of the Member States.
The Council, acting by a qualified majority on a proposal from the Commission, may also adopt recommendations for the purposes set out in this Article.

Community action in the field of public health shall fully respect the responsibilities of the Member States for the organization and delivery of health services and medical care.

1993 - Health framework published

The Commission publishes a framework for action in the field of public health identifying eight priority areas for Community action: cancer, AIDS, health promotion-education-training, drug dependence, health monitoring, rare diseases, pollution-related diseases, accidents and injuries. The Commission gives a commitment to produce regular reports on health across the full range of its activities and responsibilities.

1996 - BSE emerges

UK government identified, in 1996, Bovine spongeform encephalitis (BSE) as a threat to human health. The European Parliament launches an inquiry into the failure of the Community to protect the health of EU citizens.

1997 - Treaty of Amsterdam agreed

As a consequence the legal competence on public health was now strengthened when the European Union was mandated in Article 152 to ensure that ' a high level of health protection shall be ensured in the definition and implementation of all Community policies and activities'. While the article extends the scope of public health related policy, it maintains the subsidiary principle for health, which provides that the Union shall respect the Members States responsibilities for the organisation and delivery of their own health services and medical care. However, the EU has a specific right to legislate on blood, organs and tissues (safety and quality of blood, blood derivates, human tissues and human cells used in medical treatments).

1999 - Health Directorate established

The new European Commission president, Romano Prodi, makes health protection a priority for the European Commission. The Directorate of Health and Consumer Protection is established and a new European food safety regime and agency are presented as key objectives.

2000 – The first European Health strategy proposals

European Commission publishes proposals for the development of a public health policy, the Public Health program and adopts a Communication on the Health Strategy of the European Community[1]. It describes the Community's role in public health as follows: "... to complement (Member States') efforts, to add value to their actions and in particular to deal with issues that Member States cannot handle on their own. Infectious diseases, for example, do not respect national borders; neither does air and water pollution." EU action on health is based on three key principles: integration, sustainability and focus on priority issues. This has led to an integrated approach to health-related work at Community level, making health-related policy areas work together towards achieving health objectives.

The May 2000 communication, supported by the public health programme, led to the development of public health activities and to strengthening links to other health-related policies. General health policy lines were set out in the concept of a Europe of Health in 2002. Work was undertaken on addressing health threats, developing cross-border co-operation between health systems and tackling health determinants. The Community's health information system provides a key mechanism underpinning the development of health policy. The EU Health Forum, which brings together organisations active in health to advise the European Commission on health policy, is also a key element of the EU Health policy. The Forum enables the health community to participate in health policy making from the start, in particular on cross-border issues such as patient mobility.

2000 - EU-WHO Memorandum

Commission signs a Memorandum of Agreement with WHO in December 2000. In May 2002, high-level EU-WHO consultations take place in Brussels. New areas of collaboration are identified as poverty, EU enlargement, and children's health.

2002 - The Community Action Programme for Public Health 2003-2008

The Public Health Programme[2] runs with a budget of 312 million euros. MEPs demanded increased measures to "reduce the threat of diseases and other health hazards, including bio-terrorism, from crossing borders". They also call for "health to be taken more fully into account across all Community policies" and endorse the Commission's consultation proposals, especially with European-level non-governmental organizations.

The program is based on the three general objectives: health information, rapid reaction to health threats and health promotion through addressing health determinants. Networks, coordinated responses, sharing of experience, training and dissemination of information and knowledge will be inter-linked and mutually reinforcing. The aim is to embody an integrated approach towards protecting and improving health. As part of this integrated approach, particular attention is paid to the creation of links with other Community programs and actions. Health impact assessment of proposals under other Community policies and activities, such as research, internal market, agriculture or environment will be used as a tool to ensure the consistency of the Community health strategy.

Institutions, associations, organizations and bodies in the health field are encouraged to submit projects for implementing specific priorities, defined on an annual basis by the Commission in its work plan. In this task a Committee composed of national representatives of each Member State assists the Commission.

2002 - The High Level Process of Reflection on Patient Mobility and Healthcare developments

The Forum was convened following the conclusions of the Health Council in June 2002 and delivered its first report towards the end of 2003 (HLPR/2003/16). This reflection process represented a political milestone by recognising the potential value of European cooperation in helping Member States to achieve their health objectives. The Commission set out its response to the report in the Communication “Towards the Europe of Health (COM 20 April 2004). One of the mechanisms for taking forward the work was to establish a High Level Group on health services and medical care.

2003 - The Treaty of Nice:

The treaty of Nice makes adaptations to the European institutions, which are necessary for enlargement. It also aims to facilitate decision-making in the Council by shifting the decision rule from unanimity to qualified majority. The Treaty foresees a major reform of the Union's judicial system, and it improves the procedure to detect and address a serious breach of fundamental rights by a Member State.

2004 – Reflection process on enabling good health for all

The Commission launched a public debate on the future EU Health strategy. The consultation was framed by a policy document ‘ enabling good health for all', which set out a vision statement for health 2010. Key issues raised were the role of good health as a driver of economic growth and the urgency of addressing health inequalities both between Member States and within them. The paper proposed a shift from treating ill health to proactively promote good health. More than 170 responses were received that largely welcomed the Commissions approach.

2004 - High Level Group on Health Services and Medical Care

The High Level Group brings together experts from all Member States. Working groups involving interested Member States have been established on the following seven areas, with regular reporting to the full High Level Group.

Health technology assessment: The work was concluded in 2004 stating the usefulness of establishing a sustainable European health technology assessment network through the public health programme. A pilot network was to connect national agencies and health ministries, enabling an effective exchange of information on the short- and long-term effectiveness of health technologies and thus supporting policy decisions by Member States to improve quality of care and efficient use of resources.

Cross-border healthcare purchasing and provision: Guidelines have been developed for cross-border healthcare purchasing in order to help clarify the legal and practical uncertainties identified by Member States. The High Level Group also recommended that the guidelines should be accompanied by a mechanism for exchanging best practice and experience regarding their implementations in practice. Continued work should be focused on the provision of information to patients; the financial impact of patient mobility; monitoring cross-border healthcare purchasing and provision; and addressing issues of medical malpractice and liability.

Health professionals: Initial analysis of a pilot study of professional mobility in 6 Member States suggest that current impact of mobility is marginal, however there is a potential for more impact in certain geographical areas and clinical specialists. Work should be taken forward through exchanging information on continuing professional development to ensure quality; ensuring that basic data on migration of health professionals is provided by all Member States; surveying the impact of migration out of Member States; and sharing information on recruitment practices in order to assess whether common principles could be developed; The group is considering a European certificate of current professional status and the question of ethical recruitment between EU Member States and into the EU from other countries.

Centres of reference: Some principles have been developed regarding European centres of reference, including their role in tackling rare diseases or other conditions requiring specialised care as well as volumes of patients, and some criteria that such centres should fulfil. Options and procedures for designating European centres of reference for limited periods of time at European level based on agreed lists of pathologies, technologies and techniques are also being developed. The High Level Group has invited the Commission to test the feasibility of this approach through pilot activities and will begin with rare diseases.

Information and e-health (including data protection): An overall health systems information strategy in a European context is needed, considering mobility of citizens and availability of Europe-wide e-health services. The Commission should together with Member States examine the feasibility of introducing a “minimum data set” for patients to be available throughout the Union, and make necessary proposals, using the knowledge of involved national organisations. Member States should also consider including investment in the necessary eHealth structure and services as part of their health system development plans. Thirdly Member States and the Commission should consider including investment in eHealth in proposals for support from the structural funds, in particular with regard to the new Member States.

Health impact assessment and health systems: The group aims to have an operational tool for assessing the impact of proposals on health systems, combining a methodology, operational manuals for use by officials evaluating specific proposals or policies and a network of contact points able to provide information on healthy systems in the different Member States. The High Level Group proposes to establish a network on health systems impact assessment across the Member States, who can act as contact points for information regarding their specific health system.

Patient safety: Health care interventions, although intended to benefit patients, may in some cases cause harm. An EU patient safety network or forum, working with other international organisations, could provide focus for efforts to improve the safety and care for patients in all EU Member States, through sharing information and expertise. The High Level Group recommends that health ministers undertake to establish patient safety programmes and an operational network between Member States' patient safety contact points at European level, with a forum for involvement of civil society and other stakeholders.

The High Level Group has also contributed to other work relevant to health services and medical care, including the open method of coordination on healthcare and long-term care as outlined in Communication COM(2004) 304. The High Level Group reports annually to the EPSCO Council (Employment, Social Policy, Health and Consumer Affairs). The progress of work of the High Level Group is summarized in its 2006 Report[3].

2007 EU Health Strategy

The new EU Health Strategy was adopted on the 23 October 2007, building on the results of the open consultation in both 2004 and 2007. The Strategy aims to provide an overarching strategic framework spanning core issues in health as well as health in all policies and global health issues. The Strategy aims to set clear objectives to guide future work on health at the European level and to put in place an implementation mechanism to achieve those objectives. The strategy identifies areas where the Member States cannot act effectively alone and where cooperative action at the Community level adds value to national actions. It addresses major challenges to the health of the European population that require a new strategic approach and proposes actions aimed at fostering good health in an ageing Europe, protecting citizens from health threats, supporting dynamic health systems and new technologies. This strategic approach is underpinned by four fundamental principles. The Strategy is based on shared health values; health is the greatest wealth; health in all policies (HIAP) and strengthening the EU voice in global health. It is also based on shared values including the "participation of citizens in and their influence on decision making".

2007 – 2013 the Community Action Programme for Public Health 2007-2013

On 24 May 2006 the Commission adopted a proposal for a European Parliament and Council Decision creating the Programme for Community Action in the field of Health 2007-2013[4]. This proposal sets the framework for the Commission's funding of projects relating to health from 2007-13 and will be part of a strategy bringing together the broad range of Community health actions to define goals and priorities to help improve the health of European citizens. This proposal replaced the proposal of 6 April 2005 for a Community Programme for Health and Consumer Protection 2007-2013. This was done following the European Parliament's first reading and in light of the final decision on the budget for 2007-13. The budget is now 365.6 million euro, approximately one third of the amount foreseen in the April 2005 proposal.

Where the April 2005 proposal had six health strands, the May 2006 proposal has three broad objectives. These objectives align future health action with the overall Community objectives of prosperity, solidarity and security. This will help to create synergies with other Community programmes and policies.

The objectives are to:

  • Improve citizens' health security; actions will be taken to protect citizens against health threats including working to develop EU and Member State capacity to respond to threats. It will also cover actions such as those in the field of patient safety, injuries and accidents, and community legislation on blood, tissues and cells and in relation to the International Health Regulation.
  • Promote health for prosperity and solidarity; actions will be taken to foster healthy active ageing and to help bridge inequalities, with a particular emphasis on the newer Member States and will incorporate action to foster cooperation between health systems on cross-border issues such as patient mobility and health professionals. It will also cover action on health determinants such as nutrition, alcohol, tobacco and drug consumption as well as the quality of social and physical environments.
  • Generate and Disseminate Health Knowledge; actions will be taken to exchange knowledge and best practice in areas where the Community can provide genuine added-value in bringing together expertise from different countries, e.g. rare diseases and cross-border issues related to cooperation between health systems. It will provide for action on the horizontal issues of gender health, children's health and mental health. It will also allow for action to expand EU health monitoring and develop indicators and tools as well as ways of disseminating information to citizens in a user-friendly manner, such as the health portal.

While the health challenges at a European level are increasing, the programme proposal has been dramatically reduced.

[1]Communication on Health Strategy of the European Community- COM (2000) 285 final of 16 May 2000