Rapporteurs:

Paulo BARROS VALE Carlos Manuel TRINDADE Danko RELIĆ

Referral	European Commission, 8.2.2023
Legal basis	Article 304 of the Treaty on the Functioning of the European Union
Section responsible	External Relations
Adopted in section	18.7.2023
Adopted at plenary	21.9.2023
Plenary session No	581
Outcome of vote (for/against/abstentions)	207/0/2

1.   Conclusions and recommendations

1.1.

The European Economic and Social Committee (EESC) is in favour of adopting a comprehensive renewed approach to the EU Global Health Strategy by addressing the social, economic and environmental determinants of health opportunities in terms of ensuring universal health coverage, climate change, decreasing biodiversity and increasing environmental pollution, as well as new opportunities provided by better knowledge and technological innovation.

1.2.

The EESC recognises the urgent need for global action to address communicable diseases (CDs) and non-communicable diseases (NCDs). It emphasises the importance of strengthening disease surveillance systems, promoting vaccination programs, improving access to essential medicines, addressing antimicrobial resistance, and enhancing health systems to prevent and manage CDs effectively. Additionally, it emphasises the development of prevention strategies, early detection, awareness of risk factors, collaboration among stakeholders and addressing social determinants in the prevention and management of NCDs.

1.3.

The EESC underscores the significance of adopting a comprehensive approach to health and well-being by addressing the social, economic and environmental determinants of health. It emphasises the importance of policies and actions that tackle poverty, inequality and lack of access to education, and promote a healthy environment. The EESC also supports the promotion of reproductive health and birth control rights.

1.4.

The EESC emphasises the importance of integrating health considerations, including mental health, into all areas of EU external engagement, including trade agreements, development cooperation and other relevant initiatives.

1.5.

The EESC recommends that by enhancing investment in health, the EU should continue to strengthen its global leadership role in health promotion and health care systems, in a way that stimulates its own economic growth and creates opportunities for a stronger role in technological development and innovation, among other goals. The priorities in infrastructure development, universal access to health care and primary health care development need to take fully into account the principles and tools of person-centred integrated health care.

1.6.

The EESC emphasises the need to progress rapidly in the development of the European Health Data Space and focus on its personal empowerment objectives and global implications. The EESC recommends a piloting approach based on countries more advanced in the digitalisation process through the work already developed in the ‘European eHealth network’, including selected global partners.

1.7.

The EESC is particularly concerned with the challenges posed by the current shortage of healthcare workers in Europe and globally. The EESC recommends that the EU Global Health Strategy reinforces its health workforce policies taking into account (a) that health personnel must benefit from improved working conditions through upward convergence and upward levelling of working conditions within the EU and globally, and that (b) the health care workforce migration is certainly a complex and difficult issue, but one that needs to be properly and urgently addressed — the concept of ‘circular migration’ must be taken into account in this context.

1.8.

The EESC firmly recommends a global health strategy and mission that will focus on the principle of ‘more health and fewer diseases’ by adopting national and transnational strategies for health promotion, disease prevention and the dissemination of health knowledge. It will raise awareness among the general public about healthy habits, such as physical activity, healthy eating, disease prevention, respect for animals, the environment and the ecosystem, as well as the proper use of health services.

1.9.

While healthcare systems remain the responsibility of Member States, the EESC supports the development of integrated national and international information systems to strengthen epidemiological surveillance, early detection, and global identification of communicable and other diseases, with a focus on the ‘One Health’ concept. In the same context, the EESC highlights the relevance of ensuring the digital transition as a new determinant in health and a special focus, support and investment on mental health, gender issues, disabilities, harmonisation of the needs of different generations, migration and labour markets, commercial determinants of health, big data and health indicators, competitive aspects of global health information systems, and the impact of the environment on health (environmental health footprint).

1.10.

The EU already has a considerable number of health-related activities in the global sphere. The EESC strongly recommends realigning these activities with the objectives and priorities of the Global Strategy and adding relevant initiatives in line with such priorities. The EESC strongly recommends the development of robust health diplomacy. In this context, the EESC fully supports the EU’s request to be given a seat as an observer in the World Health Organization.

1.11.

The EESC supports the Communication’s contention that there is currently a complex geopolitical global context and in which global health challenges require partnerships and international cooperation, where the EU can play a significant role, to be broadened and reinforced based on a multilateral approach.

1.12.

The EESC stresses the importance of well-developed scientific advisory bodies and processes in ensuring that research and knowledge play their rightful role in policy decision-making.

1.13.

The EESC notes that universal health targets established in the 2030 Agenda for Sustainable Development and its Goals (SDGs) are not progressing as expected. Countries most in need should benefit from a broader developmental support agenda. Cooperation strategies and actions for development with countries particularly in need, where basic socioeconomic conditions seriously impair their capacity for health promotion and protection, must be pursued.

1.14.

The EESC calls for improved governance at country level, where action takes place. The implementation challenge is of critical importance. Change management needs to take into account the complexity of health systems, shifting from fragmented uncoordinated actions towards more systemic approaches. This requires an identifiable body in public administrations capable of strategic analysis, planning and management. The participatory atmosphere, culture and continuous engagement expected in good governance demands a shift from a hierarchical intelligence culture towards collective, distributed and collaborative intelligence. The EESC calls for the establishment of a civil society engagement mechanism for the effective implementation of a co-constructed strategy.

2.   General comments

2.1.

The last Communication from the Commission on this matter was issued in 2010. Since then, several important developments — in terms of climate change, decreasing biodiversity, increasing environmental pollution, as well as new opportunities provided by better knowledge and technological innovation — require a renewed approach to the EU Global Health Strategy.

2.2.

The experience of recent years, particularly since the COVID-19 pandemic, has highlighted as never before that health has no borders. The well-being and lives of citizens, the prosperity and stability of societies and economies, and sustainable development, all depend on addressing health from this perspective.

2.3.

Building on ideas from EU Member States, this strategy suggests practical ways to improve coordination. This includes facilitating information- and intelligence-sharing among the EU and Member States and strengthening upstream coordination with Member States in the G7, G20, and OECD forums. Achieving the goals of this Strategy requires more coordination between the Commission, the Member States and partners.

2.4.

The Strategy sets out three EU global health priorities: (1) deliver better health and well-being of people across the life course; (2) strengthen health systems and advance universal health coverage; and (3) prevent and combat health threats, including pandemics, applying a ‘One Health’ approach. It also outlines issues of governance (points 3 to 7 of the Communication), regarding how to achieve these priorities.

3.   Deliver better health and well-being of people across the life course

3.1.

The EESC stands firm in recognising health as a fundamental social right and the basis of the Member States’ socioeconomic development and further development. The EESC asserts the importance of achieving the health-related SDGs globally, particularly Goals 1, 3, 5, 8, 10, 16 and 17. In line with the recommendations of the Conference on the Future of Europe, the EESC commits to leveraging the collective strength of the European Union and engaging with countries worldwide to contribute actively to the attainment of these goals, promoting global health equity.

3.2.

The EESC emphasises the need to address the root causes of ill health, including social determinants and environmental factors, and to prioritise actions that tackle them and promote a healthy environment (1), (2), (3), (4). Furthermore, the EESC advocates for improving working conditions, addressing climate change impacts and reducing health inequalities. The EESC underlines that social inclusion is vital in promoting mental health and well-being.

3.3.

Acknowledging that individual behaviour contributes significantly to a person’s health (5), the EESC stresses that health services, including hospitals and healthcare providers, also play an important role in influencing peoples’ health. Consequently, the EESC highlights the need to address political, socioeconomic and environmental factors. This includes advocating for policies prioritising health in all its components in trade agreements, development cooperation and other areas of EU external engagement.

3.4.

The EESC supports an approach of universal health coverage throughout the strategy, emphasising the importance of addressing health needs based on sex and gender, adopting a life-cycle approach that covers women, children, young people, elderly people, people with disabilities and other minority and vulnerable groups with a focus on intersectional issues. Furthermore, the EESC promotes gender equality to combat poverty, advocates for non-discrimination regardless of origin, children’s health, adolescent health, healthy aging and ensuring respect for privacy and informed consent. The EESC also supports the promotion of reproductive health and birth control rights.

3.5.

The EESC recognises the urgent need to lead the fight against communicable diseases (CDs). It advocates for strengthening disease surveillance systems; promoting vaccination programmes; improving access to essential medicines for the treatment of CDs; addressing the growing threat of antimicrobial resistance; and strengthening health systems to prevent and manage CDs effectively.

3.6.

The EESC highlights the importance of preventing and managing non-communicable diseases (NCDs). It calls for the development of prevention strategies, improved early detection, increased awareness of risk factors and prevention, collaboration among stakeholders, addressing social determinants, and supporting research and innovation in NCD management.

3.7.

The EESC underscores the significance of increasing access to inclusive preventive services and strengthening primary healthcare systems. It advocates for expanding access to preventive services for all, empowering patients through health literacy initiatives and patient-centred care models, promoting digital health technologies and investing in low-income and marginalized communities, with a particular focus on their health needs.

3.8.

Healthy lifestyles and behaviours should be encouraged through health promotion and education campaigns, community-based interventions and policy measures to reduce tobacco and alcohol consumption, as individual choices play a huge role in a healthy life. The EESC also recalls the importance of occupational health and safety, including mental health support and work-life balance policies.

3.9.

The EESC recognises that mental health is interconnected with various social, economic and environmental factors. It advocates for policies prioritising mental health in all areas of EU external engagement, including trade agreements, development cooperation and other relevant initiatives. By integrating mental health considerations into these areas, the EESC aims to promote a comprehensive approach to health and well-being, ultimately fostering a more inclusive and sustainable Europe for all its citizens.

3.10.

The EESC stresses the need to address environmental health risks and natural disasters, reduce exposure to toxins, improve air and water quality, promote sustainable and healthy transport options and incorporate green infrastructure, public spaces and active transport in urban planning.

4.   Strengthen health systems and advance universal health coverage

4.1.

Aspects relevant to achieving health systems that are effective, resilient and accessible are clearly set out in the Communication. The guiding principles proposed by the Commission, which participating Member States will be encouraged to follow, cover several critical issues: (i) improving primary healthcare (with built-in surge capacity); (ii) fostering digitalisation as a fundamental enabler; (iii) boosting global health research; and (iv) addressing key workforce issues.

4.2.

Most EU Member States have achieved a considerable level of health and well-being (comparatively positive health indicators), offer universal health coverage to their citizens and have well-performing health systems. In such a context, the EU is in a credible position to exert a leadership role in Global Health.

4.3.

The EESC suggests that by enhancing investment in health, the EU can continue to strengthen this leadership role in a way that stimulates its own economic growth and, through its health systems, creates opportunities for a stronger role in technological development and innovation. This is more likely to occur whenever economic, financial and social policies can be well harmonised, rather than become hierarchical.

4.4.

In many countries, major efforts in health service infrastructure development are needed. Ensuring universal access to essential care for everyone is a very high priority. The EESC suggests that this need should not override the importance of adopting key principles of quality of care, currently universally recognised as relevant for health system development. Person-centred care is one of these principles. This includes ensuring that everyone has ‘voice and choice’ in all decisions pertaining to their healthcare, within the policy framework adopted in each country and in the context of major investments in general, health and digital literacy. It is also important to ensure that medical prescriptions of different sorts factor in their consequences on the living conditions and life experiences of patients (6).

4.5.

The EESC calls for special attention to be given to the transition from fragmented and episodic care to continuous, integrated care. This relates to both long-term care in the case of communicable diseases and persons with multimorbidity, very often associated with the aging process. Functional integration relates to the capability of effectively managing patient pathways as they seek the different kinds of services they need.

4.6.

The EESC stresses the importance of decentralising decision-making closer to the health provider and the patient, both for provider performance and patient satisfaction.

4.7.

The Communication emphasises the need to achieve a transformational impact through a ‘Team Europe’ initiative on digital health, building on the principles underpinning the planned European Health Data Space. The EESC emphasises that person-centred information systems need to go beyond sharing data and move towards adopting shared individual health plans, focused on agreed well defined outcomes, that can be monitored and evaluated by those formally involved in a particular healthcare process. The EESC also considers that, given considerable global competition in this arena, this EU initiative needs to progress rapidly — a piloting approach based on countries more advanced in the digitalisation process through the work already developed in the ‘ehealth network’, including now selected global partners, could take place. The WHO’s recent use of the EU’s successful Covid Certificate to create a Global Certification Network is a step in the right direction.

4.8.

The EESC considers that special attention should be given to upgrading local public health infrastructure, technically, technologically and in terms of human resources. This need became very evident in managing the COVID-19 pandemic. Major emphasis should be put on developing capabilities as regards analysing community health and healthcare needs and possible upcoming threats and thereafter designing local health strategies, with contingency components.

4.9.

The EESC strongly emphasises that, currently the healthcare workforce requires a very particular focus (7). Attractive working conditions and environment, awareness of current lifestyle expectations and trust in the present and future of the organisations they serve are of paramount importance. Health personnel must benefit from improved working conditions through upward convergence and levelling up of working conditions within the EU and have access to adequate training and reskilling. It is important that healthcare delivery personnel are not overloaded with administrative requirements — caregiver time must be protected. Timely human resources planning is essential.

4.10.

One key issue relating to the global health workforce is the very significant migration of health professionals from low and middle income countries to high income countries. This trend will become even more noticeable in the future, as shortages in the health workforce in developed economies seem to be increasing. The EESC recognises that this is certainly a complex and difficult issue, but one that needs to be properly and urgently addressed. The issue of ‘circular migration’ must be taken into account in this context (8).

4.11.

Support for relevant health-related research is necessary for health system development. However, the EESC feels that this relates to all three priority areas of action referred to in the Communication and requires a number of partnerships involving public administrations, academia, civil society and industry — but not health-harming industries such as the tobacco and alcohol industries. Therefore, this issue may be better placed in the realm of governance.

5.   Prevent and combat health threats, including pandemics, applying a ‘One Health’ approach

5.1.

The EU (with its Member States) is developing close interactions with the United Nations and United Nations organisations including the World Health Organization, which include better preparedness, prevention and response to pandemics (International Pandemic Treaty). The EESC recommends implementing the organisation of health in the EU and Europe, before positioning itself at the heart of a global strategy by adapting it to the specific conditions and objective limits of each of the health systems concerned.

5.2.

The EESC reinforces the need to define a global health strategy and mission that will focus on the principle of ‘more health and fewer diseases’ by adopting national and transnational strategies for health promotion, disease prevention and the dissemination of health knowledge. It should also raise awareness among the general public about healthy habits, such as physical activity, healthy eating, disease prevention, respect for animals, the environment and the ecosystem, as well as the proper use of health services.

5.3.

The EESC strongly recommends that countries support independent national public institutes with their own budget appropriate to the mission of ‘More Health and Less Disease’. The institutes must include professionals from different strategic areas enabling coordinated work in a team. Education, architecture, engineering, physics, medicine, veterinary medicine and other areas of global health, as well as students, municipalities, and the environment must all be factored into the development of a strategy, with education programmes for global health starting in schools and continuing in polytechnic education and universities, and involving healthy cities and municipalities (‘cities that walk’ (9) and 15-minute cities). The strategies should also incorporate engineering, including bioengineering and information technologies, and expand to all health units and all municipalities, based on the protection of the environment, people and animals.

5.4.

The EESC underlines the importance of: — supporting the Directorate-General for Health and the European Health Emergency Preparedness and Response Authority (HERA) (10) so they can plan joint actions with national institutes; — creating the conditions for effective cooperation between health actors, including public and private institutions, in terms of response and prevention capacities, as well as training and research; — improving resilience through national and transnational solidarity, promoting social justice on a global scale; — strengthening a strategic plan to establish foresight provisions for global health, in accordance with the ethical principles defined by National Councils on Ethics for the Life Sciences (11).

5.5.

The EESC encourages leadership at the national and global levels in the structuring of responses, contingency plans and care capacities, as well as building national and international strategic reserves of equipment and medicines.

5.6.

The EESC recommends investing in the training of public health professionals and other types of actors, developing their capacities and recruiting them, as well as promoting effective human resource management.

5.7.

The EESC stresses the need to strengthen clinical governance through experience, leading-edge positioning, autonomy and the practice of multiannual budgets, in accordance with technical recommendations, to strengthen general health security.

5.8.

The EESC insists on effectively improving international cooperation mechanisms on the prices of medicines also through public procurement, facilitating access to new therapies under favourable conditions.

5.9.

The EESC emphasises the importance of developing integrated information systems at national and international level to strengthen epidemiological surveillance, early detection and global identification of communicable or other diseases, focusing on the ‘One Health’ concept.

5.10.

The EESC calls for comprehensive health cover (social protection), during and outside of periods of pandemics, at all times.

5.11.

The EESC considers that the essential role of defence in national security, particularly in relation to public health emergencies, should be strengthened, with particular emphasis on investments in infrastructure and equipment, so that the planning, organisation and means available contribute to the state of preparedness for possible pandemics. Universal health must prevail in all circumstances, including conflicts.

6.   Governance

6.1.

The EU already has a considerable number of health-related activities in the global sphere. The EESC recognises the importance of realigning these activities with the objectives and priorities of the Global Strategy, and that adding relevant initiatives in line with such priorities is an important function of its governance.

6.2.

The EESC supports the Communication’s contention that there is currently a complex geopolitical global context in which the EU Global Health Strategy can play a significant role, with an emphasis on a multilateral approach in the EU’s external policies.

6.3.

The EESC supports the contention that global health challenges require partnerships and international cooperation, where the EU can play a significant role, to be broadened. Granting the EU a seat as observer in the WHO could be an important step in that direction, which the EESC would support wholeheartedly. The principles outlined in the WHO Report on ‘Health for All: transforming economies to deliver what matters’ deserve special attention in global health governance (12). The capabilities and skills of health diplomacy need to be further developed and can play a key role here.

6.4.

The EESC notes that universal health targets established in the 2030 Agenda for Sustainable Development and its Goals (SDGs) are not progressing as expected. It is important to recall that the SDGs need to be addressed jointly as development challenges. Countries most in need should benefit from a broader developmental support agenda.

6.5.

The EESC would like to stress the need to pursue cooperation strategies and actions for development with countries particularly in need where basic socioeconomic conditions seriously impair their capacity for health promotion and protection. It is suggested that ‘cooperation for socioeconomic development’ become a visible component of the EU Global Health Strategy.

6.6.

The EESC calls for the establishment of a civil society engagement mechanism for the effective implementation of a co-constructed strategy. Civil society as an intermediary body relaying the needs of the field in health policies (participatory research) need to be involved. Civic health spaces need to be strengthened. The social economy and mutual insurance companies can also play an important role.

6.7.

The EESC supports the idea that evidence-based actions and governance require well-developed scientific advisory processes and bodies. Research is of fundamental importance, but ensuring that knowledge plays its rightful role in policy decision-making is equally important. The COVID-19 experience has recently shown severe shortcomings in many countries, in establishing appropriate scientific advisory mechanisms.

6.8.

The EESC points out that it would be highly desirable for the monitoring and evaluation exercises of the EU Global Health Strategy to be broadly and effectively shared with both technical and public audiences.

6.9.

The EESC calls for improving governance at country level, where action takes place (13). The implementation challenge is also of critical importance. Several observations in this regard follow.

6.10.

A systematic approach to ‘change management’ in national health governance requires an identifiable body in public administrations capable of strategic analysis, planning and management. This needs to include competences for a continuous analysis of current and prospective stakeholders’ agendas and the ability to converge them into agreed policies. It also requires the ability to address simultaneously and in a coordinated way the key critical health system features involved in generating change.

6.11.

Societies feature, currently, multiple sources of initiative. The participatory atmosphere, culture and continuous engagement expected in good governance demands a shift from hierarchical intelligence towards collective, distributed and collaborative intelligence. Community and digital networking mechanisms need to be promoted for this purpose. These are important concerns when addressing country/local good governance.

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(1)  National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States. Communities in Action: Pathways to Health Equity. Baciu A, Negussie Y, Geller A, Weinstein JN, editors. Washington (DC): National Academies Press (US); 2017 Jan 11. PMID: 28418632.

(2)   Healthy environments for healthier populations: Why do they matter, and what can we do? Geneva: World Health Organization; 2019 (WHO/CED/PHE/DO/19.01).

(3)   Policies, regulations and legislation promoting healthy housing: a review. Geneva: World Health Organization; 2021.

(4)  Opinion of the European Economic and Social Committee on ‘Water politics — Between desertification and securitization — Time for a Blue Diplomacy’ (own-initiative opinion)(OJ C, C/2023/862, 5.12.2023, ELI: http://data.europa.eu/eli/C/2023/862/oj

(5)  Short SE, Mollborn S. Social Determinants and Health Behaviors: Conceptual Frames and Empirical Advances. Curr Opin Psychol. 2015 Oct; 5:78-84. doi: 10.1016/j.copsyc.2015.05.002. PMID: 26213711; PMCID: PMC4511598.

(6)  Opinion of the European Economic and Social Committee on Health Workforce and Care Strategy for the future of Europe (own-initiative opinion) (OJ C 486, 21.12.2022, p. 37).

(7)  Opinion of the European Economic and Social Committee on Health Workforce and Care Strategy for the future of Europe (own-initiative opinion (OJ C 486, 21.12.2022, p. 37).

(8)  Opinion of the European Economic and Social Committee on Proposal for a directive of the European Parliament and of the Council concerning the status of third-country nationals who are long-term residents (COM(2022) 650 — final) — Proposal for a directive of the European Parliament and of the Council on a single application procedure for a single permit for third-country nationals to reside and work in the territory of a Member State and on a common set of rights for third-country workers legally residing in a Member State (COM(2022) 655 — final) — Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions — Attracting skills and talent to the EU (COM(2022) 657 — final) (OJ C 75, 28.2.2023, p. 136).

(9)  Cidades que caminham/Ciudades que caminan.

(10)  Opinion of the European Economic and Social Committee on Communication from the Commission to the European Parliament, the European Council, the Council, the European Economic and Social Committee and the Committee of the Regions — Introducing HERA, the European Health Emergency Preparedness and Response Authority (COM(2021) 576 final) (OJ C 275, 18.7.2022, p. 58).

(11)  National Council of Ethics for the Life Sciences (CNECV). State of Health Preparedness in Public Health Emergencies. Recommendation 2/2022, June 2022.

(12)   WHO Council on the Economics of Health for All. Health for all: transforming economies to deliver what matters — Final report. Geneva: World Health Organization; 2023.

(13)  Opinion of the European Economic and Social Committee on Health Workforce and Care Strategy for the future of Europe (own-initiative opinion) (OJ C 486, 21.12.2022, p. 37).