Introduction

This paper provides an initial outline and suggested content for an ‘All Policies for a Healthy Europe’ multi-stakeholder manifesto (see below). It reflects the outcomes of the AP4HE co-creation session at the European Health Forum Gastein on 3 October 2018, as well as the initiative summary paper (see attached).

A number of questions (both general and specific) have been included in this covering note. Stakeholders are invited to contribute to the development of the manifesto by responding to questions (where possible), and providing comments/feedback on the outline content which follows.

Please send your feedback/comments to secretariat@ap4he.eu by Wednesday 5 December 2018. Your input will be used to develop a more advanced draft of the manifesto that will be shared with all contributing organisations/individuals in January 2019. A manifesto co-creation session will be held on 22 January to finalise the text and discuss how the key messages can be most effectively communicated.

Questions:

  1. What examples of cross-sectoral action on health and well-being at national level, could be used to strengthen the case for adopting such an approach at EU level?
  2. The outline manifesto proposes a number of institutional mechanisms to enable cross-sectoral action, including a Commission Vice President for Health and Well-being, Health Impact Assessments, and the European Semester. What other mechanisms/structures would you propose?
  3. If the EU established a monitoring framework for well-being, which indicators/measures of well-being would you consider it most important to include? (e.g. Healthy life expectancy, housing affordability, air quality, rates of depression)?
  4. During the AP4HE co-creation session in Gastein, actions to promote health and well-being in (i) the workplace and (ii) educational environments were strongly supported. What European level policies/actions would best contribute to these objectives?
  5. Are there examples of local level cooperation on environment and health (e.g. around clean air, transport and waste management), which the European Union could promote or enable through regional funds?
  6. Another popular idea was the creation of a Digital Health Passport for EU citizens. What information should such a passport contain, and what impediments may need to be overcome at Member State level?

AP4HE manifesto outline

Section headings and proposed content

1. Health and well-being as contributors to a new economic model

  • A new economic model is needed: one that encompasses more than just GDP and fiscal rules, and which targets inclusive growth and sustainable development.
  • The current focus on doing less more efficiently fails to respond to the aspirations of European citizens. 70% of European citizens want to see more EU action on health and social security (Eurobarometer, May 2018), while three-quarters want greater European action on environmental protection.
  • All Policies for a Healthy Europe aims to provide a bold vision for a Europe that works cross-sectorally to improve the health and well-being of citizens as a core component of inclusive growth. It is a vision that fully respects Member State competence for the organisation and delivery of health services.

2. The case for cross-sectoral action on health and well-being

  • The economic dimension: good health is a driver of societal well-being; it also makes a crucial contribution to productivity and employment. There is a growing recognition that the challenges presented by ageing populations and strained health budgets require a radical upgrade in prevention and health promotion, including by addressing the societal and environmental causes of ill health.
  • Improved health and well-being cannot be delivered by the health sector alone: in many cases, effective action to address the causes of ill health will require the involvement, and even the leadership, of non-health sectors (supported by appropriate tools and expertise from the health sector).
  • The importance of cross-sectoral action is not currently reflected in the work and priorities of the European Commission. Action on health (with a few exceptions) is confined to the Directorate-General responsible for health (DG SANTE). All Policies for a Healthy Europe calls for a new approach, one in which all policy areas take responsibility for health impacts/linkages within their sectors – be it health in the workplace, air quality, sustainable food production and consumption, or the societal application of digital tools to create new opportunities for improved health and well-being.

3. Designing and implementing an ‘All Policies’ approach to health and well-being at EU level

3.i. Institutional aspects and legal base

  • The central principle of AP4HE is that improved health and well-being of citizens should be a strategic goal for the next Commission, and that all Directorates-General (DGs) should be responsible for ensuring that their sectoral policies and legislation contribute to that goal. That includes DGs for Economic and Financial Affairs, Employment and Social Affairs, Health and Food Safety, Digital (Connect), Transport, Environment, Regional policy, Industry and the Internal Market, Agriculture, Research, and Education.
  • Implementation of that cross-sectoral approach should fall under the remit of a Commission Vice-President for Health and Well-being. In that respect, AP4HE would resemble the ‘better regulation’ agenda of the current First Vice-President, Frans Timmermans, or Vice President Andrus Ansip’s role in coordinating the team of Commissioner’s responsible for the Digital Single Market.
  • An ‘All Policies’ approach has a firm and long-standing legal base: Article 168 of the TFEU states that ‘A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities.’ It would also build upon ideas set out in the Commission’s 2008-13 Health Strategy (see the ‘Together for Health’ Communication 2007).

3.ii. Implementation tools

Key tools in the implementation of a cross-sectoral approach include:

  • Health Impact Assessments (HIA) should be incorporated into the European Commission’s existing regulatory Impact Assessment procedure. The work can be supported by the Joint Research Centre, and should take into account previous EU level initiatives (see ‘Together for Health’ above), as well as national examples and experiences (see World Health Organization: https://www.who.int/hia/about/guides/en/).
  • The European Pillar of Social Rights: jointly signed by the European Commission, EU Council, and European Parliament, the European Pillar of Social Rights sets out 20 principles grouped into three categories: i. Equal opportunities and access to the labour market; ii. Fair Working conditions; iii. Social protection and inclusion. These include principles on health and safety in the workplace; child poverty; incomes for the elderly; housing and assistance for the homeless; inclusion of people with disabilities; access to affordable, preventative and curative health care; and access to essential services.
  • The EU Budget: the EU’s Multi-annual Financial Framework can be used to support a cross-sectoral approach to health. Opportunities to contribute to health goals should be identified across all sectoral allocations, in particular the Cohesion and Values cluster – encompassing the European Social Fund Plus (including the Health Programme) and Regional Development – the Single Market, Innovation and Digital cluster, and the Natural Resources and Environment cluster. Synergies should be sought with investments in EU implementation of the Sustainable Development Goals.

3.iii. Role of Commission health services

An ‘All Policies’ approach to health and well-being should be supported by knowledge and expertise of the Commission’s health services (DG SANTE). In particular, it is envisaged that SANTE would be responsible for:

  • Making more visible the interrelations between health and other sectors, and providing technical assistance to the team working to the Vice President for health and well-being.
  • Improving the evidence-base on the short and longer-term health impacts of EU policies and supporting other DGs with undertaking health impacts assessment of proposed policies and legislation.
  • Acting as the focal point for WHO cooperation with the EUin particular to make the most of synergies between cross-sectoral EU action on health and WHO work on Health Governance.

3.iv. EU action on health systems

  • At the same time, current EU action on health systems should be maintained and enhanced. The State of Health in the EU reports marked an important step forward in improving cross-country knowledge of health system performance. From a fiscal sustainability perspective, a greater emphasis on public health remains a priority for all Member States, and DG SANTE and DG ECFIN should to continue to cooperate to advance this agenda.
  • EU health services should also focus on helping Member States prepare for future challenges and opportunities: increasingly health services will need to be provided in the community, requiring more coordinated approaches to care delivery, and presenting new challenges for the health workforce; new technologies will present new opportunities – from artificial intelligence to early disease interception; patient involvement in health care decision-making (from the clinical to the management level) too often remains an aspiration, and there may be opportunities to learn from best practices across Member States.

4. Proposals for cross-sectoral action

At the European Health Forum in Gastein, participants were asked to develop proposals for cross-sectoral action under three thematic headings: i. Healthy Societies; ii. Healthy Environment; iii. Healthy Systems.

  • Healthy Societies focuses on social determinants of health and well-being, health in schools and workplaces, implementing the European Pillar of Social Rights, and the EU’s contribution to health outside of Europe (for example through trade agreements).
  • Healthy Environments addresses environmental impacts on health, such as air quality, water management and waste management. Emphasises that environmental health and human health are inextricably linked.
  • Health Systems focuses on the readiness of health systems for the challenges that will be presented by ageing populations and changing health needs, as well as the need to upscale prevention.
  • Digital tools will be cross-cutting theme – including digital communications as a driver for social inclusion, digital innovation to address societal needs, and building a health data ecosystem underpinned by trust.

Based on the input received at Gastein, proposed priority topics have been identified under each heading. Possible recommendations to be included in the manifesto are also listed below. The list of potential recommendations is indicative at this stage, and not all of them will necessarily appear in subsequent drafts.

Healthy Societies

  • Priority topics: healthy workplaces; health in education; healthy lifestyles; social inclusion; data ecosystem for health, underpinned by policies that promote trust.
  • Possible recommendations to the European Commission include:
    1. Adopt 10 indicators for monitoring and reporting on health and well-being in the EU (drawing upon existing Eurostat data and the OECD’s ‘How’s Life’ indicator set). Report annually on EU-level picture and variations between countries.
    2. Integrate implementation of the European Pillar of Social Rights into the European Semester process (alongside fiscal sustainability considerations).
    3. Disseminate Member State best practices in health promotion and health literacy, including digital health, in the context of:
      • Workplace: in the knowledge that a healthy workforce will be a productive workforce, employers should be encouraged to place more emphasis on prevention and health promotion in the workplace – for example through encouraging and facilitating exercise (e.g. gym memberships and access to green spaces), smoking cessation; work-life balance, and measures to identify and combat stress and depression.
      • Educational environments schools and universities present important opportunities to influence health-related behaviours at an early age – for example through an emphasis on exercise, nutrition, and dental care. Teachers should also be trained to identify children/young people that may be experiencing mental health issues. Counselling services should be made easily accessible to all students.
    4. Take measures to build a health data ecosystem across Europe, including open data policies that facilitate trusted and transparent data sharing across sectors. In that context, build trust around the use and sharing of (privacy protected) health data for societal benefit.
    5. Include health as a core component of Sustainable Development chapters in EU trade agreements (in that framework, tobacco products should cease to be treated as an EU ‘offensive interest’).

Healthy Environment

  • Thematic priorities: healthy regional policies (including public transport systems and urban planning); healthy air quality; water management (scarcity, pollution, link with AMR); waste management (waste reduction and treatment); sustainable corporate footprints (e.g. energy use, waste management, supply chain sustainability); sustainable procurement policies (public and private); food chain sustainability; inclusion of environmental impacts in public health outcomes monitoring (national and EU level).
  • Possible recommendations to the European Commission include:
    1. Regional funds should target: i. the modernisation of public transport systems, including cross-border rail services as a substitute for travel by air/road; ii. sustainable cities (clean transport, clean buildings, clean businesses) – ensuring fair distribution of benefits across social groups.
    2. Ensure health and environmental impacts are equally considered in the development of EU air quality rules / legislation (for example, air quality impacts on cognitive development).
    3. Promote sustainable environmental footprints in private and public organisations and their supply chains – for example through adoption of sustainability criteria for procurement (focusing on environmental and social impacts), and analysis of product lifecycle impacts.
    4. Review EU food hygiene legislation to identify and, where possible, address barriers to food sustainability and circular economy objectives.

Health Systems

  • Thematic priorities: improving financial sustainability and value for money through a stronger focus on prevention and measuring health outcomes that matter to people (patients, carers, and citizens); innovation in the delivery of health services – in particular more integrated and person-centred care; health workforce preparedness; development of digital health infrastructure; and cross-border portability of health data (Digital Health Passport). 
  • Possible recommendations to the European Commission include:
    1. The Structural Reform Support Service (SRSS) should be equipped to support Member States with the implementation of (i) preventative services and (ii) integrated health/social care services.
    2. Continue to invest in OECD patient-reported indicators survey for cross-country comparisons of patient-reported outcomes and experiences. Extend this to include care-giver reported outcomes.
    3. Use structural funds to support the development of digital health infrastructures, including health information systems. In that context, maintain and enhance EU and national work on Digital Health interoperability and standardisation.
    4. For the future readiness of health systems, provide guidance on policies to promote health workforce sustainability, health literacy and self-care, and address ‘brain drain’ of healthcare professionals from east to west.