BT-Drucksache 16/9412

zu der Unterrichtung durch die Bundesregierung -16/7575 Nr. 1.5- Weißbuch Gemeinsam für die Gesundheit: Ein strategischer Ansatz der EU für 2008 - 2013 (inkl. 14689/07 ADD 1 bis 14689/07 ADD 3) KOM (2007)630 endg.; Ratsdok 14689/07

Vom 3. Juni 2008

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Deutscher Bundestag Drucksache 16/9412
16. Wahlperiode 03. 06. 2008

Beschlussempfehlung und Bericht
des Ausschusses für Gesundheit (14. Ausschuss)

zu der Unterrichtung durch die Bundesregierung
– Drucksache 16/7575 Nr. 1.5 –

Weißbuch
Gemeinsam für die Gesundheit: Ein strategischer Ansatz der EU für 2008–2013
(inkl. 14689/07 ADD 1 bis 14689/07 ADD 3)
KOM(2007) 630 endg.; Ratsdok. 14689/07

A. Problem

Nach Ansicht der Europäischen Kommission steht die Gemeinschaft vor wach-
senden gesundheitspolitischen Herausforderungen, die die einzelnen Mitglied-
staaten im Rahmen ihrer nationalen Zuständigkeit für diesen Politikbereich al-
lein nicht meistern können. Gesundheitspolitische Probleme mit grenzüber-
greifenden oder internationalen Auswirkungen resultierten vor allem aus drei
Entwicklungen: Erstens verändere der demographische Wandel die Erkran-
kungsmuster und belaste die Nachhaltigkeit der Gesundheitssysteme der EU.
Zweitens gingen von Pandemien, größeren Unfällen und biologischen Zwi-
schenfällen sowie Bioterrorismus mögliche größere Gesundheitsgefahren aus.
Drittens hätten sich in den vergangenen Jahren die Gesundheitsversorgungs-
systeme aufgrund einer raschen Entwicklung neuer Technologien im Hinblick
auf Gesundheitsförderung, Prognosen, Prävention und die Therapierung von
Erkrankungen enorm weiterentwickelt.

B. Lösung

Kenntnisnahme des Weißbuchs „Gemeinsam für die Gesundheit“ und An-
nahme einer Entschließung, mit der die Bundesregierung aufgefordert wird, bei
der Erarbeitung der Schlussfolgerungen zur Umsetzung des Weißbuchs der
Kommission die vom Deutschen Bundestag eingenommene Position zu beach-
ten. Die Bundesregierung soll sich insbesondere für den Erhalt der autonomen
Zuständigkeit der Mitgliedstaaten für ihre Gesundheitssysteme einsetzen und
darauf achten, dass es nicht zu einer Aushöhlung nationalstaatlicher Kompeten-

zen im Gesundheitsbereich kommt. Außerdem wird die Bundesregierung er-
sucht, den von der Kommission geplanten neuen Mechanismus der „struktu-
rierten Zusammenarbeit“ bei den Beratungen im Rat ausdrücklich abzulehnen.

In Kenntnis der Unterrichtung auf Drucksache 16/7575 Nr. 1.5 Annahme
einer Entschließung mit den Stimmen der Fraktionen CDU/CSU, SPD,
FDP und DIE LINKE. bei Stimmenthaltung der Fraktion BÜNDNIS 90/
DIE GRÜNEN

Drucksache 16/9412 – 2 – Deutscher Bundestag – 16. Wahlperiode
C. Alternativen

Kenntnisnahme der Vorlage ohne Annahme einer Entschließung bzw. Kennt-
nisnahme der Vorlage und Annahme einer alternativen Entschließung.

D. Kosten

Kosten wurden im Ausschuss nicht erörtert.

Deutscher Bundestag – 16. Wahlperiode – 3 – Drucksache 16/9412

Beschlussempfehlung

Der Bundestag wolle beschließen,

in Kenntnis der Unterrichtung auf Drucksache 16/7575 Nr. 1.5 folgende Ent-
schließung anzunehmen:

I. Der Deutsche Bundestag stellt fest:

1. Die Europäische Kommission hat Ende Oktober 2007 das Weißbuch
„Gemeinsam für die Gesundheit: Gesundheitsstrategischer Ansatz der
EU für 2008–2013“ vorgelegt. Während die Kommission darin die
„Hauptzuständigkeit“ der Mitgliedstaaten für die Gesundheitspolitik her-
vorhebt, betont sie zugleich, dass es Bereiche gibt, in denen die Mit-
gliedstaaten allein nicht wirksam handeln können und in denen eine Zu-
sammenarbeit auf Gemeinschaftsebene unverzichtbar ist. Die Kommis-
sion hebt hervor, dass der Reformvertrag von Lissabon der Gesundheit
mehr politisches Gewicht in der EU-Politik verleiht. Daraus leitet die
Kommission ihre Absicht ab, einen neuen Mechanismus der struktu-
rierten Zusammenarbeit im Gesundheitsbereich auf EU-Ebene vorzu-
schlagen. Diesen Vorschlag hinterfragt der Deutsche Bundestag kri-
tisch.

2. Das politische System der EU basiert grundsätzlich auf dem Prinzip der
begrenzten Einzelermächtigung. Danach setzen bindende Rechtsakte
die ausdrückliche vertragliche Ermächtigung der Organe der Union vo-
raus. Daneben gibt es heute bereits für den nichtharmonisierten Bereich
eine Verpflichtung der Mitgliedstaaten und der Europäischen Kommis-
sion, ihre Politiken zu koordinieren. Eine klare Abgrenzung der Zustän-
digkeiten der Mitgliedstaaten und der EU-Ebene entsprechend dem
Subsidiaritätsprinzip könnte damit verwischt werden. Die dargestellten
Bedenken lassen sich gleichermaßen auf den im Weißbuch Gesundheit
beabsichtigten neuen Mechanismus der strukturierten Zusammenarbeit
im Politikbereich Gesundheit und auf die Offene Methode der Koordi-
nierung im Bereich des Sozialschutzes übertragen.

3. Grundsätzlich sieht der Vertrag von Lissabon für den Bereich der Ge-
sundheitspolitik eine Zusammenarbeit der EU-Mitgliedstaaten auch im
nichtharmonisierten Bereich der Gesundheitspolitik vor. Der neue, auf
dem alten Artikel 152 basierende Artikel 168 des Vertrags von Lissabon
enthält in Absatz 2 eine Förder- und Unterstützungskompetenz der Eu-
ropäischen Union. Danach kann die Europäische Kommission in enger
Abstimmung mit den Mitgliedstaaten alle Initiativen ergreifen, die der
Koordinierung der Gesundheitspolitiken der Mitgliedstaaten unterein-
ander förderlich sind, insbesondere Initiativen, die darauf abzielen,
Leitlinien und Indikatoren festzulegen, den Austausch bewährter Ver-
fahren durchzuführen und die erforderlichen Elemente für eine re-
gelmäßige Überwachung und Bewertung auszuarbeiten.

4. Die Bundesregierung sowie der Bundesrat haben bereits frühzeitig im
Konsultationsprozess zur Gesundheitsstrategie Stellung bezogen. In der
Stellungnahme wird zum Ausdruck gebracht, dass Deutschland die Ini-
tiative der Europäischen Kommission grundsätzlich als eine Chance be-
trachtet, der europäischen Gesundheitspolitik als zentralem Politik-
bereich innerhalb der EU eine besondere Stellung zu verleihen. Gleich-
zeitig wurde verdeutlicht, dass aus Sicht Deutschlands die klare
Kompetenzabgrenzung bei der Gesundheitspolitik zwischen den

Mitgliedstaaten und der Europäischen Union gewahrt bleiben muss und
nicht von der gesundheitspolitischen Strategie zur Disposition gestellt

Drucksache 16/9412 – 4 – Deutscher Bundestag – 16. Wahlperiode

werden kann. Hinsichtlich der Frage möglicher Implementierungsme-
chanismen hat Deutschland betont, dass ausufernde, ressourcenbinden-
de Berichtspflichten von Deutschland nicht unterstützt werden. Gleich-
zeitig trat Deutschland in der Stellungnahme für die Verschlankung be-
stehender Gremien im Bereich der europäischen Gesundheitspolitik
ein: Durch klarere Abgrenzung der gesundheitspolitischen Gremien vor
dem Hintergrund der inhaltlichen Vorgaben der Strategie könnten
Entscheidungs- und Konsultationsprozesse transparenter gestaltet und
unnötige Doppelarbeiten vermieden werden. Ressourcen der Gemein-
schaft wie auch der Mitgliedstaaten könnten effektiver eingesetzt und
Synergieeffekte nutzbar gemacht werden.

5. Unter slowenischer Ratspräsidentschaft verhandelt der Rat Schluss-
folgerungen zur Gesundheitsstrategie auch unter Bezug auf einen mög-
lichen Umsetzungsmechanismus. In der Verhandlung der Ratsschluss-
folgerungen hat Deutschland die Gesundheitsstrategie als einen kohä-
renten Politikansatz der europäischen Gesundheitspolitik ausdrücklich
begrüßt und die effektive Umsetzung der Strategie unterstützt, um der
europäischen Gesundheitspolitik den Stellenwert in Europa zu verlei-
hen, der ihr gebührt. Die Gesundheitsstrategie müsse genutzt werden,
um dem Bereich Gesundheit auf europäischer Ebene zu mehr Sicht-
barkeit zu verhelfen. Gleichzeitig stellte sich Deutschland der Gefahr
einer Ausuferung der europäischen Kompetenzen im Rahmen der Um-
setzung der Gesundheitsstrategie entschieden entgegen. Während der
Verhandlungen im Rat betonte Deutschland, dass bei der Umsetzung
der Strategie eine Konzentration auf diejenigen Bereiche erforderlich
ist, in denen eine europäische Zusammenarbeit einen klaren Mehrwert
zugunsten der einzelnen Mitgliedstaaten vermittelt. Hierin versteht
Deutschland das Kernanliegen der Strategie: gesamteuropäischen Her-
ausforderungen entgegenzutreten, denen die Mitgliedstaaten durch ein-
zelstaatliches Handeln nicht angemessen begegnen können. Darüber
hinaus hat Deutschland eine Initiative gegen die Fragmentierung der
europäischen Gesundheitspolitik gestartet mit der Forderung, die Struk-
turen im Gesundheitsbereich auf europäischer Ebene zu überprüfen und
deutlich zu vereinfachen, mit dem Ziel der besseren Transparenz und
Sichtbarkeit der europäischen Gesundheitspolitik.

6. Der Deutsche Bundestag hält es für dringend geboten, bei allen auf
europäischer Ebene angestoßenen Diskursprozessen zur Gesundheits-
politik die nationale Autonomie der Gesundheitssysteme der Mitglied-
staaten zu wahren. Er spricht sich gegen die erkennbare Absicht der
Europäischen Kommission aus, in einem als „prozessgesteuerte Sys-
temkongruenz“ bezeichneten Prozess einen schleichenden Weg zur
Harmonisierung der Gesundheitssysteme in der Europäischen Union zu
beschreiten.

7. Besonders kritisch betrachtet der Deutsche Bundestag Versuche der
Europäischen Kommission, in verschiedenen gesundheitspolitisch rele-
vanten Diskursprozessen quantifizierte Ziele festzulegen und die Mit-
gliedstaaten dadurch politisch zu binden. Dies beobachtet der Deutsche
Bundestag mit wachsender Skepsis auch im Bereich der Offenen Me-
thode der Koordinierung im Rahmen des Sozialschutzes. Für Deutsch-
land sind europäisch festgelegte quantifizierte Ziele in der Gesundheits-
politik nicht akzeptabel und unvereinbar mit der originären Zustän-
digkeit der Mitgliedstaaten für die Gesundheitspolitik. Angesichts der
Komplexität der Gesundheitssysteme und ihrer historisch bedingten
Systemunterschiede erscheint ein Versuch der mittelbaren Steuerung

nationaler Gesundheitspolitiken durch von der Europäischen Kommis-
sion koordinierte quantitative Zielvorgaben als politisch und metho-

Deutscher Bundestag – 16. Wahlperiode – 5 – Drucksache 16/9412

disch verfehlter Ansatz. Dagegen unterstützt der Deutsche Bundestag
den europäischen Austausch bewährter Praktiken, denn gerade hieraus
können die einzelnen Mitgliedstaaten einen konkreten Mehrwert schöp-
fen, insbesondere im Bereich der Steigerung der Effizienz der Gesund-
heitssysteme.

8. Die unter slowenischer Ratspräsidentschaft erarbeiteten Ratsschluss-
folgerungen betonen auch aus diesen Gründen das Erfordernis einer en-
gen Kooperation zwischen Mitgliedstaaten und der Europäischen Kom-
mission. Deshalb wird die zentrale Rolle der Mitgliedstaaten bei der
Festlegung von Prioritäten hervorgehoben und die Europäische Kom-
mission zur Vereinfachung bestehender Strukturen aufgefordert. Aus
deutscher Sicht zentral ist die Begrenzung auf Bereiche mit einem kla-
ren europäischen Mehrwert zugunsten der einzelnen Mitgliedstaaten
sowie die Feststellung, dass der neue Kooperationsmechanismus nicht
die Schaffung neuer Gremien nach sich zieht, sondern vielmehr die be-
stehenden Gremien zukünftig effektiver nutzen will.

9. Die Implementierung der Gesundheitsstrategie muss auf Bereiche be-
schränkt werden, die bei Erörterung auf europäischer Ebene echten
Mehrwert für die Bürgerinnen und Bürger in der EU schaffen können.
Die politische Zusammenarbeit in Fragen der Aids-Strategie oder beim
Themenfeld Ernährung und Bewegung zeigt insoweit positive Beispiele
auf.

10. Der Deutsche Bundestag sieht zudem hohe Anforderungen an die
Erstellung von Indikatoren zum Vergleich von Gesundheitssystemen
auf EU-Ebene. Gerade im Gesundheitswesen ist die Datenlage für EU-
weite Systemvergleiche in einigen wesentlichen Bereichen äußerst un-
befriedigend. Nicht selten sind die für die Definition, Erstellung und se-
riöse Interpretation von Indikatoren benötigten Daten gar nicht vorhan-
den, zum Teil liegen sie nur in sehr unterschiedlicher Qualität vor. Dies
verhindert oft eine Vergleichbarkeit. Hinzu kommt, dass aus erhobenen
Daten nur dann Aussagen abgeleitet werden dürfen, wenn sie im jewei-
ligen gesundheitspolitischen Kontext gesehen und ausgewertet werden
können. Schon deshalb ist die Entwicklung von quantifizierten Zielen,
die die Mitgliedstaaten in der Gesundheitspolitik binden sollen, abzu-
lehnen.

Dies spricht dafür, die gesundheitspolitische Kompetenz nicht von den
Mitgliedstaaten weg auf die EU-Ebene zu verlagern. In Einzelfällen, in
denen die europäische Zusammenarbeit im Gesundheitsbereich von Vorteil
ist, sind die Mitgliedstaaten, das Europäische Parlament und die nationalen
Parlamente an der Erstellung von Indikatoren verstärkt zu beteiligen.

II. Der Deutsche Bundestag fordert die Bundesregierung auf,

1. sich weiterhin für den Erhalt der autonomen Zuständigkeit der Mitglied-
staaten für ihre Gesundheitssysteme einzusetzen und bei der Erarbeitung
von Schlussfolgerungen zur Umsetzung des Weißbuchs der Kommission
darauf zu achten, dass es nicht zu einer Aushöhlung nationalstaatlicher
Kompetenzen im Gesundheitsbereich kommt,

2. die von der Kommission geplante strukturierte Zusammenarbeit abzu-
lehnen, soweit hiermit die Schaffung neuer europäischer Strukturen ein-
hergeht,

3. sich weiterhin für die effizientere Nutzung bestehender Strukturen auf eu-
ropäischer Ebene einzusetzen und die europäische Koordinierung auf die

Bereiche zu fokussieren, in denen ein europäischer Mehrwert identifiziert
wird und wo die Herausforderungen grenzüberschreitend sind,

Drucksache 16/9412 – 6 – Deutscher Bundestag – 16. Wahlperiode

4. entschlossen gegen Versuche der Europäischen Kommission vorzugehen,
mit der Offenen Methode der Koordinierung zu Gesundheit und Lang-
zeitpflege quantifizierte Ziele festzulegen und die Mitgliedstaaten da-
durch politisch zu binden. Die Bundesregierung wird aufgefordert, an
ihrer bisherigen Verhandlungsposition festzuhalten.

Berlin, den 3. Juni 2008

Der Ausschuss für Gesundheit

Dr. Martina Bunge
Vorsitzende

Jens Ackermann
Berichterstatter

die Koordinierung zwischen den Mitgliedstaaten fördern Aktualisierung beinhalte, die den Schlussfolgerungen der

soll. Konkrete Maßnahmen: Annahme einer Erklärung über
grundlegende Gesundheitswerte, stärkere Einbeziehung von
Gesundheitsaspekten in alle Politikbereiche der Gemein-

slowenischen Ratspräsidentschaft Rechnung trage. Im Kern
gehe es darum, deutlich zu machen, dass angesichts der na-
tionalen Zuständigkeit für die Gesundheitspolitik der Euro-
Deutscher Bundestag – 16. Wahlperiode – 7 – Drucksache 16/9412

Bericht des Abgeordneten Jens Ackermann

I. Überweisung

Das Weißbuch Gemeinsam für die Gesundheit: Ein strategi-
scher Ansatz der EU für 2008–2013 (inkl. 14689/07 ADD 1
bis 14689/07 ADD 3) – KOM(2007) 630 endg.; Ratsdok.
14689/07 wurde mit Überweisungsdrucksache 16/7575 Nr.
1.5 vom 17. Dezember 2007 gemäß § 93 Abs. 1 GO-BT
dem Ausschuss für Gesundheit zur federführenden Bera-
tung sowie dem Ausschuss für Wirtschaft und Technologie,
dem Ausschuss für Ernährung, Landwirtschaft und Verbrau-
cherschutz, dem Ausschuss für Arbeit und Soziales, dem
Ausschuss für Familie, Senioren, Frauen und Jugend, dem
Ausschuss für Bildung, Forschung und Technikfolgenab-
schätzung und dem Ausschuss für die Angelegenheiten der
Europäischen Union zur Mitberatung überwiesen.

II. Wesentlicher Inhalt der Vorlage

Die neue Gesundheitsstrategie definiert die Rolle der Euro-
päischen Gemeinschaft in den Bereichen der Gesundheits-
politik, in denen die Mitgliedstaaten nach Auffassung der
Europäischen Kommission allein nicht wirksam handeln
können und in denen die Zusammenarbeit auf Gemein-
schaftsebene unverzichtbar sei. Nach Ansicht der Kommis-
sion ist es angesichts wachsender gesundheitspolitischer
Herausforderungen erforderlich, der Gesundheit im Rah-
men der verschiedenen politischen Strategien der Gemein-
schaft mehr Gewicht zu verleihen. Das vorliegende Weiß-
buch soll einen kohärenten Rahmen skizzieren, der für die
Gemeinschaftsmaßnahmen im Gesundheitswesen richtung-
weisend sein soll. Grundlage seiner Strategie sind folgende
vier Prinzipien: 1. Bekenntnis zu gemeinsamen Wertvorstel-
lungen in der Gesundheitspolitik, 2. Betonung der Bezie-
hung zwischen dem Gesundheitszustand der Bevölkerung
und wirtschaftlicher Produktivität und Wohlstand, 3. stär-
kere Einbeziehung von Gesundheitsaspekten in alle Politik-
bereiche der Gemeinschaft und 4. mehr Mitsprache der EU
in der globalen Gesundheitspolitik. Vor diesem Hintergrund
formuliert die Kommission drei strategische Ziele als vor-
rangige Bereiche für die kommenden Jahre: 1. Förderung
der Gesundheit in einem alternden Europa, 2. Schutz der
Bürger vor Gesundheitsgefahren und 3. Förderung dynami-
scher Gesundheitssysteme und neuer Technologien. Gemäß
dem Vertrag habe die EG eine besondere Aufgabe bei der
Verbesserung und dem Schutz der Gesundheit und zudem
bei der Erleichterung der Zusammenarbeit im Gesundheits-
bereich. Da die Zuständigkeit für das Gesundheitswesen auf
nationaler, regionaler und kommunaler Ebene bei den Mit-
gliedstaaten liege und das Subsidiaritätsprinzip zu beachten
sei, seien die Mitgliedstaaten eng in die Durchführung der
Strategie einzubinden. Die Kommission will daher einen
neuen Mechanismus der strukturierten Zusammenarbeit auf
EU-Ebene vorschlagen, der die Kommission beraten und

sammenarbeit in Gesundheitsfragen mit strategischen Part-
nern und Ländern, Maßnahmen der Gesundheitsförderung
für Kinder, Jugendliche, ältere Menschen und für Beschäf-
tigte, Stärkung der Mechanismen zur Überwachung und Re-
aktion auf Gesundheitsgefahren, Gemeinschaftsrahmen für
sichere hochwertige und effiziente Gesundheitsdienstleis-
tungen.

III. Stellungnahmen der mitberatenden
Ausschüsse

Der Ausschuss für Wirtschaft und Technologie hat in
seiner 53. Sitzung am 16. Januar 2008 einvernehmlich die
Kenntnisnahme der Vorlage empfohlen.

Der Ausschuss für Ernährung, Landwirtschaft und Ver-
braucherschutz hat in seiner 65. Sitzung am 16. Januar
2008 einvernehmlich die Kenntnisnahme der Vorlage emp-
fohlen.

Der Ausschuss für Arbeit und Soziales hat in seiner
73. Sitzung am 16. Januar 2008 einvernehmlich die Kennt-
nisnahme der Vorlage empfohlen.

Der Ausschuss für Familie, Senioren, Frauen und Jugend
hat in seiner 47. Sitzung am 16. Januar 2008 einvernehm-
lich die Kenntnisnahme der Vorlage empfohlen.

Der Ausschuss für Bildung, Forschung und Technikfol-
genabschätzung hat in seiner 48. Sitzung am 16. Januar 2008
einvernehmlich die Kenntnisnahme der Vorlage empfohlen.

Der Ausschuss für die Angelegenheiten der Europäischen
Union hat in seiner 48. Sitzung am 16. Januar 2008 einver-
nehmlich die Kenntnisnahme der Vorlage empfohlen.

IV. Beratungsverlauf und Beratungsergebnisse im
federführenden Ausschuss

Der Ausschuss für Gesundheit hat die Vorlage in seiner
85. Sitzung am 28. Mai 2008 abschließend beraten. Im Er-
gebnis empfiehlt er einvernehmlich die Kenntnisnahme des
Weißbuchs Gemeinsam für die Gesundheit: Ein strategi-
scher Ansatz der EU für 2008–2013 (inkl. 14689/07 ADD
1 bis 14689/07 ADD 3) – KOM(2007) 630 endg.; Ratsdok.
14689/07 sowie mit den Stimmen der Fraktionen CDU/
CSU, SPD, FDP und DIE LINKE. bei Stimmenthaltung der
Fraktion BÜNDNIS 90/DIE GRÜNEN, in Kenntnis der
Vorlage auf Drucksache 16/7575 Nr. 1.5, die in der Be-
schlussempfehlung wiedergegebene, von den Fraktionen
CDU/CSU, SPD, FDP und DIE LINKE. vorgelegte Ent-
schließung anzunehmen.

Die Fraktion der CDU/CSU erklärte, dass der geänderte
Entschließungsantrag auf Ausschussdrucksache 16(14)0381
gegenüber dem ursprünglichen Entschließungsantrag eine
schaft und der Mitgliedstaaten, Stärkung des Gemein-
schaftsstatus in internationalen Organisationen und der Zu-

päischen Union nur dann eine Regelungskompetenz zu-
stehe, wenn die europäische Zusammenarbeit einen erkenn-

in Bezug auf die diesbezüglichen Daten mehr Transparenz
hergestellt werde. Es müsse vor allem auf eine bessere Ver-
gleichbarkeit der Daten hingewirkt werden. Der Prozess,
der zur Realisierung dieses Ziels führen solle, müsse von
der Europäischen Union moderiert werden. Demgegenüber
spreche man sich entschieden dagegen aus, dass quanti-
fizierte Ziele im Bereich der Gesundheitspolitik von der
Europäischen Union vorgegeben würden. In dieser Frage
sei man sich mit allen anderen Unterzeichnern des Ent-
schließungsantrages einig. Gleichwohl unterstütze man alle
Initiativen, die durch Vergleiche dazu beitrügen zu überprü-
fen, welche Länder über die erfolgreichsten Methoden bei
der Bekämpfung von Krankheiten und bei der Gesundheits-
förderung verfügten. Die Europäische Union sei gefordert,
die nötigen Informationen zur Verfügung zu stellen, um
Best-Practice-Lösungen möglich zu machen und die einzel-
nen Staaten in die Lage zu versetzen, ihre selbst gesetzten
gesundheitspolitischen Ziele zu realisieren.

Die Fraktion der FDP wies darauf hin, dass diejenigen In-
stitutionen, die die gesundheitspolitischen Ziele vorgäben,

linie Ziele für die nationalen Gesundheitssysteme vorgege-
ben habe, deren Realisierung negative Konsequenzen für
die flächendeckende Versorgung und die Finanzierung der
medizinischen Infrastruktur in Deutschland gehabt hätte.
Dieses Beispiel habe gezeigt, wie wichtig es sei, dass die
Formulierung gesundheitspolitischer Ziele in nationaler
Verantwortung verbleibe.

Die Fraktion BÜNDNIS 90/DIE GRÜNEN erklärte, sie
stimmte mit dem Inhalt des Entschließungsantrages teil-
weise überein. Man wolle ebenfalls verhindern, dass die Eu-
ropäische Union über ihre vertraglich festgelegten Zustän-
digkeiten hinaus in nationale Kompetenzen eingreife. Die
Europäische Union müsse jedoch die Möglichkeit haben,
qualitative und quantitative gesundheitspolitische Zielset-
zungen für die Gemeinschaft zu formulieren. Den Einzel-
staaten müsse zwar die Entscheidung überlassen bleiben,
wie sie die gesteckten Ziele erreichen wollten, es sei aber
sinnvoll, durch Zielvorgaben einen Wettbewerb im Interesse
der Patienten auszulösen, der möglicherweise zu einer bes-
seren Gesundheitsversorgung führe.

Berlin, den 3. Juni 2008

Jens Ackermann
Berichterstatter
Drucksache 16/9412 – 8 – Deutscher Bundestag – 16. Wahlperiode

baren Nutzen für die grenzüberschreitende Gesundheitsver-
sorgung erbringe. Das neue Instrument der „strukturierten
Zusammenarbeit“ werde abgelehnt, um zu verhindern, dass
ähnlich wie im Falle der Offenen Methode der Koordi-
nierung ein neues Instrumentarium geschaffen werde, das
vertraglich nicht vorgesehen sei und das sich der parlamen-
tarischen Kontrolle entziehe. Kritisch stehe man auch der
Tendenz der Europäischen Union gegenüber, in zunehmen-
dem Maße quantifizierte Ziele festzulegen. Man sei zwar
grundsätzlich dafür, Vergleiche zwischen den Leistungs-
standards verschiedener Länder möglich zu machen, weil
dies fruchtbare Diskussionen über die Ursachen von Leis-
tungsunterschieden auslösen könne. Der Bundestag dürfe
sich aber nicht die Möglichkeit nehmen lassen, im eigenen
Zuständigkeitsbereich Ziele und Wege der Zielerreichung
eigenständig festzulegen.

Die Fraktion der SPD betonte, es sei ihnen daran gelegen,
dass der Leistungsstandard in den Gesundheitssystemen der
Mitgliedsländer der Europäischen Union gesteigert und dass

letztlich über die Politik bestimmten. Deshalb berge die
Formulierung von Zielen auf europäischer Ebene die Gefahr
einer Aushöhlung der nationalstaatlichen Zuständigkeiten.
Aus diesem Grund lehne man das Vorhaben der Europäi-
schen Union, quantifizierte Ziele im Bereich der Gesund-
heitspolitik festzulegen, ab. Die Option, Vergleiche an-
zustellen und Benchmarking zu betreiben, bleibe davon
jedoch unberührt. Es gebe derzeit bereits hinlängliche
Möglichkeiten, sich die Erfahrungen anderer Länder in der
Gesundheitspolitik sowie die von ihnen erhobenen Daten
zunutze zu machen und die Politik dort, wo es erforderlich
sei, zu koordinieren.

Die Fraktion DIE LINKE. stimmte mit den anderen Un-
terzeichnern des Entschließungsantrages in der grundsätz-
lichen Kritik an dem Weißbuch der Europäischen Union
überein. Sie verweist in diesem Zusammenhang auf die
Auseinandersetzung über den Entwurf für eine Gesund-
heitsrichtlinie im vergangenen Jahr. Der Grund für die Ab-
lehnung des Entwurfs sei gewesen, dass die geplante Richt-

Deutscher Bundestag – 16. Wahlperiode – 9 – Drucksache 16/9412

Anlage

RAT DER
EUROPÄISCHEN UNION

Brüssel, den 6. November 2007 (07.11)
(OR. en)
14689/07
SAN 193

ÜBERMITTLUNGSVERMERK
Absender: Herr Jordi AYET PUIGARNAU, Direktor, im Auftrag des General-

sekretärs der Europäischen Kommission
Eingangsdatum: 23. Oktober 2007
Empfänger: der Generalsekretär/Hohe Vertreter, Herr Javier SOLANA
Betr.: Weißbuch

Gemeinsam für die Gesundheit: Ein strategischer Ansatz der EU für
2008-2013

Die Delegationen erhalten in der Anlage das Kommissionsdokument KOM(2007) 630 endgültig.

Anl.: KOM(2007) 630 endgültig

Drucksache 16/9412 – 10 – Deutscher Bundestag – 16. Wahlperiode

KOMMISSION DER EUROPÄISCHEN GEMEINSCHAFTEN

Brüssel, den 23.10.2007
KOM(2007) 630 endgültig

WEISSBUCH

Gemeinsam für die Gesundheit:
Ein strategischer Ansatz der EU für 2008-2013

(von der Kommission vorgelegt)
{SEK(2007) 1374}
{SEK(2007) 1375}
{SEK(2007) 1376}

Deutscher Bundestag – 16. Wahlperiode – 11 – Drucksache 16/9412

WEISSBUCH

Gemeinsam für die Gesundheit:
Ein strategischer Ansatz der EU für 2008-2013

1. WOZU EINE NEUE GESUNDHEITSSTRATEGIE?

Die Gesundheit ist ein zentrales Anliegen der Menschen und muss durch effektive politische
Strategien und Maßnahmen in den Mitgliedstaaten, auf EG1-Ebene sowie auf globaler Ebene
gefördert werden.

Die Hauptzuständigkeit für die Gesundheitspolitik und die gesundheitliche Versorgung der
europäischen Bürger liegt bei den Mitgliedstaaten. Die Aufgabe der Europäischen
Gemeinschaft besteht nicht darin, die Arbeit der Mitgliedstaaten widerzuspiegeln oder zu
wiederholen. Gleichwohl gibt es Bereiche, in denen die Mitgliedstaaten allein nicht wirksam
handeln können und in denen Zusammenarbeit auf Gemeinschaftsebene unverzichtbar ist.
Dazu gehören größere Gesundheitsgefahren und Probleme mit grenzübergreifenden oder
internationalen Auswirkungen wie Pandemien und Bioterrorismus sowie Fragen des freien
Verkehrs von Waren, Personen und Dienstleistungen.

Zur Wahrnehmung dieser Aufgabe bedarf es der sektorübergreifenden Zusammenarbeit. Laut
Artikel 152 des EG-Vertrags „wird bei der Festlegung und Durchführung aller
Gemeinschaftspolitiken und –maßnahmen ein hohes Gesundheitsschutzniveau sichergestellt“.
Die vorliegende Strategie verleiht der Gesundheit mehr Gewicht in politischen Strategien wie
der Lissabon-Strategie für Wachstum und Beschäftigung, indem sie die Verknüpfung von
Gesundheit und wirtschaftlichem Wohlstand betont, und der „Bürgernahen Agenda“, indem
sie den Bürgern das Recht zuerkennt, selbst über ihre Gesundheit und ihre gesundheitliche
Versorgung zu entscheiden. Die Maßnahmen der Strategie betreffen gesundheitsrelevante
Arbeiten in allen Sektoren. Gesundheit wird in den Artikeln des Vertrags zu Binnenmarkt,
Umwelt, Verbraucherschutz, soziale Angelegenheiten, einschließlich der Sicherheit und
Gesundheit am Arbeitsplatz, Entwicklungspolitik und Forschung sowie vielen anderen
angesprochen2.

Welch wichtige Rolle die Europäische Gemeinschaft in der Gesundheitspolitik spielt, wurde
im Reformvertrag erneut bestätigt, auf den sich die Staats- und Regierungschefs der EU am
19. Oktober 2007 in Lissabon geeinigt haben; darin wird vorgeschlagen, der Gesundheit mehr
politisches Gewicht zu verleihen. Zu erwarten ist ein neues übergeordnetes Ziel zur Förderung
des Wohls der Bürger ebenso wie eine Aufforderung der Mitgliedstaaten zur Zusammenarbeit
im Gesundheitswesen und in der Gesundheitsversorgung. Gesundheitsrelevante Maßnahmen
auf Gemeinschaftsebene bringen einen zusätzlichen Nutzen zu den Maßnahmen der
Mitgliedstaaten, insbesondere im Bereich der Prävention, einschließlich
Lebensmittelsicherheit und Ernährung, Sicherheit von Arzneimitteln, Bekämpfung des
Rauchens, Rechtsvorschriften für Blut, Gewebe und Zellen, Organe, Wasser- und Luftqualität
sowie Errichtung mehrerer Gesundheitsagenturen. Dennoch stehen wir weiterhin vor

1 Europäische Gemeinschaft.
2 Siehe Anhang 6 des Arbeitspapiers der Kommissionsdienststellen für die Bezugnahme auf den Vertrag.

Drucksache 16/9412 – 12 – Deutscher Bundestag – 16. Wahlperiode

wachsenden Herausforderungen, was die Gesundheit der Bevölkerung angeht, und diese
erfordern einen neuen strategischen Ansatz.

– Erstens verändert der demografische Wandel wie die Überalterung der Bevölkerung die
Erkrankungsmuster und belastet die Nachhaltigkeit der Gesundheitssysteme in der EU. Die
Förderung der Gesundheit im Alter bedeutet sowohl, die Gesundheit über die gesamte
Lebensspanne hinweg zu fördern und gesundheitlichen Beschwerden und Behinderungen
frühzeitig vorzubeugen als auch sozial, wirtschaftlich und umweltbedingte gesundheitliche
Benachteiligungen zu beheben. Diese Themen sind eng mit der Solidarität, einem
allgemeinen strategischen Ziel der Kommission, verknüpft.

– Zweitens bedeuten Pandemien, größere Unfälle und biologische Zwischenfälle sowie
Bioterrorismus mögliche größere Gesundheitsgefahren. Der Klimawandel verursacht
neue Muster von Infektionskrankheiten. Ein wesentlicher Teil der Gemeinschaftsrolle im
Gesundheitswesen besteht in der globalen Koordinierung und raschen Reaktion auf
Gesundheitsgefahren und in der Verstärkung der Handlungsfähigkeit von Mitgliedstaaten
und Drittländern. Dies ist mit der Sicherheit, einem allgemeinen strategischen Ziel der
Kommission, verknüpft.

– Drittens haben sich in den letzten Jahren die Gesundheitsversorgungssysteme teilweise
aufgrund einer raschen Entwicklung neuer Technologien enorm weiterentwickelt, welche
die Gesundheitsförderung, die Prognose, die Prävention und die Therapie von
Erkrankungen revolutioniert haben. Dazu gehören Informations- und
Kommunikationstechnologien, Innovationen in der Gentechnik, Bio- und
Nanotechnologie. Dies ist mit dem Wohlstand und der Sicherstellung einer
wettbewerbsfähigen und nachhaltigen Zukunft für Europa, einem allgemeinen
strategischen Ziel der Kommission, verbunden.

Bei der Erarbeitung einer neuen Gesundheitsstrategie wurden umfangreiche Anhörungen
durchgeführt3. Diese ergaben einen Konsens der Beteiligten darüber, wie die Gemeinschaft
ihre Rolle im Gesundheitswesen wahrnehmen sollte. Danach sollten Gesundheitsbelange in
alle Bereiche der Gemeinschaftspolitik integriert werden, gesundheitliche Benachteiligungen
sollten abgebaut werden, die Gemeinschaft sollte eine wichtige Rolle in globalen
Gesundheitsfragen spielen, Gesundheitsförderung sollte im Mittelpunkt stehen und die
Gesundheitsinformation sollten verbessert werden. Außerdem wurde hervorgehoben, dass die
Europäische Gemeinschaft, die Mitgliedstaaten und die Beteiligten zusammenarbeiten
müssen, um Ergebnisse zu erzielen.

Diese Herausforderungen und Aufgaben erfordern einen langfristigen Ansatz. Das
vorliegende Weißbuch soll einen kohärenten Rahmen skizzieren – eine erste
gesundheitspolitische Strategie der Gemeinschaft –, die für die Gemeinschaftsmaßnahmen im
Gesundheitswesen richtungweisend sein soll. Es schlägt vier Hauptprinzipien vor, die drei
strategische Ziele für die kommenden Jahre in den Mittelpunkt stellen. Die Strategie legt auch
die Durchführungsmechanismen für die Zusammenarbeit zwischen den Partnern fest, und
zwar zur verstärkten Berücksichtigung von Gesundheitsfragen in allen Politikbereichen, zur
3 Im Jahre 2004 veranstaltete die Kommission eine öffentliche Anhörung zur Zukunft der
gesundheitspolitischen Maßnahmen in der EU (Reflexionsprozess zur EU-Gesundheitspolitik:
http://ec.europa.eu/health/ph_overview/strategy/reflection_process_en.htm). 2007 fand eine zweite
Anhörung zu operativen Aspekten und den Prioritäten einer zukünftigen Strategie statt
(http://ec.europa.eu/health/ph_overview/strategy/results_consultation_en.htm).

Deutscher Bundestag – 16. Wahlperiode – 13 – Drucksache 16/9412

besseren Erkennbarkeit und zum besseren Verständnis von Gesundheitsfragen auf
Gemeinschaftsebene. Die im vorliegenden Weißbuch skizzierte Strategie gilt bis 2013;
danach soll sie überarbeitet werden, so dass weitere Maßnahmen zum Erreichen der Ziele
gefördert werden können.

Dem Weißbuch liegt ein Arbeitsdokument der Kommissionsdienststellen bei.

2. GRUNDLEGENDE PRINZIPIEN FÜR EG-MASSNAHMEN IM GESUNDHEITSWESEN

PRINZIP 1: EINE AUF GEMEINSAMEN GESUNDHEITSWERTVORSTELLUNGEN BERUHENDE
STRATEGIE

Die Gesundheitspolitik sollte intern wie extern auf klaren Wertvorstellungen beruhen. Die
Kommission hat mit den Mitgliedstaaten zusammengearbeitet, um einen wertebasierten
Ansatz für die Gesundheitsversorgungssysteme festzulegen. Im Juni 2006 nahm der Rat eine
Erklärung über gemeinsame Werte und Prinzipien in den Gesundheitsversorgungssystemen in
der EU an und nannte als übergeordnete Werte flächendeckende Versorgung, Zugang zu
qualitativ hochwertiger Versorgung, Verteilungsgerechtigkeit und Solidarität4. Darauf
wird eine neue Erklärung über gemeinsame Werte für die Gesundheitspolitik im weiteren
Sinne aufbauen. Der Rat hat die Kommission auch dazu aufgerufen, die
Geschlechterperspektive zu berücksichtigen und einzubeziehen5, diese soll die Strategie
weiter vorantreiben.

Die Grundrechte-Charta erkennt den Bürgern das Recht auf präventive
Gesundheitsversorgung und auf Inanspruchnahme medizinischer Behandlung zu6. Mehrere
internationale Erklärungen erkennen Grundrechte in Bezug auf die Gesundheit an7.

Ein Grundwert besteht in der Stärkung der Bürgerrechte. Die Gesundheitsversorgung rückt
immer mehr den Patienten in den Mittelpunkt und wird immer stärker auf den Einzelnen
abgestimmt; dem Patienten fällt dabei eine immer aktivere Rolle zu. Aufbauend auf der
Arbeit der „Bürgernahen Agenda“ muss die gemeinschaftliche Gesundheitspolitik die Rechte
der Bürger und Patienten als Ausgangspunkt nehmen. Dies umfasst Beteiligung und
Mitwirkung an der Entscheidungsfindung ebenso wie die nötigen Fähigkeiten, gesund zu
leben, beispielsweise die so genannte Gesundheitskompetenz8, im Einklang mit dem
Europäischen Rahmen der Schlüsselkompetenzen für lebensbegleitendes Lernen9, d. h. das
Verständnis von schulischen und internetgestützten Programmen.

Die Werte zur Verbesserung der Gesundheit müssen auch die Verringerung
gesundheitlicher Benachteiligungen einschließen. Zwar leben viele Europäer länger und
gesünder als frühere Generationen, doch bestehen weiterhin große Ungleichheiten in der
4 Gemeinsame Werte und Prinzipien in den EU-Gesundheitssystemen – Schlussfolgerungen des Rates

(2006/C 146/01).
5 Gesundheit bei Frauen – Schlussfolgerungen des Rates (2006/C146/02).
6 Artikel 35 über die Gesundheitsversorgung (ABl. C 364 vom 18.12.2000).
7 Einschließlich der Allgemeinen Erklärung der Menschenrechte der Vereinten Nationen und des
Internationalen Pakts über wirtschaftliche, soziale und kulturelle Rechte.
8 Die Fähigkeit, Gesundheitsinformationen zu lesen, herauszufiltern und zu verstehen, um sich ein

begründetes Urteil bilden zu können.
9 http://eur-lex.europa.eu/LexUriServ/site/en/oj/2006/l_394/l_39420061230en00100018.pdf.

Drucksache 16/9412 – 14 – Deutscher Bundestag – 16. Wahlperiode

Gesundheit10 in und unter den Mitgliedstaaten und Regionen sowie auch weltweit. So wird
zwar die Gesamtbevölkerung der EU immer älter, doch die Lebenserwartung von Frauen bei
der Geburt variiert um 9 Jahre zwischen den einzelnen EU-Mitgliedstaaten, bei Männern
sogar um 13 Jahre, und die Säuglingssterblichkeit ist in einigen Ländern sechsmal so hoch
wie in anderen11. Die Kommission wird Maßnahmen vorschlagen, mit denen
Benachteiligungen abgebaut werden können, dazu gehören auch gezielte
Gesundheitsförderung und der Austausch vorbildlicher Verfahren.

Schließlich muss sich die Gesundheitspolitik auf die besten wissenschaftlichen Erkenntnisse
stützen, die auf zuverlässigen Daten und Informationen sowie einschlägiger Forschung
beruhen. Die Kommission ist in der Lage, vergleichbare Daten aus den Mitgliedstaaten und
Regionen zusammenzustellen und muss auf die Aufrufe zu besserer Information und
transparenterer Politikgestaltung reagieren, einschließlich eines Systems von Indikatoren, die
alle Ebenen – die nationale und die subnationale – abdecken.

Maßnahmen

Annahme einer Erklärung über grundlegende Gesundheitswerte (Kommission,
Mitgliedstaaten)

System von EG-Gesundheitsindikatoren mit gemeinsamen Mechanismen zur Erhebung
vergleichbarer Gesundheitsdaten auf allen Ebenen, einschließlich einer Mitteilung über den
Austausch von Gesundheitsinformationen (Kommission)

Weitere Erarbeitung von Möglichkeiten zur Verringerung gesundheitlicher Benachteiligungen
(Kommission)

Förderung von Programmen zur Stärkung der Gesundheitskompetenz verschiedener
Altersgruppen (Kommission)

PRINZIP 2: „GESUNDHEIT IST DAS HÖCHSTE GUT“12

Gesundheit ist für das Wohl des Einzelnen wie der Gesellschaft insgesamt von Bedeutung,
eine gesunde Bevölkerung ist aber auch Voraussetzung für wirtschaftliche Produktivität und
Wohlstand. Im Jahre 2005 wurden die gesunden Lebensjahre (Healthy Life Years - HLY) in
die Lissabonner Strukturindikatoren aufgenommen, um zu unterstreichen, dass die
Lebenserwartung der Bevölkerung bei guter Gesundheit, d.h. nicht nur nach der Zahl der
Lebensjahre, einen Schlüsselfaktor für das Wirtschaftswachstum darstellt.

Der Bericht der Kommission an die Frühjahrstagung des Europäischen Rates 2006 rief die
Mitgliedstaaten nachdrücklich dazu auf, die hohe Zahl der krankheitsbedingt arbeitsunfähigen
Menschen zu senken13. Er betonte, dass die Politik in vielen Bereichen die Gesundheit
zugunsten der allgemeinen Wirtschaftslage verbessern kann.
10
Definiert als vermeidbare und ungerechte Ungleichheiten der Gesundheit.
11 Eurostat (Ed.) (2007): Europa in Zahlen – Eurostat-Jahrbuch 2006-07.
12 Vergil (70-19 v. Chr.).
13 Anhang zu KOM(2006) 30 vom 25.1.2006.

Deutscher Bundestag – 16. Wahlperiode – 15 – Drucksache 16/9412

Die Ausgaben im Gesundheitsbereich sind nicht nur als Kostenfaktor, sondern auch als
Investition zu sehen. Gesundheitsausgaben können zwar als wirtschaftliche Belastung
betrachtet werden14, doch die wahren Kosten entstehen der Gesellschaft durch die direkten
und indirekten Ausgaben für Erkrankungen sowie durch den Mangel an Investitionen in die
einschlägigen Bereiche des Gesundheitswesens. Schätzungen zufolge beträgt die jährliche
wirtschaftliche Belastung durch koronare Herzkrankheiten bis zu 1 % des BIP15; die durch
psychische Erkrankungen verursachten Kosten belaufen sich sogar auf 3-4 % des BIP16. Die
Ausgaben im Gesundheitswesen sollten durch Investitionen in die Prävention, den Schutz und
die Verbesserung der allgemeinen körperlichen und seelischen Gesundheit der Bevölkerung
flankiert werden, die nach OECD17-Daten derzeit durchschnittlich nur 3 % des
Gesundheitsbudgets der OECD-Mitgliedstaaten für Prävention, Gesundheitsförderung und
öffentliche Gesundheit ausmachen; im Vergleich dazu betragen die Ausgaben für kurative
Versorgung und Behandlung 97 %18.

Der EU-Gesundheitssektor ist ein wichtiger Arbeitgeber und Ausbilder: Der Sektor
Gesundheitswesen und Sozialfürsorge ist seit dem Jahr 2000 die treibende Kraft für die
Expansion des Dienstleistungssektors (bis zu 2,3 Mio. Arbeitsplätze)19. Der wachsende
Gesundheitssektor ist außerdem wichtige Quelle und Einsatzgebiet für innovative
Technologien und unterstützt die Regionalpolitik sowie den sozialen und wirtschaftlichen
Zusammenhalt.

Das Verständnis der wirtschaftlichen Faktoren in Bezug auf Gesundheit und Krankheit und
die wirtschaftlichen Auswirkungen der Gesundheitsverbesserung sowohl in der EU als auch
global muss durch die Weiterentwicklung von Informationen und Analysen in der
Kommission sowie die enge Zusammenarbeit mit Partnerländern wie den USA oder Japan
sowie internationalen Organisationen wie der OECD und dem Europäischen Observatorium
für Gesundheitssysteme und Gesundheitspolitik vertieft werden.

Maßnahmen

Entwicklung eines Programms von Analysen der wirtschaftlichen Beziehungen zwischen
Gesundheitszustand, Gesundheitsinvestitionen sowie Wirtschaftswachstum und -entwicklung
(Kommission, Mitgliedstaaten)

PRINZIP 3: GESUNDHEIT IN ALLEN POLITIKBEREICHEN

Die Gesundheit der Bevölkerung ist nicht nur ein Thema für die Gesundheitspolitik. Auch
andere Bereiche der Gemeinschaftspolitik spielen eine wichtige Rolle, beispielsweise die
Regional- und Umweltpolitik, Tabakbesteuerung, Arzneimittel- und Lebensmittelvorschriften,
Tiergesundheit, Gesundheitsforschung und -innovation, die Koordinierung der Systeme der
14 Snapshots: Health Care Spending in the United States and OECD Countries January 2007

http://www.kff.org/insurance/snapshot/chcm010307oth.cfm
15 M. Suhrcke, M. McKee, R. Sauto Arce, S. Tsolova, J. Mortensen The contribution of health to the

economy in the EU, Brüssel 2005.
16 Gabriel, P. & Liimatainen, M.-R. (2000). Mental Health in the Workplace. Internationale
Arbeitsorganisation, Genf.
17 Organisation für wirtschaftliche Zusammenarbeit und Entwicklung.
18 OECD Health Data 2006, Statistics and Indicators for 30 Countries. CDROM, Paris 2006.
19 Beschäftigung in Europa 2006, Bericht der Europäischen Kommission.

Drucksache 16/9412 – 16 – Deutscher Bundestag – 16. Wahlperiode

sozialen Sicherheit, Gesundheit in der Entwicklungspolitik, Gesundheit und Sicherheit am
Arbeitsplatz, IKT und Strahlenschutz sowie die Koordinierung von Agenturen und Stellen für
die Regelung von Einfuhren. Eine starke gemeinschaftliche Gesundheitspolitik muss
unbedingt Synergien mit diesen und anderen Sektoren entwickeln. Viele Sektoren werden
dazu beitragen, die Ziele und Maßnahmen dieser Strategie zu erreichen.

Dieses Vorgehen bedeutet auch, neue Partner in die Gesundheitspolitik einzubeziehen. Die
Kommission wird Partnerschaften entwickeln, um die Ziele der Strategie zu fördern, unter
anderem mit Nichtregierungsorganisationen, der Industrie, der Wissenschaft und den Medien.

Dieser Ansatz ist auch in der Entwicklungs-, Außen- und Handelspolitik zu verfolgen.
Globalisierung bedeutet, dass sowohl die Gesundheitsprobleme als auch deren Lösungen
grenzübergreifenden Charakter haben, zudem haben sie oft sektorübergreifende Ursachen und
Auswirkungen. Beispiele hierfür sind der koordinierte Ansatz zur Bekämpfung von HIV/Aids
in der EU und benachbarten Ländern20 und die EU-Strategie für Maßnahmen zur Bekämpfung
des akuten Fachkräftemangels im Gesundheitswesen der Entwicklungsländer21.

Maßnahmen
Stärkere Einbeziehung der Gesundheitsaspekte in alle Politikbereiche auf den Ebenen der
Gemeinschaft wie der Mitgliedstaaten und auf regionaler Ebene, einschließlich des Einsatzes
von Folgenabschätzungs- und Bewertungsinstrumenten (Kommission, Mitgliedstaaten)

PRINZIP 4: MEHR MITSPRACHE DER EU IN DER GLOBALEN GESUNDHEITSPOLITIK

Die EG und ihre Mitgliedstaaten können bessere Gesundheitsergebnisse für die EU-Bürger
und andere durch nachhaltige kollektive Führung in der globalen Gesundheitspolitik
erzielen22.

In unserer globalisierten Welt lassen sich einzelstaatliche oder EU-weite Aktionen schwer von
der globalen Politik trennen, da globale Gesundheitsfragen Einfluss auf die interne
gemeinschaftliche Gesundheitspolitik haben und umgekehrt. Die EG kann weltweit zur
Gesundheit beitragen, indem sie ihre Wertvorstellungen, Erfahrungen und Kenntnisse mitteilt
und konkrete Schritte zur Verbesserung der Gesundheit unternimmt. Die Arbeit kann
Bemühungen unterstützen, um die Kohärenz zwischen der internen und externen
Gesundheitspolitik zur Erzielung globaler Gesundheitsziele23 sicherzustellen, um Gesundheit
als wichtiges Element bei der Bekämpfung der Armut durch Gesundheitsaspekte in der
externen Entwicklungszusammenarbeit mit einkommensschwachen Ländern zu
berücksichtigen, um auf Gesundheitsgefahren in Drittländern zu reagieren und die
Durchführung internationaler Gesundheitsabkommen wie des Rahmenübereinkommens der
20 KOM(2005) 654.
21 KOM(2005) 642.
22 Dies folgt aus Artikel 152, der zur Zusammenarbeit mit Drittländern und internationalen Organisationen

im Gesundheitswesen aufruft, und aus dem strategischen Ziel der Kommission „Europa als Partner in
der Welt“ (Jährliche Strategieplanung für 2008 - KOM(2007) 65). Es wird erwartet, dass der neue
Reformvertrag auch ein neues Ziel der EU enthält, dem zufolge die EU in ihren Beziehungen zur

übrigen Welt die Wertvorstellungen und Interessen der Union vertritt und fördert und zum Schutz ihrer
Bürger beiträgt.

23 Beispielsweise Milleniums-Entwicklungsziele, Europäischer Konsens über
Entwicklungszusammenarbeit und Pariser Erklärung von 2005.

Deutscher Bundestag – 16. Wahlperiode – 17 – Drucksache 16/9412

Weltgesundheitsorganisation (WHO) zur Eindämmung des Tabakkonsums und der
internationalen Gesundheitsvorschriften zu fördern.

Der Beitrag der EU zur globalen Gesundheit erfordert die Interaktion der Gesundheits-,
Entwicklungs-, Außen-, Forschungs- und Handelspolitik. Die verstärkte Koordinierung in
Gesundheitsfragen mit internationalen Organisationen wie der WHO und anderen
einschlägigen Organisationen der Vereinten Nationen, der Weltbank, der Internationalen
Arbeitsorganisation, der OECD und dem Europarat sowie anderen strategischen Partnern und
Ländern wird der Stimme der EU mehr Gewicht in globalen Gesundheitsfragen verleihen
sowie ihren Einfluss und ihre Außenwirkung entsprechend ihrem wirtschaftlichen und
politischen Gewicht verstärken.

Maßnahmen

Stärkung des Gemeinschaftsstatus in internationalen Organisationen und der Zusammenarbeit
in Gesundheitsfragen mit strategischen Partnern und Ländern (Kommission)

Sicherstellung einer angemessenen Einbeziehung der Gesundheit in die EU-Außenhilfe im
Einklang mit den mit Drittländern vereinbarten Prioritäten und dem politischen Dialog sowie
den sektoriellen Konzepten, die für die Außenhilfe entwickelt wurden, und

Förderung der Durchführung internationaler Gesundheitsabkommen, insbesondere des
Rahmenübereinkommens der Weltgesundheitsorganisation (WHO) zur Eindämmung des
Tabakkonsums und der internationalen Gesundheitsvorschriften (Kommission).

3. STRATEGISCHE ZIELE

Die Gesundheitspolitik auf Gemeinschaftsebene sollte die Gesundheit fördern, die Bürger vor
Gefahren schützen und die Nachhaltigkeit unterstützen. Um die größeren Herausforderungen
annehmen zu können, vor denen das Gesundheitswesen in der EU steht, legt diese Strategie
drei Ziele als vorrangige Bereiche für die kommenden Jahre fest. Die Kommission wird mit
den Mitgliedstaaten zusammenarbeiten, um spezifischere operative Ziele innerhalb dieser
strategischen Ziele zu entwickeln.

ZIEL 1: FÖRDERUNG DER GESUNDHEIT IN EINEM ALTERNDEN EUROPA

Die Überalterung der Bevölkerung aufgrund niedriger Geburtenraten und steigender
Lebenserwartung ist nun eine Tatsache. Bis zum Jahr 2050 wird die Zahl der über 65-jährigen
EU-Bürger um 70 % ansteigen. Die Altersgruppe der über 80-Jährigen wird um 170 %
zunehmen24.

Diese Veränderungen werden voraussichtlich zu einer steigenden Nachfrage nach
Gesundheitsdienstleistungen führen, und gleichzeitig wird die Zahl der Beschäftigten
zurückgehen. Dadurch könnten die Ausgaben im Gesundheitswesen in den Mitgliedstaaten
bis zum Jahr 2050 um 1 bis 2 % des BIP ansteigen, was zu einem durchschnittlichen Anstieg
der Gesundheitsausgaben um 25 % als BIP-Anteil führen würde. Nach den Prognosen der

24 Eurostat-Bevölkerungsvorausschätzungen, veröffentlicht am Internationalen Tag der älteren Menschen

am 29. September 2006.

Drucksache 16/9412 – 18 – Deutscher Bundestag – 16. Wahlperiode

Kommission ließe sich der Anstieg der Gesundheitsausgaben jedoch halbieren, wenn die
Menschen bei höherer Lebenserwartung länger gesund blieben25.

Die Gesundheit im Alter muss durch Maßnahmen unterstützt werden, die während der
gesamten Lebensspanne die Gesundheit fördern und Erkrankungen vorbeugen, indem sie
wesentliche Faktoren wie schlechte Ernährung, Bewegungsmangel, Alkohol-, Drogen- und
Tabakkonsum, Umweltrisiken, Straßenverkehrsunfälle sowie Heim- und Freizeitunfälle
berücksichtigen. Die Verbesserung der Gesundheit von Kindern, Erwachsenen im
Erwerbsalter und älteren Menschen wird zu einer gesunden produktiven Bevölkerung
beitragen und heute wie zukünftig ein gesundes Altern unterstützen. Gleichermaßen
unterstützen Maßnahmen zur Förderung gesunder Lebensweisen und zur Verringerung
schädlicher Verhaltensweisen sowie zur Prävention und zur Behandlung bestimmter
Erkrankungen, einschließlich genetischer Störungen, die Gesundheit im Alter. Die
Weiterentwicklung der geriatrischen Medizin muss aktiv gefördert werden, wobei der
Schwerpunkt auf individualisierter Pflege liegen sollte. Palliativversorgung und ein besseres
Verständnis neurodegenerativer Erkrankungen, wie z. B. der Alzheimer-Krankheit, sind
ebenfalls wichtige Themen, die in Angriff zu nehmen sind. Auch bedarf es weiterer Arbeiten
im Bereich Blut, Gewebe, Zellen und Organe, einschließlich Transplantationsfragen.

Zur Unterstützung dieser Maßnahmen ist mehr Forschung nötig, einschließlich
Langzeituntersuchungen, ebenso wie höhere Kapazitäten in Gesundheitswesen, beispielsweise
durch verstärkte Ausbildung und Gesundheitsstrukturen. Da die öffentliche Hand durch den
demografischen Wandel und andere Herausforderungen zunehmend unter Druck steht, ist es
von größter Bedeutung, dass die getroffenen Maßnahmen effizient und effektiv sind.

Maßnahmen

Maßnahmen zur Förderung der Gesundheit älterer Menschen und der Beschäftigten und
Maßnahmen zur Förderung der Gesundheit von Kindern und Jugendlichen (Kommission)

Weiterentwicklung und Erarbeitung von Maßnahmen zu Tabak, Ernährung, Alkohol,
psychischer Gesundheit und anderen umweltbedingten und sozioökonomischen
Gesundheitsfaktoren (Kommission, Mitgliedstaaten)

Neue Leitlinien für Krebsvorsorgeuntersuchungen und eine Mitteilung über europäische
Maßnahmen im Bereich seltener Krankheiten (Kommission)

Folgemaßnahmen zur Mitteilung über Organspende und Transplantation26 (Kommission)

ZIEL 2: SCHUTZ DER BÜRGER VOR GESUNDHEITSGEFAHREN

Der Schutz der menschlichen Gesundheit ist eine Verpflichtung gemäß Artikel 152 EG-
Vertrag. Die Verbesserung der Sicherheit und der Schutz der Bürger vor Gesundheitsgefahren
25 „The impact of ageing on public expenditure: Projections for the EU25 Member States on pensions,
health care, long term care, education and unemployment transfers (2004-2050)“, Ausschuss für
Wirtschaftspolitik und Europäische Kommission (GD ECFIN) 2006, Europäische Wirtschaft,
Sonderbericht Nr.1/2006.

26 KOM(2007) 275.

Deutscher Bundestag – 16. Wahlperiode – 19 – Drucksache 16/9412

sind seit jeher ein zentrales Anliegen der gemeinschaftlichen Gesundheitspolitik. Gleichzeitig
trägt die EU auch Verantwortung für die Gesundheit der Bürger in Drittländern.

Die Arbeit auf Gemeinschaftsebene umfasst wissenschaftliche Risikobewertung,
Bereitschaftsplanung und Reaktionen auf Epidemien und Bioterrorismus, Strategien zur
Bekämpfung der Risiken durch bestimmte Erkrankungen und Zustände, Maßnahmen bei
Unfällen und Verletzungen, die Verbesserung der Sicherheit am Arbeitsplatz und Maßnahmen
zur Verbesserung der Lebensmittelsicherheit und des Verbraucherschutzes.

Die Kommission wird diese Arbeit fortsetzen, konzentriert sich jedoch auch auf
Herausforderungen, die bisher noch nicht in vollem Maße berücksichtigt wurden. Weltweit
haben der verstärkte Handel und zunehmende Reisen neue Risiken mit sich gebracht, da sie
die Ausbreitung übertragbarer Krankheiten erleichtern. Die Bekämpfung von Pandemien oder
biologischen Zwischenfällen und die Reaktion auf die Bedrohung durch Bioterrorismus
erfordern die Zusammenarbeit und Koordinierung auf Gemeinschaftsebene und mit den
internationalen Akteuren. Auch müssen Maßnahmen gegen neu auftretende
Gesundheitsgefahren ergriffen werden, wie beispielsweise im Zusammenhang mit dem
Klimawandel, damit dessen mögliche Auswirkungen auf die öffentliche Gesundheit und die
Gesundheitsversorgungssysteme behandelt werden. Die Patientensicherheit ist ein weiteres
zentrales Anliegen. Im Vereinigten Königreich tragen 10 % der stationär aufgenommenen
Patienten unerwünschte Wirkungen ihrer gesundheitlichen Versorgung davon27, und dieses
Problem dürfte in anderen EU-Mitgliedstaaten ein ähnliches Ausmaß annehmen. Es bedarf
eines neuen Ansatzes, um Gesundheitsgefahren innerhalb und außerhalb der EU zu
bekämpfen.

Maßnahmen

Stärkung der Mechanismen zur Überwachung und Reaktion auf Gesundheitsgefahren,
einschließlich Überprüfung der Zuständigkeit des Europäischen Zentrums für die Kontrolle
von Krankheiten (Kommission)

Gesundheitsaspekte der Anpassung an den Klimawandel (Kommission)

ZIEL 3: FÖRDERUNG DYNAMISCHER GESUNDHEITSSYSTEME UND NEUER TECHNOLOGIEN

Die Gesundheitssysteme in der EU stehen unter wachsendem Druck, auf die
Herausforderungen zu reagieren, die die Bevölkerungsüberalterung, die steigenden
Erwartungen der Bürger, die Migration und die Mobilität von Patienten und Beschäftigten des
Gesundheitswesens mit sich bringen.

Neue Technologien haben das Potenzial, die Gesundheitsversorgung und die
Gesundheitssysteme zu revolutionieren und deren künftige Nachhaltigkeit mit zu
unterstützen. Gesundheitstelematik, Genomik und Biotechnologien28 können die Prävention
von Krankheiten und die Behandlung verbessern sowie den Schwerpunkt von der stationären
27 Dies macht etwa 850 000 unerwünschte Wirkungen pro Jahr aus. Quelle: Expertengruppe des britischen
Gesundheitsministeriums. An organisation with a memory: report of an expert group on learning from
adverse effects in NHS. Chairman: Chief Medical Officer London: The Stationery Office, 2000.

28 Siehe Mitteilung der Kommission zur Halbzeitüberprüfung der Strategie für Biowissenschaften und
Biotechnologie - KOM(2007) 175.

Drucksache 16/9412 – 20 – Deutscher Bundestag – 16. Wahlperiode

Versorgung auf die Prävention und Primärversorgung verlagern helfen. Die
Gesundheitstelematik kann dazu beitragen, dass eine bessere bürgerzentrierte Versorgung
erbracht, die Kosten gesenkt und die grenzübergreifende Interoperabilität unterstützt werden,
um die Patientenmobilität und -sicherheit zu erleichtern29. Neue Technologien müssen
hingegen auch angemessen bewertet werden, auch hinsichtlich ihrer Kosteneffizienz und
Verteilungsgerechtigkeit. Ebenso sind die Auswirkungen auf die Ausbildung der
Beschäftigten im Gesundheitswesen und dessen Kapazitäten zu berücksichtigen. Neue und
unbekannte Technologien können ethische Bedenken aufwerfen, daher sind auch Fragen des
Vertrauens und der Zuversicht der Bürger anzusprechen.

Zur Steigerung der Investitionen ins Gesundheitswesen wurde die Gesundheit in Instrumente
einbezogen, die darauf abzielen, das Wachstum, die Beschäftigung und die Innovation zu
fördern, einschließlich der Lissabon-Strategie, des Siebten Forschungsrahmenprogramms mit
der Gemeinsamen Technologie-Initiative zur innovativen Medizin, des Programms für
Wettbewerb und Innovation sowie der Regionalpolitik in der EU. Es bedarf jedoch weiterer
Maßnahmen, z. B. in Bezug auf die Kapazitäten der Regionen, die Schlüsselakteure bei der
Erbringung von Gesundheitsdienstleistungen sind.

Ein klarer Gemeinschaftsrahmen wird außerdem dazu beitragen, dynamische und nachhaltige
Gesundheitssysteme zu fördern, indem er die Anwendung der EG-Rechtsvorschriften auf die
Gesundheitsdienstleistungen klarstellt und die Mitgliedstaaten in Bereichen unterstützt, in
denen koordinierte Maßnahmen den Gesundheitssystemen einen zusätzlichen Nutzen bringen
können.

Maßnahmen

Gemeinschaftsrahmen für sichere, hochwertige und effiziente Gesundheitsdienstleistungen
(Kommission)

Unterstützung der Mitgliedstaaten und Regionen beim Umgang mit Innovationen in den
Gesundheitssystemen (Kommission)

Unterstützung der Durchführung und Interoperabilität von gesundheitstelematischen
Lösungen in den Gesundheitssystemen (Kommission)

4. GEMEINSAM FÜR DIE GESUNDHEIT: DURCHFÜHRUNG DER STRATEGIE

4.1. Durchführungsmechanismen

Diese Strategie zielt auf konkrete Ergebnisse bei der Verbesserung der Gesundheit ab. Gemäß
dem Vertrag hat die EG eine besondere Aufgabe bei der Verbesserung und dem Schutz der
Gesundheit und zudem bei der Erleichterung der Zusammenarbeit im Gesundheitsbereich.

Da die Zuständigkeit für das Gesundheitswesen auf nationaler, regionaler und kommunaler
Ebene bei den Mitgliedstaaten liegt und das Subsidiaritätsprinzip zu beachten ist, sind die
Mitgliedstaaten eng in die Durchführung der Strategie einzubinden. Die Kommission wird zu
diesem Zweck einen neuen Mechanismus der strukturierten Zusammenarbeit auf EG-Ebene

29 Siehe KOM(2004)356 über einen Aktionsplan für einen europäischen Raum der elektronischen

Gesundheitsdienste.

Deutscher Bundestag – 16. Wahlperiode – 21 – Drucksache 16/9412

vorschlagen, der die Kommission beraten und die Koordinierung zwischen den
Mitgliedstaaten fördern soll. Dazu gehört auch eine neue Struktur mit den Mitgliedstaaten, die
einige bestehende Ausschüsse ersetzen soll. Dieser Kooperationsmechanismus wird der
Kommission helfen, Prioritäten zu nennen, Indikatoren festzulegen, Leitlinien und
Empfehlungen zu erarbeiten, den Austausch bewährter Verfahren zu fördern und Fortschritte
zu bewerten. Er soll außerdem Möglichkeiten für lokale und regionale Mitwirkung bieten. Die
Kommission wird sektorübergreifend arbeiten und die Kohärenz mit anderen Gremien
sicherstellen, die sich mit Gesundheitsfragen befassen wie die Verwaltungskommission und
der Ausschuss für Sozialschutz.

Die Maßnahmen der Mitgliedstaaten können ergänzt werden, indem die Zusammenarbeit mit
den Akteuren auf Gemeinschaftsebene gefördert wird. Die Kommission wird die
Partnerschaften mit ihnen weiterentwickeln und dabei auf den Erfahrungen von Gremien wie
dem Gesundheitsforum, dem Europäischen Forum für Alkohol und Gesundheit sowie der
Plattform für Ernährung, körperliche Bewegung und Gesundheit aufbauen.

Maßnahmen

Die Kommission wird einen Mechanismus zur strukturierten Zusammenarbeit vorschlagen
(Kommission)

4.2. Finanzierungsinstrumente

Die Maßnahmen dieser Strategie werden bis zum Ende des laufenden Finanzierungszeitraums
(2013) durch die vorhandenen Finanzierungsinstrumente ohne weitere Folgen für den
Haushalt gefördert. Die Jahresarbeitspläne des neu angenommenen Gesundheitsprogramms
der Gemeinschaft30 werden ein Kerninstrument für die Förderung der Strategieziele bilden.

Maßnahmen anderer Gemeinschaftsprogramme oder -strategien wie der EU-Strategie für
Sicherheit und Gesundheit am Arbeitsplatz 2007-2012 werden ebenfalls eine wichtige Rolle
spielen.

Mehrere weitere Gemeinschaftsprogramme stellen ebenfalls Fördermittel für das
Gesundheitswesen bereit, beispielsweise das Siebte Forschungsrahmenprogramm und die
Regionalpolitik31.
30 Es soll das laufende Programm im Bereich der öffentlichen Gesundheit (2003–2008) ersetzen und hat
drei breit gefasste Ziele: die Verbesserung der Gesundheitssicherheit des Bürgers, die Förderung der
Gesundheit zugunsten des Wohlstands und der Solidarität und die Verbreitung von
Gesundheitsinformationen.

31 Eine umfassendere Liste ist Anhang 3 des Arbeitspapiers der Kommissionsdienststellen zu entnehmen.

Drucksache 16/9412 – 22 – Deutscher Bundestag – 16. Wahlperiode

COUNCIL OF
THE EUROPEAN UNION

Brussels, 6 November 2007
14689/07
ADD 1

SAN 193
COVER NOTE
from: Secretary-General of the European Commission,

signed by Mr Jordi AYET PUIGARNAU, Director
date of receipt: 23 October 2007
to: Mr Javier SOLANA, Secretary-General/High Representative
Subject: Commission Staff Document

Accompanying document to the White Paper "Together for Health: A Strategic
Approach for the EU 2008-2013
Impact Assessment

Delegations will find attached Commission document SEC(2007) 1374.

________________________
Encl.: SEC(2007) 1374

Deutscher Bundestag – 16. Wahlperiode – 23 – Drucksache 16/9412

COMMISSION OF THE EUROPEAN COMMUNITIES

Brussels, 23.10.2007
SEC(2007) 1374

COMMISSION STAFF WORKING DOCUMENT
Accompanying document to the

WHITE PAPER
Together for Health:
A Strategic Approach for the EU 2008-2013
Impact Assessment

{COM(2007) 630 final}
{SEC(2007) 1375}
{SEC(2007) 1376}

Drucksache 16/9412 – 24 – Deutscher Bundestag – 16. Wahlperiode

TABLE OF CONTENTS

Executive Summary ................................................................................................................. 4

1. Procedural Issues and Consultation of Interested Parties ..................................... 5

1.1. Organisation and Timing ............................................................................................. 5

1.2. Consultation Processes................................................................................................. 5

1.3. Consultation Meetings ................................................................................................. 6

1.4. Consultation Results .................................................................................................... 6

2. Problem definition...................................................................................................... 7

Introduction.................................................................................................................. 7

2.1. Changing Health Challenges........................................................................................ 9

(1) Enlarged EU with Greater Inequities in Health.................................................... 10

(2) Current and Emerging Threats to Health.............................................................. 14

(3) Sustainable Health Systems.................................................................................. 16

(4) Globalisation and Health ...................................................................................... 18

2.2. Advancing Good Governance .................................................................................... 20

(5) Creating a Coherent Framework .......................................................................... 20

(6) Increasing 'Health In All Policies' Cooperation ................................................... 22

(7) Improving Visibility and Transparency ............................................................... 24

2.3. Subsidiarity Test ........................................................................................................ 25

Conclusion ................................................................................................................. 29

3. Objectives.................................................................................................................. 29

4. Policy Options........................................................................................................... 32

Option 1: Status Quo: No new Health Strategy ......................................................... 32

Option 2: Health Strategy with Enhanced Intersectoral Action at EU level.............. 33

Option 3: Health Strategy with Enhanced Intersectoral Action and Structured
Cooperation with Member States and Other Stakeholders ........................................ 34

Option 4: Health Strategy with Enhanced Intersectoral Action, Structured
Cooperation with Member States and Other Stakeholders, and Binding Targets ..... 35

5. Analysis of Impacts .................................................................................................. 36
Option 1: Status Quo: No new Health Strategy ......................................................... 36

Option 2: Health Strategy with Enhanced Intersectoral Action at EU level.............. 38

Deutscher Bundestag – 16. Wahlperiode – 25 – Drucksache 16/9412

Option 3: Health Strategy with Enhanced Intersectoral Action and Structured
Cooperation with Member States and Other Stakeholders ........................................ 40

Option 4: Health Strategy with Enhanced Intersectoral Action, Structured
Cooperation with Member States and Other Stakeholders, and Binding Targets ..... 44

6. Comparing the Options ........................................................................................... 47

7. Monitoring and Evaluation ..................................................................................... 51

Annexes ................................................................................................................................... 53

Annex 1: Health Strategy Consultation Meetings...................................................... 53

Annex 2: Health Activities Across the European Community .................................. 57

Annex 3: Key Health Determinants ........................................................................... 61

Annex 4: Health and its relationship to the Economy................................................ 70

Annex 5: ECHI Indicators – 'First Set'....................................................................... 77

Annex 6: Glossary...................................................................................................... 79

Drucksache 16/9412 – 26 – Deutscher Bundestag – 16. Wahlperiode

EXECUTIVE SUMMARY

This Impact Assessment considers the need for and potential impact of a new European
Community Health Strategy. The strategy would aim to take a new approach to key health
challenges by putting in place a strategic framework with clear objectives, setting the
direction of travel for the coming years.

The EU has a clear role to play in health. Working towards the EU's fundamental mission, to
enable free movement of people, goods and services, and to cooperate on cross-border issues,
requires the consideration of health issues. From common standards for health-related
products to ensuring healthcare for travellers, the EU has a role to play, while at the same time
respecting the subsidiarity principle. In some cases, such as coordination for pandemic
preparedness, the EU's role is clearly indispensable. In other cases, the EU is able to add value
to actions at national level by means such as facilitating the sharing of best practice,
developing networks, and funding projects. Much valuable work has been done in the field of
health at EU level, not only in the health sector but in many other sectors such as research,
regional policy, enterprise, employment and environment. However, there are growing calls
for more health action at EU level. As the Union has enlarged since 2004, health gaps have
widened. Threats from communicable and non-communicable disease continue, alongside
globalisation and increasing concern about the future sustainability of health systems,
particularly given the predicted ageing of the population. A new strategic approach to EU
health policy is needed to address these challenges.

This IA does not examine a list of specific actions to take on health. Rather, it looks at options
for a strategic framework that will set the direction of travel for work on health across the
European Community for the next ten years. The objectives comprise both governance and
health objectives. In terms of governance, the strategy aims to develop and put in place
strategic objectives, increase Health In All Policies cooperation and improve the visibility of
work on health at EU level. In terms of health objectives, four key areas are identified,
fostering healthy lifestyles and reducing inequities in health, tackling threats to health,
supporting sustainable health systems and strengthening the EU's voice in global health.
These broad objectives will be achieved through the continuation of current action and
through new actions at EU, national and local level, supported by an appropriate
implementation mechanism to drive real change.

The policy options considered were firstly to continue as present, without a new Health
Strategy. Options 2-4 consider different methods for putting a strategy in place. These options
set out cumulative levels of action in relation to such a Strategy. Option 2 describes a Strategy
with increased intersectoral action at the EU level only, Option 3 adds to this Structured
Cooperation with Member States and Stakeholders, and Option 4 adds legislation for Binding
Targets.

Option 3 was identified as the preferred option because it allows for ownership and
engagement on the Strategy by Member States and Stakeholders, but is a proportionate
approach. Through a Structured Cooperation mechanism, Member States would agree
indicators through which to measure the broad objectives set out in the Strategy. These
indicators would be expected to be taken from the existing indicators used at EU level to

prevent imposing an additional burden on Member States. The Structured Cooperation
mechanism would then lead work towards the achievement of the objectives alongside a
renewed focus on health across all sectors and working with all partners.

Deutscher Bundestag – 16. Wahlperiode – 27 – Drucksache 16/9412

1. PROCEDURAL ISSUES AND CONSULTATION OF INTERESTED PARTIES

1.1. Organisation and Timing

A White Paper on Health Strategy was included as a strategic initiative in the Commission's
Legislative Work Programme for 20071, with DG SANCO as the lead Directorate General.
Work on the Impact Assessment began after the completion of the Roadmap in late October
2006, and was finished ahead of Interservice Consultation in July 2007.

The Impact Assessment Board was consulted on 16 May 2007. The Board's recommendations
reflected the challenges of producing an Impact Assessment for a broad, overarching strategy
spanning multiple different elements, where the impact of each individual action cannot be
analysed. The main recommendations of the Board were that the internal logic of the IA
should be clarified, that the added value of action at EU level should be more clearly brought
out, that the analysis of options section should focus more clearly on economic, social and
environmental impacts, and that justification for the 10 year time-span of the strategy should
be included. Following the recommendations of the Board, a structure based on the set of
seven 'health' and 'governance' objectives of the IA was developed, to run throughout the
document, simplifying the presentation of the issue and clarifying the areas where added
value was achievable. The analysis of environmental, social and economic impacts was more
clearly defined in the analysis section, and a paragraph was added more clearly explaining the
reasoning behind the 10 year timescale. The second opinion of the Board recognised the
improvements made. Suggestions to further enhance the IA included a stronger focus on the
shortcomings of current activities and more detailed objectives. As, in most areas, the
Strategy aims to build on effective current work, only minor changes were made in relation to
the first point. In relation to the second point, the aim is that the Commission and Member
States should work together to develop precise objectives, so they will not be fully defined at
this stage. However, some priorities in the areas of demographic change, climate change, and
new technologies have been suggested in the text.

An Interservice steering group was set up for the Strategy and met on 17 November 2006, 31
January 2007, and 27 March 2007. DGs participating were AGRI, AIDCO, COMP, DEV,
EAC, ECFIN, ECHO, ELARG, EMPL, ENTR, ENVI, EUROSTAT, INFSO, JLS, JRC,
MARKT, REGIO, RELEX, RTD, SG, SJ, TAXUD, and TRADE. As well as offering input
into the development of this Impact Assessment, the group members contributed to a mapping
exercise on their work on health, which will be included as an Annex to the White Paper.

1.2. Consultation Processes

In late 2004, the Commission consulted stakeholders on what future action the EU should
take in the field of health through the initiative ‘Enabling Good Health for All – A Reflection
Process for a new EU Health Strategy’. The reflection process generated a broad debate
amongst stakeholders, national and regional authorities, NGOs, universities, individual
citizens and the private sector2.

On 11 December 2006 a Discussion Document was released to enable stakeholders to
comment further on plans for a new Health Strategy, this time with a focus on objective-
setting and implementation mechanisms. This process ended on 12 February 2007.

1 COM(2006) 629, item 11, p. 15.
2 http://ec.europa.eu/health/ph_overview/strategy/reflection_process_en.htm

Drucksache 16/9412 – 28 – Deutscher Bundestag – 16. Wahlperiode

Members of the High Level Committee on Public Health (all Member States) also received a
supplementary questionnaire requesting their views on objective-setting and implementation
mechanisms in relation to developing a new Health Strategy. Responses were received from
12 of the 27 Member States.

Comments from all consultation processes have been reflected in this Impact Assessment.
Regarding the consultation process, the requirements of the Commission's minimum
standards for consultation have been respected3.

1.3. Consultation Meetings

Alongside the two processes described above, consultation took place through a wide range of
meetings. Annex 1 sets out a list of consultation meetings that took place between October
2006 and March 2007. This list includes consultation with Member States, in particular at the
biannual High Level Committee on Public Health in October 2006, and also with regional
groups. It includes consultation with other Commission services, including 3 meetings of the
Interservice Steering Group (see above), as well as bilaterals with services with a particular
interest in health, including INFSO, EMPL, ENTR, RTD, REGIO, MARKT and
EUROSTAT. Meetings were held with NGOs, in particular the Health Policy Forum which
meets regularly and has a membership of 49 health-related NGOs. Meetings were also held
with a wide range of experts and other stakeholders, including industry representatives and
three meetings with a small discussion group of health strategy experts.

1.4. Consultation Results

193 responses were received to the 2004 reflection process, including 12 Member States. Key
outcomes4 were that stakeholders want a comprehensive approach to health that mainstreams
health concerns into all Community policies; that they see a need to bridge inequalities in
health across the EU; that the EU should take a much stronger role in global health; that the
EU should focus on health promotion; that it should tackle key issues such as mental health
and cross-border matters, and that the EU, its Member States and stakeholders should work
together to deliver concrete results. This input has formed the basis of the proposed Strategy
as set out in section 2.

156 responses were received for the 2006-2007 consultation process, including 16 Member
States. Key outcomes5 were general support for a new overarching, strategic and coherent
framework for health policy in the coming decade. The vast majority supported the three
broad priorities proposed by the Commission: working on core issues, ensuring health
considerations in all policies and engaging global considerations. The respondents advised
that policy coherence should be ensured through an enhanced use of health Impact
Assessment and that European as well as national administrations should ensure internal
coordination in their activities impacting on health.

There was broad support for enhancing European cooperation in a number of fields including
health threats, reducing inequalities in health, health information and promotion of healthy
3 COM(2004) 704 - http://ec.europa.eu/civil_society/consultation_standards/index_en.htm
4
See http://ec.europa.eu/health/ph_overview/strategy/reflection_process_en.htm for full text of responses

and consultation report.
5 See http://s-sanco-wcm/health/ph_overview/strategy/results_consultation_en.htm for full text of

responses and consultation report.

Deutscher Bundestag – 16. Wahlperiode – 29 – Drucksache 16/9412

lifestyles. Respondents from all level stressed the need for the development of a European
health information system with an open access to comparable data.

In terms of implementation mechanisms, there was broad support for the establishment of a
Structured Cooperation mechanism, similar to the Open Method of Coordination which was
developed to measure the progress towards Lisbon goals. In parallel, alternative approaches
were proposed, including development of legislation or enhancement of existing structures
with centralised expertise. Finally, it was highlighted that the success of the strategy would
also be linked to the sense of ownership at local, regional and national level. To that end,
action plans at European and National level were recommended by respondents with the
establishment of a regular reporting system and a mid term review.

Key outcomes of the consultation meetings have also been fed into this paper6.

2. PROBLEM DEFINITION

INTRODUCTION

This document is an assessment of the potential impact of the proposed White Paper 'Together
for Health: A Strategic Approach for the EU 2008-17', a new Community Strategy which
aims to bring together all sectors in working towards common health objectives. Developing a
useful Impact Assessment for something as broad as an overarching Strategy is a challenge. It
is not possible to evaluate the impact of individual actions, and the link between strategic
actions and concrete results is very difficult to quantify. This Impact Assessment therefore
sets out a broad-ranging 'problem definition' section (Section 1) looking at current health
challenges, good governance challenges, and conducting a subsidiarity test. The 'policy
options' and 'analysis of impacts' sections (Section 3 and 4) estimate, in broad terms, the
impact of a number of different methods of putting in place a Community strategic framework
for health.

Health is important for individuals and for society. People expect to be protected against
illness and disease. They want to bring up their children in a healthy environment, and
demand that their workplace is safe and hygienic. They need access to reliable and high-
quality health services. At the same time, improving the health and well-being of European
citizens is also important for the European Union. The EU's core aims to enable free
movement of people, goods and services, and cooperation on cross-border issues, means that
work at EU level has always had, and will continue to have a health dimension, at the same
time as the subsidiarity principle is respected. From the movement of health products to
providing a safe environment, from ensuring the production and processing of safe and
nutritious food, to responding to people's need for healthcare when travelling, it is impossible
to avoid health in policy at the EU level. The importance of health for the EU has been
reaffirmed by the agreement at the European Council meeting of 21-22 June 2007 on the
framework for a Reform Treaty, which proposes to reinforce health as a major focus of the
EU's work.

6 In the text, 'Consultation' refers to the 2006-7 consultation, while 'reflection process consultation' refers

to the earlier 2004 consultation

Drucksache 16/9412 – 30 – Deutscher Bundestag – 16. Wahlperiode

The achievement of the Commission's strategic objectives of Prosperity, Solidarity, Security
and Europe in the World is clearly linked to health. In terms of security, EU action on cross-
border health threats from communicable diseases such as avian flu, and on bioterrorism
continues to be vital. In relation to solidarity, reducing inequities across the enlarged EU in
terms of life expectancy, health status and provision of high-quality health services is part of
achieving the goal of a more cohesive Europe. In relation to prosperity, population health is a
key factor for productivity and growth, and this is reflected in the inclusion of the Healthy
Life Years indicator as a Lisbon agenda indicator7 and in relation to Europe in the world, the
EU has an important role in international health governance as well as in terms of trade in
health products and responses to humanitarian crises and development aid.

Table 1: Key Health Challenges and Objectives linked to current Commission
Objectives

Key Health Challenges Key Health Objectives Commission Objectives

Communicable disease e.g.
Pandemic, bioterrorism

Increase Capacity to Tackle
Health Threats

Security

Enlarged EU with 27 Member
States – Wider Health Gaps

Promote Health and Reduce
Health Inequities

Solidarity

Population Ageing, Rise of
new Technologies

Increase Sustainability of
Health Systems

Prosperity

Consequences of
Globalisation

Improve EU Effectiveness on
the Global Stage

Europe in the World

Much has been achieved in health policy at the EU level in a range of areas, based on
different parts of the Treaty, for example in health and safety at work, pharmaceuticals, public
health, food safety, research and environment. Following the introduction of specific public
health provisions into the EU Treaty8, in the 1990s the EU worked on several ‘sectoral’ health
programmes, looking at individual issues such as cancer, communicable diseases, rare
diseases and health promotion. In 2000 the Commission adopted a first public health strategy9
which gave rise to the Public Health Programme (2003-2008), setting out a framework for
action on health determinants, health threats, information and monitoring within the health
sector at EU level.

However, the EU is now facing new challenges, which require a new approach. Europe is
changing as globalisation continues and innovative technologies are developed every day. The
ageing population is changing disease patterns and putting pressure on health systems, new
disease threats such as avian flu and the risk of bioterrorist attacks are emerging. Lifestyle-
related illness, particularly linked to obesity and smoking, are a major part of the disease
7 See Annex 4 for further information about the relationship of health to the economy.
8
Initially in Article 129 of the Maastricht Treaty and then in a strengthened form in Article 152 of the

Treaty of Amsterdam.
9 Proposal for a Decision of the European Parliament and of the Council adopting a Programme of

Community Action in the Field of Public Health (2001-2006) - COM(2000) 285.

Deutscher Bundestag – 16. Wahlperiode – 31 – Drucksache 16/9412

burden. Table 1 shows some of the key health challenges facing the EU, linked the
Commission's overarching objectives, and to key health objectives. A new strategy will aim to
maximise the EU's ability to tackle these health challenges, while supporting the
Commission's broader objectives.

In order to address these increasing health challenges, the Strategy aims to advance good
governance methods, by putting an overarching strategic framework in place with effective
objectives and an implementation mechanism, building Health In All Policies cooperation,
and increasing visibility and understanding about health at EU level.

The proposed Strategy would set out a first stage to 2013, the end of the current financial
perspectives, when an evaluation will take place to support the definition of further work
towards strategic objectives.

2.1. Changing Health Challenges

The EU is currently facing new challenges. Four key health challenges for the EU, which
relate to the Commission's objectives of prosperity, security, solidarity and Europe in the
world, are the increased health inequities caused by EU enlargement, current and emerging
threats to health, the challenge of supporting sustainable health systems, and the opportunity
to increase EU activity in the field of global health. Within the scope of this document it is
impossible to describe all the actions that are currently undertaken or will be undertaken in the
future. Therefore a short introduction to key concerns is included, describing the added value
of current and future EU action in that area. The overall subsidiarity test addressing the
necessity and added-value of EU policies in the area of health is then summarized in section
2.3.

These four areas are not discrete but overlap with one another. For example, tackling
inequities means reducing inequities in access to health systems and in treatment of disease.
Increasing the focus on global health means recognising the global element in all areas of
health, e.g. the employment of health professionals, which is an issue for sustainable health
systems, and tackling health threats like communicable disease. Setting objectives in these
areas would therefore provide a dynamic and inclusive framework for focusing on protecting
and improving health across the EU.
Drucksache 16/9412 – 32 – Deutscher Bundestag – 16. Wahlperiode

(1) Enlarged EU with Greater Inequities in Health

Although most Europeans today enjoy the prospect of a longer and healthier life than previous
generations, major inequities still exist. Health inequities are inequalities in health
(differences in health status, and differences in access to treatment and care) that are
avoidable and unfair.

A major reason for inequity comes from conditions related to socio-economic factors, lifestyle
and environmental conditions. Poverty, low levels of education, differences in gender,
membership of some minority ethnic groups, and disability are some of the factors that are
associated with poorer health. Inequalities will always exist within and between countries.
The EU has a role to address areas where change can be made and where added value is
achievable, for example by facilitating the sharing of best practice and taking action where
issues have a cross border impact.

Key Facts

The difference in life expectancy at birth between people living in different countries within
the EU is more than 7 years for females and 12 years for males. A baby is more than 6 times
more likely to die before their first birthday in Romania than in Sweden.10 Graph 1 shows the
differences in life expectancy including the clear gap between EU-15 and EU-12 Member
States. In the majority of EU Member States life expectancy has improved consistently over
the last 50 years but this general trend masks major differences between countries. Some
Member States experienced a decline in life expectancy during the mid 1990s and in Latvia
and Lithuania life expectancy at birth has dropped significantly in the latest figures (2005)11.

Graph 1: Life Expectancy at Birth (1970 to 2005) in EU Members before 1 May 2004, EU
Members after 2004, and selected countries

10 European Community Health Status Indicators 2005, infant mortality per 1000 live births, Romania

15.0, Sweden 2.4.
11 Source: Eurostat.

Deutscher Bundestag – 16. Wahlperiode – 33 – Drucksache 16/9412

65

70

75

80

1970 1980 1990 2000 2010

Bulgaria
Hungary
Latvia
Lithuania
Poland
Romania
EU members before May 2004
EU members since 2004 or 2007

Life expectancy at birth, in years

The Healthy Life Years indicator, an indicator of the Lisbon agenda, is used to measure how
much time people are spending in good health. This varies widely across the EU. In 2003
Healthy Life Years ranged from 71 years in Italy to 53 in Hungary for men, and 74 in Italy to
57 in Finland for women.

Inequities in health are closely linked to the economic prosperity of a country. Increasing
economic prosperity through initiatives like the Lisbon agenda will therefore support
improvements in health. However, specific health interventions are also effective. Promoting
health, addressing health determinants, improving health literacy and health information,
increasing the availability of healthy choices and improving the efficiency and responsiveness
of health services can help to narrow the health gaps.

The predicted trend of population ageing, resulting from low birth rates, increasing longevity,
and the ageing of the 'baby boom' generation is now well established on political agendas
across Europe. The additional health expenditure that this will entail, and other consequences,
such as the likely shortage of healthcare professionals, will clearly pose a major challenge to
the sustainability of health systems. By 2050 the number of people in the EU aged 65+ will
increase by 70% and the 80+ age group will increase by 170% in the same period. DG ECFIN
projections have estimated that if healthy life expectancy evolves broadly in line with change
in age-specific life expectancy, then the projected increase in spending on healthcare due to
ageing would be halved. 12 A healthy, active ageing population can be supported through
effective health policy across the lifecycle, in particular in relation to offering more healthy
choices and tackling non-communicable disease.

12 The impact of ageing on public expenditure: projections for the EU-25 Member States on pensions,

healthcare, long term care, education and unemployment transfers (2004-2050) DG ECFIN 2006,
p. 133.

Drucksache 16/9412 – 34 – Deutscher Bundestag – 16. Wahlperiode

Non-communicable diseases contribute to a substantial part of the burden of disease in the
EU. Modern patterns of living are having a complex effect on risk factors for health. Physical
activity is in decline due to reductions in the physical requirements for work, increased
motorised transport and more passive leisure activities. There is clear evidence that
overweight and obesity are rapidly increasing. Patterns of smoking and harmful alcohol
consumption are also increasing in some groups, particularly amongst young people. Chart 1
shows that tobacco use, high blood pressure, nutritional factors such as obesity and high
cholesterol, alcohol abuse, low levels of physical activity, illicit drugs and unsafe sex are
some of the most important risk factors for poor health in Europe. Many of these causes or
'determinants' of ill-health are preventable by means of ensuring that healthy choices are
available to citizens. Annex 3 sets out more information on key determinants of health.

Disability Adjusted Life Years Lost (DALYs) attributable to risk factors in the European Union

0

1000

2000

3000

4000

5000

6000

7000

8000

Tobacco Blood pressure Alcohol Overweight Cholesterol Physical
inactivity

Low fruit and
vegetable intake

Illic it drugs Unsafe sex

DALYs (000)

Chart 1: Source WHO13

Current Actions

Much work has been done to tackle inequities in health. In its Resolution of 29 June 2000 on
health determinants, the Council considered that the increasing differences in health status and
health outcomes between and within Member States called for renewed and coordinated
efforts at national and Community level.14 Additional attention on the link between social
inequalities and health inequalities has arisen since the establishment by the World Health
Organisation in 2004 of a Commission on Social Determinants and there is increasing
appreciation as part of the review of the Lisbon process, that reducing the social impact on
health can lead to improved health of the population with corresponding increases in human
capital, reductions in social payments and economic growth. In particular, the use of
Structural Funds for health through EU regional policy can lead to concrete improvements, as
demonstrated in the broad-ranging Portuguese 'Saúde' project.15 DG EMPL's Open Method of
13 World Health Organization Burden of Disease Report 2002 – Annex 3. Data are for European Countries
classified as very low child and very low adult mortality.
14 OJ C 218, 31.7.2000, p. 8.
15http://ec.europa.eu/regional_policy/country/prordn/details.cfm?gv_PAY=PT&gv_reg=ALL&gv_PGM=1999P

T161PO005&LAN=5

Deutscher Bundestag – 16. Wahlperiode – 35 – Drucksache 16/9412

Coordination on Social Protection and Social Inclusion is a key policy tackling social and
health inequalities.

In the area of non-communicable disease, strategies have been developed in the areas of
alcohol, mental health and nutrition and physical activity. Further information is included in
Annex 3. Policies with an impact on the determinants of health include agriculture, including
the promotion of healthy foods, and decoupling of subsidies for unhealthy products such as
tobacco. Close links also exist in the tobacco area between health objectives and taxation
policies. There are synergies with JLS in terms of illegal drugs, including work on indicators
for drugs along with Eurostat and expert agency EMCDDA. Synergies are also found in
relation to health promotion in workplace and schools settings with EMPL and EAC. As with
all areas, research projects support better understanding of the issues.

Added Value of a New Strategic Approach at EU level

As described above, EU is already actively involved in tackling inequities in health. However,
there is clearly scope for further work in this area. Added value would be found in particular
in a new focus towards raising awareness at Member State level in relation to the potential for
Regional Policy to contribute to the health sector, both through health-related investments and
through systematic sharing of the successful experiences of some Member States and regions
with others. This would be particularly beneficial for new Member States and regions. EU
added value would be found in measures (such as facilitating the sharing of best practice) to
support Member States to improve health literacy, to enable people to have better access to
information and services, to make more healthy choices available, and to support 'lifecycle'
approaches to health focusing on the need for effective health promotion and interventions
from childhood through to old age. The experience of some Member States has shown that
effective low-cost preventative measures, such as cancer screening can have a real impact on
health outcomes for a population. Studies have shown that screening people aged over 50 for
breast cancer and colon cancer can reduce mortality by 35% and 16% respectively16.
Therefore clear EU added value could be found in a renewed approach to disseminating best
practice in these areas, thus helping to narrow the health gaps within and between EU-27
countries. A new strategic approach would also mean enhanced networks to encourage
communication between Member States, experts, and stakeholders on the issues.

Reducing inequities in health was considered by many consultation respondents from all
backgrounds as an important objective of the strategy. In a questionnaire to the High Level
Committee on Public Health17, several Member States identified mental illness, cancer and
cardiovascular disease as key issues on which the EU should focus, and named physical
activity, smoking and alcohol/drugs as top priority risk factors to tackle. They also identified
the workplace and schools as key settings to promote health.

16 Figures from European Code Against Cancer, 2003 – www.cancercode.org
17 An informal advisory body of senior Member State officials to the Commission, which meets 2/3 times

per year and operates with a number of working groups on specific issues.

Drucksache 16/9412 – 36 – Deutscher Bundestag – 16. Wahlperiode

(2) Current and Emerging Threats to Health

Key Facts

Communicable disease remains an important health threat to European citizens. Parts of
Europe have the fastest rate of new HIV/AIDS cases in the world. In 2005, 77,553 newly
diagnosed cases of HIV infection (104 per million population) were reported in the European
Region of the World Health Organization,18 while rates of Tuberculosis (TB) increased by 8%
in Sweden and 5% in the UK, with new more resistant strains of TB a growing concern19. In
recent years threats from SARS and avian influenza, and the increased risks of a bioterrorist
attack since September 11th have shown the need for good coordination between Member
States on surveillance, preparedness and response.

Climate change is also a looming threat with the potential for a severe impact on health. In
recent years, extreme weather conditions have proved harmful and fatal particularly among
the elderly and other vulnerable groups. France suffered an estimated 15,000 deaths due to an
August heat-wave in 2003. Climate change may also change the areas affected by
communicable diseases, such as malaria and tick-bourne diseases, reduce the predictability of
communicable disease threats such as pandemics, and worsen the consequences of these.

Threats to health also occur in healthcare settings and patient safety is an important area of
concern. Studies have shown that 10% of patients admitted to a hospital in the UK encounter
an adverse effect20. These range from healthcare acquired infections to prescribing errors and
unsafe devices. In the Netherlands, research has shown that around 800,000 Dutch people
over the age of 18 have been subject, in their own perception, to errors based on the
inadequate transfer of medical information21. It is likely that this problem exists at a similar
scale in other EU Member States.

Current Actions

In terms of communicable disease, work on this area by the EU has included actions to
improve preparedness and response to epidemics or deliberate acts of threat such as
bioterrorism, to support Member States in addressing communicable disease threats such as
HIV/AIDS and TB, anti-microbial resistance, patient safety issues, pharmaceuticals and
medical devices safety, and the quality and safety of blood, tissues and cells. Many
communicable disease threats require close EU-level cooperation and coordination between
Member States and international actors. The European Centre for Disease Control was set up
in 2004-2005 in response to the need for a more coordinated approach to communicable
disease, and its mandate will be reviewed in 2008 to reflect what has been learned in the first
years of the Centre, and to ensure that the system for responding to threats is as effective as
possible in the light of current and emerging challenges, with the optimum use of resources.
The existing legal instruments for communicable disease surveillance and reporting will also
be reviewed. The introduction and implementation of the International Health Regulations is
18 HIV/AIDS Surveillance in Europe: End-year report 2005 No 73.
19 EuroTB annual report 2005.
20 This translates to ca. 850 000 adverse effects a year. Source: UK Department of Health Expert Group.
An organisation with a memory: report of an expert group on learning from adverse events in NHS.
Chairman: Chief Medical Officer London: The Stationery Office, 2000.

21 For relevant information, see http://www.npcf.nl/ Similar information is also available from WINAP
and from the Dutch Association of Pharmacists.

Deutscher Bundestag – 16. Wahlperiode – 37 – Drucksache 16/9412

currently a major priority, aiming to make alert and information systems at the EU level and
through WHO more compatible and coherent.

In the area of patient safety a working group of the High Level Group on Health Services and
Medical Care has developed a recommendation to describing the areas of patient safety where
action could be taken at Member State level and/or at the EU level. These include developing
the knowledge base, establishing reporting mechanisms, instituting training for staff, and
developing a culture of safe care in healthcare management and leadership. Based on these
recommendations, action on patient safety at the EU level is planned for 2008.

Other sectors involved in protecting citizens from a wide range of health threats include the
employment sector, in the area of health and safety at work and coordination in relation to
social security schemes, the enterprise sector in the regulation of pharmaceuticals, medical
devices, chemicals, cosmetics etc, the EC Research Framework Programmes on health, food,
environment and other health-related areas, Consumer Safety, Food Safety, Animal Health,
Environmental issues such as air quality, water quality, noise, climate change, industrial
emissions, and chemicals, and Transport in relation to accidents, in particular road safety. The
Joint Research Centre currently supports a range of research from the migration of chemicals
into food products to detecting genetically-modified organisms in imported food, which
support policy responses.

Added Value of a New Strategic Approach at EU level

Although much work has been done, the growing challenges presented by health threats to EU
citizens mean that a new focus is needed. There is a risk, given the seriousness of emerging
health threats that the usual pace of evolution of mechanisms, institutions and programmes
may prove insufficient to respond to these challenges in an effective and timely manner.
Experience in recent years with health threats such as avian influenza and SARS has
demonstrated that a priority area for development is improving surveillance and alert systems
across the EU and international lines of communication, as well as making links with existing
surveillance and alert systems for events which may have a public health impact, such as
pharmaceutical or nuclear safety systems. In addition, further information is needed on how to
address the consequences of climate change on health and health systems. Issues of
vaccination are another major area needing increased attention, including vaccinations for
pandemic and seasonal influenza, but also childhood vaccinations. For example, the EU can
add value to the issue of the introduction of HPV vaccination for cervical cancer by providing
opportunities for Member States to exchange best practice and experience.

Renewed support for these efforts led by a new strategic approach could add value by driving
forward improvements, as well as implementing new initiatives building on cross-sectoral
synergies, such as virtual mapping of disease, increased cooperation on organ donation and
transplantation, and the potential health risks of climate change. In addition, health threats,
including the need to ensure preparedness and protection of European citizens through
cooperation among Member States were identified as one of the main priority areas for the
Health Strategy by many consultation respondents. Patient safety, including work on hospital
acquired infection and epidemiology safety, was clearly identified as a key challenge,
especially by the Member States.

Drucksache 16/9412 – 38 – Deutscher Bundestag – 16. Wahlperiode

(3) Sustainable Health Systems

The sustainability of health systems in the future is a challenge where the EU can add value
due to cross border issues such as patient and health professional mobility, and in facilitating
exchange of knowledge and good practice on issues such as demographic change and the
increase in new technologies22.

Key Facts

The impact of the single market on health, with the increasing mobility of patients, services
and health professionals, coupled with more general issues that confront national health
systems such as the growing pressures from new technology, demographic change and
popular expectations, call for adequate Community responses in the field of health services
and co-operation between health systems at European level. Current economic projections
show that the future cost of healthcare between now and 2050 will depend crucially on
efficiency in provision; this will be as significant a factor as population ageing itself. Ensuring
sufficient capacity in the field of healthcare and public health is an issue needing
consideration, in particular in the new Member States.

Innovation and the development of new technologies are key issues that affect EU health
systems. For example, e-health (which has been identified as one of the 6 most promising
markets in the EU by the Lead Market Initiative) through electronic health records, personal
health devices for the elderly, the chronically sick, and disabled, and as a means to reduce
medical errors through recording adverse incidents, and biotechnologies which combine
disciplines such as genetics, molecular biology, biochemistry and cell biology, show great
potential to contribute to improved healthcare.

Furthermore, the growing use of life sciences and biotechnology, for the development of
drugs, vaccines and innovative therapies, as well as the applications of "nanomedicine",
represent huge potential for innovation and growth23. The health sector must take advantage
of innovation and technology where this will lead to greater efficiency and health
improvements. A balance must, however, be struck in terms of cost-effectiveness. Developing
means for Health Technology Assessment (HTA) is one area where the EU can add value by
enabling the exchange of knowledge and best practice, and this was supported in the
consultation.

Current Actions

To aid investment towards modernised and efficient health systems and better healthcare,
health has already been integrated into instruments aimed at enhancing growth and
employment in Europe: the Lisbon Strategy, Regional Policy and the EC Research
Framework Programmes. The complexities around cross-border healthcare have been
demonstrated in a number of judgments by the European Court of Justice concerning the right
of patients to benefit from medical treatment in another Member State. An initiative on health
services to help clarify these and other health services issues is therefore under development
22
It is expected that a new Reform Treaty will include a reference to encouraging cooperation on health

services at the EU level.
23 Communication from the Commission on the mid term review of the Strategy on Life Sciences and

Biotechnology - COM(2007) 175.

Deutscher Bundestag – 16. Wahlperiode – 39 – Drucksache 16/9412

at EU level. Since 2004, the High Level Group on Health Services and Medical Care has
brought experts together to discuss issues such as cross border care, the training and mobility
of health professionals, health and health systems Impact Assessment, patient safety,
networks of centres of reference, health technology assessment, and e-health.

Sectors with clear links to health services at European Commission level include DG
MARKT, who lead on infringement issues including relating to health professional mobility,
pharmacy restrictions, etc, DG TRADE who facilitates cross border trade with health services
and access for health professionals in and from third countries, and DG REGIO who, in
cooperation with Member States, regions and regional partners, implement Regional Policy,
including health-related aspects. DG EMPL's Open Method of Coordination on Social
Protection and Social Inclusion relates to health and long term care systems, and DG EMPL
also work on coordination in relation to social security schemes in relation to patient
mobility24 and on demographic change issues. Further examples are DG ENTR who lead on
pharmaceuticals, DG COMP who support competition between healthcare products and
services, DG INFSO who work with technologies in relation to health and healthcare, and DG
RTD who support health research on issues affecting health systems under the 7th Framework
Programme for Research. DG ECFIN has put a particular focus on ageing in recent reports,
given its huge potential impact on public finances. 25

Added Value of a New Strategic Approach at EU level

The planned Community framework for safe and efficient health services would be put in
place as an element of the overarching Health Strategy, with the aim of responding to current
inefficiencies that could undermine Europe’s potential to maintain sustainable health systems
in future years, in particular with regard to population ageing. Facing these challenges and in
particular their cross-border dimension calls for adequate support to national systems at
European level, while respecting the subsidiarity principle. Individual Member States are
already tackling these issues although some are doing more than others. As cross-border
economic activities within the EU continue to increase, there are rising numbers of patients
seeking treatment and health professionals working abroad. An EU approach is needed to
support closer cooperation at EU-level to ensure a coherent approach to these cross-border
issues, and this is where the added-value of a new strategy can be the most significant.
Similarly, EU level work on healthcare systems, especially in relation to cross-border
activities, was considered to be an important area of work in the consultation responses. Some
contributors stressed that the Strategy should ensure that patients and professionals are aware
of their rights in relation to mobility between EU Member States, including in relation to
services offered, health insurance, and costs. The consultation on the health services itself
showed general consensus in favour of a clear Community framework on health systems26.

Added value can also be found in boosting the health capacity of the regions, which are
primary actors in delivering healthcare, which would be supported by a coherent new EU
level health strategy with a strong implementation mechanism at Member State level. A more
focused approach through a new health strategy could lead to better cooperation between
healthcare systems, particularly benefiting border regions or places where there are capacity
24 Cf Regulation 1408/71 which provides for access to healthcare for people moving within the EU and its
successor Regulation (EC) No 883/2004.
25 More information on the work of different Directorate Generals on health can be found in Annex 2 and

at www.europa .eu.
26 http://ec.europa.eu/health/ph_overview/co_operation/mobility/results_open_consultation_en.htm

Drucksache 16/9412 – 40 – Deutscher Bundestag – 16. Wahlperiode

constraints or the need for particular concentrations of resources or expertise. Current
variations across the EU in terms of techniques, resources and outcomes show that there is
enormous scope to improve the results obtained from existing resources by bringing
healthcare across the Union towards the standard of the best. For example, for bladder cancer,
although survival rates are improving in general, there are substantial differences in survival
among countries in Europe, with five-year survival rates ranging from highs of 78% in
Austria to 47% in Poland and Estonia.27

(4) Globalisation and Health

In today's globalised world it is increasingly difficult to separate national or EU wide actions
from global policy. Decisions affecting EU citizens directly are often made at global level,
and EU's internal policy can have consequences outside the EU borders. The EU can therefore
add value through showing leadership in global aspects of health policy. This is essential both
for the protection of the European population and for the respect of people living outside the
EU. The EU has a Treaty obligation in article 152 to, 'foster cooperation with third countries
and the competent international organisations in the sphere of public health,' and it is likely
that a new Reform Treaty will also include a new objective for the EU, in its relations with the
wider world, to uphold and promote the Union's values and interests and contribute to the
protection of its citizens.

Key Facts

The 57th World Health Assembly on May 2005, called Member States to work towards
universal coverage of basic healthcare, and attaining internationally agreed development
goals including those contained in the United Nations Millennium Declaration. Public
financing for basic health services is essential, especially for pro-poor fair financing28.
Specific preventive and treatment interventions can reduce the burden of disease in the short
and middle term, alongside longer term measures to support the wide economy and improve
socioeconomic conditions. It has been estimated that a comprehensive package of essential
services29 costs € 20-30 per capita and year30. Developing countries face a gap in public
financing for health. If countries were to allocate 15% of their government's budgets to health
(Abuja target, OECD average), then the additional public funding from domestic sources
would be over € 25 billion.

Although investment in health is expected to increase in countries experiencing economic
growth, the need for more investment is also expected to rise, particularly in high-HIV
prevalence countries. The commitments of the EU at Monterrey and Barcelona to gradually
increase the level of aid, together with the adherence to the Paris principles of alignment and
coordination, provide the EU with a historic opportunity to champion the global right to
health, through supporting equitable access to basic healthcare. EU action in this field can
help to tackle major ongoing problems, including over 20 million preventable premature
deaths, the global threats of pandemics, resistant strains of micro-organisms, emerging and re-
27 EUROCARE 3 - survival of cancer patients in Europe; see http://www.eurocare.it/
28 The concept of pro-poor financing of healthcare systems (e.g. based on healthcare insurance rather than

out-of-pocket payments) aims to ensure equitable access to healthcare, even for the poorest population
groups.

29
Services to address priorities through cost-effective interventions (costing less than € 50 per Disability
Adjusted Life Year; including HIV/AIDS).

30 Investing in Health”, WB WDR 1993; ”Attacking Poverty”, WB WDR 2000/01, ”Macroeconomics and
Health” 2002 : http://www.cmhealth.org/cmh_desc.htm.

Deutscher Bundestag – 16. Wahlperiode – 41 – Drucksache 16/9412

emerging diseases and growing levels of insecurity, unrest and massive migration flows.
Global HIV/AIDS deaths are projected to rise from 2.8 million in 2002 to 6.5 million in
203031 The global proportion of deaths due to non-communicable diseases is projected to rise
from 59% in 2002 to 69% in 2030 and total tobacco-attributable deaths are foreseen to rise
from 5.4 million in 2005 to 8.3 million in 2030. 32

New actors are emerging on the global health arena and new forms of interactions are taking
place. For instance, new public-private-partnerships have multiplied to over 100 and gained
importance and foundations are playing a significant role in financing of global health33. At
the same time, the Paris principles call for greater respect to ownership in the recipient
countries and more predictable budget support so as to allow countries to set their national
strategies, including universal access to basic healthcare and education.

Globalisation has increased cross-border flows of people and products. A key global health
threat is the severe shortage of health professionals, particularly in developing countries.
This is a problem of cross-border nature requiring actions at the global level, as a major
contributing factor is the migration of health workers to wealthier countries, causing "brain
drain" in many developing countries. The global shortage of health workers is estimated to be
4.3 million workers and the situation is most critical in developing countries. In Sub-Saharan
Africa the average ratio of physicians and nurses per 100 000 people is 15.5 and 73.4
respectively, compared to a ratio of 311 and 737.5 in developed countries.34 This is likely to
get worse as demographic changes in developed counties mean that more health workers are
needed and less are available.

Current Actions

The EU as a whole is the world's largest development and humanitarian aid donor, and health
is an important component in the EU's assistance to world-wide efforts to save and preserve
lives, to combat poverty and to work towards the Millennium Development Goals. The EU
has also played a key role in negotiations on the WHO Framework Convention on Tobacco
Control, on the International Health Regulations and on G8 discussions on health. The WHO
is a main player in global health, but the EU is also working with other UN and international
organisations active in health as well as with other bilateral and regional partners and civil
society. Close cooperation with other international actors, for example the partnership
between the EU and the Global Fund to fight AIDS, Tuberculosis and Malaria, and other
public-private-partnerships35 dedicated to global health issues, is also a vital part of EU's work
on global health.

Global health is linked to work by the RELEX 'family' of DGs of which DG DEV and
AIDCO work towards health elements of the Millenium Development Goals. DG ECHO
responds to health threats in third countries and towards saving and preserving lives in
emergency and immediate post-emergency situations. DG RELEX deals with relations to
third countries, including European Neighbourhood policy and DG ENLARG with candidate
and potential candidate countries. Global health policy is also part of the work of DG TRADE
31 Mathers CD, Loncar D (2006) Projections of global mortality and burden of disease from 2002-2030.
32 ibid
33 Some examples are the Global Fund to tackle AIDS, Tuberculosis and Malaria; the International
Initiative for Aids Vaccination (IAVI); the Global Alliance for Vaccines and Immunisation (GAVI),
and the Bill and Melinda Gates Foundation.

34 World Health Organization, World Health Report 2006: Working Together for Health.
35 e.g. the European and Developing Countries Clinical Trials Partnership (EDCTP).

Drucksache 16/9412 – 42 – Deutscher Bundestag – 16. Wahlperiode

in terms of international trade with health goods and services and JLS on the issue of
migration. Amongst many other sectors with links to global health issues, food safety is a key
area with a clear global dimension, as food is imported into the EU from over 200 countries,
and ensuring the safety of these imports is an ongoing challenge.

Added Value of a New Strategic Approach at EU level

As described above, the EU is active on the international health stage. However, this activity
could be strengthened to give the EU a stronger voice to represent Member States on health
issues. The increased globalisation of health is presenting challenges in governance. A large
number of bilateral and international organisations and public-private partnerships are active
in global health. To avoid conflicting messages and duplication of work, and to clearly define
the roles of actors on the global health stage, close collaboration between these organisations
is crucial. Effective coordination and a coherent intersectoral approach are necessary
components of global health governance, and a new strategic focus on global health issues
would add value by supporting this more fully.

The EU is committed to take a leading role in the fight against poverty, hunger and disease in
the world.36 This has not yet been fully exploited. The EU can add value in its contributions to
global health by sharing its common European values as well as its experience in
implementing health policy that reduces health inequalities, strengthens health systems and
promotes access to basic healthcare, and improves health indicators.

Engaging more strongly in global health policy would aim to make health a key issue on the
agenda in the EU's relations with third countries – bilaterally, regionally and globally. A
key message from the new development consensus and the Paris principles is the importance
of shifting from international cooperation based on development aid to partnerships based on
solidarity and guided by the needs of the beneficiary countries.

Two additional key issues where EU added value was foreseen by a number of consultation
respondents were addressing the severe shortage of health professionals globally, and
improving access to medicines including research and development of new medicines and
health technologies, especially for neglected diseases.

2.2. Advancing Good Governance

A new governance approach is needed to better support effective work at EU level given the
changes taking place in the EU. These include setting clear objectives for work on health at
the EU level; achieving greater inter-sectoral cooperation on health, (also known as
mainstreaming, or Health in all Policies); and achieving greater transparency and visibility of
work on health at the EU level.

(5) Creating a Coherent Framework

Currently no overarching strategic framework for health exists at the EU level. Health is
clearly an important element in many areas of work; within the health sector itself the Public
Health Programme provides a framework for health spending, while the European
Environment and Health Action Plan37, ongoing E-health initiatives38 and the health themes

36 See Declaration on the occasion of the 50th anniversary of the signature of the Treaties of Rome, and

European Development Consensus 2006.
37 COM(2006) 625.

Deutscher Bundestag – 16. Wahlperiode – 43 – Drucksache 16/9412

under the EC Research Framework Programme39 are three examples in other sectors. The
expansion of the EU and emerging health challenges as set out in the previous section mean
that it is now time to build on these successful initiatives with a more inclusive framework to
set the direction of travel for health policy for the coming decade. The need for a strategic
approach, setting measurable objectives, is supported by past evaluations of the Public Health
Programme (see Box 1.)

Box 1: Evaluations of Previous Health Programmes

Evaluations of previous health programmes support a more coherent approach to EU health
policy, including setting clear and well-defined objectives and goals.

In the evaluation of the eight separate programmes run in the field of health from 1996-2002
(health promotion, information, education and training, rare diseases, pollution-related
diseases, AIDS and communicable diseases, cancer, drug prevention, injury prevention, and
health monitoring), one comment was that 'the implementation of the programmes seems to
have been rather compartmentalised. There were few bridges between programmes'. It
recommends

'the development of a complete and coherent theory of action for the general public health
framework, identifying the levels of (quantified) objectives, the target groups, and possible
monitoring indicators. This strategic thinking should be accompanied by a long-term
perspective of where the Commission wants to go in the field of public health in the 15 or 20
coming years'.40

The evaluation of the Public Health Programme 2003-2008 (PHP) recommends development
of,

'more quantitative intermediary outcome measures to support milestones which could chart
progress towards more general public health measures (e.g. comparable health indicators
such as the Healthy Life Years indicator).'41

It notes that measuring the effectiveness of the PHP faced considerable barriers due in part to
a lack of measurable performance indicators,42 stating,

'we recommend making the objectives and success indicators of the PHP more explicit and
ensure the dissemination of these to stakeholders…monitoring progress against these and
communicating progress transparently.
38 ec.europa.eu/information_society/activities/health
39 http://ec.europa.eu/research/fp7/index_en.cfm?pg=health
40 Deloitte report of 2004 : “Final Evaluation of the eight Community Action Programmes on Public
Health (1996-2002) – web link: http://europa.eu.int/comm/health/ph_programme/evaluation_en.htm.
41 Interim Evaluation of the Public Health Programme 2003-2008, Final Report 12 January 2007, Rand

Europe, p. 5.
42 Ibid, p. 3

Drucksache 16/9412 – 44 – Deutscher Bundestag – 16. Wahlperiode

Added Value of a Coherent Framework at EU level

A coherent framework for health policy would encompass the broad range of work on health
across the European Community. Setting objectives to which all sectors agree, which build
upon the aims of existing sectoral strategies and programmes and serve to bring them together
and underpin them, can act as a 'beacon' to encourage progress towards key health objectives.
If those objectives are supported by measurable indicators, this provides a means for
monitoring of progress and a driver for achieving the objectives.

A new framework would also add value in terms of rationalising and simplifying, where
appropriate, groups and initiatives currently ongoing in the health field at EU level. An
implementation mechanism for the Strategy could replace a number of current groups where
energies could be channelled towards achieving the Strategy's objectives.

While the Strategy's broad aims are expected to be compatible with national health strategies
in those Member States which have a broad health strategy in place, they should also support
the development of health strategies in all Member States and more generally support
strengthened health action at national, regional and local level. This is supported by
responses to the consultation in which some Member States, regional and local
administrations saw the Strategy as a potential guide for their own activities. Member States
including regions and local areas would be responsible for delivering progress towards the
objectives, and a small number of broad objectives set by the Commission as part of a new
health strategy would therefore be supported by more specific objectives developed with
Member States. Member States would also agree on indicators to measure progress against
the objectives. Other stakeholders, including health professionals, academic bodies, non-
governmental organisations, industry and others should also be aware of the Strategy's
objectives and support them through their own activities.

Objectives set by the European Community on health would complement other international
goals and objectives for health including the WHO Europe's Health 2143 and the Millennium
Development Goals44 to which EU Member States have already committed themselves, as
well as EU objectives (see section 3). The goals set by international bodies are focused on
tackling similar health challenges, but the EU has a unique role to play in health and added
value is found in the definition of a framework to guide the use of EU policies,
programmes, instruments and actions in tackling these health challenges as well as other
areas where the EU can add value.

(6) Increasing 'Health In All Policies' Cooperation

Health in all Policies (HIAP) is a concept that underpins work on health at the European
Level. Under article 152 of the Treaty, the EU is required to make sure that a high level of
health protection is ensured in ‘the definition and implementation of all Community Policies
and Activities’. Many sectors take actions that have an impact on health, for example regional
development, environment, research, economic policy, social policy, etc. Policy partnerships
are ongoing, for example in the fields of pharmaceuticals; demographic change and ageing;
Regional policy health-related actions (infrastructure, research, training), health research in
the RTD Framework Programmes, and health in the information society. Annex 2 contains a
list of health-related actions across many different sectors at the European level. It is

43 WHO Europe (1999) Health 21 - Health for All in the 21st Century Copenhagen: WHO.
44 http://www.un.org/millenniumgoals/

Deutscher Bundestag – 16. Wahlperiode – 45 – Drucksache 16/9412

necessary not only to acknowledge this fact but to encourage active coordination between
sectors to develop long-term strategic approaches to health problems.

Significant work to increase HIAP cooperation has been undertaken at EU level in recent
years; methodologies have been developed for Health Impact Assessment (HIA) and Health
Systems Impact Assessment (HSIA), a number of projects have been funded45. An
interservice group meets several times each year to share information on health-related
initiatives. Council Conclusions on Health In All Policies were agreed under the Finnish
Presidency on 30 November 2006, which, inter alia, invited the Commission to set out a plan
for work in Health in All Policies with a specific emphasis on equity in health and to consider
including such activities in its new Health Strategy. A recent evaluation found that use of the
key Healthy Life Years indicator 'is not (yet) widespread, especially within Commission
Services and by National and Regional Non-Health Ministries'. It recommends improving
dissemination activities, supporting HIAP aims within the proposed new health strategy, and
developing further coordinated action plans linking health with other policy areas.46

There is therefore potential to strengthen the current approach by putting in place a
mechanism that links actions across all sectors to the achievement of strategic health
objectives. A cross sectoral approach is a vital element of the proposed new strategic
framework, as work in the health sector alone would limit the possible achievements.
Increasing HIAP cooperation at EU level in relation to the strategic health objectives will
mean that the value of action on health in other policy areas is fully recognised and that
possibilities for partnerships to share knowledge and expertise are fully exploited, and this
will be reflected within Member States.

Added Value of a Renewed Health in All Policies Approach (HIAP)

While some countries are active in working towards HIAP, in many Member States health
policy is not linked up to other sectors. Building on current achievements in HIAP at EU level
will support the development of a cross-sectoral approach for more effective health policy
at national, regional and local level. For example, enhanced HIAP cooperation to support
the objective to reduce inequities in health could lead to better understanding of the links
between health and economics and an increase of the use of the full scope of Regional Policy
for health-related actions by Member States and regions. Similarly, an enhanced cooperation
between health, employment and education sectors to promote health in the workplace and
schools would encourage Member States to make similar cross-sectoral links and achieve
related health gains.

Increasingly, real change is being made by involving partners outside the health sector in
achieving health improvements. The Platform for Action on Diet, Nutrition and Physical
Activity has successfully engaged the food and broadcasting industry on issues relating to
improving population health. This can be replicated in other sectors, and a similar platform is
being developed in relation to alcohol misuse. A new strategy would build on this approach,
expanding it to other areas and encouraging similar approaches at national, regional and local
levels to achieve health gains in key areas.

By setting a governance objective on HIAP the Strategy can also add value through a more
focused dissemination of practical information and tools in relation to HIAP, for example

45 For example, http://ec.europa.eu/health/ph_projects/2001/monitoring/monitoring_project_2001_full_en.

htm#11 and http://ec.europa.eu/health/ph_projects/2004/action1/action1_2004_20_en.htm
46 Rand Europe, Evaluating the Uptake of the Healthy Life Years Indicator, December 2006.

Drucksache 16/9412 – 46 – Deutscher Bundestag – 16. Wahlperiode

in relation to Health Impact Assessment and Health Systems Impact Assessment for new
initiatives. Added value could also be found in improved coordination in working between the
different sets of health indicators managed for different policies, including ECHI indicators,
Social Protection indicators, and Sustainable Development indicators in relation to health.

Consultation responses in both the 2004 reflection process and the 2006-2007 process were
strongly in favour of strengthening HIAP, including at national, regional and local level.
There was also a large consensus on the importance of ensuring the application of Health
Impact Assessment at all policy levels and in all sectors.

(7) Improving Visibility and Transparency

The rejection of the EU Constitution in 2005 by referenda in two Member States has led to
the EU reflecting on how it can better connect with its citizens. The Commission's White
Paper on European Governance47 stresses the need for greater attention to five key principles
of governance, 'openness, participation, accountability, effectiveness and coherence'. An
overall health strategy can support these five aims.

The evaluation of the Public Health Programme 2003-2008 recommended giving 'sharper
definition'48 to the Programme to build on its visibility within the health community, and
recommended better coordination and effective information across the European Community
to avoid overlaps and improve synergies between EC programmes and policies.49

Added Value of Greater Visibility and Transparency of EU Health Action

A new health strategy can support openness and accountability by clarifying the role of the
EU in health to Member States and stakeholders, and therefore decrease the chance of the EU
being misunderstood and undervalued in this field. A health strategy will help to define the
role of the EU, Member States and other stakeholders in improving and protecting health, and
encouraging participation. A health strategy will offer a coherent, transparent vision of what
the EU's aims are in terms of health, and what actions it may take, leading to greater
effectiveness through a focus on key areas where added value is achievable. Developing an
EU health strategy will, in itself, send a strong political message about the important role of
the EU in health to all stakeholders including European citizens and international
organizations, and lead to greater understanding of the rationale for and legitimacy of action
on health at the EU level. This clarification of the EU's role may lead to more effective
partnerships with Member States and other stakeholders who may be more willing to work
closely with the EU on those issues where EU added value is demonstrated.

As great social and technological change has taken place in recent years, citizens are seeking
to understand and take greater control of their own healthcare. Although Member States have
a clear role to advise citizens on health issues, citizens also have the right to information on
what is happening at EU level. The Commission has a role in offering information directly to
citizens, for example through the Health Portal, which aims to provide European citizens with
easy access to comprehensive information on Public Health initiatives and programmes at EU
level, and to promote the improvement of public health in the EU.50 Added value can be
47
COM(2001) 428.
48 Ibid, p. 4
49 Ibid, p. 8
50 www.health.europa.eu

Deutscher Bundestag – 16. Wahlperiode – 47 – Drucksache 16/9412

found in building on this approach to make EU health policy more accessible to citizens
including through the communication of a coherent, strategic EU approach to health.

The EU's ability to collect comparable data and information to provide an overview across
Member States is invaluable for policymakers at the national level, and can also be useful for
hospital managers, health professionals, health research centres, universities and others. This
can range from information on best practice and techniques, to data on the prevalence of
diseases, to information on cross-border issues relating to the mobility of patients and health
professionals. Providing this information helps to share knowledge across the EU while at the
same time respecting the Member States' prerogative on the establishment and organisation of
their health systems. One example of a successful information tool supported by the European
Commission is the Orphanet website which offers free information on rare diseases for
patients, families, industry, health professionals and researchers.51 A new strategy would
build on the success of current practices by offering accessible and coherent comparable
data on progress towards the strategic health objectives that can act as benchmarks
across the EU and drive improvements towards the level of the best performers. At the same
time, the visibility and accessibility of health information in general will be enhanced at both
EU and national levels through, for example, sharing best practice in promoting health in a
wide range of settings such as schools and workplaces, exploiting new media to communicate
health messages, and clarifying rights for patients and professionals when crossing borders for
treatment or employment.

2.3. Subsidiarity Test

The subsidiarity test asks whether EU action is really necessary (the 'necessity test'), or
whether action by Member States is sufficient to solve the problem. It asks whether action at
EU level add value to the work done by Member States (the 'added value test'), and it asks if
the measures chosen are proportionate to the objectives (the 'boundary test'). This section
looks at the first two tests. The subsidiarity test, in particular the boundary test, is also applied
to options under Section 4. This section also draws from the analysis of the added value of a
new strategic approach presented within the description of each of seven challenges in
Sections 2.1 and 2.2.

EU Member States have the prime responsibility for protecting and improving the health
of their citizens. As part of that responsibility, it is for them to decide on the organisation and
delivery of health services and medical care. However, the fundamental aims of the EU in
terms of free movement of goods and services, and working together on cross-border issues,
necessarily have a health dimension. It is recognised that there are many areas relating to
health where, to be effective, action needs to involve cooperation and coordination between
countries. The prevention of the major health scourges and issues with a cross-border or
international impact, such as pandemic preparedness or movement of patients or health
professionals within the single market, where Member States cannot act alone effectively, are
areas where cooperative action at EU level is indispensable. In addition, applying the single
market and striving for EU integration must include health issues because health is affected
by many different policy areas, and is provided for in many areas of the Treaty (see below).

There are also a wide range of health issues where the EU has a key role in undertaking
actions which add value to and complement the work done by Member States in making
European Citizens healthier and safer. In recent years the EU, in partnership with Member

51 www.orpha.net

Drucksache 16/9412 – 48 – Deutscher Bundestag – 16. Wahlperiode

States, has made important progress in improving and protecting health. Important
achievements have included, for example, legislation on tobacco advertising and on blood
products, and the launch of the European Centre for Disease Control (ECDC). Through the
EU Public Health Programme and other funding mechanisms, work has been developed on a
EU health information and knowledge system including the creation of a comparable system
of indicators to monitor health statuts of Europeans, the European Health Indicators (ECHI)
system, a comparable system of tools to collect health information (health interview surveys,
health examination surveys, hospital information system, etc) in cooperation with the EU
Statistical Programme, and a series of health reports. Policy initiatives have been launched on
mental health, and accidents and injuries. Networks have been developed in the rare diseases,
major and chronic diseases, lifestyle, health and environment and health systems areas.

The EU can add value through a wide range of activities. These may include working to reach
critical mass or obtain economies of scale, for example sharing information on rare diseases
where only a small number people are affected in each Member State. It may mean working
with Member States to enlarge the internal market and increasing the international
competitiveness of health services. Added value can be found in health promotion
campaigns (such as the 'Help' tobacco campaign52), in devising common standards such as
food labelling, in the support of pharmaceutical research, in e-health development and
deployment, and in research in a wide range of areas. Sharing best practice and
benchmarking activities in many areas can play a major role for the efficient and effective
use of scarce resources and therefore the European coordination of MS action can prove
particularly important in terms of future financial sustainability.

Importantly, the Community as a whole has a major role to play in creating the conditions
which support and maintain health, such as employment, health and safety at work,
sustainable economic growth, technology, high quality environment, effective energy and
transport infrastructure, and safe products. Many "non-health" sectors have a major, direct
role in improving and protecting health, for example, in the field of environmental health,
health and safety at work, pharmaceuticals, and research. This role is recognised in the Treaty
(see Box 2) which situates what has become known as 'Health in All Policies' (HIAP) at the
heart of work on health at the EU level.

The EU therefore clearly adds value in a wide range of areas relating to health. Given the
need to tackle current and emerging health challenges in the most effective manner and to
advance good governance in health at the EU level, there is also an important added value
resulting from taking a new strategic approach in relation to the seven challenges identified.
As set out in Sections 2.1 and 2.2, clear added value examples can be identified in the seven
areas:

� 1) Enlarged EU with Greater Inequities in Health

Added value of a new strategic EU approach is found in, e.g. utilising the potential of
Regional Policy for health-related actions; a renewed focus on making healthy choices
available and enabling more access to information on health

� 2) Current and Emerging Threats to Health

52 http://ec.europa.eu/health/ph_determinants/life_style/Tobacco/help_en.htm

Deutscher Bundestag – 16. Wahlperiode – 49 – Drucksache 16/9412

Added value of a new strategic EU approach is found in, e.g. improving surveillance and alert
systems; increasing cooperation on issues such as vaccination, organ donation, and climate
change

� 3) Sustainable Health Systems

Added value of a new strategic EU approach is found in, e.g. taking forward a new
Community framework for health services; greater support for improving health capacity in
the regions; supporting greater cooperation between health systems

� 4) Globalisation and Health

Added value of a new strategic EU approach is found in, e.g. a stronger voice for the EU in
global health governance; raising health on the agenda of work with third countries; an
increased global perspective for all health issues (e.g. communicable disease threats, etc.)

� 5) Creating a Coherent Framework

Added value of a new strategic EU framework for health is to drive forward positive change;
rationalise current mechanisms; support strategic action on health at national level; strengthen
cooperation between Member States at EU level

� 6) Increasing Health In All Policies Cooperation

Added value of increasing HIAP cooperation at EU level is to ensure optimal policy
approaches to protecting and improving health; to support multisectoral approaches at
national and international levels; involve more partners leading to more effective initiatives;
development and dissemination of tools for HIAP

� 7) Improving Visibility and Transparency of EU Health Action

Added value of improving visibility of EU Health Action is to clarify the role of the EU in
health to all stakeholders, to make EU health policy more accessible to citizens, and to
improve availability of comparable data and information to support progress towards
objectives.
Box 2: Health in the Treaty Establishing the European Community

The Treaty clearly states that the activities of the Community shall include 'a contribution to the
attainment of a high level of health protection' Article 3 (1) (p)

EU action on health is also explicitly provided for in Treaty Article 15253, which states that 'a high
level of human health protection shall be ensured in the definition and implementation of all
Community policies and activities'.

Article 152 also states that

"The Community shall encourage cooperation between the Member States in the areas referred to in
this Article, and if necessary, lend support to their action. Member States shall, in liaison with the
Commission, coordinate among themselves their policies and programmes………The Commission
may, in close contact with Member States, take any initiative to promote such coordination", bearing

53 European Union Consolidated Versions on the Treaty of the European Union and of the Treaty

Establishing the European Community (OJ C 325, 24.12.2002).

Drucksache 16/9412 – 50 – Deutscher Bundestag – 16. Wahlperiode

in mind that, "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."

However, health is also mentioned in other articles throughout the Treaty. For example,

Article 95 (3), (6) and (8) concerning health in relation to the internal market

Article 133 (6) concerning common commercial policy, stating that health services "…shall fall
within the shared competence of the Community and its Member States…".

Article 137 (1) (a) "1.'The Community shall support and complement the activities of the Member
States in the following fields: a) improvement in particular of the working environment to protect
workers' health and safety"

Article 153 "The Community shall contribute to protecting the health, safety and economic interests
of consumers"

Article 174 (1) "Community policy on the environment shall contribute to pursuit of the following
objectives: (…)- protecting human health.

Articles 18(1), 39(3), 46(1) and 55 concerning the right to limit free movement of persons if
necessary on the grounds of public health

Article 163 concerning the objective to promote 'all the research activities deemed necessary by virtue
of other chapters of this Treaty'.

Following agreement at the European Council meeting of 21-22 June, it is likely that a new
Reform Treaty will introduce amendments strengthening scope for EU action in the field of
health.

In response to the consultation, many Member States acknowledged the substantial
achievements of the Commission in the field of health over the recent years including the
aspects of health promotion and prevention, management of health threats and combating
communicable disease. Many also highlighted the importance of designing a strategy that
would respond to the actual challenges while respecting the principle of subsidiarity, by
focusing on issues that had cross-border aspects or European added-value. Some respondents
also called for more clarity on the respective competencies and responsibilities of Member
States and the EU in the field of health.

The EU's legal right and obligation to take action on cross-border health issues, and its
demonstration of success in taking relevant and effective action on health, while respecting
Member States' prerogative, is clear. The ability of the EU to add value to work done by
Member States in the field of health is also demonstrated. As a new health strategy will cover
the broad range of work on health at EU level, providing a more coherent framework for this
work, we can assume that the necessity test and added value test have been passed. (The
subsidiarity test, in particular the boundary test, will also be applied under section 4 in
relation to each option).

Deutscher Bundestag – 16. Wahlperiode – 51 – Drucksache 16/9412

CONCLUSION

In conclusion, therefore, this Problem Definition section of the Impact Assessment has argued
that new health challenges facing the EU action in four key areas of inequities in health,
current and emerging threats to health, the need to support the sustainability of health
systems, and the need to better address global health issues, require a new focus at EU level.
The EU can provide important added value in all these areas, which can be maximised
through employing a new overarching EU health strategy.

It was also argued that to ensure the effectiveness of a new Strategy, three governance
challenges need to be addressed: a coherent overarching framework including strategic
objectives should be put in place, Health In All Policies cooperation should be reinforced, and
visibility of the EU approach should be increased. A focused approach reflecting these three
elements will produce clear added value.

The subsidiarity test concluded that the EU has a clear mandate for action and can add value
in many areas in the field of health, including playing a role in addressing key existing and
emerging health challenges in the EU. Member States are responsible for national health
services, but the EU has a wide range of roles to play, and the EU's potential for helping to
address health challenges in the EU should be optimised through the development of a new
strategic framework.

3. OBJECTIVES

The objectives for the Health Strategy relate to the problems defined in section 2.1 and 2.2.

It is not possible in the context of this Impact Assessment to cover the detailed content of the
proposed Health Strategy. This will contain multiple actions, many of which are already
ongoing both in DG SANCO and other services, which will address a range of challenges.
The Strategy does not aim to replace actions currently undertaken on health at EU level, but to
put in place a new overarching strategic framework to focus on key challenges and guide
current and future actions in all sectors (see diagram below).

Drucksache 16/9412 – 52 – Deutscher Bundestag – 16. Wahlperiode

Overarching Health Strategy
objectives, indicators and

implementation mechanisms

Action on health
in

DG SANCO Action on Health across all
EU policies

Action on Health
at

Member State
level

•Pandemic preparation
•Alcohol Strategy
•Health Services Initiative
•Mental Health Strategy
•Smokefree Environments
Etc…..

Health-related work in DG REGIO,
EMPL, RTD, ENTR, ENVI, Etc….

Health policy at national, regional
and local level contributes to the
overarching aims of the Strategy

Action by
Stakeholders

NGOs,
academia,
Industry…

Health Objectives:

Four broad health objectives are defined, relating to the Changing Health Challenges
identified in Section 2.1. These general objectives will be supported by specific and
operational objectives which will be defined in cooperation with Member States in the initial
phase of the implementation process. Some of these individual actions would require a
specific Impact Assessment and monitoring process. These areas will need to remain flexible
enough to cover work in relation to existing challenges and to avoid excluding any new
challenges that may not have been foreseen.

These four objectives relate closely to the Commission's existing objectives of Solidarity,
Security, Prosperity, and Europe in the World, as well as with key European strategies.
Objective 1 relates to the solidarity objective, in assisting all Member States to achieve the
health standards of the best, and it also relates to the Open Method of Coordination on Social
Protection and Social Exclusion. Objective 2 relates to security and the protection of citizens
from heath threats. Objective 3 relates particularly to prosperity and the Sustainable
Development Strategy, as sustainable and cost-effective health systems support a health
population and therefore a strong economy. Objective 4 relates to the objective of Europe in
the World. All four objectives are in line with the Lisbon Strategy, as all aim for better health
and healthcare which is clearly linked to economic prosperity.

Deutscher Bundestag – 16. Wahlperiode – 53 – Drucksache 16/9412

The four health objectives are as follows:

� Objective 1 – To Foster Healthier Lifestyles and Reduce Inequities In Health
Across The EU – particularly in relation to supporting healthy ageing

� Objective 2 – To Protect Citizens and Patients from Known and Unknown
Threats to Health

� Objective 3 – To Increase The Sustainability Of Health Systems with a focus on
New Technologies

� Objective 4 – Strengthening the EU's Voice in Global Health
Good Governance Objectives:

Three good governance objectives are defined, relating to the issues identified in Section 2.2
These will be supported by operational objectives that are linked to the implementation of an
effective strategy.

� Objective 5 – to set a Strategic Framework with objectives and measurable
indicators

The Strategy would identify clear objectives measurable by indicators for progress at EU level
in the field of health over the coming 10 year period. This will enable a focused approach to
tackling health objectives 1-4. Further specific and operational objectives would be developed
with Member States and would need to be in line with the Lisbon Strategy, the Sustainable
Development Strategy, the Open Method of Coordination on Social Protection and Social
Exclusion and other key EU policies.

� Objective 6 – To Achieve Greater Health In All Policies Cooperation

Health is affected, and has the potential to be affected in both positive and negative ways, by a
wide range of non-health policies. This general objective is central to supporting health
objectives 1-4 as health policy alone will not fulfil potential for positive change without
partnerships in other sectors.

� Objective 7 – To Achieve Greater Visibility for work on health at European level

A key objective for the Health Strategy, which will be a clear measure of its success, is that it
creates greater visibility and understanding of work done on health at the EU level, and

supports the enhanced communication of health information.

Drucksache 16/9412 – 54 – Deutscher Bundestag – 16. Wahlperiode

4. POLICY OPTIONS

It is not the function of this Impact Assessment to set out in detail the lists of actions that will
support the health objectives. Many actions are already ongoing, and new actions will have
their own Impact Assessment where necessary. The purpose of the strategy is rather to put in
place a new framework to set the direction of travel. The options therefore look at different
ways of putting such a framework in place.

Overview of Options

Option 1 Status Quo: No new Health Strategy

Option 2 Health Strategy with Enhanced Intersectoral Action at EU level

Option 3 Health Strategy with Enhanced Intersectoral Action and Structured
Cooperation with Member States and Other Stakeholders

Option 4 Health Strategy with Enhanced Intersectoral Action, Structured Cooperation
with Member States and Other Stakeholders, and Binding Targets

Option 1: Status Quo: No new Health Strategy

Continue with existing and planned work without setting overarching objectives or
developing a coherent, strategic approach for key actions in the health sector, cross sectoral
actions and global issues.

Instruments: continue as present using a range of tools as appropriate.

Deutscher Bundestag – 16. Wahlperiode – 55 – Drucksache 16/9412

Option 2: Health Strategy with Enhanced Intersectoral Action at EU level

This would include:

a) Setting 4 health objectives to guide future actions, supported by specific and operational
objectives, and observing the 3 good governance objectives.

b) Selecting quantitative indicators to measure progress against these objectives where
appropriate. These might be, for example, increase cancer screening, increase numbers of
networks of centres of reference, or increase numbers of Member States with e-medical
records. Under Option 2, these indicators would be selected by the Commission.

c) Development of an enhanced 'Health in all Policies' Intersectoral Approach to support
action to achieve the objectives of the Strategy alongside other sectors and specialised EU
agencies, for example in relation to the Lisbon Agenda and competitiveness, technology and
innovation, young people’s health, health prevention/life-long learning, ageing and health,
health and the world of work, health and regional development.

Instruments: White Paper Communication, Commission interservice monitoring mechanism
Diagram: Option 2

Drucksache 16/9412 – 56 – Deutscher Bundestag – 16. Wahlperiode

Option 3: Health Strategy with Enhanced Intersectoral Action and Structured Cooperation
with Member States and Other Stakeholders

In addition to Option 2, Option 3 would include:

a) Setting up a new consensus mechanism of 'Structured Cooperation' with Member
States. The new mechanism would use methods that have been tried and tested under the
Open Method of Coordination which is used for work towards the Lisbon goals, and would
involve agreeing indicators in relation to the objectives of the Strategy, developing specific
and operational objectives to support the achievement of the 4 health objectives, sharing
information to support national, regional and local policy development to support the
objectives, mutual learning processes, and other relevant activities. This new structured
cooperation would also establish a process for monitoring the Strategy. 54

b) A Health In All Policies approach which goes beyond EU level to support greater
intersectoral cooperation at national, regional and local levels.

c) Building closer links with regions through, for example, greater cooperation with the
Committee of the Regions and through the Structural Funds mechanism.

d) Strengthening existing mechanisms of dialogue and cooperation with health partners, with
a particular focus on civil society, through a new advisory board or forum.

Instruments: White Paper Communication, Commission interservice monitoring mechanism,
coordination and partnership mechanisms

54 Fostering cooperation and coordination with the Member States has its basis in Article 152, and it is

likely that a new provision to strengthen cooperation on health will be included in a new Reform
Treaty, following the European Council meeting of 21-22 June 2007.

Deutscher Bundestag – 16. Wahlperiode – 57 – Drucksache 16/9412

Option 4: Health Strategy with Enhanced Intersectoral Action, Structured Cooperation
with Member States and Other Stakeholders, and Binding Targets

Option 4 would be a strengthened version of Option 3. As in Options 2 and 3, a set of
indicators would be agreed. However, this option would include legislation to set binding
targets to drive forward work towards the objectives by close scrutiny of progress across
Member States. Other stakeholders could report in line with Member State reporting, on a
voluntary basis.

Instruments: White Paper Communication, Commission interservice monitoring mechanism,
other coordination and partnership mechanisms, legislation for binding targets

Drucksache 16/9412 – 58 – Deutscher Bundestag – 16. Wahlperiode

5. ANALYSIS OF IMPACTS

This section looks at the possible impacts of each of the four policy options set out in the last
section. Given the broad nature of the Strategy, it is not possible to provide detailed and
quantifiable estimates of the impact of the options. Instead, general estimates of the impact of
each approach have been made.

Before analysing Options 1-4, it is worth briefly considering the negative impacts of not
having any EU-level work on health. Under 1.2 above, the justification for EU action on
health is set out; some issues are of a cross border nature, and EU action is indispensable. For
other issues, the EU can clearly add value. Box 4 sets out some concrete examples of the
'impact' of no action on health at EU level. This acts as a baseline for the consideration of
Options 1-4.

Box 4 – Negative Consequences of No Health Action at EU level

� No coordination of pandemic influenza planning; lines of communication would be
confused, and mutual agreements between Member States bilateral or fragmented.

� No projects within the Health Programme; many projects on key health issues are
funded each year, with 353.77 million euros available for projects between 2003 –
2008.

� Without EU mutual recognition of qualifications, movement of health professionals
between countries would be much more difficult.

� No transnational health research in Framework Programmes to improve understanding
of health issues while increasing EU competitiveness and innovative capacity.

� No ban on tobacco advertising across the EU, leading to the continued promotion of a
product which causes more than 79,000 deaths per year in the EU55.

� No advice from EU health-related scientific committees on issues like
nanotechnologies or exposure to electromagnetic radiation or environmental
pollutants.

� No European Health Insurance Card, covering EU citizens for necessary medical care
when travelling within the European Economic Area.

� Less interchange of knowledge, ideas, and best practice in the field of health between
national health administrations and experts from across the EU.

Option 1: Status Quo: No new Health Strategy

Introduction

Current work on health at EU level is valuable and will lead to positive benefits in terms of
Economic, Social and Environmental aspects. Although these are too complex and numerous
to mention in detail, this section sets out some examples and analysis, with a particular focus

55 Lifting the Smokescreen, 10 reasons for a smoke free Europe, Smoke Free Partnership 2006.

Deutscher Bundestag – 16. Wahlperiode – 59 – Drucksache 16/9412

on the relationship between health and economic prosperity. The aim of a new Health
Strategy is not necessarily to do more (although some new actions will be identified) but to
give health policy at EU level more focus, coherence, direction, and prioritisation and thus
enable it to be more effective and efficient. Continuing as at present would mean that
potential benefits of this approach will not be realised.

Economic Impact of Option 1

There is a clear link between health and economic prosperity, both in terms of costs of health
systems and of illness to the economy, and in terms of the facts that effective investment in
health can support future sustainability particularly given the demographic ageing of the
population, and that the health market is a key sector for growth and innovation. Annex 3
contains a more detailed analysis of the relationship between health and the economy. It is
becoming more widely accepted that work done at EU level on health contributes to economic
prosperity and sustainability. This is recognised in the inclusion of the Healthy Life Years
indicator (a measure of the number of years that a person can expect to live in good health) in
the Lisbon agenda, and in the fact that Structural Funds can be broadly used for improving
health infrastructure and workforce and supporting actions on health prevention and
promotion so that they contribute to the overall cohesion and economic development of the
EU's regions. However, continuing with the Status Quo option makes it likely that the full
potential for supporting the economy through health is not achieved, particularly in relation to
Objective 3, to increase the sustainability of health systems with a focus on New
Technologies, because the lack of a visible, strategic framework means that the link between
health and the economy is not fully taken into account in all areas, and this may lead to a less
sustainable economic future for Europe.

Social Impact of Option 1

As health itself falls into the category of social impacts, it is clear that a broad range of
positive impacts can be expected from the 'no new action' option, which cannot be
enumerated here, but include current initiatives to protect citizens including pandemic
preparedness planning, work to prevent ill-health such as the Commission's initiative on
smoke-free environments, mental health and the adopted EU strategy to reduce alcohol related
harm56, work in the area of health services including the proposed new initiative on health
services, and the Pharmaceutical Forum which brings together industry, Member States and
stakeholders, work to increase knowledge on health issues including using DG Research
framework programme projects, and many other actions including those done in non-health
policy areas.

There are, however, limitations in continuing as present as there is potential for better
cooperation, coherence and objective setting. As set out in the problem definition section of
this Impact Assessment, new challenges to health mean that the EU needs to refocus on key
priorities where added value is achievable, building on current actions. Continuing with the
Status Quo would mean that the benefits of a renewed focus on the four health objectives, (1
-to foster healthier lifestyles and reduce inequities in health across the EU, 2 - to protect
citizens and patients from known and unknown threats to health, 3 - to increase the
sustainability of health systems with a focus on New Technologies and 4 - to stenghten
the EU's voice in global health), would be lost.

56 Commission Communication on an EU strategy to support Member States in reducing alcohol related

harm - COM(2006) 625.

Drucksache 16/9412 – 60 – Deutscher Bundestag – 16. Wahlperiode

Similarly, positive social impacts in relation to the three governance objectives (5 - to set a
strategic framework with objectives and measurable indicators, 6 - to achieve greater
Health In All Policies cooperation, and 7 - to achieve greater visibility for work on
health at European level) would be lost. No clear direction of travel would be set for the EU
in terms of a strategic framework, leading to less focus on key areas. Synergies between
sectors at all levels may not be exploited fully leading to a limited impact of health initiatives,
and citizens and stakeholders would not have improved clarity on, and participation in, the
EU's work on health.

Environmental Impact of Option 1

In terms of environmental impacts, ongoing positive work will take place on environment and
health under the European Environment and Health Action Plan 2004-201057, which aims to
reduce the disease burden caused by environmental factors in the EU, to identify and prevent
new health threats caused by environmental factors and to strengthen EU capacity for
policymaking in this area. Positive impact on health is also expected by the ongoing work
done in the sectoral health related environmental policies such as REACH58 legislation for
chemicals, the thematic Strategy on the Sustainable Use of Pesticides59, the 200560 strategy on
Mercury, Thematic Strategy on Air Pollution61, policy on water quality62, noise63, etc.
However, more visibility of environment and health actions could be achieved Objective 7 to
achieve greater visibility for work on health at European level. Further, integration across
the EU in line with Objective 6 to achieve greater Health In All Policies cooperation could
lead to the development of actions in other areas where synergies between health and
environment are to be found. For example, environmental problems have often a global
dimension where only initiatives coordinated at local, national and international level can
ensure that the actions taken are effective and will deliver expected health and environmental
benefits (e.g. greenhouse gas emissions and climate change which are key concerns for the
coming years) and there is potential for these to be further developed (see Annex 3d).

Conclusion

Although positive impacts will be achieved by continuing with current work on health at the
EU level, choosing Option 1 would not, however, refocus on significant new challenges
within and beyond the EU and would therefore not address these challenges in the optimum
way. Options 2-4 refer to the introduction of a new Health Strategy which sets clear
objectives, identifies priorities and gives a clear sense of direction.

Option 2: Health Strategy with Enhanced Intersectoral Action at EU level

Option 2 aims to draw together the work done on health at EU level in all sectors. The Health
Strategy will not be a 'DG SANCO' strategy but a Community-wide Strategy. The
achievement of common objectives by all sectors working in partnership will require a new
57 COM(2006) 625.
58 Registration, Evaluation and Authorisation of Chemicals.
59 COM(2006) 327.
60 Communication from the Commission to the Council and the European Parliament on a Community

Strategy Concerning Mercury - COM(2005) 20, SEC(2005) 101.
61
COM(2005) 446.
62 E.g. Drinking Water Directive 98/93/EC, Bathing Water Quality Directive 76/160/EEC, and Directive

91/271/EEC on urban waste water treatment.
63 See Green Paper - COM(96) 540 -, Directive 2002/49/EC, etc.

Deutscher Bundestag – 16. Wahlperiode – 61 – Drucksache 16/9412

cross-sectoral 'Health in all Policies' approach including an improved mechanism for
monitoring progress.

Economic Impact of Option 2

Under Option 2, the relationship between health and economic growth and prosperity could
be more fully exploited than under Option 1 through more focused development of cross-
sectoral synergies in a wide range of fields, building on the significant progress being made in
relation to, for example, the impact of a healthy population on the labour force, innovation in
the field of health, e-health technology, taxation policy on products such as tobacco,
supporting efficient health systems to ensure effective public spending, and health in regional
policy and the Structural Funds, many of these contributing in particular to Objective 3 - to
increase the sustainability of health systems with a focus on New Technologies. This is
turn may help to stimulate greater understanding EU-wide of the importance of investments in
health and health systems. However, without the full engagement of Member States and other
stakeholders as foreseen in Options 3 and 4, the impact on economic prosperity would be
limited, and beyond the use of European Funding mechanisms there might be little change at
national level.

Social Impact of Option 2

In terms of social impact, Option 2 would build on existing cross-sectoral synergies,
particularly in the fields of employment and education, which are increasingly recognised as
settings for health promotion and prevention of disease and ill-health, supporting the
achievement in particular of Objective 1 - to foster healthier lifestyles and reduce
inequities in health across the EU. One benefit would be strengthened health links with the
Open Method of Coordination for social protection and social inclusion, which already works
with Member States on key issues affecting Lisbon agenda goals. In comparison with Option
1, therefore, Option 2 could lead to improved clarification of key health issues at the EU level
which could lead to some health gains. Enhanced HIAP cooperation at EU level might also
stimulate greater HIAP cooperation at national, regional and local levels, supporting
Objective 6 - to achieve greater Health In All Policies cooperation. However, without the
full engagement of Member States and other stakeholders as foreseen in Options 3 and 4,
changes in health status and other positive social impacts would be unlikely to be significant.
In particular, the fact that indicators to measure progress against the health objectives would
be selected at Commission level would mean that the 'buy-in' required to drive changes in
health policy and therefore changes in outcomes at national, regional and local level would be
unlikely to be achieved. Other stakeholders such as NGOs representing a wide range of health
groups, as well as academia and industry may benefit from the clarity given by the EU health
strategy but as no new mechanism is set up under Option 2, the possibilities for their
involvement and therefore their contribution to positive social and economic impacts may not
be maximised.

Drucksache 16/9412 – 62 – Deutscher Bundestag – 16. Wahlperiode

Environmental Impact of Option 2

In terms of environmental impact, Option 2 would build on existing work in relation to the
European Environment and Health Action Plan as under Option 1. Cross-sectoral work could
be further developed in fields like the health impact of climate change, health impacts within
the built environment, etc, in order to work towards positive environmental health outcomes.
Option 2 may offer a slightly greater positive impact on environmental health than Option 1,
but without full engagement of Member States, the ultimate outcomes are unlikely to be
significantly different.

Enhanced Intersectoral Action - Boundary Test

Under Option 2, a means of measuring progress by all sectors against the common objectives
would be implemented, alongside a package of measures to support better cross-sectoral
working on health. It is likely that this Option would achieve a generally positive impact on
health policy due to more coherent cross-sectoral work and better understanding across
sectors. It would not place any new burden on Member States and so would respect the
boundary test and subsidiarity principle. However, the value of a new, more coherent strategy
will be limited unless Member States and stakeholders are closely involved in development of
strategic objectives and the implementation of the objectives of the Strategy at national level.
Option 3 and 4 go further than Option 2 in looking at a coherent strategy paired with new,
stronger coordination and cooperation mechanisms outside the Commission.

Option 3: Health Strategy with Enhanced Intersectoral Action and Structured Cooperation
with Member States and Other Stakeholders

Option 3 aims to build on Option 2 by adding a new mechanism of structured cooperation
between MS and other stakeholders, aiming for recognition and 'ownership' by all players in
the strategy through setting new mechanisms for stronger cooperation and coordination.

Economic Impact of Option 3

Option 3 is expected to have a stronger positive economic impact than Options 1 and 2. As
Member States are responsible for public spending, facing the need to ensure future economic
sustainability, and planning the use of convergence funding, their 'buy-in' to a new Strategy
will support economic benefits. At the same time, the structured cooperation mechanism will
support sharing of knowledge on economic issues between Member States. A new strategy,
developing both intersectoral work and relationships with actors and partners could help to
support a 'culture change' towards a better understanding across all sectors and at all levels
that health is an important economic factor and that effective investment in health, including
in health promotion and prevention, is vital in terms of future sustainability of health systems.
More specifically, engagement with Member States and other stakeholders to tackle broad
health objectives could support economic gains in relation to the four health objectives; for
example, reducing health inequity and improving population health status go hand in hand
with economic prosperity supporting Objective 1, more efficient health systems are more cost
effective for public spending, supporting Objective 3, and a stronger EU presence in global
health governance could lead to economic benefits in terms of, for example, trade and

sustainability of supply of health professionals, supporting Objective 4.

Social Impact of Option 3

Deutscher Bundestag – 16. Wahlperiode – 63 – Drucksache 16/9412

The social benefits of Option 3 would be found in the more directed approach by all partners
to all four health objectives. Gains would be expected in health status through improvement
at all levels in a broad range of disease measures and operational processes, in greater
understanding of how to run health systems efficiently to ensure future financial sustainability
in the fact of pressures such as the ageing population, and in an enhanced engagement in
global governance. This engagement with Member States could be expected to achieve a
significantly greater health and social outcomes than Options 1 and 2. Some successful
examples of EU implementation mechanisms in partnership with Member States are shown in
Box 3.

Box 3 - Examples of EU-Member State Implementation Mechanisms

Example 1: The Open Method of Coordination

The Open Method of Coordination (OMC) was introduced by the European Council of
Lisbon in March 2000 as a method of helping member states progress jointly in the reforms
they needed to undertake in order to reach the Lisbon goals. Since then it has been applied in
the European employment strategy, social inclusion, pensions, immigration, education and
culture and asylum.

OMC is the soft governance tool, agreed between Member States in Lisbon, to ensure
satisfactory progress in policy areas which are primarily of Member State competence. OMC
involves:

“- fixing guidelines for the Union combined with specific timetables for achieving the goals

which they set in the short, medium and long terms;

- establishing, where appropriate, quantitative and qualitative indicators and benchmarks

against the best in the world and tailored to the needs of different Member States and sectors

as a means of comparing best practice;

- translating these European guidelines into national and regional policies by setting specific

targets and adopting measures, taking into account national and regional differences;

- periodic monitoring, evaluation and peer review organised as mutual learning processes”.

(Lisbon Strategy)

An external evaluation of OMC activities in DG Enterprise and Industry found that in the area
of Small and Medium sized Enterprises where it had mainly been used, the OMC work was
successful. It recommended that there was strong potential to developed OMC in other
areas.64

Example 2: CREST

64 Evaluation of the Open Method of Coordination activities coordinated by DG Enterprise and Industry,

GHK/Technopolis, Sept 2006, p. 9.

Drucksache 16/9412 – 64 – Deutscher Bundestag – 16. Wahlperiode

Under the broader OMC, DG Research set up CREST (Committee de la Recherche
Scientifique et Technique) as an advisory body to the European Council. This created five
expert groups on different areas to address key actions, identify good practice and suggest
policy recommendations to Member States in relation to achieving the goals of the OMC. In
the first OMC cycle they used reports from the five groups to produce an overall report with
30 recommendations for the second OMC Cycle. The second cycle then went on to
concentrate on more focused topics.65 CREST found that in the first cycle the OMC,

'resulted in a number of concrete benefits' in the field of research including the establishment
of networks of national policymakers, the collection, collation and exchange of information
on national policies, the identification through peer review of good practices, and the
identification of key issues and, in some instances, specific recommendations for the future.'66

Example 3: The Bologna Declaration

This example of an international implementation system is being used in the area of
education. It is a pledge by 29 countries, in 1999, to reform the structures of their higher
educations systems in a convergent way, with 40 countries now participating. By aiming for
convergence, the process preserves the fundamental principles of autonomy and diversity. The
process includes a single common goal, a deadline of 2010 and a set of specified objectives,
e.g. 'the adoption of a common framework of readable and comparable degrees'. It is followed
by a consultative group of all countries, as well as a smaller follow-up group.

In 2005 a further meeting in Bergen noted that progress had been made: convergent reforms
are already in place in several European countries, signalling a move towards shorter studies,
2-tier degree structures, external evaluation, and other changes. 67

Setting up the structured cooperation mechanism would mean that existing EU-level
committees in the public health sector may need to be rationalised or streamlined to better
support a new Health Strategy. This would achieve a positive social impact as work would be
more efficiently focused towards well-defined health objectives in a smaller number of
groups, and work with other sectors such as social protection policy could also be
strengthened. The mechanism would also compliment and support the work of existing
mechanisms including the OMC on Social Protection and Social Exclusion. This simplified
structure would support Objective 7 in making EU health policy more accessible, visible and
transparent.

Alongside a mechanism for Structured Cooperation between Member States, Option 3 also
provides for new means of Structured Cooperation with stakeholders, including EU citizens.
Health experts have advocated a 'network governance' approach for policy to focus on the
determinants of health, asserting that the most successful policymaking engages a wide range
of players from all sectors, complemented by 'policy commitments at different levels of
government and in the private and non-governmental sector'.68 These partners have an
important role in delivering health policy. This approach is a step further than Option 2,
65 http://ec.europa.eu/invest-in-research/coordination/coordination01_en.htm
66
http://ec.europa.eu/invest-in-

research/pdf/download_en/crest_report_barcelona_research_investment_objective.pdf, p. 10.
67 http://ec.europa.eu/education/policies/educ/bologna/bologna_en.html
68 Kickbusch I. Innovation in health policy: responding to the health society. Gac Sanit 2007;21 (in press).

Deutscher Bundestag – 16. Wahlperiode – 65 – Drucksache 16/9412

which allows for enhanced intersectoral work at the European level only. Option 3 would aim
for enhanced intersectoral and multi-partner work at all levels, therefore enabling many more
opportunities for work to achieve positive health and social impacts, and supporting
Objective 6 to achieve greater HIAP cooperation more strongly than Options 1 and 2.

Positive outcomes of innovative work with stakeholders also include the Platform for Action
on Diet Nutrition and Physical Activity, and the Pharmaceutical Form (see Box 4). This
supports the likelihood of a positive impact through new stakeholder mechanisms developed
under the Health Strategy, as well as though a new strategic view of the work of the existing
platforms.

Box 4 – Examples of Multi-Stakeholder Activities in Health-Related Areas

The Platform for Action on Diet, Nutrition and Physical Activity is an example of an
implementation mechanism which has had positive outcomes. The Commission set up the EU
Platform on Diet, Physical Activity and Health in March 2005 as a voluntary forum for
diverse stakeholders operating at European level to contribute to tackling growing levels of
obesity. Members include organisations representing industry, research organisations and
public health civil society. Platform members have committed to taking steps to reduce
obesity within their areas of work, and a clear and reliable system of monitoring the
commitments to demonstrate progress has been developed.

The Pharmaceutical Forum is another example of successful cooperation between partners.
The Pharmaceutical Forum is a high-level political platform for discussion supported by a
Steering Committee and three expert Working Groups. The aim is to enhance the
competitiveness of the pharmaceutical industry in terms of its contribution to social and
public health objectives. The Forum brings together Ministers from all European Union
Member States, representatives of the European Parliament, patients, the pharmaceutical
industry, healthcare professionals, and insurance funds.

Environmental Impact of Option 3

Under Option 3, greater improvement in the field of environmental health could be expected
than in Options 1 and 2. Building on ongoing work, Option 3 would allow for increased
opportunities to share knowledge and experience on environmental health issues between
Member States and with other Stakeholders. Emerging issues such as tackling climate change
could be better addressed within the new mechanisms, particularly in relation to the global
stage, supporting Objective 4, to strengthen the EU's voice in global health.

A 'Structured Cooperation' Approach – Subsidiarity and Boundary Test

The Open Method of Coordination (OMC) is a Member State-led approach, set up by the
Council of Lisbon in March 2000. Its benefits are that it is a robust procedure which binds
Member States to working towards its goals, and is therefore likely to have greater outputs
and outcomes than less binding procedures. The Structured Cooperation suggested by Option
3 would take lessons from the methods of the OMC. On the other hand, the requirements
placed on Member States by OMC-style approaches to meet, gather data and report on a

regular basis could be seen as burdensome. Member States and other stakeholders were
therefore consulted about implementation mechanisms to test whether there would be support
for a formal system of structured cooperation for the Strategy.

Drucksache 16/9412 – 66 – Deutscher Bundestag – 16. Wahlperiode

In the response to the consultation, there was a general consensus in favour of developing a
Structured Cooperation mechanism. In a separate questionnaire to the High Level Committee
on Public Health, support for an OMC-style approach was also expressed by a number of
respondents. Many respondents referred to positive impressions of the existing Open Method
of Coordination on Social Protection and Social Exclusion, and those responsible for leading
on that work within the Commission noted that Member States preferred to work within a
mechanism which gave them ownership over the setting of indicators. Some respondents said
that an OMC-style approach would have the correct set of tools for exchange of experiences
and good practice, and as a way of providing general orientation and key messages without
developing obligations or mandatory guidelines. The method was also seen as a way to
facilitate consensus and ownership among representatives at national, regional and local level.

A Structured Cooperation mechanism would support the Subsidiarity Principle, which
states that the EU should only take on tasks which cannot be performed effectively at a more
immediate or local level. The EU is in the position to agree cross-cutting objectives with all
players, but a Structured Cooperation mechanism would place ownership in the hands of
Member States. In general, therefore, support from many Member States and stakeholders as
well as positive past experience of similar implementation mechanisms suggests that a new
mechanism of structured cooperation would have a broadly positive impact towards
improving and protecting health in the EU, while being proportional in terms of burden
placed on Member States and respecting the Subsidiarity Principle and Boundary Test.

Administrative Burden

Although it is difficult to evaluate, it is likely that a new mechanism of Structured
Cooperation would not carry a significant administrative burden for Member States or for
other stakeholders. The potential burden of developing new indicators will be avoided, as the
Strategy will focus on bringing together existing indicators to more fully exploit data for a
better overall view of the situation, to inform the policy response, and to measure progress
against the objectives. The Structured Cooperation mechanism would offer advantages in
terms of opportunities for a more streamlined approach to EU level discussion on key issues.
However, future actions under the Strategy (particularly any legislative actions) may carry a
burden which would be evaluated for each initiative.

Conclusion

Structured Cooperation under Option 3 would mean greater visibility and transparency of EU
health policy. It would contribute to more structured and strategic cooperation with all
partners and a more coherent and well coordinated approach to promote health within the EU
and globally. It would mean streamlining of existing mechanisms at EU level to ensure
efficiency of work towards the objectives. It is likely that this approach would have a
generally positive impact on improving and protecting health in the EU, and would be
stronger than Option 2 without imposing an unreasonable burden on Member States and other
partners.

Option 4: Health Strategy with Enhanced Intersectoral Action, Structured Cooperation
with Member States and Other Stakeholders, and Binding Targets
Option 4 goes a step further than Option 3. It recommends using legislation to set binding,
obligatory targets for the Member States to achieve, rather than agreeing, through negotiation
within the Structured Cooperation mechanism, on specific objectives to support the 4 health

Deutscher Bundestag – 16. Wahlperiode – 67 – Drucksache 16/9412

objectives. This would be a strong and definitive step towards achieving health goals. On the
other hand, it could be seen as too heavy-handed.

Economic Impact of Option 4

In terms of economic impacts, these would be expected to be similar to those described under
Option 3. Given the nature of binding legislation, it could be expected that the positive impact
described may be stronger. However, this would be offset against the concern that setting
legislative targets may be burdensome and problematic for Member States, with the potential
to reduce the flexibility available to tailor national, regional and local policies to particular
needs.

Social Impact of Option 4

Option 4 could be expected to achieve greater positive social impacts than Options 1 to 3.
Targets are likely to produce positive results. Binding health targets in a high profile EU
strategy are likely to attract media attention, which can in turn act as a lever to achieving the
targets. However, there is a risk that a target oversimplifies the ultimate aim, for example
reducing the mortality rates relating to a disease ignores the non-fatal consequences of that
disease. At the EU level, targets must be agreed by all Member States, who are likely to be
starting from very different baselines. This can lead to a 'lowest common denominator' being
set, which fails to be a challenge to the majority of Member States, so that even though setting
binding targets may be effective, it will only be effective for a few Member States.

Targets are 'resource-intensive' at all levels and require administrative time in setting up
mechanisms to capture, input, collect and return data and then to run those mechanisms. They
need some level of policing, or checking, that data is accurate and being collected correctly.
This investment can be justified when there is a specific issue that needs timely attention, for
example targets for reducing emissions. An overarching EU Health Strategy, however, covers
a huge number of issues. Either a large number of targets would need to be set, leading to a
substantial administrative burden, or targets would have to be focused on a small number of
very specific issues, with the risk of excluding important issues. Setting binding targets for
health would therefore be likely to have some localised positive social outcomes but not in all
Member States, and not across all key areas. Other stakeholders would not be bound by the
targets and may be less engaged with them than with a system of objectives in which they
have more opportunity for discussion and engagement on how to proceed. Binding targets
may not be as effective in terms of the balance of resources needed to run them as a broader,
direction setting approach in cooperation with Member States and other Stakeholders, as in
Option 3.

Environmental Impact of Option 4

The environmental impact of Option 4 is likely to be similar to that of Option 3. If a specific
binding target or targets was set on environmental health, this could support significant
positive outcomes. However, as the European Environment and Health Action Plan and other
initiatives are ongoing under the Status Quo, this could be seen as an unnecessary and
confusing move, whereas under Option 3 a more open approach allowing for discussion and
knowledge sharing between partners on a range of issues could be seen as contributing more

to a positive environmental impact.

Option 4: Subsidiarity and Boundary Test

Drucksache 16/9412 – 68 – Deutscher Bundestag – 16. Wahlperiode

Binding Targets could be set at EU level by means of legislation, supporting the requirement
to attain a high level of health protection as set out in Article 3 (1)(p). Broadly, it could be
expected that setting targets would ultimately have a positive impact on health in the EU. In
terms of subsidiarity, if binding targets on health issues at national level were found to be
ineffective for some cross-border issues, it could be argued that Option 4 would respect the
subsidiarity principle. However, in terms of proportionality, the objectives of the strategy
could be met by less stringent action by the EU than this Option and the boundary test is
therefore not respected by Option 4.

Conclusion

Option 4 would be the strongest option in terms of requiring action by Member States. It
could be expected to achieve positive outcomes, particularly in the health and social fields.
However, the limitations of setting binding legislative targets as opposed to agreeing
operational objectives within a structured cooperation system are that this may unnecessarily
divert resources at national, regional and local level to administering the targets, that the
targets may only be meaningful for some Member States, and that targets would either be too
numerous or too reductive. Crucially, binding targets appear to be a disproportionate measure
for achieving the objectives of the health strategy and may not respect the subsidiarity
principle.

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6

O ategy
sectoral

ed

Option 4: Health Strategy
with Enhanced
Intersectoral Action,
Structured Cooperation
with Stakeholders and
Binding Targets

H

1.
H
L
R
In
T

e all
s

tive of
d

estyles. In
pport

ming at
pectrum

learn
f others.

likely to
e.

Option 4, like Option 3,
would be likely to have a
positive outcome in reducing
inequities and supporting
healthy lifestyles. The impact
might be greater than in
Option 3 due to the imposing
of binding legislative targets.

However, this may be seen as
disproportionately
burdensome to Member
States.

2.
C
P
K
U
T

ely to
ts on

alth, due
icators by

sure
bjective.

Option 4 could be expected to
have a slightly stronger
positive impact than Option 3
due to the imposing of
binding legislative targets.
However, this may be seen as
disproportionately
burdensome to Member
. COMPARING THE OPTIONS

bjective Option 1: Status Quo Option 2: Health Strategy with
Enhanced Intersectoral Action

Option 3: Health Str
with Enhanced Inter
Action and Structur
Cooperation with
Stakeholders

ealth Objectives

To Foster
ealthier

ifestyles and
educe Inequities

Health Across
he EU

Option 1 would lead to benefits
based on the continuing
knowledge and information
sharing between Member
States, and, in particular, the
use of the Structural Funds for
health.

However, given the
enlargement to 27 Member
States from 15 since 2004,
continuing as present may not
support the changing needs of
the larger EU.

Option 2 could lead to a stronger
focus on reducing inequities and
healthy lifestyles through
increased work to develop
synergies across the EU, through
bringing together in a more
strategic way the many varied
actions across the EU that impact
on health and health
determinants. However, without
full engagement by Member
States the added value and actual
outcomes would be limited.

Option 3 would engag
Member States to focu
attention on the objec
reducing inequities an
supporting healthy lif
particular, this may su
Member States perfor
the lower end of the s
on particular issues to
from the experience o
This option would be
have a positive outcom

To Protect
itizens and

atients from
nown and

nknown
hreats to Health

Option 1 would lead to benefits
based on continuing action to
protect people's health.
However, the lack of a coherent
strategic direction may mean
that potential for improvement
would not be fully exploited.

Option 2 could lead to benefits in
protecting people's health,
particularly through a new focus
on exploiting synergies between
sectors e.g. the applications of e-
health to address risk
management. However, without
the full engagement of Member

Option 3 would be lik
lead to positive impac
protecting people's he
to the definition of ind
Member States to mea
progress against this o

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States and may reduce their
flexibility in addressing
problems at national level.

3
T
S
H
w
N
T

ely to
t by

tes and
ards

his
t the

ices
d address

Option 4 could be expected to
have a slightly stronger
positive impact than Option 3
due to the imposing of
binding legislative targets.
However, this may be seen as
disproportionately
burdensome to Member
States particularly given their
right to manage national
health systems independently.

4
th
in
H

ely to
t through

r focus on
l which

nicated at
Option

e
al issues in

els.

Option 4 would be likely to
have a stronger impact than
Option 3, particularly through
requiring Member States to
include global health
considerations in their
national health policies.
However, this may be seen as
a disproportionate approach.
States, the impact would be
limited.

. To Increase
he

ustainability Of
ealth Systems

ith a focus on
ew

echnologies

Option 1 would lead to
continued exchange of
knowledge and good practice.
However, this may not achieve
the EU's full potential for action
and could lead to the loss of
economic benefits that may
arise from a more targeted
approach to health systems
issues.

Although enhanced dialogue
across sectors at EU level on
issues around health systems
could lead to further clarification
of issues and action needed,
Option 2 would be unlikely to
lead to great added value in
relation to the Status Quo as
Member States have the right to
control national health systems,
and would need to be fully
engaged in any work in this area
at EU level.

Option 3 would be lik
have a positive impac
engaging Member Sta
directing activity tow
sustainability issues. T
Option would suppor
proposed Health Serv
Initiative which woul
some issues.

. To Strengthen
e EU's Voice

Global
ealth

Option 1 would mean
continuing collaboration on
health with key international
bodies, and ongoing work
particularly in the Relex family
of DGs in relation to
development aid. However, this
would not provide a new focus
on global health issues that is
necessary given the increasing
challenges of globalisation.

In Option 2, enhanced dialogue
across sectors at EU level on
global health issues could be
valuable but without full
engagement of Member States,
this may not lead to real change
towards a more global approach
to health policy in the EU.

Option 3 would be lik
have a positive impac
putting in place a clea
key issues at EU leve
would then be commu
the global level. This
would also support th
consideration of glob
health policy at all lev

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5
S
O

place
well as a

n'
m with

rt work
es. It

more
s 1 and 2.

Option 4, like Option 3, is
likely to be an effective
option in relation to objective
setting. It is likely to be
slightly more effective than
Option 3 as it enforces
Member States to work
toward the objectives through
binding targets, rather than
relying on the cooperation
process alone. This Option,
however, could be seen as
disproportionately
burdensome to Member
States.

6
H
P
C

on Option
ng HIAP

an level,
ed

m, would
to a
ortance

ng at
local

and
f non-

rs as
alth aims.

Option 4 would be as
effective as Option 3 in
increasing HIAP cooperation.
Good
Governance

Objectives

. Setting
trategic

bjectives

Option 1 would not set strategic
objectives, so a new, coherent
framework would not be put in
place. Although effective work
would continue, a clear,
strategic vision for the future
would not be achieved, and
there would not be a focus on
addressing key new challenges.

Option 2 would set strategic
objectives which would help to
strengthen synergies across
sectors by offering a clear,
strategic framework and direction
of travel. However, as this
approach would be essentially
confined to the European
Commission, it is likely that the
objectives would not become
widely recognised by Member
States and other stakeholders, and
that progress towards the
objectives would therefore be
limited.

Option 3 would put in
strategic objectives as
'structured cooperatio
implementation syste
Member States and
stakeholders to suppo
towards these objectiv
would be likely to be
effective than Option

. Increasing
ealth In All

olicies (HIAP)
ooperation

Option 1 would continue with
existing HIAP cooperation,
with effective partnerships and
synergies relating to health
continuing across a range of
policy areas. There would,
however, be no strategic
overview of work across all
policy areas, with the risks of
duplication of work, of not fully
exploiting synergies, and not
engaging Member States as
strongly as possible on the issue
of HIAP.

Option 2 would boost HIAP
cooperation at the European level,
building on partnerships that are
already well established.
However, without the full
engagement of Member States,
opportunities to achieve a 'culture
change' similar to that achieved in
the environment sector (i.e.
recognition that health is an issue
that requires cooperation between
all policy areas) would be limited,
and gains at EU level may not be
reflected at national level.

Option 3 would build
2 by not only enhanci
cooperation at Europe
but due to the structur
cooperation mechanis
be likely to contribute
move towards greater
recognition of the imp
of intersectoral worki
national, regional and
levels across the EU,
greater involvement o
traditional stakeholde
partners to achieve he

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7
V

ikely
lfil
h at

es and
ly
the

d
pen

Option 4 could be slightly
more effective than Option 3
in improving visibility of
work done at the EU level, as
setting binding targets may
mean that more policymakers
at national, regional and local
levels are required to consider
EU health objectives.
However, this Option, could
be seen as disproportionately
burdensome to Member
States.

P

O place a new implementation system. This
O me time it does not go too far in placing a
b re the preferred Option which is expected
t tional input from EU Member States.
. Improving
isibility

Option 1 would not adequately
meet the objective of improving
visibility and understanding of
work on health at the EU level.
Without a well defined
Strategy, presenting a clear
direction of travel that
stakeholders and citizens can
engage with would be difficult.

Option 2 would be unlikely to
adequately fulfil the objective of
greater visibility, understanding
and transparency of work on
health at EU level. Putting in
place a strategic framework
without the full engagement of
Member States and stakeholders
will limit the extent to which that
framework is recognised and
used.

Option 3 would be more l
than Options 1 and 2 to fu
the objective of improved
visibility of work on healt
EU level, as Member Stat
Stakeholders would be ful
involved in supporting the
strategic objectives set by
Strategy, and the structure
cooperation process will o
up new opportunities for
sharing knowledge and
information at all levels.

referred Option

ption 3 uses the powers given to the EU in the Treaty to go a step further than Option 2, by putting in
ption would ensure that the new strategy is not just a paper exercise, but that it drives real change. At the sa

urden on Member States and respects the subsidiarity and proportionality principles. This Option is therefo
o have the greatest positive impact for EU citizens balanced against a reasonable level of addi

Deutscher Bundestag – 16. Wahlperiode – 73 – Drucksache 16/9412

7. MONITORING AND EVALUATION

Monitoring and evaluation will be on the basis of measurement against the seven objectives
set out in section 3.

Good Governance Objectives

The three 'good governance' objectives can be measured by the following indicators:

� Process indicator – that a framework with objectives has been put in place (objective 5)

� Quantitative indicator – awareness of the new strategy among policymakers, professionals,
academia and the public

� Qualitative indicator – that HIAP is more common practice at all levels

Health Objectives

Setting the parameters for monitoring and evaluation of the four health objectives of the
Strategy are outside the scope of the White Paper and will need to be decided by and with
EU Member States following adoption of the Strategy. The recommendation to take
forward Option 3 means that a new implementation mechanism of Structured Cooperation
will be agreed and set up by and with Member States. One of the first tasks of this new
Cooperation process will be to set indicators for monitoring the Strategy, target values for
those indicators, how the data will be disaggregated, and how frequently data will be
collected.

It is expected that the Strategy will set a small number of broad, overarching objectives in the
field of health, based on the three objectives set out in Section 2, to which all players can
agree. These objectives will in turn be supported by indicators. The EU already collects a
substantial number of indicators in the field of health and it is expected that the Strategy
can be monitored by means of existing indicators from various sources (e.g. see Box 5),
thus placing no further burden on Member States in terms of collecting new data.

To set appropriate indicators, the following questions will need to be considered:

– What have Member States done to implement a particular policy?

– What have other stakeholders done to implement a particular policy?

– What changes of behaviour need to be measured for the policy to succeed?

– What information do citizens need for the policy to be successfully implemented?

– What are the health outcomes resulting from the policy in question?

– What are the health in all policies aspects of the policy?

In terms of evaluation, the Strategy will have a mid-term evaluation to determine whether
adequate progress is being made and to make any necessary changes, and a final evaluation.

The Strategy will cover a period of 10 years.

Drucksache 16/9412 – 74 – Deutscher Bundestag – 16. Wahlperiode

In the consultation, many respondents acknowledged the importance of setting indicators. In
some contributions it was stressed that Member States should have the responsibilities for
collecting data while the European Commission should be responsible for the comparison of
the results, setting milestones, and identifying best practice. Many respondents advised setting
indicators that could precisely measure the economic or clinical benefits of specific action or
reforms. Respondents called for coherence in the development of indicators, and many
advised the use of indicators already defined within SANCO such as ECHI, measurements
developed using the Eurobarometer survey or the use of specific measures such as mortality
and morbidity rate, blood pressure or cholesterol level. The use of the Healthy Life Years
(HLY) indicator, on of the Lisbon Process indicators was supported by most of the
contributors, although some respondents stressed its limitations due to the fact that the self-
assessment element can lead to problems of comparability between cultures, and some would
prefer the use of the similar DALY or QALY measures. It was noted that process indicators
for Health In All Policies could be developed. Some suggested that qualitative targets
appropriate to each country could be defined.

The vast majority of the contributors suggested setting up a system of surveillance and
reporting on the Health Strategy at the European level based on comparable data. Many
suggested that high level objectives and specific indicators together with milestones should be
subjected to annual monitoring, contributing to an annual health report.

Many respondents, including Member States, proposed that the list of the indictors should be
agreed and established as a second step, once the broader objectives of the strategy were in
place. Some contributors recommended producing, in addition to the Strategy document, a
more detailed action plan where information on actors and responsibilities, timeline, tools,
milestones would be defined in cooperation with Member States and with the involvement of
stakeholders. The mid-term review of the strategy was seen important for reviewing progress.

Box 5 - Examples of existing indicators that, among others, could be used to monitor the Health
Strategy:

� % difference in life expectancy between women and men within the EU (Eurostat mortality
data)

� Infant mortality, under 18 mortality (Eurostat mortality data)
� Proportion of population aged 18-65 years reporting not working due to own illness or

disability (EU Labour Force Survey)
� Loss of life expectancy (LLE) – used for air quality in relation to particulate matter (RAINS

model)
� Healthy Life Years Indicator (Lisbon Structural Indicators)
� Smoking prevalence (ECHI)
� Obesity in adults (Health interview surveys, health examination surveys)

The ECHI-1 and ECHI-2 projects under the Health Monitoring Programme have developed a
comprehensive list of indicators in close cooperation with Member States69. The first list of 40
indicators on the ECHI list could be used in the monitoring of the Strategy (see Annex 4). Further
developments on comparable instruments for collection of data should permit the expansion of the
ECHI list to around 400 indicators in the coming years.

69 http://ec.europa.eu/health/ph_information/dissemination/dissemination_en.htm

Deutscher Bundestag – 16. Wahlperiode – 75 – Drucksache 16/9412

ANNEXES

Annex 1: Health Strategy Consultation Meetings

Commission – blue Member States, Regions and Neighbourhood Countries - yellow

NGOs – orange Other Stakeholders/Experts/multiple stakeholders – pink

EVENT DATE DESCRIPTION

European Health Forum Gastein 4 October 2006 200 policymakers, NGOs and
experts from across the EU

Interservice Group on Health 10 October 2006 An interservice group which meets
regularly to share information on
work in the health field. Services are
to nominate colleagues to attend the
Strategy Interservice Steering Group
ISSG)

Stockholm Region 20 October 2006 8 visitors from Swedish Stockholm
Region

High Level Committee on
Public Health

25 October 2006 A biannual meeting of high level
civil servants from National Health
Ministries

Conference Bleue 27 October 2006 Industry group with a focus on
pharmaceuticals

UK Deputy Chief Medical
Officer in charge of Public
Health

8-9 November
2006

Visit by high level UK delegation

Bilateral with EUROSTAT 10 November 2006 Interservice Bilateral

Meeting with Graham Lister
and SANCO Unit O2

13 November 2006 Discussion with expert on strategic
planning

Interservice Steering Group on
the Health Strategy

17 November 2006 First meeting of ISSG

North West England Region
EUBO meeting

20 November 2006 Meeting with 150 members of
regional offices in Brussels
Health Policy Forum 22 November 2006 Annual meeting of health-related
NGOs (49 member organisations)

Drucksache 16/9412 – 76 – Deutscher Bundestag – 16. Wahlperiode

South East Europe group 23-25 November
2006

Health Strategy presented to 9 South
East Europe countries including
Accession and Candidate Countries.

Meeting with Mark Suhrcke and
Svetla Tsolova, WHO European
Office

4 December 2006 Discussion with experts on Health
Economics

Meeting with European Free
Trade Association

5 December 2006 Presentation to Iceland, Norway,
Switzerland and Liechtenstein

Meeting with Welsh National
Assembly

7 December 2006 Presentation to 2 representatives
from the Wales Brussels Office

Meeting with English public
health and strategy experts in
London

12-13 December
2006

Discussions on strategic planning
and objective setting

Taskforce on Health
Expectancies, Luxembourg

12 December 2006 Presentation to Expert Taskforce

Bilateral with INFSO 12 December 2006 Interservice Bilateral

Taskforce on Major and
Chronic Diseases, Luxembourg

13 December 2006 Presentation to Expert Taskforce

European Public Health
Alliance meeting

13 December 2006 Presentation to a network of 80
NGOs

Trilateral with INFSO and
EUROSTAT

18 December 2006 Interservice Trilateral

Health Attachés 18 December 2006 Presentation to Member State Health
Attachés group

Agence Spatiale Europeen 9 January 2007 Discussion meeting

Bilateral with EMPL 10 January 2007 Interservice Bilateral

Meeting with ENTR 11 January 2007 Interservice Discussion

Meeting with REGIO 11 January 2007 Interservice Discussion

Meeting with World Health
Organisation

16 January 2007
Discussion meeting

SANCO International Affairs
Committee

17 January 2007 Presentation to Commission Services
with an interest in international

aspects of health

Meeting with UNICE, Union of 17 January 2007 Discussion with Industry

Deutscher Bundestag – 16. Wahlperiode – 77 – Drucksache 16/9412

Industrial and Employers
Confederations in Europe

Stakeholders

Bilateral with RTD 18 January 2007 Interservice Bilateral

Meeting of Expert Panel70 25 January 2007

Discussion meeting with 5 experts in
the field of health

Second Interservice Steering
Group on the Health Strategy

31 January 2007
Second ISSG

EU-Ukrainian Coordination
Committee

31 January 2007 Presentation

EU-Jordan Subcommittee 2 February 2007 Presentation

Meeting with English
operational research analysts

6 February 2007 Discussion Meeting

Meeting with World Bank
European representative

7 February 2007 Discussion Meeting

Meeting with Martin McKee
London School of Hygiene and
Tropical Medicine

7 February 2007 Expert meeting

Meeting with European Public
Health Alliance

14 February 2007 Discussion meeting with EPHA
management

Meeting with European Patients
Forum, Nicola Bedlington and
Anders Olauson

14 February 2007

Discussion meeting with
stakeholders

Meeting with Assembly of the
Regions

14 February 2007 Discussion meeting with secretariat

Meeting with DG SANCO
Directorates E (Willem
Daelman) and D (Eric Marin)

15 February 2007 Intra-SANCO meeting with animal
health and food safety Directorates

Meeting with UK Treasury 15 February 2007 Discussion meeting

Meeting with DG SANCO Dir
B

20 February 2007 Intra-SANCO meeting with
consumer protection Directorate
70 A selection of experts on a range of health policy issues, including Ilona Kickbusch, expert on health
governance, health promotion and public health, Nick Boyd, expert on EU health policy from a
Member State perspective, Philip Berman, expert on health organisations, Josep Figueras, expert on
European health systems and policies, Adam Kozierkiewicz, expert on health policy from a Member
State perspective.

Drucksache 16/9412 – 78 – Deutscher Bundestag – 16. Wahlperiode

Meeting of Expert Panel 20 February 2007 Discussion meeting with 3 experts in
the field of health

Meeting with EuropaBio 26 March 2007 Meeting with industry stakeholder

Third Interservice Steering
Group on Health Strategy

27 March 2007 Third ISSG

Commission-WHO-European
Health Observatory TAIEX
seminar on health in all policies
to the attention of European
Neighbourhood Policy partners

25-26 June 2007 Discussion meeting

Deutscher Bundestag – 16. Wahlperiode – 79 – Drucksache 16/9412

Annex 2: Health Activities Across the European Community

This list is not exhaustive but gives an indication of the wide range of ongoing activities on
health across the European Community. These have been grouped in relation to the four
health objectives described in the Impact Assessment. Activities planned for the coming years
have not been included.

A list of health-related EU agencies and funding mechanisms is also included.

Further information on these initiatives can be found at www.ec.europa.eu

1. Foster Healthier Lifestyles and Reduce Inequities in Health Across the EU

� European Territorial Cooperation, cross border cooperation, convergence Regions -
REGIO

� Evaluation of the budgetary impact of changes in the demographic and health status -
ECFIN

� Evaluation of the available policy measures to control growth of the Healthcare costs
- ECFIN

� Non life Insurance Directive - MARKT
� Minimum rate for tobacco taxation- TAXUD
� EU action plan on Drugs 2005-2008 – JLS/SANCO
� Council Regulation on Promotion for EU agricultural products on the Internal

Market-AGRI
� Recognition of health professional qualifications – MARKT
� Infringement action on cases relating to restrictions on pharmacies and biomedical

laboratories - MARKT
� Open Method of Coordination on social protection and social inclusion – EMPL
� Protection of social security rights of migrant people - Regulation 1408/71 on

coordination of social security schemes – EMPL
� electronic European Health Insurance Card (eHIC) – EMPL
� Infringement action on cases relating to refusal to reimburse medical costs of patients

treated abroad - MARKT
� EU Disability Action Plan 2005 – EMPL
� Council resolution on common objective for a greater understanding and knowledge

of youth: implementing measures include health style – EAC
� Communication about equity and efficiency in European education and training style

– EAC
� Framework Programme 6 and Framework Programme 7 including Health, Scientific

support to policies and Food quality and safety as research themes – RTD
� European Social Funds - EMPL
� “Common Basic Principles” including on healthcare developed in the "common

agenda for integration" - JLS

� Regulation on the access to healthcare in the MS by 3rd country nationals – JLS
Drucksache 16/9412 – 80 – Deutscher Bundestag – 16. Wahlperiode

2. Protect Citizens and Patients from Known and Unknown Threats to Health

� Health and safety at work - EMPL
� Pharmaceutical Legislation, its revision in application since Nov. 2005, Specific

Regulation for Orphan Medicinal Products, for medicinal products of paediatric use –
ENTR

� New Approach for Medical Devices: legal framework with a set of directives – ENTR
� Cosmetics legal framework – ENTR/JRC
� Consumer products safety – JRC
� Chemicals: Directive REACH – ENTR/ENVI/JRC
� Electronical and medical equipment legal framework - ENTR
� Assessment on counterfeit medicines situations in terms of legislation, enforcement,

communication, public awareness – ENTR
� Fight against counterfeit -TAXUD/JRC
� Health and Environment action plan 2004-2010 – ENVI
� Policies in impacting environment on air quality, water quality, noise – ENVI/JRC
� Framework Programme 6 and Framework Programme 7 including Health, Scientific

support to policies and Food quality and safety as research themes – RTD/JRC

3. Increase the Sustainability of Health Systems with a focus on New Technologies

� Green paper on demographic future of Europe, from challenge to opportunity – EMPL
� OMC on healthcare and long term care-EMPL
� Communication on elder abuse planned for Oct 2007 - EMPL
� Pharmaceutical Forum established in 2005 – ENTR/SANCO
� Strategy on Life Science and Biotechnology - ENTR
� Framework Programme 6 and Framework Programme 7 including Health, Scientific

support to policies and Food quality and safety as research themes – RTD
� Implementation state aid competition rules in health markets – COMP
� Competitions rules on mergers - COMP
� eHealth research projects, e-Health Action Plan - INFSO

4. Strengthening the EU's voice in global health

� Promotion of health policies in the framework of various types of agreement or
political dialogue with partner countries. RELEX

* European Neighbourhood Policy (ENP): On the basis of the health sections in all

ENP action plans, dialogue and cooperation is being stepped up. Health cooperation
projects are ongoing and planned through the European Neighbourhood and

Deutscher Bundestag – 16. Wahlperiode – 81 – Drucksache 16/9412

Partnership Instrument. The Commission is increasingly involving ENP partners in
EU meetings and networks (e.g. Think Tank HIV/Aids, network of Competent health
authorities, TAIEX funded seminar on Health in all policies)

* Country Strategies (2007-2013) for Asia includes health sector

* Development Cooperation Instrument for Asia and Latin America allows
cooperation in field of health to strengthen health systems

� Multilateral trade negotiations: Doha Development Agenda launched in 2000. EC
policy is that services considered as public utilities may be subject to government
monopolies or to exclusive rights granted to private operator – TRADE

� Bilateral and regional negotiations: including inter alia health and social services, and
services of Health professionals - TRADE

� Communication and Programme for action on health workforce crisis - DEV
� Model Guidelines on Mainstreaming HIV/AIDS; – ECHO
� Review of Quality Assurance Mechanisms for Medicines and Medical Supplies in

Humanitarian Aid - ECHO
� Thematic programs against main poverty diseases to support achievement of the

Millennium Development Goals- AIDCO
� Specific health actions for populations affected by humanitarian crisis (natural or man-

made): primary healthcare, secondary healthcare, temporary health infrastructures,
specific horizontal issues - ECHO

� IPR and better access to medicines in developing countries, Regulation on compulsory
licensing of patents for pharmaceuticals for exports to developing countries adopted in
2006 – MARKT

� Framework Programme 6 and Framework Programme 7 including Health, Scientific
support to policies and Food quality and safety as research themes – RTD

� Envelop to fight new health treats/ emerging disease in animal and human health as
fight against and prevention of Avian and Pandemic Influenza plus coordination to
wards the external response. RELEX

� Regulation on the right of MS to refuse residence permits for reasons related to public
health -JLS

Agencies in the field of Health

� European Centre for Disease Prevention and Control (ECDC)
� European Foundation for the Improvement of Living and Working Conditions

(EUROFOUND)
� European Environment Agency (EEA)
� European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)
� European Medicines Agency (EMEA)
� European Agency for Fundamental Rights (FRA)
� European Agency for Health and Safety at Work
� European Food Safety Authority (EFSA)

� European Chemicals Agency (ECHA)
� European Space Agency (ESA)

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Funding Mechanisms

� Public Health Programme
� Framework Programme 6/ Framework Programme 7
� European Regional Development Funds
� European Social Funds

Deutscher Bundestag – 16. Wahlperiode – 83 – Drucksache 16/9412

Annex 3: Key Health Determinants

This Annex provides additional data and information on key health determinants which
supports the discussion of changing health challenges in section 2.1, and the objectives of the
Strategy described in section 3. More information on EU policies can be found at the Health
Portal, www.health.europa.eu.

a) Obesity, Diet and Nutrition

b) Alcohol

c) Smoking

d) Environmental Health

e) Mental Health

f) Drugs

A number of these topics are included in the FP7 Call for Proposals of the thematic focus
"Health" under pillar 3: "Optimising the delivery of healthcare to European citizens"71.

a) Obesity, Diet and Nutrition

Around 30% of school children in the EU are estimated to be overweight or obese (EU 25).
The obesity phenomenon is responsible for a number of very serious physical and mental
health problems, ranging from diabetes to cancer, heart disease, infertility and psychological
disorders. It is estimated that obesity accounts for up to 7% of healthcare costs in the EU, in
addition to the wider costs to the economy due to lower productivity and premature death.
Nutritional habits have changed significantly over the last decades, and unhealthy food is
often cheap to buy. Being overweight is the most important risk factor for Type II Diabetes,
while direct costs for diabetes in the EU vary between 2 and 7% of total health expenditure.
Progress has been made on raising awareness of the dangers of high fat, salt and sugar diets.
Some industry players have responded to the change in public opinion. Pepsico has reduced
saturated fats in Walkers crisps by 70%, and salt by 25% in the UK.72 Increased economic
growth also appears to have a beneficial effect on cardiovascular disease.73 Further research is
needed to explore potential genetic susceptibility of obesity.
71
http://cordis.europa.eu/fp7/dc/index.cfm?fuseaction=UserSite.CooperationDetailsCallPage&call_id=63
72 http://www.pepsicowiderworld.co.uk/health.php
73 Suhrke and Urban, Are Cardiovascular Diseases Bad for Economic Growth? CESifo Working Paper

No. 1845, November 2006.

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Obesity in European adults % (BMI>30)74

0,0

5,0

10,0

15,0

20,0

25,0

30,0

uk de mt lv hu ee pt lt cz sk fi es bg pl sl ie cy be el nl se ro fr dk at it

females
males

Percentage of overweight and obese children aged 7-11 in selected countries in the
World Health Organisation European Region75

The Commission adopted a White Paper on a Strategy for Europe on Nutrition, Overweight
and Obesity related health issues on 30 May 2007. This sets out the Community policies
relevant to tackling these conditions, and how the Community can support Member States in
their efforts. Relevant and on-going actions include the body of Community food law and
regulation on labelling and health claims which contributes to creating a supportive
information environment for consumers. Other community actions include a proposed scheme

74 Source: Eurostat.
75 World Health Organisation: The challenge of obesity in the WHO region, Fact sheet (EURO/13/05),

September 2005.

Deutscher Bundestag – 16. Wahlperiode – 85 – Drucksache 16/9412

to distribute Fruit and Vegetables to school children (through the common agricultural policy)
and therefore improve availability of these foods to a key vulnerable group, as well as
cohesion and transport policy for which fund are available that can be used by Member States
to improve their physical environment (such as in the development of urban planning and
transport systems that encourage walking and cycling.)

Approaches to tackling obesity and overweight are therefore highly intersectoral and a key
public health challenge is to engage other policies areas at all levels from Community to local
level. Successful approaches necessitate the involvement of a wide range of stakeholders
(such as the food industry, advertising and media sector, schools, clinicians and the NGO
community). For this reason, the Commission set up the EU Platform for action on Diet,
Physical Activity and Health (see page 38). A new, high profile strategic framework would be
valuable to improve the buy-in from the range of stakeholders involved (both in governments
and among private stakeholders such as the major food companies) by clarifying the strategic
environment for public health, leading to greater transparency of our motives, goals and
objectives and thereby promoting greater trust between partners. A new Strategy may also
support the development of new multi-stakeholder forums in other areas, building on the
success of the Platform.

b) Alcohol

Harmful and hazardous use of alcohol can cause 60 different types of diseases and
conditions76. estimated to be responsible for about 195 000 deaths each year in the EU77 The
young shoulder a disproportionate amount of this burden with over 10% of youth female
mortality and around 25% of youth male mortality due to alcohol (15 000 deaths/year).
Alcohol related deaths peak in the age group 15 – 29. Harmful use of alcohol has effects not
only on the drinker but also on the society as a whole. Alcohol is estimated to be a causal
factor in 16% of child abuse and neglect78 and one out of four fatalities on EU roads is caused
by drink-driving (more than 10,000 per year).

Percentage of deaths attributable to alcohol among EU citizens under 70 (2000)

76 Gutjahr et. Al. 2001; English et. Al. 1995: Ridolfo and Stevenson 2001; Room et. al. 2005.
77 Anderson, P and Baumberg B (2006) Alcohol and Europe, London Institute of Alcohol Studies.
78 English et al.

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The cost of alcohol related harm to the EU’s economy has been estimated at €125 billion for
2003, equivalent to 1.3% of GDP. This estimate includes losses due to underperformance at
work, work absenteeism, premature death etc79

In October 2006 the Commission adopted the EU alcohol Strategy80. The adoption was the
starting point of a long-term work to reduce alcohol harm in the EU. This strategy will be put
into practice through; a Committee on National Policy and Action and a European Alcohol
and Health Forum with economic operators and non-governmental organisations willing to
step up actions aimed at reducing alcohol harm.

c) Smoking

In the EU, one in four people aged between 15 and 24 are daily smokers,81 while studies have
shown that the majority of smokers want to stop smoking.82 Smoking has been proven to have
a causal relationship with many serious and life-threatening diseases. Current cigarette
smokers have over twice the risk of dying from all cancers combined than people who have
never smoked. For heavy smokers the risk is three-fold compared with never-smokers83. It is
estimated that in 2006 there were almost 335000 deaths for lung cancer in Europe84. Mortality
from chronic obstructive pulmonary disease (COPD) is 14-times higher in cigarette smokers
than in never-smokers.85 Smoking also increases a person's risk of cardiovascular disease. The
risk of mortality from any cardiovascular disease in all cigarette smokers is greater than 1.6
79 Anderson, P and Baumberg B (2006) Alcohol and Europe, London Institute of Alcohol Studies.
80 COM(2006) 625.
81 Eurostat, Health Interview Surveys 2004 (NewCronos Database).
82 Fong et al, The near-universal experience of regret among smokers in four countries: findings from the

International Tobacco Control Policy Evaluation Survey. Nicotine Tob Res. 2004 Dec;6 Suppl 3:S341-
51.

83 Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years' observation s on
male British doctors. BMJ 2004; 328:1519-1528.

84 Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P. Estimates of the cancer incidence and

mortality in Europe in 2006. Ann Oncol. 2007 Mar;18(3):581-92.

85 Peto R, Lopez AD, Boreham J,Thun M. Mortality from Smoking in Developed Countries 1950-2010.
2nd Edn. Data updated 23 August 2004. Imperial Cancer Research Fund, World Health Organization.
Oxford, Oxford University Press.

Deutscher Bundestag – 16. Wahlperiode – 87 – Drucksache 16/9412

times that of never-smokers, with the figure rising to 1.9 times in heavy smokers.86
Environmental tobacco smoke is associated with serious risks to health. Chronic exposure to
second-hand smoke has been established as a cause of many of the same diseases caused by
active smoking, including respiratory diseases, lung cancer (20-30% increased risk when
living with a smoker87), cardiovascular disease (25-30% increased risk of coronary heart
disease when living with a smoker), and childhood disease (sudden infant death, pneumonia,
bronchitis, asthma and middle ear disease). Exposure in pregnant women can cause lower
birth weight, foetal death and preterm delivery.

Recently, the risks of environmental tobacco smoke have been more clearly recognised with
several European Member States instituting bans on smoking in the workplace. According to
the most recent estimates by the Smoke Free Partnership, more than 79,000 adults die each
year as a result of passive smoking in the 25 countries of the EU. There is evidence that
passive smoking at work accounted for over 7,000 deaths in the EU in 2002, while exposure
at home was responsible for a further 72,000 deaths88.

Smoking also carries serious financial implications, both on a personal level and to the wider
economy. In the EU, for some families up to 10% of total household expenditure goes on
tobacco. The direct and indirect costs of smoking in the EU-25 were estimated for 2000
ranging from 97.7 to 130.3 billion Euros in 2000, corresponding between 1.04% and 1.39% of
the EU GDP89.

The tobacco policy of the EU is based on a four stage approach: legislative instruments,
support for prevention and cessation activities, mainstream of tobacco control into other
Community policies and impact beyond frontiers of the EU. The current tobacco framework
consists of two Directives on tobacco advertising and product regulation as well as a
recommendation on tobacco control and the WHO Framework Convention on Tobacco
Control (FCTC). The Commission adopted recently a Green Paper on smoke-free
environment which is now being followed up. A revision of tobacco taxation is on-going as
well as discussions about FCTC-protocols on illicit trade and cross-border advertising and the
Commission is planning to put forward a comprehensive strategy on tobacco control.
Measures aimed particularly at reducing demand for tobacco products by children and
adolescents are important. The campaign “Help - for a life without tobacco” targets young
people (15-25) as a priority, with a maximum total budget of around €60 million, funded
through the Community Tobacco Fund. The Health Strategy provides a useful tool for
gathering all these efforts and to link the work to other important health determinants.
86 Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years' observation s on

male British doctors. BMJ 2004; 328:1519-1528.
87 International Agency for Research on Cancer (2002). Monographs on the Evaluation of Carcinogenic

Risks to Humans. Tobacco Smoke and Involuntary Smoking. Volume 83, Lyon, IARC, World Health

Organization.

88 Lifting the smokescreen. 10 reasons for a smoke free Europe. Smoke Free Partnership. 2006.
89 The ASPECT Consortium. Tobacco or health in the European Union. Past, present and future.

European Commission. 2004.

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d) Environmental Health

Environmental factors are a major contributor to health and disease. Air, water and soil
pollution, and the impact of the built environment via physical exercise, noise, accidents and
injuries are major determinants of health in Europe. Climate change may also create health
risks that are not yet well understood.

Although the long-term health effects of poor environmental conditions need to be further
studied, available estimations suggest that this is a serious health problem. OECD90 estimates
that environmental conditions are responsible for 2 to 6 % of the total burden of diseases in
OECD countries mainly due to exposure to outdoor and indoor air pollutants and chemicals in
the environment. The same report estimates the possible costs of healthcare expenditure due
to environmental condition might be roughly estimated at 0.5 % of GDP in OECD countries.
WHO estimates91 that exposure to fine particulate matter in outdoor air leads to about 100 000
deaths and 725 000 years of life lost each year in Europe. In the last decades there has been a
dramatic increase in Europa in asthma and allergies. According to the WHO92 11.5% of
children suffer from asthmatic symptoms in Europe.

Health effects can also be observed as consequence of climate change. Health effects relate to
extreme weather conditions (heat waves, floods, and extreme cold periods) as well as to an
increase of human and animal diseases. Other health effects can be observed as a consequence
of exposure to ultra violet radiation (cancer and cataracts), water availability, crop production,
wildfires etc. A preliminary analysis of the 2003 heat wave in Europe estimated that it caused
about 65 000 deaths in Europe. Other health effects are not well estimated for the time being.

Efforts to better understand and prevent such environment related diseases started in the EU at
different levels and through a series of activities and projects decades before the adoption of
the European Environment and Health Strategy in 200393 and the European Environment and
Health Action Plan 2004-2010 in 200494. In the framework of this Action Plan considerable
progress has been made , with respect to the evaluation of existing environment and health
information and monitoring systems95. The EU has undertaken a series of actions to improve
and better integrate the existing systems already in place EU-wide. Of particular relevance for
scope and extent is the cooperation established by the Commission and the WHO to develop a
comprehensive information system (Environment and Health Information System – EHIS) to
monitor and assess the relations between the environment and human health, and the
effectiveness of related policies with a special focus on children's health. This cooperation is
carried out in the framework of the ENHIS2 project. Several activities and projects have been
undertaken to tackle specific health conditions such as skin cancers, asthma and other
respiratory diseases, and other environment-related allergies.

Growing concerns on the effects of Electromagnetic Fields (EMF) on human health have
pushed the European Commission to undertake actions aiming at improving knowledge on
potential dangerous effects. An updated Opinion on "Possible effects of Electromagnetic
90 2001 OECD Environmental Outlook.
91 Results from the WHO project "systematic review of health aspects of air pollution in Europe". June

2004.
92
http://www.euro.who.int/eprise/main/who/progs/whd2/20030307_6
93 COM(2003) 338.
94 COM(2004) 416.
95 SEC(2006) 1461.

Deutscher Bundestag – 16. Wahlperiode – 89 – Drucksache 16/9412

Fields (EMF) on Human Health" has been recently adopted by the Scientific Committee on
Emerging and Newly Identified Health Risks (SCENIHR). An interesting project currently
financed by the Commission regards the analysis of any potential impact of EMF on the
human ear and in particular any relations between EMF and the development of specific
forms of ear cancer.

The Commission is working to ensure that environmental health hazards are identified and
addressed through a number of specific initiatives on indoor air quality and an assessment of
the health risks of climate change. It has also launched a call for proposals under FP7 to
develop a coordinated EU approach to human biomonitoring, .. It will further develop actions
being taken within the framework of the Environment and Health Action Plan and through the
renewed Sustainable Development Strategy contributing to the goals of the Lisbon Agenda.

e) Mental Health

Positive mental health enables wellbeing and good quality of life, whereas mental health
problems and mental disorders have a severe negative impact on people. It is estimated that
mental disorders account for 12% of the burden of disease in Europe96. Mental health
problems are a major cause of work absenteeism and early retirement, thereby causing
immense economic losses and social burdens. Suicide is in most cases linked to mental illness
and causes the deaths of about 60,000 citizens per year. While the rate of suicide across the
EU has fallen over the last 10 years by more than 10%, partly due to improved treatment and
prevention policies, the variation between Member States is still very large (see graph below)
which suggests that there is still great potential for improvement if those with the worst
figures could be improved towards those with the best.

However, mental health does not yet get the attention it deserves. A great proportion of people
with mental health problems do not receive appropriate treatment, and funding for mental
health remains relatively low in several Member States. The potential for prevention of
mental illness and promotion of good mental health, for instance through measures in
educational and workplace settings, is not sufficiently exploited.

At present, the Commission is developing a Communication setting out a strategy on mental
health, drawing from the conclusions of a Green Paper in 200597. It will establish a framework
for cooperation on mental health across Community policies and between Member States, in
order to learn from mutual good practice and to strengthen the visibility and implementation
of commitments made. A new health strategy would support integration across EU policy in
relation to mental health issues, thereby strengthening the credibility and effectiveness of the
action.

96 WHO World Health Report 2001.
97 COM(2005) 484.

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Standardised Death Rate for suicide and self-intentional harm per 100 000 people across
EU Member States - 200598

37,0

24,1 23,2 22,0
19,5 19,3 18,7

16,4 15,0 14,7 14,0 12,8 12,7 12,2 11,8 11,7 11,0 11,0 9,9 9,6 9,5 9,0
6,7 6,6 6,0

4,2 3,1
0,7

0

5

10

15

20

25

30

35

40

lt lv hu si be fi ee fr pl at cz ro sk dk se eu27 bg de lu pt ie nl uk es it mt gr cy

f) Drugs99

Between 1990 and 2003, between 6500 to over 9000 acute drug deaths (overdoses) were
reported each year by EU countries. Drug overdoses are one of the main causes of mortality
among young adults in the EU countries, and is linked to alcohol abuse (see b. above). Opiate
users (mainly those who inject) have an overall mortality that is up to 20 times higher that the
general population of the same age due to overdoses, but also to violence, disease (AIDS and
others), etc.

Population mortality rates due to acute drug-related deaths varied widely between European
countries, ranging from 0.2 to over 50 deaths per million inhabitants (average of 13). Acute
drug-related deaths (overdoses) account for 3% of all deaths among Europeans aged 15 to 39
years in 2003 to 2004, and for more than 7% in Denmark, Estonia, Luxembourg, Malta,
Austria, United Kingdom and Norway. The majority of overdose victims are men. Most
victims are in their twenties or thirties. Since 2000, many EU countries have reported
decreases in the numbers of drug-related deaths, although figures are still high from a longer
term perspective. However, among countries reporting data in 2004 (19), there was an overall
increase of 3 %, with increases reported in 13 out of the 19 reporting countries (inferences for
the whole EU should be made with caution).

The European Action–Plan on Drugs 2005-2008100, adopted by the Council on 27/06/2005, is
based on the framework of the European Drugs Strategy 2005-2012101, describes specific
interventions and actions, focusing on two main strands of action, demand and supply
reduction. It also includes a number of cross-cutting themes related to coordination,
international relations and information, research and evaluation. On the demand side, this
Action-Plan includes the Commission report on the implementation of the 2003 Council
Recommendation on the prevention and reduction of health-related harm associated with drug
dependence, which was adopted on 18 April 2007102 and calls for more links to other areas
with regard to further initiatives in the field of harm reduction, e.g. drugs and driving, alcohol,
HIV/AIDS, mental health, drugs at workplace and civil society. The Action-Plan also
98 Source: Eurostat.
99
Source: EMCCDA Statistical Bulletin 2006.
100 http://eur-lex.europa.eu/LexUriServ/site/en/oj/2005/c_168/c_16820050708en00010018.pdf
101 http://register.consilium.europa.eu/pdf/en/04/st15/st15074.en04.pdf
102 COM(2007)199.

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includes a report on drug treatments and good practices across Europe and a proposal for a
Council Recommendation on drugs and prisons. A new approach would support more cross
sectoral work on the issue at all levels.

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Annex 4: Health and its relationship to the Economy

This annex describes some relationships between health and economic prosperity, including
looking at public spending and financial sustainability, costs of illness, the health of the
labour market, health investment in the prevention of illness, and the economic growth
potential of the health sector itself.

Spending in the health sector is an important and rising cost for national administrations.
There is mounting pressure for increased growth and efficiency in health sector. This pressure
is created by factors such as the development of expensive new technologies, and
demographic ageing which, according to analysis by DG ECFIN103, will pose major
economic, budgetary and social challenges which are expected to have a significant impact on
growth and lead to considerable pressure to increase public spending, making it difficult for
Member States to maintain sound and sustainable public finances in the long-term (see also
section 2.3(5)). Healthcare spending around the world generally is rising at a faster rate than
economic growth.104 For example, the USA increased its spending on health as a percentage
of GDP by 7% in 2003 (15.2%) compared to 8.8% in 1980, with EU Member States also
showing increases. Chart 3 shows rising health spending as a percentage of GDP for OECD
countries. Looking ahead, therefore, the EU must consider the financial sustainability of the
health sector. The Commission's Sustainable Development Strategy was reviewed in 2006 and
recognised the important role health will play in future economic and social sustainability.105

Chart 3:
103 The long-term sustainability of public finances in the EU, DG ECFIN, EUROPEAN ECONOMY. No.

4. 2006, an annex to the Commission's Communication on 'The long-term sustainability of public
finances in the EU' - COM(2006) 574, SEC(2006) 1247.

104 Snapshots: Healthcare Spending in the United States and OECD Countries Jan 2007

http://www.kff.org/insurance/snapshot/chcm010307oth.cfm

105 COM(2005) 37 of 9.2.2005: 'The 2005 review of the EU Sustainable Development Strategy: Initial
Stocktaking and Future Orientations' and SEC(2005) 161 of 9.2.2005: 'Sustainable Development
Indicators to monitor the implementation of the EU Sustainable Development Strategy'.

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Alongside the rising costs of running health systems and services and the need for reform, the
cost of ill health is in itself a significant burden to the economy. 'Cost of illness' is notoriously
difficult to measure, but some estimates are presented in Box 6, taking into account not only
costs to the health sector, but to employers. Despite the problems in measuring these costs, it
is clear that the impact of illness on the economy is huge. Poor health is an important factor in
early retirement and worker absenteeism. Studies have shown that in Germany, the
probability of leaving the workforce at the earliest possible age is four times higher for men
with disabilities than those without, and in Ireland, the proportion of labour participation is
61% lower for men with chronic diseases.106 People who continue to work despite health
problems are also likely to be less productive than healthy people.107
106 Suhrke et al, The contribution of health to the economy in the EU, European Commission, 2005.
107 Ibid, p.20-22.

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Box 5. Cost of Illness Estimates

Treating Cardiovascular Disease costs around €74 billion per year in the EU and losses in
production of goods and services cost around €106 billion108. 80% of all cardiovascular
diseases are considered to be preventable by reducing risk factors like smoking and unhealthy
diet.

WHO European Region studies show that estimates of direct costs of obesity during the 1990s
ranged from 1% of healthcare expenditure in the Netherlands109 to 1.5% in England and
France, and 3.1–4.2% in Germany. A study from Belgium reported estimates of 6%.110 In
England it was estimated that in 1998 obesity accounted for 18 million days of sickness
absence and 30,000 premature deaths, equivalent to €715 million per year to treat obesity.111

25% of people suffer mental health problems at some point in their lives and in several
countries this is shown to be an increasing factor in worker absenteeism. It is estimated that
mental disorders cost 3-4% of GDP per year.112

It is estimated that alcohol abuse cost the health, welfare, and criminal justice sector in the EU
approximately €125 billion in 2003.

The loss to Scottish employers due to decreased productivity, higher rates of absenteeism and
fire damage caused by smoking has been calculated at 0.51% - 0.77% of Scottish GDP113.
Currently asthma affects 30 million people across the continent and costs healthcare services
approximately €17.7billion a year.114

The SARS epidemic in 2003 was a serious incident which was brought under control by an
effective international response. It ultimately killed about 800 people, and despite the well-
organised response, led to a total cost for the East and Southeast Asian economies as a whole
of about US $18 billion.115 Without the effective intervention, the cost would have been much
higher.

A UK study from 2000 indicated that a 10% reduction in the number of hospital acquired
infections could result in a saving of 150 million euros per year116.
108 Liu et al, Heart 2002;88:597-603.
109 Seidell JC, Deerenberg I. Obesity in Europe: prevalence and consequences for use of medical care.

Pharmacoeconomics, 1994; 5: 38–44.
110 Institute Belge de l'Economie de la Santé. Evaluation du coût de l'obesité en Belgique. Briefing 29, June

2000.
111 National Audit Office (England) 2001.
112 Estimation by ILO. http://agency.osha.eu.int/publications/newsletter/8/en/index_23.htm.
113 Parrott S, Godfrey C, Raw M. Costs of Employee Smoking in Scotland. Tobacco Control 2000; 9: 187-

192.
114 The European Lung White Book: The First Comprehensive Survey on Respiratory Health in Europe

2003.
115
Assessing the Impact of SARS in Developing Asia, Asian Development Outlook 2003 Update

(www.adb.org/documents/books/ado/2003/update/sars.pdf).
116 Plowman R., Graves N., Griffin M., Roberts J.A., Swan A., Cookson B, et al. The socio-economic

burden of hospital acquired infection. London: PHLS, 2000.

Deutscher Bundestag – 16. Wahlperiode – 95 – Drucksache 16/9412

However, measuring only the costs associated with poor health ignores the fact that good
health has a positive effect on the economy. A healthy population supports the workforce and
reduces pressure on health services; the health services sector is a major source of jobs, and is
a driver of innovation. Health has been shown to be a “robust and sizeable predictor of
subsequent economic growth” in many studies looking at differences in growth between poor
and rich countries.117 Health policymakers have long been arguing that ‘health means wealth’
(see Figure 1); that a healthy population is necessary for economic productivity and
prosperity, and that this is a 'virtuous circle', as wealth also leads to better health.

Figure 1: 'Health Means Wealth' Source: M. Suhrcke, M. McKee, R. Sauto Arce, S. Tsolova,
J. Mortensen The contribution of health to the economy in the EU, Brussels 2005

The theoretical underpinning to the 'health means wealth' argument was developed by Becker
(1964)118 and then further developed and strengthened by Grossman (1972)119 and others. As
Suhrcke, McKee at al explain,120 according to neo-classical economic theory, economic
growth depends on three factors: the stock of capital, the stock of labour, and productivity, the
latter depending in turn on technological progress and, in neo-classical theory, considered to
be an exogenously given factor (i.e. external and unaffected by economic growth). Becker and
Grossman argued that in fact technological progress can be seen as an ‘endogenous’ process
that could be driven in particular by investments in human capital, largely understood as
skilled labour. In their research, Becker focused primarily on effect of education, while
Grossman added an analysis of the impact of health improvements. Grossman distinguishes
between health as a consumption good and health as a capital good. As a consumption good,
health enters directly into the utility function of the individual, as people enjoy being healthy.
As a capital good, health reduces the number of days spent ill, and therefore increases the
117 Suhrcke, McKee et al, The contribution of health to the economy in the European Union, European

Commission 2005, p. 12.
118 Becker, G. S. (1964), Human capital: A theoretical and empirical analysis with special reference to
education, Third Edition, Chicago and London: The University of Chicago Press.
119 Grossman, M. (1972), On the concept of health capital and the demand for health, Journal of Political

Economy, 80(2): 223–255.
120 Suhrcke, McKee et al, ibid.

Drucksache 16/9412 – 96 – Deutscher Bundestag – 16. Wahlperiode

number of days available for both market and non-market activities. Thus, the production of
health affects an individual’s utility not only because of the pleasure of feeling in good health,
but also because it increases the number of healthy days available for work (and therefore
income) and leisure.

Accordingly to this theory, the following factors affecting the economic outcomes can be
observed121.

� Labour productivity - healthier individuals could reasonably be expected to produce more
per hour worked. Productivity could increase directly due to enhanced physical and mental
activity but also due to the fact that more physically and mentally active individuals could
also make a better and more efficient use of technology, machinery or equipment. A
healthier labour force could also be expected to be more flexible and adaptable to changes
(e.g. changes in job tasks, in the organisation of labour). A number of studies also find a
significant impact of physiological proxies for health (e.g. height or body mass index) on
earnings and wages, not only in developing but also in some high-income countries. It is,
however, likely that some of the links between these physiological measures and labour
market outcomes can be accounted for by the social status attributed to height, and by
social stigma in the case of obesity, rather than by a direct effect on productivity.

� Labour supply - the impact of health on labour supply is theoretically ambiguous. Good
health reduces the number of days an individual spends sick, but health also influences the
decision to supply labour through its positive impact on wages and earnings. Several
studies from high-income countries show that poor health negatively affects wages and
earnings. In addition, health also increases labour force participation (also for
household members of ill people) and is likely to delay retirement (some economists,
however, argue that income effect might result in early retirement).

� Education - according to human capital theory, more educated individuals are more
productive (and obtain higher earnings). Since children with better health and nutrition
tend to achieve higher educational attainment and suffer less from school absenteeism and
early drop-out, improved health in early ages indirectly contributes to future productivity.
Moreover, if good health is also linked to higher life expectancy, healthier individuals
would have greater incentives to invest in education and training, as the depreciation rate
of the skills acquired would be lower. This link while theoretically plausible and
empirically supported in the case of developing countries, so far has not been sufficiently
tested in high-income countries.

� Savings and investment – the state of health of an individual or a population is likely to
impact not only upon the level of income but also the distribution of this income between
savings and consumption and the willingness to undertake investment. Individuals in good
health are more likely to look ahead to the long-term future and their savings ratio may
consequently be higher than the savings ratio of individuals in poor health. In the same
way as the education argument however, although plausible, there is little published
research in this area as far as high income countries are concerned.

Therefore, there is a sound theoretical and empirical basis to the argument that human capital
contributes to economic growth. At the same time, economic outcomes also matter for health.

121 Ibid.

Deutscher Bundestag – 16. Wahlperiode – 97 – Drucksache 16/9412

Surprisingly, however, despite the evidence supporting the link between health and economic
prosperity, it is not always adequately taken into account. The Lisbon Agenda did not
mention health during the first years that it was in place. In 2005, the Healthy Life Years
indicator was included as a Lisbon Structural Indicator, recognising that the population's life
expectancy in good health was an important measure in understanding and supporting
economic growth. The Commission pointed out in its report to the 2006 Spring European
Council that Member States need to reduce the high numbers of people who are inactive
because of their ill-health122 and that Europe cannot afford to have people drop out of the
labour market when they are in their fifties123. This report urged action; rather than just seeing
health as a negative cost, it recognised that policy in many sectors has a role in improving
health for the benefit of the wider economy.

Although increases in the share of GDP spent on health can be seen as problematic, provided
expenditure is well-founded and effective, these increases may represent necessary
investment in health. ECFIN have estimated that if healthy life expectancy evolves broadly in
line with change in age-specific life expectancy, then projected increase in spending on
healthcare due to demographic ageing would be halved124. Effective investment in health can
lead to more efficient health systems, more people avoiding illness, and therefore to greater
future financial sustainability. It is important to balance the consideration of spending on the
healthcare sector with investments in public health and prevention policies. These have
been shown to have substantial effects on reducing major and chronic diseases through action
on better nutrition, prevention of smoking, prevention of alcohol related harm, reduction of
accidents and injuries and specific approaches for different genders as well as groups like
children, older people, and migrants. For example, a study based in Nordmaling, Sweden,
found that a group of older people who received home visits from a health professional
showed a decrease in indicating pain and anxiety, a decrease in GP visits and lower mortality
than the control group.125 The investment in this kind of prevention is much less demanding
than that required to treat or cure diseases which could have otherwise been prevented. At the
same time, there is underinvestment in these cost-effective preventative measures. OECD data
show that Member States spend an average of 2.9% of their overall budget for health on
prevention, health promotion and public health.126 A new Health Strategy would increase
opportunities for Member States to share good practice in relation to health promotion and
prevention.

The health sector itself can also contribute to economic growth. Health represents a high-
innovation, high-technology industry, with a growing market and potential high multiplier
effects, i.e. many people using similar services. Health systems themselves employ vast
numbers of people and contribute significantly to national economies, but the broader health
sector can be understood to include not only hospitals, clinics and insurance providers, but
laboratories, research, training and education organisations, pharmaceutical and medical
device companies, health-related technology, and even spas, fitness centres and health foods
which are on the increase as people become increasingly concerned about their own health
and wellbeing and want to take responsibility for it. The growth of these areas lead to
increased competitiveness at the regional, national and international levels.
122 Annex to COM(2006) 30 of 25.1.2006.
123 2006 Commission Communication to the Spring European Council - COM(2006) 30, 25.1.2006.
124
DG ECFIN ''The Impact Of Ageing On Public Expenditure', special report 1/2006, p. 133.
125 A cost-utility analysis of preventive home visits in Nordmaling, Sweden, Umea University, project

ongoing.
126 OECD Health Data 2006, Statistics and Indicators for 30 Countries. CDROM, Paris 2006.

Drucksache 16/9412 – 98 – Deutscher Bundestag – 16. Wahlperiode

According to data from the Eurostat Labour Force Survey (LFS) the number of people
employed in the area of Health and Social Work in the EU-15 has grown steadily, from 13 to
15 million in total between 1995 and 2000 and represents in 2005 around 20.1 millions in the
EU-27. In Germany, despite an economic slow-down, 1.1 million new jobs were created in
the health and social sector between 1996 and 2005, and a group of Länder have developed
plans specifically for expanding the health industry127. Similar patterns are observed for most
part of other EU countries in the same period, e.g. 800 000 in the UK, and 600 000 in Spain.

127 Kickbusch I. Innovation in health policy: responding to the health society. Gac Sanit 2007;21 (in press).

Deutscher Bundestag – 16. Wahlperiode – 99 – Drucksache 16/9412

Annex 5: ECHI Indicators – 'First Set'

(indicators are hyperlinks to internet data)

Demographic and socio-economic factors

1. Population by gender/age

2. Age dependency ratio

3. Crude Birth rate

4. Mother's age distribution (teenage pregnancies, aged mothers)

5. Fertility rate

6. Population projections

7. Total unemployment

8. Population below poverty line

Health status

9. Life expectancy

10. Infant mortality

11. Perinatal mortality (foetal deaths plus early neonatal mortality)

12. Standardised death rates Eurostat 65 causes

13. Drug-related deaths

14. HIV/AIDS

15. Lung cancer

16. Breast cancer

17. (Low) birth weight

18. Injuries: road traffic

19. Injuries: workplace

20. Perceived general health, prevalence
21. Prevalence of any chronic illness

Drucksache 16/9412 – 100 – Deutscher Bundestag – 16. Wahlperiode

22. Health expectancy, based on limitation of usual activities

Determinants of health

23. Regular smokers

24. Total alcohol consumption

25. Consumption/availability of fruit, excluding juice

26. Consumption/availability of vegetables, excluding potatoes and juice

27. PM10 (particulate matter) exposure

Health interventions: health services

28. Vaccination coverage in children

29. Breast cancer screening coverage

30. Cervical cancer screening coverage

31. Hospital beds

32. Physicians employed

33. Nurses employed

34. MRI units, CT scans

35. Hospital in-patient discharges, limited diagnoses

36. Average length of stay (ALOS), limited diagnoses

37. GP utilisation

38. Surgeries: PTCA, hip, cataract

39. Expenditures on health

40. Survival rates breast, cervical cancer

Deutscher Bundestag – 16. Wahlperiode – 101 – Drucksache 16/9412

Annex 6: Glossary

Centres of Reference – places accredited with particular expertise in one subject, e.g. a
hospital could be a European centre of reference for a particular rare disease

Chronic Disease – a long lasting or recurrent disease, generally non-communicative, e.g.
cancer or cardiovascular disease

Comitology - the procedures under which the Commission executes its implementing powers
conferred to it by the legislative branch (the European Parliament and the Council), with the
assistance of "comitology" committees consisting of Member State representatives

ECDC – European Centre of Disease Control; the EU Agency to defend infectious diseases
by identifying, assessing and communicating current and emerging threats to human health

ECHI – European Community Health Indicators; a list of indicators which were developed in
collaboration with Eurostat, DG Research, DG Sanco, OECD and WHO with the aim to
provide comparable data on health, covering the 27 Member States and Third Countries

EFSA – European Food Safety Authority; specialised on European Union (EU) risk
assessment regarding food and feed safety, provides independent scientific advice on existing
and emerging risks

EMCDDA – European Monitoring Centre for Drugs and Drug Addiction; the central source
of comprehensive information on drugs and drug addiction in Europe

EMEA – European Medicines Agency; evaluates and supervises medicines for human and
veterinary use. Some medicines are licensed by the EMEA, others by national administrations

EU-10 - The ten Member States who joined the EU in 2004

EU-12 - The ten Member States who joined the EU in 2004, plus Romania and Bulgaria who
joined in 2007

EU-15 – The fifteen Member States who were Members of the Union before May 2004.

EU-OSHA – European Agency for Safety and Health at Work; addresses the diversity of
occupational safety and health issues in the EU in order to make Europe's workplaces safer,
healthier and more productive

EUPHIX – European Union Public Health Information System; develops a prototype for a
sustainable, web-based health information system for the EU

Euratom – European Atomic Energy Community, founded in March 1957, by a second treaty
of Rome

European Commission – The executive body of the European Union and one of the three
main institutions governing the Union, the Commission produces proposals which are then
considered by Parliament and Council

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European Community (EC) – a group of institutions at the European level which was
originally founded in 1957 under the name of European Economic Community, by the signing
of the Treaty of Rome

GDP – Gross Domestic Product; is defined as the market value of all goods and services
produced within a country in a given period of time

Health Determinants – refers to Social Determinants of Health (see below) as well as lifestyle
choices such as smoking, alcohol use, physical activity levels, etc

Health Inequalities – differences in health between geographical areas, or between different
groups (e.g. rich/poor, men/women, old/young)

Health Inequities – inequalities in health which are avoidable and unfair

HIA – Health Impact Assessment; consists of a combination of procedures, methods and tools
by which e.g. a policy is judged as to its potential outcomes and effects on the health of a
population

HIAP – Health in All Policies; mainstreaming of health, with the aim of integrating
consideration of health issues and impacts into all relevant policymaking, both at the
European level and national, regional and local levels

HLY – Healthy Life Years Indicator (similar to disability-free life expectancy); measures the
number of years which a person of a certain age is expected to live without disability

HSIA – Health Systems Impact Assessment; consists of a combination of procedures,
methods and tools by which e.g. a policy is judged as to its potential outcomes and effects on
health systems

HTA – Health Technology Assessment; consists of a comprehensive evaluation of medical
technologies (e.g. pharmaceuticals, products, services) regarding technical performance,
efficacy and effectiveness of the technology application as well as economic, social, legal and
ethical aspects

Mainstreaming – see Health in All Policies (HIAP)

OECD – Organisation for Economic Co-operation and Development, group of 30 Member
Countries with the commitment to democratic government and market economy. Issues range
from macroeconomics to trade, education, development, sciences and innovation

OMC – Open Method of Coordination: a methodology for Member States to work together
toward the goals of the Lisbon agenda

Orphan drugs – Medicines to treat very rare diseases for which demand is low and therefore
industry cannot expect to recuperate costs of research through sales

Social Determinants of health; comprise economic and social conditions under which people
live and which influence their health (e.g. income, social status, education, health literacy,

working conditions, social and physical environments, culture)

Deutscher Bundestag – 16. Wahlperiode – 103 – Drucksache 16/9412

Troika – A group of current, past and future EU Presidencies who meet to share knowledge
and planning

Drucksache 16/9412 – 104 – Deutscher Bundestag – 16. Wahlperiode

COUNCIL OF
THE EUROPEAN UNION

Brussels, 6 November 2007
14689/07
ADD 2

SAN 193
COVER NOTE
from: Secretary-General of the European Commission,

signed by Mr Jordi AYET PUIGARNAU, Director
date of receipt: 23 October 2007
to: Mr Javier SOLANA, Secretary-General/High Representative
Subject: Commission Staff Document

Accompanying document to the White Paper "Together for Health: A Strategic
Approach for the EU 2008-2013
Summary of the Impact Assessment

Delegations will find attached Commission document SEC(2007) 1375.

________________________
Encl.: SEC(2007) 1375

Deutscher Bundestag – 16. Wahlperiode – 105 – Drucksache 16/9412

COMMISSION OF THE EUROPEAN COMMUNITIES

Brussels, 23.10.2007
SEC(2007) 1375

COMMISSION STAFF WORKING DOCUMENT
Accompanying document to the

WHITE PAPER
Together for Health:
A Strategic Approach for the EU 2008-2013

SUMMARY OF THE IMPACT ASSESSMENT
{COM(2007) 630 final}
{SEC(2007) 1374}
{SEC(2007) 1376}

Drucksache 16/9412 – 106 – Deutscher Bundestag – 16. Wahlperiode

1. PROBLEM DEFINITION

The need for a new Strategy is based on growing and changing challenges that face the EU,
and which can only be met effectively by a coordinated response at EU level involving all
partners and stakeholders. These include the ageing of the population which is changing
disease patterns and putting pressure on the sustainability of health systems and the wider
economy in an enlarged EU. Health threats such as communicable disease pandemics and
bioterrorism are a growing concern, while the health impact of climate change raises new
threats. New technologies are revolutionising the way health is promoted and illness is
predicted, prevented and treated, and globalisation continues to change the way we interact
with the wider world.

Enlarged EU with Greater Inequities in Health

In an EU of 27 Member States there are wide health inequities (inequalities that are avoidable
and unfair) within and between countries. For example, in Italy, men live 71 Healthy Life
Years (HLY) compared to 53 HLY for men in Hungary. The ageing population will put a
strain on health systems and the wider economy. Commission projections have estimated that
if HLY increase at the same rate as increasing life expectancy, health care costs due to ageing
would be halved. Although action is already taking place in this area, the EU could add value
by, for example, further encouraging the use of Regional Policy programmes for health and
by sharing good practice in this and other areas.

Current and Emerging Threats to Health

Protecting citizens against health threats such as communicable and non-communicable
diseases, and improving safety and security are ongoing health challenges where the EU
provides clear added value, because these are issues which cross boundaries and cannot be
tackled effectively by individual Member States. A new Strategy can add value by providing
new opportunities to share good practice and drive forward improvements in areas such as
communicable disease surveillance where EU systems can be further developed, and patient
safety, where currently as many as 10% of hospital patients suffer an adverse effect.

Sustainable Health Systems

The sustainability of health systems in the future is a challenge where the EU can add value
on cross border issues such as patient and health professional mobility, and in facilitating
exchange of knowledge and good practice on issues such as demographic change and the
appropriate use of new technologies. The new Strategy can add value through the Community
Framework for Safe and Efficient Health Services which is one of the initiatives it will
encompass.

Globalisation and Health

In today's globalised world it is increasingly difficult to separate national or EU wide actions
from global policy. Decisions affecting EU citizens directly are often made at global level,
and EU's internal policy can have consequences outside the EU borders. The proposed Health

Strategy can add value by putting a new focus on strengthening the EU's voice on global
health issues on the international stage and on tackling issues such as the global shortage of
health professionals and improving access to medicines and technologies.

Deutscher Bundestag – 16. Wahlperiode – 107 – Drucksache 16/9412

Good Governance

To be effective, a new Strategy needs to support the principles of good governance, meaning
that the EU's response to these challenges would be coordinated, effective, transparent, and
coherent.

A coherent framework for health policy at EU level would act as a driver for achieving
objectives, and would help to rationalise and simplify existing structures. A Strategy at EU
level would help strengthen health action at national level, and would guide the use of EU
instruments and actions for health.

The proposed Strategy would have a focus on Health in All Policies, a concept which
underpins the EU health action in the Treaty. A cross-sectoral approach is more effective than
an approach which is limited to the health sector. The Strategy would encourage this approach
at national as well as EU level.

A new Strategy would also make EU health action more visible to stakeholders including
Member States, international organisations, NGOs, industry, academia and citizens.

2. SUBSIDIARITY TEST

EU Member States have the prime responsibility for protecting and improving the health of
their citizens. As part of that responsibility, it is for them to decide on the organisation and
delivery of health services and medical care. However, the fundamental aims of the EU in
terms of free movement of goods and services and working together on cross-border issues,
necessarily have a health dimension. It is recognised that there are many areas relating to
health where, to be effective, action needs to involve cooperation and coordination between
countries. The prevention of major health scourges, pandemic preparedness, or movement of
patients or health professionals are areas where Member States cannot act alone effectively,
and where cooperative action at EU level is indispensable.

The EU can add value through a wide range of activities. These may include working to reach
critical mass or obtain economies of scale, for example sharing information on rare diseases
where only a small number people are affected in each Member State. It may mean working
with Member States to enlarge the internal market and increasing the international
competitiveness of health services. Added value can be found in health promotion
campaigns such as the 'Help' tobacco campaign1, in devising common standards such as
food labelling, in the support of pharmaceutical research and in e-health development and
deployment. Sharing best practice and benchmarking activities in many areas can play a
major role for the efficient and effective use of scarce resources and support future financial
sustainability.

The EU's legal right and obligation to take action on cross-border health issues, and its
demonstration of success in taking relevant and effective action on health, while respecting
Member States' prerogative, and the ability of the EU to add value to work done by Member
States in the field of health are clearly demonstrated.

1 http://ec.europa.eu/health/ph_determinants/life_style/Tobacco/help_en.htm

Drucksache 16/9412 – 108 – Deutscher Bundestag – 16. Wahlperiode

3. OBJECTIVES

The broad objectives of the Strategy are to address the key health challenges faced in the
coming decade, through protecting citizens from health threats, supporting healthy ageing,
supporting sustainability of health systems and the wider economy, increasing the focus on
global health, working to reduce inequities in health, and supporting a Health In All Policies
approach. More detailed specific actions would be defined in the follow-up to the Strategy.

4. POLICY OPTIONS

Four options were analysed.

Option 1: to continue the status quo.

Option 2: to put in place a Health Strategy with an enhanced Health In All Policies approach
at EU level but no new mechanisms with Member States or other stakeholders

Option 3: to put in place a Health Strategy with an enhanced Health In All Policies approach
at EU level and a new Structured Cooperation implementation mechanism to engage Member
States and other stakeholders

Option 4: to put in place the same measures as in Option 3, with the addition of legislation to
set binding targets for key objectives in the Strategy

5. ANALYSIS OF IMPACTS

Economic Impacts

There is a clear link between a healthy population and economic prosperity. Under Option 1,
the full potential for enhancing support for the wider economy through health improvements
would not be achieved. Under Option 2, enhanced development of cross-sectoral synergies
could lead to a positive impact on the economy through better understanding of, for example,
the impact of health on the labour force and the impact of innovation on health systems.
However, without the full engagement of Member States these gains would be limited. Under
Options 3 and 4, a stronger positive impact would be expected as a new Structured
Cooperation mechanism would allow Member States to share knowledge and good practice in
relation to, for example, investments in health. Through a visible new Strategy, the link
between health and economic prosperity would be better understood, supporting sustainable
health systems and economic gains in the long term.

Social Impacts

Positive social impacts would continue from ongoing health actions under the Status Quo
option, but this would ignore the potential for improvements through a new strategic
framework. Option 2 would build on existing cross-sectoral synergies which could lead to a
positive social impact particularly in fields like employment and health, and health education.
However, this impact would be likely to be limited without the full engagement of Member

States and other stakeholders. Under Option 3, positive social impacts would be expected
through the new strategic focus and Structured Cooperation mechanism. A risk of binding

Deutscher Bundestag – 16. Wahlperiode – 109 – Drucksache 16/9412

legislative targets under Option 4 could be that this would oversimplify complex issues,
leading to less 'across the board' improvement than in Option 3.

Environmental Impacts

Ongoing work on environmental health issues would mean some positive impacts under the
Status Quo option. Option 2 could offer further benefits through increasing cross-sectoral
cooperation in fields such as climate change, and by building on existing work. Option 3
would offer the greatest potential for improvement through increasing opportunities for
Member States and other stakeholders to share knowledge and experience on environmental
health issues, including global issues. Option 4 would offer similar outcomes to Option 3, but
could be seen as unnecessarily burdensome.

Comparing the Options

Option Impact for Health Objectives Impact for Governance
Objectives

Option 1: Status
Quo

Option 1 would lead to benefits based
on continuing action to protect and
improve people's health, including
sharing knowledge and best practice.

However, the lack of a coherent
strategic direction may mean that
potential for improvement would not
be fully exploited. New health
challenges, including those linked to
the enlargement to 27 Member States
from 15 in 2004, may not be
adequately addressed. Economic
benefits of a more targeted approach to
health systems issues could be lost.

Effective work would continue,
including work with other sectors.

However, a clear, strategic vision for
the future would not be achieved, and
there would not be a focus on
addressing key new challenges and
fully exploiting synergies between
sectors at all levels.

Without a well defined Strategy,
presenting a clear direction of travel
that stakeholders and citizens could
engage with would be difficult.

Option 2: Health
Strategy with

Enhanced
Intersectoral
Action

Through a more strategic approach to
the many varied actions across the EU
that impact on health, Option 2 could
lead to benefits, for example a stronger
focus on supporting healthy lifestyles,
or further clarification of issues
relating to the use of new technologies
within health systems.

However, without full engagement by
Member States the added value and
actual outcomes under this Option
would be limited.

Option 2 would set strategic
objectives which would help to
strengthen HIAP cooperation across
sectors by offering a clear, strategic
framework and direction of travel.

However, it is likely that the new
framework would not become widely
recognised by Member States and
other stakeholders, and that progress
towards the objectives would
therefore be limited. Option 2 would
be unlikely to adequately fulfil the
objective of greater visibility and
understanding of work on health at

EU level.

Option 3: Health Option 3 would be likely to lead to Option 3 would put in place a system

Drucksache 16/9412 – 110 – Deutscher Bundestag – 16. Wahlperiode

Strategy with

Enhanced
Intersectoral
Action and

Structured
Cooperation with
Stakeholders

positive impacts by engaging all
Member States through a Structured
Cooperation system, including
measuring progress against indicators,
to focus attention on tackling new
challenges, such as protecting health,
reducing inequities, supporting healthy
lifestyles, addressing the future
sustainability of health systems, and
supporting the consideration of global
issues in health policy at all levels.

of Structured Cooperation with
Member States and stakeholders to
support work towards objectives and
open up new opportunities for sharing
knowledge and information.

It would go beyond Options 1 and 2
by supporting greater recognition of
the importance of intersectoral
working at national, regional and
local levels across the EU, and greater
involvement of non-traditional
stakeholders as partners to achieve
health aims.

Option 3 would be more likely than
Options 1 and 2 to fulfil the objective
of improved visibility of work on
health at EU level.

Option 4: Health
Strategy with

Enhanced
Intersectoral
Action,

Structured
Cooperation with
Stakeholders and

Binding Targets

Option 4, like Option 3, would be
likely to have a positive outcome
through putting in place a new
Structured Cooperation mechanism to
help focus attention on key challenges.
The impact might be greater than in
Option 3 due to the imposing of
binding legislative targets.

However, this may be seen as
disproportionately burdensome to
Member States and may reduce their
flexibility in addressing problems at
national level.

Option 4 would be likely to be
slightly more effective than Option 3
as it would enforce Member States to
work toward the objectives through
binding targets, rather than relying on
the cooperation process alone.

Similarly, it might be slightly more
effective in improving visibility of
work done at the EU level, as setting
binding targets may mean that more
policymakers at national, regional and
local levels are required to consider
EU health objectives.

This Option, however, could be seen
as disproportionately burdensome to
Member States.

Option 3 uses the powers given to the EU in the Treaty to go a step further than Option 2, by
putting in place a new implementation system. This Option would ensure that the new
strategy is not just a paper exercise, but that it drives real change. At the same time it does not
go too far in placing a burden on Member States and respects the subsidiarity and
proportionality principles. This Option is therefore the preferred Option.

Monitoring and Evaluation

Monitoring and evaluation will be on the basis of measurement against the seven objectives.
The three 'good governance' objectives can be measured by the following indicators:

� Process indicator – that a framework with objectives has been put in place (objective 5)
� Quantitative indicator – awareness of the new strategy among policymakers, professionals,
academia and the public

Deutscher Bundestag – 16. Wahlperiode – 111 – Drucksache 16/9412

� Qualitative indicator – that HIAP is more common practice at all levels

Setting the parameters for monitoring and evaluation of the four health objectives of the
Strategy are outside the scope of the White Paper and will need to be decided with Member
States following adoption of the Strategy. The recommendation to take forward Option 3
means that a new implementation mechanism of Structured Cooperation will be agreed and
set up by and with Member States. One of the first tasks of this new Cooperation process will
be to set indicators for monitoring the Strategy, target values for those indicators, and how
frequently data will be collected.

The Strategy will have a mid-term evaluation and a final evaluation and will cover a period of
10 years.

Consultation of Interested Parties

Two consultation processes took place in relation to the proposed Strategy. The first was in
2004 where the document 'Enabling Good Health for All – A Reflection Process for a new EU
Health Strategy' generated a broad debate among stakeholders. 193 responses were received,
which supported a focus on mainstreaming health into other policy areas, reducing health
inequalities within and between Member States, health promotion, a stronger role for the EU
in global health issues, and tackling key issues including those with a cross-border impact.

The second consultation was launched on 11 December 2006 and ended on 12 February 2007.
156 responses were received including responses from 16 Member States. Responses
reflected the previous consultation and expressed general support for the Strategy. Inter alia,
responses called for a focus on tackling health threats, reducing health inequalities, promoting
healthy lifestyles, and improving the availability of comparable data across the EU. There was
also broad support for an implementation mechanism similar to the Open Method of
Coordination that is used for achieving progress towards the goals of the Lisbon agenda.

Drucksache 16/9412 – 112 – Deutscher Bundestag – 16. Wahlperiode

COUNCIL OF
THE EUROPEAN UNION

Brussels, 6 November 2007
14689/07
ADD 3

SAN 193
COVER NOTE
from: Secretary-General of the European Commission,

signed by Mr Jordi AYET PUIGARNAU, Director
date of receipt: 23 October 2007
to: Mr Javier SOLANA, Secretary-General/High Representative
Subject: Commission Staff Document

Accompanying document to the White Paper
"Together for Health: A Strategic Approach for the EU 2008-2013

Delegations will find attached Commission document SEC(2007) 1376.

________________________
Encl.: SEC(2007) 1376

Deutscher Bundestag – 16. Wahlperiode – 113 – Drucksache 16/9412

COMMISSION OF THE EUROPEAN COMMUNITIES

Brussels, 23.10.2007
SEC(2007) 1376

COMMISSION STAFF WORKING DOCUMENT
Document accompanying the
WHITE PAPER

Together for Health:
A Strategic Approach for the EU

2008-2013
{COM(2007) 630 final}
{SEC(2007) 1374}
{SEC(2007) 1375}

Drucksache 16/9412 – 114 – Deutscher Bundestag – 16. Wahlperiode

1. INTRODUCTION

This paper has been prepared to support and provide background on the White Paper
"Together for Health: A Strategic Approach for the EU 2008-2013" (COM(2007) 630) of the
European Commission. The Health Strategy aims to be a cohesive framework document,
giving clear direction to Community activities in the field of health for the coming years in
order to further improve and protect health in the EU and beyond its borders. It reinforces the
importance of health within key EC1 policies such as the Lisbon Strategy for Growth and
Jobs, in terms of the links between health and economic prosperity, and the Citizens' Agenda,
in terms of people's right to be empowered in their health and healthcare. The Strategy is a
framework which goes across sectors, recognising the contributions to health of a wide range
of other policy areas.

The Strategy puts forward an overall approach, based on four fundamental principles and
three strategic objectives, selected with the aim of tackling areas in which strong European
added value can be achieved. This Staff Working Paper aims to provide background on the
principles and strategic objectives of the Strategy and to provide more detail on the actions
identified in the White Paper. Priority actions where the aim is to make specific proposals
within the next 2 years are set out in the White Paper and elaborated in this document, while
further actions will be proposed throughout the life of the Strategy. The Commission will
work with Member States to develop more specific operational objectives within these
strategic objectives.

One of the major differences between this Health Strategy and previous strategic documents
on health is that it proposes key cooperation mechanisms together with the Member States
and stakeholders to implement the Strategy and to reach concrete results as well as a
strengthened approach to Health in All Policies. Annexes 1-6 therefore aim to provide an
overview on what is done on health at European level, not only in health policy, but also in
other policy areas. Annex 1 lists the main Community public health legislation. Annex 2 sets
out how different Commission departments contribute to health policy, and Annex 3 gives an
overview of financial Community instruments that are used to finance health related actions.
Community agencies working in health are listed in Annex 4, and international commitments
in health are provided in Annex 5. Annex 6 provides text from the Treaty showing examples
of articles where health is mentioned.

2. FUNDAMENTAL PRINCIPLES FOR EC ACTION ON HEALTH

PRINCIPLE 1: A STRATEGY BASED ON SHARED HEALTH VALUES

Shared Values

The European Union is "founded on the principles of liberty, democracy, respect for human
rights and fundamental freedoms, and the rule of law, principles which are common to the
Member States"2.

1 European Community.
2 Article 6 TEU (http://europa.eu.int/eur-lex/lex/en/treaties/dat/12002M/pdf/12002M_EN.pdf).

Deutscher Bundestag – 16. Wahlperiode – 115 – Drucksache 16/9412

The EC aims not only to provide a well functioning internal market for goods, capital and
services, it also supports social justice and respect for human dignity, and therefore its internal
and external actions should strive to support these values. This is particularly important in the
field of health, which is a key element in individual and social well being.

Community actions to support the objectives of the Health Strategy should therefore be built
on fundamental rights relating to health and health as a global public good. In addition, they
should make concrete common values such as equity, participation and empowerment of
citizens, and transparency.

Equity and Solidarity

Although today's Europeans are healthier, wealthier and can expect to live longer than their
predecessors, there are still major differences in health between and within EU Member States
and regions in terms of life expectancy, health status and access to high quality health
services. Health inequities (which can be defined as inequalities in health that are avoidable
and unfair) is a term which has been used widely to refer to a broad range of issues – to
differences in health outcomes, differences in access to treatment and care, and differences in
health between different groups within countries, such as between rich and poor, or between
male and female. It also refers to differences between countries and the need to work towards
a situation where all European citizens have an equal opportunity to enjoy a high level of
healthcare regardless of where they live or their social status.

In the last 25 years, life expectancy at birth has increased by an average of over 4.5 years in
the EU Member States. But this general trend masks major differences between countries.
Some Member States experienced a decline in life expectancy during the mid-1990s and in
Latvia and Lithuania life expectancy at birth has dropped significantly in the latest available
figures (2005)3. Life expectancy is a key summary indicator of health but it is based entirely
on death rates. Healthy Life Years (HLY) is a concept which allows us to consider how much
time people are spending in good health, which can be expected to correlate better than life
expectancy with the level of active participation in society and with the strain placed on health
systems by a population in poor health. Healthy life expectancy in the EU has not increased
consistently year on year and there are major differences between Member States which are
related to factors influencing good health during life, rather than life expectancy.

Huge differences in health also exist within Member States between people living in different
parts of the same country and between people in the best and worst socio-economic situations.
There is a clear link between income and child mortality. Poverty, unemployment, low levels
of education, differences in gender, genetic risks, membership of some minority ethnic
groups, and disability are some of the factors that are often associated with poorer health.
Typical differences in life expectancy between groups of people with highest and lowest
educational levels or highest and lowest income groups within an EU country are in the region
of 4 to 5 years4.

Reducing these health gaps is essential not only because health is important in its own right,
but because they contribute to undesirable pressure on the social and economic development
of the EU as whole and hinder its integration and competitiveness.

3 Source: Eurostat.
4 Health Inequalities: Europe in Profile. Mackenbach J. 2006

(http://ec.europa.eu/health/ph_determinants/socio_economics/keydo_socioeco_en.htm)

Drucksache 16/9412 – 116 – Deutscher Bundestag – 16. Wahlperiode

Tackling inequalities in the economic, social, environmental, genetic and behavioural
determinants of health as well as in the quantity and quality of health services is a major
challenge which requires coordinated action both at national and European level, and a new
focus is needed in this area to review existing policies and mechanisms for doing so, on the
basis of solid data and information on developments. Working across different sectors is also
vital in reducing health inequalities. In particular, mainstreaming of gender issues in relation
to health policy must be undertaken with the aim of reducing health inequities related to
gender5 The Commission is committed to improving quality and comparability of gender-
specific health data6. Technologies can also support the full participation of citizens in their
healthcare, in particular the elderly and those with disabilities, including through new
developments such as e-health and e-inclusion (supporting social integration)7.

EC regional policy can help play a role in closing gaps in health inequalities between
countries and regions, both through the health benefits of appropriate economic development
and through specifically targeted investments in the health sector. In the programming period
2000-2006, 3% of the Structural Funds budget was planned to fund actions on social
infrastructure and health in the EU Member States (including EU cross-border cooperation).
For the period 2007-13, indications are that expenditure in the category 'health infrastructure'
will constitute around 1.5% of the Structural Funds' budget. Further health-related
interventions beyond this percentage include health-related research infrastructures and
support, support to SMEs in the health sector and labour market and training activities in the
health sector. Cooperation on the development of intersectoral policies to tackle inequities in
health should be part of strategic cooperation with Member States and Regions. The potential
for Regional Policy to contribute to the health sector and help improve the population's health
should be maximised. This includes not only direct investments in health infrastructure,
health-related research and innovation and training, but also facilitating exchange of good
practices and experiences between and within Member States, including through the Regions
for Economic Change initiative8.

The large and growing inequities in access to healthcare at global level also call for EU joint
action on global health. At present, the level of public funding for health in the EU is on
average some 100 times higher than the level of spending in sub-Saharan Africa. There is a
need to expand the concepts of equity and solidarity beyond the EU's borders and to progress
towards universal access to basic healthcare. The EC’s external relations should priorities
health inequities and act in coherence with internal health policies.

Citizens' Empowerment
Individuals must play a role in taking care of their own health, and therefore citizens' and
patients' participation and empowerment need to be regarded as core values in all health-
related work at EC level. A recent Eurobarometer survey showed that healthcare was one of
5 In June 2006 the Council invited the commission to take into account and integrate the gender

dimension (Council Conclusions on Women's Health 2006/C146/02). The Commission roadmap for
equality between women and men recognises the gender dimension in health - COM(2006) 192.

6 Council resolution of 4 December 1997
7 See COM(2007) 332 "Ageing Well in the Information Society, an i2010 initiative, Action Plan on

Information and Communication Technologies and Ageing".
8
COM(2006) 675 and SEC(2006) 1432 of 8.11.2006 include in the list of priority themes for

modernisation several themes of relevance to the proposed health strategy, including 'Making healthy
communities', 'Promoting a healthy workforce in healthy workplaces' and 'Meeting the demographic
challenge'.

Deutscher Bundestag – 16. Wahlperiode – 117 – Drucksache 16/9412

the main concerns of EU citizens9. Health policy should provide mechanisms and support for
citizens to acquire the necessary knowledge and competences to enable them to act effectively
in the interests of their own health and that of their families and communities, both in their
everyday lives at home, work and school as well as when they are using the healthcare
system.

Information and Communication Technology (ICT) is a key instrument for supporting
empowerment of citizens and patients in health. E-health applications make health
information widely available so that people are becoming more knowledgeable about health
and want to be actively involved in decisions affecting their health and wellbeing. Reflecting
this, healthcare is becoming increasingly patient-centred. Building on the work on the
Citizens’ Agenda10, Community health policy must take citizens' and patients' rights as a key
starting point. This includes the ability to participate in and influence decision-making as well
as to gain competences, through education, to maintain their wellbeing, in line with the
European Framework of Key Competences for lifelong learning11. Community health policy
should also support better access to individualised health information, prevention tools and
healthcare. The EC has a role in sharing good practice on innovative e-health solutions and on
encouraging more access for citizens to better information about healthcare.

Citizens' empowerment can also be supported by civil society and NGOs, including patients'
groups and disease support and advocacy networks. This principle also applies to the global
dimension, and relates to the need to ensure "grassroots" ownership of development policies
in respect of the Paris Declaration on Aid Effectiveness12, which states that citizens and
governments should play an active role in policy making.

The diversity of information about health is also stimulating requests from the public for
reliable and comparable EU health data, for a stronger evidence-basis for policy decisions and
enhanced transparency. A comparable European Health Information and Knowledge System
is crucial for supporting decision-making at the health systems’ strategic, control and
operational levels, monitoring their implementation and evaluating their impact. It aims to
create a harmonised and methodologically agreed system for health monitoring and
surveillance in the EU sharing common mechanisms for collection of health data.

To support the transparency of health policy and to underline its link to scientific evidence,
information on how the results of health-related research are used as a basis for health policy
also needs to be actively and widely disseminated. Contacts between health experts are also
crucial for enabling information sharing, finding partners for projects and development and
testing of new ideas. Opportunities and mechanisms for contacts and networking should be
enhanced across the EU and more broadly, for example by using web-based technology and
building on the experience of the Health Portal13.
9 https://www.eurobarometer-conference.eu/pdf/eb65/eb65_first_en.pdf
10
COM(2006) 211.
11 http://eur-lex.europa.eu/LexUriServ/site/en/oj/2006/l_394/l_39420061230en00100018.pdf
12 Adopted at the High Level Forum, Paris 2005.
13 www.health.europa.eu

Drucksache 16/9412 – 118 – Deutscher Bundestag – 16. Wahlperiode

Actions

� Adoption of a Statement on fundamental health values (Commission, Member States)

Following the statement of the Council on common values and principles in EU Health
systems, adopted in June 200614, further values will be elucidated for all EC action on health
in agreement with Member States. These will relate both to individual citizens and patients
and society, covering health policy in the EU and in its external relations, as a reference for
actions.

� System of European Community Health Indicators with common mechanisms for
collection of comparable health data at all levels, including a Communication on the
exchange of health-related information (Commission)

To improve the collection, comparability and compatibility of health data, current work on
developing a comparable European system of health indicators needs to be continued, based
on common mechanisms for collecting comparable health data (for example, the European
Health Survey System including a European Health Examination Survey, the EU Hospital
Information System and the System of Health Accounts), including at the regional level. The
statistical element of this system will be further developed within the context of the
Community Statistical Programme in general and the forthcoming legislative framework for
Community health statistics15 in particular. In relation to this action, a Communication will be
developed on the European Union Health Information, Knowledge and eHealth System
covering the future organisation and responsibilities for health information in the EU between
the different stakeholders participating in the health information generation process.

� Further work on how to reduce inequities in health

This Communication will set out measures to be taken by the Commission to support the
efforts of Member States and other organizations to reduce inequities in health.

� Promotion of health literacy programmes for different age groups (Commission)

To help citizens make sound judgements about their health based on reliable and up-to-date
information and data, health literacy needs to be improved within the EU. Initiatives within
this package will explore the use of approaches including school education systems,
programmes for children, extra curricular activities and peer education for young people,
web-based education modules for adults, and health education in the workplace.

14 Reference number 2006/C 146/01.
15 COM(2007) 46.

Deutscher Bundestag – 16. Wahlperiode – 119 – Drucksache 16/9412

PRINCIPLE 2: "HEALTH IS THE GREATEST WEALTH"16

There is growing evidence showing how health contributes to wealth and how investment in
health contributes to long term growth and sustainability of economies17. Health policymakers
have long argued that ‘health means wealth’; that a healthy population is necessary for
economic productivity and prosperity, and that wealth, particularly in the form of effective
investment, also supports better health. Despite clear evidence supporting the link between
health and economic prosperity, it is not always adequately taken into account. In 2005, the
Healthy Life Years (HLY) indicator was included as a Lisbon Structural Indicator,
recognising that the population's life expectancy in good health was an important measure in
understanding and supporting economic growth. The use of the HLY indicator at all levels
still needs to be encouraged and increased. The Commission pointed out, in its report to the
2006 Spring European Council, that Member States need to reduce the high numbers of
people who are inactive because of their ill-health18 and that Europe cannot afford to have
people drop out of the labour market when they are in their fifties19. This report urged action;
rather than just seeing health as a negative cost, it recognised that policy in many sectors has a
role in improving health for the benefit of the wider economy.

Spending in the health sector is an important and rising cost for national administrations and
social security schemes - healthcare spending around the world is generally rising at a faster
rate than economic growth20. Furthermore, alongside the rising costs of running health
systems and services, the cost of ill-health is in itself a significant burden to the economy.
Despite the problems in measuring these costs, it is clear that the impact of illness on the
economy is huge. Poor health is an important factor in early retirement and worker
absenteeism. Studies have shown that in Germany, the probability of leaving the workforce at
the earliest possible age is 4 times higher for men with disabilities, and in Ireland, the
proportion of labour participation is 61% lower for men with chronic diseases21. People who
continue to work despite health problems are also likely to be less productive than healthy
people22.

Costs associated with health are significant, but effective investment in health can lead to
more efficient health systems and social security schemes, more people avoiding illness, and
therefore to greater future financial sustainability. As well as healthcare treatment, effective
prevention programmes can have substantial effects on reducing major and chronic diseases.
For example, the largest single factor contributing to the decline in cardiovascular disease
occurring in the EU over the last 20 years has been the decrease in tobacco smoking owing to
a combination of tobacco control measures and support to individuals to quit. Investment in
this kind of prevention can be much more cost effective than that required to treat or cure
diseases which could have otherwise been prevented. There is growing evidence that an
16 Virgil (70-19 BC).
17 Cf. in particular ‘The contribution of health to the economy in the European Union’. M. Suhrcke, M.

McKee, R. Sauto Arce, S. Tsolova, J. Mortensen, Luxembourg, August 2005 (study carried out with a
grant from the European Commission, Directorate General for Health and Consumer Protection).

18 Annex to COM(2006) 30, 25.1.2006 (www.adb.org/documents/books/ado/2003/update/sars.pdf).
19 2006 Commission Communication to the Spring European Council - COM(2006) 30, 25.1.2006.
20
Snapshots: Health Care Spending in the United States and OECD Countries Jan 2007

(http://www.kff.org/insurance/snapshot/chcm010307oth.cfm)
21 The contribution of health to the economy in the EU, European Commission, 2005.
22 The contribution of health to the economy in the EU, European Commission, 2005, p. 20-22.

Drucksache 16/9412 – 120 – Deutscher Bundestag – 16. Wahlperiode

increase in investment in preventative measures could reduce the expected growth in
healthcare costs. Data from the Organisation for Economic Cooperation and Development
(OECD) show that their Member States spend on average only 2.9% of their overall budget
for health on prevention, health promotion and public health23, and there is therefore potential
for the EC to work to encourage Member States to develop and share best practice in
investment in these areas. The understanding of economic factors relating to health and illness
and the economic impact of health improvement both in the EU and globally must be
improved including through developing information and analysis in the Commission as well
as working with partners such as the OECD and the European Observatory on Health Systems
and Policies.

Furthermore, the health sector itself can contribute to economic growth. Health represents a
high-innovation, high-technology industry, with a growing market and potential high
multiplier effects, i.e. many people using similar services. Healthcare industries constitute a
strong and growing sector of the EU's economy. The main industries include pharmaceuticals
and biotechnology, medical devices and e-health with the latter currently growing at the
fastest rate24. Health systems themselves employ vast numbers of people and contribute
significantly to national economies, but the broader health sector can be understood to include
not only hospitals, clinics and insurance providers, but also laboratories, pharmacies, research,
training and education organisations, safety and health at work institutions, pharmaceutical
and medical device companies e-health industries, and even spas, sport and fitness centres and
health foods which are on the increase as people become increasingly concerned about their
own health and wellbeing and want to take responsibility for it. According to data from the
Eurostat Labour Force Survey (LFS) the number of people employed in the area of Health and
Social Work in the EU-15 has grown steadily, from 13 to 15 million in total between 1995
and 2000, and rising to around 20.1 million in 2005 in the EU-27. In Germany, despite an
economic slow-down, 1.1 million new jobs were created in the health and social sector
between 1996 and 2005, and several Länder have developed plans specifically for expanding
the health industry25. Similar patterns are observed for most other EU countries in the same
period, e.g. 800 000 in the UK, and 600 000 in Spain.

For individuals too, health and socio-economic factors are linked. People in poorer areas and
those with lower social, economic and educational status suffer more illness and die younger
than those better off. The wealthy have access to better quality health care than other groups –
good health in turn enables people to work longer and more productively, thus ensuring their
income.

The link between health and economic growth is just as relevant globally where the impact of
a disease such as HIV/AIDS can have a devastating effect on the whole economic and social
fabric of poorer countries. For example, the SARS outbreak in 2003 which ultimately killed
about 800 people, led, despite the well-organised international response, to a total cost for the
East and Southeast Asian economies as a whole of about US $18 billion26. Without this
effective international action, the human and financial cost would have been much higher.
23 OECD Health Data 2006, Statistics and Indicators for 30 Countries. CDROM, Paris 2006.
24 Esko Aho, Creating an Innovative Europe: Report of the Independent Expert Group on R+D and

Innovation Appointed Following the Hampton Court Summit, available at: http://ec.europa.eu/invest-in-
research/pdf/download_en/aho_report.pdf

25
Kickbusch I. Innovation in health policy: responding to the health society. Gac Sanit. 2007;21(4):338-
42.

26 Assessing the Impact of SARS in Developing Asia, Asian Development Outlook 2003 Update
(www.adb.org/documents/books/ado/2003/update/sars.pdf)

Deutscher Bundestag – 16. Wahlperiode – 121 – Drucksache 16/9412

The global relevance to the ‘health is wealth’ principle is also clear in the fact that developing
countries face the greatest challenges in providing adequate health financing. There is a
critical need to address the issue of enabling public financing of basic healthcare for all.

Actions

� Development of a programme of analytical studies of the economic relationships
between health status, health investment and economic growth and development
(Commission, Member States)

The Commission, working with partners, will develop a programme of analytic studies of the
links between economic growth and investments and innovation in the health and life sciences
sectors, including ICT for health. This will aim to inform the Member States through
synthesising the most up-to-date knowledge and experience on cost-effective health policies
and actions, Including, for example, evaluating the relative weight to the economies of
different EU Member States of compensation paid for various forms of ill-health
(occupational diseases and/or accidents) contracted during work, analysing the economic
impact of different investments in health and different kinds of health interventions (including
prevention measures as opposed to treatment), and analysing economic pressures on health
systems including the impact of technologies, or demographic and social change, and of
mobility of patients and health professionals.

PRINCIPLE 3: HEALTH IN ALL POLICIES

Health in All Policies (HIAP) is a concept that underpins work on health at the European
level. Under article 152 of the Treaty, the EC is required to make sure that a high level of
health protection is ensured in ‘the definition and implementation of all Community Policies
and Activities’. Health is also mentioned in other articles throughout the Treaty. For example,
Article 137(1)(a) which requires the European Community to support and complement the
activities of the Member States in the field of health and safety and work27. A list of other
references in the Treaty is included in Annex 6.

There are many other fields which have an impact on health, such as regional policy, external
policy, trade, agriculture, transport, environment, energy, research, economic policy, and
social policy. Policy partnerships are ongoing in many of these fields, and important work to
integrate health into other policies has been undertaken at Community level. Examples
throughout this document relate not only to policy in the health sector but policy across many
different sectors at Community level. This Strategy sets out a number of actions in the field of
health, many of which are in areas with clear cross-sectoral links, and which will involve the
participation of different sectors to achieve them. Methodologies such as Health Impact
Assessment (HIA) and Health Systems Impact Assessment (HSIA) have been developed. In
addition, a number of European Agencies are doing important health-related work (see Annex
4). However, systems for supporting health-related work in non-health policy areas need to be
strengthened and made more systematic at all levels of government.

Taking action on health within the health field alone is not sufficient and can even have
negative consequences: that the health benefits of actions in other areas are not fully

27 Article 137(1)(a).

Drucksache 16/9412 – 122 – Deutscher Bundestag – 16. Wahlperiode

recognised; that the impact of other policies on health and health systems is not sufficiently
taken into consideration by the health sector; that the possibilities for sharing knowledge and
expertise are not exploited, and that full potential for health improvement and protection is not
achieved. A multi-sectoral approach needs to be supported and strengthened at EC, national,
regional and local levels to contribute to more efficient actions on health. This approach
should include recognition of the importance of a solid evidence base to demonstrate impacts
on health. The EU has a role in working with Member States to share best practice on
increasing capacity for cross-sectoral working in the field of health.

A HIAP approach also needs to permeate external policies, building on existing international
commitments28. These should complement internal Community actions, in the same way as
the Community should build on its internal experience when participating in global
negotiations.

Actions

� Strengthening integration of health concerns into all policies at Community, Member State
and regional levels, including use of Impact Assessment and evaluation tools
(Commission, Member States)

HIAP approaches will be encouraged and promoted at all levels, including through giving
Member States new opportunities to network, share experience and best practice, with the aim
of supporting increased intersectoral cooperation in the field of health. The use of HIA and
HSIA, which are already recognised as part of the Commission’s Impact Assessment
mechanism, will be encouraged. The online Health Systems Impact Assessment Tool, which
offers a methodology and background information on key policy areas in relation to their
interaction with and impact on health systems, will be further developed. This will include
adding further assessments of policy areas and disseminating the Tool at EC, national,
regional and local levels to make it available to people assessing new initiatives which may
have an impact on health systems. Opportunities for using post-hoc evaluation to support the
integration of health into other policies will be explored.

PRINCIPLE 4: STRENGTHENING THE EU'S VOICE IN GLOBAL HEALTH

The EC has a Treaty obligation in Article 152 to 'foster cooperation with third countries and
the competent international organisations in the sphere of public health.'

Global health refers to health issues which transcend EU and national borders and individual
governments. It includes those health problems affecting citizens inside and outside the EU
which need to be addressed through actions at global level.

Globalisation has increased cross-border flows of people and products. Huge inequities in
access to basic healthcare and exposure to the determinants of ill-health are a significant
destabilizing factor. This results in an increased global spread of both communicable and life-
style related disease, which causes human suffering for both EU and non-EU citizens. In
relation to communicable disease, global HIV/AIDS deaths are projected to rise from 2.8
million in 2002 to 6.5 million in 2030. There is also an important burden of disease and

28 See Annex 5 of the Impact Assessment accompanying the White Paper for key commitments.

Deutscher Bundestag – 16. Wahlperiode – 123 – Drucksache 16/9412

premature deaths by respiratory conditions during childhood, and non-communicable diseases
are gradually becoming more important. The global proportion of deaths due to non-
communicable diseases is projected to rise from 59% in 2002 to 69% in 2030 and total
tobacco-attributable deaths are foreseen to rise from 5.4 million in 2005 to 8.3 million in
203029.

The EC is already active in global health. The EU as a whole is the world's largest
development and humanitarian aid donor, and health is an important component in the EC's
assistance to world-wide efforts to combat poverty, to work towards the Millennium
Development Goals and European Consensus on Development Cooperation, and to preserve
the lives of people affected by humanitarian crisis. The EU also contributes significantly to
the Global Fund to fight AIDS, Tuberculosis and Malaria. Development aid will work
towards alignment with the Paris principles30, improving its coordination and predictability.
This will require greater in-depth analysis and dialogue between national and global health
policies. The European programme for action to tackle the critical shortage of health workers
in developing countries is an example of an important EU activity in global health, linking
internal and external actions in health.

Extensive collaborative working with international organisations already takes place. The EU
played a key role in negotiations on the World Health Organization (WHO) Framework
Convention on Tobacco Control and on the International Health Regulations, and is currently
actively involved within the WHO debate on public health, innovation and intellectual
property. Another recent example of work with the WHO includes involvement with the
WHO Commission on Social Determinants of Health, and joint action on communicable and
non communicable diseases.

The EU's contribution to global health requires interaction of policy areas such as health,
development cooperation, external action, research and trade. New actors are also emerging in
the global health arena and new forms of interactions are taking place. For instance, public-
private-partnerships have gained importance and foundations are playing a significant role in
financing of global health. This new nature of global health governance is presenting
challenges in coordination, as well as raising questions about accountability and visibility, and
the roles and responsibilities of different actors.

However, activities in the field of global health should be strengthened to give the EU a
stronger voice in global health and to create better health outcomes for EU citizens and for
others. The Community can add value in its contributions to global health by sharing common
European values, as well as its experience in implementing health policy that reduces health
inequalities, strengthens the health systems and promotes health. International collaborative
research should continue to be supported through EC Framework Programmes for Research in
areas of mutual interest and benefit, and the EU must also respond to health threats in third
countries and to save and preserve life in emergency and immediate post-emergency
situations.

29 Mathers CD, Loncar D (2006) Projections of global mortality and burden of disease from 2002-2030.
30 Paris Declaration 2005.

Drucksache 16/9412 – 124 – Deutscher Bundestag – 16. Wahlperiode

Actions

� Enhance the Community's status in international organisations and strengthen
cooperation on health with strategic partners and countries (Commission)

Building on existing cooperation with international organisations active in health, action will
be taken to enhance the EC’s status in international organisations (such as the WHO, the
International Labour Organisation, other United Nations agencies, the OECD, the Council of
Europe and the Observatory on Health Systems and Policies), recognising the substantial
contribution of the EU in financial and other support to third countries. Cooperation with
other strategic partners will also be strengthened, including private and public partnerships in
health such as the Global Fund to fight AIDS, Tuberculosis and Malaria, and with third
countries, with a particular emphasis on the regional dimension and on candidate, potential
candidate and European Policy Neighbourhood countries.

� In line with the priorities agreed with third countries and with the policy dialogue and
sectoral approaches developed for external assistance, ensure an adequate inclusion of
health in the EU's external assistance and promote the implementation of international
health agreements, in particular FCTC and IHR (Commission)

The principles of international health agreements should be reflected in the Community's
external instruments. This would mean in particular supporting full implementation of the
International Health Regulations (IHR) and the Framework Convention on Tobacco Control
(FCTC) as well as contributing to further development of the FCTC. IHR and FCTC
commitments should be properly addressed in bilateral and regional relations and financial
programmes.
3. STRATEGIC OBJECTIVES

OBJECTIVE 1: FOSTERING GOOD HEALTH IN AN AGEING EUROPE

The predicted trend towards demographic ageing, resulting from low birth rates, increasing
longevity, and the ageing of the 'baby boom' generation is now well established on political
agendas across Europe.

By 2050 the percentage of people aged 65+ is expected to increase by 70%, and the
percentage of people aged 80+ by 170% in the EU-2531. Commission projections support the
prediction that population ageing will pose major economic, budgetary and social challenges
which are expected to have a significant impact on growth and lead to significant pressures to
increase public spending, making it difficult for Member States to maintain sound and
sustainable public finances in the long-term32. However, if the population ages in good health
31 The impact of ageing on public expenditure: projections for the EU25 Member States on pensions,

health care, long term care, education and unemployment transfers (2004-2050) Economic Policy
Committee and European Commission (DG ECFIN), 2006, European Economy. Special Report

no.1/2006.

32 'The long-term sustainability of public finances in the EU', EUROPEAN ECONOMY. No. 4. ,
European Commission (DG ECFIN) 2006, Annex to the Commission's Communication on 'The long-
term sustainability of public finances in the EU' - COM(2006) 574, SEC(2006) 1247.

Deutscher Bundestag – 16. Wahlperiode – 125 – Drucksache 16/9412

and remains active this is positive both for the individual and for the wider economy. If
healthy life expectancy evolves broadly in line with change in age-specific life expectancy,
then the projected increase in spending on healthcare due to ageing would be halved33.

In order to maximise the healthy life years and to achieve healthy ageing, it is important to
promote health and prevent disease throughout the lifespan, including by tackling health
determinants such as nutrition, physical activity, alcohol, drugs and tobacco consumption,
environment and socioeconomic factors. Improving the health of children, adults of working
age and older adults will help to create a healthy, productive population and support a healthy
older population now and in the future. This involves redesigning health policies and actions
to target different age groups.

The health of children and young people is a particular concern. Poor health in early life can
lead to long term impacts. Threats to health such as falling levels of physical activity and
rising levels of obesity, harmful alcohol use, drug abuse and mental stress pose risks to the
health of young people now and in future. Inter-sectoral collaboration should be enhanced to
promote children and young people’s health, building on and contributing to existing action
on rights of the child, combating poverty and social exclusion, and promoting participation of
young people, as well as on EC youth-oriented public health activities on tobacco, alcohol,
drugs, environment, nutrition, obesity, safe sex and mental health. The EC and Member States
need to engage with a broad range of stakeholders, including youth and business
organizations to protect and improve the health of young people, including using settings such
as schools.

The health of the working age population is a key factor for economic sustainability, and
Community policy initiatives in this area, including the Safety and Health at Work Strategy
2007-2012, can help to promote health and to reduce losses to the labour force due to physical
and mental ill health. The health of migrants should have a particular focus. It would be
beneficial to integrate EC action in public health with action on employment, social protection
and safety and health at work, and strengthen mechanisms for information exchange and
cooperation on this issue between Member States, the Commission and the business
community.

Given the increasing numbers of older people, a new focus on their specific health needs is
required. The European Union Labour Force Survey 1995 showed that illness or disability,
although very variable across the Member States, accounts for up to 25% of retirements of
males in the EU-15. As the population grows older, older people will need to remain at work
for longer and stay active longer, and will therefore need to be more empowered to take
control of their own health. At the same time, health and social care services will need to
adapt to support the older population, through for example training health professionals and
providing more preventive interventions and care closer to home. The widespread use of new
technologies would provide more accessible products and services that meet the needs of
older people, particularly home healthcare, telemedicine, continuity of care, chronic disease
management etc. More can also be done to promote the development of geriatric medicine
with a focus on individualised care, and to tackle diseases that are particularly prevalent in
33
The impact of ageing on public expenditure: projections for the EU25 Member States on pensions,

health care, long term care, education and unemployment transfers (2004-2050) Economic Policy
Committee and European Commission (DG ECFIN), 2006, European Economy. Special Report No
1/2006,

Drucksache 16/9412 – 126 – Deutscher Bundestag – 16. Wahlperiode

this age-group, such as neurodegenerative diseases and Alzheimer's, and to increase the
effective use of vaccination including the influenza vaccine.

Community policies should also help people of all ages to live healthier lives. A major part of
the burden of disease comes from conditions related to lifestyle, environmental conditions,
and socio-economic factors.

In the EU, 25% of people aged between 15 and 24 are daily smokers34, while studies have
shown that the majority of smokers want to stop smoking35. Smoking has been proven to have
a causal relationship with many serious and life-threatening diseases. It is estimated that in
2006 there were almost 335,000 deaths for lung cancer in Europe36. Recently, the risks of
environmental tobacco smoke have been more clearly recognised with several European
Member States banning smoking in the workplace. More than 1 out of every 4 deaths among
young men (aged 15 – 29 years)37 in the EU is due to the consequences of harmful alcohol
use, thus making it the 3rd biggest cause of early death and illness in the EU38. Sexual health
promotion should be strengthened, including through the follow-up to the review of the
implementation of current policy on HIV/AIDS39. Accidents and injuries are the main cause
of death in children and young people.

The worrying rise in obesity is leading to a rapid increase in Type II diabetes and obesity is
also an important risk factor for cardiovascular diseases. Three quarters of type 2 diabetes, a
third of ischaemic heart disease, half of hypertensive disease, a third of ischaemic strokes and
about a quarter of osteoarthritis can be attributed to excess weight gain. Studies from the UK
and the USA already show that obesity reduces life expectancy40,41, and the impact may
become greater in future given the increase in childhood obesity. The need to promote
physical activity will be part of the Commission's considerations in producing a Green Paper
on Urban Transport in 2007 and guidelines on sustainable urban transport plans. The
implementation of a White Paper on sport will also be relevant to the physical activity agenda
through joint actions to encourage increased participation and improved opportunities
particularly for young people.

The EC therefore has a role to play in supporting healthy ageing through improving healthy
lifestyles through initiatives to support Member States to tackle health determinants.
Moreover, it also has a role in coordinating responses to disease.

Supporting healthy ageing at Community level is also achieved through initiatives in relation
to specific diseases, in relation to prevention, diagnosis, treatment, genetic testing (70% of the
34 Eurostat, Health Interview Surveys 2004 (NewCronos Database).
35 Fong et al, The near-universal experience of regret among smokers in four countries: findings from the

International Tobacco Control Policy Evaluation Survey. Nicotine Tob Res. 2004 Dec;6 Suppl 3:S341-
51.

36 Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P. Estimates of the cancer incidence and
mortality in Europe in 2006. Ann Oncol. 2007 Mar;18(3):581-92.

37 Anderson P, Baumberg B (2006) Alcohol and Europe, London Institute of Alcohol Studies.
38 The WHO Global Burden of Disease Study (Rehm et al 2004).
39 Set out in the Commission Communication to combat HIV/AIDS within the European Union and in the

neighbouring countries 2006-2009 - COM(2005) 654.
40 Peeters A et al. Obesity in adulthood and its consequences for life expectancy: a life-table analysis.
Annals of Internal Medicine, 2003, 138:24-32.
41 Department of Health – Economic and Operational Research. Life expectancy projections, Government

Actuary's Department: estimated effect of obesity (based on straight line extrapolation of trends).
London, The Stationary Office, 2004.

Deutscher Bundestag – 16. Wahlperiode – 127 – Drucksache 16/9412

disease burden are complex genetic diseases42), information and telemedicine. Priorities for
work on diseases vary according to different perspectives (citizens, patients, healthcare
providers, others). The EC needs to explore ways to prioritise its work by means of a
quantitative assessment of the relative impacts of diseases and strategies to tackle those
diseases. A European Network of Disease Registers with agreed procedures for designation
should be set up to accredit EU-wide disease registers. Further actions in the field of blood,
tissues and cells, and the quality, safety and availability of organs should also be taken,
following the Commission Communication on organ donation and transplantation43.

Community priorities may be set to tackle diseases which cause the greatest burden such as
cardiovascular disease and cancer, but the Community also has a key role in tackling rare
diseases. Rare diseases, including those of genetic origin, are life-threatening or chronically
debilitating diseases which are of such low prevalence that special combined efforts are
needed to address them to prevent significant morbidity, perinatal or early mortality or a
considerable reduction in an individual's quality of life or socio-economic potential. The EC is
well placed to coordinate action to improve knowledge, facilitate access to information and
create reference networks for these diseases.

Actions

� Measures to promote the health of older people and the workforce and actions on
children's and young people's health (Commission)

A Communication on the health of the workforce will be launched to integrate EU action in
public health with action on employment and social protection and to strengthen mechanisms
for information exchange and cooperation on this issue between Member States, the
Commission, and the business community. A Communication on healthy ageing will be put
forward by the Commission. A series of initiatives on the health of children and young people
will also be launched. These will be developed with the input of young people and other
stakeholders and will build on and contribute to existing action on the rights of the child,
combating poverty and social exclusion and promoting participation of young people, as well
as on EU youth-oriented public health strategies on alcohol, drugs, environment, nutrition,
obesity, safe sex, oral health and mental health.

� Development and delivery of actions on tobacco, nutrition, alcohol, mental health and
other health determinants (Commission, Member States)

To promote healthy lifestyles and to address the burden of disease, the Commission will build
upon the current work on addressing key health determinants. This will include taking
forward strategies and actions that have recently been developed, including the EC strategy on
nutrition, overweight and obesity, including strengthening the EC Platform on Diet, Physical
Activity and Health and facilitating an EC salt campaign; the EC strategy on reducing alcohol
related harm, the Green Paper on smoke free environments, the outcome of the recent
consultation on tobacco taxation44, actions on mental health, and the Council recommendation
42 Diseases associated with the effects of multiple genes in combination with lifestyle and environmental

factors.
43
See COM(2007) 275.
44

http://ec.europa.eu/taxation_customs/resources/documents/common/consultations/tax/consultation_pap
er_tobacco_en.pdf

Drucksache 16/9412 – 128 – Deutscher Bundestag – 16. Wahlperiode

on injury prevention and safety promotion in Member States. The Commission will continue
to use the full potential of its instruments to combat tobacco consumption.

� New Guidelines on Cancer screening and a Communication on European Action in the
Field of Rare Diseases (Commission)

The Commission will follow up on the actions from the programme Europe Against Cancer45
by adopting a Commission Communication on Cancer including new guidelines on cancer
prevention, early diagnosis, control, workplace exposure and access to treatment and
information, as well as a new version of the European Code Against Cancer. Premature death
and disability from cardiovascular diseases should also be combated and the European Heart
Health Charter taken forward. Further EC-coordinated initiatives on specific diseases will be
introduced where these can offer clear added value to actions in Member States. These may
include initiatives in relation to diabetes and to neuro-degenerative diseases such as
Alzheimer’s and dementias, as well as rare diseases, for which a Commission Communication
and a Council Recommendation will be adopted.

� Follow up of the Communication on organ donation and transplantation46
(Commission)

Following the conclusions of the Communication, the Commission will develop in the coming
years an EU legal framework on quality and safety for organ donation and transplantation.
This legal instrument will be complemented with an action plan to strengthened cooperation
between Member States in this field. Through this plan the Commission will promote
cooperation and assist Member States to share experience and best practices with a view to
increasing organ availability, enhancing the efficiency and accessibility of transplantation
systems and complementing the legal instrument on quality and safety.

OBJECTIVE 2: PROTECTING CITIZENS FROM HEALTH THREATS

Protecting citizens against health threats such as communicable and non-communicable
diseases and the health effects of climate change are ongoing health challenges where work at
Community level provides clear added value, because these are issues which cross boundaries
and cannot be tackled effectively by individual Member States. Protection of human health
has been specifically set out in the Treaty47, and security is also one the broad strategic
objectives of the Commission.

Work in this area has included actions to improve preparedness and response to epidemics or
deliberate acts such as bioterrorism, to support Member States in addressing communicable
disease threats such as HIV/AIDS and tuberculosis, patient safety issues, medical devices,
road safety and action to tackle environmental threats such as water and air pollution, and the
body of EC legislation on health products including pharmaceuticals, quality and safety of
blood, tissues and cells. Work on health threats also links closely to the health of animals, and
45
See Decisions 96/646/EC and 521/2001/EC.
46 COM(2007 )275.
47 Article 152: "A high level of human health protection shall be ensured in the definition and

implementation of all Community policies and activities".

Deutscher Bundestag – 16. Wahlperiode – 129 – Drucksache 16/9412

coordination must be ensured on issues such as animal diseases which can be transferred to
humans48, and on ensuring food safety.

The European Centre for Disease Control (ECDC) was established in 2004 to identify, assess
and communicate current and emerging threats to human health posed by infectious diseases.
Recent work has included validating scientific recommendations regarding the best use of
seasonal flu vaccination, and advice on improving comparability of childhood immunisation
approaches in the Member States, in particular to take account of increased cross-border
mobility. The review of the ECDC’s remit in 2008 will aim to strengthen further the response
to disease threats.

Much has therefore been done, but some challenges have not yet been adequately tackled.
Poor environmental quality is a significant cause of avoidable ill health. Recent estimates of
the impact of air pollution made in the 'Clean air for Europe' (CAFE) programme found that
in the EU about 350 000 people died prematurely in 2000 due to outdoor air pollution caused
by fine particulate matter (PM2.5) alone. According to the WHO49, 11.5% of children suffer
from asthmatic symptoms in Europe. Indoor air pollution is also a significant problem. Lead
intake from water and food is a major cause of brain damage - particularly in children from
poorer backgrounds. WHO has estimated that in the WHO European region environmental
lead pollution causes around 4% of the healthy life years lost. To improve indoor air quality
and mitigate health risks, activities related to information, research and addressing key indoor
pollutants should be brought together, building on the EC Environment and Health Action
Plan (2004-2010).

Climate change has the potential to have a major impact on health, including on patterns of
disease. It may reduce the predictability of communicable disease threats such as pandemics,
and worsen their consequences, with gene-environment interactions playing a part. In
extremes of heat there are increased cases of food poisoning, and an increased likelihood of
malaria and tick-borne diseases, as well as the longer term implications of an increase in skin
cancers. There is a risk of more water shortages, with reduced availability of clean water and
an increase in water-borne diseases. In recent years, extreme weather conditions have proved
harmful and fatal particularly among the elderly and other vulnerable groups, for example,
France suffered an estimated 15,000 deaths in one month due to a heat-wave in 2003. Floods
and severe cold are also threats to vulnerable groups, and extreme conditions leading to loss
of electrical power can cause significant problems very quickly, particularly for health
infrastructure. A number of reports on Climate Change have been carried out recently50 and
the EC can build on these in its work to add value to Member States' actions in this area,
which will include health issues as well as other issues.

Patient safety is a further area of concern. Adverse events due to healthcare processes are
wide in range, from healthcare acquired infections (HCAIs) to those stemming from unsafe
48 A new Animal Health Strategy to improve the prevention and control of animal disease in the EU was

adopted on 19 September 2007.
49 http://www.euro.who.int/eprise/main/who/progs/whd2/20030307_6
50 These include: Report of the Intergovernmental Panel on Climate Change (IPCC) - 2007,

http://www.ipcc.ch/
Rapport 2007 de l’ONERC consacré aux changements climatiques et risques sanitaires en France -
2007, http://www.ecologie.gouv.fr/-ONERC-.html
Stern Review on the economics of climate change, HM Treasury, UK - 2006, http://www.hm-

treasury.gov.uk/independent_reviews/stern_review_economics_climate_change/stern_review_report.cf
m

Drucksache 16/9412 – 130 – Deutscher Bundestag – 16. Wahlperiode

devices, from prescribing errors to contaminated blood, and many more. The UK Department
of Health, in its 2000 report, An organisation with a memory51, estimated that adverse events
occur in around 10% of hospital admissions or about 850 000 adverse events a year in the
UK. The UK National Audit Office estimated that around 50% of these incidents could have
been avoided if lessons from previous incidents had been learned52. In the Netherlands,
research has shown that around 800,000 Dutch people over the age of 18 have been subject, in
their own perception, to errors based on the inadequate transfer of medical information53. The
economic costs of adverse events in health systems can also be huge. For example, in the UK,
it is estimated that adverse events cost approximately €3 billion a year in additional hospital
stays alone, while litigation represents a further cost54. ICT can be a useful tool to support
patient safety through, for example, systems for pre-screening patients to support optimal
diagnoses, and incident reporting systems. The Community can add value in relation to
patient safety and a proposal is planned for 2008, which will include proposals to combat
HCAIs.

The human and economic cost of accidents is also high. Road accidents killed 39000 people
in the EU in 2006, and the direct cost to society has been estimated at €45 billion/year55.
Strengthened efforts are needed to reduce the burden of traffic accidents in the EU.
Approaches may include education of drivers, technological advances such as safety features
in vehicles and road infrastructure, and judicial measures.

In terms of the global aspect of health threats, the EC should continue to provide humanitarian
aid to save and preserve life, reduce or prevent suffering and safeguard the integrity and
dignity of third country populations affected by humanitarian crises. More specifically, this
should aim to support access to basic curative and preventive health services in crisis
situations with an emphasis on the most vulnerable groups, and rapid and appropriate
reactions to the emergence of life-threatening epidemics and health hazards.

Actions

� Strengthen EC mechanisms for surveillance and response to health threats, including
review of the remit of the ECDC. (Commission)

To enhance protection of the health and safety of European citizens, European mechanisms
for surveillance and response to health threats, including newly emerging and re-emerging
threats, will be strengthened. This will include streamlining current structures, such as
reconsidering the remit of the European Centre for Disease Prevention and Control (ECDC)
and the work of the network for the epidemiological surveillance and control of
51 Department of Health Expert Group. An organisation with a memory: report of an expert group on

learning from adverse events in NHS. Chairman: Chief Medical Officer London: The Stationery Office,
2000.

52 NAO (National Audit Office) (2005) A Safer Place for Patients: Learning to improve patient safety,
November 3, 2005, Department of Health, http://www.nao.org.uk/publications/nao_reports/05-
06/0506456.pdf, p. 1.

53 For relevant information, see http://www.npcf.nl/ Similar information is also available from WINAP
and from the Dutch Association of Pharmacists.

54 Department of Health Expert Group. An organisation with a memory: report of an expert group on

learning from adverse events in NHS. Chairman: Chief Medical Officer London: The Stationery Office,
2000.

55 Impact Assessment for the Proposal for a Directive of the European Parliament and of the Council on
Road Infrastructure Safety Management.

Deutscher Bundestag – 16. Wahlperiode – 131 – Drucksache 16/9412

communicable diseases in the Community, the Health Security Committee and the
International Health Regulations. To enhance real time data-gathering on illnesses, epidemics
and environmentally related health problems and to aid rapid response, possibilities for
developing an EU-wide virtual medical mapping system will be explored.

� Health aspects on adaptation to climate change (Commission)

The Commission will produce a report on Climate Change covering a range of areas of
concern including health. The most up-to-date scientific information on health effects from
extreme weather and events relating to climate change will be gathered and analysed to
support effective responses in preventing and responding to them. The implementation of
surveillance systems for the main effects of climate change such as heat-waves and flooding
will be examined. The capacity of EU health systems and infrastructure to cope with different
levels of climate-related health threats will be estimated, with the aim of supporting
contingency planning for hypothetically dangerous situations as necessary.

OBJECTIVE 3: SUPPORTING DYNAMIC HEALTH SYSTEMS AND NEW TECHNOLOGIES

Health systems throughout the EU are under pressure to respond to challenges such as the
increasing mobility of patients and professionals as well as migration in general, citizens’
rising expectations, population ageing and changing disease patterns. They need to constantly
adapt in order to meet their objectives. Innovation and the development of new technologies
are key issues that affect EU health systems in today’s quickly changing world.

Ensuring sufficient capacity in the field of healthcare and public health is a crucial issue,
particularly in the new Member States, and this is closely linked to the issue of health
professional mobility, as well as the increasing challenges of new technologies and population
ageing. More investment in capacity building for health professionals and workforce
planning, including in public health and healthcare management training and evaluation, is
necessary to improve the efficiency of health systems, to raise the level of European public
health expertise and to strengthen Europe's place in the global health market. At EU and
international level, issues of brain-drain and ethical recruitment are emerging: some places are
suffering from a lack of qualified personnel, whereas others are facing an influx of healthcare
professionals from other countries. To improve the quality and availability of education and
training for health professionals, the potential for Regional Policy programmes and other tools
such as the Lifelong Learning Programme and possibilities for networking should be fully
exploited.

Health systems have to deal with a wide range of issues that have a cross-border impact, from
pharmaceuticals and medical devices to organ donation and transplantation, mobility of
patients and health professionals, to the availability of a single European emergency phone
number. The new framework for health services56 will help to identify and support further
areas where EC action can add value, such as developing of European networks of centres of
reference ensuring that patients can have access to highly specialised care requiring a
particular concentration of resources or expertise that is beyond the capacity of every Member
State to provide; creating a network for assessment of new health technologies to share results
quickly between health systems and to avoid unnecessary duplication of efforts; or

56 Due to be launched by the end of 2007.

Drucksache 16/9412 – 132 – Deutscher Bundestag – 16. Wahlperiode

cooperation in border regions where the nearest appropriate healthcare provider may be across
the border in another Member State. Efficient provision of care may be then best achieved
through cooperation between providers serving populations across borders throughout their
local region.

The new framework will also clarify the application of Community Law to health services
and healthcare. It will set out clearly the common principles for healthcare in the EU, identify
which Member State will be responsible for ensuring compliance with those principles and
what those responsibilities include, in order to ensure that there is clarity and confidence with
regard to which authorities are setting and monitoring healthcare standards throughout the
EU.

The Community can support health systems by providing information and analytical support,
reporting on developments and good practice in different health systems, supporting,
facilitating and encouraging the use of targeted research, and facilitating dialogue and peer-to-
peer cooperation. Close collaboration with Member States and international organisations
such as the WHO, the World Bank, the ILO, the OECD and the European Observatory on
Health Systems and Policies57 is valuable in identifying key issues facing health systems and
responding appropriately, and will be enhanced. The Commission will also explore the
possibility of becoming a member of the Observatory.

Health is a sector that strongly and directly benefits from research and technological
development, but also one that triggers it, an example of a 'business driving technology'. For
example, the growing use of life sciences and biotechnology for the development of drugs,
vaccines, genome-based diagnostics and innovative therapies, as well as the applications of
"nanomedicine", represent a huge potential of innovation and growth58. The health sector
must take advantage of innovation and technology where this can contribute to greater
efficiency and health improvements. In the future, greater attention to innovation in the fields
of major and chronic diseases, such as cancer, diabetes and cardiovascular disease could over
time substantially reduce the burden on care services. Evidence shows that effective eHealth
investments improve quality productivity, which in turn liberates capacity and enables better
access to care59. Technologies can support a shift from reliance on hospital care to more
prevention and primary care which is important for future sustainability of healthcare given
population ageing, and can support better health outcomes. A balance must, however, be
struck in terms of cost-effectiveness, and health systems must consider on a case by case basis
what kind of investment in technology is the most cost-effective. Moreover, new and
unfamiliar technologies can also give rise to ethical concerns, and issues of citizen's trust and
confidence must be properly addressed. Health Technology Assessment (HTA) is one tool
where current work is being taken forward by the Community in partnership with Member
States to support the evaluation of new technologies and the exchange of best practice. The
assessment of new technologies benefits from EU-level cooperation to gather evidence and
share best practice.
57 The Observatory is a partnership between the WHO Regional Office for Europe, the Governments of

Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the
European Investment Bank, the Open Society Institute, the World Bank, the London School of
Economics and Political Science (LSE), and the London School of Hygiene & Tropical Medicine

(LSHTM).

58 Communication from the Commission on the mid term review of the Strategy on Life Sciences and
Biotechnology - COM(2007) 175.

59 "eHealth is worth it" Study funded under "eHealth Impact", European Commission September 2006.

Deutscher Bundestag – 16. Wahlperiode – 133 – Drucksache 16/9412

E-Health is already an important tool for making substantial productivity gains, and in the
future it is likely to be a key instrument to achieve restructured, citizen-centred health
systems. There are many examples of successful e-Health developments including health
information management and networks, electronic health records, telemedicine services,
wearable and portable monitoring systems, and health portals. Today, at least four out of five
European doctors have an Internet connection, and a quarter of all Europeans use the Internet
for health information. European Community research programmes have been supporting e-
Health for the last fifteen years. Technical work to develop electronic health records is also
being supported by the EC. This is necessarily a long-term project but there is scope for this
type of action to support cross-border healthcare if developed as a web-based system. More
broadly, supporting the interoperability of health systems within and across national
boundaries will support mobility and the safety of patients by ensuring continuity of care.
Member States have shown that they are keen to take the e-Health agenda forward, drawing
on best practice and experience from across the EU. This should enable a move towards a
“European e-Health Area"60.

In support of these kinds of forward-looking solutions, international standardization initiatives
have potential to increase interoperability, innovation and productivity in the field of health.
The EC therefore has a role to encourage and monitor the development, adoption and use of
technical standards, namely on ICT; common vocabularies, classifications, nomenclatures and
thesaurus; guidelines and best practices; and stable working and legal frameworks in the
health domain, and especially for eHealth and transborder services.

Facing these challenges and in particular their cross-border dimension calls for adequate
support to national systems at European level, while respecting the subsidiarity principle.

Actions

� Implementation of Community framework for safe, high quality and efficient health
services (Commission)

To reinforce cooperation between the Member States on issues relating to health services and
in particular to cross-border healthcare, and to provide certainty over the application of
Community law to health services and healthcare, the Commission will propose a Community
framework for safe, high quality and efficient health services.

� Support Member States and Regions in managing innovation in health systems
(Commission).

The Commission will develop work under to support Member States in identifying, assessing
and providing guidance on innovation in healthcare. This will look at mechanisms that
Member States use within their healthcare systems, and identify existing structures and tools
for support at European level, such as the European health technology assessment network,
the Innovative Medicines Initiative (IMI), and the 7th Research Framework Programme (2007-
2013), in particular the Health Theme under the specific programme 'Cooperation' and the
Competitiveness and Innovation Programme. The potential for a new structure for making and
disseminating technical recommendations at European level will be explored. In particular,
the important and emerging areas of genomics and nanotechnology will be addressed.

60 Communication from the Commission on e-Health - making healthcare better for European citizens: An

action plan for a European e-Health Area - COM(2004) 356.

Drucksache 16/9412 – 134 – Deutscher Bundestag – 16. Wahlperiode

� Support implementation and interoperability of e-health solutions in health systems
(Commission)

The Commission will develop work to support the effective use of e-health solutions in health
systems, including issues of interoperability between different systems both within and
between countries. The Commission will continue to support ehealth as a Lead Market within
the Lead Market Initiative. The Commission will also develop and implement a protected web
platform for multimedia content and communication, capable of extracting and sending
relevant information to and from a range of sources, building on the experience of recent
successful internet projects such as the UK's MyHealthSpace.

4. TOGETHER FOR HEALTH: IMPLEMENTATION OF THE STRATEGY

4.1. IMPLEMENTATION MECHANISMS

The EC has a clear requirement in the Treaty to improve and protect health. Fostering
coordination and cooperation with the Member States is also enshrined in the EC Treaty, and
seems likely to be further strengthened in a future Reform Treaty. The objectives and
principles of the Strategy need to be supported by an appropriate practical mechanism in order
to create real improvements in health in the EU. The key component of the implementation
mechanisms of the Strategy will be a new Structured Cooperation mechanism to advise the
Commission and to promote coordination between the Member States. (see Action below).

The Commission will work to strengthen further the involvement of key stakeholders in
contributing to the development and implementation of actions to protect and improve the
health of European citizens. Building on the progress made through structures such as the EC
Platform on diet, physical activity and health, the European Alcohol and Health Forum, the e-
Health stakeholders' group and the Health Policy Forum, the Commission will work closely
with stakeholder groups, and with regional and local level bodies with a view to optimising
their contribution to the implementation of the Strategy.

The European regions are key actors in delivering healthcare but often lack crucial resources
and effective communication channels. Regional cooperation in healthcare could be enhanced
through better sharing of knowledge and expertise and more efficient transfer and integration
of health innovation. Community support, in complementarity with Regional Policy, needs to
be provided to regions willing to set up mechanisms to foster regional cooperation on key
health themes, such as health inequities, high quality health services, health professionals and
healthy lifestyles. The participation of the regions in the implementation of the Strategy will
be ensured.

In implementing the Strategy, the Commission will work across sectors in accordance with
the HIAP principle, and will make use of a full range of instruments at its disposal:
legislation, communications, recommendations, guidelines and networks as well policy
instruments such as strategies on tobacco, nutrition and physical activity, safety and health at
work, emerging technologies, alcohol and mental health. In a number of areas clear objectives
for action already exist, for example following the recently adopted strategy on nutrition,

Deutscher Bundestag – 16. Wahlperiode – 135 – Drucksache 16/9412

overweight and obesity related issues61. The new implementation mechanism will build on
those areas and refer to those objectives as part of the broader implementation of the Strategy.

Regular overviews and reports on health issues in the EU and of progress in tackling them
will be undertaken to ensure the visibility of the Strategy and enable its progress to be
followed. This White Paper sets out the first stage of the Strategy to 2013, when a review will
take place to support the definition of further work towards the Strategy's objectives.

Actions

� The Commission will put forward a Structured Cooperation implementation
mechanism (Commission)

To ensure strategic cooperation, the Commission will propose a new mechanism for the
implementation of the strategy with the Member States. This would include a Committee with
Member States to identify priorities, define indicators, produce guidelines and
recommendations, foster exchange of good practice, measure progress. This would include a
structure for working with Member States, replacing some existing committees, which the
new mechanism would make redundant. It will also ensure consistency with the work of the
other existing bodies which deal with health related issues (such as the Administrative
Commission, and the Social Protection Committee).

4.2. FINANCIAL INSTRUMENTS

The actions set out in this Strategy will be supported by existing financial mechanisms until
the end of current financial framework (2013), without additional budgetary consequences.

Key mechanisms include the health programmes. To ensure that the actions under the current
Public Health Programme (2003-2008) and the new Second Programme of Community
Action in the Field of Health (2008-2013) support the objectives of the Strategy, clearly
defined priorities will be set by identifying specific objectives and deliverables on an annual
basis.

The new Safety and Health at Work Strategy 2007-2012 will also have a major role in
financing health-related actions.In addition, a number of other Community instruments
provide funding relevant to health, e.g. the 7th Framework Programme on Research, Regional
Policy, the European Action Plan for 'Ageing Well in the Information Society' and the
Development Cooperation Instrument and Pre-accession Instrument. For a more
comprehensive list see Annex 3.

61 COM(2007) 279.

Drucksache 16/9412 – 136 – Deutscher Bundestag – 16. Wahlperiode

ANNEX 1:

KEY EC PUBLIC HEALTH ACQUIS62

HEALTH - HORIZONTAL MEASURES

Legislation Description

COM(2000)285 Commission Communication on EU Health Strategy 2000

Commission
Decision
(2004/210/EC)

Commission Decision of 3 March 2004 setting up Scientific
Committees in the field of consumer safety, public health and the
environment

Decision No
1786/2002/EC

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 field of public health (2003-2008)

COM(2006)234
Proposal for a Programme for Community Action in the field of
Health 2007-2013

Decision
2004/858/EC

Commission Decision of 15 December 2004 setting up an executive
agency, the 'Executive Agency for the Public Health Programme', for
the management of Community action in the field of public health -
pursuant to Council Regulation (EC) No 58/2003 (2004/858/EC)

HEALTH - VERTICAL MEASURES

Communicable diseases

Decision No
2119/98/EC

Decision No 2119/98/EC of the European Parliament and of the
Council of 24 September 1998 setting up a network for the
epidemiological surveillance and control of communicable diseases in
the Community

Decision
2000/57/EC

Commission Decision of 22 December 1999 on the early warning and
response system for the prevention and control of communicable
diseases under Decision No 2119/98/EC of the European Parliament
and of the Council
Decision
2000/96/EC

Commission Decision of 22 December 1999 on the communicable
diseases to be progressively covered by the Community network
under Decision No 2119/98/EC of the European Parliament and of the
Council

62 This list does not include the very large number of legislative acts which are related to health in other

policy areas, for example in the fields of environment and consumer protection.

Deutscher Bundestag – 16. Wahlperiode – 137 – Drucksache 16/9412

Decision
2002/253/EC

Commission Decision of 19 March 2002 laying down case definitions
for reporting communicable diseases to the Community network under
Decision No 2119/98/EC of the European Parliament and of the
Council

Decision
2003/542/EC

Commission Decision of 17 July 2003 amending Decision
2000/96/EC as regards the operation of dedicated surveillance
networks and Corrigendum (OJ L 185 of 24.7.2003)

Decision
2003/534/EC

Commission Decision of 17 July 2003 amending Decision No
2119/98/EC of the European Parliament and of the Council and
Decision 2000/96/EC as regards communicable diseases listed in
those decisions and amending Decision 2002/253/EC as regards the
case definitions for communicable diseases

Regulation (EC) No
851/2004

Regulation (EC) No 851/2004 of the European Parliament and of the
Council of 21 April 2004 establishing a European Centre for disease
prevention and control

Council
Recommendation
2002/77/EC

Council Recommendation of 15 November 2001 on the prudent use of
antimicrobial agents in human medicine

Treaty Establishing
the European
Atomic Energy
Community
(Euratom)

Chapter 3 (conferring competences to the Community for the
protection of the health of workers and the general public against the
dangers arising from ionising radiations).

Blood, tissues, cells and organs

Directive
2002/98/EC

Directive 2002/98/EC of the European Parliament and of the Council
of 27 January 2003 setting standards of quality and safety for the
collection, testing, processing, storage and distribution of human
blood and blood components and amending Directive 2001/83/EC

Directive
2004/23/EC

Directive 2004/23/EC of the European Parliament and of the Council
of 31 March 2004 on setting standards of quality and safety for the
donation, procurement, testing, processing, preservation, storage and
distribution of human tissues and cells.

Directive
2004/33/EC

Commission Directive 2004/33/EC of 22 March 2004 implementing
Directive 2002/98/EC of the European Parliament and of the Council
as regards certain technical requirements for blood and blood
components.

Drucksache 16/9412 – 138 – Deutscher Bundestag – 16. Wahlperiode

Directive
2005/61/EC

Commission Directive 2005/61/EC of 30 September 2005
implementing Directive 2002/98/EC of the European Parliament and
of the Council as regards traceability requirements and notification of
serious adverse reactions and events.

Directive
2005/62/EC

Commission Directive 2005/62/EC of 30 September 2005
implementing Directive 2002/98/EC of the European Parliament and
of the Council as regards Community standards and specifications
relating to a quality system for blood establishments.

Directive
2006/17/EC

Commission Directive 2006/17/EC implementing Directive
2004/23/EC of the European Parliament and of the Council as regards
certain technical requirements for the donation, procurement and
testing of human tissues and cells

Council
Recommendation
(98/463/EC)

Council Recommendation on the suitability of blood and plasma
donors and the screening of donated blood in the European
Community

COM(2007)275
Commission Communication on Organ Donation and Transplantation:
Policy Actions at EU Level

Mental health

Council Conclusions
2-3 June 2003

Council meeting - Employment, Social policy, Health and Consumers
affairs on 2-3 June 2003: Conclusions on Mental health

Council Resolution
(2000/C 86/01)

Council Resolution of 18 November 1999 on the promotion of mental
health

Council Conclusions
(2002/C 6/01)

Council conclusions of 15 November 2001 on combating stress and
depression-related problems

Council Conclusions
(2003/C 141/01)

Council Conclusions of 2 June 2003 on combating stigma and
discrimination in relation to mental illness

Council Conclusions
9805/05 Council Conclusions on Community mental health action, 6 June 2005

Healthy lifestyles; socio-economic determinants

Council Conclusions
(2004/C 22/01)

Council Conclusions of 2 December 2003 on healthy lifestyles:
education, information and communication

Council Resolution
(2000/C 218/03) Council Resolution of 29 June 2000 on action on health determinants

Deutscher Bundestag – 16. Wahlperiode – 139 – Drucksache 16/9412

Nutrition

Council Conclusions
9803/05

Council Conclusions of 6 June 2005 on Obesity, nutrition and
physical activity

COM(2007)279
White Paper on a Strategy for Europe on Nutrition, Overweight and
Obesity related health issues.

Directive

2002/178/EC

Directive laying down the general principles and requirements of food
law, establishing the European Food Safety Authority and laying
down procedures in matters of food safety. 63

Directive
89/398/EEC

Directive on the approximation of the laws of Member States relating
to foodstuffs intended for particular nutritional uses

Directive
90/496/EEC

Directive on nutritional labelling of foodstuffs

Regulation
1924/2006

Regulation on nutritional and health claims made on foods

Regulation
1925/2006

Regulation on the addition of vitamins and minerals and of certain
other substances to foods

Directive
2002/46/EC

Directive relating to food supplements

Tobacco

Directive
2001/37/EC

Directive 2001/37/EC of the European Parliament and of the Council
on the approximation of the laws, regulations and administrative
provisions of the Member States concerning the manufacture,
presentation and sale of tobacco products

Directive
2003/33/EC

Directive 2003/33/EC of the European Parliament and of the Council
on the approximation of the laws, regulations and administrative
provisions of the Member States relating to the advertising and
sponsorship of tobacco products

Decision
2003/641/EC

Commission Decision 2003/641/EC on the use of colour photographs
or other illustrations as health warnings on tobacco packages

63 The EU has a significant acquis on food safety. It is not possible to include the entire list in this

document but more information is available at http://ec.europa.eu/food/index_en.htm.

Drucksache 16/9412 – 140 – Deutscher Bundestag – 16. Wahlperiode

Decision C(2005)
1452

Commission Decision C(2005) 1452 on the library of selected source
documents containing colour photographs or other illustrations for
each of the additional warnings listed in annex 1 to Directive
2001/37/EC of the European Parliament and of the Council

Decision C (2006)
1502

Commission Decision C (2006) 1502 amending Commission Decision
C(2005) 1452 of 26 May 2005 on the library of selected source
documents containing colour photographs or other illustrations for
each of the additional warnings listed in Annex 1 to Directive
2001/37/EC of the European Parliament and of the Council

Decision
2004/513/EC

Council Decision 2004/513/EC concerning the conclusion of the
WHO Framework Convention on Tobacco Control

Council
Recommendation
(2003/54/EC)

Council Recommendation of 2 December 2002 on the prevention of
smoking and on initiatives to improve tobacco control

Council Resolution
(96/C 374/04)

Council Resolution of 26 November 1996 on the reduction of smoking
in the European Community

Council Resolution
(89/C 189/01)

Resolution of the Council and the Minister of Health of the Member
States of 18 July 1989 on banning smoking in places open to the
public

Regulation (EC) No
2182/2002

Commission Regulation (EC) No 2182/2002 of 6 December 2002
laying down detailed rules for the application of Council Regulation
(EEC) No 2075/92 with regard to the Community Tobacco Fund

Council Conclusions
(2000/C 86/03)

Council Conclusions of 18 November 1999 on combating tobacco
consumption

Green Paper of
January 2007

Towards a Europe free from tobacco smoke: policy options at EU
level

Alcohol

Council Conclusions
(2001/C 175/01)

Council Conclusions of 5 June 2001 on a Community strategy to
reduce alcohol-related harm

Council
Recommendation
2001/458/EC)

Council Recommendation of 5 June 2001 on the drinking of alcohol
by young people, in particular children and adolescents

Council Conclusions
on Alcohol and
young people 2004/
/EC

Council Conclusions of 2 June 2004 reiterated Council Conclusions of
5 June 2001 on a Community strategy to reduce alcohol-related harm
COM(2006)625 Commission Communication on an EU strategy to support Member States in reducing alcohol related harm

Deutscher Bundestag – 16. Wahlperiode – 141 – Drucksache 16/9412

Drugs

Council
Recommendation
(2003/488/EC)

Council Recommendation of 18 June 2003 on the prevention and
reduction of health-related harm associated with drug dependence

Safety and Health at Work64

Directive
89/391/EEC

Council Directive 89/391/EEC of 12 June 1989 on the introduction of
measures to encourage improvements in the safety and health of
workers at work

As of September 2006, 19 Directives exist under this framework
Directive on issues including work equipment, exposure to substances,
pregnant workers and workers in specific industries like mining or
fishing.

Directive
2003/88/EC

Directive 2003/88/EC of the European Parliament and of the Council
of 4 November 2003 concerning certain aspects of the organisation of
working time

Directive 94/33/EC Council Directive 94/33/EC of 22 June 1994 on the protection of
young people at work

Directive
91/322/EEC

Commission Directive 91/322/EEC of 29 May 1991 on establishing
indicative limit values by implementing Council Directive
80/1107/EEC on the protection of workers from the risks related to
exposure to chemical, physical and biological agents at work

Regulation (EC) N°
2062/94

Council Regulation (EC) No 2062/94 of 18 July 1994 establishing a
European Agency for Safety and Health at Work

Council Resolution of 3 June 2002 on a new Community strategy on
health and safety at work (2002-2006)

Commission Recommendation of 19 September 2003 concerning the
European schedule of occupational diseases
64
Although a key part of the EU's work in the field of health, the extensive acqui in the field of Safety and

Health at Work cannot be reproduced here in total. A small selection of the most relevant legislation is
represented in this table. A complete list can be found at
http://ec.europa.eu/employment_social/labour_law/index_en.htm

Drucksache 16/9412 – 142 – Deutscher Bundestag – 16. Wahlperiode

Veterinary and
Phytosanitary
Legislation65

Regulation (EC)
999/2001

Laying down rules for the prevention, control and eradication of
certain transmissible spongiform encephalopathies

Regulation 396/2005 On maximum residue levels of pesticides in or on food and feed of
plant and animal origin and amending Council Directive 91/414/EEC
(Not yet fully applicable. Treaty base under Article 37 and Article
152)

Specific Health Topics

Cancer

Council
Recommendation
(2003/878/EC) Council Recommendation of 2 December 2003 on cancer screening

Cardiovasular Diseases

Council Conclusions Council Conclusions of 2 June 2004 on promoting heart health

Accidents and injuries

COM(2006)329
Proposal for a Council Recommendation on the prevention of injury
and the promotion of safety

8344/07

Council Recommendation On The Prevention Of Injury And The
Promotion Of Safety

Women's Health

97/C 394/01
Council Resolution of 4 December 1997 concerning the report on the
state of women's health in the European Community

External Action

COM(2005)179
A European Programme for Action to Confront HIV/AIDS, Malaria
and Tuberculosis through External Action (2007-2011)

COM(2006) 870
A European Programme for Action to tackle the critical shortage of
health workers in developing countries (2007 – 2013)

65 See Annex 6, reference to Treaty Article 152, 4(b). Two key Regulations in the veterinary and

phytosanitary areas are listed here that have an Article 152 base due to having a direct objective of
protecting public health.

Deutscher Bundestag – 16. Wahlperiode – 143 – Drucksache 16/9412

ANNEX 2:

HEALTH ACROSS THE EUROPEAN COMMISSION

DG Key Health Links

AGRI Nutritional aspects in promotional campaigns for EU agricultural products,
information campaigns on smoking (funded up to 2008)

BEPA Investing in youth

COMP Competition rules in health markets

EAC Education on healthy lifestyles; Lifelong learning; Young people and health,
Promotion of sport

ECFIN Economic projections re: demographic change, healthcare spending

EMPL Safety and Health at work; coordination of Social security schemes including
the EHIC card; access of people with disabilities to social and health services;
European Social Fund; Open Method of Coordination on Healthcare and
Long Term Care

ENTR Pharmaceuticals; Medical Devices; Biotechnology; Safety of Cosmetics;
Chemicals; Innovation

ENV Environmental health e.g. air quality, water quality, noise; 'European Environment and Health Strategy', COM(2003)338, and 'European
Environment and Health Action Plan 2004-2010', COM(2004)416

EUROSTAT Data collection in field of health and safety

INFSO Development and deployment of e-Health tools and services66.

JLS Illegal Drugs; Immigration policy and integration, protection of personal data
concerning health

JRC Scientific and Technical Support in areas which may have an impact on
health directly or indirectly (chemicals, air pollution, deteriorated water
quality, food, genetically-modified organisms, nanotechnology, consumer
products)

MARKT Benefits of Internal market to patients and healthcare providers; recognition
of professional qualifications; Intellectual property rights and access to
medicines; legal framework for public private partnership

REGIO Regional Policy actions to support health policy, including through 'Regions
for Economic Change'

66 http://ec.europa.eu/information_society/activities/health/index_en.htm

Drucksache 16/9412 – 144 – Deutscher Bundestag – 16. Wahlperiode

RTD Research framework programmes FP6, FP7

SANCO Public health, consumer policy, food safety, animal health

SG Coordination policy on Biotech and sustainable development

TAXUD Policy on enforcement to combat introduction of products with a health risk

TREN Road safety, Energy, Ionising radiation, Working and Driving Hours

AIDCO External aid for health

DEV Health in EC and EU development policy, ACP country and regional
programmes, and thematic programmes for all regions

ECHO Humanitarian aid operations. Access to healthcare in crisis situations and
rapid response to life-threatening epidemics and other health hazards.

ELARG Assisting EU accession countries to put in place the health acquis

RELEX Relations with third countries, including European Neighbourhood countries
on health

TRADE Trade negotiations re: Health and social services and services of health
professionals

OLAF Illicit trade in tobacco products

Deutscher Bundestag – 16. Wahlperiode – 145 – Drucksache 16/9412

ANNEX 3:

FINANCIAL COMMUNITY INSTRUMENTS RELEVANT FOR HEALTH

DG Financial instrument

AGRI Nutrition aspects of promotion campaigns under CAP; Tobacco Fund information
campaigns (ending 2008)

EAC Lifelong Learning Programme (2007-2013)

Youth programme

EMPL European Social Fund (2007-2013), projects/actions under the Safety and Health at
Work Strategy 2007-2012

ENTR Competitiveness and Innovation Framework Programme (CIP) (2007-13)
ENV LIFE (supporting environmental and nature conservation projects)
EUROSTAT Statistical Programme
INFSO eTEN Programme67, Competitiveness and Innovation Programme, Ambient Assisted

Living Programme68
JLS Programme Security and Safeguarding Liberties

Framework programme on Solidarity and the management of migration flows
Drugs Prevention and Information Programme (Council Common Position July
2007)
Daphne III (combating violence against women, young people and children)

REGIO Regional Policy programmes co-financed with the European Regional Development
Fund (2007-2013)

RTD Research Framework Programmes FP6, FP7 ( research on health and treatment
including public health and health systems, food safety, eHealth, Innovative
Medicines Initiative, actions related to global health, road safety)

SANCO Programme of Community Action in the field of Public Health (2003-2008)
Programme for Community Action in the field of Health (2008-2013)
Programme of Community action in the field of consumer policy (2007-2013)
Council Decision of 26 June 1990 on expenditure in the veterinary field
(90/424/EEC)

TREN Intelligent Energy Europe, actions under the Euratom Framework Programmes
(radiation protection)

DEV Development cooperation instrument, European development fund
ECHO Humanitarian aid operations
ELARG Instrument for Pre-accession Assistance – IPA

Technical Assistance and Information Exchange Instrument - TAIEX
RELEX European Neighbourhood and Partnership Instrument including

TAIEX, Development and Cooperation Instrument (DCI), Stability Instrument (SI),
Humanitarian Assistance Instrument, and other thematic instruments including
'Investing in People', 'Cooperation with Non-State Actors', etc.

OLAF Hercules programme

67 http://ec.europa.eu/information_society/activities/eten/index_en.htm
68 http://ec.europa.eu/information_society/activities/einclusion/research/aal/index_en.htm

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ahlperiode

H

A Mission/Role

EU orkplaces safer, healthier and more
g together and sharing knowledge and

moting a culture of risk prevention.
EC d communicate current and emerging

posed by infectious diseases.
EC ut technical, scientific and administrative

an EC regulation on the safe use of
006) and to ensure consistency at

ation to these aspects
ber States and the institutions of the

best possible scientific and technical
elating to chemicals which fall under

idance documents, tools and data bases
pdesk and run a helpdesk for registrants

n chemicals publicly accessible
EE le development and to help achieve

asurable improvement in Europe's
e provision of timely, targeted, relevant

n to policy making agents and the public.
EF scientific advice on all matters with a

t on food and feed safety, contribute to a
of human life and health through taking

alth and welfare, plant health and the
ontext of the operation of the internal
ANNEX 4:

COMMUNITY AGENCIES DIRECTLY RELEVANT TO HEALT

bbreviation Agency

-OSHA European Agency for Safety and Health at Work (Bilbao, Spain) To make Europe's w
productive by bringin
information, and by pro

DC European Centre for Disease Prevention and Control (Stockholm,
Sweden)

To identify, assess an
threats to human health

HA European Chemicals Agency (Helsinki, Finland) To manage and carry o
aspects of REACH (
chemicals, No 1907/2
Community level in rel
To provide the Mem
Community with the
advice on questions r
REACH
To manage IT based gu
To support national hel
To make information o

A European Environment Agency (Copenhagen, Denmark) To support sustainab
significant and me
environment through th
and reliable informatio

SA European Food Safety Authority (Parma, Italy) To provide objective
direct or indirect impac
high level of protection
account of animal he
environment, in the c
market.

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EM ellence in the evaluation and supervision

nefit of public and animal health.
EM munity and its Member States with

comparable information at European
ugs and drug addiction and their

EU n, advice and expertise – on living and
ustrial relations and managing change in

s in the field of EC social policy on the
formation, research and analysis.

FR and data, provide advice to the European
States, and promote dialogue with civil

awareness of fundamental rights. Article
undamental Rights enshrines the right to

ES ent in space continues to deliver benefits
rope and the world, including satellite

elp to provide the information needed to
nt, understand and mitigate the effects of

sure civil security for Europe.
EA European Medicines Agency (London, UK) To foster scientific exc
of medicines, for the be

CDDA European Monitoring Centre for Drugs and Drug Addiction
(Lisbon, Portugal)

To provide the Com
objective, reliable and
level concerning dr
consequences.

ROFOUND European Foundation for the Improvement of Living and Working Conditions (Dublin, Ireland)
To provide informatio
working conditions, ind
Europe – for key actor
basis of comparative in

A European Union Agency for Fundamental Rights To collect information
Union and its Member
society to raise public
35 of the Charter of F
healthcare.

A European Space Agency To ensure that investm
to the citizens of Eu
technology which can h
manage the environme
climate change, and en

Drucksache 16/9412 – 148 – Deutscher Bundestag – 16. Wahlperiode

ANNEX 5:

INTERNATIONAL COMMITMENTS ON HEALTH (CAPITA SELECTA)

I. BINDING INSTRUMENTS

� WHO Framework Convention on Tobacco Control, 2003

� WHO International Health Regulations (IHR), 2005

� Convention on Human Rights and Biomedicine of the Council of Europe, 1997

II. GLOBAL COMMITMENTS

� United Nations Millennium Declaration adopted by the General Assembly
resolution, 2000

� Paris Declaration on Aid Effectiveness, adopted at the High level Forum, Paris,
2005

� Global Strategy on Diet, Physical Activity and Health, endorsed by the WHA
within the WHO, 2004

� Global health strategy for the prevention and control of noncommunicable
diseases, adopted by the WHA, 2007

� Resolution on public health problems caused by harmful use of alcohol, adopted
by the WHA, 2005

III. EUROPEAN COMMITMENTS ON HEALTH

� European Charter on Counteracting Obesity, adopted at the WHO European
Ministerial Conference in Istanbul, 2006

� Children's environment and health action plan for Europe and the Ministerial
Declaration on environment and health, endorsed by the WHO RC, 2004

� Council of Europe guide to the preparation, use and quality assurance of blood
components, 2007

� Council of Europe Guide to safety and quality assurance for organs,
tissues and cells, 2006

� Mental health Declaration for Europe launching the Mental Health Action Plan for
Europe, endorsed by the WHO RC, 2005
� Gaining health: the European strategy for the prevention and control of
noncommunicable diseases, adopted by the WHO RC, 2006

Deutscher Bundestag – 16. Wahlperiode – 149 – Drucksache 16/9412

� Framework for alcohol policy in the WHO European Region, endorsed by the
WHO RC, 2005

� European Strategy for Tobacco Control and the Declaration for a Tobacco-free
Europe, adopted by the WHO Regional Committee for Europe (RC), 2002

� European Consensus on Development Cooperation, Joint Declaration of the
Council and Member States, Official Journal C 46/01 of 24 February 2006

Drucksache 16/9412 – 150 – Deutscher Bundestag – 16. Wahlperiode

ANNEX 6:

HEALTH IN THE TREATY ESTABLISHING THE EUROPEAN COMMUNITY
The Treaty clearly states that the activities of the Community shall include 'a contribution to
the attainment of a high level of health protection' Article 3 (1) (p)

EU action on health is also explicitly provided for in Treaty Article 152:69

Article 152

1. A high level of human health protection shall be ensured in the definition and
implementation of all Community policies and activities.

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 causes, 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.

2. The Community shall encourage cooperation between the Member States in the areas
referred to in this Article and, if necessary, lend support to their action.

Member States shall, in liaison with the Commission, coordinate among themselves their
policies and programmes in the areas referred to in paragraph 1. The Commission may, in
close contact with the Member States, take any useful initiative to promote such coordination.

3. The Community and the Member States shall foster cooperation with third countries and
the competent international organisations in the sphere of public health.

4. 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
harmonisation 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.

69 European Union Consolidated Versions on the Treaty of the European Union and of the Treaty

Establishing the European Community (OJ C 325, 24.12.2002).

Deutscher Bundestag – 16. Wahlperiode – 151 – Drucksache 16/9412

5. Community action in the field of public health shall fully respect the responsibilities of the
Member States for the organisation and delivery of health services and medical care. In
particular, measures referred to in paragraph 4(a) shall not affect national provisions on the
donation or medical use of organs and blood.

Health is also mentioned in other articles throughout the Treaty. For example,

Article 95 (3), (6) and (8) concerning health in relation to the internal market

Article 133 (6) concerning common commercial policy, stating that health services "…shall
fall within the shared competence of the Community and its Member States…".

Article 137 (1) (a) "1.'The Community shall support and complement the activities of the
Member States in the following fields: a) improvement in particular of the working
environment to protect workers' health and safety"

Article 153 "The Community shall contribute to protecting the health, safety and economic
interests of consumers"

Article 174 (1) "Community policy on the environment shall contribute to pursuit of the
following objectives: (…)- protecting human health.

Article 163 concerning the objective to promote 'all the research activities deemed necessary
by virtue of other chapters of this Treaty'.

Article 177 on development cooperation includes a requirement to 'contribute to the general
objective of…respecting human rights and fundamental freedoms'