EUROPEAN COMMISSION

Brussels, 6.11.2020

SWD(2020) 256 final

COMMISSION STAFF WORKING DOCUMENT

Accompanying the document

Report from the Commission to the European Parliament and the Council

Implementation of the third programme of Union action in the field of health (2018)

{COM(2020) 691 final}

Table of Contents

Introduction    

JOINT ACTIONS    

1.    Joint action on reducing alcohol-related harm (RARHA)    

2.    Joint action on nutrition and physical activity (JANPA)    

3.    Joint action to support the eHealth network (JAseHN)    

4.    Strengthening cooperation to operate pharmacovigilance in Europe (SCOPE)    

PROJECTS    

1.    Tobacco cessation guidelines for high-risk groups (TOB.g)    

2.    Reference Sites Network for Prevention and Care of Frailty and Chronic Conditions in community-dwelling persons from EU countries (SUNFRAIL)    

3.    Operational knowledge to improve the early diagnosis and treatment of HIV among vulnerable groups in Europe (Euro HIV EDAT)    

4.    Statistical data and guidance document for medicinal product pricing and for the use of external reference pricing (EURIPID)    

5.    BRidging Information and Data Generation for Evidence-based Health Policy and Research (BRIDGE Health)    

6.    European Expert Paediatric Oncology Reference Network for Diagnostics and Treatment (ExPO-r-Net)    

OPERATING GRANTS    

1.    European cancer leagues cooperating for impact on cancer control    

2.    Smoke-free partnership coalition: smoking prevention in action    

3.    European network for smoking and tobacco prevention (ENSP) – united for a tobacco-free Europe    

DIRECT GRANT AGREEMENTS WITH INTERNATIONAL ORGANISATIONS    

1.    OECD health workforce: feasibility study for an international survey of health workers’ skills    

2.    OECD - economic burden and health impact of antimicrobial resistance    

CALLS FOR TENDERS    

1.    Further development and implementation of the ‘EU compass for action on mental health and wellbeing’    

2.    Study on cross-border cooperation: capitalising on existing initiatives for cooperation in cross-border regions (request for specific services No Chafea/2016/Health/22)    

3.    Provision of a market study on telemedicine (request for specific services Chafea/2016/Health/17)    

HIGHLIGHTS OF CO-FUNDED ‘CROSS-CUTTING’ AND ‘OTHER’ ACTIONS    

1.    Dissemination activities carried out in 2018    

2.    Other actions    

2.1.    Sub-delegations to Eurostat, the statistical office of the European Union    

Background information    

2.2.    What did the ERNs achieve in practice with the first year of SGA support?    

IMPLEMENTATION OF THE ANNUAL WORK PROGRAMME FOR 2018    

CALLS FOR PROPOSALS    

Expert evaluators    

Project grants    

European reference networks (mono-beneficiary grants)    

Operating grants    

JOINT ACTIONS    

DIRECT GRANT AGREEMENTS AND PRESIDENCY CONFERENCES    

Other direct grants    

Presidency conferences    

PRIZES – EU health award for NGOs    

PROCUREMENTS (SERVICE CONTRACTS)    

OTHER ACTIONS    

DETAILED OVERVIEW OF THE REPORTING YEAR 2018    

Funding per thematic priority and financial instrument    

Introduction

This Commission staff working document (SWD) accompanies the report on the implementation of the third health programme (‘the programme’) in 2018. The report provides an overview of all the actions funded under the annual work programme for 2018 (2018 AWP). The Commission SWD showcases the key results achieved in 2018 by actions co-funded under the programme in previous years, divided up by financing mechanism (grants and service contracts). These actions fall under the four objectives of the second and third health programmes.

The SWD also provides the full figures and statistics of the programme’s 2018 operational budget, including the lists of all co-funded initiatives and contracts by programme objective, type of action and type of beneficiary organisation.

Several actions co-funded under the second health programme came to an end in late 2017 and in 2018, and achieved important results that were taken up at national or EU level. Several examples are described in the document.

More information about these actions and their outputs can be found in the health programme database 1 managed by the Consumers, Health, Agriculture and Food Executive Agency (Chafea) 2 .

JOINT ACTIONS

Objective 1. Promote health, prevent diseases and foster supportive environments for healthy lifestyles

1.Joint action on reducing alcohol-related harm (RARHA) 

More information is available on the joint action (JA) website 3 and in Chafea’s Health Programme database 4 .

Background information

The RARHA JA was funded under the 2013 annual work programme to support EU countries in working on shared priorities in line with the EU alcohol strategy.

The JA was coordinated by Portugal, specifically the Ministry of Health’s department for combating addictions and dependent behaviours (Serviço de Intervenção nos Comportamentos Aditivos e nas Dependências. It involved 32 associated partners and 29 collaborating partners from all 28 EU Member States plus Iceland, Norway and Switzerland. The EU contribution was EUR 1 533 383.

Brief description of activities

The RARHA JA contributed to capacity building in alcohol prevention among EU countries and in the wider public health community through three core activities:

·work package (WP) 4 focused on strengthening capacity in alcohol survey methodology and providing a common instrument for monitoring progress in reducing alcohol-related harm;

·WP5 worked to highlight the scientific basis and provide information on the practical implications of drinking guidelines as a public health measure, to build consensus on key messages about harmful drinking to the general public and health professionals;

·WP6 focused on improving access to cost-efficient, transferable interventions that proved effective both in influencing attitudes or behaviour and in terms of cost.

Specific results

As regards monitoring of drinking patterns and alcohol-related harm, the action:

a)Provided a baseline assessment and suggestions for comparative monitoring of alcohol epidemiology 5 (HARMES – harmonising alcohol-related measures in European surveys), including drinking levels and patterns and alcohol-related harm across the EU. Data collected from 24 surveys completed in a 5-year period (2008-2012) in 17 countries were pooled in a shared database with over 300 000 records.

b)Designed and implemented a survey instrument (SEAS – standardised European alcohol survey) in 20 European countries representing all European regions. The survey, carried out on random samples of the general public aged 18-64, generated an integrated European database comprising over 32 000 interviews. It covered alcohol consumption, risky single-occasion drinking, the context in which people drink, harm from others’ drinking, attitudes and opinions on alcohol policy, and unrecorded alcohol supply.

The action resulted in a summary report, ‘Good practice principles in the use of drinking guidelines’. It also identified examples of readily transferable good practice, i.e. practice that is adaptable to other contexts and has been shown to be efficient and effective in influencing attitudes to and patterns of alcohol consumption. The examples of good practice in prevention programmes (public awareness, school-based interventions, and early interventions) were compiled to create a toolkit for evidence-based good practices 6 , which includes guidance on criteria of good practice approaches to reducing alcohol-related harm.

2.Joint action on nutrition and physical activity (JANPA) 

More information is available on the JA website 7 and in Chafea’s Health Programme database 8 .

Background information

Within the general context of the 2014-2020 EU action plan on childhood obesity, JANPA was designed to help stop the rise in overweight and obesity in children and adolescents by 2020. 24 EU countries participated, either as partners or as collaborating stakeholders, including the World Health Organization’s Regional Office for Europe and the Commission’s Joint Research Centre (JRC). The EU contribution was EUR 1 200 000.

Brief description of activities

JANPA comprised four technical work packages, each involving 7-14 countries, and focused on the following activities:

·the use of economic evaluations of the cost of child obesity, to spur public action;

·the sharing of specific tools to promote improvement of the nutritional quality of foods and of consumer information at national level;

·the identification and sharing of integrated actions at local or national level for diet and physical activity, prioritising children, families and professionals as the main participants in the actions, and pre-school and school settings as the main place to take action.

Specific results

JANPA mapped the sources and types of food information presentation currently available to consumers, analysed the use of food information in nutrition policy and presented the use and understanding of food information by families. The work produced by JANPA in this area provided useful information to the European Commission for its work supporting food reformulation, and best practices identified in this area were also transferred to many interested EU countries through other actions.

The JA produced a set of good practice criteria for childhood obesity prevention in kindergartens and schools, with particular attention paid to the issues of sustainability and inequalities in health. The criteria were compiled in a web-based toolbox for programme planners and decision-makers, supporting them in their efforts to design and implement effective interventions.

Objective 3. Contribute to innovative, efficient and sustainable health systems

3.Joint action to support the eHealth network (JAseHN)

For more information, see the JA website 9 and Chafea’s Health Programme database 10 .

Background information

The JA was the main preparatory body for the eHealth network, established by EU legislation on cross-border healthcare 11 . More specifically, it was tasked with developing political recommendations and instruments supporting the electronic exchange of health data in four priority areas, as specified in the eHealth network's multiannual work plan for 2015-2018: (i) interoperability and standardisation; (ii) monitoring and assessment of implementation; (iii) exchange of knowledge; and (iv) global cooperation and positioning.

The JA brought together ministries, national competent authorities or executive agencies, and other public bodies from 26 EU countries, the UK and Norway. The EU contribution was EUR 2 400 000.

Brief description of activities

JAseHN had already updated existing guidelines on the use of which form the health data exchange under the eHealth Digital Service Infrastructure (eHDSI). These are the patient summary for unscheduled care, ePrescription and eDispensations.

JAseHN also cooperated closely with the bodies implementing the eHDSI. It facilitated the application process for funding from the Connecting Europe Facility (CEF) Telecom programme for 21 Member States. It also helped the EU countries prepare for participation in CEF calls by providing frameworks and policy documents linked with the preparation, deployment and operation of the national contact point for eHealth.

JAseHN also facilitated a legal agreement between national authorities or national organisations responsible for national contact points for eHealth that serves as the basis for the facilitation of cross-border exchange of personal health data.

Specific results

JAseHN delivered 37 policy documents to the eHealth network, most of them supporting the establishment of the eHDSI launched in the beginning of 2017. This effort has made the cross-border exchange of information operational through three key documents: patient summaries, ePrescriptions and eDispensations.

What this means in practice is that each patient’s essential health data can be accessed by health professionals anywhere in the EU. This makes it easier for patients to travel within the EU, especially if they need to access emergency care. Patients moving to another EU country can expect to receive similar medication to that in their home country, thanks to ePrescriptions and eDispensations: the first enables a prescription to be sent electronically to a pharmacy, while the second refers to the electronic retrieval of a prescription and the provision of the prescribed medicine to the patient.

JAseHN has successfully fulfilled its purpose, i.e. providing the support services needed to set up an operational framework for exchanging cross-border health data across the EU, contributing to ongoing positive and dynamic development, and enabling the eHealth network to focus on future implementation and sustainability challenges.

Objective 4 - Facilitate access to better and safer healthcare for Union citizens

4.Strengthening cooperation to operate pharmacovigilance in Europe (SCOPE)

More information is available on Chafea’s Health Programme database 12 and in a peer-reviewed article that appeared on the website of the US National Center for Biotechnology Information (NCBI) 13 .

Background information

The JA for SCOPE brought together national medicines regulators from 24 EU countries, Norway, Iceland and the UK to develop guidance and training in key aspects of pharmacovigilance, and tools and templates to support best practice. The EU contribution was EUR 3 300 000.

The JA supported pharmacovigilance operations in the European network, minimised duplication of work and made the best use of work sharing and resources. One of the project’s key aims was to help national competent authorities with fewer resources to develop skills and capacity in pharmacovigilance, and thereby help safeguard public health both at country level and in the EU as a whole.

Brief description of activities

The JA collected information and expertise on how national regulators run their national pharmacovigilance systems to meet the requirements of the pharmacovigilance legislation that took effect in June 2012. The SCOPE JA evaluated current practices and developed tools to further improve skills and capability within the wider pharmacovigilance network, including through the involvement and contributions of stakeholders such as patients and the pharmaceutical industry.

Divided into five core work streams, SCOPE delivered best practice guidance, tools and templates and training on key aspects of pharmacovigilance in the following key areas: (i) collecting information on suspected adverse drug reactions; (ii) identifying and managing safety issues (signals); (iii) communicating risk; (iv) assessing risk minimisation measures; (v) effective quality management systems.

The deliverables provide practical guidance and support to the European national competent authorities, helping them strengthen their national systems.

Specific results

The work on collecting information on adverse drug reactions focused on national schemes for spontaneous reporting by healthcare providers and patients and provided national competent authorities with a better understanding of available systems and practices for collecting adverse drug reactions. An EU-wide social media campaign, launched to raise awareness of national systems for reporting spontaneous adverse drug reactions, reached more than 2.5 million people. The work on signal management improved understanding of this area within the EU network of national competent authorities, developed best practices in signal management and provided training to national medicines regulators.

The work on risk communication, which focused on mapping current practices in the EU network, improved understanding of communication channels, tools used and the effectiveness of the various strategies and methods. The work on quality management systems developed tools to support quality standards in pharmacovigilance systems and to increase existing knowledge through a training programme.

The work on lifecycle pharmacovigilance explored existing standards for pharmacovigilance assessments and examined the availability and use of alternative data sources (other than spontaneous reports) for pharmacovigilance assessments in various European national competent authorities.

The SCOPE outputs have been extremely useful to other stakeholders involved in pharmacovigilance activities, including the pharmaceutical industry, healthcare professionals, patient and consumer organisations, and academia. The SCOPE training materials and outputs are publicly available for interested parties to use and implement according to their needs. In addition, a sustainable solution has been found for using and, as necessary, updating the deliverables: the learning materials are transferred to the EU Network Training Centre, a joint training initiative endorsed by the heads of medicines agencies and the European Medicines Agency.

PROJECTS

Objective 1. Promote health, prevent diseases and foster supportive environments for healthy lifestyles

1.Tobacco cessation guidelines for high-risk groups (TOB.g)

More information is available on the project website 14 and in Chafea’s Health Programme database 15 .

Background information

Tobacco use is one of the leading causes of premature death and disability in Europe. It also exacts a heavy economic toll on the European healthcare system, with direct healthcare costs alone estimated at EUR  1 900 billion. Certain subgroups or populations are especially vulnerable and more sensitive when exposed to tobacco use. The TOB.g project developed and implemented an innovative and cost-effective approach to preventing chronic diseases associated with tobacco dependence and also to helping health professionals provide guidance and target prevention to high-risk populations. The project brought together partners from four EU countries and received an EU contribution of EUR 541 890.80.

Brief description of activities

The action targeted five high-risk groups. These were cardiovascular disease patients, chronic obstructive pulmonary disease patients, adults suffering from type 2 diabetes, adolescents and pregnant women. Given the relative shortage of tobacco cessation specialists, the action provided training to primary care physicians to help make quality advice on tobacco cessation and support more accessible.

The action established five scientific groups of health professionals with different types of expertise. Each group performed a situation analysis and assessment of the high-risk groups to develop bespoke, targeted tobacco cessation guidelines.

Drawing on the evidence-based tobacco cessation good practices of the European network for smoking and tobacco prevention (ENSP), the guidelines were validated before the implementation of the pilot got under way. Pilot implementation of the TOB.g project guidelines in turn allowed their effectiveness and usefulness to be assessed.

Specific results

The TOB.g project enabled health professionals to improve their knowledge of tobacco-related health risks. Moreover, better knowledge enables improved prevention of chronic diseases by adapting smoking cessation tools that are appropriately assessed and tailored to the specific needs of high-risk groups.

The e-learning course and training sessions developed through the project are easily transferable to everyday clinical practice and techniques, thus improving access to specialised support and expert advice for high-risk groups. Finally, the approach of targeting primary care physicians is consistent with recognising the important role that primary care can play in disease prevention and control.

2.Reference Sites Network for Prevention and Care of Frailty and Chronic Conditions in community-dwelling persons from EU countries (SUNFRAIL) 

More information is available on the project website 16 and in Chafea’s Health Programme database 17 .

Background information (policy priority, partnership and budget)

The project’s overall objective was to promote independence for ageing elderly people, encouraging autonomy, empowerment and commitment to the community. SUNFRAIL was also designed to help decision-makers and health service providers adopt effective policies, strategies and care pathways, bridging the gap between people’s needs and the services on offer.

The SUNFRAIL project designed an integrated model to improve the identification, prevention and management of frailty and the care of multimorbidity in people aged over 65 living in communities in EU countries.

The consortium, coordinated by the Emilia-Romagna Region (Italy), brought together 11 partners of the European Innovation Partnership on Active and Healthy Ageing from five EU countries and the UK. The EU funding was EUR 886 193.

Brief description of activities

The project mapped existing practices in the areas of risk assessment and the identification of frailty, based on several analytical tools. It developed a ‘SUNFRAIL model of frailty and multimorbidity’. This model is an easy-to-use tool with nine questions designed to identify early onset of frailty and multimorbidity in three domains: biological (physical), psychological (cognitive and psychological), and social.

The tool was tested on adults over 65 in 11 regions across Europe. The main outcomes were reduced hospital and emergency admissions for ambulatory care for people with sensitive conditions.

Specific results

The main results confirmed that the tool was suitable for identifying the early onset of frailty and related risks in elderly people (over 65) with multimorbidity, especially in primary care and community settings. The tool appears particularly well suited to identifying frailty risks in a population without clear signs of disability, or that is not identified as frail by the health services of the regions taking part. The intervention was therefore tailored to guiding the target population of elderly people to appropriate preventive care pathways, thus reducing visits to hospital services.

Finally, the project consortium also tested the adaptability, usability and adoption of the ‘SUNFRAIL tool’ in the countries where the model was implemented, to verify its potential for reproducibility in other EU countries. The tools showed a high level of transferability, especially when linked to other risk assessment and risk stratification strategies.

Objective 2. Protect Union citizens from serious cross-border health threats

3.Operational knowledge to improve the early diagnosis and treatment of HIV among vulnerable groups in Europe (Euro HIV EDAT) 

More information is available on the project website 18 and in Chafea’s Health Programme database 19 .

Background information

The number of new HIV diagnoses continues to rise in many European countries, with the epidemic largely concentrated in certain sub-populations, namely MSM (men who have sex with men), who account for the highest proportion of diagnoses, and migrants. Recent data estimates that in EU countries, 30% of those infected are unaware of their infection and that many patients diagnosed with HIV start treatment over a year after diagnosis.

The populations most at risk of becoming HIV infected are also difficult to reach in healthcare settings. Community-based voluntary counselling and testing services (CBVCTs) have therefore been identified as key to increasing early HIV diagnosis and treatment, provided that they are tailored specifically to the target population and local context.

The action brought together 14 organisations from 9 EU countries, including both non-governmental organisations (NGOs) and government agencies. EU funding was EUR 1 179 927.

Brief description of activities

The project’s overall aims were to generate operational knowledge to improve understanding of the role and impact of CBVCTs across Europe, explore the use of innovative strategies based on new technologies, and increase early HIV/STI diagnosis and treatment among the groups worst affected.

The project sought to generate harmonised monitoring and evaluation data from CBVTCs across Europe, using the indicators and data collection instruments developed by the HIV-COBATEST 20 project, and to explore the acceptability, feasibility and effectiveness of innovative strategies. Such strategies included point-of-care technologies for HIV and STI diagnosis, HIV self-testing and web-based outreach and counselling approaches.

An internet-based toolkit was developed to support recently established NGOs and/or those wanting to start a CBVCT service/checkpoint for MSM ( http://www.msm-checkpoints.eu/ ). It includes the main Euro HIV EDAT project products. The action also:

·Monitored and evaluated the community-based voluntary HIV counselling and testing activities of the 41 services/networks. It also tested data from 168 409 clients tested for HIV in these CBVCT services/networks.

·Updated the document ‘A guide to do it better in our CBVCT centres’ and developed a new tool for self-evaluation, to identify barriers to and facilitators for the implementation of good practices in CBVCT.

·Established a cohort of seronegative patients for HIV MSM (COBA-Cohort). This cohort collects common data among 4 145 HIV-negative MSM attending 17 CBVCT services in 6 countries.

·Performed a qualitative and a quantitative study to describe different mechanisms of linkage to care used by CBVCTs and their acceptability, feasibility and effectiveness among managers and clients.

·Conducted a qualitative and a quantitative study describing the use of testing and care services for HIV/STI by migrant populations, and barriers to using them among such populations, in the participating countries. The ‘Guide to best practices to improve earlier testing and care among migrant populations in Europe’ was published on the basis of these results.

·Carried out two studies to evaluate the acceptability and foreseeable impact of innovative HIV testing strategies among potential users and stakeholders: (i) an online survey among MSM recruited online and (ii) an online study among key stakeholders involved in the diagnostic process.

·Implemented a pilot intervention to assess the acceptability and feasibility of an outreach intervention for HIV testing among MSM and migrants and online communication of test results in six EU countries (Belgium, Spain, Portugal, Denmark, Romania and Slovenia). A separate website was developed to make test results available ( www.swab2know.eu ).

Specific results

Guidelines and manuals were developed for MSM and migrants, two of the groups worst affected by the HIV/STI epidemics in Europe.

The project helped improve CBVCT services and inform policy-makers, enabling them to contextualise these interventions better within their national HIV prevention programmes. Crucial data was provided to improve the design of preventive interventions and thereby boost test uptake among MSM and migrants.

The project generated information on the acceptability, feasibility and effectiveness of innovative interventions as self-testing and outreach interventions and on the use of new technologies to provide results and counselling.

The project thus contributed to better-informed policymaking, reduced transmission of HIV and other STIs, and improved clinical outputs of HIV and STIs patients across Europe.

Objective 3. Contribute to innovative, efficient and sustainable health systems

4.Statistical data and guidance document for medicinal product pricing and for the use of external reference pricing (EURIPID)

More information is available on the project website 21 and in Chafea’s Health Programme database 22 .

Background information

EURIPID cooperation is based on voluntary and strictly non-profit cooperation between national competent authorities for the pricing and reimbursement of medicinal products, most of them in the EU. EURIPID is in the process of building up and maintaining a database of information on national prices and regulations on the pricing of medicinal products in a standardised format. Based on cooperation that started in 2010 between the Hungarian National Institute of Health Insurance Fund Management and the Austrian Public Health Institute, the project currently covers data from more than 26 European countries. It is managed by four Member States and receives EU co-funding of EUR 299 999.70.

Brief description of activities

The EURIPID database contains data on the official prices of publicly reimbursed, mainly outpatient medicinal products, as published by national authorities in line with the Transparency Directive (89/105/EC). The action encompasses regular maintenance tasks, developing a new database interface and predefined queries, an improved search function, user-reported errors, a new country background information system and several other functionalities which boost user experience and make database management easier.

The data content of the EURIPID database was also extended by making available information on sales volumes and on the existence of managed entry agreements. This enabled authorities to obtain price information in a more efficient way, reducing the risk of making decisions based on incorrect or incomplete data.

Specific results

Through cooperation with all relevant stakeholders, EURIPID has developed a technical guidance document on a coordinated approach by national authorities to the use of ‘external reference pricing’ (ERP), which uses medicinal product prices from other countries to obtain a ceiling price. Thiso avoids/mitigates potential negative impact on patients’ access to medicines. The document is available to national authorities and, in part, to the general public.

This grant was followed by a new grant in early 2019 that is designed to (i) further expand the information provided on the existence of managed entry agreements, prices and sales volumes of reimbursable medicinal products, (ii) improve services to users and the general public and (iii) strengthen cooperation by creating a platform for dialogue with stakeholders. Thanks to this cooperation, the recommendations in the technical guidance document on ERP will be more widely shared.

5.BRidging Information and Data Generation for Evidence-based Health Policy and Research (BRIDGE Health) 

More information is available on the project website 23 and in Chafea’s Health Programme database 24 .

Background information

Health policy and decision-making must be based on robust evidence in the form of high-quality, timely data on population health and health systems and the outcomes of thorough research.

The BRIDGE Health project was co-funded by the EU to provide a baseline for such data and create European health information and data generation networks covering major EU health policy areas. The partnership brought together 31 partners from 14 EU countries, Norway and the UK, receiving EU co-funding of EUR 3 473 044.23.

Brief description of activities

BRIDGE Health developed a blueprint to integrate health care information systems with the aim of providing a European research infrastructure consortium on health information.

The project addressed the EU countries’ health information needs. More specifically, helped the participating countries ensure that data on health information needs (i) is available at EU, national and subnational level, including information on social inequalities and vulnerable groups, (ii) are structured and comparable, (iii) include information about key determinants of ill health, (iv) include information on healthcare systems and (v) build on information derived from best practice.

Specific results

The project delivered a feasibility analysis for a sustainable European health information structure. It included scope, tasks, activities and governance structure, and the possible strengths and limitations of a set of possible structures including a European research infrastructure consortium on health information.

Objective 4. Facilitate access to better and safer healthcare for Union citizens

6.European Expert Paediatric Oncology Reference Network for Diagnostics and Treatment (ExPO-r-Net) 

More information is available on the project website 25 and in Chafea’s Health Programme database 26 .

Background information

Childhood cancer is rare, affecting one in approximately 500 children, with multiple subtypes defined clinically and by biology that are relevant for specialist diagnostics and treatment. There is a clear need for certified and recognised European diagnostic and complex treatment reference networks. Paediatric oncology European clinical trial groups have been building cancer-specific cross-border networks in recent decades. With ExPO-r-Net, a focused initiative was started to connect existing networks better and to improve the visibility of hospitals with high-level expertise on special diagnostic needs and/or treatment interventions.

The project brought together 18 partners from 8 Member States and the UK, and received EU funding of EUR 1 499 343.

Brief description of activities

ExPO-r-Net tackled inequalities in childhood cancer survival rates and healthcare capabilities in different Member States, and took the first steps towards improved access to high-quality healthcare for children with cancer whose conditions require specialised resources or expertise that are not widely available due to low case volumes and lack of local resources.

ExPO-r-Net initiated cooperation between healthcare systems based on the existing networks of paediatric oncology European clinical trial groups. The aim was to achieve cost-effective, high-quality cross-border healthcare. Further, ExPO-r-Net identified target patient groups at risk who would benefit from access to concentrated expertise and resources.

The ExPO-r-Net project built a pilot paediatric oncology ERN providing the essential conditions for cross-border healthcare, the aim being to enable children and young people with cancer to receive care in another Member State. An important step was identification and quality control actions targeting healthcare providers in countries with low expenditure rates on healthcare, where childhood cancer outcomes are 10-20% below the western European average.

Because of the potential burden on families seeking cross-border healthcare – i.e. leaving their supportive family and language environment and entering social isolation for treatments that may last many months – ExPO-r-Net sought mechanisms to facilitate, whenever possible, the movement of information and knowledge rather than patients.

Specific results

ExPO-r-Net fostered access to expedited expert diagnosis, described and identified childhood cancer patients in need of high-level treatment interventions and specialised care, identified reference centres across Europe for the paediatric oncology ERN (ERN-PaedCan), and initiated, coordinated and encouraged the establishment of international and national tumour boards at coordination hubs. A routing contact point was established to guide requests to the right forum.

An e-health-based interoperability strategy was developed with e-health based IT tools, making it easier and safer to interact. It launched an identification and self-evaluation process and gathered the information in a manual defining terminology and definitions for use in future certification processes describing quality criteria.

ExPO-r-Net also encouraged measures to summarise treatments in a standard way in a survivor’s passport model for every European childhood cancer survivor. It also advised on risk-based appropriate surveillance. The late effect advisory board platform within the PanCare community enabled the creation of a central point of reference to help healthcare professionals understand and treat late cancer treatment-related effects better.

OPERATING GRANTS

The 17 NGOs that signed a framework partnership agreement (FPA) in 2017 27 were asked to submit their proposals for a specific grant agreement (SGA) to cover their 2018 recurrent operational expenses.

The FPAs and their SGAs helped achieve three of the third health programme’s objectives. 13 NGOs tackled objective 1, ‘Promote health, prevent diseases and foster supportive environments for healthy lifestyles’, 1 worked on objective 3, ‘Contribute to innovative, efficient and sustainable health systems’, and 3 focused on objective 4, ‘Facilitate access to better and safer healthcare for Union citizens’.

Table 1: List of applicant organisations awarded an FPA 2017-2021 and subsequent SGAs

Throughout 2018, in line with their SGAs, the organisations achieved their objectives, did valuable work for their stakeholders and supported Commission health policy initiatives in their areas of activity.

Below we present the work and outcomes of three organisations active in cancer prevention: the Association of European cancer leagues (ECL), the smoke-free partnership (SFP) coalition, and the ENSP. All three are examples of EU umbrella networks supported by the EU health programme.

1.    European cancer leagues cooperating for impact on cancer control 

More information about the association of European cancer leagues is available on the organisation’s website 28  and in Chafea’s Health Programme database 29 .

Background information

Cancer is a leading cause of death worldwide, accounting for 8.2 million deaths (22% of all deaths from non-communicable diseases) in 2012. In that year, there were 3.45 million new cases of cancer (excluding non-melanoma skin cancer) and 1.75 million deaths from cancer in Europe 30 . In the EU, new cases of cancer were estimated at 1.4 million in males and 1.2 million in females, and around 707 000 men and 555 000 women died of cancer in the same year.

The association of ECL provides a unique platform, being the only organisation whose raison d’être is to bring together national and regional cancer leagues at pan-European level in efforts to make Europe cancer-free. It provides strategic added value by sharing good practice and providing input into EU policy development and implementation, through knowledge supplied by cancer leagues with first-hand practical experience.

Under the 2018 SGA, the beneficiary received EU co-funding of EUR 302 895.

Brief description of activities 

The overall objectives of the ECL’s SGA were to:

·monitor EU cancer prevention, as well as EU legislation and policy action;

·continue working towards a tobacco-free Europe;

·explore patient issues among the member leagues in areas in which the ECL can make recommendations for use by leagues and at EU level, through the patient support working group (PSWG);

·advocate for equal access to medicines for cancer patients, through the ECL task force on access to medicines;

·communicate and promote the implementation of the European code against cancer in cooperation with member leagues.

Action taken by the ECL in 2018 covers the whole spectrum of cancer control, targeting primary and secondary prevention by promoting the European code against cancer (ECAC) and tobacco control advocacy. ECL’s sustained long-term focus on the ECAC has enabled more cancer leagues to develop their activities to promote the ECAC by sharing knowledge and experience with peers. It also conducted the first systematic evaluation of the ECAC’s impact, over 30 years after its initial publication.

ECL action plan methods include: (i) holding workshops and round-table meetings; (ii) online communication, including social media; and (iii) surveys and study visits to enable cancer leagues to learn from their peers.

The ECL coordination team supported cooperation with nominated representatives of cancer societies on prevention and tobacco control issues, and participation in EU fora and platforms such as the EU diet and physical activity platform and the European Commission initiative on breast cancer.

Specific results

The ECL organised a policy dialogue during the European week against cancer; stepped up action on cancer screening by publishing a layman’s version of the recent EU cancer screening report and developed training for cancer leagues in this area.

The ECL promoted implementation of the ECAC by networking and by enhancing the role played by youth ambassadors in these efforts. The ECL’s PSWG and task force on access to medicines have produced patient support guidelines.

The ECL continued to support EU policy through the ongoing secretariat function of the European Parliament’s successful ‘MEPs against cancer’ group. There was increased demand for the ECL to organise events, both at the request of MEPs themselves and of other umbrella organisations.

The ECL’s SGA delivered the following main outputs:

-a guide for patients on how they can improve communication and obtain all the information they need when consulting healthcare professionals;

-a guide for European cancer societies on how to develop and manage volunteers to provide patient support;

-a presentation for employers on how to handle cancer at the workplace;

-the sharing of best practice from various schemes in France and Belgium, to avoid discrimination against cancer survivors;

-a position paper stating cancer leagues’ priorities on European cooperation on health technology assessment (HTA);

-a toolkit for cancer societies on HTA;

-the publication of an article on pricing of CAR T-cell therapies;

-a White Paper on tackling challenges in access to medicines.

Several workshops and visits were organised to promote the ECAC, with more than 80% of participants later reporting that they were making active use in their daily work of what they had learned through these events.

2.Smoke-free partnership coalition: smoking prevention in action 

For more information about the work of the SFP coalition 31 , see the organisation’s website and Chafea’s Health Programme database 32 .

Background information

The SFP coalition’s overarching goal is to prevent cancer and chronic diseases through activities at EU and national level to support the prevention of smoking, focusing particularly on young people and health in all policies.

To achieve its mission, the SFP mobilises stakeholders and decision-makers to make tobacco control a political priority in Europe and advocates for evidence-based tobacco control policies. The SFP engages health organisations, researchers and international networks to strengthen the global response to tobacco and support the implementation of the WHO framework convention on tobacco control (FCTC) in Europe. Under the 2018 SGA, the beneficiary received EU co-funding of EUR 419 906.

Brief description of activities

As an advocacy organisation, the SFP used a variety of appropriate methods to convey its key message. These included factsheets, myth-busting documents, briefings, position papers, events and conferences, reports, website updates, joint coalition letters, press releases and statements, various toolkits, newsletters, presentations at Europe-wide and national conferences, Facebook status updates and Twitter feeds.

The SFP also worked to build capacity within civil society and to help coalition members prepare for, coordinate and respond collectively to the possible revision of the Tobacco Tax Directive, 2011/64/EC. It raised awareness among policy-makers and civil society of Article 20 (tobacco research policies) of the FCTC.

The coalition also continued to raise awareness and support the ratification of the international protocol to eliminate illicit trade in tobacco products. It strongly supported the adoption of the technical standards underpinning the tracking and tracing system for tobacco products in the EU, in line with the relevant implementing and delegated acts 33 . Finally, SFP activities also targeted Article 5.3 of the FCTC regarding the protection of public policy from tobacco industry interference.

Specific results

The SFP coalition stepped up its cooperation and boosted its membership to the current total of 49 partners across Europe, broadening its scope for actions such as influencing tobacco control policies, reducing illicit trade, increasing financial resources for tobacco control research, and increasing the overall minimum excise duties on tobacco 34 .

Two major events were held in 2018: one on tobacco taxation and the illicit trade in tobacco products, which took place in Sofia under Bulgaria’s EU Presidency, and the other a meeting marking World No Tobacco Day in the European Parliament.

The SFP participated in the eighth session of the conference of the parties (COP8) and at the meeting of the parties (MOP1) of the illicit trade protocol in October 2018, ensuring regional coordination communication with the global team and its priorities, and successfully pursuing its advocacy of civil society objectives. The coalition also strongly supported the first-ever global strategy to accelerate tobacco control and the roadmap for accelerated progress on tobacco control towards the achievement of sustainable development goal target 3a.

In addition, SFP coalition members continued to share ideas and information, coordinate their efforts and engage in collective advocacy on shared objectives and campaigns, thereby advancing tobacco control policies at both EU and international level. The coalition achieved all this as a well-established, professional and well-respected network for the coordination of advocacy.

3.European network for smoking and tobacco prevention (ENSP) – united for a tobacco-free Europe 

For more information about the ENSP’s work, see its website 35 and Chafea’s Health Programme database 36 .

Background information

Based on its secretariat’s increased capacity for action, the ENSP made it a key task under the operating grant to provide local help to its network members on implementation of EU legislation on tobacco and related products 37 at national level.

It also focused on stepping up its role as a source of scientific evidence and academic research for its members, with a view to having a real impact on tobacco use in Europe. Under the 2018 SGA, it received EU co-funding of EUR 393 648.

Brief description of activities

The ENSP’s main activities are:

-working with local, regional and national players to support the implementation of the FCTC and the transposition of the EU Tobacco Products Directive into national law within the EU;

-strengthening the network, by increasing the number of national coalitions and their pro-activeness, and by promoting links between members;

-becoming involved in Europe-wide projects;

-improving internal and external communication, sharing information effectively, and building the capacity of all members and stakeholders working on tobacco control in Europe;

-building the organisation’s capacity and capability by consolidating the secretariat team, increasing the number of members, and reaching out to new sectors.

Specific results

As a bridge and information platform between EU institutions and national members, the ENSP uses a mix of tools to disseminate, and keep the network up-to-date with, the latest developments in tobacco control issues. These include communication resources, presentations, information dissemination, meetings, events and write-ups.

In 2018 the ENSP:

(I)organised five major events;

(II)maintained its updated website;

(III)produced a monthly newsletter and increased frequency of publication;

(IV)strengthened the position of its official scientific journal, ‘Tobacco Prevention and Cessation’; and

(V)was very active on social media.

It also conducted two expert support visits to France and Georgia, and took the lead on national advocacy campaigns.

Through its new communication strategy, the ENSP produced a range of resources to boost recognition and awareness of the organisation among both members and wider stakeholders. It fundamentally strengthened its role as a capacity builder and confirmed its position in the research arena by creating a new peer-reviewed journal and setting up a network of universities involved in tobacco control.

DIRECT GRANT AGREEMENTS WITH INTERNATIONAL ORGANISATIONS

1.OECD health workforce: feasibility study for an international survey of health workers’ skills 

More information about the health workforce report is available on the OECD’s website 38 .

Background information

The direct grant agreement explored the feasibility of carrying out a sector-specific survey on the skills of health professionals. It received EU co-funding of EUR 150 000.

The study built on the findings of a previous OECD action, ‘Overview of education and training programmes for health professionals in the EU’, which included an analysis of changes in education and training capacities in the EU and other OECD countries and identified a significant skills mismatch among doctors and nurses in the health sector.

Brief description of activities

The OECD undertook extensive consultations with key stakeholders and experts to identify the priority policy questions and skill requirements for different categories of health professionals. It also reviewed the existing data sources, including international surveys and profession-specific surveys, identified the priority skills shared across all categories of health professionals and compared the various survey instruments and analytical approaches used in previous skills assessment surveys in the health sector.

Based on these reviews, the OECD proposed a general competency framework and a set of transversal skills, including possible content areas (types of services, professional categories, domains of competence) and instruments (e.g. direct and indirect assessment tools) to be included in a survey of health workforce skills, and discussed various options for its implementation in terms of design and testing.

Finally, it proposed the next steps for taking the findings of the feasibility study towards implementation at national and international levels.

Specific results

The health workforce study concluded that healthcare professionals need to apply adaptive problem-solving skills to respond to complex and non-routine patient care issues, while working in complex, multi-disciplinary and frequently stressful occupational environments. In the coming years, countries will need resilient and flexible health workers who are armed not only with technical and clinical skills, but also with cognitive skills, self-awareness and social skills that will enable them to monitor and assess the situation, make decisions, take a leadership role, and communicate and coordinate their actions within a team in order to achieve high levels of patient safety and efficiency and ensure their own safety and job satisfaction. The feasibility study was received with great interest among OECD member states during the OECD health committee meeting in December 2017, and a number of countries indicated their intention to adopt a number of its recommendations in their health workforce surveys.

Dissemination of the study at policy-relevant debates and events and through health professional associations, regulatory bodies and patient groups helps shape policymaking in the areas of skills assessment and development of relevant education, organisation and regulatory policies and reforms.

2.OECD - economic burden and health impact of antimicrobial resistance 

For more information about the economics of antimicrobial resistance (AMR), see the OECD’s website 39 .

Background information

The direct agreement received EU funding of EUR 340 000 to prevent AMR and control healthcare-associated infections. This action supported the implementation of the EU strategy to combat AMR, focusing on two objectives: the development of a model to analyse the economic and health impact of antimicrobial resistance, and an analysis of the effectiveness and efficiency of potential prevention and control measures in the human sector.

Brief description of activities

The main activities carried out with the help of this grant included review and analysis of the available econometric models evaluating the economic implications of AMR. This work made it possible to (i) identify the pros and cons of different approaches, (ii) contribute to the identification of underlying drivers of AMR and (iii) design the model.

The work also included:

-reviewing and quantifying the related epidemiological inputs (e.g. incidence of AMR) and cost drivers (e.g. longer hospitalisation, use of more costly drugs/medical tests, increased mortality, longer absenteeism from work) underlying the AMR burden;

-identifying key interventions to tackle the burden that AMR places on humans (i.e. preventing new AMR infections through appropriate use of antibiotics and limiting the spread of existing AMR infections), extracting the evidence to model such interventions, and creating a taxonomy of interventions;

-developing economic and epidemiological model(s) replicating the burden of AMR (including the consequences of routine use of antibiotics in modern healthcare) and calculating the effectiveness and efficiency of actions to tackle AMR in the human sector;

-evaluating the effectiveness and cost-effectiveness of selected interventions to tackle AMR by using the economic model developed.

Specific results

The key findings support three main packages of interventions that EU countries can implement to reduce the burden of AMR, as follows:

-The first package addresses the hospital setting (including improved hand hygiene, stewardship programmes and enhanced environmental hygiene in healthcare settings).

-The second package consists of community-level actions (including delayed prescriptions, mass media campaigns and use of rapid diagnostic tests).

-The third package is a mixed intervention package (including stewardship programmes, enhanced environmental hygiene, mass media campaigns and the use of rapid diagnostic tests).

According to the final report, putting these packages in place would reduce the burden of disease from AMR by 85%, 23% and 73% respectively and would also achieve annual savings per capita of USD purchasing power parity (PPP) 4.1, 0.9 and 3 respectively.

CALLS FOR TENDERS

1. Further development and implementation of the ‘EU compass for action on mental health and wellbeing’ 

Background information

The mental health policy consortium (MHPol) was selected to implement the further development of the ‘EU compass’, with a budget of EUR 800 000. It followed up the work of the JA on mental health and wellbeing (JA-MHWB), and, more specifically, its final recommendations, summarised in a report entitled ‘European framework for action on mental health and wellbeing’.

Led by the Dutch Trimbos Institute, the consortium included the NOVA University of Lisbon, the Finnish Association for Mental Health, and EuroHealthNet. It collected, shared and analysed information on policy and stakeholder activities in mental health.

Brief description of activities

The compass disseminated the outcomes of the JA and put in place a platform to monitor and analyse mental health and wellbeing policies and the activities of EU countries and non-governmental stakeholders. It further identified and disseminated good practices in Europe in the areas of mental health and wellness promotion and the prevention of mental disease.

The consortium produced four thematic position papers on the following key issues: (i) preventing depression and promoting resilience, (ii) improving access to mental healthcare services, (iii) mental health in the workplace and (iv) providing community-based mental health services. Finally, it also conducted three annual surveys for Member States and stakeholders, and organised three annual forum events and several national workshops.

Specific results

During the implementation of the contract, the EU compass forum positioned itself as a substantial event in the European calendar. In its three annual fora it brought together all national and EU-level stakeholders representing a range of players, including the governmental sector, NGOs and intergovernmental organisations, academics based in universities and research centres, organisations of service users and carers, European networks, professional associations, health service providers and stakeholders from other connected fields.

By identifying, assessing and disseminating best practices among Member States, it made a key contribution to the debate on mental health at both national and European level. This helped raise the profile of mental health challenges in the EU public health agenda. The OECD flagged up mental health as a key issue in the ‘State of health in the EU’ cycle.

Best practices validated by the action, such as the iFightDepression programme (run by the European alliance against depression) and the housing first programme (‘Casas primeiro’ in Portugal), were selected by the JRC 40 during a marketplace workshop and were subsequently included among those to be implemented under the AWP 2020, which is another clear sign of success.

More information about the study is available on the website of the Directorate-General for Health and Food Safety (DG SANTE) 41 .

Request for specific service Chafea/2017/Health/18 for the organisation of the tabletop exercise on hybrid threats involving public health and civil protection/security authorities – exercise chimera.

Background information

The ‘Chimera’ exercise focused on improving preparedness and strengthening the capacity to coordinate a response to hybrid threats: it was a table top exercise held in Luxembourg on 30-31 January 2018 by Public Health England, which received EU co-funding of EUR 229 209.

Its main purpose was to bring together experts from the public health and civil protection/security sectors to consider the coordinated crisis response to cross-border hybrid threats facing EU and European Economic Area (EEA) countries, other countries, EU institutions and agencies and international organisations.

Brief description of activities

The scenario for the exercise was a fictitious terrorist organisation that caused an outbreak of a communicable disease following a deliberate release and undertook concurrent cyber-attacks on critical infrastructure including hospitals.

The main objective of this simulation was to challenge the use and usability of existing systems and communications tools in response to a hybrid threat through 11 objectives.

Over 80 experts from the health, civil protection and security sectors took part from 24 EU Member States, the EEA countries Iceland and Norway, and Serbia and Moldova. The European Commission’s DG SANTE, Secretariat-General (SG), Directorate-General for Migration and Home Affairs , Directorate-General for European Civil Protection and Humanitarian Aid Operations , and the JRC were represented, as were the European Centre for Disease Control , the European External Action Service (EEAS), the Computer Emergency Response Team for the EU , the EU Hybrid Fusion Cell within the EU Intelligence and Situation Centre of the EEAS, the Council of the EU, Chafea, the WHO and NATO.

Specific results

The Chimera exercise provided an opportunity for participants from the public health and civil protection/security sectors to come together and engage for the first time with a hybrid threat scenario. While the exercise demonstrated that in general there is a good understanding of the roles and responsibilities during such an incident and a high level of awareness of the reporting systems that are available, it also highlighted that further work is required at Member State and EU levels to ensure interoperability between the various sectors.

A key recommendation was that regular training and exercises should be held at Member State and EU level in order to improve inter-sectoral crisis management and raise awareness of the range of the mechanisms in place across the different sectors to deal with threats. Such training and exercises would raise awareness of hybrid threats and promote an understanding of how they differ from other threats. Finally, it was suggested that best practice in preparedness and response from the most developed sectors could be shared at these events.

More information about the study is available on DG SANTE’s website 42 .

2.Study on cross-border cooperation: capitalising on existing initiatives for cooperation in cross-border regions (request for specific services No Chafea/2016/Health/22) 

Background

While there is no legal obligation for Member States to engage in cross-border cooperation, the Cross-Border Care Directive (2011/24/EU) tasks the Commission with encouraging cooperation between EU countries and with taking, in close contact with them, any useful initiative to facilitate and promote such cooperation.

At the informal health ministerial meeting held in Luxembourg in September 2015, several Member States called on the Commission to draw up an exhaustive overview of all existing cross-border initiatives. A study was therefore launched, carried out by a consortium led by Sogeti Luxembourg S.A. This received EU co-funding of EUR 254 570 to consolidate the scoping work and examine the question of cross-border cooperation, not solely but especially in border regions.

Brief description of activities

The study investigated past achievements and potential future developments in cross-border healthcare cooperation. The findings were based on a mapping of cross-border healthcare initiatives funded by the EU health programme (e.g. project HonCAB on pilot hospital networks for payment of care for cross-border patients), foresight modelling for cross-border healthcare in 2030, a systematic literature review on fraud and fraud mitigation in cross-border healthcare, and an evaluation of the take-up of the JA on patient safety and quality of care (PaSQ). The study also provided practical tools to assist stakeholders including local and regional authorities intending to start a cross-border healthcare cooperation project.

Specific results

The study, which deepened understanding of cooperation on cross-border healthcare, provides new information about various aspects of cross-border healthcare research. Seven lessons were summarised:

1.Cross-border healthcare initiatives are more effective in regions where ease of cooperation is already established, owing to similar welfare traditions or close historical ties, for instance.

2.Key players such as regional policy-makers or hospital managers should receive support, to reduce the transaction costs of cross-border healthcare. The toolbox developed in this study is a way of providing help.

3.There are several scenarios for future cross-border healthcare. One of the most realistic ones builds on regional networks oriented towards addressing local and regional needs.

4.Regional networks are likely to represent a low-cost option, but the downsides are that they are likely to remain small-scale and they may create inequities by not benefiting all regions equally.

5.The top categories of cross-border healthcare initiatives to receive EU funding over the past 10 years are those focused on knowledge sharing and management, and on sharing treatment and diagnosis of patients.

6.Forms of cooperation such as high-cost capital investments and emergency care tend to have more discernible economic and social benefits, but require more formalised terms of cooperation.

7.Although information on the effectiveness and sustainability of current cross-border healthcare initiatives is scarce, the funding of cross-border healthcare projects could help achieve these aims.

More information about the study is available on DG SANTE’s website 43 .

3.Provision of a market study on telemedicine (request for specific services Chafea/2016/Health/17) 

Background

Following up the mid-term review of the digital single market, which highlighted a strong willingness to facilitate the accessing and sharing of health data for research or treatment purposes, the Commission published a communication in 2018 on enabling the digital transformation of health and care in the digital single market 44 .

In support of the above, Chafea procured a study on the telemedicine market in Europe and the factors determining its development. PwC Luxembourg conducted the study for EUR 283 950.

Brief description of activities

The analysis mapped telemedicine applications and solutions, and applicable technical standards and guidelines, and described the market dynamics and potential barriers that limit the wider deployment and uptake of telemedicine solutions in Europe.

It also assessed the cost-effectiveness of a larger-scale deployment of telemedicine under current and future market conditions and provided relevant recommendations for policy-makers.

The study identified and mapped successful existing initiatives which have already facilitated the adoption of telemedicine solutions.

The study also identified the following additional interventions needed to support the wider deployment and uptake of telemedicine: (i) raising public awareness about the benefits of telemedicine, (ii) supporting large‑scale projects where telemedicine can be tested and its benefits assessed and (iii) legislative interventions by the Commission or Member States to address some of the barriers to adopting telemedicine in the EU.

Specific results

The key take-away points of the study are as follows:

·Both the market potential and the cost-effectiveness, if properly applied, of telemedicine solutions can support the overall efficiency and resilience of health systems in the EU.

·The lack of a common legal framework reinforces the other underlying obstacles (reimbursement, lack of interoperability, lack of acceptance) to the development of telemedicine.The EU has a key role to play in supporting the Member States as they set their own national standards, both at the regulatory and the technical levels.

·The EU can minimise regulatory fragmentation through the support for a common approach among national standards setting bodies and regulators responsible for the different components of telemedicine systems;

·It should ensure common interoperability solutions to enhance the cross-border use of the various telemedicine applications and solutions and the data they generate.

More information about the study is available on DG SANTE’s website 45 .

HIGHLIGHTS OF CO-FUNDED ‘CROSS-CUTTING’ AND ‘OTHER’ ACTIONS

1.Dissemination activities carried out in 2018

The dissemination actions carried out in 2018 focused on communication priorities indicated by DG SANTE (such as vaccination), the European reference networks (ERNs) for rare diseases, health technology assessment, crisis preparedness in health, medical devices, and combating AMR,

Activities associated with the ERNs included:

-publishing an e-booklet on rare diseases 46 ;

-publishing an info sheet on ERNs’ results after their first year of operations 47 ;

-the fourth conference of ERNs 48 , held on 21-22 November 2018 in Brussels, organised by DG SANTE and Chafea.

Activities associated with crisis preparedness included:

-publishing a specific e-booklet on health threats 49 ;

-organising a conference in cooperation with the Greek Ministry of Health on 7-8 June 2018, ‘Best practices in implementing the International Health Regulations’ 50 .

Chafea also participated in five major public health conferences at European level where scientists and health professionals were the target audience.

-18th International Conference on Integrated Care, 23-25 May 2018, Utrecht, the Netherlands 51 , Health Programme workshops and stand.

-21st European Health Forum Gastein, 3-5 October 2018 52 .

-European Public Health Conference 2018, 28 November-1 December 2018, Winds of change: towards new ways of improving public health in Europe 53 , health programme workshop, Ljubljana, Slovenia.

-49th Union World Conference on Lung Health, 24-27 October 2018 54 , stand exhibition and ‘meet and greet’ sessions, The Hague, the Netherlands.

-AIDS 2018, health programme workshops, 23-27 July 2018 55 , EU stand and ‘meet and greet’ sessions, Amsterdam, the Netherlands. The e-booklet on HIV/AIDS, viral hepatitis and tuberculosis was produced and disseminated at the AIDS conference.

Among the other dissemination actions, the medical device campaign 56 on the new EU Regulations on medical devices (MDR) and in vitro diagnostic medical devices (IVDR) was launched in 2018. Its purpose was to inform all parties involved, especially the manufacturers, about changes, new requirements and the timelines of the new regulations before their entry into force in 2020.

In 2018, Chafea spent EUR 824 686 on dissemination activities, i.e. for organising events and covering the costs of venues renting space for stands in exhibitions, travel and accommodation of experts, and the production and printing of materials.

2.Other actions 

1.

2.

2.1. Sub-delegations to Eurostat, the statistical office of the European Union 

Background information

Eurostat, the statistical office of the European Union, is the main source of comparable EU health data. Its mission is based on the framework regulation on health statistics 57 and derived legal acts 58 .

Brief description

Eurostat provides two kinds of health statistics: administrative, such as statistics on the cause of death, and self-reported data from the European health interview survey or the minimum European health module of the EU-SILC survey . Themes covered by these statistics include:

-health status;

-health determinants;

-healthcare expenditure;

-healthcare resources and activities;

-causes of death;

-health and safety at work.

Specific results

The budget spent on all the activities under the support to Eurostat sub-delegations was EUR 987 580. This covered implementing the health information and knowledge system priorities to contribute to evidence-based decision-making, including supporting the scientific committees set up in accordance with Commission Decision 2008/721/EC.

-EUR 413 943 - testing new modules/variables for future waves of European health interview surveys.

Through this action, Eurostat delivered health data for a large proportion of European core health indicators and other European health indicators, such as joint assessment framework health indicators.

EU co-funding supported national adaptations, testing, and implementation of new variables/modules in countries that want to integrate them on a voluntary basis in the 2019 European health interview survey for preparing possible inclusion in future waves of this survey in all Member States. The resulting data and indicators contribute to and are used in the ‘State of Health in the EU’ 59 cycle. Topics of interest included:

§patient experience (taking OECD developments into account);

§dietary habits, including sugar intake;

§mental health-related issues;

§disability and variables related to children’s health.

-    EUR 527 575 - morbidity statistics.

Pilot data collection on morbidity statistics supports the statistical authorities in the European statistical system in their efforts to provide data on morbidity and to develop the existing (or planned) sources and methods with a view to producing best national estimates for the indicators included in the Eurostat morbidity indicators shortlist. EU co-funding was used to run pilot data collection on diagnosis-based morbidity at national level. A coordinated approach by Member States to morbidity statistics is required to ensure data comparability. The action helped to develop and increase the availability and comparability of data in 10 participating countries.

-EUR 46 062 non-monetary healthcare statistics.

The action on non-monetary healthcare statistics supports the statistical authorities in the European statistical system in their efforts to increase quality and coverage of non-monetary data on healthcare. The action also supports countries to advance their readiness to provide data under an implementing regulation. EU co-funding supported efforts with EU added value, enabling countries to report complete, high-quality data sets. This action contributes to the availability and comparability of data across the EU and provides a basis for policy-making grounded in factual evidence. The data are validated and disseminated annually by Eurostat.

More information about EU health data can be found on Eurostat’s website 60  and on DG SANTE’s health indicators and data website 61 .

2.2.What did the ERNs achieve in practice with the first year of SGA support?

Background

ERNs are virtual networks involving healthcare providers across Europe. Their purpose is to tackle complex or rare diseases and conditions requiring highly specialised treatment and a concentration of knowledge and resources.

To review a patient’s diagnosis and treatment, ERN coordinators convene ‘virtual’ advisory boards of medical specialists across different disciplines, using a dedicated IT platform and telemedicine tools. ERNs offer the potential to give patients and doctors throughout the EU access to the best expertise and timely exchange of life-saving knowledge, without having to travel to another country.

Following the first call for proposals in July 2016, the first ERNs were approved in December 2016 and launched in March 2017 in Vilnius, where their inaugural meetings were held. At their inception, the networks comprised more than 900 highly specialised healthcare units located in 313 hospitals in 25 Member States (plus Norway).

The budget earmarked for the ERNs under specific objective 4.1 priority - European reference networks in 2018 was as follows:

·EUR 13 691 043.13 on SGAs for 23 ERNs;

·EUR 4 000 000 on activities related to capacity building, communication, exchange of information and best practices, and other networking support actions.

Brief description

In the first year of their specific grants, the ERNs laid the groundwork for the key strategic activities by building their operational framework and setting up all the necessary support and coordination services for full operational capacity. The first-year grants enabled them to achieve the following specific objectives:

1.improving the provision of high-quality and homogeneous specialised care to European patients by developing and promoting standard recommendations for better diagnosis and treatment;

2.improving physicians’ activity and patients’ empowerment by developing the necessary personalised IT services, such as e-health and e-learning tools;

3.improving medical knowledge by sharing experience and through interaction between European healthcare providers; by developing and conducting training courses and activities for both physicians and patients;

4.facilitating epidemiological, clinical and translational research by developing a standard approach for the collection of patients’ data and the creation of registries.

Specific results

The ERNs have established their governance models, including advisory boards, steering committees or other means of involving stakeholders (e.g. patient representatives). Several ERNs have established or further developed databases or registries, including quality assurance schemes for diagnostics. Others have focused on learning and development activities, e.g. surveys to identify educational gaps, e-learning and e-training tools, and twinning programmes. Capacity building has been improved by holding workshops and producing webinars, while several ERNs have also focused their work in order to identify e-health and ICT and research gaps. A clinical patient management system 62 has been set up by the Commission, and ERN consultations were carried out through the system 63 .

Transversal cooperation among ERNs was ensured through dedicated working groups on (a). education, clinical guidelines and recommendations, (b). registries and bio banks, (c).molecular testing, IT and e-health, stem cell and gene therapies, (d). pharmacovigilance and biological therapies, transition care, research, patient organisations and communication.

For more on ERNs, see DG SANTE’s website 64 and Chafea’s Health Programme database 65 .

IMPLEMENTATION OF THE ANNUAL WORK PROGRAMME FOR 2018

CALLS FOR PROPOSALS

Between January 2018 and January 2019 Chafea launched calls for proposals for projects, and invitations to submit proposals for JAs, for specific grants for ERNs, and operating grants for NGOs on the single electronic data interchange area for funding and tender opportunities 66 . 

Four calls for proposals for projects were published. Two of these were for health promotion, prevention and integrated care for non-communicable diseases, including transferring and/or scaling up existing good and best practices. The other two had to do with supporting voluntary cooperation between EU countries on national policies for the pricing of medicinal products and improving information-gathering on rare diseases through the implementation of Orphacodes.

All applications for ERN-specific grants in 2018 and FPA/SGA for operating grants to NGOs were submitted by organisations in the EU-15 67 , apart from one FPA/SGA signed with an EU umbrella organisation from Cyprus.

The JA designed to improve EU preparedness for serious cross-border health threats and to support the implementation of the international health regulationsknown as SHARP, brought together 26 countries. Thirteen beneficiaries were organisations from EU-15 countries, nine were from EU-12 (countries that joined the EU after 2004) and four other partners were non-EU countries (EEA, and European neighbourhood policy (ENP) countries).

Looking at the geographical distribution of the 211 grant beneficiaries, 156 (74%) are from an EU-15 country, 46 (22%) from EU-12 countries, four from Norway or Iceland (2%) and five from ENP countries (Bosnia Herzegovina, Serbia and Moldova) (2%).

Graphic 4: Participation in health programme grants (%)

Chafea organised two webinars as information days to promote the 2018 AWP: the first, presenting funding opportunities and held on 30 January 2018, attracted 154 participants. The second, held on 2 February 2018, drew 55 participants; it was restricted to competent authorities of the countries participating in the programme and presented the JA nomination process and the policy priorities. This initial information session was followed by a JA 2018 preparatory workshop held on 16 June 2018 and by the quality assurance workshop on 11 October 2018.

To promote participation in the 2018 calls, the national focal points 68 for the health programme held eight national information days 69 from February to March 2018 in five EU countries and three in other countries participating in the health programme. Chafea made guidelines for applicants available on the participant portal. The Chafea helpdesk also provided assistance and practical help.

Expert evaluators

Applications were evaluated in accordance with the rules and criteria set out in the 2018 AWP and in the specific calls for proposals.

The proposals submitted under different calls for proposals were evaluated by external experts (peer reviewers) drawn from a list established after the call for expressions of interest in the area of public health – EMI H2020 database 70 . The external evaluation of the call for proposals supports the efficient and transparent selection of proposals funded under the 2018 AWP.

17 external experts from 12 countries took part in the evaluation process for the award of the operating grants, projects and ERN grants and assessed the JA during the quality assurance workshop.

The evaluation process took place in two stages:

·At the first stage, three external evaluators assessed each proposal. They drew up a consolidated evaluation report for each proposal at the consensus meeting organised by Chafea. 

·At the second stage, the evaluation committee reviewed the work of the external evaluators and drew up the final lists of proposals recommended for funding, together with the reserve lists. The evaluation committee comprised representatives from DG SANTE, the Directorate-General for Research and Innovation, and Chafea.

Project grants

Project grants were awarded to actions involving 105 organisations, mainly public health bodies, research institutions and NGOs. The maximum EU contribution is 60% of eligible costs. However, the EU contribution may go up to 80% if a proposal meets the criteria for ‘exceptional utility’ indicated in the AWP.

Chafea launched the first call for proposals for projects in January 2018, in the following areas:

·A call for projects on scaling up integrated care: nine proposals were submitted, two of which were funded.

·Supporting Member States’ voluntary cooperation in the area of pricing through EURIPID cooperation: one proposal was funded.

·The Orphacodes project: one proposal was funded.

Two calls for projects were launched in June 2018 to support the implementation of best practices to promote health and prevention of non-communicable diseases and reduce health inequalities as part of the work of the steering group on health promotion, disease prevention and management of non-communicable diseases (SGPP):

· Transferring the Swedish ‘physical activity on prescription’ initiative to other countries : one proposal was submitted and funded.

·Transferring the Italian CARDIO 50 programme to other countries: two proposals were submitted, one of which was funded.

A third call for projects to transfer the Wholegrain promotion initiative to other countries was launched in December 2008. One proposal was received and funded.

In all, 15 proposals were submitted in response to the 3 calls for proposals for projects. One proposal was ineligible, 14 proposals were evaluated and 9 proposals reached the threshold values.

In 2018, seven projects were funded for the six topics of the calls for proposals.

The table below lists the project grants funded by objective and priority.

European reference networks (mono-beneficiary grants)

In 2017, 23 ERNs submitted an FPA proposal, together with their SGA proposals for the first year of operation of the ERNs. In 2018, Chafea awarded 23 SGAs covering three years (2019-2021).

There were two waves of ERN SGA 2018 grant preparation. Initially, 18 ERNs were sent an invitation to submit their annual work programme for funding. A second wave of invitations was sent after an amendment had been adopted on the five ERNs with UK-based coordinators.

Under the financing decision, each network could receive up to EUR 200 000 annually. However, not all networks requested the full amount available. The co-funding awarded to each ERN is set out below.

EU funding for three-year SGA grants for ERNs totalled EUR 13 691 043.13.

Operating grants

Operating grants are awarded to non-governmental bodies that pursue one or more of the health programme’s specific objectives and

·are non-governmental;

·are non-profit-making and independent of industry, commercial and business or other conflicting interests;

·work in public health;

·play an effective role in civil dialogue processes at EU level;

·pursue at least one of the programme’s specific objectives;

·active at EU level and in at least half of Member States; and

·have a balanced geographical coverage of the EU.

All activities covered by Annex 1 to the Regulation establishing the third health programme can be funded by a specific grant awarded under an FPA for the functioning of non-government bodies (operating grants).

Sixteen EU umbrella organisations signed an FPA in 2017, covering 2018-2021 and focusing on, though not limited to, the following priority areas: prevention and health determinants, chronic diseases, cancer, dementia, rare diseases, HIV/AIDS, tuberculosis, hepatitis, access to healthcare, substances of human origin.

FPA recipients are eligible for an SGA for their operations. In 2018, FPA recipients were asked to apply for an SGA to cover their operating costs for 2019. The maximum EU contribution is 60% of their annual operating costs, but may rise to 80% if a proposal meets the criteria for exceptional utility.

In 2018, six of the 16 operating grants signed, 37.5% 71 , met the exceptional utility conditions.

At the end of 2018, the grant preparation process was completed, representing a volume of EUR 5 887 958.53.

The table lists all operating grants funded by objective and priority.

JOINT ACTIONS

The grants for actions co-financed with Member State authorities are ‘actions having a clear Union added value co-financed by the competent authorities that are responsible for health in the Member States or in third countries participating in the Programme pursuant to Article 6, or by public sector bodies and non-governmental bodies, as referred to in Article 8(1), acting individually or as a network, mandated by those competent authorities 72 ’.

They thus enable the nominated national authorities of the Member States and other countries participating in the programme, and the Commission, to take forward work on jointly identified issues.

The maximum EU contribution is 60%, but may rise to 80% if a proposal meets the criteria for exceptional utility.

Countries participating in the third health programme nominate the competent authorities or other bodies, which are asked to submit a proposal under the direct grant procedure.

In 2018, co-funding totalling EUR 7 900 000.00 was provided to a JA addressing objective 2 of the health programme, ‘Protect Union citizens from serious cross-border health threats’. This was because it qualified as exceptional utility.

The SHARP JA brings together 26 associated partners, 33 affiliated entities, and 9 collaborating stakeholders, in a total of 30 countries (24 EU countries, three EEA/EFTA members, and three European neighbourhood countries).

The table below lists the joint actions funded by objective and priority.

DIRECT GRANT AGREEMENTS AND PRESIDENCY CONFERENCES

Direct grant agreements are awarded to international organisations active in the area of public health ‘for activities with specific characteristics that require a particular type of body on account of its technical competence, its high degree of specialisation or its administrative powers, on condition that the activities concerned do not fall within the scope of a call for proposals 73 ’.

Funding for actions with international organisations will be allocated exclusively through grant agreements, without a call for proposals on topics specifically identified in the work programme. The maximum EU contribution is 60%.

In 2018, five direct grant agreements were signed by Chafea, covering a total of EUR 4 020 000, with the WHO, the OECD and the Council of Europe.

The table below lists all direct grant agreements funded by objective and priority.

Other direct grants

The table below lists other direct grants funded by objective and priority.

Presidency conferences

The Presidency conferences financed under the 2018 AWP were the ones held under the Austrian and Romanian EU Presidencies.

The conference on ‘People's food, people's health: towards healthy and sustainable European food systems’ 74 was held on 22-23 November 2018 in Vienna. It facilitated dialogue between all relevant stakeholders in the food sector on moving towards a healthier and more equitable future. A healthy and sustainable diet must become available, affordable, acceptable and appealing to all.

Under the Romanian Presidency, the ministerial conference ‘Next steps towards making the EU a best practice region in combating antimicrobial resistance through a One Health approach’ 75  was held in Bucharest on 1 March 2019. The key content of the Council conclusions on AMR was adopted in June 2019.

PRIZES – EU health award for NGOs

In 2018, the Commission rewarded outstanding initiatives by NGOs that contributed to a higher level of public health in the EU by working to prevent tobacco use. Eleven candidate NGOs were considered for the prize. The Commission announced the winners on 12 November 2018 at the award ceremony hosted at the annual meeting of the EU Health Policy Platform, in the presence of the EU Commissioner for Health and Food Safety, Vytenis Andriukaitis 76 .

PROCUREMENTS (SERVICE CONTRACTS)

Procurement service contracts were used to purchase different types of services. Unlike the grants, the health programme covers the full cost of the procurement actions for the following tasks:

·evaluation, monitoring of actions and policies, including impact assessment;

·studies, data analysis and information on health;

·developing and maintaining databases;

·organising workshops, courses, expert panels and coordination groups;

·scientific and technical assistance, provision of advice and opinions;

·communication, translations and publications;

·awareness raising and dissemination of the results; and

·information technology applications in support of policies.

In 2018, DG SANTE signed several service contracts and specific requests using existing framework contracts (FWC). Most of these contracts and requests were for cross-cutting actions such as communication and IT services for the maintenance and functioning of existing IT tools.

Procurement contracts also included contracts with experts working for the scientific committees, evaluating proposals and monitoring studies.

The amounts by objective and authorising organisation were as follows:

The overall public procurement budget implemented by DG SANTE amounted to EUR 10 373 942.37.

The overall public procurement budget implemented by Chafea amounted to EUR 2 618 012.85.

In 2018, Chafea managed nine procurement procedures for the acquisition of services – seven under ‘health promotion’, one under ‘health systems’, none under ‘health threats and objectives for better and safer healthcare’ and one cross-cutting contract supporting the dissemination of the health programme results.

The table below lists, by objective and priority, all contracts signed by Chafea and by DG SANTE.

OTHER ACTIONS

EUR 5 509 503.09 was committed for other actions in 2018. Other actions cover contributions paid by the EU as a member of the European Observatory on Health Systems and Policies and the administrative agreements with the Commission’s JRC.

This also includes the cost of the cross-sub-delegations with Eurostat for morbidity statistics and the European health interview surveys (EHIS), the medical device coordination group (MDCG) meetings, the VICH and ICH international cooperation, and the special indemnities paid to experts for participating in meetings and for work on scientific opinions and advice on health systems.

The table below provides more information on ‘other actions’.

DETAILED OVERVIEW OF THE REPORTING YEAR 2018

Funding per thematic priority and financial instrument

(1)

The database covers actions co-funded under the health programmes from 2003 to 2020.

(2)

  http://ec.europa.eu/chafea/health/index.html  

(3)

 Joint action on reducing alcohol-related harm: http://www.rarha.eu/Pages/default.aspx  

(4)

  https://webgate.ec.europa.eu/chafea_pdb/health/projects/20132202/summary  

(5)

http://www.rarha.eu/Resources/Deliverables/Lists/Work%20Package%204/Attachments/7/Comparative%20monitoring%20%20of%20alcohol%20epidemiology%20%20across%20the%20EU%2019.08.pdf  

(6)

http://www.rarha.eu/Resources/Deliverables/Lists/Work%20Package%206/Attachments/10/RARHA_Toolkit_WP6.pdf  

(7)

  www.janpa.eu/

(8)

  https://webgate.ec.europa.eu/chafea_pdb/health/projects/677063/summary  

(9)

  https://jasehn.eu/  

(10)

  https://webgate.ec.europa.eu/chafea_pdb/health/projects/677102/summary  

(11)

Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the application of patients’ rights in cross-border healthcare (OJ L 88, 4.4.2011, p. 45).

(12)

  https://webgate.ec.europa.eu/chafea_pdb/health/projects/20132102/summary  

(13)

  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6223699/  

(14)

  http://tob-g.eu/  

(15)

  https://webgate.ec.europa.eu/chafea_pdb/health/projects/664292/summary  

(16)

  http://www.sunfrail.eu/  

(17)

  https://webgate.ec.europa.eu/chafea_pdb/health/projects/664291/summary

(18)

  https://eurohivedat.eu/

(19)

  https://webgate.ec.europa.eu/chafea_pdb/health/projects/20131101/summary  

(20)

  https://webgate.ec.europa.eu/chafea_pdb/health/projects/20091211/summary  

(21)

  www.euripid.eu

(22)

  https://webgate.ec.europa.eu/chafea_pdb/health/projects/664317/summary  

(23)

  http://www.bridge-health.eu/  

(24)

  https://webgate.ec.europa.eu/chafea_pdb/health/projects/664691/summary  

(25)

  https://www.expornet.eu/  

(26)

  https://webgate.ec.europa.eu/chafea_pdb/health/projects/20131207/summary  

(27)

A total of 17 FPAs covering 2017-2021 were signed with successful applicant organisations, resulting in eligibility for financial support on an annual basis for each of the years covered by the FPA.

(28)

  https://www.europeancancerleagues.org/

(29)

  https://webgate.ec.europa.eu/chafea_pdb/health/projects/811112/summary  

(30)

Defined as the WHO European Region

(31)

  https://www.smokefreepartnership.eu/  

(32)

  https://webgate.ec.europa.eu/chafea_pdb/health/projects/747248/summary  

(33)

https://ec.europa.eu/health/tobacco/tracking_tracing_system_en

(34)

SFP’s position paper – ‘Tobacco Tax for a Healthier Europe’: https://www.smokefreepartnership.eu/news/sfp-news/updated-sfp-position-paper-on-tobacco-taxation

(35)

  ensp.network/  

(36)

  https://webgate.ec.europa.eu/chafea_pdb/health/projects/881565/summary

(37)

Directive 2001/37/EC of the European Parliament and of the Council of 5 June 2001 on the approximation of the laws, regulations and administrative provisions of the Member States concerning the manufacture, presentation and sale of tobacco products (OJ L 194, 18.7.2001, p. 26) (more widely known as the Tobacco Products Directive or TPD) is the centrepiece of EU legislation in the area of tobacco control and tobacco market regulation.

(38)

http://www.oecd.org/health/health-systems/Feasibility-Study-On-Health-Workforce-Skills-Assessment-Feb2018.pdf

(39)

https://www.oecd-ilibrary.org/docserver/9789264307599-en.pdf?expires=1583926955&id=id&accname=oid031827&checksum=7706E2ECF3790A1E6FAAFAA319FAA16F  

(40)

  https://ec.europa.eu/health/non_communicable_diseases/events/ev_20190514_en  

(41)

  https://ec.europa.eu/health/non_communicable_diseases/mental_health/eu_compass_en  

(42)

  https://ec.europa.eu/health/sites/health/files/preparedness_response/docs/2018_hybridthreatsexercise_en.pdf  

(43)

  https://ec.europa.eu/health/sites/health/files/cross_border_care/docs/2018_crossbordercooperation_frep_en.pdf

(44)

  Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions on enabling the digital transformation of health and care in the Digital Single Market; empowering citizens and building a healthier society, COM(2018) 233.

(45)

  https://ec.europa.eu/health/sites/health/files/ehealth/docs/2018_provision_marketstudy_telemedicine_en.pdf  

(46)

  https://ec.europa.eu/chafea/health/bookshelf/brochures/index_en.htm  

(47)

  https://ec.europa.eu/chafea/health/bookshelf/infosheets/index_en.htm  

(48)

  https://ec.europa.eu/health/sites/health/files/ern/docs/ev_20181121_ag_en.pdf

(49)

https://publications.europa.eu/en/publication-detail/-/publication/13b6f22d-75e4-11e8-ac6a-01aa75ed71a1/language-en?WT.mc_id=Selectedpublications&WT.ria_c=19980&WT.ria_f=3170&WT.ria_ev=search  

(50)

  https://eody.gov.gr/en/event/best-practices-in-implementing-the-international-health-regulations/  

(51)

  https://integratedcarefoundation.org/events/icic18-18th-international-conference-on-integrated-care-utrecht  

(52)

  https://www.ehfg.org/archive/2018/conference  

(53)

  https://ephconference.eu/conference-2018-Ljubljana-184  

(54)

  https://thehague.worldlunghealth.org/  

(55)

  https://www.aids2018.org/  

(56)

  https://ec.europa.eu/growth/sectors/medical-devices_en  

(57)

Regulation (EC) No 1338/2008 of the European Parliament and of the Council of 16 December 2008 on Community statistics on public health and health and safety at work (OJ L 354, 31.12.2008, p. 70).

(58)

  https://ec.europa.eu/health/indicators_data/key_documents_en#anchor1  

(59)

  https://ec.europa.eu/health/state/summary_en  

(60)

  https://ec.europa.eu/eurostat/web/health/overview  

(61)

  https://ec.europa.eu/health/indicators_data/overview_en

(62)

  https://ec.europa.eu/health/sites/health/files/ern/docs/ev_20181121_frep_en.pdf  

(63)

CMPS is a web-based clinical software application allowing healthcare providers from all over the EU to work together virtually to diagnose and treat patients with rare, low-prevalence and complex diseases.

(64)

  http://ec.europa.eu/health/ern/networks_en

(65)

  https://webgate.ec.europa.eu/chafea_pdb/health  

(66)

https://ec.europa.eu/info/funding-tenders/opportunities/portal/screen/opportunities/topic-search;freeTextSearchKeyword=;typeCodes=1;statusCodes=31094501,31094502,31094503;programCode=3HP;programDivisionCode=null;focusAreaCode=null;crossCuttingPriorityCode=null;callCode=Default;sortQuery=openingDate;orderBy=asc;onlyTenders=false;topicListKey=topicSearchTablePageState  

(67)

EU-15 countries (Belgium (BE), Denmark (DK), France (FR), Germany (DE), Greece (EL), Ireland (IE), Italy (IT), Luxembourg (LU), the Netherlands (NL), Portugal (PT), Spain (ES), United Kingdom (UK), Austria (AT), Finland (FI) and Sweden (SE), https://ec.europa.eu/eurostat/statistics-explained/index.php/Glossary:EU_enlargements  

(68)

  http://ec.europa.eu/chafea/health/national-focal-points/index_en.htm  

(69)

  https://ec.europa.eu/chafea/health/national-info-days/2018-nid_en.htm  

(70)

EMI - https://ec.europa.eu/info/funding-tenders/opportunities/portal/screen/work-as-an-expert  

(71)

Operating grants, SGA 2018 with EU funding higher than 60%: smoke-free partnership, correlation network, AIDS action Europe, European network for smoking and tobacco prevention, European public health alliance, and Thalassaemia in action.

(72)

Definition of joint actions in Article 7.2(a) of the Regulation for the third Health Programme 2014-2020, https://ec.europa.eu/health/funding/programme_en  

(73)

Article 195(f) of Regulation (EU, Euratom) 2018/1046.

(74)

https://www.eu2018.at/calendar-events/political-events/BMASGK-2018-11-22-EU-Food-Systems.html

(75)

http://www.ms.ro/wp-content/uploads/2019/01/Outcomes-document-PRES-RO-AMR-conference.pdf

(76)

2018 Working to prevent tobacco use, https://ec.europa.eu/health/ngo_award/previous_editions/2018/preventing_tobacco_use_en