Opinion of the European Economic and Social Committee on ‘Proposal for a Regulation of the European Parliament and of the Council on the establishment of a Programme for the Union's action in the field of health for the period 2021-2027 and repealing Regulation (EU) No 282/2014 (“EU4Health Programme”)’

(COM(2020) 405 final – 2020/0102 (COD))

(2020/C 429/32)

Rapporteur-general:	Antonello PEZZINI (IT-I)
Co-rapporteur-general:	Alain COHEUR (BE-III)

Referral	European Parliament, 17.6.2020 Council, 10.6.2020
Legal basis	Article 304 of the Treaty on the Functioning of the European Union
Plenary Assembly decision	9.6.2020
Section responsible	Employment, Social Affairs and Citizenship
Adopted at plenary	18.9.2020
Plenary session No	554
Outcome of vote (for/against/abstentions)	218/0/2

1.   Conclusions and recommendations

1.1.

The EESC points out that the coronavirus pandemic has demonstrated, more than ever before, the need to strengthen the European Union's role on health, its capacity to react, manage and coordinate, and its powers by means of a ‘European Union of Health’. This will enable it to respond to the plight of the public and of those in the health sector, including frontline medical and paramedical staff, and to meet their expectations of an effective European public health policy, providing for interaction between European, national and regional levels through ‘multilevel governance’ (1).

1.2.

The EESC welcomes the European Commission's ‘EU4Health Programme’ proposal of May 2020, mobilising dedicated funds both in the ‘Next Generation EU’ proposal and in the Multiannual Financial Framework 2021-2027. It regrets, however, that cuts were made by the European Council in July 2020 despite the fact that public health is facing, in both the short and the long term, complex political, social, economic, digital and environmental challenges for which innovative, cross-cutting and integrated measures and major strategic investments (in the social and healthcare sectors) are needed.

1.2.1.

The EESC considers that ‘Europe à la carte’ (2) (or ‘multi-speed Europe’) will not enable the Union to meet the current challenges which go beyond national borders, nor to seek to achieve ambitious and solidarity-based European integration founded on being ‘united in diversity’ and steered by common goals of cooperation.

1.3.

The EESC calls on the EU institutions and the Member States to demonstrate the political will to implement a ‘Health Pact for the Future of Europe’ that reflects the fundamental values of the European Union, including European solidarity, and the pledges made both internationally (Sustainable Development Goals, the promotion of human rights and the application of international conventions) and at European level (priorities of the German Presidency of the Council of the European Union and delivering on the European Pillar of Social Rights).

1.4.

The EESC calls on the European Parliament, in its capacity as co-legislator, to negotiate with the Council to both step up funding for the health programme and other instruments promoting synergies in health (research, cohesion and cross-border cooperation) and tap European Stability Mechanism funds to lead us out of austerity.

1.5.

The EESC insists that when implementing the programme particular heed be paid to: combating social inequality in health; access to high-quality healthcare; continuity of care (including cross-border care) in all circumstances; support for and consolidation of universal health coverage systems; and the development of multidimensional European action in the sphere of public health in line with the principles of the European Pillar of Social Rights, including ‘health care’, ‘inclusion of people with disabilities’ and ‘long-term care’.

1.5.1.

More specifically, the EESC calls for European guidelines to be adopted to meet the needs of the most vulnerable among us: people with a precarious existence, the elderly and people with disabilities, particularly those who have to live in facilities accommodating considerable numbers of people, which have been hit hard across Europe by the pandemic and its aftermath.

1.5.2.

Special attention must be paid to strengthening the rights of the elderly and people with a disability; in particular, a framework for joint assessment needs to be drawn up providing for a personalised care plan, prioritising assistance in the home or in small residential homes, ensuring that residential care is governed by criteria of quality and accessibility, and providing the long-term care that these people need. The very high mortality rates in many care homes for the elderly and for people with a disability must focus attention on the need to improve care home management, something that has been called into question in many EU countries. As a general principle, the entire policy of support for elderly people should be reviewed, partly in connection with the European Commission's work on the impact of demographic change in Europe. In line with work already carried out on specific determinants of health, the EESC calls for clear and innovative guidelines to be drawn up, putting human beings and the human rights of the elderly and the most fragile people at the heart of priorities.

1.6.

The EESC regards coordinated European governance in health as a priority. This should include methods for implementing the health programme, with appropriate funding and initiatives to make the ‘Europe of Health’ a reality. The Committee also calls for an operational approach to ‘Health in all policies’.

1.7.

Given the ongoing emergency, the risk of a resurgence in pandemics and the inspiration offered by experience with the ‘Europe of energy’ and defence and civil protection measures, the EESC proposes that a European mechanism for coordination and rapid intervention should be deployed as soon as possible.

1.8.

A task force of experts must be set up immediately to act as a knowledge and resource coordinator to create a network of the best virology and epidemiology centres and the best diagnostic capacities.

1.9.

The EESC's idea is that, working in part with the army's emergency response units, this task force must make an inventory of available and easily allocated resources, including emergency departments, and must provide for the dispatch of mobile units. It must link up the best available resources, in terms of artificial intelligence and IT support, to develop simulations and strategies.

1.9.1.

The task force should also delve into the state of health of the whole health workforce itself, which is critical not only for the right to health, but also for an effective response to any further crisis. The task force could also lay the foundations for a European specialisation of ‘crisis and emergency medicine’, as suggested by the Commission document.

1.9.2.

The cost of this crucial operation would appear to be very modest, since most of the members are already employed by universities, research institutions or military health services.

1.9.3.

The EESC considers that it is vital that this task force be made operational immediately.

1.9.4.

The EESC regrets that during the pandemic, which is still ongoing, the authoritative voice of the European Commission was missing: by drawing on top-level European experts, the Commission could have shed light on both the use of cordons sanitaires to restrict people's movement and the impact of the virus on the population, and could have debunked often contradictory ideas regarding aspects of and developments in the disease. The European institutions responded to previous epidemics with tangible measures, such as setting up the Directorate-General for Health (DG SANTE) or establishing the European Centre for Disease Prevention and Control (ECDC). The EESC feels that this dynamic needs to be kept up.

1.10.

The EESC believes that the health programme can only achieve real results by adopting an inclusive approach that involves international organisations (including the World Health Organization, with which collaboration and synergies should be stepped up), the Convention on the Rights of Persons with Disabilities (UNCRPD) and those health sector stakeholders most familiar with people's situations, and by conducting regular assessment of the objectives.

1.11.

The EESC stresses the value of healthcare personnel, who work in a particularly sensitive and difficult sector, and calls for constant monitoring to anticipate their needs in terms of training, organisation, protective equipment and economic and social well-being.

1.12.

The EESC strongly supports European public/private partnerships in the field of health along the lines of the IMI 2 Joint Undertaking, and upholds the joint efforts to redevelop European technology and manufacturing by making greater use of European scientific and health bodies seeking to create a genuine European health space.

2.   Learning lessons from the multidimensional crisis triggered by the coronavirus pandemic

2.1.

The coronavirus pandemic has shone a spotlight on the fragility of the health systems of many countries around the world, including EU Member States whose systems have been affected by weak public investment and the direct application of European economic governance imperatives imposing budgetary restrictions. The amount of funding allocated to health systems thus differs greatly from one Member State to another, as does the amount of funding allocated by each Member State to combating the coronavirus pandemic.

2.2.

Europe is confronting a triple threat — uncontrolled pandemics and an increase in social inequality with regard to health, inadequate economic policy toolboxes and geopolitical ‘black swans’ — which could jeopardise the health and well-being of its people and push the global economy into a lasting depression, triggering financial market crashes and capital flight.

2.3.

The coronavirus crisis has once again flagged up the importance of restoring the balance between human activity and nature. The impact of the environment (together with climate change, air quality, biodiversity, food systems, etc.) on health has been made abundantly clear.

2.3.1.

The Commission and the European Parliament, which have been working hard on sustainable development, environment and biodiversity issues, should do more to make their voices heard. Most importantly, at this difficult time and with the assistance of top-level European experts, they should give Europeans advice and possible solutions based on science on how to cope more safely with the difficult health situation which is causing confusion and suffering.

2.4.

Non-communicable diseases (NCDs) are rising steadily in Europe and are the chief cause of disability and death in Europe: heart disease, diabetes, cancer and respiratory diseases make up 77 % of the burden of disease and 86 % of premature deaths. Many NCDs are linked to a combination of factors, including environmental ones.

2.5.

The Green Deal presented by the European Commission lays the groundwork for a new sustainable and inclusive growth strategy seeking to improve people's health and quality of life, to preserve nature and to ensure that no one is left behind.

2.6.

Border areas are particularly well-suited to European action in the field of health. These areas are usually geographical regions characterised by strong mobility. They have been the first to see the benefits of agreements or conventions between bordering countries aiming to boost access to healthcare.

2.7.

However, the cross-border health cooperation begun more than 20 years ago by the INTERREG programmes and founded on negotiation, constructive action, organisation and sometimes complex solutions between stakeholders was swept away in just a few hours by the arrival of COVID-19 and unilateral decisions to close borders taken without any consideration for the situation in cross-border areas nor any desire to keep up this spirit of cooperation.

3.   Reinforcing health systems and the capacity of the European Union (EU) to act

3.1.

The COVID-19 pandemic has had and is still having a strong impact at global, European and cross-border level, particularly on individuals and society and on economic, social and health infrastructures. It has been made quite clear that both health and crisis management systems need to be bolstered.

3.2.

The EU's objectives with regard to health policy are promoting health, safeguarding against threats to health and coordinating strategies between the Member States. The COVID-19 pandemic has shown that cooperation and coordination between EU countries are vital for dealing with the crisis.

3.3.

The EU's capacity to respond to emergencies must be reinforced in order to combat any further cross-border health threats effectively. Generally speaking, this should be combined with the roll-out of the European Pillar of Social Rights (and particularly principle 16 thereof) and with broader EU competences in the field of health, including by revising the European Treaties.

3.4.

While the EU currently has only supporting competences in the field of public health, a factor which limits what it can do, it acts in this matter through its other policies, particularly the cycle of economic and internal market policy coordination.

3.5.

A Europe of health must be a priority for the Future of Europe: EU4Health is the first step in this direction.

3.6.

The EU has implemented several initiatives which need to be continued and consolidated, two of which deserve particular mention: European reference networks (ERNs) and European plans.

3.7.

Since 2017, the ERNs have been intended to link up European experts on rare illnesses. These networks ensure that it is the information that moves around rather than the patients themselves, so that patients receive the best possible care without the inconvenience of being transferred from one treatment facility to another. They now cover more than 900 highly specialised healthcare facilities in more than 300 hospitals. This model could be applied to other health conditions.

3.8.

In terms of governance and working methods, the EU has five agencies together with other bodies such as the European Medical Corps and the White Helmets enabling it to react more swiftly to emergencies.

3.9.

National governments are supported by two agencies with regard to health issues. The European Centre for Disease Prevention and Control (3) assesses and monitors emerging threats of disease in order to coordinate the response to them. At the same time, the European Medicines Agency (4) manages scientific assessment of the quality, safety and effectiveness of all medicines in the EU. Other agencies carry out key additional tasks. Other agencies carry out key additional tasks.

3.10.

The current COVID-19 crisis has shown that now more than ever before, greater priority must be given to allocating resources to health under the future Multiannual Financial Framework.

3.11.

The experience gained from the crisis has shown us that further efforts are needed to ensure that health systems are ready to provide state of the art medicines and medical services, technologies and products and are prepared to cope with epidemics and other unpredictable crises and challenges.

3.12.

We need a system that can meet future demands and is crisis-resistant in order to guarantee timely access to safe, good quality and effective medicines in all circumstances, tackle shortages of and dependence on imported medicines and active pharmaceutical substances due to their being manufactured outside the EU and, most importantly, we need to be able to boost cooperation and coordination between regulatory authorities in the event of emerging threats to health.

3.13.

We need to invest on the ground, strengthening local assistance and home care in order to remain close to people through technologies for distance monitoring, telemedicine, apps or personalised medical devices stemming from the ‘4Ps’ approach to medicine (Predictive, Preventive, Personalised and Participatory). We also need to invest in boosting mandatory health insurance, initially at national level and subsequently to be coordinated more broadly at EU level (5).

4.   Giving Europe resources on a par with its ambitions

4.1.

Investments in health and the various financial programmes must be coordinated, with a cross-cutting approach. Treatment, prevention and promotion must all be taken into consideration.

4.2.

Horizon Europe also now provides for a series of missions or research partnerships with ambitious objectives seeking to find answers to urgent problems which have an impact on people's daily lives.

4.3.

One issue which will assume considerable importance in European financing policies is the digitalisation of the health sector. In this respect, Horizon Europe has again, under the health cluster, earmarked EUR 1 bn solely for the development of information and communication technology (ICT) solutions in the field of prevention, diagnosis, treatment and care.

4.4.

The Connecting Europe Facility (CEF) has allocated around EUR 80 m to the development and interoperability of e-health systems. The future Digital Europe also plans to support the creation and consolidation of a common European space for health data, to include the standardisation of types of shared data and an agreement on common indicators in which Eurostat will be actively involved.

4.5.

The EU's Emergency Support Instrument has been triggered for the health sector. The RescEU reserve, part of the EU Civil Protection Mechanism (6), focuses on rapid, direct responses to the health crisis.

4.6.

Health must be promoted as a priority in INTERREG cross-border cooperation programmes, which are managed on a delegated basis.

5.   Deploying an ambitious joint European response as part of the recovery process

5.1.

In its resolution adopted on 17 April 2020 (7), the European Parliament called for a specific budget to support national health systems during the crisis with greater investment in order to make the European health sector more resilient and help countries in difficulty. It also called for a new autonomous European health programme to be set up.

5.2.

The Committee has on several occasions given its views on European health policy (8). On 17 March 2020, the EESC and its members called for stronger solidarity and joint action at European level in order to combat the consequences of the pandemic effectively.

5.3.

Like recovery, the various measures adopted by the European institutions under EU4Health must be inclusive and involve all health stakeholders (health insurance organisations, mutual societies, etc.).

6.   Rolling out an integrated, cross-sectoral health programme

6.1.

The EESC welcomes the Commission's initiative for a coordinated and integrated response with European-level management of health crises triggered by pandemics, giving a fully European dimension to health policy, prevention and early remote diagnosis networks, the reinforcement of innovation and health research and the development of digital health technologies.

6.2.

The Committee also emphasises the need for better European coordination on targets relating to non-communicable diseases and chronic disabling conditions and draws attention to safeguarding vulnerable groups, to mental health issues and to combating loss of autonomy among older people.

6.3.

The EESC stresses the importance of the One Health approach, adopted on the understanding that generally speaking a response cannot focus on a single sector and that improving treatment is not the only solution; it is clear that public health problems must instead be tackled by means of a comprehensive, integrated approach.

6.4.

The Committee considers that coordination is fundamental and cannot be relegated to one of over 70 possible measures with the potential establishment and operation of a mechanism for cross-sectoral coordination following the One Health approach. The EESC believes that this aspect must be prioritised, given that managing a mechanism for cross-sectoral coordination is key to dealing with crises.

6.5.

The Committee believes that the proposed approach will ensure that we do not overlook the balance between human and animal health (see the role of potential animal reservoirs in communicable diseases) and ecosystems (such as focusing on the impact of sensitive waste disposal during a crisis), and that we build crisis resilience strategies around safeguarding vulnerable groups.

6.6.

The EESC is however concerned that this coordinated approach to safeguarding against and preventing serious cross-border health threats and pandemics might end up being coordinated by a range of agencies (9) with specific backgrounds, missions and remits, agencies which appear unable to coordinate automatically and efficiently in the event of mobilisation and the need for an urgent, integrated response.

6.7.

The EESC emphasises that the agencies should work together using a cross-sectoral coordination mechanism, and pool their efforts to generate proposals for the EU.

6.8.

With regard to the agencies' governance and role, steps must be taken to boost the operational capacity of the European Commission's Directorate-General for Health and Food Safety (DG SANTE), the way it coordinates its work with that of the Directorate-General for Employment, Social Affairs and Inclusion (DG EMPL) and their cross-cutting follow-up of the health and social aspects of all European policies.

6.9.

The EESC firmly believes that due account must be taken of the fact that three successive coronavirus epidemics have proven both around the world, and most recently in Europe, that shortcomings in providing immediate, integrated responses, inadequate capacity to manage information, the inability to coordinate responses, and even a lack of interest in doing so, the lack of resources and even more seriously shortcomings in sourcing and strategically managing potentially available resources have enabled epidemics to spread when they could have had a milder impact.

6.10.

The Committee emphasises that the most critical aspect of the response to COVID-19 in many countries around the globe, and at least partly in Europe as well, has been the lack of any capacity to sound the alarm and deliver an integrated response. Given the need to act swiftly, the situation has been exacerbated by the lack of legal capacity to implement transitional emergency rules without delay. We therefore need to explore the possibility of a European rapid alert mechanism.

6.11.

The EESC insists that health must be exempted from all measures involving the closing of borders. Health cannot have borders, and this principle must be enshrined in the European Treaties. In this respect, the EESC calls for measures recognising the mobility of health workers and patients.

6.12.

The Court of Auditors has on several occasions spoken out about the need to boost Europe's presence in and action on health systems to bring them closer to Europeans across borders and improve health services, particularly for the most vulnerable and economically disadvantaged people. The EESC likewise calls on the Commission to give greater visibility to the social values clearly enshrined in the Treaties, which must in actual practice become an integral part of culture and action for a European Union of health.

6.13.

The EESC endorses the position taken by the Court of Auditors which has on several occasions pointed out that European Union action on health needs to be improved, that efforts must be made to ensure cross-border convergence of health systems for the benefit of European citizens, and that health services need to be made more accessible, again particularly for the most vulnerable and economically disadvantaged people.

7.   Adapting operational, functional and strategic measures

7.1.

Increasing the total amount of human and financial resources is certainly laudable, but with an integrated approach and stronger cooperation the resources available at the time would have provided sufficient supplies and skills to contain outbreaks.

7.2.

Coordination and cooperation are therefore fundamental for coping with the demands of a health emergency and for supporting economic activity and laying the groundwork for recovery.

7.3.

The EESC considers it vital to establish an analysis, prevention and response simulation body within the ECDC which is able to provide the data needed to plan strategies and source the best available resources extremely quickly.

7.4.

Applying the ERN (10) approach to other sectors would have the advantage of establishing consortia able to recruit top-level talent in Europe on issues relevant to the crisis and to lay the groundwork for a synergy-based approach.

7.5.

However, the EESC considers that this approach does not go far enough as the real problem is who to put in charge of coordinating and finalising the work performed by these networks (or of setting up and managing networks of networks).

7.6.

European campaigns and plans must be developed, with a stronger focus on the most vulnerable. Promoting healthy lifestyles, prevention and testing, setting up integrated care and well-being pathways and combating social inequality are just some of the issues which must be tackled.

8.   Regular monitoring and an inclusive approach to establishing progress in achieving the objectives

8.1.

The EESC stresses the need to focus on checking and quality control indicators for the programme's objectives. General ‘macro’ programme indicators are crucial, but promoting and deploying European resources to deal with one or more crises requires a flexible system which, in order to meet contingencies and changing demands, must be able to continually produce ad hoc ‘micro’ indicators to respond to the constant contingencies planned.

8.2.

The Committee considers that steps must be taken to establish a pool of Member State health operators and experts in various disciplines. At least some of them must be skilled in dealing with health crises and of these, some should have experience of integrated working methods as used in European research, civil protection and military health systems.

8.3.

The EESC welcomes the Commission programme highlighting the need for a crisis oversight mechanism. In addition to the proposed measures geared towards producing supplies and technologies, the EESC flags up the need to establish a coordination, planning, monitoring and guidance system for rapid prevention and intervention.

8.4.

Whereas the Union's role in health matters is to support the Member States, in the case of training its role is a central one. The role of verifying individual bodies in the health training sector must be stepped up (the EU must play a key role with regard to teaching hospitals as they also train health workers).

8.5.

The EESC endorses balanced participation and an equal gender balance in decision making: in addition to the appropriate regulatory frameworks, adopting an approach which integrates gender issues into social and family life will contribute to an equal gender balance in decision making and political, economic and social life.

8.6.

The Committee considers that the EU should constantly monitor quality in these health sectors: this should also focus on ensuring that the Member States provide sufficient health facilities and bodies for training which meets European requirements.

8.7.

The EESC reiterates that digital solutions can promote equal access to healthcare, if the following conditions are met: — they provide uniform local and regional coverage; — they reduce the digital divide; — the entire digital architecture is interoperable; and — they comply with the general regulation on the protection of health data (11).

9.   Supporting health workers

9.1.

The EESC firmly believes that direct EU involvement in training health workers should be increased, partly in view of the fact that further reinforcing civil protection systems creates the need for a new career profile: that of expert in crisis coordination and monitoring. A person matching this profile must be present in every regional and local branch of civil protection.

9.2.

A pilot project could be envisaged to set up a European school of university-level training, organised together with European universities.

9.3.

In addition to training, the EESC recognises that the EU needs to push to establish decent working conditions for health workers, the real heroes of the crisis.

10.   Making the EU a pioneer in the field of research

10.1.

As regards the policy supporting research into medicines which might be useful during crises, it must be pointed out that part of this (particularly research into medicines already used in similar conditions) concerns medicines which are of little interest to the market as they are off patent. Independent research would therefore have to be encouraged, including on critical issues such as vaccines, partly to secure European sovereignty with regard to technology and manufacture.

10.2.

A very recent study showed that the main universities are no longer ranked as high in terms of scientific production (2015-2019), a trend that is much more marked in Europe (only one European university is ranked in the top 30), whilst businesses specialising in internet services, technology and data analysis are becoming increasingly significant in the field of research.

10.3.

The EESC considers that mechanisms are needed to identify synergies between EU4Health 2021-2027 and all other programmes and funds geared towards research and technological innovation in the field of health. These mechanisms would be able to boost innovation and the number of patents and to work alongside and foster high-level biomedical manufacturing.

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(1)  Committee of the Regions, Charter for Multilevel Governance in Europe.

(2)  EUR-Lex.

(3)  https://www.ecdc.europa.eu/en

(4)  https://www.ema.europa.eu/en

(5)  OJ C 434, 15.12.2017, p. 1.

(6)  https://what-europe-does-for-me.eu/en/portal/2/X07_26001

(7)  https://www.europarl.europa.eu/doceo/document/TA-9-2020-04-17-TOC_EN.html

(8)  Coronavirus Response Investment Initiative, EESC-2020-01536-00-01-PAC-TRA (ECO/515, ongoing); OJ C 227, 28.6.2018, p. 11; OJ C 240, 16.7.2019, p. 10; OJ C 271, 19.9.2013, p. 122; OJ C 14, 15.1.2020, p. 52; OJ C 434, 15.12.2017, p. 1; OJ C 242, 23.7.2015, p. 48; OJ C 116, 20.4.2001, p. 75; OJ C 255, 22.9.2010, p. 76; OJ C 143, 22.5.2012, p. 102; OJ C 234, 30.9.2003, p. 36; OJ C 18, 19.1.2011, p. 74; OJ C 120, 20.5.2005, p. 54; OJ C 44, 15.2.2013, p. 36; OJ C 218, 11.9.2009, p. 91; OJ C 242, 23.7.2015, p. 48; OJ C 44, 11.2.2011, p. 10; OJ C 13, 15.1.2016, p. 14; OJ C 440, 6.12.2018, p. 150; OJ C 283, 10.8.2018, p. 28; OJ C 440, 6.12.2018, p. 57.

(9)  See point 2.6.

(10)  OJ L 88, 4.4.2011, p. 45.

(11)  See footnote 5.