EN

(...PICT...)|EUROPEAN COMMISSION|

Brussels, 31.3.2010

SEC(2010) 380 final

COMMISSION STAFF WORKING DOCUMENT

Global health – responding to the challenges of globalisation Accompanying document to the COMMUNICATION FROM THE COMMISSION TO THE COUNCIL, THE EUROPEAN PARLIAMENT, THE EUROPEAN ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS The EU Role in Global Health

{COM(2010) 128} {SEC(2010) 381} {SEC(2010) 382}

COMMISSION STAFF WORKING DOCUMENT

Global health – responding to the challenges of globalisation

TABLE OF CONTENTS

Introduction 2

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1. The global state of play in Health – what change is needed and why? 4

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1.1. Five challenges calling for Action 5

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Health has become a question of politics, security and economics. 5

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1.1.1. Lack of coordination / fragmentation of health policies and programmes 5

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1.1.2. Global Health challenges 5

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1.1.3. Development needs 7

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1.1.4. Globalisation 8

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2. Global Health - Role of the Commission 9

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3. A Global Health Policy and Strategy 9

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3.1. Four principles underpinning EU action on global health 10

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Principle 1: A strategy based on shared health values 10

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3.1.1. Principle 2: Health Is Wealth 12

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3.1.2. Principle 3: Health in All Policies (HIAP) 12

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3.1.3. Principle 4: Strengthening the EU's Voice in Global Health 12

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3.2. Three areas of EU added value in addressing global health challenges 13

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Objective 1: Fostering Good Health in a changing world 13

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3.2.1. Objective 2: Protecting Citizens from Health Threats 13

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3.2.2. Objective 3: Supporting Health Professionals, Dynamic Health Systems and new Technologies 13

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4. Seven Pillars for Action 14

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4.1. Development: the crucial role of ensuring that coherence for development addresses global health challenges 15

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4.2. Promotion of Fundamental Rights and Public Goods 19

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4.3. Research/Knowledge Management 20

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4.4. Cooperation, Coordination, Export of Knowledge and Experience 22

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4.5. Foreign Policy, Governance 23

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4.6. Security 25

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4.7. Response to Globalisation (Markets/Services) 27

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5. Benefits of Cooperation for Global Health at EU and Global Level 28

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6. Outcomes for Global Health 29

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Introduction

This Commission Staff Working Document is intended to complement the Communication on the EU role in Global Health by describing in further detail those policy areas and actions impinging on global health where the EU is already active.

Four main drivers of change and trends are identified and need to be addressed in the coming years, namely globalisation, changing society, confidence and governance. Strengthening the EU's voice in global health is a key principle underlying the EU Health Strategy 2008 – 2013, it is therefore necessary that work takes place at a strategic and global level, using a cross-sectoral strategy that ensures coherence of relevant EU internal and external actions related to global health and developing new partnerships and approaches as appropriate. The expected benefits to citizens in the EU and globally include a more efficient and targeted use of public resources to save lives and improve health, a democratic and inclusive governance and better coherence among actors and across policies in the area of health as well as increased health security for them in the broader global context.

The Commission Communication and related working documents are intended to contribute to international discussions in this area - an area currently suffering from fragmentation and lack of leadership.

This should also enhance EU visibility, presence, status and influence on the world stage.

1. The global state of play in Health – what change is needed and why?

Globalisation and changes in societies around the world are altering the global health landscape to the point where the existing governance and framework is no longer sufficient to ensure the confidence of citizens in their future health and wellbeing.

The shortcomings of the now-outdated view of global health as a purely development issue was highlighted over the last decade by SARS and the threat of pandemic influenza, and even more recently with the Influenza A (H1N1) pandemic. Over the past 15 years, decisions had to be made about how to react to cholera in Zimbabwe, plague in India, Ebola in Zaire, mad cow disease in Europe, anthrax in the United States, AIDS throughout the world and the annual waves of influenza, among others. Therefore, when it comes to public health preparedness the EU must think global and not local. And for that reason EU policies and views on global health should always be up to date. Diseases and their causes do not respect political borders, and health cannot be dealt within a European vacuum.

A lack of global leadership and uneven levels of national commitment and aligned cooperation has fragmented the field, bringing in a variety of new actors, mechanisms and agendas that the existing framework has difficulty adjusting to. Thus public health can no longer be pursued just at the national level. It needs renewed global institutions, mechanisms and funding for security, development and global public goods.

The health sector can no longer deal with emerging challenges on its own. It needs multi-sectoral action and broad public and private partnerships at national and international levels. Neither can health still be seen as a purely professional and technical endeavour; it needs the strong voice and support of civil society and of political leaders to address the issues at stake. The financial and workforce-related pressures on health systems to deliver quality care to ageing populations are also universal, and can only be addressed with better international collaboration.

1.1. Five challenges calling for Action

Health has become a question of politics, security and economics.

Globally, it can be argued that improved health at the population level will depend not so much on new discoveries or on technological advances as it will on working towards achieving greater social justice and equity. The 2008 WHO Report on Social Determinants provides ample evidence that progress requires social and economic redistribution mechanisms which may also require changes in power balances. In the area of access to medicines, during trade negotiations, some developed countries have been accused of putting their own economic interests before the health needs of developing countries. The lack of agreement in the WHO on the sharing of avian influenza virus strains because of disagreements on access to benefits is yet another example where politics seems to trump health.

1.1.1. Lack of coordination / fragmentation of health policies and programmes

· The multitude of policy fields influencing global health (development, trade, research, employment, social systems, finance, education…) poses a particular challenge for the formulation and implementation of a consistent cross government global health policy (both within and between countries).

· The multitude of players and activities (countries, organisations for cooperation among industrial countries, organisations of middle-income countries, regional organisations, NGOs, UN bodies) that have entered the global health arena are a welcome sign of the strong interest in the area but they can also mask the reality that in many countries there are problems at national level in delivering healthcare to the citizens and that in some cases the sheer number of actors involved in a country can even be an obstacle to progress.

· The substantial increase in the number of donors and in funding is a positive development but global coordination and strategic direction is lacking, and this may have an negative impact on the effectiveness of aid

· Coordination is insufficient at global level and what is really needed is leadership . The UN, and particularly WHO, has not been able to fill this role in an era of increased interdependence and multilateralism. The private sector and NGOs have moved in to fill a vacuum with the result that global health (as a notion, objective, and tool of action) now lacks clear definition and direction.

1.1.2. Global Health challenges

Global health challenges affecting all worlds' citizens relate to health risks (communicable, lifestyle, trade), health resources (mainly medicines and human resources) and the effects of climate change and the financial and food crisis.

· Health risks:

o There is a need to protect populations from communicable diseases such as HIV/AIDS, SARS, Avian Influenza, Influenza A (H1N1), zoonoses, food poisoning and so on. Given that many of these diseases are of zoonotic nature, it is necessary to implement global and national surveillance systems covering animal and human health to assure early prediction, detection and mitigation of these health threats. Special health issues (e.g. antimicrobial resistance and nosocomial infections) also need to be addressed so as to ensure full protection of the population. The International Health Regulations (2005) provide a legal framework to the international community to prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide. However, the capacities of developing and enforcing these legal frameworks are uneven.

o Lifestyle-related health determinants – Globalization fuels certain risk factors such as inadequate diets, low levels of physical activity, tobacco consumption and alcohol abuse. These are increasingly important contributors to avoidable morbidity and mortality on a global level. Global concerted action is required to limit the negative health effects of those lifestyle-risk factors.

o Globalisation of markets requires evidence-based safety norms for food, feed, and products . The high standards expected by EU citizens require coordination with WTO rules. Structures to control and test food, feed, and other products need to be strengthened in order to assure that agreed norms are respected and that Public Health aspects are taken into account. It also ensures the safety for food, feed and products at a global scale.

· Health resources:

o Health professionals tend to follow market forces towards better salaries and conditions, to the detriment of poorer countries. There is a difficult balance between the rights of free movement, quality of life and career development of health workers, with the States' responsibility to guarantee the right to access of the population to quality health care. Brain drain to the private sector, to international organizations and to third countries, undermines the capacities of national public health services which aim to bring about equitable and universal coverage of health services. A voluntary code for recruitment of health professionals will offer an opportunity for an EU vision and voice in a more equitable distribution of health workers in the EU and worldwide, while respecting their individual rights. Migration policies also affect the health of migrants, which is often undermined by policies which restrict their access to basic social services including health promotion and care.

o A long-term supply of effective and affordable vital health products is of critical importance and requires action at global level. New drugs and vaccines subject to patent-rights risk being unattainable for a large proportion of the world's population due to high costs. The lack of effective drugs and vaccines for neglected diseases or new effective antibiotics in the context of antimicrobial resistance are of particular concern at global level. These challenges require coordinated actions to ensure the access to existing and shared knowledge for R&D, and for the development of new pharmaceutical and diagnostic tools according to global needs. In addition, the world market for counterfeit and substandard drugs, which is increasing at a rapid rate, is problematic for both developing and developed countries.

· Effects of global crises:

o Neither the causes nor the effects of climate change are shared equitably but all need to work jointly towards a solution. Changes in the climate will affect availability of food and water, and other direct consequences for health and in some developing countries undermine already fragile health systems. Global actions to respond to the climate change need to include adaptation and mitigation policies and actions in the health sector.

o The current economic crisis poses a substantial threat to health funding from EU Member States, making it more important than ever that existing ODA commitments in the development field be honoured. The financial crisis has caused global unemployment to rise and triggered investments in health to fall and health actors must ensure that health issues remain a prominent matter on the global arena so to ensure that the financial crisis does not bring about a social disaster.

o The threat of a food crisis for health is not to be underestimated. The World Bank estimates that it ranks amongst the top three global crises, next to an influenza pandemic and climate change. Health issues are heavily attributed to poor nutrition, which in turn reflects the large disparities in excess and shortage. It requires global analysis, monitoring and actions related to global food security and multi-sectorial health strategies under a global action plan.

1.1.3. Development needs

Several of the Millennium Development Goals (MDGs), including those in the health field, are not being met and developing countries fear that the economic crisis will encourage donors to renege on their development aid commitments. This is not just a problem of developing countries – many countries in the WHO European Region are also behind schedule on meeting the MDG targets.

Improving health conditions in developing countries is essential to reduce poverty and to achieve the health-related MDGs. To help these countries meet global development challenges in the field of health, the EU is taking action at different levels aimed at promoting access to health care for the poor and other disadvantaged groups; achieving universal access to prevention, treatment, care and support for the main poverty-related, neglected and emerging diseases; and strengthening countries' ability to train, support and retain healthcare personnel. Other priority issues in the field of health include nutrition, water and sanitation, information and education for healthier behaviour. However, in the last decade integrated approaches to health care have proved to be more effective and sustainable, and support is being progressively redirected from specific and single disease interventions to developing and strengthening more comprehensive health systems.

A variety of approaches have been put into practice by the EU for delivering effective development assistance and improved health outcomes in developing countries. While country level approaches remain the focus of EU's health interventions under the European Development Fund, the Development Cooperation Instrument and the European Neighbourhood Policy Instrument, the EU has engaged at the global and regional level in areas where it can add particular value. In this context, an Africa-EU Partnership was endorsed by the EU-Africa summit in December 2007 to serve as a forum for intensified continent-to-continent policy dialogue, cooperation and joint action at all levels, with a view to achieving the MDGs in all African countries. EU geographically-based instruments are supplemented by thematic development programmes such as "Investing in people", which focus on strengthening the country approach by contributing to global or regional initiatives and improving access to global goods for public health.

1.1.4. Globalisation

Globalisation is conducive to many positive developments on health, such as the increase in opportunities for cross-border health-related transactions, trans-national cooperation, support, and knowledge sharing - for example the development of medicines, vaccines and medical devices, which in turn allows for the development of new forms of treatment and prevention. Access to medical information and treatment has also been significantly improved.

On the other hand, t he interdependence produced by globalisation has turned health into an increasingly important challenge and responsibility for foreign policy and governance at all levels. It can give rise to, or increase, potential threats to health. Health problems and diseases can spread more rapidly; increased migration may strain the capacity of health services, from both incoming patients and outgoing health professionals; and inequalities in access to medical progress may rise. In developing countries in particular this would result from pressures on public expenditures; increased prices for newly-developed medical drugs and devices due to more stringent international property rights rules; low research and development expenditures on many tropical diseases; donor focus on disease-specific programmes rather than on health system strengthening; and lack of priority assigned to health by some of the countries themselves.

As any other workforce, the health workforce is influenced by globalisation. There are also difficulties in many poor countries to retain medical staff, which are attracted by higher salaries in rich countries.

Significant work needs to be done to address the draw back of globalisation on global health without losing the benefits of an increasingly more open world. There is therefore an urgent need to find shared values and approaches in the area of global health that would be embodied in relations between countries. Recognition of the need for policy coherence, strategic direction and a common value base in global health is beginning to emerge at the level of countries. A few European countries are beginning to address global health more consistently at national level by mapping many global health activities across all government departments, establishing new mechanisms for coordination within government and developing a ‘national global health strategy’, frequently on the initiative of the international departments in the Ministries of Health. The financial crisis has also pushed foreign security policy-makers to set a clear agenda for moving at least global health security higher up the foreign policy agenda. However, foreign policy and global health are not only relevant to national health security and development. Health and foreign policy are also crucial for alliances and for trade issues. In all these areas, health and governance are intrinsically entwined.

2. Global Health - Role of the Commission

Priority-setting for global health action still lacks a coherent approach between EU Member States, between European organisations and between different parts of the EU. It is often still more issue-based and responsive rather than defined by long-term investments in health infrastructures, action on health determinants and intergenerational health sustainability.

Although the organisation and delivery of health services remains primarily a responsibility of the Member States, the EU also holds a range of responsibilities in the field of global health. The EU's role is to complement national policies although in some specific areas it has explicit authority to legislate (early warning and response to communicable diseases, quality and safety of substances of human origin, organs, blood and blood derivatives, food and product safety, veterinary and plant health measures directly aimed at public health). It also has a Treaty obligation in Article 168 to " foster cooperation with third countries and the competent international organisations in the sphere of public health ".

It is also explicitly recognised in the 2008-2013 Health Strategy that the EU and its Member States " can create better health outcomes for EU citizens and for others through sustained collective leadership in global health" . With an overarching, coherent and comprehensive approach to global health, the Commission can provide real added value, and speaking with one voice in international and global health questions will underline the EU's strength as a credible player in this field.

3. A Global Health Policy and Strategy

The future challenges confronting the EU in health, consumer and food policies were identified at a high-level conference organised by the European Commission on 29-30 October 2008 ("Delivering for Tomorrow's European Consumers"). The main four drivers of change and trends that were identified were globalisation , changing society , confidence and governance .

Globalisation :

· There is a need to reaffirm the EU position on the global scene, to better promote EU policies and influence standard setting as well as respond effectively to global risks .

· As regards preparedness for unpredictable disasters (e.g. pandemics, natural disasters), the EU crisis preparedness tools is being reinforced and a prevention-led approach is being strengthened in the different policy areas to minimise risks as much as possible.

· There is an ongoing effort to reinforce EU relevance at global level with regards to EU normative functions of standard setting (e.g for food, pharmaceuticals, medical devices etc).

Changing Society :

· There is a growing need to examine more closely and include social and health inequalities in policy delivery.

· Sustainability is a real challenge not only for the future, but to be acted upon today.

· Consumers are increasingly in control of their communications agenda than in the past.

Confidence :

· The Commission faces the challenge of obtaining public acceptance if it is to become more entrepreneurial as well as Member State acceptance if it is to implement a process whereby delivery is more closely monitored to achieve quality.

Governance :

· Implementing a common culture of working together whereby cooperation and tolerance are ensured is a challenge but needs to be further developed. The Commission must be in a position to clarify why and how to improve global health governance. It must identify the benefits to global health of an enhanced EU role in global health governance. It is important to assess the benefits and identify mechanisms needed to ensure a more participative and accountable global health governance.

3.1. Four principles underpinning EU action on global health

EU principles for global health policy have been set out in the EU's Health Strategy adopted in 2007 (" Together for Health: A Strategic Approach for the EU 2008-2013 "). The principles include taking a value-driven approach, recognising the links between health and economic prosperity, integrating health in all policies, and strengthening the EU's voice in global health. The strategic themes are Fostering Good Health in an Ageing Europe, Protecting Citizens from Health Threats , and Dynamic Health Systems and New Technologies.

The Strategy also focuses on the importance of coordination between the EU and its Member States and other countries and international organizations which would help to foster good health in the EU and beyond and strengthen the EU's voice on global health issues.

Principle 1: A strategy based on shared health values

The EU aims not only to provide a well functioning internal market for goods, capital and services; it also supports social justice and respect for fundamental rights in line with the Charter of Fundamental Rights of the EU with particular attention to children's rights OJ C 303/7, 14.12.2007, p.1. In particular, the following rights such as human dignity, integrity of the person, health care, non-discrimination, equality between women and men and rights of the child are at stake. In accordance with the Commission's Communication Towards an EU Strategy on the Rights of the Child, all EU internal and external actions should be fully compatible with the principles and provisions of the UN Convention on the Rights of the Child. Article 24 UNCRC obliges Member States to recognize the right of the child to the enjoyment of highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. , 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 wellbeing. EU action to support the objectives of the EU Health Strategy should therefore be built on fundamental rights relating to health with particular attention to children's rights and health as a global public good. They should make concrete common values such as participation and empowerment of citizens, transparency, and the overarching values of universality, non-discrimination, access to good quality care, equity and solidarity Council Conclusions on Common Values and Principles in European Union Health Systems (2006/C 146/01) . The Council has also invited the Commission to take into account and integrate the gender dimension Council Conclusions on Women's Health (2006/C 146/02) .[1][2][3]

OJ C 303/7, 14.12.2007, p.1. In particular, the following rights such as human dignity, integrity of the person, health care, non-discrimination, equality between women and men and rights of the child are at stake. In accordance with the Commission's Communication Towards an EU Strategy on the Rights of the Child, all EU internal and external actions should be fully compatible with the principles and provisions of the UN Convention on the Rights of the Child. Article 24 UNCRC obliges Member States to recognize the right of the child to the enjoyment of highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health.

Council Conclusions on Common Values and Principles in European Union Health Systems (2006/C 146/01)

Council Conclusions on Women's Health (2006/C 146/02)

Equity and solidarity are of importance between and within Member States and regions in terms of life expectancy, health status and access to high quality health services. Issues at stake include differences in health outcomes, differences in access to treatment and care, differences in health between different groups within countries, such as between rich and poor, or between male and female. Working across different sectors is vital for reducing health inequalities, and tackling inequalities in the economic, social, environmental, genetic and behavioural determinants of health. A recent Communication addresses health inequities in the EU "Solidarity in health: Reducing health inequalities in the EU" , Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions, COM(2009)567, Brussels, 20 October 2009 . . [4]

"Solidarity in health: Reducing health inequalities in the EU" , Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions, COM(2009)567, Brussels, 20 October 2009 .

The Commission regards the extent of the health inequalities between people living in different parts of the EU and between socially advantaged and disadvantaged EU citizens as a challenge to the EU's commitments to solidarity, social and economic cohesion, human rights and equality of opportunity . At the EU level, the Commission plays an important role in raising awareness, promoting and assisting the exchange of information and knowledge between the concerned Member States, identifying and spreading good practices and in facilitating the design of tailored made policies for the specific issues prevailing in Member States and/or special social groups. It also monitors and evaluates the progress in the application of such policies.

The same factors apply to equity and solidarity between EU and other regions of the world. For example, the differences with sub-Saharan Africa are striking. Progress towards health MDGs is off track in over 50 developing countries, especially in sub-Saharan Africa and is almost stagnant in reducing maternal mortality rates (MDG 5) The Millennium Development Goals Report 2009 : htt p ://www.undp.org/mdg/basics_ontrack.shtml . The general failure to progress in the health MDGs is a reflection of the high burden of disease globally Burden of disease is measured by Disability Life Adjusted years, comprising the health years lost to premature deaths and to the degrees of disability during disease. , especially in developing countries. Over 60 million persons die every year prematurely, most of them due to social and environmental factors and low or absent access to adequate health care The global burden of disease: 2004 update.WHO. . Nine million of them are children below the age of five The State of the World’s Children 2009. UNICEF . The difference of life expectancy in the world has been widening, with the richer top billion enjoying an average life expectancy close to 80 years, which is twice the life expectancy of those living in the poorest billion WHO Statistical information system : http://www.who.int/whosis/en/ . At the same time, half of the loss in potential healthy and productive life is due to disability caused by acute and chronic diseases, with a 30% higher burden of disease on the limited lifespan of the poorer (even though on average they are younger). Altogether the exposure to risks for ill health and the inadequate access to health care translate to a loss of 20% of the potential healthy life worldwide due to premature deaths or disability. The average in the EU is 10% but between and within countries there are also differences of twice the levels of ill health, mainly due to socio-economic inequities. The annual burden of disease is 4 times higher in the world's poorest billion (with almost half their potential healthy life lost due to poverty and perpetuating it) than in the richest billion which most EU citizens belong to. [5][6][7][8][9]

The Millennium Development Goals Report 2009 : htt p ://www.undp.org/mdg/basics_ontrack.shtml

Burden of disease is measured by Disability Life Adjusted years, comprising the health years lost to premature deaths and to the degrees of disability during disease.

The global burden of disease: 2004 update.WHO.

The State of the World’s Children 2009. UNICEF

WHO Statistical information system : http://www.who.int/whosis/en/

3.1.1. Principle 2: Health Is Wealth

There is growing evidence showing how health contributes to wealth and how investment in health contributes to long term growth and sustainability of economies. In 2005, the Healthy Life Years (HLY) indicator was included as a Lisbon Agenda Structural Indicator, recognising that the population's life expectancy in good health was an important measure in understanding and supporting economic growth. But health does not only contribute to economic growth, it also represents a major provider of employment in the EU and globally.

3.1.2. Principle 3: Health in All Policies (HIAP)

HIAP is a concept that already underpins work on health at the European level. Under article 168 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 Policies and Activities of the Union". HIAP approaches will be further 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 inter-sectoral cooperation in the field of health. The use of HIA (Health Impact assessment) and HSIA (Health Systems Impact Assessment), is already recognised as part of the Commission's Impact Assessment mechanism also in reference to encourage "health-in-all-policies" in third countries.

3.1.3. Principle 4: Strengthening the EU's Voice in Global Health

The EU has a Treaty obligation in Article 168 to "foster cooperation with third countries and the competent international organisations in the sphere of public health", with a particular emphasis on the regional dimension and on candidate, potential candidate and the European Neighbourhood Policy countries. The EU is committed to create better outcomes for health through "sustained collective leadership in global health". Coherence between internal and external health policies, as well as the sharing of values, experience and expertise, is essential in attaining the EU's global health goals.

3.2. Three areas of EU added value in addressing global health challenges

Objective 1: Fostering Good Health in a changing world

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 worldwide. The demographic trend, together with the effects of lifestyle- risk factors, influences a changing epidemiology with growing effects of non-communicable and chronic diseases. It 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-term. In order to address this problem, the EU needs to ensure that its population ages in good health and remains active and that healthy life expectancy evolves broadly in line with change in age-specific life expectancy. Actions include the promotion of health and prevention of disease throughout the lifespan, including the tackling of health determinants such as nutrition, physical activity, alcohol, drugs and tobacco consumption, environment and socioeconomic factors. The EU can contribute with third countries in exchanging experiences related to this challenge.

3.2.1. Objective 2: Protecting Citizens from Health Threats

Protecting citizens from health threats (such as communicable and non-communicable diseases, and special health issues including health threats from deliberate releases of pathogens, chemicals, radiological, and nuclear substances, and the health effects of climate change) and enhancing global response capacity to tackle acute threats is of ever increasing importance in an interconnected and interdependent world. At international level the WHO's International Health Regulations (2005) have been implementing global rules to enhance national, regional and global public health security. This legally-binding agreement significantly contributes to global public health security by providing a new framework for the coordination of the management of events that may constitute public health emergencies of international concern, and improves the capacity of all WHO countries to detect, assess, notify and respond to public health threats. As the protection of human health is also an obligation under Article 168 of the Treaty an EU action is necessary to coordinate health threats of cross-border character and multi-sectoral nature in order to provide a coherent approach in front of the WHO. This is crucial when cross-sectoral issues where IHR involve matters of the EU exclusive competence and shared competence between the EU and Member States (e.g. common safety concerns in public health matters).

3.2.2. Objective 3: Supporting Health Professionals, Dynamic Health Systems and new Technologies

In light of the fact that Member States are facing a number of common problems with their health workforces, there is much to be gained by promoting cooperation and common approaches between the Member States and at a later stage exchange best practices at a global level. This will inform the EU position towards the global voluntary code of recruitment of health workers and contribute to the sustainable availability of adequate national health workforce in third countries.

To support dynamic health systems, the EU needs to respond to the challenges of increasing mobility of patients and professionals, migration in general, citizens' rising expectations, population ageing, changing disease patterns, as well as innovation and development of new technologies. More investment will be needed in capacity building for health professionals and workforce planning; quality and availability of education and training for health professionals needs to be improved; the potential for Regional Policy programmes and other tools such as the Lifelong Learning Programme needs to be recognised; and possibilities for networking need to be encouraged and the further development of eHealth solutions needs to be supported. eHealth is inextricably linked to all of these challenges and its development and deployment will be key to ensuring the future sustainability of health systems. In all these areas, the use of information and communication technologies will offer major opportunities. The Commission could support Member States and Regions in identifying, assessing and providing guidance on innovation in healthcare, and share with third countries its experiences.

4. Seven Pillars for Action

In this approach to EU global health policy and strategy, EU overarching action is built upon seven pillars as essential and distinct action fields: Development, Public Goods and Security , Research, Internal and External Cooperation and Coordination, Foreign Policy , and Response to Globalisation (Market/Services ).

Goals, priority issues and approaches are divided into Action Pillars, many of which are cross-sectional, and cooperation and coordination between action fields remains of crucial importance.

The following sections give an outline of ongoing European Commission action in the field, with specific examples.

The Accra Agenda for Action (AAA) reflects the international commitment to support the reforms needed to accelerate an effective use of development assistance and to help ensure the achievement of the MDGs by 2015.

· W ork on a multisectoral health strategy , including education, gender, equality, non-discrimination, and respect for fundamental rights with particular attention to children's rights, adequate nutrition, safe water and hygienic environments.

· W ork on sustained development and economic growth , in order to ensure long-term improved living conditions.

· A ddress the global shortage of health workers and the crisis in human resources for health in developing countries as well as for same aspects in the EU, e.g. as a follow up to the 2008 Commission Green Paper on the European Workforce for health Commission Communication in 2004: Communication on patient mobility and healthcare developments in the EU (COM(2004) 301 of 20 April 2004 http://ec.europa.eu/health/ph_systems/docs/workforce_gp_en.pdf and responding to the WHO code of practice on the international recruitment of health personnel Resolution WHA57.19 (http://www.who.int/hrh/en) . Health workers' international migration has been increasing worldwide over the past decades, especially from lower income countries whose health systems are already very fragile, in several cases leading to what is often referred to as "brain drain".[10][11]

Commission Communication in 2004: Communication on patient mobility and healthcare developments in the EU (COM(2004) 301 of 20 April 2004 http://ec.europa.eu/health/ph_systems/docs/workforce_gp_en.pdf

Resolution WHA57.19 (http://www.who.int/hrh/en)

· Respond to food crisis , combat malnutrition , enhance food and feed safety.

All the above are influenced by many aspects that go beyond the health sector (global economy, incentives for migration, global negotiation on services etc). Therefore, they can only be modified through political action at the national, regional, and global level.

Ongoing Commission action

· Commission services working on global health are pursuing a coordinated and coherent approach in this area. Health is a strong component of programming and assistance, not just towards achievement of the Millennium Development Goals but also in responding to health threats in third countries and towards saving and preserving lives in emergency and immediate post-emergency situations.

· The Commission plays a key role in intergovernmental discussions to improve medicine access, availability and affordability of human resources for health in the developing world, including through constructive input to the WHO debate on public health, innovation and intellectual property (the (IGWG) process).

· The Commission works for strong international cooperation to tackle antimicrobial resistance in both human and veterinary medicines. It notably participates in the EU/US Transatlantic Task force on antimicrobial resistance focusing on appropriate therapeutic use of antimicrobial drugs in the medical and veterinary communities, prevention of both healthcare- and community-associated drug-resistant infections, and strategies for improving the pipeline of new antimicrobial drugs.

· The Commission also works for strong international agreements in health which are of greater relevance to EU citizens, in particular by supporting full implementation of the International Health Regulations (IHR) and the Framework Convention on Tobacco Control (FCTC).

4.1. Development: the crucial role of ensuring that coherence for development addresses global health challenges

Health is a central, cause and consequence of poverty reduction and sustainable development while, ill health is a barrier to any social and economic progress. However, there are good examples where the combination of stability, democracy, political commitment, adequate levels of domestic public funding for health, complementary aligned and predictable international support resulting in public funding above a minimum threshold, frank and inclusive policy dialogue leading to health sector reforms aimed at greater efficiency and equity, a harmonized progress in other social sectors, mainly education and social cohesion with especial emphasis on gender equity and protection of children rights, and sustainable and wide based economic growth, have led to sustained progress in reducing child and maternal mortality.

The European social model includes common features, including systems of guaranteed healthcare for all citizens across Europe. The EU has agreed to the value of solidarity towards equitable and universal coverage of quality care .

The Staff Working Paper "Contributing to Universal Coverage of Health Services through Development Policy" defines how the EU external action can more effectively contribute to the reduction of health inequities worldwide and progress towards universal coverage of health services. Despite a decade of unprecedented increase in health development aid, the progress towards health MDGs is uneven and grossly off track in least developed countries. The mentioned Staff Working Document identifies actions in the level of EU health aid, a more equitable distribution to partner countries, increasing the compliance with aid effectiveness commitments in the health sector, strengthening the EC and EU capacities in the health sector dialogue, ensuring inclusive processes and paying special attention to fair financing schemes towards equitable and universal coverage of health services.

However, despite the best efforts of development policies, the net effect of EU policies in the health sector in third countries may be negative if there is no clear attention to ensuring coherence between internal and external policies that affect global health. The five main areas are reflected in the priority issues under the EU policy on policy coherence for development:

· Financing and trade policies influence the overall national financing capacities and the access to affordable and essential medicines and health commodities. Fiscal policies , which increase equitable tax revenues and prevent tax evasions, are critical to enable adequate levels of public financing for health. In parallel to this communication, the European Commission is adopting a staff working document on fiscal governance and development. EU fiscal frameworks allow almost three times higher tax revenues on GDP than those in developing countries and are linked with national social spending. This experience can be a clear added value in the dialogue and cooperation with third countries. The EU has a major influence in the International Financing Institutions (IFIs) which in turn enable or limit the national capacities to finance health services and progress to equitable access to health services. Fiscal and public spending policies influenced by IFIs serve the frameworks on which the EU channels an increased share of its ODA through budget support. The Court of Auditors report on EC support to health in sub-Saharan Africa, calls for increased links between budget support and health policies, strategies and outcomes. The EU dialogue on fiscal and macroeconomic frameworks and health policies is fundamental to ensure coherence towards MDGs and improved health. Trade policies also influence the economies of the EU and third countries and have a direct effect in the access to medicines, subject to global markets and patent rights, which may hinder access to affordable medicines in poor countries. TRIPS provisions theoretically enables exemptions to patent monopolies but these have not been used in an effective manner and have been further challenged by the enforcement of TRIPS in middle income countries (and major generic producers as India) and will be further tested by the compliance of least developed countries in 2016. In addition, EU bilateral trade agreements need to ensure and facilitate the use of TRIPS provisions and assess the effects of liberalization of health services (GATTS), to ensure coherence towards the principle of solidarity towards equitable and universal access to health services.

Migration policies have a major impact on global health. Health professionals tend to follow market forces towards better salaries and conditions, to the detriment of health resources in poorer countries. There is a difficult balance between the rights of free movement, quality of life and career development of health workers, with the State's responsibility to guarantee the right to access of the population to quality health care. Further, if not conceived carefully, public investments in training health workers may fuel brain drain to the private sector, to international organizations and to third countries, undermining the capacities of national public health services aimed at equitable universal coverage of health services. A voluntary code for recruitment of health professionals will be discussed in the 2010 WHA where this Communication on global health can better inform an EU vision and voice in a more equitable distribution of health workers in the EU and worldwide, while respecting their individual rights. While there is a need to recruit additional health workers, some telemedicine services also have the potential to contribute to a more balanced global health approach.

· Migration policies also affect the health of migrants, which is often undermined by policies which restrict their access to basic social services including health promotion and care. Besides the compliance with the mentioned EU health principles, the equitable access to health services by migrant communities has an indirect effect in the overall health of their host community. The EU has the challenge to promote equitable health services for migrant communities in the EU and promoting the same principles in third countries.

· Security policies are an essential element of the EU external policies. Early integration of public health into peace building strategies and programmes is a priority for the safety of populations and an important element towards recovery and long-term development. Additionally, progressive flows of goods and people may also pose increased health threats . A recent European Commission's staff working document describes the concerns to health security in the EU. At the global level, the growth of trade and migration carries a risk of pandemics from emergent, re-emergent and resistant pathogens; as well as on goods, especially food, with negative effects on health. The International Health Regulations set a framework for detection and response to health threats, based on national and a global coordinating mechanism. However, the national capacities, in correlation with comprehensive national health services, remain weak in most developing countries which may impact on health negatively. On the other hand, the access to global goods to respond to health threats remains also subject to the market and undermines the equity of global response. The recent H1N1 pandemic, although of lesser global impact than foreseen, is a clear example of a biased availability of global goods (vaccines and medicines) against poorer economies, often subject as well to greater risks. There is a need to regulate the markets of global goods with major implications in global health and to enable developing countries to increase their capacities to predict, detect and react to health emergencies. The EU plays a leading role in Humanitarian health aid , now under the same coordination of civil protection services for emergencies in the EU region; and can better link health relief to the development aid towards increased national capacities. The EU will progressively benefit from the ECDC, which can also play a major role in improving to the EU and global capacity to react to health threats.

· Food security is directly related to nutrition , possibly the most important attributable risk for ill health globally, and responsible for one third of under five mortality. Over 1 billion persons in poorer communities lack access to adequate calories, proteins and micronutrients. The number of hungry people in the world is increasing due to the effects of the financial and economic crisis, the food prices' crisis and climate change. At the same time, obesity grows even faster and affects not only the EU and industrialized economies, but also middle income countries and middle and upper classes in developing countries. The EU is the main food importer globally and applies food safety regulations in protection of EU citizens. On the other side, the EU Common Agricultural Policy protects its rural and agricultural sectors through agricultural subsidies which may condition the export capacities of third countries. The EU can share its experience of public health interventions aimed at reducing obesity and sedentary lifestyles with countries gradually facing the same health challenges. In the external action, the EU prioritizes actions in promotion of rural development and food security and provides high levels of humanitarian food assistance. A parallel communication will propose an update of the EU policy on food security outlining its four dimensions: availability, access, utilization and crisis management. These dimensions relate to the right to food and food governance, undermined by poverty, marginalization and lack of participation in decision making. The coherence of external action with internal policies, towards increased global food security should also include global health challenges to ensure that it effectively leads to adequate nutrition and improved health.

· Climate change is potentially the most serious challenge humanity has ever faced in history. Its consequences in health are multi-faceted. It is already and will progressively affect the access to safe and sufficient water and food, the main risk factors for ill health. It will also gradually affect the epidemiology of vector-borne and food-borne diseases. Thermal excesses will affect health globally while the effects in low lands and economic disruption will affect the health of citizens in all regions in ways still difficult to forecast. The EU plays also a leading role in committing to reducing CO2 emissions in the development of renewable energies. There is a large potential of new energy sources in developing countries which can benefit rural communities by reducing deforestation and in-door smoke, and improving the capacities of remote health services. The promotion of new healthier lifestyles will also encourage more responsible and sustainable use of natural resources (reducing carbon footprint) such as active transport and healthier diets. The climate change conventions will be a source of global funding mechanisms which should also contribute to the potential mitigating and necessary adaptation measures of health services worldwide.

4.2. Promotion of Fundamental Rights and Public Goods

As set out in the EU Health Strategy 2008-2013, EU action in global public health should build on fundamental rights relating to health as a global public good. Health equity, social justice, equal access to good quality care, elimination of all forms of discrimination on grounds as stipulated in Art. 21 of the Charter of Fundamental Rights, provision of highest attainable standard of health to children and universality stand at the core of Commission's work.

The central areas of work include the encouragement of universal access and the elimination of financial and other barriers to health access (which in turns allows us to move away from user fees and generalising of prepayment and pooling schemes), as well as health system strengthening and health system financing .

“ Healthy lifestyles and good health for all ” is a strategic theme of the 2008-2013 EU Health Strategy. It covers specific actions and areas of work and is particularly targeted to addressing the problem of population ageing in Europe. In order to address the latter, we need to have healthy life expectancy evolving broadly in line with change in age-specific life expectancy. The Commission is committed to promoting health and prevent disease throughout the lifespan by tackling health determinants such as nutrition, physical activity, alcohol, drugs and tobacco consumption, environment and socioeconomic factors and by the encouragement of further development of ICT health solutions (eHealth). The development of Personal Health Systems (PHS), for example, can assist in the provision of continuous, quality controlled, and personalised health services to empowered individuals regardless of location and can help prevent complications in chronic conditions. When faced with a challenge, there should always be a right approach to addressing it. By addressing the problem locally – within Europe – the EU will be in a better position to assist in addressing the challenge globally as well.

Global health cannot be improved without addressing the growing burden of health problems associated with non-communicable diseases . Chronic diseases such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes, are by far the leading cause of mortality in the world, representing 60% of all deaths, with 80% of these deaths in low- and middle-income countries. These deaths are preventable but require concerted action by all. Cf. ECOSOC Annual Ministerial Review: Implementing the internationally agreed goals and commitments in regard to global public health , Geneva, 30 June – 3 July 2009, Report of the Secretary-General, p.8 People should be better informed about the effects of certain lifestyles on their health. At European level, there has been some progress but this is not enough. The exchange of knowledge and practices should be done at global level. [12]

Cf. ECOSOC Annual Ministerial Review: Implementing the internationally agreed goals and commitments in regard to global public health , Geneva, 30 June – 3 July 2009, Report of the Secretary-General, p.8

Health information systems: The EU's current health information system does not always provide consistently high-quality and fully comparable information. The European Commission is actively working to improve the mechanisms for health reporting including Electronic Health Records and interoperability of health systems and has therefore outlined recommendations and strategies for improving quality, widening access to and improving comparability of health information at EU level. internationally agreed set of international classifications, operational systems for collection of data on the state of health of populations, summary measures and population health indicators; current work on developing a 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); improve the collection and compatibility of health data is a strategic objective of the Commission Staff working document accompanying the White Paper [13]

internationally agreed set of international classifications, operational systems for collection of data on the state of health of populations, summary measures and population health indicators; current work on developing a 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); improve the collection and compatibility of health data is a strategic objective of the Commission Staff working document accompanying the White Paper

In addition to this the Commission has managed to upgrade and improve two very important alert systems for food and feed and also for all dangerous (non food) consumer products. Through these systems the Commission has managed to provide a high level of protection of health, on both the global and EU level.

Rapid Alert System For Food and Feed (RASFF) : this system was set up so as to provide the control authorities with an effective tool for exchange of information on measures taken to ensure food safety. In 2006, with the entry into force of the "Feed Hygiene" Regulation (EC) N° 183/2005, animal health and environmental risks were added to the scope in relation to feed. RASFF was set up some 30 years ago and significant development has been made since as the system is moving into new regions and parts of the world. International co-operation is a priority area for action, for example with other systems such as the International Food Safety Authorities Network (INFOSAN) of the World Health Organization.

This international aspect is crucial. For example, although Europe was only marginally affected by the recent melamine crisis, products containing contaminated milk ingredients were shipped all around the world. Due to the global scope of the problem, the EU and RASFF needed to collaborate with third countries as well as with regional networks and INFOSAN. This marked a new level of international cooperation in relation to a food safety crisis .

RAPEX is the EU rapid alert system for all dangerous consumer products, with the exception of food, pharmaceutical and medical devices. It allows for the rapid exchange of information between Member States via central contact points and the Commission of measures taken to prevent or restrict the marketing or use of products posing a serious risk to the health and safety of consumers. Both measures ordered by national authorities and measures taken voluntarily by producers and distributors are covered by RAPEX.

4.3. Research/Knowledge Management

The third Action Pillar is that of Research and Knowledge management, an area of work necessitating its own and distinct delineation, especially in the sphere of global health. It is now widely understood that the determinants of health extend far beyond the health sector and that “research for health” must encompass not only the immediate causative agents of diseases but also social, political, economic and environmental factors that contribute to the health status of individuals and populations.

Health research and scientific evidence are crucial to improve the health of all individuals, to harness knowledge, science and technology , but also to increase credibility and transparency of health policy at a global scale. Information on how the results of health-related research are used as a basis for health policy thus also needs to be actively and widely disseminated. Only then can the EU gain and retain a strong voice in global health and contribute to shaping the global health research agenda. Indeed, it one of the values stated in the Health Programme that health policy must be "based on the best scientific evidence derived from sound data and information, and relevant research."

To generate valuable knowledge, the Commission also ensures coherence with health research under the Seventh Framework Programme, which supports public health research with a budget of 6 100 billion (2007-2013).

Priority should be given to the following activities:

· Biomedical research:

Ensuring that the results of biomedical research will ultimately reach the citizens. Special attention will be given to communicating research outcomes and engaging in dialogue with civil society, in particular with patient groups, at the earliest possible stage, of new developments arising from biomedical and genetics research.

· Modern biotechnology

The Commission has 30 years of sustained and increasing involvement in biomedical and health research. The activity "Biotechnology, generic tools and technologies for human health" aims to expand and validate the necessary tools and technologies that will make possible the production of new knowledge and its transition into practical applications in the area of health and medicine. ftp://ftp.cordis.europa.eu/pub/fp7/docs/health_factsheets_en.pdf[14]

ftp://ftp.cordis.europa.eu/pub/fp7/docs/health_factsheets_en.pdf

· Health Security Research

In order to assure that Health Security issues are addressed in an evidence-based manner, the EU has been financing in the past research in the area of Health security. The outcomes are used for policy making in that crosscutting area.

· Health policy and system research

There has been a great evolution in healthcare systems in part as a result of the rapid development of new technologies which are revolutionising the way we promote health and predict, prevent and treat illness. These include information and communication technologies (ICT), innovation in genomics, biotechnology and nanotechnology. Work under FP7 and CIP ICT Policy Support will focus on policy formulation, relationship of policy to evidence, and prioritisation; on health systems management, functions, efficiency, effectiveness, system factors affecting access, scale-up, monitoring and evaluation. In particular by co-funding deployment across national borders ICT funding is also enabling Member States to address in a coordinated manner the political and regulatory issues which are hindering such development.

· Social sciences and behavioural research

Social, political, economic, environmental determinants for health and their relation to equity, access, lifestyles and health seeking behaviours.

· Operational research

Research on factors affecting the functioning of programmes, effectiveness of targeting, impact on behaviour, disease burdens and public health.

· Business Opportunities

Increasing and strengthening of the competitiveness and innovative capacity of European health-related industries and businesses.

· Research and Development

EU should support the development of knowledge management for health in developing countries and assist them in developing information products and services to meet the needs they identify.

· Clinical Research

Under FP7, clinical research will tackle a number of diseases such as cancer, cardiovascular, infectious, mental and neurological diseases, and in particular those linked with ageing, such as Alzheimer's and Parkinson's diseases. Through international multi-centre trials involving the required number of patients, new drugs and treatments would be developed in a shorter time frame. New technologies as the Virtual Physiological Human (VPH) will enable academic, industrial and clinical researchers to improve their understanding of human physiology and pathology, to derive predictive hypotheses and simulations, develop and test new therapies, with the eventual outcome of better disease diagnosis, treatment and prevention tools in healthcare.

4.4. Cooperation, Coordination, Export of Knowledge and Experience

Sharing expertise, experience and best practice in global health is essential for research, governance, coordination and cooperation within and outside the EU. The EU works on different fronts in order to achieve dissemination of knowledge , the promotion of EU values and principles and capacity building :

Firstly, platforms, fora and events as mentioned under Action Pillar 2, are crucial for gathering sustained information on consumers and stakeholders. They also serve as contact points between health experts for information sharing, finding partners for projects and developing and testing new ideas. This is also enhanced across the EU and more broadly, for example by using web-based technology, the Health Portal of the EU www.health.europa.eu and newsletters Eg. published by DG SANCO: "Health and Consumer Voice Newsletter", "Newsletter of the European Commission Scientific Committees", "What’s Next?, DG Health and Consumers’ Futures’ Newsletter", "Health and Consumer e-News" .[15][16]

www.health.europa.eu

Eg. published by DG SANCO: "Health and Consumer Voice Newsletter", "Newsletter of the European Commission Scientific Committees", "What’s Next?, DG Health and Consumers’ Futures’ Newsletter", "Health and Consumer e-News"

Secondly, international co-operation with third countries and international organisations, which is also an explicit requirement under Article 168 of the Treaty can also gather knowledge and encourage experience sharing. On a bilateral basis, the EU is strengthening its links with Switzerland, Canada, China, Russia and the USA in health questions. Health plays an important role in its relations with the ACP countries and the EU-Africa strategy. EU action also aims at strengthening the regional dimension of cooperation on health by active involvement in the work of several regional networks (South East European Health Network and the Northern Dimension Partnership in Health and Social well-being). The EU encourages participation of third countries, particularly candidate countries, potential candidate countries and European Neighbourhood countries in the Health Programme and in EU Agencies related to health. Regional health networks (South East European Health Network and Northern Dimension Partnership) are also an important multiplier for the EU. The EU also constantly works on improving its relations with international organisations in health. An example is its work with third countries and the World Organisation for Animal Health (OIE) towards the eradication of animal diseases and pathogens as well as the supply of animal vaccines, leading also to the improvement of lot of farmers in developing countries.

Ongoing Commission action

· Routinely promotes the EU health acquis in its bilateral relations with third countries – particularly candidate countries, potential candidate countries, European Neighbourhood countries and Switzerland.

· Encourages where appropriate capacity building and the establishment of networks for exchange of best practices. This includes areas such as rare disease treatments, nanotechnology, neglected poverty diseases, but equally in the area of zoonoses and food safety related issues, where these can affect public health.

· Contributes to normative work at global level for setting high safety standards for food, feed, animal and plant health as well as product safety.

· Promotes its Rapid Alert Systems and makes information available on the internet relating to food and feed safety, product safety, animal, plant and human health.

· Routinely inspects facilities in Member States and third countries and publishes the results of its inspections on the internet. As with the Rapid Alert systems, this can be considered as a global public good in that it raises standards and informs all interested parties of problems with the food supply.

· Encourages training throughout the world to increase the capacities of third countries in dealing with food and feed law, animal health and welfare and plant health rules. For example, the Commission training initiative "Better Training for Safer Food" trains Member States' and candidate countries' national authority staff involved in official controls in these areas. Training is also organised specifically for third, particularly developing country participants, so as to familiarise them with EU approach and requirements. Other programmes under the various external assistance instruments help developing countries building their capacity in these fields.

· Contributes wherever possible in international meetings on global health.

4.5. Foreign Policy, Governance

The interdependence produced by globalisation has turned health into an increasingly important challenge. In pursing self-interest, nations might undermine the solutions that respond to the challenges of growing interdependence, and there is thus an urgent need to find shared values and approaches in the area of global health, that would be embodied in the relations between countries. The UNGA Resolution on Global Health and Foreign Policy UN General Assembly A/64/L.16 of 4 December 2009 Global health and foreign policy of December 2009 drew specific attention to the issues of emerging infectious diseases and of workforce but there are many other potential examples.[17]

UN General Assembly A/64/L.16 of 4 December 2009 Global health and foreign policy

The objectives at EU level are to build strategic alliances and collaborate effectively with global health partners, to enhance EU visibility in global health and contribute to shaping the global health agenda.

The EU is dedicated to strengthening its voice in global health through sustained collective leadership. This follows from TFEU Article 168 calling for cooperation with third countries and international organisations in public health and from the Commission's strategic objective of Europe as a World Partner (Annual Policy Strategy for 2008 – COM(2007) 65) By sharing values, experience and expertise and by ensuring coherence between its internal and external health policies, the EU can provide significant support to attaining global health goals (e.g. Millennium Development Goals, European Consensus on Development Cooperation, the 2005 Paris Declaration and the Accra Agenda for Action). In addition, this will ensure that the EU plays a crucial role in the response to global health threats (European Centre for Disease Control, implementation of international health agreements such as Framework Convention for Tobacco Control and International Health Regulations).[18]

This follows from TFEU Article 168 calling for cooperation with third countries and international organisations in public health and from the Commission's strategic objective of Europe as a World Partner (Annual Policy Strategy for 2008 – COM(2007) 65)

But the relevance of foreign policy and global health is not only about national health security and development . Health and foreign policy are also of crucial importance for alliances , for reputation and for trade issues. In all of these areas, health and governance are mutually dependent on each other, in fact intrinsically entwined. Global health issues have an impact on EU health issues and governance and vice versa.

Health can be a good entry point to initiate dialogue across borders, thus contributing to building trust between parties (e.g. breakdown of health services in armed conflicts, high casualties, damage to infrastructure, loss of health workers in natural disaster situation and re-establishing of health services as a primary focus during the reconstruction phase, post-conflict, and in the aftermath of a disaster). For example, in South-East Europe following the conflicts in the Balkans during the 1990's the establishment of the South-East Europe Health network helped to build bridges across hitherto hostile communities which then faced common problems.

Recognition of the need for policy coherence, strategic direction and a common value base in global health is beginning to emerge at the level of nation states. A few European countries are beginning to address global health more consistently at the national level by mapping many activities in global health across all government sectors, establishing new mechanisms of coordination within government and developing a " national global health strategy ", frequently at the initiative of the international departments in the ministries of health. The realisation of a financial crisis has also pushed foreign security policy makers to set up a clear agenda for bringing at least global health security higher in the foreign policy agenda.

In Europe, the most recent – and possibly the first – such national global health policy document has been developed in Switzerland , where a joint strategic approach to global health was developed by the Departments of the Interior (represented by the Swiss Federal Office of Public Health) and the Department of Foreign Affairs. The document is unique in documenting the interface between the protection of the health interests of the Swiss population and the improvement of the global health situation. It forms the basis for a new type of policy coherence between national interests and global responsibilities.

The UK Government has also launched a national global health strategy, in September 2008, which aims at greater coherence between government departments in matters of global health. A number of other European countries are also working on similar agreements between sectors in order to advance global health.

Ongoing Commission action

· Brings together stakeholders from all Member States and from the private and public sector monthly in the Global Health policy forum.

· Builds upon existing EU/WHO cooperation in areas such as tobacco control, obesity, mental health, humanitarian aid and health research. In 2008-2009 it seconded an official to WHO in Geneva.

· Consistently calls upon partner countries to give priority to the implementation of international health agreements to which they are parties.

· Encourages participation of third countries, particularly candidate countries, potential candidate countries and European Neighbourhood countries in the 2008-2013 Health Programme and in EU Agencies related to health.

· Encourages enhanced cooperation and dialogue on health with European Neighbourhood policy partners including through the implementation of the European Neighbourhood Policy Action Plans.

· Is negotiating a Health Agreement with Switzerland on health and has signed agreements with Canada, China and Russia on how to improve health cooperation. It is ready to open discussion with the new US Administration on how to expand existing cooperation.

· Is expanding the ongoing collaboration with Africa in the area of health as emphasised in the Joint Declaration between the African Union Commission and the European Commission in their meeting in October 2008.

· Works with third countries and the OIE towards the eradication of animal diseases and pathogens, supply of animal vaccines and generally improving the quality and productivity of the global herd – thus improving indirectly the economic status of farmers in developing countries and working towards the eradication of malnutrition there.

· The EU's integrated approach to food safety is also reflected in the Commission's involvement in the work of the OIE and Codex Alimentarius.

4.6. Security

Protecting citizens against health threats, such as communicable and non-communicable diseases, including health threats from deliberate releases of pathogens, chemicals, radiological, and nuclear substances, and the health effects of climate change, as well as enhancing global capacity to respond to acute threats is of ever increasing importance in an interconnected and interdependent world.

The Commission has a key role in coordinating the efforts of Member States on addressing health security threats effectively and in a coherent way as it provides clear added value as many of these trans-border issues cannot be tackled effectively by individual Member States. The protection of human health has been specifically set out in the Treaty Article 168: "A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities" . Commission work in this area includes consumer protection, combating cross border health threats such as infectious diseases and food contaminants, improving preparedness and response to epidemics or bioterrorism, and supporting Member States in addressing communicable disease threats.[19]

Article 168: "A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities"

Consumer protection: The EU integrated approach to food production aims to assure a high level of food safety, animal welfare and plant health within the European Union through coherent farm-to-table measures and adequate monitoring, while ensuring the effective functioning of the internal market. Coordination must be ensured on issues such as animal diseases which can be transferred to humans, and on ensuring food safety.

Combat cross border health threats: The need for communicable diseases to be addressed effectively and in a coordinated way internationally has been demonstrated over the last decade, especially with the outbreak of SARS, Avian Influenza A (H5N1) and most recently the influenza A (H1N1). The Commission is committed to improving preparedness and response to this kind of epidemic or deliberate acts such as bioterrorism, as well as to supporting Member States in addressing communicable disease threats such as HIV/AIDS and tuberculosis/MDR-TB. In order to respond rapidly to health threats globally and enhance the EU’s and third countries’ capacity to do so, the Commission put in place a set of mechanisms to coordinate measures at the EU level and globally Council Conclusions, 30 April 2009 . [20]

Council Conclusions, 30 April 2009

· Actively participates in the G7+ Global Health Security Initiative and hosted the Ministerial Meeting of G7+ Health Ministers in December 2008 and the extraordinary ministerial meeting on pandemic H1N1 (2009) in September 2009.

· Works with the WHO and others to reinforce global responsiveness and to provide funding through the pledging process for avian influenza response.

· Works very closely with the European Centre for Disease Control (ECDC) to monitor, assess and respond to communicable disease health threats.

· Encourages European Neighbourhood countries to participate increasingly in EU Communicable diseases networks.

· Promotes bio security measures as a crucial component of its Animal Health Strategy for 2007-13.

· Promotes evidence-based and high levels of food safety, animal and plant health as well as product safety at the multilateral level, with a view to facilitating trade under safe conditions and improving the contribution of these policy areas to overall health protection.

4.7. Response to Globalisation (Markets/Services)

With globalisation and the opening up of international trade and business opportunities, health has become an important part of export and trade profit in the EU (export of health solutions, policies, products, services, knowledge). But health has also become increasingly dependent on global market dynamics. Health systems and health policies are becoming more interconnected than ever in the past, human resources and access to essential medicines depends on market dynamics, and so does also international safety of medicines, of food, feed and other products .

This is due to many factors, including the movement of patients and professionals (facilitated by rulings of the European Court of Justice); the common public expectations across Europe; the dissemination of new medical technologies; and techniques through information technology. .A coherent strategy on health in relation to trade within the EU and with other countries is thus needed.

Patient mobility: Until recently, the circumstances under which cross-border healthcare could be provided and reimbursed were still unclear. On 2 July 2008, the Commission adopted a proposal for a Directive on the application of patients' rights in cross-border healthcare, which, once adopted by the European Parliament and the Council, will provide a Community framework for safe, high quality and efficient cross-border healthcare, by reinforcing cooperation between Member States and providing legal certainty over the rights of patients to seek healthcare in another Member State. EU citizens facing a health problem while travelling in another Member State can already obtain healthcare and be reimbursed thanks to the coordination of EU social security systems. Those who cannot get the healthcare they need in their own country within a reasonable time can also rely on this system. But citizens may have other reasons for travelling abroad to receive treatment. For example, they may live in a border region where the closest health facilities are across the border. These people will in future find it easier and safer to be treated in other Member States thanks to the Commission initiative. [21]

EU citizens facing a health problem while travelling in another Member State can already obtain healthcare and be reimbursed thanks to the coordination of EU social security systems. Those who cannot get the healthcare they need in their own country within a reasonable time can also rely on this system. But citizens may have other reasons for travelling abroad to receive treatment. For example, they may live in a border region where the closest health facilities are across the border. These people will in future find it easier and safer to be treated in other Member States thanks to the Commission initiative.

Trade agreements (TRIPS flexibilities etc): Trade policy measures can have, indirectly, both negative and positive effects on the health of a country’s population. This potential conflict of interest is taken into account in one of the major exceptions to the WTO’s basic principle of unrestricted market access whereby measures essential to protecting health are permitted in principle, provided they are not discriminatory or used as a covert means of restricting international trade.

Another example is the agreement on TRIPS flexibilities , which ensures both adequate protections of intellectual property as well as access to essential drugs for the world's poorest countries. The EU has consistently led efforts to widen access to vital medicines in developing countries and to strike the right balance between the intellectual property rights of pharmaceutical companies and the need to ensure that medicines are available for poor countries facing public health crises.

In 2003, the EU adopted new rules on tiered pricing that prevented the re-export to the EU of drugs sold by European pharmaceutical companies to developing countries at heavily discounted prices, thus enabling the European pharmaceutical companies to sell their goods to developing countries at prices cheaper than they charge in Europe.

Moreover, the EU has now integrated an amendment to the TRIPS Agreement which extends the concept of compulsory licensing The principle of compulsory licensing allows a developing country facing a public health crisis, after consultation with the patent-holder, to grant a license to a domestic company without the approval of the patent-holder to produce a generic medicine patented by a foreign pharmaceutical company. This medicine is for the use of the domestic market and may not be exported. to other countries into its own law so that EU pharmaceutical companies can apply for a licence to manufacture, without the authorisation of the patent holder, pharmaceutical products for export to countries in need of medicines and facing public health problems.[22]

The principle of compulsory licensing allows a developing country facing a public health crisis, after consultation with the patent-holder, to grant a license to a domestic company without the approval of the patent-holder to produce a generic medicine patented by a foreign pharmaceutical company. This medicine is for the use of the domestic market and may not be exported.

International safety standards: Finally, the European Commission also works to agree and ensure international safety standards for food, feed and products regardless of origin. As the world's biggest importer and exporter of foodstuffs, the European Union works closely with international organisations and offers advice as well as assistance to third country trading partners. Indeed, the high standards of food, feed and product safety expected by EU citizens imposes a requirement on the Community to have the high EU standards accepted at global level so that we can stay compliant with WTO rules.

5. Benefits of Cooperation for Global Health at EU and Global Level

It is not an easy task to establish policy coherence across such a wide variety of sectors, services and Member States involved in global health issues. However, if the sectors involved in each action field manage to collaborate effectively, if concerted policy approaches are taken both within and between Action Pillars, and if policy coherence can be ensured across Member States, then it will be possible to reach increased visibility, competence, credibility and effectiveness of the EU .

The legal basis for this is to be found in various Treaty articles, such as on the Internal Market, Environment, Consumer Protection, Fundamental rights, Social Affairs including the Safety and Health of Workers, Development Policy, and Research, amongst many others. The important role of the EU in health policy has also been reaffirmed in the Lisbon Treaty.

With greater visibility, competence, credibility and effectiveness, the EU will be able to appear on the global scene as a leader with a strategic framework. It will gain greater political and economic weight in international health; its role will be shifted from donor to convening EU collective voice and action; in short, it will become a more trusted, more efficient and more powerful global player in the field of health. In fact, considering its remarkable system of shared sovereignty between its 27 Member States and the Union, the EU will be particularly suited to serving as a model on the global scene.

The main actors involved in the global health field (the EU, International Organisations, countries, NGOs, Foundations, Think Tanks, Academia etc) need to come together and establish partnerships and processes to define a global health agenda. There is a need to engage systematically with policy makers and stakeholders at all levels, including the private sector, industry and civil society; a need to promote new ways of working within a range of traditional and non-traditional stakeholders, and to find ways of bringing in new partners and building synergies.

6. Outcomes for Global Health

Collective and coordinated power and a strong political will to improve the health of all citizens could thus lead to sustained, imaginative and democratically accountable political leadership and a successful global health agenda. Prosperity, security and stability could be improved in the field of health as such, but also in all related spheres. Economic prosperity is heavily reliant on the sound health of the population As also specifically recognised under the Lisbon Agenda. . Working towards a sustained and concerted global health agenda by agreeing on adequate global health objectives and mechanisms will be essential to reaching the ultimate and ideal state of global health.[23]

As also specifically recognised under the Lisbon Agenda.

[1] OJ C 303/7, 14.12.2007, p.1. In particular, the following rights such as human dignity, integrity of the person, health care, non-discrimination, equality between women and men and rights of the child are at stake. In accordance with the Commission's Communication Towards an EU Strategy on the Rights of the Child, all EU internal and external actions should be fully compatible with the principles and provisions of the UN Convention on the Rights of the Child. Article 24 UNCRC obliges Member States to recognize the right of the child to the enjoyment of highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health.

[2] Council Conclusions on Common Values and Principles in European Union Health Systems (2006/C 146/01)

[3] Council Conclusions on Women's Health (2006/C 146/02)

[4] "Solidarity in health: Reducing health inequalities in the EU" , Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions, COM(2009)567, Brussels, 20 October 2009 .

[5] The Millennium Development Goals Report 2009 : htt p ://www.undp.org/mdg/basics_ontrack.shtml

[6] Burden of disease is measured by Disability Life Adjusted years, comprising the health years lost to premature deaths and to the degrees of disability during disease.

[7] The global burden of disease: 2004 update.WHO.

[8] The State of the World’s Children 2009. UNICEF

[9] WHO Statistical information system : http://www.who.int/whosis/en/

[10] Commission Communication in 2004: Communication on patient mobility and healthcare developments in the EU (COM(2004) 301 of 20 April 2004 http://ec.europa.eu/health/ph_systems/docs/workforce_gp_en.pdf

[11] Resolution WHA57.19 (http://www.who.int/hrh/en)

[12] Cf. ECOSOC Annual Ministerial Review: Implementing the internationally agreed goals and commitments in regard to global public health , Geneva, 30 June – 3 July 2009, Report of the Secretary-General, p.8

[13] internationally agreed set of international classifications, operational systems for collection of data on the state of health of populations, summary measures and population health indicators; current work on developing a 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); improve the collection and compatibility of health data is a strategic objective of the Commission Staff working document accompanying the White Paper

[14] ftp://ftp.cordis.europa.eu/pub/fp7/docs/health_factsheets_en.pdf

[15] www.health.europa.eu

[16] Eg. published by DG SANCO: "Health and Consumer Voice Newsletter", "Newsletter of the European Commission Scientific Committees", "What’s Next?, DG Health and Consumers’ Futures’ Newsletter", "Health and Consumer e-News"

[17] UN General Assembly A/64/L.16 of 4 December 2009 Global health and foreign policy

[18] This follows from TFEU Article 168 calling for cooperation with third countries and international organisations in public health and from the Commission's strategic objective of Europe as a World Partner (Annual Policy Strategy for 2008 – COM(2007) 65)

[19] Article 168: "A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities"

[20] Council Conclusions, 30 April 2009

[21] EU citizens facing a health problem while travelling in another Member State can already obtain healthcare and be reimbursed thanks to the coordination of EU social security systems. Those who cannot get the healthcare they need in their own country within a reasonable time can also rely on this system. But citizens may have other reasons for travelling abroad to receive treatment. For example, they may live in a border region where the closest health facilities are across the border. These people will in future find it easier and safer to be treated in other Member States thanks to the Commission initiative.

[22] The principle of compulsory licensing allows a developing country facing a public health crisis, after consultation with the patent-holder, to grant a license to a domestic company without the approval of the patent-holder to produce a generic medicine patented by a foreign pharmaceutical company. This medicine is for the use of the domestic market and may not be exported.

[23] As also specifically recognised under the Lisbon Agenda.