Transcript European Public Health Alliance
European Public Health Alliance
Health and the EU
Cyprus training seminar
20 and 21 September 2003
I: Global principles of health
II: Health and the EU
III: Health and the individual
Training on health in the EU, Cyprus 20-21 September 2003
European Public Health Alliance
A network of 90 non governmental and not-for-profit organisations across Europe working on health and health related issues
Our mission is to improve the health of European citizens and to increase their participation in EU policy-making
Training on health in the EU, Cyprus 20-21 September 2003
European Public Health Alliance (EPHA)
Part I
Global principles of health
Training on health in the EU, Cyprus 20-21 September 2003
A definition of health A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
World Health Organisation, 1946
Training on health in the EU, Cyprus 20-21 September 2003
The globally recognised right to health The States Parties to the present Covenant recognise the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.
UN International Covenant on Economic, Social and Cultural Rights (CESCR), Article 12, 1966. Ratified by more than 145 countries across the world.
Training on health in the EU, Cyprus 20-21 September 2003
The right to health explained
The right to health contains both
freedoms entitlements
. and Freedoms include the right to control one's health and body, including sexual and reproductive freedom, and the right to be free from interference, such as the right to be free from torture, non-consensual medical treatment and experimentation. Entitlements include the right to
a system of health protection
, which provides equality of opportunity for people to enjoy the highest attainable level of health.
(General Comment, adopted by UN Committee on Economic, Social and Cultural Rights, May 2000)
Training on health in the EU, Cyprus 20-21 September 2003
Key criteria to evaluate health rights
Availability:
public health and healthcare services
Accessibility:
economic and physical accessibility, adequate information and non discrimination. Safe access for marginalised and disenfranchised groups.
Acceptability:
culturally appropriate, medically ethical, must improve health status, respect confidentiality and gender issues.
Quality:
medically and scientifically appropriate, good quality
(The UN Committee on Economic, Social and Cultural Rights monitors the implementation of the 1966 Covenant and can adopt ‘General Comments’ to provide guidance on the interpretation of the Covenant. This ‘General Comment’ on the right to health was adopted in May 2000)
Training on health in the EU, Cyprus 20-21 September 2003
What does the EU treaty state?
The EU Treaty is the legal basis for the EU role on specific policy areas.
Article 152
of the 1997 Amsterdam Treaty covers public health: “
a high level of health protection shall be ensured in the definition and implementation of all Community policies and activities
” But the EU must respect Member State responsibilities for organisation and delivery of healthcare. (11 of the current 15 countries have de-centralised healthcare systems).
The key EU mechanism of legislation to harmonise Member States laws is not permitted except on the safety of
blood and blood products
(law finalised in autumn 2002) and
human tissues and cells
(law expected to be adopted in 2004). Training on health in the EU, Cyprus 20-21 September 2003
What EU rights to health exist?
“
Everyone has the right of access to preventative healthcare and the right to benefit from medical treatment under the conditions established by national law and practices
”
Article 35 of the Charter of Fundamental Rights of the EU, Adopted in Nice, 12/2000
In practical terms this means the right to be treated by a doctor. It does not cover issues such as ‘quality’ and ‘timeliness’. It is less ambitious than the WHO definition of health and the UN CECSR. Training on health in the EU, Cyprus 20-21 September 2003
European Governance issues
Citizens put health in the top 5 priority areas they want addressed by the EU
. (see Eurobarometer survey results on CAP, Enlargement, sustainable development etc)
Health should be fully integrated in all EU policies
consumption in the developing world!
(eg: implementation of Article 152). The Common Agriculture Policy (CAP) results in destruction of 1 million tonnes of fruit and vegetables annually and pays farmers to grow tobacco for
Very limited resources allocated to public health at EU level
(13.98 cents per person annually, 6.5 research and >800
Citizens are stakeholders
in decision-making and setting policy priorities not just passive consumers of healthcare
Consultation and participation
in health decision-making.
Training on health in the EU, Cyprus 20-21 September 2003
The role of NGOs on health
Advocacy
of health rights for all
Representation
interest of citizen and public
Awareness raising
rights issues on health and human
Monitoring
rights of implementation of health
Challenging
violations of health rights Training on health in the EU, Cyprus 20-21 September 2003
What does EPHA stand for?
Health protection as a goal in all EU policy-making - eg health impact assessments for all proposed legislation Involvement of citizens in decision-making related to their own health.
Addressing health inequalities. (Children born in poor areas have a shorter, less healthy life than those born in richer parts of the same city, region and country).
Equal access to good quality healthcare for all EU citizens.
Ensuring that EU internal policies (
eg; competition, transport, energy, agriculture, industry
) and external policies (
eg: trade, development, external aid
) actually promote health.
Training on health in the EU, Cyprus 20-21 September 2003
Goals for EPHA
A
rights-based approach
in health policy Campaign to
change the EU Treaty
to strengthen the competence on public health. This would allow a more ambitious, integrated EU approach to health and specifically address health determinants such as tobacco, alcohol, nutrition etc.
EU health policy to be based around delivering the
highest attainable standards
rather than the lowest common denominator that can be agreed by all countries.
Training on health in the EU, Cyprus 20-21 September 2003
European Public Health Alliance (EPHA)
Part II
Health and the EU
•
Institutions, policies and programmes
Training on health in the EU, Cyprus 20-21 September 2003
The European Council
The EU is a union of Member States. The highest political and legislative authority is the European Council which consists of Member States.
Twice a year the heads of state meet at a Summit meeting of the European Council. Other Ministers meet more regularly in thematic Councils (eg; Employment, Social Policy, Health and Consumer Affairs)
National civil servants posted to Brussels
meet weekly to prepare the Ministerial meetings. They receive instructions from their governments and the meetings establish the basic positions of each country. Most of the inter-governmental negotiations take place at this level. This is known by the French acronym of
COREPER
(Committee of Permanent Representatives).
The Council is supported by a small staff of European civil servants. Every 6 months the
Presidency of the EU
rotates between Member States (note that this rotation system will change post-enlargement).
Training on health in the EU, Cyprus 20-21 September 2003
Employment, Social Policy, Health and Consumer Affairs Council
The Council is comprised of representatives of each Member State, but reaches decisions (for this particular purpose) on the basis of a weighted voting system. The votes are allocated as follows: Country Votes Country Votes Country Votes
Austria 4 Germany 10 Netherlands 5 Belgium Denmark 5 3 Greece Ireland 5 3 Portugal Spain 5 8 Finland 3 Italy 10 Sweden 4 France 10 Luxembourg 2 United Kingdom 10
A ‘qualified majority’ needs 62 votes out of a total of 8. In practice, it is politically necessary to do better than this. A 'satisfactory solution' should command at least 65 votes.
Training on health in the EU, Cyprus 20-21 September 2003
The European Parliament (EP)
The
'democratic'
institution. Since 1999 the European Parliament has been directly elected by citizens. Most countries use a party list and a regional representation
Agenda setting
: Decides with the Council on the broad guidelines for EU policies and programmes
Budgetary approval
: The EP has to sign off on the accounts of the EU. It can withhold approval of the accounts and create specific budget lines.
European legislation:
(Co-Decision process means that EP approval is needed for all legislation).
More info on
http:www.europarl.eu.int
Training on health in the EU, Cyprus 20-21 September 2003
Members of the European Parliament
P
oliticians - elected for five years
- as party members/national members - as members of EP political groups - as Committee members as special interest 'experts’ e.g., Health Forum Intergroup - supported by European civil servants - and a large number of 'permanent visitors' Training on health in the EU, Cyprus 20-21 September 2003
The European Commission
Official role as the
‘Guardian of the Treaty’
sole right to initiate legislation, and monitors . It has the implementation of EU laws. If Member States do not implement laws adequately the Commission can start infringement procedures and can levy a financial penalty.
Commissioners
are appointed by the Member States but are required to act in the ‘European interest’ and not of their home country. They are supported by a Cabinet, usually of political appointees.
Directorates-General
are the core EU civil service, responsible for drafting EU legislation, organising public consultations and the day-to-day business of the EU. Training on health in the EU, Cyprus 20-21 September 2003
How is responsibility for health issues covered at EU level?
DG Health and Consumer Protection
(public health, food safety, animal health, monitoring of health, tobacco and alcohol policies)
DG Environment
(chemicals, pesticides, soil, air and water pollution, bio-diversity, nature reserves)
DG Employment and Social Affairs
(health and safety at work, combating discrimination and poverty, maternity and parental leave).
DG Internal Market
(Recognition of professional qualifications)
DG Competition
(approving mergers eg; Pharma companies)
DG Agriculture
(Common Agriculture Policy)
DG Development
(EU is the world largest source of overseas aid)
DG Education and Culture
(sport, youth policies) Training on health in the EU, Cyprus 20-21 September 2003
How is responsibility for health issues covered at EU level? Part II
DG Trade
(TRIPS, GATS, access to medicines)
DG Research
(scientific research on genomics, food safety, causes of diseases, environmental health)
DG Information Society
(e-health applications)
DG Transport and Energy
transport, road safety) (energy generation, rail
DG Enterprise
(pharmaceuticals and medical devices)
DG Tax and Customs
(excise duties on tobacco/alcohol)
European Medicines Evaluation Agency
authorisation of drugs, pharmacovigilance (EMEA) Training on health in the EU, Cyprus 20-21 September 2003
Why health needs to be addressed at EU level
Many EU policies have an impact – direct or indirect – on the health of EU citizens Implementation of internal market legislation is de-facto creating policy on health related issues Health does not stop at internal borders but is a cross-border issue.
Training on health in the EU, Cyprus 20-21 September 2003
The New Public Health Programme 2003 - 2008
Replaces the earlier 8 separate programmes on AIDS, Cancer, Injuries, Rare diseases, Health Monitoring, Health Promotion, Drugs, Pollution-related diseases.
First Call for Proposals closed on 16 May 2003
. > 400 projects submitted, 1 in 10 selected. New Call for proposals in early 2004.
Strand 1
: Improving health information and knowledge
Strand 2
:
Strand 3:
Responding rapidly to health threats Addressing health determinants Training on health in the EU, Cyprus 20-21 September 2003
The EU Health Policy Forum
A 48 member multi-stakeholder group containing NGOs, health professionals, patients, consumers, trade unions, industry, insurers. Set up by the European Commission in November 2001, membership fixed for 2 years Meets every 6 months Information exchange, consultation, policy recommendations (Enlargement, Social policy and health, mobility of health professionals).
Preparation for an Open Health Forum in 2004 Training on health in the EU, Cyprus 20-21 September 2003
The Enlarged Union
The Treaty of Nice (2000) sets out the institutional arrangements for enlarged Union. This will be changed by the Constitutional Treaty currently being negotiated.
Parliament
criteria set out in the Treaty (next elections June 2004) : 732 seats allocated according to
Commission
Jan 2005) : Each Member State has the right to a Commissioner (new college of Commissioners,
Council
: 345 votes with a Qualified Majority of 255 votes Enlargement negotiations were concluded at the Copenhagen Summit, 12-13 December 2002 Training on health in the EU, Cyprus 20-21 September 2003
The Subsidiarity Principle
Any proposed piece of EU legislation must respond to two principles :
subsidiarity and proportionality
.
This principle means that
decisions should be taken at the lowest administrative level possible
, eg local, regional, national or EU level. The EU Treaty sets out which policy areas are European competence and which issues remain a national responsibility. For policy areas where the EU does not have exclusive competence, the subsidiarity principle applies and the EU can act: only if the
Member States could not achieve the policy objective on their own
and if the Union, because ot its scale or potential impact,could achieve the objective more effectively.
But any action by the Union
must not go beyond what is necessary
to achieve the objectives of the Treaty.
Training on health in the EU, Cyprus 20-21 September 2003
The Proportionality test
Consists of three questions: What is the objective to be pursued?
Are the means employed suitable for the achievement of that measure?
Do they go beyond what is necessary to achieve it?
An example of this in practice is the European Court of Justice’s decision to annul the 1990 EU Tobacco Advertising Directive was based on the fact that this was a ‘dis-proportionate’ response to the stated problem (differences in the way that Member States controlled tobacco advertising), ie; the law was judged to have failed the proportionality test.
Training on health in the EU, Cyprus 20-21 September 2003
A new EU Treaty
Compete revision of the EU Treaty
. A Convention worked for 18 months to discuss the basic principles of the EU and produced a draft Constitutional Treaty. Its mandate was to ensure that the Treaty responds to expectations and demands of citizens Preparing the institutions for an enlarged Europe of 25+ members Member States take the debate into the Inter Governmental Conference (IGC) New Treaty of Rome in December 2003?
Training on health in the EU, Cyprus 20-21 September 2003
EPHA Recommendations
Convention and Treaty reform
: critical political opportunity to adequately prioritise human health (currently the Commission has more powers to protect animals than humans)
Organisation of health at EU level
: fragmented across many Directorates, lacks coherence and consistency
Inadequate resources
: € and human
European policies
: balancing economic priorities with social, environment and health aspects in internal and external policies Training on health in the EU, Cyprus 20-21 September 2003
Goals for EPHA
Campaign to change the EU Treaty to strengthen the competence on public health.
Raise the profile of the health community amongst EU policy-makers.
Develop key consultative role for civil society as partners in health EU Policy to be based on the highest common denominator rather than lowest.
Training on health in the EU, Cyprus 20-21 September 2003
European Public Health Alliance (EPHA)
Part III
Health and the individual
Training on health in the EU, Cyprus 20-21 September 2003
Not all patients are the same
There are a variety of different types of patients and therefore patient needs can be diverse. A simplified overview identifies 3 types of patients:
Casual
: occasional visit to the doctor. Short-term illnesses
Acute
: treatment for a specific illness or condition that is usually cured (+/- 6 months)
Chronic
: long-term, lifetime conditions and illnesses. Diabetes, cardiovascular disease, genetic disorders etc. (46 % of the global burden of disease and only 50 % of patients follow their treatment regime) Training on health in the EU, Cyprus 20-21 September 2003
Patients rights: an overview
No standard approach across the EU.
Legislation in some countries eg; Finland, Holland, Israel, Lithuania, Iceland and Denmark Patient charters or codes eg; France, Germany and UK WHO and Council of Europe have created some consensus principles, strategies and mechanisms.
Training on health in the EU, Cyprus 20-21 September 2003
Opposing forces in health
Financial sustainability of healthcare systems
(demography : ageing population in Europe), high cost of new drugs and treatments. Explosion in lifestyle-related illnesses much of which are preventable (diabetes, heart disease and cancer).
Citizen expectations:
greater demand for healthcare services and interventions. Training on health in the EU, Cyprus 20-21 September 2003
Principles of patients rights
WHO Consultation on patients rights, Amsterdam, 1994 Respect as a human being Self-determination Physical, mental integrity and security Respect for privacy Respect for ethical, cultural and religious values Protection of health through disease prevention and healthcare
Training on health in the EU, Cyprus 20-21 September 2003
Strategies to promote patient rights
WHO Consultation on patients rights, Amsterdam, 1994 Legislation and regulation Medical and professional codes, Charters Networking among patient and providers Government support for NGOs (patients) National conferences Involvement of the media, public awareness Communication and advocacy skills Promotion of research
Training on health in the EU, Cyprus 20-21 September 2003
Some principles for an empowered patient doctor relationship
Mutual
respect
Fullest possible
information
on diagnosis, prognosis and treatment options Effective
communication
appropriate for the patient in a way that is
Joint decision-making
patient’s preferences in support of the
Encompasses the patient’s context
(social support, religious and cultural values, personal preferences and concerns) Training on health in the EU, Cyprus 20-21 September 2003
Effective patient organisations
Transparent:
funding, management board, membership, communication
Representative:
both of the patient group and of society (gender, ethnic and age balance)
Consultative:
have mechanisms to consult members and constituencies on key policy issues. Provides opportunities for members to make decisions (eg Annual General Meetings)
Pro-active:
collaborates with other stakeholders such as healthcare professionals, providers and legislators Training on health in the EU, Cyprus 20-21 September 2003
International Treaties and texts that cover health and patients rights
WHO founding document, 1948 UN Convention on Economic, Social and Cultural rights, 1966 WHO Ottowa Charter on Health Promotion, 1986 Art 129, EU Maastricht Treaty, 1992 Declaration: promotion of patients' rights in Europe, WHO 1994 Art 152, EU Amsterdam Treaty 1997 Patients’ rights and citizens’ empowerment, WHO, 1999 EU Charter of fundamental rights, 2000 Recommendation: development of structures for citizen and patient participation, Council of Europe, 2000 WHO Framework Convention on Tobacco Control, 2003 New EU Treaty, 2003/4 Training on health in the EU, Cyprus 20-21 September 2003
The social framework of health
Health includes
quality of social and emotional experiences
not just experience of disease and disability
Poverty, limited education and poor health
interact and reinforce each other. Greatest impact on children who take these physical, psychological and social issues into adulthood and across generations Policy goal to raise overall prosperity with a focus on marginalised and disadvantaged groups Training on health in the EU, Cyprus 20-21 September 2003
A recipe for good health
Be rich Pick your parents well Get educated Live in supportive, safe communities Live in quality housing Avoid stressful low-paid manual work Don’t lose your job
Roy Romanow, Commissioner, Commission on the Future of Health Care
Training on health in the EU, Cyprus 20-21 September 2003
Information resources
PATIENTS
List of websites of legislation on patients rights http://home.online.no/~wkeim/patients.htm
IAPO website http://www.patientsorganizations.org
WHO links on patients http://www.who.dk/eprise/main/WHO/Progs/LPR/Home List of websites of legislation on patients rights http://home.online.no/~wkeim/patients.htm
Overview of patients rights legislation in several European countries http://www.index-bg.org/Frame/Index.htm
EU INTERNAL MARKET AND HEALTH (EG PATIENT MOBILITY)
AIM website with reports on European Court of Justice judgements on patient mobility particularly the landmark Kohl & Decker case http://www.aim-mutual.org/uk/index.htm
Analysis: impact of ECJ case law on patients on healthcare systems http://www.ose.be/files/pie/intro39.pdf
Irish view on EU internal market and health http://www.forumoneurope.ie/submission_docs/adelaide_meath.doc
EHMA report on healthcare and market http://www.ehma.org/The_European_Union_and_Health_Services_Summary.pdf
GENERAL HEALTH
European Union: http://www.europa.eu.int/comm/health/ World Health Organisation Euro Region http://www.who.dk/ Health and social policy http://www.who.dk/document/e81384.pdf
Training on health in the EU, Cyprus 20-21 September 2003
European Public Health Alliance
33 Rue de Pascale B-1040 Brussels Belgium Tel : +32-2 230 30 56 Fax : +32-2 233 38 80 [email protected]
www.epha.org
Training on health in the EU, Cyprus 20-21 September 2003