PREMESSA

Il coraggio è la più grande risorsa dell’umanità.

E’ stato necessario del coraggio per scegliere una tesi di tale complessità, che si inscrive nella cornice della

salute globale, così come per aver voluto scriverla in lingua italiana e inglese, proprio per il suo carattere

internazionale.

Il coraggio ha determinato l’aver voluto aderire a un gruppo di tesi connesse a Urbanpromo1.

Il coraggio caratterizza oggi il sentirsi parte del sistema universale della salute e sostenere che “uno scoglio,

insieme ad altri scogli, può arginare il mare”2.

Solo il coraggio consente di cercare di tradurre in concreto, a livello locale, gli assunti teorici e i grandi ideali.

SOMMARIO

Parole chiave: European vision, local action, politiche per la salute, innovazione integrata, health promotion

and production, capacity building, conversazione costruttiva, delivery of health care – economics, health care

costs, financial management, sustainability

La tesi verte sul significato che la salute riveste oggi in un’epoca completamente diversa dal passato. Stiamo

infatti vivendo sotto una crisi globale, che impone una rivisitazione dei concetti di medicina e di salute. Dopo

alcuni cenni storici sulla strategia sanitaria europea, è stata quindi condotta un’analisi approfondita della nuova

cornice internazionale, delle politiche per la salute a livello comunitario, di come esse siano cambiate negli

ultimi anni (in tempo di crisi). La domanda cardine su cui riflettere è stata quale sia l’impatto (sia esso un

incontro oppure uno scontro) fra le concezioni europeistiche e quelle localistiche, ovvero in qual modo una

concezione alta, di livello internazionale, possa tradursi poi nella pratica a livello delle realtà locali. Si è voluto

indagare se e come le politiche per la salute comunitarie siano state implementate a livello locale (regionale

e/o macroregionale) e individuare le eventuali criticità da superare.

Dopo aver effettuato una disamina del quadro internazionale di riferimento e dei riflessi che la salute ha

sempre più su tutti gli aspetti della vita quotidiana e sulla sfera economica, si è focalizzata l’attenzione su un

aspetto, rappresentato dalla European Innovation Partnership on Active and Healthy Ageing (EIP-AHA). E’

stato a tal fine presentato un progetto che, fondato sulla innovazione integrata sociale, tecnologica e

finanziaria, risponde pienamente a quanto richiesto per affrontare le sfide, coniugando a ideali universali la

concretezza operativa.

Data la vastità del tema, ci si riserva di effettuare un successivo approfondimento sugli spunti di riflessione

emersi.

1 In un contesto denso di storia, nel cuore della città antica di Bologna, nel complesso delle Sette Chiese e nel Palazzo

Isolani in Piazza Santo Stefano, il 9 novembre 2011 si è svolto nell’ambito della VIII Edizione di Urbanpromo il Convegno nazionale “Interventi innovativi per la valorizzazione del patrimonio storico: small historical towns for healthy ageing (I borghi della salute)”, organizzato dal Centro ricerca Fo.Cu.S dell’Università degli studi “La sapienza” di Roma, in collaborazione con l’Equity in Health Institute (Ehinst) e l’Associazione Nazionale Piccoli Comuni d’Italia (ANPCI). Sono state presentate le esperienze realizzate in Puglia e in Sardegna, nonchè quelle a cura della Provincia di Terni, accomunate dal concetto di “Territorio socialmente responsabile” e in linea con il programma European Innovation Partnership on Active and Healthy Ageing (EIP-AHA). L’attenzione che l’Europa ha deciso di dedicare all’invecchiamento attivo e alla solidarietà fra generazioni ha infatti condotto a dedicare il 2012 a tale tema. Gli anziani sono non tanto forma costruita, quanto forma di memoria . Il servizio sanitario non è più inteso solo come cura e mera erogazione di prestazioni, ma come strumento di promozione della salute e di una nuova cultura del ben-essere, in cui l’idea di prevenzione sia promossa anche attraverso la diffusione di stili di vita più sani. Ecco allora che i centri di dimensione minore, diffusi capillarmente sull’intero territorio nazionale, possono valorizzare gli elevati livelli di valore ambientale e storico-architettonico e la qualità della vita e di relazioni sociali, mettendoli a disposizione di tutti e, integrandoli con attività di assistenza, cura e wellness, rappresentare quindi luoghi di “presidio della salute”. L’Università degli studi “La sapienza” di Roma sta coordinando su un tema così complesso più tesi di laurea, con la caratteristica comune di approfondire tre filoni: urbanistico, tecnologico, di fattibilità, cui si aggiunge in modo trasversale quello medico; l’aspetto architettonico visto in maniera innovativa, tecnologica, assume un rilievo fondamentale nei lavori succitati, i cui risultati, integrati, costituiranno un modello di riferimento per la capacità di riconoscere i bisogni attraverso una lettura basata sulla innovazione integrata – sociale, tecnologica e finanziaria –. 2 Si fa riferimento a: Lucio Battisti, “Il mio canto libero” (1972), “Io vorrei... Non vorrei... Ma se vuoi...”.

INTRODUCTION

In Lewis Carroll’s classic children’s story Through the looking glass, Alice encounters Humpty Dumpty

(Carroll, 1994).

“When I use a word” Humpty Dumpty said in a rather scornful tone “it means just what I choose

it to mean, neither more nor less”.

“The question is” said Alice “whether You can make words mean so many different things”.

“The question is” said Humpty Dumpty “which is to be master, that’s all”.

Humpty Dumpty issues a sharp challenge to those who advocate constructive conversation about health. The

literature on health policy is vast. On offer are models of health services, economic theory, management

theory, disquisition on ethical principles, social analyses, literally thousands of publications. In a globalized

and electronically networked world, this literature has already generated its own particular language, a policy

jargon replete with terms that look deceptively familiar, terms that will be much in evidence in what now

follows, terms whose meanings require our closest attention.

Although I acknowledge the force of Humpty Dumpty’s relativism, my aim will be to limit some of the

damage caused by a systemic ambiguity in the way we talk about health. When we choose a word it cannot

mean just what we choose it to mean, although it almost always means both more and less. Humpty Dumpty’s

assertion is the dilemma that lies at the heart of constructive conversation about health.

In 1847 Rudolf Virchow, who famously averred that medicine was a social science, was asked to investigate

the causes and containment of a typhus epidemic among immigrant Polish workers in Silesia. He

recommended ameliorating the hardships and injustices experienced by the workers, improving their

education, increasing their income, involving them in local politics and permitting them to use Polish for

official purposes.

Some forty years later Robert Koch was to demonstrate the bacterial causes of infectious diseases. Yet more

than a century after Koch and a century and a half after Virchow, Victor Rodwin describes the cities of the

West, citing New York, London, Paris and Tokyo, as socially infected breeding grounds for both disease and

urban terrorism and implies an overlapping of causes. He links a failure to deal adequately with fresh

epidemics of infectious diseases, including AIDS and TB, with problems of water and air pollution,

homelessness, poverty, the exclusion of ethnic minority groups and terrorism.

What is the link, in Rodwin’s analysis, between TB and AIDS, which can be described in terms of a biological

model and urban terrorism which cannot? What model of disease could possibly have connected the severity

of the typhus outbreak to the denial of use of a mother tongue? How are we to understand the full meaning of

the public health?

Marc Danzon (Danzon, 2006) observes that “health seems to be universally recognized as the hard currency of

modern times”. The word has been so often defined, by philosophers, politicians, poets. What does health

mean to the individual, to the citizen, in whose name all health policy is made?

The following quotation is ascribed to the novelist Katherine Mansfield, written in a letter when, as a young

woman, she was already dying of tubercolosis. The words, or some version of them, appear in a number of

contexts, such that perhaps the feelings expressed were thematic throughout her writing and life. “By health I

mean the power to live a full, adult, living, breathing life in close contact with what I love …omissis… the

earth and the wonders thereof – the sea, the sun – …omissis… I want to be all that I am capable of becoming”.

I italicize those seven words because they resonate with the capabilities approach of Amartya Sen and others

(Sen, 1999). In Bismarck’s terms, health was a means to a public end – the productive capacity of Prussia’s

workforce and the fight capacity of its soldiery. Referring to Sen and others, Jennifer Prah Ruger (Ruger,

2006) observes that “…omissis… the degree to which individuals have the capability actively to participate in

their work, social and political life, to be well-educated …omissis… are ends in themselves” (Marinker,

2006).

CHAPTER I

A NEW INTERNATIONAL FRAMEWORK

I Introduction. I.1 Why is it important to discuss health and economic development now? I.2 What is the relevance of the CMH’s

report for the European Union? I.3 What do we find in high-income countries? I.4 What is the cost of illness?I.5 What is the impact of

health at the individual and household level? I.5.1 Wages and earnings. I.5.2 Labour supply. I.5.3 Education. I.5.4 Savings. I.6 What is

the macroeconomic impact of health? I.7 What is the contribution of health to the ‘full income’? I.8 What is the contribution of the

health systems on the economy? I.9 Investing in health? I.10 Where do we go from here? I.11 Why is the issue relevant for the EU

countries — and why just now? I.12 Channels of influence between health and the economy. I.12.1 Labour productivity. I.12.2 Labour

supply. I.12.3 Education. I.12.4 Savings and investment. I.13 From management culture the excellence of providing model. I.14

Administering under financial crisis. I.14.1 World crisis: The Path to the World Afterwards. I.14.2 The double and contemporary

challenge of Ageing and the Financial Crisis – The need of a new Model of Rights & Budgets balance based on Social, Technological

and Financial Integrated Innovation – Active and Healthy Ageing . Financing? I.14.3 Per una riforma del sistema finanziario e

monetario internazionale nella prospettiva di un’autorità pubblica a competenza universale. I.14.3.1 Prefazione. I.14.3.2 Conclusioni.

I.14.3.1.1 Sviluppo economico e disuguaglianze. I.14.3.1.2. Il ruolo della tecnica e la sfida etica. I.14.3.1.3 Il governo della

globalizzazione. I.14.3.1.4. Verso una riforma del sistema finanziario e monetario internazionale rispondente alle esigenze di tutti i

Popoli I.15 Bottom up planning vs/ top down planning: the economic value of participation, consent and control. I.16 To plan

intervents acting as needs knowledge: the rediscovery of the quantitative approach for the planning on a large scale. I.17 Capacity

building : information, formation and remotivation. I.17.1 What is capacity building? I.17.2 Definitions. I.17.3 History. I.17.3.1

Changes in international developmental approaches. I.17.4 Capacity building in developing societies. I.17.5 Capacity building in

governments. I.17.6 Local capacity building in practice. I.17.7 In NGOs. I.17.8 Evaluating capacity building. I.17.9 Specification.

I.17.10 Agencies providing capacity building. I.17.11 Global Europe Anticipation Bulletin. I.18 Advanced technology in

administrations. I.19 Financing Equity and Excellence in Health through Integrated Innovation. I.19.1 Are we walking? I.19.2 How to

succeed in achieving equity and excellence in health field? I.19.3 What does “Integrated Innovation” mean? I.19.4 Financing Health

(HP, HC, LTC, MH) in the European Union: towards a Financial PPP? I.19.5 Three ways to go. I.19.6 European instruments. I.19.7

European Parliament resolutions. I.19.8 Conclusions. I.19.9 Next step

I Introduction

The relevance of the CMH findings for Europe lies mainly in the provision of the underlying rationale and

evidence as to why and in how far investment for health should generally be seen as a key determinant of

economic development and poverty reduction. Moreover, the CMH Report also presents a set of useful

methodological tools that can be applied in various settings (World Health Organization, European Office for

Investment for health and development: Macroeconomics and health: the WHO-EURO dimension).

The European Commission has adopted a draft legislative package which will frame cohesion policy for 2014-

2020. The new proposals are designed to reinforce the strategic dimension of the policy and to ensure that EU

investment is targeted on Europe's long-term goals for growth and jobs ("Europe 2020"). Through Partnership

Contracts agreed with the Commission, Member States will commit to focusing on fewer investment priorities

in line with these objectives. The package also harmonizes the rules related to different funds, including rural

development and maritime and fisheries, to increase the coherence of EU action.

European Public Health Alliance (EPHA) - a network of NGOs and other not-for-profit organizations working

in the field of public health in Europe towards better health for all – on 03.11.2011 wrote a letter to all of its

members, which is reported below because of its important content:

“Dear EPHA member,

On 25 November 2011, EPHA will organize a workshop at the Party of European Socialists (PES) convention,

entitled "Health as a Public Good - Fiscal measures supporting national health systems and preventing

illhealth"; the workshop will be part of the “just society and equality” workshops of the PES convention.

The event will bring together 1000 participants from social democratic parties, from trade unions and civil

society, to discuss the future political challenges and to prepare the PES’ first European Fundamental

Programme.

In the current European political context Health is all too often seen simply as a sector with potential for

investment, innovation and economic growth. While this is important in order to further the innovation agenda

and can indeed boost economic growth, the primary concern of a public authority should be to maintain the

health and wellbeing of its population.

Much public health evidence has shown that interventions on the marketing, pricing mechanisms, and

availability of products, to name but a few, have a concrete impact on consumers’ behaviour and choices.

What is the responsibility of public authorities in order to make sure that their population’s right to health is

protected? Are Member States using all of their power to ensure that their population’s health comes first, and

economics second?

With the cost of the management of NCDs reaching record levels, are European States using the appropriate

mechanisms to have budget savings? Investing in prevention will not only substantially bring down costs (as a

large number of these diseases are preventable) but will actually fulfil one of the key responsibilities of the

State, which is protecting the health of those living within it. …omissis…”.

(EPHA, Letter to EPHA members, 03.11.2011)

A very important document comes recently from the European Commission, Directorate-General, Health and

Consumers protection. It is entitled “The contribution of health to the economy in the European Union”. Its

main content will be reported below.

“In March 2000, the European Union’s Heads of State or Government came together to agree the ambitious

goal of making the European Union ‘the most competitive and dynamic knowledgebased economy in the

world, capable of sustainable economic growth with more and better jobs and greater social cohesion’. They

highlighted the need to: create a knowledge-based economy and society, accelerate the process of structural

reform for competitiveness and innovation; modernize the European social model, by investing in people and

combating social exclusion; and sustain favourable growth prospects by means of an appropriate

macroeconomic policy mix.

The relationship between health and the economy is one of the cornerstones of this agenda. Yet this

relationship is complex. While it has long been recognized that increased national wealth is associated with

improved health, it is only more recently that the contribution of better health to economic growth has been

recognized. Yet while this relationship is now well established in low income countries, the evidence from

high-income countries, such as the Member States of the European Union, has been more fragmented.

The authors of this important book have, for the first time, brought this evidence together. Having confirmed

the high cost falling on Europe’s economies as a result of illness, they assemble a wealth of evidence to

demonstrate how good health promotes earnings and labour supply. Of particular relevance to Europe, with its

ageing population, they show how poor health increases the likelihood of early retirement. Taken together, this

evidence provides a powerful argument for European governments to invest in the health of their populations,

not only because better health is a desirable objective in its own right, but also because it is an important

determinant of economic growth and competitiveness.

As the High-Level Group on the Lisbon Strategy for Growth and Employment noted, Europe needs to increase

its investment in human capital as the productivity and competitiveness ‘of Europe’s economy are directly

dependent on a well-educated, skilled and adaptable workforce that is able to embrace change’. It went on to

emphasize that health and healthcare play a key role ‘in generating social cohesion, a productive workforce,

employment and hence economic growth’. By bringing together the information underpinning this argument in

an accessible form, the authors have made an important contribution to the debate on the future of the

European social model. I encourage you to read this excellent contribution”.

(Markos Kyprianou, Commissioner for Health and Consumer Protection)

I.1 Why is it important to discuss health and economic development now?

Recent years have seen important advances in our understanding of the link between health and economic

development in low-income countries, exemplified by the report of the Commission on Macroeconomics and

Health (CMH). Yet this issue has so far received scant attention in rich countries.

Is this lack of attention justifiable? We argue that it is not. While the economic argument for investing in

health in high-income countries may differ in detail from that in low-income countries, we have found

considerable and convincing evidence that significant economic benefits can be achieved by improving health

not only in developing, but also in developed countries. At the same time, we point to the existence of

significant gaps in our understanding that can be addressed by scholars working in the field.

The Commission on Macroeconomics and Health made a strong economic case for investing in health in their

final report published in 2001. Although confined primarily to evidence from low- and middle-income

countries, it helped bring about a shift in the prevailing paradigm: health was no longer seen as a mere by-

product of economic development, but as one of several key determinants of economic development and

poverty reduction. This has helped pave the way for health to be included in national development strategies

and policy frameworks in poor countries.

In contrast, the potential contribution of health to the economy has received rather less attention in high-

income countries, where health has not made its way into national economic development strategies and plans.

In most of these countries, the thrust of contemporary discussions on health reform typically sees interventions

that promote health and the delivery of healthcare as costs that need to be contained. In most countries, health

is among the weakest of ministries and there are only a few examples of finance ministries having engaged in

discussions with health ministries about how the latter could contribute to national economic outcomes

through activities that improve health, rather than exhorting them to cut costs.

There is a sound theoretical and empirical basis to the argument that human capital contributes to economic

growth. Since human capital matters for economic outcomes and since health is an important component of

human capital, health matters for economic outcomes. At the same time, economic outcomes also matter for

health. A recurring theme throughout this book is the existence of feedback loops offering the scope for

mutually reinforcing improvements in health and wealth.

From a European perspective, this question links closely with the debate on the European Union’s Lisbon

agenda. This discourse increasingly accepts that greater investment in human capital constitutes a necessary,

albeit not sufficient, condition for making the European economy more competitive in the wider world. If this

is to be achieved, it will be necessary to increase our understanding of the benefits to be derived from

investments in human capital, including those in population health.

Making the economic case for health is especially relevant at this moment in the history of European

integration, following the most recent enlargement. Income disparities between the 10 new Member States and

the EU-15 are large, but the health gap is also large. Some of the new Member States have life expectancies

that are more than 10 years lower than the average of the EU-15. Closing this health gap will be both

necessary for reducing the income differences in the EU and for demonstrating the success of enlargement.

A related issue is the scope for restraint on future growth of European economies exposed to the costs of

ageing populations that fall on pension and healthcare expenditures, with implications for macroeconomic

stability. This highlights the need to make timely investments in health in order to reduce the future burden of

preventable diseases and to allow Europe’s citizens to lead healthier and more productive lives.

It is not possible to assume that previous health gains will continue in the future. New health challenges, such

as rising levels of obesity, particularly among children, mental illness, microbial resistance to antibiotics and

newly emerging epidemics, remind us of the possibility of stagnation or even roll-back of the health status of

the European population in the longer run.

These trends give rise to increasing concern and are sufficiently worrying to justify undertaking a profound

reconsideration of the role of public health policy.

I.2 What is the relevance of the CMH’s report for the European Union?

The report of the Commission on Macroeconomics and Health constitutes an important reference point for our

work and provides a powerful underpinning of the argument that good health is an essential determinant of

economic growth, especially in developing countries, and that, conversely, bad health is a significant brake on

economic and social development. However, our work also shows that the situation in high-income countries

is specific in two important ways.

First, while in developing countries the predominant disease burden is attributable to communicable diseases,

maternal and perinatal conditions and nutritional deficiencies, in developed countries the greatest burden is

attributable to non-communicable diseases (such as cardiovascular disease, diabetes, injuries and mental health

problems). The Commission on Macroeconomics and Health was able to identify certain basic interventions to

address the former type of diseases.

The threats to health in Europe, however, are substantially more complex, and the nature of those threats is

such that they will require multifaceted intersectoral policies to prevent them from arising and integrated

multi-disciplinary management strategies to treat them.

Second, production techniques in high-income countries have particular features. Agriculture and primary

extraction are less important within the economy. Technological progress has meant that manual labour has

become a less important factor in generating output than in developing countries. Whether labour is

predominantly manual or not is likely to influence the ways in which ill health impacts upon labour market

outcomes.

I.3 What do we find in high-income countries?

The main contribution of this book is its review and synthesis of the dispersed evidence on the contribution of

health to the economy in high-income countries, bringing the relevant material together in a single place: cost-

of-illness studies; the impact of health at the individual and household level; the macroeconomic impact of

health, the ‘full income’ impact of health and the impact of the health system on the economy.

In our simple theoretical framework, we consider that health may contribute to economic outcomes in high-

income countries through four main channels: higher productivity, higher labour supply, improved skills as a

result of greater education and training, and increased savings available for investment in physical and

intellectual capital.

I.4 What is the cost of illness?

There are numerous cost-of-illness studies in high-income countries. These studies estimate the quantity of

resources (in monetary terms) used to treat a disease as well as the size of the negative economic consequences

(in terms of lost productivity) of illness to the society. They represent a useful first step in developing some

idea of the economic burden of ill health, showing that the magnitude of the economic impact is substantial. At

the same time they are limited by certain methodological challenges and by their failure to determine the

direction of causality in the relationship between health and economic outcomes. This is why we

predominantly look at more ‘structural’ analysis in the subsequent sections.

I.5 What is the impact of health at the individual and household level?

A significant amount of evidence exists to support the economic importance of health in the labour market in

rich countries. We present evidence that health matters for a number of economic outcomes: wages, earnings,

the amount of hours worked, labour force participation, early retirement and the labour supply of those giving

care to ill household members. In addition we reviewed the comparatively scarce evidence from developed

countries of the effect of health on education and on savings. The impact of health on savings has received

only limited attention in rich countries, despite the highly policy-relevant insights that could potentially be

gained from studying these relationships.

I.5.1 Wages and earnings

Several studies from high-income countries show that poor health negatively affects wages and earnings. The

magnitude of the impact obviously differs across studies (given different health proxies and methodologies)

and direct cross-country comparability of results is therefore limited.

While a significant number of studies have analyzed the impact of health on earnings and wages in high-

income countries, overall there appear to be comparatively few studies dealing explicitly with EU countries.

A number of studies find a significant impact of physiological proxies for health (e.g. height or body mass

index) on earnings and wages, not only in developing but also in some high-income countries. Height tends to

affect these labour market outcomes positively, while a higher body mass index (linked to overweight and

obesity) appears to depress wages and earnings more for women than for men. It is, however, likely that some

of the link between these physiological measures and labour market outcomes can be accounted for by the

social meaning attributed to height, and by social stigma in the case of obesity, rather than by a direct effect on

productivity.

I.5.2 Labour supply

An extensive empirical literature, mainly from the USA but recently also from Europe, confirms that health

increases the probability of participating in the labour force. There is, however, no consensus about the

magnitude of this effect and comparison of results from different studies is difficult as they use different

measures of health, model forms and estimation techniques.

A relatively large number of studies from high-income countries find a significant and robust role for ill health

in anticipating the decision to retire from the labour force. The relationship has been more extensively

researched in the USA than in Europe. When interpreting the results from different countries, one should keep

in mind that they are likely to be very sensitive to the institutional framework (e.g. pension rules, availability

of disability benefits and occupational insurance arrangements).

Ill health matters not only for the labour market performance of the individual directly concerned but also for

that of the household members, who have been found to adjust their labour market behaviour in response to

another household member’s illness. In the studies reviewed, men appear to reduce their own labour supply by

substantial amounts in the event of their wives’ illness, while in the reverse case women tend to increase their

labour supply. This can partly be explained by the unequal distribution of gender roles within the family and

the different situation of men and women in the labour market. The availability of health insurance can

critically affect the response to a spouse’s health condition.

I.5.3 Education

Human capital theory predicts that more educated individuals are more productive (and obtain higher

earnings). Good health in childhood enhances cognitive functions and reduces school absenteeism and early

drop-out rates. Hence, children with better health can be expected to attain higher educational levels and

therefore be more productive in the future. Moreover, healthier individuals with a longer lifespan in front of

them would have more incentives to invest in education and training, as they can harvest the associated

benefits for a longer period.

While theoretically plausible and empirically supported in the case of developing countries, there has been

relatively little work exploring and confirming this link in high-income countries.

More research would be needed.

I.5.4 Savings

It is again highly plausible to imagine that savings increase with the prospect of a longer and healthier life. The

idea of planning and, hence, saving for retirement would be expected to occur only when mortality rates

become low enough for retirement to be a realistic prospect. Some studies confirm such an effect in the case of

developing countries. For high-income countries, our review found comparatively little published research in

this area.

I.6 What is the macroeconomic impact of health?

Turning to the effect of health at the macroeconomic, i.e. country, level, historical studies exploring the role of

health in a specific country over one or two centuries have shown that a large share of today’s economic

wealth is directly attributable to past achievements in health.

Health — typically measured as life expectancy or adult mortality — enters as a very robust and sizeable

predictor of subsequent economic growth in virtually all studies that have examined growth differences

between poor and rich countries. However, researchers have focused rather less on the specific role of health

in economic growth among high-income countries alone, and in the few cases where this was done, health was

not always found to be positively related to economic growth. In some cases there was even a negative

relationship. We attribute these results partly to the use of health indicators that imperfectly capture the

existing health differences between high-income countries.

This is confirmed by a very recent analysis showing that if cardiovascular disease mortality is used as a health

proxy, health does matter significantly for subsequent economic growth in high income countries, but not in

low- and middle-income countries.

I.7 What is the contribution of health to the ‘full income’?

Taking the welfare or ‘full income’ impact of health into account gives an even stronger illustration of the

‘true’ economic importance of health. This approach starts from the uncontroversial recognition that GDP is

an imperfect measure of social welfare because it fails to incorporate non-market goods, such as the value of

health. The true purpose of economic activity is the maximization of social welfare, not necessarily the

production of goods by themselves. Since health is an important component of properly defined social welfare,

measuring the economic cost of ill health only in terms of foregone GDP leaves out a potentially major part of

its ‘full income’ impact, defined as its impact on social welfare. Most of the existing studies in this domain

have focused on the US context.

I.8 What is the contribution of the health systems on the economy?

While there is a direct effect of health on the economy, there is also an impact of the health system on the

economy irrespective of the ways in which the health system affects health. The health sector ‘matters’ in

economic terms simply because of its size. As one of the largest service industries, it represents one of the

most important sectors in developed economies. Currently its output accounts for about 7 % of GDP in the

EU-15, larger than the roughly 5 % accounted for by the financial services sector or the retail trade sector. And

around 9 % of all workers in the EU-25 are employed in the health and social work sector. Through its sheer

accounting effect, trends in productivity and efficiency in the health sector will have a large impact on these

performance measures in economies as a whole. Moreover, the performance of the health sector will affect the

competitiveness of the overall economy via its effect on labour costs, labour market flexibility and the

allocation of resources at the macroeconomic level.

I.9 Investing in health?

Following the evidence presented in this book, policy-makers who are interested in improving economic

outcomes would have a strong case for considering investment in health as one of their options by which to

meet their economic objectives.

It is beyond the scope of this book to define which health and healthcare policies should be implemented.

What is important is for governments to establish an integrated policy framework by which they can assure

themselves that what is being done to achieve good health is appropriate and effective.

This book argues the case for mechanisms that will permit the assessment of the health needs of a population,

the identification of effective interventions to respond to those needs and the monitoring of the results

achieved. This will enable resources to be targeted most effectively.

The fact that the disease burden in developed countries is mainly due to non-communicable diseases, many of

which are driven by lifestyle-related factors, and that, consequently, health, education, and cultural factors are

intimately related, implies that health investment must inevitably involve actions and measures addressing

issues lying outside the reach of the traditional healthcare systems. Health investment therefore requires action

across government.

I.10 Where do we go from here?

There is a crucial need to enhance the quality and availability of data on health as well as on the impact of

health on household behaviour in Europe. It has become apparent that, in this respect, most of the EU Member

States are far behind the United States where research can be undertaken with the benefit of a number of

public domain longitudinal surveys, such as the Health and Retirement Survey (HRS). The serious lack of data

is, as could be expected, a prime cause of the relative weakness of research on the effects of health on the

economy in most EU countries. And to the extent that evidence serves as an input into policy-making, the lack

of evidence may have been holding back an adequate policy response.

There is a need for more research on the role of health in economic growth in rich countries. This requires the

testing and development of health indicators that are more contextually appropriate than those commonly used

in the worldwide cross-country regressions. There is a particular need to explore the role of mental illness,

obesity and other emerging epidemics for economic outcomes (including economic growth) in high-income

countries.

As the next step in developing the economic argument further, more research is needed to assess the costs and

benefits of broader public health interventions. This would represent the ultimate and necessary step in order

to enable a direct comparison of the returns to health investment with alternative uses of money. In doing so, it

would further facilitate the integration of health investment into overall national economic development plans.

I.11 Why is the issue relevant for the EU countries — and why just now?

There are a number of reasons why acknowledging the importance of health for the economy is important for

the EU countries, particularly now.

Some might argue that the major gains in health in high-income countries over recent decades have brought

them to a level where further investment is unlikely to bring adequate returns. Life expectancy at birth in the

European Union Member States is already significantly above retirement age, with some commentators

arguing that further gains will simply increase the numbers of the unproductive retired. Leaving aside the

ethical issues that arise from such a position, it ignores two facts. First, average life expectancy at birth

conceals a wide dispersion in actual lengths of life lived by individuals.

In all European Union Member States a significant number of 20-year-olds (typically 10–15 %) will not

survive to retirement. Second, the number of years lived in good, and thus potentially productive, health is

even lower. Whether considering life expectancy or healthy life expectancy, there are widespread variations in

the European Union, both within and among countries, and much could be achieved simply by bringing the

worst-performing groups up to the level of the best. Reducing the inter-country differences in health has

become a particular challenge with the latest enlargement.

Some of the new Member States have life expectancies more than 10 years lower than the average of the EU-

15. Closing this health gap will be both necessary for reducing the income differences in the EU, and for

demonstrating the success of the process of enlargement.

The sheer endeavour to demonstrate the economic benefits of health may also seem a redundant activity to

some observers, since they consider it intuitively clear that good health provides a sound basis for labour

productivity and for the capacity to learn and grow intellectually, physically and emotionally.

For individuals and families, health provides the capacity for personal development and economic security.

Popular beliefs are not, however, always viewed by policy-makers as a substitute for rigorous empirical

research as an input into decision-making. In fact, while human capital has long been recognized as a

contributor to economic wealth in a substantial body of research, most of the theoretical and empirical

research has for a long time considered education as the only relevant contributor to human capital. This is

somewhat surprising, since people can only provide effective human capital if they are alive and healthy. The

role of health as a decisive component of human capital and, hence, as a potential determinant of economic

growth has only recently been the subject of major research attention.

One reason for this new interest has been a recognition that it is not possible to assume that previous health

gains will continue as before. The experiences of both the former Soviet Union and sub-Saharan Africa show

that, even in peacetime, life expectancy can decline (McMichael et al. 2004).

While the situation is very different in the European Union, rising levels of obesity among children and the

failure to reduce smoking rates among young women in some countries constitute an omen of possible

stagnation or even a roll-back of the health status of the European population in the longer run. These trends

are giving rise to increasing concern among politicians and their advisers and are sufficiently worrying to

justify undertaking a profound reconsideration of the role and potential of public health policy.

Within the European Union the debate about health and economic development is currently also being shaped

by discussions about the EU’s Lisbon agenda. This discourse increasingly accepts that greater investment in

human capital constitutes a necessary, albeit not sufficient, condition for making the European economy more

competitive. This is said to require intensification of investment in research and development (R & D) but also

investment in the education and health of the population.

The formulation of public policies to achieve these goals will, however, require a considerable enhancement of

our understanding of the effectiveness of and return on investments in human capital, including investments in

public health.

Underlying the Lisbon agenda is a concern about Europe’s slow labour productivity growth as well as its

limited labour supply compared with the USA. For the first time in the post-war period, the average labour

productivity growth in the EU since 1996 has been lower than in the USA. This has been linked to a decline in

hourly productivity growth in the EU, while at the same time the American economy benefited from the longer

hours worked and from higher labour force participation rates by the elderly. The report by the High Level

Group on the Lisbon Strategy for Growth and Employment (2004) argues that Europe needs to increase the

level and efficiency of investments in human capital as the productivity and competitiveness ‘of Europe’s

economy are directly dependent on a well-educated, skilled and adaptable workforce that is able to embrace

change’3. As the same report states, health and healthcare play a key role ‘in generating social cohesion, a

productive workforce, employment and hence economic growth’.

It is not only labour productivity and supply that is a concern for Europe. The process of population ageing

will also pose important challenges to all European economies. The low fertility rates of the last few decades

will soon have an impact on the size of the available workforce. European economies facing slowing

population growth, or even declines, cannot afford to lose potential labour resources due to avoidable disease

3 High Level Group on the Lisbon Strategy for Growth and Employment (2004).

and disability. In particular, the need to boost the participation in the labour force of older workers, which is

one of the Lisbon targets, will require not only investments in lifelong learning, but also in policies that

promote the physical and mental health of Europe’s older population. A further concern is the expected costs

attributable to an ageing population that will fall on pension and healthcare budgets. This presents an

important challenge to macroeconomic stability that could restrain future growth of European economies. In

this context, it is important to consider the potential for savings on health costs that could come from more

effective and efficient prevention and treatment of disease and disability, especially as they impact upon the

elderly.

For all of these reasons, the moment seems to have arrived for the EU Member States to take health more

seriously as an important contributor to the economy and to act upon this recognition.

I.12 Channels of influence between health and the economy

Since human capital matters for economic outcomes and since health is an important component of human

capital, health also matters for economic outcomes. At the same time, economic outcomes matter for health4.

Health is determined by genetic, economic, social, cultural and environmental factors. But the health of a

population may also, in return, influence the economic context.

In line with the scheme proposed by Bloom et al. (2001), we suggest in this study that health could contribute

to economic outcomes (at both the individual and the country level) in high-income countries mainly through

four channels: higher productivity, higher labour supply, higher skills as a result of greater education and

training, and more savings available for investment in physical and intellectual capital.

The health of an individual depends on many factors: genetic endowments, lifestyle, living and working

conditions (access and use of healthcare, education, wealth, housing, occupation) and the more general

socioeconomic, cultural and environmental conditions5. Several of these determinants of health can be

influenced by public policies.

The main interest of the present study is to review the evidence on the positive effect of good health on the

economy, not the reverse pathway, which has been widely documented elsewhere (Marmot 2002). The four

principal mechanisms that could explain the effect of health on the economy are briefly described in the

following sections.

I.12.1 Labour productivity

Healthier individuals could reasonably be expected to produce more per hour worked. On the one hand,

productivity could increase directly due to enhanced physical and mental activity. On the other hand, more

physically and mentally active individuals could also make a better and more efficient use of technology,

machinery or equipment. A healthier labour force could also be expected to be more flexible and adaptable to

changes (e.g. changes in job tasks, in the organisation of labour).

I.12.2 Labour supply

The impact of health on labour supply is theoretically ambiguous. Good health reduces the number of days an

individual spends sick, which consequently results in an increase in the number of healthy days available for

either work or leisure. But health also influences the decision to supply labour through its impact on wages,

preferences and expected life horizon. The effect of health on labour supply through each of these intermediate

factors is not always obvious. On the one hand, if wages are linked to productivity, and healthier workers are

more productive, health improvements are expected to increase wages and thus the incentives to increase

labour supply (substitution effect). On the other hand, being healthy might allow higher lifetime earnings and

therefore an earlier withdrawal from the labour force (income effect).

4 Zweifel and Breyer (1997) argued for instance that the empirical evidence would fail to confirm the crucial Grossman

model prediction of the positive partial correlation between medical care and good health. Accordingly, the notion that expenditure on medical care constitutes a demand derived from an underlying demand for health cannot be upheld. This criticism, however, was countered by Grossman (1999). 5 Definition of health determinants in the website of the Health and Consumer Protection DG:

http://europa.eu.int/comm/health/ph_determinants/healthdeterminants_en.htm

The way in which health affects individual preferences also affects whether and how health determines

economic outcomes. One could imagine that, as health improves, working becomes less cumbersome, and

therefore the individual might be ready to take up more work in exchange of leisure time. However, one could

also imagine that a health improvement reduces the needs for consumption (e.g. of health treatments or

medicines) and therefore reduces the relative preference for work, leading to a reduction of working time and

an increase in leisure time.

Finally, if good health changes neither preferences nor wages, but raises life expectancy, the individual’s

needs for lifetime consumption would increase, leading to a higher labour supply6.

I.12.3 Education

According to human capital theory, more educated individuals are more productive (and obtain higher

earnings). Since children with better health and nutrition tend to achieve higher educational attainment and

suffer less from school absenteeism and early drop-out, improved health in early ages indirectly contributes to

future productivity.

Moreover, if good health is also linked to higher life expectancy, healthier individuals would have higher

incentives to invest in education and training, as the depreciation rate of the skills acquired would be lower.

I.12.4 Savings and investment

The state of health of an individual or a population is likely to impact not only upon the level of income but

also the distribution of this income between savings and consumption and the willingness to undertake

investment.

Individuals in good health are likely to have a wider time horizon and their savings ratio may consequently be

higher than the savings ratio of individuals in poor health. Other things being equal, a population whose life

expectancy increases may therefore also be expected to have higher savings. This should also result in a higher

propensity to invest in physical or intellectual capital.

In sum, there are a number of channels that may causally link health and economic outcomes on the individual

and on the aggregate (macro) level. The most common denominator of all of these channels is that health can

be seen as an integral part of human capital.

I.13 From management culture the excellence of providing model

In the 52 countries that comprise the WHO European Region, values are present in the preamble of almost

every National health policy. However they are not so visible in the core text of these policies, in the parts that

describe actions, resources, implementation and evaluation. Some sort sham seems to exist. On one side there

are values, seen as inspirational, taken-for-granted, self-explanatory general statements. On the other side there

is the reality of policy making in public health. The headline preambles and the detailed texts do not always

link. It is easy to use values as a mantra rather than an agenda.

The World Health Organization (WHO) Regional Office for Europe was confronted with this discrepancy

when it began work on developing the 2005 update of the European Health for All policy framework, further

referred in this text as Health for All. The process of preparing the update (2003-2005) included a careful re-

examination, to render them more useful and relevant and thus encourage their practical implementation.

Several important questions were raised:

- What role do values play in the Region’s national health sectors?

- What are the values valid for the European health sectors in the twenty-first century?

- Do these values also lie at the heart of policies formulated in other sectors – particularly the major

policy dealing with national, social and economic development –?

6 The decision to work could also be influenced by the health of relatives. In this case the impact of health is also

theoretically ambiguous. On the one hand, if other family members leave work due to health deterioration, this could cause a drop in household income, which the individual might try to compensate for by increasing his or her labour supply. This could also be the case if the onset of a health problem increases financial needs (for example due to increased need for healthcare). On the other hand, the need to care for a sick or disabled person could lead the individual to reduce his or her labour supply or to exit from the labour force.

- How can these values be better understood; how can they be made more useful to policy makers?

- What kinds of mechanism would contribute to the practical implementation of these values?

The approach was to address these problems. The European Observatory of Health Systems and Policies made

a systematic study of the health policies of all the 52 member States of the WHO European Region. Further, a

think tank was created, bringing together experts with diverse professional backgrounds, with broad

knowledge and experience in formulating, assessing and implementing health policies internationally,

nationally and sub-nationally, all across the Region. Finally, a review was made of a wide range of available

tools that might enable policy makers to assess whether values are present and respected in their national

health policies.

The analysis revealed that, either directly or indirectly, many national policies referred to the core values

described in the 1998 update of the European Health for All policy (health 21) and also before that update.

This suggests that the European Region shares a general ethical orientation.

However the regional Office now wished to check whether these declared ethical commitments were in any

way consistent with actual decisions taken and activities implemented. Was this measurable? In short, how to

verify that the deeds matched the words? Although the work on the 2005 Health for All update revealed a

general deficit of well developed methodologies capable of making such evaluations, at the empirical level

some national experiences demonstrated a lack of consistency between stated values and actual practice.

For instance, while most national health policy documents declare commitment to equity and solidarity, in

practice equity is not progressing and the gaps in health status and health gains between different social sub-

groups are increasing. What is the value of values then, if evidence suggests that it is not respected in actions

taken?

Raising these concerns does not mean denying the importance of values for European health policy making.

Rather, it means that we are brave enough to ask the obvious question: “Do we need values?”.

Modern science constantly brings people to new thresholds. The exploding progress in research and

technologies offers significant benefits and health gains. At the same time, this progress raises some ethical

problems. Improvement in health has no limits, but resources do have limits. In real life, not all advances can

be made available to everyone who would benefit from them. “Medicine… has no equity plan”.

This means that policy makers always confront the need to make choices. And here is where values can be

valuable. Policy makers can best justify their choices when they demonstrate, through their decisions, that they

have respected and implemented the values cherished by their societies.

In reality, all health policies – and all other public policies – imply ethical assumptions. It is hard to imagine a

health policy making procedure without them. And because certain shared core values permeate all sectors of

society, frameworks of common values are essential for any policy making process and mark out the range of

policy options that is politically acceptable (Danzon, 2006).

I.14 Administering under financial crisis

I.14.1 World crisis: The Path to the World Afterwards

On March 29th

2009, Franck Biancheri - Director of European Political Anticipation Laboratory - signed an

open letter in the Financial Times international edition from LEAP/E2020 to the g20 leaders who were going

to meet in London the next week. In its introduction, this text predicted that if the three recommendations it

contained were not implemented as soon as possible, rather than a crisis of three to five years, the world would

sink into a crisis for more than a decade.

Here we are two and a half years later and, alas, it is now clear that not only has the crisis revealed in 2008 not

been resolved7, but is getting worse instead now combining loss of confidence in paper currencies and the

Western banking system8, relapse of the world economy into recession, permanent rise in Western

unemployment, explosive public debt in Western countries and growing unease of the emerging powers in

front of an old order that refuses to think of its’ succession.

In 2009, LEAP/E2020 gave three pieces of strategic advice to the g20 leaders:

. in priority, create a new international reference currency to replace the US Dollar, which is now unable to

hold the role of the pillar of the global monetary system;

7 Contrary to what the majority of the political, financial and economic leaders have unceasingly maintained during

these last two years. 8 Of which gold’s return to the forefront as a safe haven is the best indicator.

. at the same time ensure that the public authorities take control of the major banks which have become real

"black holes" of liquidity, either by nationalization or other methods;

. finally, carry out via the IMF, a thorough audit of the American, British and Swiss financial systems at the

heart of the financial world.

Without these essential reforms and their rapid implementation in the six months following the g20 summit in

London, we indicated that the "window of opportunity" would close for several years.

To complete these recommendations, the open letter stressed the importance of publishing a statement from

the g20 which should be brief and easily understood by world public opinion in the absence of the power to

curb people’s fears.

Today everybody realizes that almost three years wasted since the same problems remain a burning issue9.

But political anticipation is not a school of regret, but an instrument to help decision-making.

For LEAP/E2020 it is time, therefore, on the eve of the new g20 summit to be held in Cannes on 3-4

November 2011, to continue the effort begun in 2009. This effort is intended to prevent the world plunging

into what Franck Biancheri calls "the tragic scenario for the 2010-2020 decade"10

. And the time seems

particularly favourable since, according to our team, a new "window of opportunity" will open in 2012, for a

maximum period of two years.

A new window of opportunity for action by the g20 opens in 2012

In effect, during 2012, the leaders of almost half the g20 countries will be replaced. This will be the case for

Mexico, South Korea, the United States, China, Russia, India, France, Italy and probably Germany11

. From the

end of 2012, the g20 Summit will, therefore, bring together political leaders mainly elected "in the crisis", and

not before the crisis as is now the case. On this basis, the preparation of summits for 2012, 2013 and 2014 will

no longer be paralyzed and / or interfered with by the many "taboos", "impossibilities" or, on the contrary,

"now obsolete certainties" or "the obvious which is no more" belonging to the world before the crisis. In any

case, this new generation of leaders will not be able to pretend they have discovered a situation for which it

has not been prepared; and to paraphrase the conclusion of our 2009 open letter, it won’t be able to pretend

either not to have been advised of the available opportunities to take the planet on a path of peaceful transition

to the world after the crisis.

At the same time, the recent widespread awareness (since the beginning of the second half of 2011) of the fact

that that everything remains to be done to try to overcome the global systemic crisis created, for a year or two

at the most, a situation conducive to political audacity. Exhausted by the consequences of the crisis and

alarmed by the inefficiency of the steps taken to resolve it, public opinion everywhere is now ready to support

or go along with major upheavals in the order that has prevailed in recent decades, both in socio-economic and

geopolitical terms. But here also, please remember that this state of mind will only be positive if it is exposed

to proposed ambitious solutions reflecting the interests of the vast majority and that otherwise, from 2013, it

will metamorphose into destructive anger everywhere, targeting existing systems and leaders.

Having defined the conditions for the exercise of a first effective power by the g20, LEAP/E2020 advises the

g20 leaders to focus on three strategic priorities in 2012/2013. We emphasize the importance of a tight agenda,

refusing dissemination over a wide variety of subjects. In fact, the complexity of the problem, namely the

emergence of a new global governance, like the need to communicate to convince public opinion consisting of

several billions of citizens in very diverse political, social, cultural, economic contexts, requires focus on the

essentials.

The g20’s three strategic priorities for constructing the future from 2012/2013

And for LEAP/E2020, the essentials are contained in these three strategic priorities that fundamentally

determine all the future architecture of global governance and, at the same time, purify the dangerous areas of

the current system. Simply put, it’s a case of building the future whilst defusing the present from the bombs of

the past.

First priority: from 2012 (at the latest) launch the process for creating a new global reserve currency. At this

stage the simplest method would be to turn SDRs into this new global monetary instrument giving it a more

appealing name of course, and retaining the currencies of the major economies in the basket defining its value:

9 In addition, LEAP/E2020 recommended that the Eurozone leaders, from 2007, establish a Euroland governance as soon

as possible. We recall here that the term Euroland, which has become very fashionable, was created by Franck Biancheri and used for the first time in an article entitled "2004 or the birth of Euroland", published the 02/11/2004 in NewropMag . 10

In his book « World crisis: The Path to the World Afterwards » published at the end of 2010 by Editions Anticipolis. 11

Where the prospect of early elections is very likely.

US Dollar, Euro, Yen, Yuan, Real, Ruble, the Gulf currency (if it emerges by then), South African Rand, and

possibly gold, which de facto has once again become a safe haven currency. It’s a case of restructuring the

world monetary system on the real economy, then exiting the "financial" currencies such as the Pound sterling

or the Swiss Franc.

Technical problems do not exist. The expertise exists within the international institutions to carry out all the

work required to create such a currency within a year. The difficulty exclusively arises, therefore, from the

emergence of a determined political will from the g20 to keep to a schedule of two years to create and launch

this new currency.

This willingness, and the decisional weight necessary and sufficient to bring it to fruition, will potentially exist

in a subgroup of the g20 consisting of Euroland, the BRICs, and several other emerging countries. The

political changes at the head of the main Euroland countries like the current growing confrontation between

Euroland on the one hand and Wall Street and the City on the other will create, in the next 12 months at most,

the perfect conditions for a Euroland-BRICS convergence on such an agenda.

It’s starting with this "creative" core that the g20 summit’s agenda in late 2012 must be prepared which will

include of course, otherwise nothing will happen, a radical reform and with immediate effect of the

composition of the capital and caucus of the major global organizations (IMF, World Bank, WTO, UN

Security Council)12

. At the rate of evolution of the crisis, in 2012, neither Washington nor London will no

longer be able (even if they still wanted to13

) to oppose the creation of this new global reference currency.

The vision and determination of Euroland leaders14

, the BRICs and other emerging countries in the g20 will be

the only factors of the success or failure of this fundamental reform without which the current international

monetary system will continue to sink into increasing chaos year after year, producing terrible setbacks for

world trade, the global economy and international cooperation, all whilst fuelling the rise in unemployment

and the impoverishment of Western middle classes, and considerably slowing down the development of

emerging economies.

Without a "reliable standard" there is no stable economic and financial system. It’s here that this priority is

strategic: without it, nothing significant or lasting can be done since any measure is corrupted by a standard

(the US Dollar) which has become weak, elastic and unpredictable.

Second priority: Put all the world’s major financial institutions under public tutelage, wholly or partly, from

the beginning of 2013 at the latest. The list is known already since it’s those that, at the request of the g20, the

Financial Stability Board qualify as carrying systemic risk. To which should be added the BRICs and

emerging countries’ major institutions because it is obvious that many of them will become "systemic" in the

next five years. The objective in this area is twofold: first to ensure that these institutions resist speculative

temptations - although we already know that it isn’t possible to trust their leadership and / or private

shareholders in this area; second, to organize a "gentle deflation", which doesn’t break the real economy, of

the virtual economy. Any country refusing such a policy will have their establishments concerned blacklisted,

just like what has been tried unsuccessfully for tax havens. Without success, because there was no determined

political will on the subject, and especially because it’s not the tax haven that speculates ... it is the major bank

that uses it. This time, the g20 has no room for error: neither mistaking the target, nor the method.

Third priority: At the end of 2012 launch a huge ten-year public infrastructure programme on a world scale. In

the term "infrastructure", LEAP/E2020 particularly includes all essential public services such as education,

access to medical care and basic services (water, electricity, telecommunications) and some symbolic science

programs (medicine, space and energy). Through this bias of supporting effective and sustainable 15

global

growth by the best and safest use16

of the current imbalances in financial resources: the countries benefiting

from substantial surpluses finding a useful and safe means of recycling them. It’s also, in our opinion, the only

way to put a stop to the accelerated evaporation of trillions of US dollar assets generated by the current

financial crisis and economic recession. Imagine a budget of one trillion Euros (a symbolic figure in

communication terms) split into two geopolitical envelopes: one for infrastructure or projects involving many

12

If the G20 wants to be at the heart of global governance, the leaders who participate must act as political leaders on a scale that addresses and resolves the major issues, and not as managers discussing technical issues. 13

Which would be the proof for LEAP/E2020 that their leaders lack vision for their countries’ medium and long term interests; because, anyway, the developments in this area are inevitable. The only question to ask is: will this be done as part of a peaceful and controlled process or via a decade of all sorts of conflict? 14

And their advisors. 15

By means of a decennial programme taking into consideration the requirements in terms of energy savings . 16

The other option consists of seeing their surplusses continue to lose value due to the crisis.

regions of the world; the other focused on a single region or one country. Western countries should also

benefit because otherwise we remain in the logic of the world before the crisis and their economies and

because their economies also need a big hand (especially the United States as regards infrastructure).

To conclude this second piece of advice to the g20 leaders in less than three years, LEAP/E2020 wishes to

draw their attention to a fundamental methodological point. The content and form are closely related, it is

essential that from the end of 2012 the world should be able to see a radical change in the process of the

geographic location of the g20’s work, and beyond, from 2013, global governance. The urgency and

complexity of the g20’s work in this period justifies the holding of two g20 summits per year. After that

planned in Mexico mid-2012, it is necessary to make provision for one in the last quarter of 2012 so that all

the new leaders elected during the year can begin to bring their weight to bear on the institution’s work and

agenda.

In addition, from this date, it would be desirable, for obvious reasons of global credibility, that the summits

leave the Atlanticist fold17

to be held with the emerging powers: China, Brazil, India and Russia seem obvious

choices, to show that the g20 is not a g7 decorated with invited countries. No doubt this will help to radically

progress the agendas, an indispensable condition for overcoming the crisis.

Finally, in this sense, it is inevitable that from 2013/2014 the discussion will start on the relocation of major

international institutions to ensure that the geography of global governance after the crisis reflects the real

world and not that of 1945. Far from being details, these changes go to the heart of the decision making

process and will be tremendous assets in convincing public opinion so it really feels that there is indeed an

historic change taking place in the minds of those who lead them and not just in their meetings’ press releases.

Speaking of method, we have to explain to our subscribers what we have chosen for this "G-20 2011Action"18

.

This year LEAP/E2020 has chosen a very different approach from that adopted in 2009. There will be no open

letter published in the Financial Times or any other international newspaper: first, because LEAP/E2020’

audience today is wide enough to no longer need an intermediary19

. Secondly, because it’s time to no longer

depend on the Anglo-Saxon media, whose international coverage reflects "the world before the crisis", to

communicate such messages aimed at preparing "the world after the crisis". Thus we reaffirm by example that

the content and form are closely linked to ensure coherent action and discussion, thus ensuring maximum

effectiveness for the effort undertaken.

This advice will, therefore, be distributed to GEAB subscribers initially then exceptionally20

posted publicly

on the website in mid-October, two weeks before the Summit in Cannes. Meanwhile, for the last six months,

in partnership with LEAP and Anticipolis editions, Franck Biancheri , LEAP/E2020 Director, has begun an

operation to distribute the international edition21

of his book "The World Crisis: The Path to the World

Afterwards" and LEAP/E2020’s work with diplomats and special advisers from all countries participating in

the G20 summit in Cannes22

[16]. Moreover, we can only praise the very positive welcome received to date by

almost all the countries concerned. This awareness work will continue right up to the summit itself in early

November.

In the book "World crisis: The Path to the World Afterwards" Biancheri says:

“The financial and economic crisis that the world has been facing in the past two years marks the end of the

world order established after 1945. In 1989, the “Soviet pillar” has collapsed and we are now witnessing the

accelerated decomposition of the “Western pillar” with the United States at the heart of the process of

disintegration.

After two decades spent living in the myth of an “ended history” in which our Western camp would be

imposed universally, it is almost impossible to imagine “a world after” where tendencies would not be defined

17

Since the end of 2008 summits have been held in Washington, Pittsburgh, Toronto and Seoul. The next will be held in Cannes and the following in Mexico. These are very American-centred locations. Source: Wikipedia. 18

And this is especially true since many of you ask us how we can share our analyses at the highest level. 19

See the information on LEAP/E2020 site traffic, which has become the site on the global crisis benefiting from the largest global audience. Source: LEAP, 08/21/2011. 20

We are sure that GEAB subscribers will understand this bending of our rule of waiting three months before eventually putting any excerpts from a GEAB issue in the public domain. We are sure that GEAB subscribers will understand this bending of our rule of waiting three months before eventually putting any excerpts from a GEAB issue in the public domain. 21

English, German, Spanish and Italian versions. 22

Who will, of course, receive the advice formulated here by LEAP/E2020.

in Washington or Wall Street, where “Anglo-American” would not necessarily mean “modern” and where the

dollar would no longer be king.

As in Eastern Europe before 1989, neither our media nor our leaders are capable of helping us “imagine the

unimaginable”, they are too busy trying to make us “forget the unforgettable”, in particular, the socio-

economic consequences of the crisis throughout the world. This book attempts to fill this lack of anticipation

of our leaders and elites by giving a concrete vision of the future in Europe and the world by 2020.

What conflicts can this world-after-the-crisis generate? How to prepare for monetary and economic upheavals

coming up in the next few years? How can we and should we cope as Europeans? How will the emerging

powers such as Brazil, India, Russia and China interact in the first place? What difficulties will these countries

meet on their way up? How can our children position themselves to prepare for this world afterwards, as

citizens and as professionals?

These are some of the questions that this book tries to answer by providing leads for reflection and action to

the individual as much as to the group. Because this crisis we are experiencing is not only the end of the

“world before”, it is also an unprecedented opportunity to rebuild a “world after”, provided not to be mistaken

about the dangers, challenges and opportunities that lie ahead.” (Biancheri, 2010).

I.14.2 The double and contemporary challenge of Ageing and the Financial Crisis – The need of a new Model

of Rights & Budgets balance based on Social, Technological and Financial Integrated Innovation – Active and

Healthy Ageing . Financing?

Financial crisis will progressively lower the public budget sustainability with huge negative consequences in

social and health expenditure. Not only reliable public long term commitments will be almost difficult, but a

reduction of services due to cutting of costs is expected. The cuts of the costs will happen without knowing the

costs of the cuts and a “crisis in the crisis” will occur.

The passage from “concepts to services” will be interrupted or slowed and solidarity as well as quality of life

for elders will be affected. The same prolongation of life years will be put in discussion.

It is time to study, plan and work well understanding we’re not only “during” the crisis, but “under” the crisis.

To build an inclusive and sustainable society now is not like ten years ago. We’re in front of a new dangerous

challenge and we cannot act and react as if it would be absent.

Social Science and Humanities Research could play now a pivotal role analyzing and promoting new alliances

through the indispensable passage from actions to interactions and from interactions to integrations.

It is just the time to study the art of alliance focusing on common goals, starting from redefining the Common

Good, its innovation and its proper and stable financing.

Social Science and Humanities Research could promote a model of Integrated Innovation coming from Social,

Technological and Financial fields. These three fields cannot walk alone anymore: it is a luxury we cannot

afford.

At all.

A new regulatory and financial framework is strongly needed, coming from a new epistemological approach.

Understanding, explaining and acting need to become a method to be stronger than financial crisis and to look

forward in the mean and long period. Short termism is the enemy that Social Science and Humanities Research

can fight, helping Society, Institutions and Policy to find the right way for the future and a better idea of

Europe.

Social, Technological and Financial Integrated Innovation does really constitute a model out of traditional

paradigms, as financial crisis is out of traditional paradigms of development, progress and democracy.

Financing Social Innovation in respect of equity and excellence is quite a huge matter: necessary resources

must be considered also out of the fiscal ones. We’re not speaking now of our destination, but about our

destiny.

The so called “Financial Industry” has in its hands something like 74 times the World GDP and Pension Funds

represent almost half of this amount. Good practices related to “Pension Fund Investment in Infrastructure”

were described by OECD in a report in 2009 : schools, railways, hospitals, roads could be built.

Of course a Regional Innovation Model for Active and Healthy Ageing (on a large scale Integrated Health

Promotion & Healthcare, e-health, ICT, AAL, LLL , proper health workforce number, training and skills etc)

does really represent a wider application requiring wider investments not affordable by Public but obviously

affordable by Pension Funds.

Although pension funds exist for the benefit of workers, control of the assets rests with trustees who, in turn,

usually turn over the funds to a bank, an insurance company, or an independent investment manager. Control

of the investment of such vast sums necessarily confers power to influence the economic and social direction

of the nation.

While investment policies have been traditionally dictated by purely economic considerations, growing

concern for the social consequences of investment decisions now poses new questions of both law and policy.

To the partisans of "socially responsible" investing, investments are more than a vehicle for financial return;

investment practice includes support or repudiation of the conduct of the entity invested in.

Interest in directing investment funds for social goals has been improved by the financial crisis.

A quantitative approach is strongly needed to understand and to manage the economic consequences of

evolving social needs. The passage from concepts to services is fundamental. Concepts are budget-free,

services are budget-related.

We wish to speak of Active and Healthy Ageing as a concrete possibility given to the European ageing

population each day, each week, each month and each year . This could seem perhaps very complicated but it

clearly indicates the quality of democracy. Democracy needs continuous maintenance, control and

surveillance.

STF - Integrated Innovation (STF INNOINTEGRA) could help a good recognition of needs using also

sophisticated methodologies. A good technological approach finalized to equity and excellence together with a

proper financial support could be not only a dream.

The “Handbook on the Socialization of Scientific and Technological Research” (Social Science and European

Research Capacities SS-ERC Project FP6 – Citizenship and Governance in a knowledge based Society) was

defined as a “tool for promoting science and technology socialization policies addressed to policy makers,

research and innovation actors and stakeholders”.

In this handbook the weak socialization of research in Europe was put in evidence. Why? Connecting Social

Innovation, Technological Innovation with Financial Innovation socialization of research could certainly

improve.

Financial Crisis recently proposed/imposed a new awareness of risks of social and financial default so

involving a multidisciplinary and interdisciplinary scientific approach: the capability to study the passage from

actions to interactions and from interactions to integrations.

This does really mean understanding the effect of multiplying the complexity of players’ actions if seen

internally to an integrated (interactive) system.

John Nash’s Theory of Games could be seen in a new way, just imagining the presence of a new player,

powerful, silent and efficacious: the limit. The Financial Crisis is now the limit.

European Innovation Partnership on Active and Healthy Ageing wants to prepare the implementation work:

the financial limit due to the crisis will last at least 10/15 years. How will be the relations between institutions,

stakeholders, professionals, scientific world, research, social, economy, etc. as they will be closer to the

financial limit?

Social Science and Humanities is a particular kind of research, useful to study and to perceive macroeconomic

models finally as part of a whole social texture in the most dynamic, interactive and integrated way. Not a

separate, invisible and unintelligible world. Democracy is weak without knowledge, information and

communication.

Always speaking of the actual Financial Crisis, the first truth that immediately appears is that redistribution of

richness is at the basis of any social functioning model.

The lesson learned from Great Crisis in USA in the 1929 and the knowledge of the role of the redistributive

model let us understand Marriner Eccles’ (President of FED under Roosvelt’s Presidency) strong and

successful reaction to avoid policy made of cuts, but protecting expenditure capacity.

Socialization of research does not mean only a better approach to social needs to enlarge technology market,

but a deeper analysis of redistribution of richness to better understand all the consequences on the life of

billions of human beings when redistribution is lacking (Felli et al., 2012).

I.14.3 Per una riforma del sistema finanziario e monetario internazionale nella prospettiva di un’autorità

pubblica a competenza universale

Si riporta di seguito una nota del Pontificio Consiglio della giustizia e della pace (2011).

I.14.3.1 Prefazione

“…omissis…

«La situazione attuale del mondo esige un’azione d’insieme sulla base di una visione chiara di tutti gli aspetti

economici, sociali, culturali e spirituali. Esperta in umanità, la Chiesa, lungi dal pretendere minimamente

d’intromettersi nella politica degli Stati, “non ha di mira che un unico scopo: continuare, sotto l’impulso dello

Spirito consolatore, la stessa opera del Cristo, venuto nel mondo per rendere testimonianza alla verità, per

salvare, non per condannare, per servire, non per essere servito”»23

.

Con queste parole, Paolo VI, nella profetica e sempre attuale Enciclica Populorum progressio del 1967,

tracciava in maniera limpida «le traiettorie» dell’intima relazione della Chiesa con il mondo: traiettorie che si

intersecano nel valore profondo della dignità dell’uomo e nella ricerca del bene comune, e che pure rendono i

popoli responsabili e liberi di agire secondo le proprie più alte aspirazioni.

La crisi economica e finanziaria che sta attraversando il mondo chiama tutti, persone e popoli, a un profondo

discernimento dei principi e dei valori culturali e morali che sono alla base della convivenza sociale. Ma non

solo. La crisi impegna gli operatori privati e le autorità pubbliche competenti a livello nazionale, regionale e

internazionale ad una seria riflessione sulle cause e sulle soluzioni di natura politica, economica e tecnica.

In tale prospettiva, la crisi, insegna Benedetto XVI, «ci obbliga a riprogettare il nostro cammino, a darci nuove

regole e a trovare nuove forme di impegno, a puntare sulle esperienze positive e a rigettare quelle negative. La

crisi diventa così occasione di discernimento e di nuova progettualità. In questa chiave, fiduciosa piuttosto che

rassegnata, conviene affrontare le difficoltà del momento presente»24

.

Gli stessi leader del g20, nello Statement adottato a Pittsburgh nel 2009, hanno affermato come «The

economic crisis demonstrates the importance of ushering in a new era of sustainable global economic activity

grounded in responsibility»25

.

Raccogliendo l’appello del Santo Padre e, al tempo stesso, facendo proprie le preoccupazioni dei popoli —

soprattutto di quelli che maggiormente soffrono il prezzo della situazione attuale — il Pontificio Consiglio

della Giustizia e della Pace, nel rispetto delle competenze delle autorità civili e politiche, intende proporre e

condividere la propria riflessione «Per una riforma del sistema finanziario e monetario internazionale nella

prospettiva di un’autorità pubblica a competenza universale».

Tale riflessione vuole essere un contributo ai responsabili della terra e a tutti gli uomini di buona volontà; un

gesto di responsabilità non solo nei confronti delle generazioni presenti, ma soprattutto di quelle future;

affinché non sia mai perduta la speranza di un futuro migliore e la fiducia nella dignità e nella capacità di bene

della persona umana.

Ogni singola persona, ogni comunità di persone, è partecipe e responsabile della promozione del bene comune.

Fedeli alla loro vocazione di natura etica e religiosa, le comunità di credenti devono per prime interrogarsi

sull’adeguatezza dei mezzi di cui la famiglia umana dispone in vista della realizzazione del bene comune

mondiale. La Chiesa, per parte sua, è chiamata a stimolare in tutti indistintamente «la volontà di partecipare a

quell’ingente sforzo con il quale, nel corso dei secoli, [gli uomini] cercano di migliorare le proprie condizioni

di vita, corrisponde[ndo così] alle intenzioni di Dio»26

.

I.14.3.1.1. Sviluppo economico e disuguaglianze

La grave crisi economica e finanziaria, che il mondo oggi attraversa, trova la sua origine in molteplici cause.

Sulla pluralità e sul peso di queste cause persistono opinioni diverse: alcuni sottolineano anzitutto gli errori

insiti nelle politiche economiche e finanziarie; altri insistono sulle debolezze strutturali delle istituzioni

politiche, economiche e finanziarie; altri ancora le attribuiscono a cedimenti di natura etica intervenuti a tutti i

livelli, nel quadro di un’economia mondiale sempre più dominata dall’utilitarismo e dal materialismo. Nei

diversi stadi di sviluppo della crisi, si riscontra sempre una combinazione di errori tecnici e di responsabilità

morali.

Nel caso di scambio di beni materiali e di servizi, sono la natura e la capacità produttiva e il lavoro in tutte le

sue molteplici forme che pongono un limite alle quantità, determinando un insieme di costi e di prezzi che

permette, sotto certe condizioni, un’allocazione efficiente delle risorse disponibili.

Ma in materia monetaria e finanziaria le dinamiche sono diverse. Negli ultimi decenni sono state le banche ad

estendere il credito, il quale ha generato moneta, che a sua volta ha sollecitato un’ulteriore espansione del

credito. Il sistema economico è stato in tale maniera spinto verso una spirale inflazionistica che

23

Paolo VI, Lettera enciclica Populorum progressio, n. 13. 24

Benedetto XVI, Lettera enciclica Caritas in veritate, n. 21. 25

Leaders’ Statement, The Pittsburgh Summit, September 24-25, 2009; Annex, 1. 26

Concilio Vaticano II, Costituzione pastorale sulla Chiesa nel mondo contemporaneo Gaudium et spes, n. 34.

inevitabilmente ha trovato un limite nel rischio sostenibile per gli istituti di credito, sottoposti a un pericolo

ulteriore di fallimento, con conseguenze negative per l’intero sistema economico e finanziario.

Dopo la Seconda Guerra Mondiale, le economie nazionali sono avanzate, sebbene con enormi sacrifici per

milioni, anzi per miliardi di persone che avevano dato fiducia, con il loro comportamento di produttori e

imprenditori da un lato, di risparmiatori e consumatori dall’altro, a un progressivo regolare sviluppo della

moneta e della finanza in linea con le potenzialità di crescita reale dell’economia.

Dagli anni Novanta dello scorso secolo si riscontra invece come la moneta e i titoli di credito a livello globale

siano aumentati in misura molto più rapida della produzione del reddito, anche a prezzi correnti. Ne sono

derivate la formazione di sacche eccessive di liquidità e di bolle speculative che poi si sono trasformate in una

serie di crisi di solvibilità e di fiducia che si sono propagate e susseguite nel corso degli anni.

Una prima crisi si è verificata negli anni Settanta fino ai primi anni Ottanta ed era relativa ai prezzi del

petrolio. In seguito si sono avute una serie di crisi in vari Paesi in via di sviluppo. Si pensi alla prima crisi del

Messico negli anni Ottanta, oppure a quelle del Brasile, della Russia e della Corea, quindi di nuovo del

Messico negli anni Novanta, della Thailandia, dell’Argentina.

La bolla speculativa sugli immobili e la recente crisi finanziaria hanno la medesima origine nell’eccessivo

ammontare di moneta e di strumenti finanziari a livello globale.

Mentre le crisi nei Paesi in via di sviluppo, che hanno rischiato di coinvolgere il sistema monetario e

finanziario globale, sono state contenute con forme di intervento da parte dei Paesi più sviluppati, la crisi

scoppiata nel 2008 è stata caratterizzata da un fattore decisivo e dirompente rispetto a quelle precedenti. Essa è

stata generata nel contesto degli Stati Uniti, una delle aree più rilevanti per l’economia e la finanza mondiale,

coinvolgendo la moneta a cui fa tuttora capo la stragrande maggioranza degli scambi internazionali.

Un orientamento di stampo liberista — reticente rispetto ad interventi pubblici nei mercati — ha fatto

propendere per il fallimento di un importante istituto finanziario internazionale, immaginando in tal modo di

delimitare la crisi e i suoi effetti. Ne è derivata purtroppo una propagazione di sfiducia che ha spinto a mutare

repentinamente atteggiamento, sollecitando interventi pubblici sotto varie forme, di enorme portata (oltre il 20

per cento del prodotto nazionale) al fine di tamponare gli effetti negativi che avrebbero travolto tutto il sistema

finanziario internazionale.

Le conseguenze sulla cosiddetta «economia reale», passando attraverso le gravi difficoltà di alcuni settori —

in primo luogo dell’edilizia — e attraverso il diffondersi di aspettative sfavorevoli, hanno generato una

tendenza negativa della produzione e del commercio internazionale, con gravi riflessi sull’occupazione e con

effetti che ancora non hanno probabilmente esaurito tutta la loro portata. I costi per milioni, anzi miliardi di

persone, nei Paesi sviluppati ma anche soprattutto in quelli in via di sviluppo, sono rilevanti.

In Paesi e aree dove mancano ancora i beni più elementari della salute, del cibo, del riparo dalle intemperie,

oltre un miliardo di persone sono costrette a sopravvivere con un reddito medio di poco più di un dollaro al

giorno.

Il benessere economico globale, misurato in primo luogo dalla produzione del reddito e anche dalla diffusione

delle capabilities, si è accresciuto, nel corso della seconda metà del XX secolo, in una misura e con una

rapidità mai sperimentate nella storia del genere umano.

Ma sono anche aumentate enormemente le disuguaglianze all’interno dei vari Paesi e tra di essi. Mentre alcuni

Paesi e aree economiche, quelle più industrializzate e sviluppate, hanno visto crescere notevolmente la

produzione del reddito, altri Paesi sono stati di fatto esclusi dal miglioramento generalizzato dell’economia e

persino hanno peggiorato la loro situazione.

I pericoli di una situazione di sviluppo economico, concepito in termini liberistici, sono stati lucidamente e

profeticamente denunciati da Paolo VI — per le conseguenze nefaste sugli equilibri mondiali e sulla pace —

già nel 1967, dopo il Concilio Vaticano II, con l’Enciclica Populorum progressio. Il Pontefice indicò come

condizioni imprescindibili, per la promozione di un autentico sviluppo, la difesa della vita e la promozione

della crescita culturale e morale delle persone. Su tali basi, affermava Paolo VI, lo sviluppo plenario e

planetario «è il nuovo nome della pace»27

.

A quaranta anni di distanza, nel 2007, il Fondo Monetario Internazionale riconobbe, nel suo Rapporto annuale,

la stretta connessione tra un processo di globalizzazione non adeguatamente governato da un lato, e le forti

disuguaglianze a livello mondiale dall’altro28

. Oggi i moderni mezzi di comunicazione rendono evidenti a tutti

i popoli, ricchi e poveri, le disuguaglianze economiche, sociali e culturali che si sono determinate a livello

globale generando tensioni e imponenti movimenti migratori.

27

Lettera enciclica Populorum progressio, nn. 76 ss. 28

Cfr. International Monetary Fund, Annual Report 2007, pp. 8 ss.

Tuttavia, va ribadito che il processo di globalizzazione con i suoi aspetti positivi è alla base del grande

sviluppo dell’economia mondiale del XX secolo. Vale la pena di ricordare che tra il 1900 e il 2000 la

popolazione mondiale si è quasi quadruplicata e che la ricchezza prodotta a livello mondiale è cresciuta in

misura molto più rapida cosicché il reddito medio pro capite è fortemente aumentato. Allo stesso tempo, però,

non è aumentata l’equa distribuzione della ricchezza, piuttosto, in molti casi essa è peggiorata.

Ma cosa ha spinto il mondo in questa direzione estremamente problematica anche per la pace?

Anzitutto un liberismo economico senza regole e senza controlli. Si tratta di una ideologia, di una forma di

«apriorismo economico», che pretende di prendere dalla teoria le leggi di funzionamento del mercato e le

cosiddette leggi dello sviluppo capitalistico esasperandone alcuni aspetti. Un’ideologia economica che

stabilisca a priori le leggi del funzionamento del mercato e dello sviluppo economico, senza confrontarsi con

la realtà, rischia di diventare uno strumento subordinato agli interessi dei Paesi che godono di fatto di una

posizione di vantaggio economico e finanziario.

Regole e controlli, sia pure in maniera imperfetta, sono spesso presenti a livello nazionale e regionale; tuttavia,

a livello internazionale tali regole e controlli fanno fatica a realizzarsi e a consolidarsi.

Alla base delle disparità e delle distorsioni dello sviluppo capitalistico c’è, in gran parte, oltre all’ideologia del

liberismo economico, l’ideologia utilitarista, ossia quella impostazione teorico-pratica per cui «l’utile

personale conduce al bene della comunità». È da notare che una simile «massima» contiene un’anima di

verità, ma non si può ignorare che non sempre l’utile individuale, sebbene legittimo, favorisce il bene comune.

In più di un caso è richiesto uno spirito di solidarietà che trascenda l’utile personale per il bene della comunità.

Negli anni Venti del secolo scorso alcuni economisti avevano già messo in guardia dal dare eccessivamente

credito, in assenza di regole e controlli, a quelle teorie oggi divenute ideologie e prassi dominanti a livello

internazionale.

Un effetto devastante di queste ideologie, soprattutto negli ultimi decenni del secolo scorso e i primi anni del

nuovo secolo, è stato lo scoppio della crisi nella quale il mondo si trova tuttora immerso.

Benedetto XVI, nella sua enciclica sociale, ha individuato in maniera precisa la radice di una crisi che non è

solamente di natura economica e finanziaria, ma prima di tutto di natura morale, oltre che ideologica.

L’economia, infatti — osserva il Pontefice — ha bisogno dell’etica per il suo corretto funzionamento, non di

un’etica qualsiasi, bensì di un’etica amica della persona29

. Egli, poi, ha denunciato il ruolo svolto

dall’utilitarismo e dall’individualismo, nonché le responsabilità di chi li ha assunti e diffusi come parametro

per il comportamento ottimale di coloro — operatori economici e politici — che agiscono e interagiscono nel

contesto sociale. Ma Benedetto XVI ha anche individuato e denunciato una nuova ideologia, l’ideologia della

tecnocrazia.

I.14.3.1.2. Il ruolo della tecnica e la sfida etica

Il grande sviluppo economico e sociale dello scorso secolo, certamente con le sue luci ma anche con i suoi

gravi coni d’ombra, è dovuto anche al continuato sviluppo della tecnica e, nei decenni più recenti, ai progressi

dell’informatica e alle sue applicazioni, all’economia e in primo luogo alla finanza.

Per interpretare con lucidità l’attuale nuova questione sociale, occorre senz’altro, però, evitare l’errore, figlio

anch’esso dell’ideologia neoliberista, di ritenere che i problemi da affrontare siano di ordine esclusivamente

tecnico. Come tali, essi sfuggirebbero alla necessità di un discernimento e di una valutazione di tipo etico.

Ebbene, l’enciclica di Benedetto XVI mette in guardia contro i pericoli dell’ideologia della tecnocrazia, ossia

di quell’assolutizzazione della tecnica che «tende a produrre un’incapacità di percepire ciò che non si spiega

con la semplice materia»30

e a minimizzare il valore delle scelte dell’individuo umano concreto che opera nel

sistema economico-finanziario, riducendole a mere variabili tecniche. La chiusura a un «oltre», inteso come un

di più rispetto alla tecnica, non solo rende impossibile trovare soluzioni adeguate per i problemi, ma

impoverisce sempre più, sul piano materiale e morale, le principali vittime della crisi.

Anche nel contesto della complessità dei fenomeni la rilevanza dei fattori etici e culturali non può, dunque,

essere trascurata o sottostimata. La crisi, di fatto, ha rivelato comportamenti di egoismo, di cupidigia collettiva

e di accaparramento di beni su grande scala. Nessuno può rassegnarsi a vedere l’uomo vivere come «un lupo

per l’altro uomo», secondo la concezione evidenziata da Hobbes. Nessuno, in coscienza, può accettare lo

sviluppo di alcuni Paesi a scapito di altri. Se non si pone un rimedio alle varie forme di ingiustizia gli effetti

negativi che ne deriveranno sul piano sociale, politico ed economico saranno destinati a generare un clima di

29

Cfr. Lettera enciclica Caritas in veritate, n. 45. 30

Ib., n. 77.

crescente ostilità e perfino di violenza, sino a minare le stesse basi delle istituzioni democratiche, anche di

quelle ritenute più solide.

Dal riconoscimento del primato dell’essere rispetto a quello dell’avere, dell’etica rispetto a quello

dell’economia, i popoli della terra dovrebbero assumere, come anima della loro azione, un’etica della

solidarietà, abbandonando ogni forma di gretto egoismo, abbracciando la logica del bene comune mondiale

che trascende il mero interesse contingente e particolare. Dovrebbero, in definitiva, avere vivo il senso di

appartenenza alla famiglia umana in nome della comune dignità di tutti gli esseri umani: «prima ancora della

logica dello scambio degli equivalenti e delle forme di giustizia, [...] che le sono proprie, esiste un qualcosa

che è dovuto all’uomo perché è uomo, in forza della sua eminente dignità»31

.

Già nel 1991, dopo il fallimento del collettivismo marxista, il Beato Giovanni Paolo II aveva messo in guardia

nei confronti del rischio di «un’idolatria del mercato, che ignora l’esistenza di beni che, per loro natura, non

sono né possono essere semplici merci»32

. Oggi occorre senz’indugio accogliere il suo ammonimento e

imboccare una strada più in sintonia con la dignità e con la vocazione trascendente della persona e della

famiglia umana.

I.14.3.1.3 Il governo della globalizzazione

Nel cammino verso la costruzione di una famiglia umana più fraterna e giusta e, prima ancora, di un nuovo

umanesimo aperto alla trascendenza, appare inoltre particolarmente attuale l’insegnamento del Beato Giovanni

XXIII. Nella profetica Lettera enciclica Pacem in terris del 1963, egli avvertiva che il mondo si stava

avviando verso una sempre maggiore unificazione. Prendeva quindi atto del fatto che, nella comunità umana,

era venuta meno la rispondenza fra l’organizzazione politica «su piano mondiale e le esigenze obiettive del

bene comune universale»33

. Per conseguenza auspicava la creazione, un giorno, di «un’Autorità pubblica

mondiale»34

.

A fronte dell’unificazione del mondo, propiziata dal complesso fenomeno della globalizzazione; a fronte

dell’importanza di garantire, oltre agli altri beni collettivi, quello rappresentato da un sistema economico-

finanziario mondiale libero, stabile e a servizio dell’economia reale, oggi l’insegnamento della Pacem in terris

appare ancor più vitale e degno di urgente concretizzazione.

Lo stesso Benedetto XVI, nel solco tracciato dalla Pacem in terris, ha espresso la necessità di costituire

un’Autorità politica mondiale35

. Tale necessità appare del resto evidente, se si pensa al fatto che l’agenda delle

questioni da trattare a livello globale diventa costantemente più ampia. Si pensi, ad esempio, alla pace e alla

sicurezza; al disarmo e al controllo degli armamenti; alla promozione e alla tutela dei diritti fondamentali

dell’uomo; al governo dell’economia e alle politiche di sviluppo; alla gestione dei flussi migratori e alla

sicurezza alimentare; alla tutela dell’ambiente. In tutti questi ambiti risulta sempre più evidente la crescente

interdipendenza tra Stati e regioni del mondo e la necessità di risposte, non solo settoriali e isolate, ma

sistematiche e integrate, ispirate dalla solidarietà e dalla sussidiarietà e orientate al bene comune universale.

Come ricorda Benedetto XVI, se non si persegue questa strada anche «il diritto internazionale, nonostante i

grandi progressi compiuti nei vari campi, rischierebbe di essere condizionato dagli equilibri di potere tra i più

forti»36

.

Lo scopo dell’Autorità pubblica, rammentava già Giovanni XXIII nella Pacem in terris, è anzitutto quello di

servire il bene comune. Essa, pertanto, deve dotarsi di strutture e meccanismi adeguati, efficaci, ossia

all’altezza della propria missione e delle aspettative che in essa sono riposte. Questo è particolarmente vero

all’interno di un mondo globalizzato, che rende persone e popoli sempre più interconnessi e interdipendenti,

ma che mostra anche il peso dell’egoismo e degli interessi settoriali, tra cui l’esistenza di mercati monetari e

finanziari a carattere prevalentemente speculativo, dannosi per l’economia reale, specie dei Paesi più deboli.

È un processo complesso e delicato. Tale Autorità sovranazionale deve, infatti, avere un’impostazione

realistica ed essere messa in atto con gradualità, con l’obiettivo di favorire anche l’esistenza di sistemi

monetari e finanziari efficienti ed efficaci, ossia mercati liberi e stabili, disciplinati da un adeguato quadro

giuridico, funzionali allo sviluppo sostenibile e al progresso sociale di tutti, ispirati ai valori della carità nella

31

Giovanni Paolo II, Lettera enciclica Centesimus annus, n. 70. 32

Ib., n. 40. 33

Giovanni XXIII, Lettera enciclica Pacem in terris, n. 70. 34

Cfr. ib. nn. 71-74. 35

Cfr. Lettera enciclica Caritas in veritate, n. 67. 36

Ib.

verità37

. Si tratta di un’Autorità dall’orizzonte planetario, che non può essere imposta con la forza, ma

dovrebbe essere espressione di un accordo libero e condiviso, oltre che delle esigenze permanenti e storiche

del bene comune mondiale e non frutto di coercizione o di violenze. Essa dovrebbe sorgere da un processo di

maturazione progressiva delle coscienze e delle libertà, nonché dalla consapevolezza di crescenti

responsabilità. Non possono, per conseguenza, essere tralasciati come superflui elementi quali la fiducia

reciproca, l’autonomia e la partecipazione. Il consenso deve coinvolgere un sempre maggior numero di Paesi

che aderiscono in maniera convinta, mediante quel dialogo sincero che non emargina, bensì valorizza le

opinioni minoritarie. L’Autorità mondiale dovrebbe, dunque, coinvolgere coerentemente tutti i popoli, in una

collaborazione in cui essi sono chiamati a contribuire con il patrimonio delle loro virtù e delle loro civiltà.

La costituzione di un’Autorità politica mondiale dovrebbe essere preceduta da una fase preliminare di

concertazione, dalla quale emergerà una istituzione legittimata, in grado di offrire una guida efficace e, al

tempo stesso, di permettere a ciascun Paese di esprimere e di perseguire il proprio bene particolare. L’esercizio

di una simile Autorità, posta al servizio del bene di tutti e di ciascuno, sarà necessariamente super partes, ossia

al di sopra di ogni visione parziale e di ogni bene particolare, in vista della realizzazione del bene comune. Le

sue decisioni non dovranno essere il risultato del pre-potere dei Paesi più sviluppati sui Paesi più deboli.

Dovranno, invece, essere assunte nell’interesse di tutti, non solo a vantaggio di alcuni gruppi, siano essi

formati da lobby private o da Governi nazionali.

Un’Istituzione sopranazionale, espressione di una «comunità delle Nazioni», non potrà peraltro durare a lungo,

se le diversità dei Paesi, sul piano delle culture, delle risorse materiali ed immateriali, delle condizioni storiche

e geografiche non sono riconosciute e pienamente rispettate. L’assenza di un consenso convinto, alimentato da

un’incessante comunione morale della comunità mondiale, indebolirebbe l’efficacia della corrispettiva

Autorità.

Ciò che vale a livello nazionale vale anche a livello mondiale. La persona non è fatta per servire

incondizionatamente l’Autorità, il cui compito è quello di porsi al servizio della persona stessa, in coerenza

con il valore preminente della dignità dell’uomo. Parimenti, i Governi non devono servire

incondizionatamente l’Autorità mondiale. È piuttosto quest’ultima che deve mettersi al servizio dei vari Paesi

membri, secondo il principio di sussidiarietà, creando, tra l’altro, quelle condizioni socio-economiche,

politiche e giuridiche, indispensabili anche all’esistenza di mercati efficienti ed efficaci, perché non

iperprotetti da politiche nazionali paternalistiche, perché non indeboliti da deficit sistematici delle finanze

pubbliche e dei Prodotti nazionali, che di fatto impediscono ai mercati stessi di operare in un contesto

mondiale come istituzioni aperte e concorrenziali.

Nella tradizione del Magistero della Chiesa, ripresa con vigore da Benedetto XVI38

, il principio di sussidiarietà

deve regolare le relazioni tra Stato e comunità locali, tra Istituzioni pubbliche e Istituzioni private, non escluse

quelle monetarie e finanziarie. Così, su un ulteriore livello, deve reggere le relazioni tra una eventuale futura

Autorità pubblica mondiale e le istituzioni regionali e nazionali. Un tale principio è a garanzia sia della

legittimità democratica sia dell’efficacia delle decisioni di coloro che sono chiamati a prenderle. Permette di

rispettare la libertà delle persone e delle comunità di persone e, al tempo stesso, di responsabilizzarle rispetto

agli obiettivi e ai doveri che loro competono.

Secondo la logica della sussidiarietà, l’Autorità superiore offre il suo subsidium, ovvero il suo aiuto, quando la

persona e gli attori sociali e finanziari sono intrinsecamente inadeguati o non riescono a fare da sé quanto è

loro richiesto39

. Grazie al principio di solidarietà, si costruisce un rapporto durevole e fecondo tra la società

civile planetaria e un’Autorità pubblica mondiale, quando gli Stati, i corpi intermedi, le varie istituzioni —

comprese quelle economiche e finanziarie — e i cittadini prendono le loro decisioni entro la prospettiva del

bene comune mondiale, che trascende quello nazionale.

«Il governo della globalizzazione» — si legge nella Caritas in veritate — «deve essere di tipo sussidiario,

articolato su più livelli e su piani diversi, che collaborino reciprocamente»40

. Solo così si può evitare il

pericolo dell’isolamento burocratico dell’Autorità centrale, che rischierebbe di essere delegittimata da un

distacco troppo grande dalle realtà sulle quali si fonda e potrebbe facilmente cadere in tentazioni

paternalistiche, tecnocratiche, o egemoniche.

Un lungo cammino resta però ancora da percorrere prima di arrivare alla costituzione di una tale Autorità

pubblica a competenza universale. Logica vorrebbe che il processo di riforma si sviluppasse avendo come

37

Cfr. ib. 38

Cfr. ib., nn. 57 e 67. 39

Cfr. ib., n. 57. 40

Ib.

punto di riferimento l’Organizzazione delle Nazioni Unite, in ragione dell’ampiezza mondiale delle sue

responsabilità, della sua capacità di riunire le Nazioni della terra e della diversità dei suoi compiti e di quelli

delle sue Agenzie specializzate. Il frutto di tali riforme dovrebbe essere una maggiore capacità di adozione di

politiche e scelte vincolanti poiché orientate alla realizzazione del bene comune a livello locale, regionale e

mondiale. Tra le politiche appaiono più urgenti quelle relative alla giustizia sociale globale: politiche

finanziarie e monetarie che non danneggino i Paesi più deboli41

; politiche volte alla realizzazione di mercati

liberi e stabili e a un’equa distribuzione della ricchezza mondiale mediante anche forme inedite di solidarietà

fiscale globale, di cui si dirà più avanti.

Nel cammino della costituzione di un’Autorità politica mondiale non si possono disgiungere le questioni della

governance (ossia di un sistema di semplice coordinamento orizzontale senza un’Autorità super partes) da

quelle di uno shared government (ossia di un sistema che, oltre al coordinamento orizzontale, stabilisca

un’Autorità super partes) funzionale e proporzionato al graduale sviluppo di una società politica mondiale. La

costituzione di un’Autorità politica mondiale non può essere raggiunta senza la previa pratica del

multilateralismo, non solo a livello diplomatico, ma anche e soprattutto nell’ambito dei piani per lo sviluppo

sostenibile e per la pace. A un Governo mondiale non si può pervenire se non dando espressione politica a

preesistenti interdipendenze e cooperazioni.

I.14.3.1.4. Verso una riforma del sistema finanziario e monetario internazionale rispondente alle esigenze di

tutti i Popoli

In materia economica e finanziaria, le difficoltà più rilevanti derivano dalla carenza di un insieme efficace di

strutture, in grado di garantire, oltre ad un sistema di governance, un sistema di government dell’economia e

della finanza internazionale.

Che dire di questa prospettiva? Quali passi muovere in concreto?

Con riferimento all’attuale sistema economico e finanziario mondiale vanno sottolineati due fattori

determinanti. Il primo è il graduale venir meno dell’efficienza delle istituzioni di Bretton Woods, a partire dai

primi anni Settanta. In particolare, il Fondo Monetario Internazionale ha perso un carattere essenziale per la

stabilità della finanza mondiale, quello di regolare la creazione complessiva di moneta e di vegliare

sull’ammontare di rischio di credito assunto dal sistema. In definitiva non si dispone più di quel «bene

pubblico universale» che è la stabilità del sistema monetario mondiale. Il secondo fattore è la necessità di un

corpus minimo condiviso di regole necessarie alla gestione del mercato finanziario globale, cresciuto molto

più rapidamente dell’economia reale, essendosi velocemente sviluppato per effetto, da un lato,

dell’abrogazione generalizzata dei controlli sui movimenti di capitali e dalla tendenza alla deregolamentazione

delle attività bancarie e finanziarie e, dall’altro, dei progressi della tecnica finanziaria favoriti dagli strumenti

informatici.

Sul piano strutturale, nell’ultima parte del secolo scorso, la moneta e le attività finanziarie a livello globale

sono cresciute molto più rapidamente della produzione di beni e di servizi. In tale contesto, la qualità del

credito ha teso a diminuire sino ad esporre gli istituti di credito a un rischio maggiore di quello

ragionevolmente sostenibile. Basti guardare alle sorti di grandi e piccoli istituti di credito nel contesto delle

crisi che si sono manifestate negli anni Ottanta e Novanta del secolo scorso e infine nella crisi del 2008.

Sempre nell’ultima parte del secolo scorso, si è sviluppata la tendenza a definire gli orientamenti strategici

della politica economica e finanziaria all’interno di club e di gruppi più o meno estesi di Paesi più sviluppati.

Pur non negando gli aspetti positivi di questo approccio, non si può non notare che esso non sembra rispettare

pienamente il principio rappresentativo, in particolare dei Paesi meno sviluppati o emergenti.

La necessità di tener conto della voce di un maggiore numero di Paesi ha, per esempio, indotto l’allargamento

dei suddetti gruppi, passando così dal g7 al g20. Questa è stata un’evoluzione positiva, in quanto ha consentito

di coinvolgere, negli orientamenti all’economia e alla finanza globale, la responsabilità di Paesi con più

elevata popolazione, in via di sviluppo ed emergenti.

Nell’ambito del g20 possono pertanto maturare indirizzi concreti che, opportunamente elaborati nelle

appropriate sedi tecniche, potranno orientare gli organi competenti a livello nazionale e regionale al

consolidamento delle istituzioni esistenti e alla creazione di nuove istituzioni con appropriati ed efficaci

strumenti a livello internazionale.

Gli stessi leader del g20, nella Dichiarazione finale di Pittsburgh del 2009, affermano del resto come «la crisi

economica dimostra l’importanza di avviare una nuova era dell’economia globale fondata sulla

41

Cfr. Concilio Vaticano II, Costituzione pastorale sulla Chiesa nel mondo contemporaneo Gaudium et spes, n. 70.

responsabilità». Per fare fronte alla crisi e aprire una nuova era «della responsabilità», oltre alle misure di tipo

tecnico e di breve periodo, i leader avanzano la proposta di una «riforma dell’architettura globale per fare

fronte alle esigenze del 21° secolo»; e quindi quella di «un quadro che consenta di definire le politiche e le

misure comuni per generare uno sviluppo globale solido, sostenibile e bilanciato»42

.

Occorre quindi avviare un processo di profonda riflessione e di riforme, percorrendo vie creative e realistiche,

tendenti a valorizzare gli aspetti positivi delle istituzioni e dei fora già esistenti.

Un’attenzione specifica andrebbe riservata alla riforma del sistema monetario internazionale e, in particolare,

all’impegno per dar vita a qualche forma di controllo monetario globale, peraltro già implicita negli Statuti del

Fondo Monetario Internazionale. È chiaro che, in qualche misura, questo equivale a mettere in discussione i

sistemi dei cambi esistenti, per trovare modi efficaci di coordinamento e supervisione. È un processo che deve

coinvolgere anche i Paesi emergenti e in via di sviluppo nel definire le tappe di un adattamento graduale degli

strumenti esistenti.

Sullo sfondo si delinea, in prospettiva, l’esigenza di un organismo che svolga le funzioni di una sorta di

«Banca centrale mondiale» che regoli il flusso e il sistema degli scambi monetari, alla stregua delle Banche

centrali nazionali. Occorre riscoprire la logica di fondo, di pace, coordinamento e prosperità comune, che

portarono agli Accordi di Bretton Woods, per fornire adeguate risposte alle questioni attuali. A livello

regionale tale processo potrebbe essere praticato con la valorizzazione delle istituzioni esistenti, come ad

esempio la Banca Centrale Europea. Ciò richiederebbe, tuttavia, non solo una riflessione sul piano economico

e finanziario, ma anche e prima di tutto, sul piano politico, in vista della costituzione di istituzioni pubbliche

corrispettive che garantiscano l’unità e la coerenza delle decisioni comuni.

Queste misure dovrebbero essere concepite come alcuni dei primi passi nella prospettiva di una Autorità

pubblica a competenza universale; come una prima tappa di un più lungo sforzo della comunità mondiale di

orientare le sue istituzioni alla realizzazione del bene comune. Altre tappe dovranno seguire, tenendo conto

che le dinamiche che conosciamo possono accentuarsi, ma anche accompagnarsi a cambiamenti che oggi

sarebbe vano tentare di prevedere.

In tale processo occorre recuperare il primato dello spirituale e dell’etica e, con essi, il primato della politica

— responsabile del bene comune — sull’economia e la finanza. Occorre ricondurre queste ultime entro i

confini della loro reale vocazione e della loro funzione, compresa quella sociale, in considerazione delle loro

evidenti responsabilità nei confronti della società, per dare vita a mercati e istituzioni finanziarie che siano

effettivamente a servizio della persona, che siano capaci, cioè, di rispondere alle esigenze del bene comune e

della fratellanza universale, trascendendo ogni forma di piatto economicismo e di mercantilismo performativo.

Sulla base di un tale approccio di tipo etico, appare, quindi, opportuno riflettere, ad esempio:

a) su misure di tassazione delle transazioni finanziarie, mediante aliquote eque, ma modulate con oneri

proporzionati alla complessità delle operazioni, soprattutto di quelle che si effettuano nel mercato

«secondario». Una tale tassazione sarebbe molto utile per promuovere lo sviluppo globale e sostenibile

secondo principi di giustizia sociale e della solidarietà e potrebbe contribuire alla costituzione di una

riserva mondiale, per sostenere le economie dei Paesi colpiti dalle crisi, nonché il risanamento del loro

sistema monetario e finanziario;

b) su forme di ricapitalizzazione delle banche anche con fondi pubblici condizionando il sostegno a

comportamenti «virtuosi» e finalizzati a sviluppare l’economia reale;

c) sulla definizione dell’ambito dell’attività di credito ordinario e di Investment Banking. Tale distinzione

consentirebbe una disciplina più efficace dei «mercati-ombra» privi di controlli e di limiti.

Un sano realismo richiederebbe il tempo necessario per costruire consensi ampi, ma l’orizzonte del bene

comune universale è sempre presente con le sue esigenze ineludibili. È pertanto auspicabile che tutti coloro

che, nelle Università e nei vari Istituti, sono chiamati a formare le classi dirigenti di domani si dedichino a

prepararle alle loro responsabilità di discernere e di servire il bene pubblico globale in un mondo in costante

cambiamento. È necessario colmare il divario presente tra formazione etica e preparazione tecnica,

evidenziando in particolar modo l’ineludibile sinergia tra i due piani della praxis e della poièsis.

Lo stesso sforzo è richiesto a tutti coloro che sono in grado di illuminare l’opinione pubblica mondiale, per

aiutarla ad affrontare questo mondo nuovo non più nell’angoscia ma nella speranza e nella solidarietà.

I.14.3.2 Conclusioni

42

Leaders’ Statement, The Pittsburgh Summit, September 24-25, 2009; cfr. Annex, paragrafo 1; G-20 Framework for Strong, Sustainable, and Balanced Growth, §1; Leaders’ Statement, nn. 18, 13.

Nelle incertezze attuali, in una società capace di mobilitare mezzi ingenti, ma la cui riflessione sul piano

culturale e morale rimane inadeguata rispetto al loro utilizzo in ordine al conseguimento di fini appropriati,

siamo invitati a non arrenderci e a costruire soprattutto un futuro di senso per le generazioni a venire. Non

bisogna temere di proporre cose nuove, anche se possono destabilizzare equilibri di forze preesistenti che

dominano sui più deboli. Esse sono un seme gettato nella terra, che germoglierà e non tarderà a portare i suoi

frutti.

Come ha esortato Benedetto XVI, sono indispensabili persone ed operatori a tutti i livelli — sociale, politico,

economico, professionale —, mossi dal coraggio di servire e promuovere il bene comune mediante una vita

buona43

. Essi soltanto riusciranno a vivere e a vedere oltre le apparenze delle cose, percependo il divario tra il

reale esistente e il possibile mai sperimentato.

Paolo VI ha sottolineato la forza rivoluzionaria dell’«immaginazione prospettica», capace di percepire nel

presente le possibilità in esso inscritte e di orientare gli uomini verso un futuro nuovo44

. Liberando

l’immaginazione, l’uomo libera la sua esistenza. Mediante un impegno di immaginazione comunitaria è

possibile trasformare non solo le istituzioni ma anche gli stili di vita e suscitare un avvenire migliore per tutti i

popoli.

Gli Stati moderni, nel tempo, sono divenuti insiemi strutturati, concentrando la sovranità all’interno del

proprio territorio. Ma le condizioni sociali, culturali e politiche sono progressivamente mutate. È cresciuta la

loro interdipendenza — sicché è divenuto naturale pensare ad una comunità internazionale integrata e retta

sempre più da un ordinamento condiviso —, ma non è venuta meno una forma deteriore di nazionalismo,

secondo cui lo Stato ritiene di poter conseguire in maniera autarchica il bene dei suoi cittadini.

Oggi tutto ciò appare surreale e anacronistico. Oggi tutte le nazioni, piccole o grandi, assieme ai loro Governi,

sono chiamate a superare quello «stato di natura» che vede gli Stati in perenne lotta tra loro. Nonostante alcuni

suoi aspetti negativi, la globalizzazione sta unificando maggiormente i popoli, sollecitandoli a muoversi verso

un nuovo «stato di diritto» a livello sopranazionale, sostenuto da una collaborazione più intensa e feconda.

Con una dinamica analoga a quella che in passato ha messo fine alla lotta «anarchica» tra clan e regni rivali, in

ordine alla costituzione di Stati nazionali, l’umanità deve oggi impegnarsi nella transizione da una situazione

di lotte arcaiche tra entità nazionali, a un nuovo modello di società internazionale più coesa, poliarchica,

rispettosa delle identità di ciascun popolo, entro la molteplice ricchezza di un’unica umanità. Un tale

passaggio, peraltro già timidamente in corso, assicurerebbe ai cittadini di tutti i Paesi — qualunque ne sia la

dimensione o la forza — pace e sicurezza, sviluppo, mercati liberi, stabili e trasparenti. «Come all’interno dei

singoli Stati [...] il sistema della vendetta privata e della rappresaglia è stato sostituito dall’impero della legge»

— avverte Giovanni Paolo II— «così è ora urgente che un simile progresso abbia luogo nella Comunità

internazionale»45

.

I tempi per concepire istituzioni con competenza universale arrivano quando sono in gioco beni vitali e

condivisi dall’intera famiglia umana, che i singoli Stati non sono in grado di promuovere e proteggere da soli.

Esistono, quindi, le condizioni per il definitivo superamento di un ordine internazionale «westphaliano», nel

quale gli Stati sentono l’esigenza della cooperazione, ma non colgono l’opportunità di un’integrazione delle

rispettive sovranità per il bene comune dei popoli.

È compito delle generazioni presenti riconoscere e accettare consapevolmente questa nuova dinamica

mondiale verso la realizzazione di un bene comune universale. Certo, questa trasformazione si farà al prezzo

di un trasferimento graduale ed equilibrato di una parte delle attribuzioni nazionali ad un’Autorità mondiale e

alle Autorità regionali, ma questo è necessario in un momento in cui il dinamismo della società umana e

dell’economia e il progresso della tecnologia trascendono le frontiere, che nel mondo globalizzato sono di

fatto già erose.

La concezione di una nuova società, la costruzione di nuove istituzioni dalla vocazione e competenza

universali, sono una prerogativa e un dovere per tutti, senza distinzione alcuna. È in gioco il bene comune

dell’umanità e il futuro stesso.

In tale contesto, per ogni cristiano c’è una speciale chiamata dello Spirito ad impegnarsi con decisione e

generosità, perché le molteplici dinamiche in atto si volgano verso prospettive di fraternità e di bene comune.

Si aprono immensi cantieri di lavoro per lo sviluppo integrale dei popoli e di ogni persona. Come affermano i

43

Cfr. Lettera enciclica Caritas in veritate, n. 71.Centesimus annus, n. 52 44

Paolo VI, Lettera apostolica Octogesima adveniens, n. 37. 45

Lettera enciclica Centesimus annus, n. 52.

Padri del Concilio Vaticano II, si tratta di una missione al tempo stesso sociale e spirituale, che, «nella misura

in cui può contribuire a meglio ordinare l’umana società, è di grande importanza per il regno di Dio»46

.

In un mondo in via di rapida globalizzazione, il riferimento ad un’Autorità mondiale diviene l’unico orizzonte

compatibile con le nuove realtà del nostro tempo e con i bisogni della specie umana. Non va, però, dimenticato

che questo passaggio, data la natura ferita degli uomini, non avviene senza angosce e senza sofferenze.

La Bibbia, con il racconto della Torre di Babele (Genesi 11, 1-9) avverte come la «diversità» dei popoli possa

trasformarsi in veicolo di egoismo e strumento di divisione. Nell’umanità è ben presente il rischio che i popoli

finiscano per non capirsi più e che le diversità culturali siano motivo di contrapposizioni insanabili.

L’immagine della Torre di Babele ci avverte anche che bisogna guardarsi da una «unità» solo di facciata, nella

quale non cessano egoismi e divisioni, poiché non sono stabili le fondamenta della società. In entrambi i casi,

Babele è l’immagine di ciò che i popoli e gli individui possono divenire, quando non riconoscono la loro

intrinseca dignità trascendente e la loro fraternità.

Lo spirito di Babele è l’antitesi dello Spirito di Pentecoste (Atti 2, 1-12), del disegno di Dio per tutta

l’umanità, vale a dire l’unità nella diversità. Solo uno spirito di concordia, che superi divisioni e conflitti,

permetterà all’umanità di essere autenticamente un’unica famiglia, fino a concepire un nuovo mondo con la

costituzione di un’Autorità pubblica mondiale, al servizio del bene comune.

…omissis…”.

I.15 Bottom up planning vs/ top down planning: the economic value of participation, consent and control

The right to health is not sufficiently equipped with a budget covering – Equity in Health Institute (EHInst)

maintains –, even though the European regulatory framework supports the centrality of the right to health also

in growth and competiveness sensitive areas.

The relationship between rights and budgets must thus necessary be reconfigured, in order to respect the

universal nature of the right to health, even through a better needs drawing using a bottom up planning.

At present European public health systems are mainly based on drugs and hospital, that unitedly absorb about

79% of health expense, leaving to health promotion and prevention together the remaining 3%.

Adding the third health promotion pillar to these two pillars, we could significantly reduce drug and assistance

demand.

A new idea to build a balanced health system where health promotion and assistance have the same right and

the same budget dignity became forming.

Therefore a European public health system is needed, in which health promotion could receive the same

dignity as assistance, the actors’ implementation role is clearly defined and awarded to the Regions and

bottom up planning methodology is encouraged. This means participation, consent and control, with a huge

involvement of local health authorities, municipalities and social society.

I.16 To plan intervents acting as needs knowledge: the rediscovery of the quantitative approach for the

planning on a large scale

We have to understand the characteristics and the economic value of health promotion and equity in health

systems.

Inside health circuit health promotion on large scale (that is to say in fair terms) really signifies reducing costs

in improving persons’ well-being and quality of life, independently of their social and economic conditions,

making them stronger against diseases, increasing workers’ efficiency and elderly people’s independence.

Development and progress are often used as synonimous. That is not true: development means producing

health, progress signifies distributing it for the common benefit.

While we are able to measure development and we call that measure gross internal product, we are not yet in a

position to measure progress and do not have both qualitative and quantitative perception of equalization of

common good.

Health promotion is a fundamental progress expression. To invest money into it really signifies to ensure high

progress levels in the population.

A health promotion on a large scale is strictly connected to a specific training and capacity building program.

In this direction a traditional training is not sufficient. A specific motivational tirocinium through well

designed masters and other means offered by ICT, with the aim to form all operators in a perspective of global

46

Concilio Vaticano II, Costituzione pastorale sulla Chiesa nel mondo contemporaneo Gaudium et spes, n. 39.

health. Particularly, global health value holds a huge purport in medical doctors’ and public health specialists’

training. (Ehinst, 2010)

I.17 Capacity building: information, formation and remotivation

I.17.1 What is capacity building?

Capacity building could be explained as a planned development of (or increase in) knowledge, output rate,

management, skills, and other capabilities of an organization through acquisition, incentives, technology,

and/or training.

Capacity building also referred to as capacity development is a conceptual approach to development that

focuses on understanding the obstacles that inhibit people, governments, international organizations and non-

governmental organizations from realizing their developmental goals while enhancing the abilities that will

allow them to achieve measurable and sustainable results.

The term capacity building emerged in the lexicon of international development during the 1990s. Today,

“capacity building” is included in the programs of most international organizations that work in development,

the World Bank (World Bank), The United Nations (UN) and non-governmental organizations (NGOs) like

Oxfam International. Wide usage of the term has resulted in controversy over its true meaning. Capacity

building often refers to strengthening the skills, competencies and abilities of people and communities in

developing societies so they can overcome the causes of their exclusion and suffering.

Organizational capacity building is used by NGOs to guide their internal development and activities.

I.17.2 Definitions

The United Nations Development Programme (UNDP) was one of the forerunners in developing an

understanding of capacity building or development. Since the early 70’s the UNDP offered guidance for its

staff and governments on what was considered "institution building.” In 1991, the term evolved to be

“capacity building.” The UNDP defines capacity building as a long-term continual process of development

that involves all stakeholders; including ministries, local authorities, non-governmental organizations,

professionals, community members, academics and more. Capacity building uses a country’s human,

scientific, technological, organizational, and institutional and resource capabilities. The goal of capacity

building is to tackle problems related to policy and methods of development, while considering the potential,

limits and needs of the people of the country concerned. The UNDP outlines that capacity building takes place

on an individual level, an institutional level and the societal level47

.

a) Individual level- Capacity-building on an individual level requires the development of conditions that allow

individual participants to build and enhance existing knowledge and skills. It also calls for the

establishment of conditions that will allow individuals to engage in the “process of learning and adapting to

change”19

b) Institutional level- Capacity building on an institutional level should involve aiding pre-existing institutions

in developing countries. It should not involve creating new institutions, rather modernizing existing

institutions and supporting them in forming sound policies, oganizational structures, and effective methods

of management and revenue control19

.

c) Societal level- Capacity building at the societal level should support the establishment of a more

“interactive public administration that learns equally from its actions and from feedback it receives from

the population at large.” Capacity building must be used to develop public administrators that are

responsive and accountable19

.

The World Customs Organization - an intergovernmental organization (IO) that develops standards for

governing the movement of people and commodities48

- defines capacity building as "activities which

strengthen the knowledge, abilities, skills and behaviour of individuals and improve institutional structures and

processes such that the organization can efficiently meet its mission and goals in a sustainable way."It is,

however, important to put into consideration the principles that govern community capacity building.

47

United Nations Committee of Experts on Public Administration (2006). United Nations Economic and Social Council Definition of basic concepts and terminologies in governance and public administration. http://unpan1.un.org/intradoc/groups/public/documents/un/unpan022332.pdf. 48

World Customs Organization. "Home Page". WCO. Retrieved 4/6/2011.

Oxfam International - a globally recognized NGO - defines capacity building in terms of its own principals.

OXFAM believes that capacity building is an approach to development based on the fundamental concept that

people all have an equal share of the world’s resources and they have the right to be “authors of their own

development and denial of such right is at the heart of poverty and suffering.”49

Organizational capacity building is another form of capacity building focused on developing capacity within

organizations like NGOs. It refers to the process of enhancing an organization’s abilities to perform specific

activities. An Organizational capacity building approach is used by NGOs to develop internally so they can

better fulfil their defined mission21

. Allan Kaplan, a leading NGO scholar argues that to be effective

facilitators of capacity building in developing areas, NGOs must participate in organizational capacity building

first. Steps to building organizational capacity include developing a conceptual framework, establishing an

organizational attitude, developing a vision and strategy, developing an organizational structure and acquiring

skills and resources50

.

Kaplan argues that NGOs that focus on developing a conceptual framework, an organizational attitude, vision

and strategy are more apt at being self-reflective and critical, two qualities that enable more effective capacity

building22

.

I.17.3 History

The term capacity building has evolved from past terms such as institutional building and organizational

development. In the 1950s and 1960’s these terms referred to community development that focused on

enhancing the technological and self-help capacities of individuals in rural areas. In the 1970s, following a

series of reports on international development an emphasis was put on building capacity for technical skills in

rural areas, and also in the administrative sectors of developing countries. In the 1980s the concept of

institutional development expanded even more. Institutional development was viewed as a long-term process

of building up a developing country’s government, public and private sector institutions, and NGOs51

.

Though precursors to “Capacity Building” existed before the 1990s, they were not powerful forces in

International development like “capacity building” became during the 1990s.

The emergence of capacity building as a leading developmental concept in the 1990s occurred due to a

confluence of factors:

New philosophies that promoted empowerment and participation, like Paulo Freire’s “Education for Critical

Consciousness” (1973), which emphasized that education, could not be handed down from an omniscient

teacher to an ignorant student; rather it must be achieved through the process of a dialogue among equals.

Commissioned reports and research during the 1980s, like the Capacity and Vulnerabilities Analysis which

posited three assumptions:

1. development is the process by which vulnerabilities are reduced and capacities increased;

2. no one develops anyone;

3. else relief programs are never neutral in their developmental impact21

I.17.3.1 Changes in international developmental approaches

During the 1980s many low income states were subject to “structural adjustment packages” – the neo-liberal

nature of the packages led to increasing disparities of wealth. In response, a series of “social dimension

adjustments were enacted.” The growing wealth gap coupled with “social dimension adjustments” allowed for

an increased significance for NGOs in developing states as they actively participated in social service delivery

to the poor. Then, in the 1990s a new emphasis was placed on the idea of sustainable development52

.

Reports like the CVA and ideas like those of Freire from earlier decades emphasized that “no one could

develop anyone else” and development had to be participatory. These arguments questioned the effectiveness

49

Deborah, Eade (2005). Capacity-building: an approach to people centered development. UK and Ireland: Oxfam UK and Ireland. pp. 30–39. ISBN 0855983663. 50

Kaplan, Allan (Aug 2000). "Capacity Building: Shifting the Paradigms of Practice". Development in Practice. 3/4 10 (10th Anniversary Issue): 517–526. doi:10.1080/09614520050116677. 51

Smillie, Ian (2001). Patronage or Partnership: Local Capacity Building in a Humanitarian Crisis. Bloomfield, CT: Kumarian Press. pp. 1–5. ISBN 1-55250-211-2. 52

Chabbott, Colette (1999). Constructing World Culture. Stanford: Stanford University Press. pp. 223–230.

of “service delivery programs” for achieving sustainable development, thus leading the way for a new

emphasis on “capacity building."

I.17.4 Capacity building in developing societies

In the UNDP’s 2008–2013 “strategic plan for development” capacity building is the “organization’s core

contribution to development.” The UNDP promotes a capacity building approach to development in the 166

countries it is active in. The UNDP focuses on building capacity on an institutional level and offers a 5–step

process for systematic capacity building53

. The steps are:

1. Engage stakeholders on capacity development

An effective capacity building process must encourage participation by all those involved. If stakeholders

are involved and share ownership in the process of development they will feel more responsible for the

outcome and sustainability of the development. Engaging stakeholder’s who are directly affected by the

situation allows for more effective decision-making, it also makes development work more transparent.

UNDP and its partners use advocacy and policy advisory to better engage stakeholders25

.

2. Assess capacity needs and assets

Assessing pre existing capacities through engagement with stakeholders allows capacity builders to see

what areas require additional training, what areas should be prioritized, in what ways capacity building can

be incorporated into local and institutional development strategies. The UNDP argues that capacity

building that is not rooted in a comprehensive study and assessment of the preexisting conditions will be

restricted to training alone, which will not facilitate sustained results25

.

3. Formulate a capacity development response

The UNDP says that once an assessment has been completed a capacity building response must be created

based on four core issues:

A. Institutional arrangements- assessments often find that institutions are inefficient because of bad or

weak policies, procedures, resource management, organization, leadership, frameworks, and

communication. The UNDP and its networks work to fix problems associated with institutional

arrangements by developing human resource frameworks “cover policies and procedures for

recruitment, deployment and transfer, incentives systems, skills development, performance evaluation

systems, and ethics and values.”19

B. Leadership-the UNDP believes that leadership by either an individual or an organization can catalyze

the achievement of development objectives. Strong leadership allows for easier adaption to changes,

strong leaders can also influence people. The UNDP uses coaching and mentoring programmers to help

encourage the development of leadership skills such as, priority setting, communication and strategic

planning.

C. Knowledge- The UNDP believes knowledge is the foundation of capacity. They believe greater

investments should be made in establishing strong education systems and opportunities for continued

learning and the development of professional skills. They support the engagement in post-secondary

education reforms, continued learning and domestic knowledge services.

D. Accountability- the implementation of accountability measures facilitates better performance and

efficiency. A lack of accountability measures in institutions allows for the proliferation of corruption.

The UNDP promotes the strengthening of accountability frameworks that monitor and evaluate

institutions. They also promote independent organizations that oversee, monitor and evaluate

institutions. They promote the development of capacities such as literacy and language skills in civil

societies that will allow for increased engagement in monitoring institutions25

.

4. Implement a capacity development response

Implementing a capacity building program should involve the inclusion of multiple systems; national,

local, institutional. It should involve continual reassessment and expect change depending on changing

situations. It should include evaluative indicators to measure the effective of initiated programs25

.

5. Evaluate capacity development

53

United Nations Development Programme. "Supporting Capacity Building the UNDP approach". UNDP. Retrieved 4/23/2011. United Nations Development Programme. "Supporting Capacity Building the UNDP approach". UNDP. Retrieved 4/23/2011.

Evaluation of capacity building promotes accountability. Measurements should be based on changes in an

institutions performance. Evaluations should be based on changes in performance based around the four

main issues: institutional arrangements, leadership, knowledge, and accountability25

.

The UNDP integrates this capacity building system into its work on reaching the Millennium Development

Goals(MDGs). The UNDP focuses on building capacity at the institutional level because it believes that

“institutions are at the heart of human development, and that when they are able to perform better, sustain

that performance over time, and manage ‘shocks' to the system, they can contribute more meaningfully to

the achievement of national human development goals.” 25

I.17.5 Capacity building in governments

One of the most fundamental ideas associated with capacity building is the idea of building the capacities of

governments in developing countries so they are able to handle the problems associated with environmental,

economic and social transformations. Developing a government’s capacity whether at the local, regional or

national level will allow for better governance that can lead to sustainable development and democracy. To

avoid authoritarianism in developing nations, a focus has been placed on developing the abilities and skills of

both national and local governments so power can be diffused across a state. Capacity building in governments

often involves providing the tools to help governments best fulfil their responsibilities. These include building

up a government’s ability to budget, collect revenue, create and implement laws, promote civic engagement54

,

be transparent and accountable and fight corruption. Below are examples of capacity building in governments

of developing countries55

:

In 1999, the UNDP supported capacity building of the state government in Bosnia Herzegovina. The program

focused on strengthening the State’s government by fostering new organizational, leadership and management

skills in government figures, improved the government’s technical abilities to communicate with the

international community and civil society within the country56

.

Since 2000, developing organizations like the National-Area-based-Development-program have approached

the development of local governments in Afghanistan, through a capacity building approach. NABDP holds

training sessions across Afghanistan in areas where there exist foundations for local governments. The

NABDP holds workshops trying community leaders on how to best address the local needs of the society.

Providing weak local government institutions with the capacity to address pertinent problems, reinforces the

weak governments and brings them closer to being institutionalized. The goal of capacity builders in

Afghanistan is to build up local governments and provide those burgeoning institutions with training that will

allow them to address and advocate for what the community needs most. Leaders are trained in “governance,

conflict resolution, gender equity, project planning, implementation, management, procurement financial, and

disaster management and mitigation.”57

The Municipality of Rosario, Batangas, Philippines provided a concrete example related to this concept. This

municipal government implemented its Aksyon ng Bayan Rosario 2001 And Beyond Human and Ecological

Security Plan using as a core strategy the Minimum Basic Needs Approach to Improved Quality of Life -

Community-Based Information System (MBN-CBIS) prescribed by the Philippine Government. This

approach helped the municipal government identify priority families and communities for intervention, as well

as rationalize the allocation of its social development funds. More importantly, it made definite steps to

encourage community participation in situation analysis, planning, monitoring and evaluation of social

development projects by building the capacity of local government officials, indigenous leaders and other

stakeholders to converge in the management of these concerns.

I.17.6 Local capacity building in practice

54

Foreign Assistance Standardized Program Structure and Definitions. program element 4.6.2. 55

Boex, Jamie; Yilmaz Serdar (December 2010). "An Analytical Framework for Assessing Decentralized Local Governance and the local Public Sector". Urban Institute Center on International Development and Governance. 56

"Capacity-building support for central government institutions of the Republika Srpska". UNDP. "Capacity-building support for central government institutions of the Republika Srpska". UNDP. 57

Shariq, Zamila; nahukul K.C (March 2011). "Enhancing Local governance institutions in Logar and Urozgan Provinces, Afghanistan". Capacity.org. Shariq, Zamila; nahukul K.C (March 2011). "Enhancing Local governance institutions in Logar and Urozgan Provinces, Afghanistan". Capacity.org. Shariq, Zamila; nahukul K.C (March 2011). "Enhancing Local governance institutions in Logar and Urozgan Provinces, Afghanistan". Capacity.org.

The capacity building approach is used throughout many levels, including local, regional, national and

international levels. Capacity building can be used to reorganize and capacitate governments or individuals.

International donors like USAID, often include capacity building as a form of assistance for developing

governments or NGOs working in developing areas. Historically this has been through a US contractor

identifying an in-country NGO and supporting its financial, M&E and technical systems towards the goals of

that USAID intervention. The NGO's capacity is developed as a sub-implementer of the donor. However many

NGOs participate in a form of capacity building that is aimed toward individuals and the building of local

capacity. In a recent report commissioned by UNAIDS and the Global Fund, Review of TA to CSO funded by

the Global Fund the individual NGOs voiced their needs and preference for broader capacity development

inputs by donors and governments. For individuals and in-country NGO, capacity building may relate to

leadership development, advocacy skills, training/speaking abilities, technical skills, organizing skills, and

other areas of personal and professional development. One of the most difficult problems with building

capacity on a local level is the lack of higher education facilities in developing countries58

. Between 2–5

percent of Africans have been to tertiary school59

. Another difficulty is ongoing brain drain that takes place in

developing countries. Often, young people who develop skills and capacities that can allow for sustainable

development leave their local origins. Damtew Teferra of Boston College’s Center for African Higher

Education argues that local capacity builders are needed now more than ever and increased resources should

be provided for programs that focus on developing local expertise and skills. The development sector,

particularly in sub-Saharan Africa has many decades of 'international technical advisors' working with and

mentoring government officials and national non-government organizations. In health service delivery,

whether maternal care or HIV related, community organizations have been started and often grew through the

strength of their staff and commitment to be national and even regional leaders in their technical fields. Whilst

higher education is still an under-served demand, there are significant resources of experienced staff. More

recent donor initiatives, including The Global Fund's Community Systems Strengthening and the US PEPFAR

Technical Assistance to the New Partners Initiative begin to address the organizational capacity needs and

stronger skills to be recognized as part of the national response to health needs in a country. To complete the

capacity development cycle, the Global Fund and UNAIDS Technical Support Facility and the TA teams for

CSO funded by the New Partners Initiative are staffed and managed by residents and nationals of those same

developing countries.

Below are some examples of NGOs and programs that utilize the term “capacity building” to describe their

activities on a local scale31

:]

The Centre for Community Empowerment CCEM- is an NGO working in Vietnam that aims to “train the

trainers” working in the development sector of Vietnam. The organization believes that the sustainability of a

project depends on the level of involvement of stakeholders and so they work to train stakeholders in the skills

needed to be active in development projects and encourage the activity of other stakeholders60

. The

organization operates by providing weeklong training courses in for local individuals in issues such as: project

management, report writing, communication, fund-raising, resource mobilization, analysis, and planning61

.

The organization does not create physical projects, rather develops the capacity of stakeholders to initiate, plan

and analyze and develop projects on their own62

. Mercy Ships-A Christian, healthcare NGO, provides another

example of an NGO participating in localized “capacity building.” While CECEM devotes its energy to

training individuals to be better project managers and participants- Mercy Ships participates in a form of

capacity building that focuses on the pre-existing capacities of certain individuals and builds on those63

. For

example, Mercy Ships focuses on training doctors and nurses about new procedures and technologies. They

also focus on building leadership skills through training workshops for teachers, priests and other community

leaders. Leaders are then trained in other areas such as, proper care and construction of hygienic water wells35

.

58

linell, Deborah (2003). Evaluation of Capacity Building: Lessons from the field. Washington, D.C: Alliance for Nonprofit management. 59

Teferra, Damtew (October 2010). "Nurturing Local Capacity Builders". Capacity.org. Teferra, Damtew (October 2010). "Nurturing Local Capacity Builders". Capacity.org. 60

Our Mission". CCEM. Retrieved 4/25/2011. 61

"Training courses 2011". CCEM. Retrieved 4/25/2011. 62

"Our Projects". CCEM. Retrieved 4/25/2011. "Our Projects". CCEM. Retrieved 4/25/2011. "Our Projects". CCEM. Retrieved 4/25/2011. "Our Projects". CCEM. Retrieved 4/25/2011. 63

"The Mission". mercy ships.

The first example depicts capacity building as tool to deliver individuals the skills they need to work

effectively in civil society. In the case of Mercy Ships, the capacity building is delivering the capacity for

individuals to be stakeholders and participants in certain defined activities, such as health care64

.

I.17.7 In NGOs

Societal development in poorer nations is often contingent upon the efficiency of organizations working within

that nation. Organizational capacity building focuses on developing the capacities of organizations,

specifically NGOs, so they are better equipped to accomplish the missions they have set out to fulfil. Failures

in development can often be traced back to an organization's inability to deliver on the service promises it has

pledged to keep. Capacity building in NGOs often involves building up skills and abilities, such as decision

making, policy-formulation, appraisal, and learning. It is not uncommon for donors in the global north to fund

capacity building for NGOs themselves. For organizations, capacity building may relate to almost any aspect

of its work: improved governance, leadership, mission and strategy, administration (including human

resources, financial management, and legal matters), program development and implementation, fund-raising

and income generation, diversity, partnerships and collaboration, evaluation, advocacy and policy change,

marketing, positioning, planning. Capacity building in NGOS is a way to strengthen an organization so that it

can perform the specific mission it has set out to do and thus survive as an organization. It is also an ongoing

process that incites organizations to continually reflect on their work, organization, and leadership and ensure

that they are fulfilling the mission and goals they originally set out to do65

. Alan Kaplan, an international

development practitioner, asserts that capacity development of organizations involves the build-up of an

organization's tangible and intangible assets. He argues that for an NGO to work efficiently and effectively in

developing country they must first focus on developing their organization. Kaplan argues that capacity

building in organizations should first focus on intangible qualities such as22

:

Conceptual framework--an organization's understanding of the world, "This is a coherent frame of reference,

a set of concepts which allows the organization to make sense of the world around it, to locate itself within

that world, and to make decisions in relation to it."22

Organizational attitude – this focuses on the way an

organization views itself. Kaplan asserts that an organization must view itself not as a victim of the slights of

the world, rather as an active player that has the ability to effect change and progress22

. Vision and Strategy –

this refers to the organization's understanding of its vision and mission and what it is looking to accomplish

and the program it wishes to follow in order to do so Organizational structure – a clear method of operating

wherein communication flow is not hindered, each actor understands their role and responsibility22

.

Though he asserts that intangible qualities are of utmost importance-Kaplan says that tangible qualities such as

skills, training and material resources are also imperative.

Another aspect of organizational capacity building is an organization's capacity to reassess, reexamine and

change according to what is most needed and what will be the most effective.

I.17.8 Evaluating capacity building

Since the arrival of capacity building as such a dominant subject in international aid, donors and practitioners

have struggled to determine a concise mechanism for determining the effectiveness of capacity building

initiatives. In 2007, David Watson, developed specific criteria for effective evaluation and monitoring of

capacity building. Watson complained that the traditional method of monitoring NGOs that is based primarily

on a linear results-based framework is not enough for capacity building. He argues that evaluating capacity

building NGOS should be based on a combination of monitoring the results of their activities and also a more

open flexible way of monitoring that also takes into consideration, self-improvement and cooperation. Watson

observed 18 case studies of capacity building evaluations and concluded that certain specific themes were

visible66

:

monitoring an organization's clarity of mission-this involves evaluating an organization's goals and how well

those goals are understood throughout the organization

64

Eade, Deborah (2007). Capacity Building an Approach to People-Centered Development. UK & Ireland: Oxfam. pp. 35. 65

Eade, Deborah (1997). Capacity Building: An approach to people centered development. UK: oxfam. pp. 35–36. 66

Ubels, Jan; Acquaye-Baddoo,Naa-Aku; Fowler, Alan (2010). "18". Capacity Development in Practice. Capacity.

monitoring an organization's leadership-this involves evaluating how empowered the organization's leadership

is-how well the leadership encourages experimentation, self reflection, changes in team structures and

approaches38

.

monitoring an organization's learning-this involves evaluating how often an organization participates in

effective self-reflection, and self-assessment. It also involves how well an organization "learns from

experience" and if the organization promotes the idea of learning from experience38

.

monitoring an organization's emphasis on on-the-job-development- this involves evaluating how well an

organization encourages continued learning, specifically through hands on approaches.

monitoring an organization's monitoring processes- this involves evaluating how well an organization

participates in self-monitoring. It looks at whether or not an organization encourages growth through learning

from mistakes38

.

In 2007, USAID published a report on its approach to monitoring and evaluating capacity building. According

to the report, USAID monitors: program objectives, the links between projects and activities of an

organization and its objectives, a program or organization's measurable indicators, data collection, and

progress reports. USAID evaluates: why objectives were achieved, or why they were not, the overall

contributions of projects, it examines qualifiable results that are more difficult to measure, it looks at

unintended results or consequences, it looks at reports on lessons learned. USAID uses two types of

"indicators" for progress. "output indicators" and "outcome indicators." Output indicators measure immediate

changes or results such as the number of people trained. Outcome indicators measure the impact, such as laws

changed due to trained advocates67

.

I.17.9 Specification

Capacity Building is much more than training and includes the following:

Human resource development, the process of equipping individuals with the understanding, skills and access

to information, knowledge and training that enables them to perform effectively.

Organizational development, the elaboration of management structures, processes and procedures, not only

within organizations but also the management of relationships between the different organizations and sectors

(public, private and community).

Institutional and legal framework development, making legal and regulatory changes to enable organizations,

institutions and agencies at all levels and in all sectors to enhance their capacities (citation: Urban Capacity

Building Network).

It also interfaces with some work by the New Institutional Economics association led notably by the 1994

Nobel prize winner Douglass North. It tries to lay out the essential organizational and institutional

prerequisites for economic and social progress ( See the paper by North, Wallis and Weingast) modestly

entitled 'A conceptual framework for interpreting recorded human history', NBER working paper 12795,

(www.nber.org/papers/w12795).

Capacity building is defined as the "process of developing and strengthening the skills, instincts, abilities,

processes and resources that organizations and communities need to survive, adapt, and thrive in the fast-

changing world." (Ann Philbin, Capacity Building in Social Justice Organizations Ford Foundation, 1996)

Capacity building is the elements that give fluidity, flexibility and functionality of a program/organization to

adapt to changing needs of the population that is served.

Infrastructure development has been considered "Economic Capacity Building" because it increases the

capacity of any developed or developing society to improve trade, employment, economic development and

quality of life. It is also true that where institutional capacity is limited, infrastructure development is probably

constrained. Currently the United States infrastructure is rated D or worse by the American Society of Civil

Engineers (ASCE). This may be an indication that the Institutional Capacity of the USA is constrained and

will impact future quality of life issues.

I.17.10 Partial list of agencies providing capacity building is:

United Nations

67

Duane Muller (November 2007). "USAID's Approach to monitoring Capacity Building Activities". UNFCCCC Experts Meeting on Capacity Building. Antigua. Duane Muller (November 2007). "USAID's Approach to monitoring Capacity Building Activities". UNFCCCC Experts Meeting on Capacity Building. Antigua.

UNFCC

United Nations

Development Programme (UNDP)

World Bank

International Monetary Fund (IMF)

Food and Agriculture Organization of the United Nations (FAO)

World Food Programme (WFP)

World Tourism Organization (UWNTO), through its UNWTO.Themis Foundation

I.17.11 Global Europe Anticipation Bulletin (GEAB)

As we are under the crisis, a special kind of information instrument is needed.

GEAB = Global Europe Anticipation Bulletin has been created since 2006. What is GEAB? GEAB is an

affordable and regular decision and analysis support instrument intended for all those whose work involves

some understanding of ongoing and future global trends seen from a European point of view: advisors,

consultants, researchers, experts, administrations heads, politicians, public servants, businessmen, big and

small investors, citizens.

As early as February 2006, the LEAP/E2020 team were the firs to send a worldwide alert on the imminence of

a global systemic crisis. Since that time, month after month, they have been anticipating precisely the different

stages of the unfolding crisis, as illustrated, for instance, by the September events. It was indeed in the

February 2008 issue of the GEAB (N°22) that LEAP/E2020 was anticipating "Global Systemlc Crisis /

September 2008 - Phase of collapse of US real economy: the end of the third quarter of 2008 will be marked

by a new tipping point in the unfolding of the global systemic crisis...".

Each month in the past two years, LEAP/E2020 has not only been anticipating the future stages of the crisis,

but also, through each edition of its Global Europe Anticipation Bulletin (GEAB), it has provided in four

languages some strategic and operational recommendations for the intention of individual savers, companies,

public institutions, financiers and policy-makers from all the continents.

At a time when most experts, leaders and investors are reacting in a panic, faced with a situation they have not

been able or wished to anticipate, LEAP/E2020 has elaborated, thanks to its series of monthly bulletins, a mine

of analyses on the current crisis, its upcoming developments and the means to face it.

If, in February 2008, the LEAP/E2020 team were able to anticipate that the crisis would suddenly accelerate in

September 2008 in the US (GEAB N°22), it has therefore been anticipating the future steps of the crisis for the

coming six months in the 23rd, 24th, 25th, 26th and 27th editions of the GEAB. It is for this reason that with

each new subscription is given access to the previous 6 issues, and therefore to precise anticipations and useful

recommendations for up to the beginning of 2009 (and after). With, of course, new anticipations each coming

months on the future developments of this historic crisis.

In times of crisis, the capacity to anticipate properly what the future is bringing us is no longer a luxury but a

key-condition of survival, as citizens, savers, wage-earners, leaders, etc. The GEAB has thus been conceived

since its beginning in 2006 as an efficient decision-support instrument, specially adapted to the global

systemic crisis we are going through.

GEAB N°61 (Jan 16, 2011) is entitled “Global systemic crisis - 2012: The year of the world’s great

geopolitical swing”. This GEAB issue makes it six years that the LEAP/ E2020 team have shared their

anticipations with their subscribers and readers of their public briefing on the development of the global

systemic crisis each month. And, for the first time, in the January issue which presents a summary of our

anticipations for the year to come, our team anticipates a year which will not result solely in a worsening of

the world crisis but which will also be characterized by the emergence of the first constructive elements of the

“world after the crisis”…

I.18 Advanced technology in administrations

ICT solutions are then mature to support the stable, cooperative processes of the most common long-term

conditions, with predictable information needs based on the agreed Evidence-Based clinical pathways.

Suitably structured routine data can be systematically captured, exchanged and reused by the different actors

(i.e. professionals, managers and citizens), for care purposes, self-assessments, governance, and epidemiology.

By coping with “subordinate responsibilities”, a physician maintains the main responsibility of the healthcare

action (care mandate). Other professionals may be involved in partial and subordinated process, i.e. with a

bounded autonomy in their decisions. Examples include the diagnostic services and the second opinion, or the

work in team with allied professions (e.g. nurses, home care operators). We noted that (i) “interoperability” is

a contraction for "ability to interoperate” or, better, "ability of healthcare information systems to interoperate"

and (ii) these activities are enough structured to be supported by standards: nearly all the standard messages

(e.g. in HL7, ISO, CEN) at the ISO-OSI 7th level deal in some respect also with "semantic interoperability"

(vs. electrical interoperability or harmonized character sets).

In the “activities with parallel responsibilities”, several healthcare professionals (and the citizen himself, his

family and volunteers) have complementary roles on the diverse aspects of the care management; an explicit

shared plan or a agreement may formalize their cooperation. These activities require a particular kind of

support, i.e. they involve the cultural, organizational and contextual “ability of healthcare professionals to

cooperate”, which we termed as “co-operability”.

Interoperability and co-operability are two complementary approaches. However achieving co-operability

among “connected people” could be far more difficult than achieving interoperability for “connected systems”,

also because the responsibility of clinicians and their communication along clinical processes often aren’t

explicit and systematic enough for an effective application of ICT solutions. In fact, the co-operability

involves:

1. the capture and the timely availability of the specific clinical data needed by a clinician to perform

his/her tasks in a particular moment. Most data depend on the context of the episode (condition of the

patient, kind of facility, node in the clinical pathway, etc). ICT performs at the best only with specific

phases of clinical pathways, i.e. with stable clinical situations that may be considered as predictable;

2. the production of Problem-specific Profiles (a kind of Patient Summary [40]), e.g. on the background

condition for an oncology patient (related to the disease stage), or for the diabetic patient, or to describe

the stable status of an elderly patient including the social issues;

3. the production of specific clinical data and documents, predictable in relation to a shared clinical

pathway, at each Interaction Point between professionals and with the patient / informal carers, across

different healthcare organizations and with the patient’s home. A particular case is the management of

data from and to home devices.

The most promising sector that could be starting point of a new strategic approach to Connected Health

initiatives is made of the stable care processes for long-term conditions. They involve a large percentage of the

burden on the care system (on the primary care and social care professionals, on the patients with their

informal carers, and on the avoidable hospital stays) and thus their optimization may contribute to the

sustainability of the health and wellness sector.

The stress here is on the management of the clinical Information and Communication, which could be assisted

by Technology (i.e. ICT). The healthcare strategies bring to regulations, grants and action plans on health-

related targets, e.g. on prevention of the consequences of chronic diseases (disease management), prevention

of cancer, coordination of elderly care. They should be the proper context to develop the eHealth policies.

The priorities of development of the ICT, and the related deployment roadmaps, will depend on the

organizational / cultural predisposition, on the state of diffusion of ICT applications, on the effective

potentialities and willingness to change the system.

From these priorities could stem the actual requirements on ICT solutions, that will be developed and

implemented gradually, in order to support step by step interventions on the healthcare world, following an

ICT plan that is function of the healthcare plans. Otherwise a heavy ICT effort that goes beyond the level of

the mere efficiency – i.e. that attempts to modify, starting from the innovation, the behaviour of managers and

clinical professionals - will be refused from the system.

The healthcare world should promote the organizational changes, dealing with the requirements and the

organizational models. In the meanwhile the technological world should complement the ongoing programs of

innovation, already undertaken to spread basic infrastructures and services, with new programs to supply

balanced and timely ICT solutions for the initiatives undertaken by the healthcare world, and suggest to new

opportunities.

Therefore eHealth could be an essential component to allow the evolution of the healthcare towards a holistic

perspective on "health" (without “e-”), by characterizing the domains of intervention of both the approaches

(technology-centric and healthcare-centric) to facilitate a synergic process of “parallel convergences”

(Rossimori a), in press).

I.19 Financing Equity and Excellence in Health through Integrated Innovation

This theme has been deeply developed by Dr. Fausto Felli, President of Equity in Health Institute (Ehinst) in a

paper presented at the European IVD Forum 2011 “Excellence in Diagnostics for a Healthier Europe” which

had place in Brussels on 18-19 October 2011. A synthesis will be reported here.

I.19.1 Are we walking?

Nobody could image Equity without Excellence as well as Excellence kept far from Equity.

Both Equity and Excellence are important for Internal Market.

If together they become strategic for it.

1. How long will the financial crisis last?

2. How long will we see cuts of costs without knowing the costs of the cuts?

3. How long will we be able to call “Healthcare system” a “We have no money system”?

John Dalli, European Commissioner for Health and Consumers’ well-being, at the European Health Forum

which was held in Austria, Gastein, on 07 October 2011, said:

“In these times of deep economical turmoil, the road to well being may not be the first issue on political

agendas across Europe. The situation is clear:

Public Health Budgets are squeezed under growing pressure

Shortages of healthcare professionals are growing, just when demand for healthcare is increasing

At the same time patients, quite rightly, expect Health Systems to provide the best possible care

4. How do we design and build a smart and sustainable healthcare

system for ourselves, our children and our grandchildren?

5. How can health systems in Europe provide more high quality

healthcare with less resources?

Squaring the circle is not easy. Europe needs Innovation”.

I.19.2 How to succeed in achieving equity and excellence in health field?

Equity is reached when rights & budgets are balanced so giving universal access to the benefits of

technological innovation.

Second level of excellence is obtained when technological innovation becomes a tool/condicio sine qua non

for on a large scale implementation of health policy, having as end user not only the patient, but also the

community and its goals.

I.19.3 What does “Integrated Innovation” mean?

…transforming actions in interactions and interactions in integrations by:

> Social Innovation

> Technological Innovation

> Financial Innovation.

I.19.4 Financing Health (HP, HC, LTC, MH) in the European Union: towards a Financial PPP ?

1. National Funds for Public Health (the cut of the costs without knowing the cost of the cuts, the “never

born”, etc.)

2. European Funds for Public Health (see also EIP AHA)

3. Pension Funds (see Pension Fund Investment in Infrastructure, OECD 2009)

4. Private Insurances

5. Eurobonds

6. Financial Transaction Tax (FTT) and Financial Activity Tax (FAT

I.19.5 Three ways to go:

a renewed model of health system , knowing and sharing the community goals under the qualitative and

quantitative point of views. Beyond traditional HTA to assess production of moral goods from material

goods;

a new model of financing, knowing effectively all opportunities and considering health as a part of

Common Good;

moving towards an European Public Health System with common standards and reduction of health

inequalities.

I.19.6 European instruments

Cohesion policy 2014-2020 (October 2011):

The main objective of cohesion policy is to diminish the gap between different regions, more precisely

between the less-favoured regions and the affluent ones. It is an instrument of financial solidarity and a

powerful force for economic integration and internal market enlargement

At EESC Staffan Nilson (EESC President) has reaffirmed his convinction “no sustainable economic

performance is possible without social cohesion”.

I.19.7 European Parliament resolutions

I) Innovative financing at global and European level (approved on 8 march 2011), with a tax about 0.05% of

financial transactions ( = 300 B € each year for Europe + FAT) that would let to invest in health,

cooperation and development if supported by the member states.

II) Reducing health inequalities in the EU in which it calls Member States to tackle health inequalities in

access to health (approved 9 march 2011) The resolution is a significant step forward ensuring equitable

access to healthcare for all, with no discrimination linked to administrative status or financial resources

European Parliament

Special Committee on the Policy Challenges and Budgetary resources for a Sustainable European Union after

2013

On investing in the future: a new Multiannual Financial Framework (MFF) for a competitive, sustainable and

inclusive Europe (2010/2211(INI)

Rapporteur: Salvador Garriga Polledo

and , from Commissioner John Dalli

Health for Growth Programme

(John Dalli, 07 October 2011 European Health Forum)

I.19.8 Conclusions:

Health as a part of Common Good

For a 360° recognition of proper health financing it is necessary to start with a long term hard work

Our proposals:

1. to create an High Level Expert Group to consider financial planning in a proper and more serious way

in order to analyze the interdependence, interaction and integration of these six sectors towards an

European Public Health System under the crisis

2. to define a clear and shared Equity and Excellence Health Model based on: quantitative approach,

bottom-up planning on a large scale, regional implementation role with the same budget dignity for

Health Promotion, Health Care, Long Term Care and Mental Health through local health

multigovernance approach

I.19.9 Next step

Brussels, April13rdth 2013, European Conference on: Investments in Common Good Innovation.

First: Health for Growth

CHAPTER II

HEALTH POLICIES AT COMMUNITARY LEVEL

II.1 European Social Policy: Rules and Actors. II.2 La tutela multilevel del diritto alla salute. II.2.1 La tutela multilevel del diritto alla

salute. II.2.2 Cenni storici sulla strategia sanitaria fino a oggi. II.2 .2 .1 La tutela della salute dal Trattato di Maastricht al Trattato di

Amsterdam. II.2.2.2 Le strategie dell’Unione europea nel processo di espansione degli interventi in materia sanità. Politiche sanitarie e

principio di sussidiarietà. II.2.2.3 Le politiche sanitarie e il principio precauzionale. II.2.2.4 Le politiche sanitarie e la creazione di un

mercato unico europeo. II.2.2.5 La strategia sanitaria. II.2.2.6 Il programma d’azione sanitario 2003-2008. II.2.2.7 Le altre politiche in

materia sanitaria. II.2.2.8 Politiche sanitarie correlate. II.2.2.8.1 Accesso alle cure mediche. II.2.2.9 L’implementazione della strategia

sanitaria. II.2.2.10 EU health strategy 2005. II.2.2.10.1 Act. II.2.2.10.2 Summary. II.2.2.10.3 Main elements. II.2.2.10.4 Preparation of

an integrated strategy. II.2.2.10.5 Related acts. II.2 .2 .11 The second programme of Community action in the field of Health (2008-

2013). II.2.2.11.1 The reasons. II.2.2.11.2 The decision. II.2.2.11.3 Annex. II.2.2.11.4 Trilateral declaration. II.2.2.11.5 Commission

declaration. II.2.2.12 L’integrazione della politica sanitaria europea: considerazioni finali. II.2.3 Europe 2020. II.2.3.1 Smart growth.

II.2.3.1.1 How will the EU boost smart growth? II.2.3.1.2 Why does Europe need smart growth? II.2.3.2 Sustainable growth. II.2.3.2.1

What does sustainable growth mean? II.2.3.2.2 How will the EU boost sustainable growth? II.2.3.2.3 Why does Europe need

sustainable growth? II.2.3.3 Inclusive growth. II.2.3.3.1 What does inclusive growth mean? II.2.3.3.2 How will the EU boost inclusive

growth? II.2.3.3.3 Why does Europe need inclusive growth? II.2.4 Horizon 2020. II.2.4.1 What is Horizon 2020? II.2.4.2 Horizon

2020: will broader innovation improve health and wellbeing? II.2.5 Active and Healthy Ageing: the sounding board of Social,

Technological and Integrated Innovation. II.2.5.1 AIP-AHA. II.2.5.2 Active and Healthy Ageing. Challenge of ageing –the key role of

innovation. II.2.5.3 Vision of health and active ageing. II.2.5.4 Definition of active and healthy ageing. II.2.5.5 New paradigm of

ageing. II.2.5.6 Innovation serving the older generation. II.2.5.7 Focus on a holistic and multidisciplinary approach. II.2.5.8 Working

and Ageing.. II.2.6 European Commission Regional policy – InfoRegio. II.2.7 A European non-discrimination law. II.2.7.1 Introducing

European nondiscrimination law: context, evolution and key principles. II.2.7.2 Context and background to European non-

discrimination law. II.2.7.2.1 The Council of Europe and the European Convention on Human Rights. II.2.7.2.2 The European Union

and the non-discrimination directives. II.2.7.3 Current and future developments in European protection mechanisms. II.2.7.3.1 EU

Charter of Fundamental Rights. II.2.7.3.2 UN human rights treaties. II.2.7.3.3 European Union accession to the European Convention

on Human Rights. II.2.7.4 Discrimination categories and defences. II.2.8 Europe for the Millennium Development Goals (MDGs).

II.2.8.1 Foreword. II.2.8.2 An overview. II.2.8.3 Toward Domains of Core Competency for Building Global Capacity in Health

Promotion. II.2.8.3.1 The Challenge: Addressing Urgent Health Needs. II.2.8.3.2 The Galway Consensus Conference Statement.

II.2.8.3.2.1Intended Audiences. II.2.8.3.2.2 Health Promotion and Health Education. II.2.8.3.2.3 Core values and principles.

II.2.8.3.2.4 Domains of Core Competency. II.2.8.3.2.5 Standards and Quality Assurance. II.2.8.3.2.6 Recommendations and Key

Actions. II.2.8.3.2.7 Moving Forward. II.2.8.3.3 International Union for Health Promotion and Education (IUHPE). II.2.8.3.3.1

IUHPE initiatives for quality, effectiveness and equity. II.2.8.3.3.2 Fundamental challenges. II.2.8.3.3.3 Health promotion’s

proven technologies. II.2.8.3.3.4 Advocacy. II.2.8.4 Values, principles and objectives of health policy in Europe. II.2.8.4 Introduction.

II.2.8.4.1 The Values Debate in Health: Key Dimensions. II.2.8.4.1.1 Health as a Value in Itself. II.2.8.4.1.1.1Health as an intrinsic

value: an end not only a means. II.2.8.4.1.1.2 Health as a public good. II.2.8.4.1.1.3 Health as a human right. II.2.8.4.1.2 Values in

Health. II.2.8.4.1.2.1 Schools of thought. II.2.8.4.1.2.2 Equity and social justice. II.2.8.4.1.2.3 Dignity. II.2.8.4.1.3 Health as a

European value. II.2.8.4.1.4 Values, Health and the European Constitution. II.2.8.4.1.4.1 The European Constitution on values.

II.2.8.4.1.4.2 The European Constitution on health. II.2.8.4.1.5 European Citizenship and Health . II.2.8.4.1.5.1 Citizenship as culture.

II.2.8.4.1.5.2 Citizenship as rights. II.2.8.4.2 Applications to Health Policy. II.2.8.4.2.1 Values in Health Policy and Public Health.

II.2.8.4.2.1.1 Values in health policy. II.2.8.4.2.1.2 Values in public health. II.2.8.4.2.2 Values and Health Governance. II.2.8.4.2.2.1

Governance and health targeting. II.2.8.4.2.2.2 Values and evidence. II.2.8.4.2.2.3 Fairness as an instrumental policy value. II.2.8.4.2.3

Participation and Accountability as Values. II.2.8.4.2.3.1 Do-ability and accountability. II.2.8.4.2.3.2 Role of the citizen. II.2.8.4.2.4

Future European Dialogue on Health and Values. II.2.8.4.2.5 Assets for Health and Wellbeing Across the Lifecourse. II.2.8.4.2.5.1

Health Assets for Young People’s Wellbeing. II.2.8.4.2.5.2 Assets for health and wellbeing across the lifecourse. II.2.8.4.2.5.3

Recommendations. II.2.8.4.2.5.3.1 For Policy and practice. II.2.8.4.2.5.3.2 For Research and Evaluation

II.1 European Social Policy: Rules and Actors

Le azioni intraprese dall’Unione Europea nel settore delle politiche sociali mettono in evidenza le connessioni

e le implicazioni in ordine alle politiche nazionali di welfare. Poiché le une si pongono in un rapporto di

complementarietà rispetto alle altre, è opportuno porre l’attenzione sui meccanismi e gli strumenti che ne

hanno determinato l’integrazione.

Nell’evoluzione e nell’ampliamento dell’azione comunitaria in tema di politiche sociali, un importante ruolo

di stimolo e di accelerazione del processo è stato giocato dall’integrazione monetaria e dal patto di stabilità.

Data infatti la complessa interrelazione tra gli equilibri economici degli Stati membri e la portata degli effetti

incrociati della gestione delle rispettive politiche nazionali che incidono fortemente sui deficit dei bilanci

pubblici - quali ad esempio la politica sociale - nei primi anni Novanta i Governi nazionali hanno affrontato un

serrato dibattito sulla possibile convivenza dei differenti sistemi nazionali di protezione sociale all’interno

dell’Unione Europea. Nell’evoluzione della politica sociale europea una tappa fondamentale si è avuta nel

1992, quando il Consiglio ha posto l’ambizioso obiettivo della convergenza de facto (poi definita strategica)

dei sistemi sociali nazionali verso un modello sociale europeo.

Successivamente, anche in ragione delle proiezioni sull’andamento demografico comune a tutti gli Stati

membri e l’opting in operato dal Regno Unito, un salto di qualità nella strategia comunitaria degli Stati

membri è stato determinato dall’adozione della regola della maggioranza per le disposizioni in materia sociale,

dall’elaborazione della Strategia Europea per l’Occupazione (1997), dalla Strategia per l’inclusione sociale

(2000) e dal coordinamento dell’azione europea attraverso l’Agenda Sociale Europea (2000).

Per quanto concerne l’implementazione della politica sociale europea, tra gli strumenti principali a cui

l’Unione è ricorsa, quello più innovativo è stato il cosiddetto Metodo di Coordinamento Aperto (OMC).

Questo strumento ha consentito di superare le resistenze dei Governi nazionali a cedere una parte della propria

sovranità relativamente a politiche nazionali di particolare rilievo in conseguenza dell’applicazione del metodo

comunitario: il metodo di coordinamento aperto, infatti, si è rilevato più idoneo a perseguire taluni obiettivi

comunitari che richiedevano una strategia di tipo bottom up in cui giocavano un ruolo importante non solo gli

Stati membri e gli Enti substatali, ma anche le parti sociali.

Naturalmente, l’ampliamento della sfera d’interesse europeo nel campo sociale ha determinato una serie di

effetti anche sulla struttura amministrativa europea e nazionale e sul ruolo svolto dai diversi attori coinvolti nel

processo di implementazione.

Esaminando gli attori principali, ovviamente, un posto di primo piano è occupato dalla Commissione e dai

Comitati europei. Accanto a questi ci si è soffermati sulla funzione svolta dalle agenzie europee, le quali, oltre

a sviluppare la funzione di raccolta, elaborazione e diffusione di dati e informazioni, creano una rete di contatti

fra gli organi nazionali competenti. La peculiarità di tali agenzie è data dal fatto che queste vanno a

circoscrivere taluni poteri di amministrazione attiva della Commissione e, al contempo, realizzano una sorta di

integrazione tra una pluralità di apparati pubblici competenti, attraverso la previsione di strumenti

organizzativi e procedimentali di collaborazione (i cosiddetti networks). La relazione che viene a istaurarsi tra

Ente sovranazionale e organi nazionali competenti configura il cosiddetto “modello dell’integrazione

decentrata”.

Nell’implementazione della politica sociale un importante ruolo è svolto dalle agenzie nazionali, con

particolare riferimento al modello della co-amministrazione attraverso il quale, infatti, si realizza una

contitolarità della competenza tra l’amministrazione europea e quella nazionale.

Mentre nel modello originario di attuazione delle politiche comunitarie denominato “modello di esecuzione

indiretta” è sempre una autorità interna che esercita una attività per conto di una istituzione della Comunità

europea, nello schema amministrativo della co-amministrazione è invece presente un soggetto nazionale al

quale viene attribuito il compito di svolgere in proprio una determinata azione che si rivela necessaria ed

indispensabile per lo svolgimento della funzione comunitaria. In tale modello, che peraltro trova piena

espressione nella disciplina dei fondi strutturali, un ruolo fondamentale nel processo di implementazione delle

politiche sociali è svolto dalle autorità regionali e locali.

Ai fini dell’identificazione degli attori e della definizione dei rispettivi ruoli, dunque, assume rilevanza il

modello di implementazione impiegato nell’attuazione della politica sociale.

Ciò che emerge in ultima analisi è che nell’implementazione della politica sociale europea prevale l’utilizzo di

strumenti che consentono un approccio bottom up e che esaltano pertanto, in ossequio al principio di

sussidiarietà, il ruolo fondamentale delle amministrazioni locali piuttosto che di quelle nazionali.

In considerazione del fatto che una parte integrante della politica sociale europea è rappresentata dalla politica

sanitaria, si è scelto di focalizzare l’analisi sull’implementazione e sull’integrazione della strategia sanitaria

dell’Unione, poiché essa determina in buona misura la riuscita stessa della politica sociale europea (Camaioni,

2004).

II.2 La tutela multilevel del diritto alla salute

II.2 .1 La tutela multilevel del diritto alla salute

Il diritto alla salute gode oggi di una tutela “multilevel” poiché è riconosciuto non solamente dagli ordinamenti

nazionali, ma anche dall’ordinamento comunitario e internazionale, seppur con limiti e forme diverse. In

particolare, con riguardo al diritto internazionale, giova in questa sede rammentare, sia pur succintamente, che

l’evoluzione dello scenario internazionale verso forme sempre più integrate di coesistenza ha determinato la

necessità di raccordare le rispettive politiche sanitarie con quelle dei Paesi limitrofi, nell’ambito di un quadro

generale con valenza sovranazionale. La necessità di una politica sanitaria sovranazionale è divenuta quindi

una esigenza dettata non tanto da ragioni umanitarie, bensì dallo stretto grado di interrelazioni che obbliga a

considerare il mondo come un’area unitaria di intervento. Una delle principali fonti in questo senso è data

dalla “Dichiarazione universale dei diritti dell’uomo”, adottata dall’Assemblea generale delle Nazioni Unite il

10 dicembre 1948, nella quale assume un’esplicita rilevanza la tutela della salute. Infatti, il par. 1 dell’art. 25

dispone che “ogni individuo ha il diritto di un tenore di vita sufficiente a garantire la salute e il benessere

proprio e della sua famiglia, con particolare riguardo all’alimentazione, al vestiario, all’abitazione, alle cure

mediche e ai servizi sociali necessari, e ha diritto alla sicurezza in caso di disoccupazione, malattia, invalidità,

vedovanza, vecchiaia o in ogni altro caso di perdita dei mezzi di sussistenza per circostanze indipendenti dalla

sua volontà”68

.

Venendo ora all’ambito dell’Unione europea69

, occorre premettere che in questi ultimi decenni il livello di

salute degli europei ha registrato un netto miglioramento, confermato ad esempio dall’aumento medio di

cinque anni dell’aspettativa di vita; tuttavia il diffondersi di malattie finora sconosciute e la scoperta di agenti

altamente dannosi presenti nella catena alimentare hanno richiesto un salto di qualità nelle politiche

dell’Unione, in quanto è aumentata la “domanda di salute” dei cittadini e la richiesta di informazioni e

strumenti per affrontare le nuove incognite. Questa situazione ha spinto dunque l’Unione Europea a

intensificare gli sforzi per una vera e propria politica sanitaria europea.

Già il Trattato di Maastricht aveva dato un primo impulso considerevole all’azione comunitaria in materia di

sanità pubblica, introducendo un articolo specifico (ex art. 129) a essa dedicato70

.

Successivamente il Trattato di Amsterdam ha introdotto importanti cambiamenti ponendo le basi per

l’evoluzione progressiva di una strategia volta a favorire la salute dei cittadini ed a garantire un’elevata qualità

del servizio sanitario pubblico nonché un sistema efficienti di assistenza agli anziani. Più esaustivamente l’art.

152 del Trattato sancisce che nella definizione e nell’attuazione di tutte le politiche ed attività della Comunità

è garantito “un livello elevato di protezione della salute umana”. Secondo tale disposizione, l’azione della

Comunità, che completa le politiche nazionali, si indirizza al miglioramento della sanità pubblica, alla

prevenzione delle malattie e all’eliminazione delle fonti di pericolo per la salute umana.

A tale scopo, si favorisce la lotta ai grandi flagelli e la ricerca sulle loro cause e l’informazione e l’educazione

sanitaria; si incoraggia altresì la cooperazione tra paesi membri, Comunità ed organizzazioni internazionali

competenti nella sanità pubblica; si prevedono misure dirette di intervento ed il riavvicinamento delle

legislazioni degli Stati membri, che comportino parametri elevati di qualità e sicurezza e la più ampia

protezione della salute umana nel settore veterinario, in quello degli alimenti ed in quello fitosanitario.

In particolare il Consiglio, deliberando secondo la procedura di codecisione e previa consultazione del

Comitato economico e sociale e del Comitato delle Regioni, contribuisce alla realizzazione degli obiettivi

previsti dal presente articolo, adottando tra l’altro le misure di incentivazione destinate a proteggere e a

migliorare la salute umana, ad esclusione però – secondo quanto stabilito nel comma 4b - di qualsiasi

armonizzazione delle disposizioni legislative e regolamentari degli Stati membri. Il par. 5 della disposizione in

parola prevede infine che “l’azione comunitaria nel settore della sanità pubblica rispetta a pieno le competenze

degli Stati membri in materia di organizzazione e fornitura di servizi sanitari e assistenza medica”71

.

Analoghe disposizioni, seppur necessariamente più concise sono ora contenute nella Carta dei Diritti

fondamentali dell’Unione europea, ovvero in quella che dovrebbe diventare – attraverso il lavoro della

Convenzione – la futura Costituzione dell’Europa unita, ove all’art. 35 si dispone che “Ogni individuo ha il

diritto di accedere alla prevenzione sanitaria e di ottenere cure mediche alle condizioni stabilite dalle

legislazioni e prassi nazionali” (Camaioni, 2004).

II.2.2 Cenni storici sulla strategia sanitaria fino a oggi

II.2.2.1 La tutela della salute dal Trattato di Maastricht al Trattato di Amsterdam

68

Sul punto cfr Luciani M., Diritto alla salute – Diritto Costituzionale, in Enciclopedia Giuridica, vol. XXVII, Roma, 1991, p. 8 ss. 69

Per un inquadramento generale delle politiche pubbliche dell’Unione cfr Fabbrini S., Morata F., (a cura di), L’Unione europea. Le politiche pubbliche, Roma-Bari, 2003. 70

Sul tema cfr Foà S., Il fondamento europeo del diritto alla salute: competenza istituzionale e profili di tutela, in Gallo e Pezzini (a cura di), Profili attuali del diritto alla salute, Milano, 1998, p. 74 ss. 71

Sul tema si veda Zanetta G. P., L’Europa e la sanità, Milano, 2003, pp. 26-38.

L’incipit molto asettico dell’ormai superato art. 129 del Trattato di Maastricht72

era molto più restrittivo

rispetto all’attuale previsione di cui all’art. 152 del Trattato in quanto lasciava intendere che l’Unione

interveniva solo di supporto alle politiche sanitarie dei singoli paesi, lasciando agli stessi forte autonomia.

Autonomia peraltro ribadita dal successivo periodo dell’art. 129 che mirava ad escludere qualsiasi

armonizzazione delle disposizioni legislative e regolamentari degli Stati membri.

L’art. 152 del Trattato, che sostituisce il precedente art. 129, amplia notevolmente la portata dell’azione

comunitaria nel settore sanitario e la stessa formulazione del testo sottolinea l’importanza che, a partire dal

Trattato di Amsterdam, viene attribuito alla salute del cittadino nell’ambito delle politiche strategiche

dell’Unione.

Il primo concetto-cardine è l’integrazione tra le attività della Comunità in quanto si prevede che nella

definizione e nell’attuazione di tutte le politiche comunitarie sia garantito un livello elevato di protezione della

salute umana. Di conseguenza la sanità e la protezione della salute non sono soltanto temi di settore, ma

diventano impegni che agiscono trasversalmente nella strategia generale della Comunità. Ne consegue che la

base giuridica per le politiche sanitarie si può rinvenire in tutte le norme dei Trattati e disposizioni conseguenti

che hanno un impatto con la salute; risulta così dilatato lo spazio per l’adozione da parte del Consiglio di

misure destinate a proteggere e migliorare la salute umana, animale e dei vegetali73

.

Il secondo concetto-cardine è contenuto nella previsione secondo la quale “l’azione della Comunità, che

completa le politiche nazionali, si indirizza al miglioramento della sanità pubblica [...]”. L’affermazione

fondamentale che la Comunità “completa le politiche nazionali” sottolinea come la nuova formulazione

dell’articolo ridisegni i rapporti tra livello comunitario e livello nazionale. Se il precedente articolo 129

sottolineava come l’azione degli Stati Il secondo concetto-cardine è contenuto nella previsione secondo la

quale “l’azione della Comunità, che completa le politiche nazionali, si indirizza al miglioramento della sanità

pubblica [...]”. L’affermazione fondamentale che la Comunità “completa le politiche nazionali” sottolinea

come la nuova formulazione dell’articolo ridisegni i rapporti tra livello comunitario e livello nazionale. Se il

precedente articolo 129 sottolineava come l’azione degli Statimembri si mantenesse autonoma e non potesse

essere modificata da iniziative comunitarie, ora il termine “completa” impiegato nell’attuale art. 152 delinea

una strategia comunitaria che, partendo dall’importanza attribuita alla salute, interviene non in modo

autoritativo, ma certamente incidendo, integrando e meglio definendo le modalità di intervento74

.

72

“La Comunità contribuisce a garantire un livello elevato di protezione della salute umana, incoraggiando la cooperazione tra gli Stati membri, e, se necessario, sostenendone l’azione”. 206 Per un’analisi approfondita sulla base giuridica delle politiche comunitarie in materia di sanità cfr Cilione G., Diritto sanitario, Ravenna, 2003, pp. 71-78. 73

Per un’analisi approfondita sulla base giuridica delle politiche comunitarie in materia di sanità cfr Cilione G., Diritto sanitario, Ravenna, 2003, pp. 71-78. 74

La Corte di Giustizia, con sentenza del 05 Ottobre 2000, causa C 376/98, ha annulla la direttiva europea 43/1998 che introduceva il divieto totale di praticare pubblicità e sponsorizzazione delle sigarette e degli altri prodotti del tabacco. Nel luglio 1998, la Germania aveva espresso voto contrario sull’applicazione della direttiva ed aveva posto una questione pregiudiziale alla Corte di giustizia del Regno Unito nell’ambito di una domanda introdotta da alcune industrie del tabacco. La sentenza in parola esprime un giudizio sulla base giuridica della direttiva comunitaria: secondo la Corte, infatti, il divieto di praticare pubblicità e sponsorizzazioni di prodotti del tabacco, sarebbe una “misura destinata alla tutela della sanità pubblica”, e non di un atto relativo al “mercato interno” come invece sosteneva la Germania. Al tempo stesso la Corte, pur dando torto alla Commissione europea, che ha originariamente proposto la direttiva, stabilisce un precedente importante, infatti, pur se il Trattato esclude la possibilità di armonizzare le disposizioni legislative e regolamentari degli Stati membri che riguardano la protezione e il miglioramento della salute (art. 152, n. 4), tale esclusione non implica “che provvedimenti di armonizzazione adottati sul fondamento di altre disposizioni del Trattato non possano avere un’incidenza sulla protezione della salute umana”. In altre parole, l’Unione, secondo la sentenza della Corte, può legiferare, almeno in una certa misura, su questioni che riguardano la sanità. Il Trattato prevede, del resto, che le esigenze di protezione della salute costituiscono una componente delle altre politiche della Comunità (ex art. 129, n. 1, terzo comma). La Corte di Giustizia, con sentenza del 05 Ottobre 2000, causa C 376/98, ha annulla la direttiva europea 43/1998 che introduceva il divieto totale di praticare pubblicità e sponsorizzazione delle sigarette e degli altri prodotti del tabacco. Nel luglio 1998, la Germania aveva espresso voto contrario sull’applicazione della direttiva ed aveva posto una questione pregiudiziale alla Corte di giustizia del Regno Unito nell’ambito di una domanda introdotta da alcune industrie del tabacco. La sentenza in parola esprime un giudizio sulla base giuridica della direttiva comunitaria: secondo la Corte, infatti, il divieto di praticare pubblicità e sponsorizzazioni di prodotti del tabacco, sarebbe una “misura destinata alla tutela della sanità pubblica”, e non di un atto relativo al “mercato interno” come invece sosteneva la Germania. Al tempo stesso la Corte, pur dando torto alla Commissione europea, che ha

Il tema della salute viene ripreso nel successivo art. 153 del Trattato, dedicato alla protezione dei consumatori:

al fine di promuovere gli interessi dei consumatori ed assicurare un livello elevato di protezione degli stessi, la

Comunità contribuisce a tutelare la salute, la sicurezza nonché gli interessi economici dei consumatori, anche

nell’ambito della definizione e dell’attuazione di altre politiche o di attività comunitaria.

Anche se è in discussione se la nuova formulazione del Trattato abbia conferito alla tutela del consumatore il

rango di vera e propria politica comunitaria, è certo però che essa ha acquistato un crescente rilievo ed è

divenuta una componente delle altre politiche ed attività comunitarie75

.

La politica di protezione dei consumatori, per quanto riguarda la salute e la sicurezza, si è finora esplicitata

nell’adozione di numerose direttive, soprattutto nel quadro del programma di ravvicinamento delle

legislazioni, volto ad assicurare l’eliminazione degli ostacoli tecnici agli scambi intracomunitari76

.

Altro articolo che richiama l’impegno comunitario in sanità è quello relativo all’ambiente, ovvero l’art. 174, il

quale recita: “La politica della Comunità in materia ambientale contribuisce a perseguire i seguenti obiettivi:

salvaguardia, tutela e miglioramento delle qualità dell’ambiente; protezione della salute umana; utilizzazione

accorta e razionale delle risorse naturali; promozione sul piano internazionale di misure destinate a risolvere i

problemi dell’ambiente a livello regionale o mondiale”. Tra i quattro obiettivi risulta ricompresa la protezione

della salute che riceve tutela indiretta nell’ambito della promozione e del miglioramento della qualità

dell’ambiente.

Può costituire uno scopo mediato della politica comunitaria ecologica, in quanto il raggiungimento di un’alta

qualità ambientale è strumentale alla protezione della salute umana e si ricollega ai compiti più propriamente

sociali dell’unione europea.

Se l’art. 152 è il cuore della politica sanitaria europea, diventano importanti ai fini della presente tesi anche

altri articoli del Trattato che riguardano settori diversi delle politiche comunitarie; infatti la tutela della salute è

trasversale rispetto ad altri settori di intervento ed è fondamentale per il raggiungimento per obiettivi strategici

dell’Unione. Ad esempio l’art. 158 del Trattato pone come obiettivo della Comunità il rafforzamento della sua

coesione economica e sociale, al fine di promuovere uno sviluppo armonioso dell’insieme delle comunità,

riducendo il divario tra i livelli di sviluppo delle varie regioni ed il ritardo di quelle meno favorite: è evidente

dunque che la tutela della salute è uno degli strumenti fondamentali per garantire uno sviluppo del territorio

armonioso e coeso. Un altro esempio ci è dato dall’art. 137 in materia di politica sociale, istruzione,

formazione professionale. L’articolo in parola prevede infatti che per conseguire gli obiettivi previsti dall’art.

13677

“la Comunità sostiene e completa l’azione degli Stati membri nei seguenti settori: a) miglioramento, in

particolare, dell’ambiente di lavoro per proteggere la sicurezza della salute dei lavoratori [...]”(Camaioni,

2004).

II.2.2.2 Le strategie dell’Unione europea nel processo di espansione degli interventi in materia sanità. Politiche

sanitarie e principio di sussidiarietà E’ interessante rilevare come proprio la disposizione di cui al sopra richiamato comma 4b dell’art. 152

esemplifichi in maniera evidente il ruolo che il principio di sussidiarietà gioca nell’ambito della politica

sanitaria. Infatti, stando a tale assunto, l’Unione dovrebbe avere competenze in tutti quegli aspetti della sanità

che hanno effetti “spillover”, o comportano “esternalità negative” che superano i confini dei singoli Stati

originariamente proposto la direttiva, stabilisce un precedente importante, infatti, pur se il Trattato esclude la possibilità di armonizzare le disposizioni legislative e regolamentari degli Stati membri che riguardano la protezione e il miglioramento della salute (art. 152, n. 4), tale esclusione non implica “che provvedimenti di armonizzazione adottati sul fondamento di altre disposizioni del Trattato non possano avere un’incidenza sulla protezione della salute umana”. In altre parole, l’Unione, secondo la sentenza della Corte, può legiferare, almeno in una certa misura, su questioni che riguardano la sanità. Il Trattato prevede, del resto, che le esigenze di protezione della salute costituiscono una componente delle altre politiche della Comunità (ex art. 129, n. 1, terzo comma). 75

Sul punto cfr Menichetti E., Il servizio sanitario nazionale ed il sistema integrato dei servizi sociali tra ordinamento interno e ordinamento comunitario, in Balduzzi R., Di Gaspare G. (a cura di), Sanità ed assistenza dopo la riforma del Titolo V, Milano, 2002, pp. 209 ss. 76

Queste direttive riguardano, tra l’altro, gli agenti conservanti e gli additivi nei prodotti alimentari, i prodotti farmaceutici, i cosmetici, etc. 77

“[...] promozione della salute, miglioramento delle condizioni di vita e di lavoro, che consenta la loro parificazione nel progresso, protezione sociale adeguata, dialogo sociale, sviluppo delle risorse umane atto a consentire un livello occupazionale elevato e duraturo, lotta contro l’emarginazione [...]”.

membri. In secondo luogo, l’Unione europea dovrebbe avere competenze in tutti quegli aspetti della sanità in

cui vi sono finalità che tutti gli Stati membri desiderano raggiungere, ma che nessun singolo Stato è

effettivamente in grado di raggiungere da solo.

Ma al di là del dato normativo testuale, è interessante rilevare come l’Unione abbia tentato di forzare questo

schema di rigida separazione di competenze tra Stati e Comunità; a tal proposito va evidenziato che in uno dei

primi documenti prodotti dalla Commissione dopo il Trattato dell’Unione, si afferma che “gli Stati membri, in

collaborazione con le professioni sanitarie e le persone coinvolte, provvedono al finanziamento e alla

prestazione dell’assistenza medica e dei trattamenti sanitari. Tuttavia, la Commissione potrebbe assistere gli

Stati membri nel migliorare la loro collaborazione nelle materie sanitarie, come per esempio nelle scelte

sanitarie fondamentali, e potrebbe fornire loro assistenza per azioni mirate a migliorare la qualità

dell’assistenza e del trattamento sanitario”78

. Possiamo dunque costatare che i suddetti compiti assegnati alla

Commissione non interessano propriamente né effetti spillover né finalità che tutti gli Stati membri desiderano

raggiungere ma che nessuno di essi è effettivamente in grado di raggiungere da solo. Di fatto, sono funzioni

finalizzate ad influenzare direttamente le caratteristiche proprie delle diverse politiche sanitarie degli Stati

membri.

Questa tendenza “centralizzatrice” dell’Unione è inoltre esplicata nel documento pubblicato dalla

Commissione nel maggio del 2000 per presentare la “Azione nel campo della salute pubblica 2001/2006” della

Comunità. Il documento inizia con la dichiarazione di rispetto del principio di sussidiarietà: “la situazione

della Comunità non è la stessa di quella degli Stati membri. La Comunità non gestisce direttamente servizi

sanitari o l’assistenza medica, che secondo il Trattato sono chiaramente responsabilità degli Stati membri.

Il ruolo della Comunità nel campo della salute pubblica è quello di complementare i loro sforzi, dare valore

aggiunto alle loro azioni ed in particolare affrontare le questioni che gli Stati membri non possono gestire da

soli”. A questo punto viene proposto un argomento classico a favore dell’azione collettiva soprannazionale:

“le malattie infettive, ad esempio, non rispettano i confini nazionali; né li rispettano l’inquinamento dell’aria e

dell’acqua. Questo è il motivo per cui il Trattato ha dato alla Comunità una responsabilità importante per

affrontare le problematiche sanitarie nel senso più ampio”79

(Camaioni, 2004).

II.2.2.3 Le politiche sanitarie e il principio precauzionale

Fra gli strumenti di cui l’Unione si è servita per espandere la propria area di intervento nel settore della salute

merita un accenno il principio precauzionale80

.

Esso interviene ogni qual volta il valore giuridico della salute viene coinvolto in una politica comunitaria ed

obbliga le autorità competenti a prendere provvedimenti al fine di prevenire taluni rischi, anche potenziali, per

la salute pubblica, per la sicurezza dei consumatori e per l’ambiente, dando priorità alla tutela di suddetti

interessi rispetto ad altri81

.

Nel 1997 il Trattato di Amsterdam ha affermato, all’art. 59, che la Commissione, nelle sue proposte che

riguardano la salute, sicurezza, protezione dell’ambiente e dei consumatori, “prenderà come base di

riferimento un livello elevato di protezione, tenendo conto in particolare di qualsiasi nuovo sviluppo basato sui

fatti scientifici. Entro i loro rispettivi poteri, il Parlamento europeo e il Consiglio cercheranno inoltre di

raggiungere questo obiettivo”. A parere della Commissione, il principio di precauzione si applica in tutti quei

casi in cui i dati scientifici siano insufficienti, non sufficientemente conclusivi o non certi; nei casi in cui a

seguito di una valutazione scientifica emerge che si possono ragionevolmente temere effetti potenzialmente

pericolosi per l'ambiente e la salute umana, animale o vegetale. In questi due casi, i rischi sono incompatibili

con il livello di protezione elevato perseguito dall'Unione europea82

.

78

Commissione Europea COM (93) 559, Buxelles, 24 novembre 1993, “Commission communication on the framework for action in the fields of public health”. 79

Commissione Europea COM (2000) 285, Buxelles, 16 maggio 2000, “Comunicazione della Commissione al Consiglio, al Parlamento europeo, al Comitato economico e sociale delle Regioni sulla strategia sanitaria della Comunità europea”, pag. 5. 80

Sull’argomento cfr Petroni A.M., La bioetica dell’Unione, in www.centroenaudi.it. 81

Ex pluris cfr Corte di Giustizia, sentt 5 Maggio 1998, in causa C 180/96, 11 Febbraio 2002, in causa C 13/99 e C 70/99. 82

Il libro bianco sulla sicurezza alimentare, la Commissione specifica tre regole a cui attenersi affinché il principio di precauzione sia rispettato: una valutazione scientifica completa condotta da un’autorità indipendente per determinare il grado d'incertezza scientifica; una valutazione dei rischi e delle conseguenze in mancanza di un’azione europea; la partecipazione, nella massima trasparenza, di tutte le parti interessate allo studio delle azioni eventuali. Inoltre, la

La questione del principio precauzionale è diventata così importante nelle politiche dell’Unione che la

Commissione, nel febbraio del 2000, ha sentito la necessità di riassumerne le linee guida. Si è sostenuto che

“quando i dati disponibili non sono adeguati o conclusivi, un approccio prudente e cauto alla protezione

ambientale, alla salute o alla sicurezza, potrebbe essere optare per l’ipotesi peggiore. L’accumulazione di

questo tipo di ipotesi porterà ad una esagerazione del rischio reale ma darà una certa sicurezza che esso non

verrà sottostimato”83

.

E’ bene ricordare che proprio il principio di precauzione ha permesso alle Istituzioni dell’Unione europea di

intervenire direttamente nella ricerca scientifica e tecnologica in campo biomedico condotta nei diversi Stati

membri sulla base del fatto che i prodotti che ne derivano devono essere “sicuri” per tutti i consumatori del

mercato comune europeo (Camaioni, 2004).

II.2.2.4 Le politiche sanitarie e la creazione di un mercato unico europeo

E’ importante ricordare che la “centralizzazione” nel campo della sanità è stata operata dalle istituzioni

dell’Unione europea giustificandola con l’obiettivo della creazione di un mercato unico europeo. A questo

proposito, per meglio comprendere il fenomeno, occorre accennare brevemente alle diverse concezioni del

mercato proposte dalla teoria economica.

Come è ben noto, ci sono vari approcci all’idea stessa di mercato, rispetto ai suoi principi ed al suo

funzionamento. Secondo la concezione standard neoclassica, si raggiunge l’efficienza quando i mercati sono

in equilibrio. A loro volta, livelli più elevati di equilibrio economico vengono raggiunti quando si abbassano i

costi di transazione e per far questo occorre che le diverse aree incluse in un dato mercato abbiano la stessa

regolazione.

Un approccio molto diverso deriva dalla cosiddetta economia austriaca secondo la quale la definizione di stato

di equilibrio data dall’economia neoclassica non descrive correttamente i veri vantaggi dell’economia di

mercato su altri modi di produzione. I vantaggi di mercato derivano infatti dall’innovazione di prodotti e

servizi; i mercati non sono mai in equilibrio in quanto il mercato è un processo di scoperta, dove diverse

alternative vengono provate e selezionate dalle scelte dei consumatori. Dato che la produzione di beni e servizi

richiede una cornice giuridica e regolamentativa, anche i diversi sistemi giuridici di regolamentazione vengono

messi in competizione e confronto fra loro.

Di conseguenza, la competizione fra i sistemi giuridici e di regolamentazione è valida tanto quanto la

competizione fra beni e servizi finali.

L’approccio dell’Unione europea è chiaramente basato sulla prima visione del mercato. In effetti, l’articolo 94

del Trattato Ce stabilisce che “il Consiglio approva all’unanimità, su proposta della Commissione, dopo aver

consultato il Parlamento europeo ed il Comitato economico e sociale, le direttive per il ravvicinamento delle

leggi, dei regolamenti e dei provvedimenti amministrativi degli Stati membri che influiscono direttamente

sull’Istituzione o il funzionamento del mercato comune”. Dato che però il sopra citato art. 152 vieta qualsiasi

armonizzazione delle leggi e dei regolamenti degli Stati membri nel campo delle politiche sanitarie, sorge un

conflitto fra le competenze degli Stati membri e la fissazione di regole uniformi per un mercato comune dei

servizi sanitari.

Commissione rammenta che le misure risultanti dal ricorso al principio di precauzione possono configurarsi in una Decisione di agire o di non agire. Questa Decisione è funzionale al livello di rischio ritenuto “accettabile”. Un’applicazione concreta del principio di precauzione, basato su quanto appena detto si e’ avuto in materia di OGM. European Commission, White Paper on Food and Safety, COM (2000), 2 February 2000. Il libro bianco sulla sicurezza alimentare, la Commissione specifica tre regole a cui attenersi affinché il principio di precauzione sia rispettato: una valutazione scientifica completa condotta da un’autorità indipendente per determinare il grado d'incertezza scientifica; una valutazione dei rischi e delle conseguenze in mancanza di un’azione europea; la partecipazione, nella massima trasparenza, di tutte le parti interessate allo studio delle azioni eventuali. Inoltre, la Commissione rammenta che le misure risultanti dal ricorso al principio di precauzione possono configurarsi in una Decisione di agire o di non agire. Questa Decisione è funzionale al livello di rischio ritenuto “accettabile”. Un’applicazione concreta del principio di precauzione, basato su quanto appena detto si e’ avuto in materia di OGM. European Commission, White Paper on Food and Safety, COM (2000), 2 February 2000. 83

Commissione delle Comunità europee COM (2000) 1, Bruxelles, 2 febbraio 2000, “Comunicazione della Commissione sul principio di precauzione”, pag. 28. Commissione delle Comunità europee COM (2000) 1, Bruxelles, 2 febbraio 2000, “Comunicazione della Commissione sul principio di precauzione”, pag. 28.

In sostanza è accaduto che a livello comunitario si è tentato di far leva sullo strumento della creazione di un

mercato unico per espandere le competente dell’Unione in settori di intervento sanitario. Infatti il Consiglio e

il Parlamento europeo hanno interpretato l’art. 94 e l’art. 95 come se estendessero la loro competenza fino a

violare la proibizione stabilita dall’art. 15284

. Questo fatto è diventato evidente quando la Corte di giustizia

europea è stata chiamata a decidere sulla questione di una direttiva che proibiva la pubblicità del tabacco. La

Corte ha stabilito infatti che “la direttiva riguarda il ravvicinamento delle leggi, dei regolamenti e dei

provvedimenti amministrativi degli Stati membri relativi alla pubblicità e alla sponsorizzazione dei prodotti

del tabacco. Le misure nazionali interessate si ispirano il larga misura a obiettivi di politiche per la salute

pubblica. Il primo intento dell’art. 129 (oggi 152) del Trattato esclude qualsiasi armonizzazione di leggi e

regolamenti degli Stati membri volti a proteggere e migliorare la salute umana. Ma quella norma non significa

che le misure di armonizzazione adottate in base ad altre norme del Trattato non possano avere alcun impatto

sulla protezione della salute umana. Anzi, il terzo paragrafo dell’art. 129 prevede che i requisiti di salute

devono formare parte costitutiva delle altre politiche pubbliche della Comunità. Altri articoli del Trattato,

tuttavia, non potrebbero essere utilizzati come base giuridica per aggirare l’esclusione esplicita

dell’armonizzazione prevista dall’art. 129 del Trattato”85

.

Come è accaduto sovente nella sua storia, la Corte di Giustizia ha rappresentato un efficace contrappeso contro

la tendenza centralizzatrice della Comunità86

. Tuttavia non ci si dovrebbe aspettare, da parte della Corte, un

potere sufficiente a domare la logica della centralizzazione. Un esempio molto significativo di questo fatto è

che il Parlamento Europeo ha istituito nel 1999 una “Commissione temporanea sulla genetica umana e altre

nuove tecnologie della medicina moderna”.

Essa sarà in carica fino alla fine della legislatura e ha un mandato molto ampio. La Commissione ha

esplicitamente invocato come principale base giuridica della propria azione gli artt. 94 e 95. La sua

conclusione è che i progressi nelle terapie genetiche e nei farmaci dovrebbero essere monitorati e valutati dal

Parlamento Europeo, e che la legislazione da parte dell’Unione Europea viene giustificata per evitare ostacoli

al mercato interno e la “distorsione della competizione”87

(Camaioni, 2004).

II.2.2.5 La strategia sanitaria

Nel 1998 la Commissione ha pubblicato una comunicazione volta ad avviare un dibattito circa la necessità di

innovare la strategia comunitaria nel settore della sanità pubblica al fine di affrontare al meglio le evoluzioni

derivanti da nuove minacce sanitarie, ma anche da crescenti pressioni sui sistemi sanitari stessi e

dall’allargamento, anche alla luce delle nuove disposizione introdotte dal Trattato di Maastricht. In particolare

il dibattito verteva sulla crescente necessità di dare risposta alle attese dei cittadini europei ad una maggiore

tutela e alla crescente domanda di servizi sanitari, nonché sull’opportunità di coordinare le altre politiche

comunitarie strettamente legate alle tematiche sanitarie e sulle esperienze dei precedenti programmi.

Infatti, già dal 1993 la Comunità aveva una propria strategia, basata su programmi d’azione distinti:

Programma d’azione per la promozione della salute: il programma si proponeva di migliorare la salute tramite

una maggiore diffusione delle informazioni sui fattori di rischio incoraggiando le persone ad adottare uno stile

di vita sano.

• Programma d’azione in materia di Monitoraggio sanitario: tramite studi, ricerche e l’elaborazione di un set di

indicatori, mirava ad ottenere informazioni di qualità sui trend sanitari della popolazione, sulle malattie e sui

sistemi sanitari.

84

La tesi è sostenuta da Petroni A.M., La bioetica dell’Unione, op cit. La tesi è sostenuta da Petroni A.M., La bioetica dell’Unione, op cit. 85

Corte di Giustizia, sentenza del 5 Ottobre 2000, causa C 376/98. 86

Sul punto cfr. Petroni A.M., A Liberal View on a European Costitution, in Weale A. e Lehning P. (a cura di), Citizenship, Justice and Rights in the New Europe, Routledge, Londra, 1997. Questo risultato non è dovuto certamente al caso. E’ dovuto sostanzialmente alla pratica giudiziaria tradizionale della Corte, che considera le parti contrapposte uguali di fronte alla legge. Ciò ha permesso ai diritti individuali e ai principi del libero mercato di prevalere su interessi diffusi e forti. Difficilmente ci si potrebbe aspettare che un processo democratico maggioritario produca risultati migliori o equivalenti. 87

Parlamento Europeo, “Temporary Commission on human genetics and other new technologies of modern medicine”, rapporto PE 300.121, 8 giugno 2001.

• Programma d’azione per la prevenzione di malattie trasmissibili: l’obiettivo prioritario era il controllo e il

contenimento della diffusione dell’AIDS, dei virus in genere e la riduzione della mortalità e morbilità

provocate da malattie trasmissibili.

• Programma d’azione per la lotta ai tumori: il programma prevedeva ventidue linee di azione, tra cui la

raccolta dei dati, l’informazione pubblica, l’educazione, la prevenzione, la qualità delle cure e della ricerca.

• Programma d’azione per le malattie rare: lo scopo del programma era migliorare la conoscenza facilitando

l’accesso alle informazioni.

• Programma d’azione per la prevenzione degli incidenti: il programma contribuiva and incrementare

l’attenzione delle autorità pubbliche sulla necessità di ridurre gli incidenti esclusi quelli sul lavoro.

• Programma d’azione per le malattie legate all’inquinamento: finalizzato allo sviluppo di politiche e strategie

ambientali, delle conoscenze e dei rischi connessi all’inquinamento ambientale.

• Prevenzione dalle droghe: il programma si prometteva di combattere la dipendenza, in particolare

incoraggiando la cooperazione tra gli Stati Membri, supportando i relativi programmi nazionali contro la

droga.

I suddetti programmi hanno sensibilizzato gli Stati Membri ad un approccio comunitario in materia sanitaria

ed hanno contribuito a ridurre le divergenze nazionali; di contro l’assenza di un meccanismo di coordinamento

di tali programmi ha comportato un onere amministrativo considerevole e una carenza di flessibilità con

conseguente dispersione di risorse finanziarie88

.

Preso atto delle passate esperienze, nel 2000 la Commissione ha presentato la nuova “strategia sanitaria” che si

basa su tre principi fondamentali: l’integrazione, la sostenibilità e la focalizzazione sugli aspetti più rilevanti

della salute umana. Nel 1998 la Commissione ha pubblicato una comunicazione volta ad avviare un dibattito

circa la necessità di innovare la strategia comunitaria nel settore della sanità pubblica al fine di affrontare al

meglio le evoluzioni derivanti da nuove minacce sanitarie, ma anche da crescenti pressioni sui sistemi sanitari

stessi e dall’allargamento, anche alla luce delle nuove disposizione introdotte dal Trattato di Maastricht. In

particolare il dibattito verteva sulla crescente necessità di dare risposta alle attese dei cittadini europei ad una

maggiore tutela e alla crescente domanda di servizi sanitari, nonché sull’opportunità di coordinare le altre

politiche comunitarie strettamente legate alle tematiche sanitarie e sulle esperienze dei precedenti programmi.

Infatti, già dal 1993 la Comunità aveva una propria strategia, basata su programmi d’azione distinti:

Programma d’azione per la promozione della salute: il programma si proponeva di migliorare la salute tramite

una maggiore diffusione delle informazioni sui fattori di rischio incoraggiando le persone ad adottare uno stile

di vita sano.

• Programma d’azione in materia di Monitoraggio sanitario: tramite studi, ricerche e l’elaborazione di un set di

indicatori, mirava ad ottenere informazioni di qualità sui trend sanitari della popolazione, sulle malattie e sui

sistemi sanitari.

• Programma d’azione per la prevenzione di malattie trasmissibili: l’obiettivo prioritario era il controllo e il

contenimento della diffusione dell’AIDS, dei virus in genere e la riduzione della mortalità e morbilità

provocate da malattie trasmissibili.

• Programma d’azione per la lotta ai tumori: il programma prevedeva ventidue linee di azione, tra cui la

raccolta dei dati, l’informazione pubblica, l’educazione, la prevenzione, la qualità delle cure e della ricerca.

• Programma d’azione per le malattie rare: lo scopo del programma era migliorare la conoscenza facilitando

l’accesso alle informazioni.

• Programma d’azione per la prevenzione degli incidenti: il programma contribuiva and incrementare

l’attenzione delle autorità pubbliche sulla necessità di ridurre gli incidenti esclusi quelli sul lavoro.

• Programma d’azione per le malattie legate all’inquinamento: finalizzato allo sviluppo di politiche e strategie

ambientali, delle conoscenze e dei rischi connessi all’inquinamento ambientale.

• Prevenzione dalle droghe: il programma si prometteva di combattere la dipendenza, in particolare

incoraggiando la cooperazione tra gli Stati Membri, supportando i relativi programmi nazionali contro la

droga.

I suddetti programmi hanno sensibilizzato gli Stati Membri ad un approccio comunitario in materia sanitaria

ed hanno contribuito a ridurre le divergenze nazionali; di contro l’assenza di un meccanismo di coordinamento

88

European Commission, The health strategy of the European Community, COM (2000) 285. European Commission, The health strategy of the European Community, COM (2000) 285. European Commission, The health strategy of the European Community, COM (2000) 285.

di tali programmi ha comportato un onere amministrativo considerevole e una carenza di flessibilità con

conseguente dispersione di risorse finanziarie89

.

La strategia mira a favorire un approccio integrato alle attività connesse con la salute su scala comunitaria in

modo che le finalità dei precedenti programmi convergano nella finalità di creare un quadro unico d’azione.

Particolare attenzione viene prestata alla creazione di collegamenti con altre strategie e attività comunitarie,

quali la ricerca, il mercato interno, l’agricoltura o l’ambiente. In altri termini, tutti i campi d’azione connessi

con la salute devono concorrere alla realizzazione degli obiettivi in materia di sanità.

La pianificazione e l’attuazione della strategia sanitaria dovrà portare a risultati sostenibili, ossia che

rispondano concretamente alle preoccupazioni in materia sanitaria in Europa. Tra le priorità figurano infatti, la

creazione di un un’informazione di qualità sui fattori determinanti della salute umana, quali la nutrizione,

l’attività fisica, il tabacco, l’alcool, le droghe, i fattori genetici, l’età e il sesso.

Inoltre si stabilisce che le risorse disponibili siano indirizzate verso quelle attività che possano garantire un

vero valore aggiunto comunitario, nel rispetto delle attività già previste o realizzate con maggior efficacia,

secondo un’ottica di sussidiarietà, dagli stessi Stati Membri o da altre Organizzazioni Internazionali.

Per risultare efficace l’azione comunitaria deve essere incentrata sulla lotta contro le grandi minacce della

salute, sulla riduzione della mortalità e delle malattie legate alle condizioni generali di vita, nonché sulla

promozione dell’uguaglianza a livello della salute in tutta l’Unione.

La strategia comunitaria nel campo della sanità pubblica si articola in due fasi principali di programmazione:

1. l’identificazione di un quadro generale di sanità pubblica che consiste in un programma d’azione nel settore

della sanità pubblica e nella politica e negli strumenti legislativi correlati;

2. la realizzazione di una strategia integrata in materia di sanità, attraverso il contributo che altre politiche e

attività comunitarie possano apportare al conseguimento di un elevato livello di protezione della salute.

Preso atto delle passate esperienze, nel 2000 la Commissione ha presentato la nuova “strategia sanitaria” che si

basa su tre principi fondamentali: l’integrazione, la sostenibilità e la focalizzazione sugli aspetti più rilevanti

della salute umana (Camaioni, 2004).

II.2.2.6 Il programma d’azione sanitario 2003-200890

Il programma d’azione comunitaria nel settore della sanità pubblica costituisce uno degli elementi chiave

dell’attuazione della strategia in materia di salute. Tale programma, adottato il 23 settembre 2002 dal

Parlamento europeo e dal Consiglio, contribuisce considerevolmente ad intensificare l’azione comunitaria nel

settore della salute.

Si tratta di un programma globale che sostituisce i precedenti otto programmi di sanità pubblica integrandoli in

una unica azione imperniata su tre obiettivi principali:

1. migliorare l’informazione e la conoscenza per una migliore sanità pubblica;

2. rafforzare le capacità di reagire rapidamente e in maniera coordinata alle minacce della salute;

3. promuovere la salute e prevenire le malattie tenendo conto dei fattori determinanti per la salute attraverso

tutte le politiche dell’Unione.

Il primo obiettivo che il programma si pone, consiste nell’intensificare la diffusione dell’informazione e della

cultura in materia di salute pubblica, a vantaggio sia dei cittadini che dei rispettivi governi, attraverso la

creazione di un sistema comunitario strutturato e completo di acquisizione, analisi e diffusione dei dati e delle

conoscenze; inoltre, la predisposizione di tale attività deve essere mirata, da un lato ad evidenziare

l’evoluzione generale della situazione sanitaria della popolazione e dei relativi parametri, dall’altro a rilevare

gli eventuali cambiamenti apportati ai sistemi sanitari.

Il secondo obiettivo consiste nel creare un meccanismo di reazione in grado di rispondere tempestivamente e

in maniera coordinata alle grandi minacce per la salute, attraverso l’istituzione, lo sviluppo e il rafforzamento

di meccanismi comunitari di sorveglianza, di allarme precoce e di reazione rapida alle minacce sanitarie.

Infine, il terzo obiettivo consiste nello studio e approfondimento dei fattori determinanti per la salute, in

particolare quelli legati allo stile di vita, come il regime alimentare e l’attività fisica, ed i fattori ambientali,

quali l’esposizione ai campi elettromagnetici o all’inquinamento chimico o acustico.

Il perseguimento dei citati obiettivi, implica la collaborazione attiva degli Stati membri e il coinvolgimento

delle NGO competenti e più rappresentative a livello internazionale.

89

Per un quadro generale sulla strategia e sui vecchi programmi si veda: www.europa.eu.int/comm/healt/ph_overview/strategy_en.html 90

Decisione 1786/2002. OJ L 271 09/10/2002224 Decisione 1786/2002. OJ L 271 09/10/2002

In ultima analisi, il programma, contribuisce a garantire un alto livello di protezione della salute umana nella

definizione e attuazione di tutte le politiche e attività comunitarie, attraverso la promozione di una strategia

sanitaria integrata ed intersettoriale; permette di affrontare disuguaglianze nel campo sanitario; mira a

incoraggiare la cooperazione tra gli Stati membri nei settori previsti dall’art. 152 del Trattato.

Nella strategia sanitaria la stessa Commissione ha ravvisato la necessità di integrare le priorità della politica

sanitaria con gli obiettivi di altre strategie che condizionano fortemente taluni determinanti fondamentali della

salute umana; due sono gli strumenti previsti affinché tali strategie correlate contribuiscano alla promozione e

alla tutela della salute umana: • la valutazione dell’impatto delle politiche comunitarie sulla salute e sui sistemi

sanitari. In particolare si cerca di sviluppare un sistema che permetta di determinare e misurare gli effetti delle

scelte politiche di altri settori che incidono sulla salute pubblica;

• lo sviluppo di azioni congiunte con altri settori di intervento allo scopo di garantire la coerenza con gli

obiettivi comunitari in materia sanitaria. Si dovrebbe procedere ad una crescente integrazione tra la materia

sanitaria e i seguenti settori: la protezione dei consumatori, la protezione sociale, la politica per l’occupazione,

ricerca e sviluppo tecnologico, istruzione, trasporti.

I collegamenti appena accennati devono essere garantiti dalla Commissione, sia in sede di definizione delle

altre strategie sia in sede di implementazione delle politiche correlate, in quanto essa è formalmente investita

del potere di iniziativa e sopratutto è espressione dell’interesse comunitario. A tale scopo la Commissione è

affiancata dal “High Level Committee on Health” il quale si occupa di consulenza informale ed è formato da

ex-autorità quali precedenti ministri della Sanità degli Stati Membri. Esso collabora con i gruppi di lavoro

delle varie direzioni sulla base della natura della connessione tra la materia sanitaria e le altre politiche

comunitarie per costruire un forum per lo scambio d’informazioni91

(Camaioni, 2004).

II.2.2.7 Le altre politiche in materia sanitaria

Oltre al programma d’azione, il quadro sanitario europeo contempla altre politiche, sempre adottate sulla base

dell’ art.152 del Trattato, di cui in questa sede è opportuno dare conto, pur senza entrare nel dettaglio. Esse

concernono le malattie trasmissibili, la droga, la lotta al tabagismo, l’argomento sangue,emoderivati e organi

(Camaioni, 2004)

II.2.2.8 Politiche sanitarie correlate

Nella definizione del panorama della cosiddetta politica sanitaria, devono essere considerati una serie di

provvedimenti normativi provenienti da altri settori di competenze europea, la cui implementazione comporta

il perseguimento degli obiettivi e dei principi riferibili alla politica sanitaria europea parziali a tutela della

salute sarebbero state invece accettabili. Sentenza Germania/Parlamento e Consiglio del 5 Ottobre 2000, causa

C-376/98.

Essi riguardano il settore farmaceutico, l’igiene e la salute alimentare, l’accesso alle cure mediche.

Inoltre, il giudice europeo è stato chiamato a pronunciarsi sulla validità della stessa direttiva 2001/37, laddove

attribuisce competenze comunitarie in materia di tabacco senza un’appropriata base giuridica. La Corte ha

stabilito che la direttiva andava comunque a migliorare le condizioni del mercato e quindi poteva essere

legittimamente adottata sulla base dell’art. 95, sul ravvicinamento delle disposizioni legislative. Per la rilevanza che esso riveste, si riporterà di seguito una estrema sintesi relativa all’accesso alle cure

mediche. II.2.2.8.1 Accesso alle cure mediche

La libera circolazione dei lavoratori, dei professionisti e dei pazienti all’interno dell’Unione europea ha posto

il problema della regolamentazione dell’accesso ai sistemi di protezione sociale. L’art. 18 del Trattato dispone

che “ogni cittadino dell'Unione ha il diritto di circolare e di soggiornare liberamente nel territorio degli Stati

91

I consigli indirizzati alla Commissione riguardano lo sviluppo della strategia, la necessità di nuove iniziative o attività riguardanti la salute pubblica, nonché gli equilibri tra la politica sanitaria e le altre politiche comunitarie. Il forum non solo provvede ad intensificare le relazioni tra la politica sanitaria e le altre politiche correlate, ma anche tra politica sanitaria Europea e quella degli Stati Membri. Ciò comporta una sorta di network non ufficiale tra i due livelli governativi che contribuisce a rafforzare l’attuazione della politica comunitaria in sede nazionale. www.europa.eu.int/comm/healt/ph_overview/strategy_en.html

membri, fatte salve le limitazioni e le condizioni previste dal Trattato e dalle disposizioni adottate in

applicazione dello stesso”.

Il regolamento 1408/71/CEE, relativo all’applicazione dei regimi di sicurezza sociale dei lavoratori e dei

familiari che si spostano all’interno della Comunità, disciplina le regole d’accesso ai sistemi di protezione

sociale allo scopo di coordinare le legislazioni degli Stati membri. Il regolamento 574/72/CEE definisce le

modalità di applicazione del precedente regolamento236.

Recentemente, il Consiglio ha esteso l’applicazione dei Regolamenti 1408/71 e 574/72 alle persone

provenienti da paesi terzi92

e ha introdotto la “carta europea d’assicurazione sanitaria” nella quale saranno

archiviati i dati sanitari fondamentali del titolare93

.

Si modifica così, seppur parzialmente, quanto stabilito dal Regolamento 1408/71, a favore di una maggiore

semplificazione delle procedure. Tramite questa tessera magnetica, infatti, i cittadini degli Stati membri

saranno esonerati dal richiedere l’autorizzazione prevista dalla stessa 1408/71 per ogni spostamento all’interno

dell’Unione (Camaioni, 2004).

II.2.2.9 L’implementazione della strategia sanitaria

La tutela della salute costituisce una priorità delle politiche sociali dell’Unione e la relativa programmazione si

ispira al perseguimento di un elevato livello di tutela del diritto alla salute dei cittadini dell’Unione stessa.

L’azione dell’Unione relativa al perseguimento delle politiche sanitarie è riferibile a un complesso schema

procedimentale, all’interno del quale gioca un ruolo fondamentale l’integrazione delle volontà politiche degli

attori, nazionali e comunitari.

La Commissione, alla quale spetta il compito di dare impulso all’intero procedimento, compone una strategia

pluriennale di politica sanitaria nella quale fissa un obiettivo globale da raggiungere, un numero ampio di

obiettivi generali e le misure attraverso le quali il programma di azione troverà applicazione.

Appare chiaro che per raggiungere l’obiettivo globale e gli obiettivi generali del programma è necessaria una

efficacie cooperazione degli Stati membri, il loro pieno impegno nell’attuazione delle azioni comunitarie e il

coinvolgimento di istituzioni, associazioni, organizzazioni e organismi nel campo della sanità. Nel definire il

programma infatti, la Commissione ha l’importante ruolo di garante dell’efficacia e del coordinamento delle

misure e delle azioni: essa, infatti, deve istituire un forte legame con le altre politiche comunitarie che possono

avere un impatto sulla salute e sulla strategia stessa ed occorre quindi che la Commissione predisponga criteri

e metodologie al fine di creare una politica europea intersettoriale.

Inoltre, per poter assicurare che le azioni ad implementazione del programma affrontino efficacemente le

problematiche e le minacce alla salute pubblica in cooperazione con altre politiche ed attività comunitarie,

evitando sovrapposizioni, il programma di azione comunitaria per le politiche sanitarie deve prevedere la

possibilità di intraprendere azioni congiunte con i programmi e le azioni comunitarie correlate. Ad esempio,

un utilizzo fattivo di altre politiche comunitarie, quali i fondi strutturali e la stessa politica sociale, potrebbero

influire positivamente sui determinanti sanitari.

In questa sede ci occuperemo ora dell’implementazione del programma di azione comunitaria nel campo della

sanità pubblica 2003 - 2008 descrivendo le principali fasi in cui si articola il procedimento di attuazione.

Le modalità di implementazione sono descritte all’art. 8 dello stesso. È prevista innanzitutto, per l’intera

durata del programma, la definizione di un quadro finanziario che ripartisce nei sei anni di intervento il

bilancio complessivamente stanziato per la politica sanitaria (riferibile al programma), che ammonta a

trecentododici milioni di euro. Al quadro finanziario predisposto per il programma va ad aggiungersi il

finanziamento proveniente da altre politiche comunitarie stanziato per azioni congiunte nell’ambito del

programma.

Successivamente la Commissione, assistita da un Comitato composto dai rappresentanti nazionali di ciascun

Stato membro, stabilisce annualmente le priorità e le azioni da intraprendere, tra cui l’assegnazione delle

risorse (di cui al piano finanziario descritto sopra); fissa inoltre le modalità, i criteri e le procedure di scelta e

di finanziamento delle azioni del programma e le modalità di valutazione delle stesse.

Una volta redatto il piano annuale, le istituzioni, le associazioni e le organizzazioni del settore sanitario, sono

invitate a presentare proposte di progetto per la realizzazione di attività prioritarie e specifiche definite dalla

Commissione.

92

Regolamento 859/2003/CE. 93

COM(2003)73 del 17/02/2003, adottata con Decisione del Consiglio: OJ L 276/1, 4, 19 del 27/10/2003.

Ogni anno viene fissata una data limite per la ricezione delle domande di finanziamento (a titolo indicativo il

30 giugno), per il finanziamento dell’anno successivo.

Va però precisato che oltre all’invito a presentare proposte, vi è una ulteriore procedura attraverso la quale i

richiedenti possono partecipare al programma di salute pubblica: la gara d’appalto94

.

Per quanto riguarda i criteri per la selezione ed il finanziamento delle azioni del programma95

, la Commissione

accorda la priorità a quei progetti che “apportino un valore aggiunto europeo96

; siano su vasta scala (in termine

di contenuto e di copertura geografica), pluriennali e multidisciplinari97

; portino a risultati sostenibili98

;

contribuiscano agli sviluppi politici su scala comunitaria in materia di sanità pubblica enunciati nelle priorità

annuali per la realizzazione degli obiettivi del programma; forniscano una adeguata attenzione alla valutazione

del processo e dei risultati”.

Va altresì evidenziato che l’identificazione dei progetti da finanziare è effettuata tramite l’applicazione di tre

serie di criteri di valutazione: si tratta di “criteri di esclusione”, che riguardano la valutazione

dell’ammissibilità, “criteri di selezione”, con riferimento alla valutazione della capacità del richiedente, e

“criteri di applicazione” concernenti invece la valutazione della qualità in rapporto ai costi del progetto.

I progetti sono finanziati in base al principio delle spese ripartite: se l’importo concesso dalla Commissione è

inferiore all’assistenza voluta dal soggetto proponente, spetta a questo ultimo trovare finanziamenti

supplementari o ridurre i costi globali del progetto senza attenuarne gli obiettivi ed il contenuto.

Inoltre, l’importo del contributo finanziario può, in linea di massima, raggiungere il sessanta percento dei costi

ammissibili per i progetti considerati. Vi è da dire che l’importo normale sarà probabilmente inferiore al

sessanta percento ma la Commissione determinerà, in ogni specifico caso, la percentuale massima da

concedere.

Da ultimo vi è la fase di monitoraggio, valutazione e divulgazione dei risultati. La Commissione infatti, in

stretta cooperazione con gli Stati membri, procede, ove necessario coadiuvata da esperti, ad un monitoraggio

periodico dell’attuazione delle azioni del programma alla luce degli obiettivi prefissati. Una volta l’anno, essa

riferisce al riguardo al Comitato e trasmette copia delle sue principali conclusioni al Parlamento europeo ed al

Consiglio. Entro la fine del quarto anno del programma, è previsto inoltre che la Commissione proceda ad una

94

Va sottolineato che la Commissione è considerata l’Ente appaltate per i contratti aggiudicati per suo conto. In tale ruolo, la Commissione è responsabile del rispetto dei principi fondamentali di trasparenza e proporzionalità, di parità di trattamento e di non discriminazione, nonché delle disposizioni legali derivanti dalle direttive “appalti pubblici”. Va sottolineato che la Commissione è considerata l’Ente appaltate per i contratti aggiudicati per suo conto. In tale ruolo, la Commissione è responsabile del rispetto dei principi fondamentali di trasparenza e proporzionalità, di parità di trattamento e di non discriminazione, nonché delle disposizioni legali derivanti dalle direttive “appalti pubblici”. 95

Cfr.COM 2003/65 “Modalità, criteri e procedure che consentono di selezionare e finanziarie le azioni del programma sanità pubblica”. 96

Il valore aggiunto europeo esprime in che misura il progetto può contribuire alla protezione della salute e/o al miglioramento della sanità pubblica, consentendo, quindi, di risolvere i problemi a livello comunitario; il richiedente deve descrivere il vantaggio dell’esecuzione del progetto a livello europeo. Ad esempio saranno considerati i progetti che: contribuiscono alla comparabilità dei dati e dei metodi tra Stati membri; contribuiscono ad una uniformizzazione e al consenso tra Stati membri; forniscano una base di esperienza per la definizione di nuove strategie; definiscono l’importanza di problemi di sanità pubblica comuni agli Stati membri; contribuiscono allo scambio delle migliori pratiche; identificano i metodi efficaci di intervento relativi alle minacce per la salute e ai fattori determinanti per la salute. Il valore aggiunto europeo esprime in che misura il progetto può contribuire alla protezione della salute e/o al miglioramento della sanità pubblica, consentendo, quindi, di risolvere i problemi a livello comunitario; il richiedente deve descrivere il vantaggio dell’esecuzione del progetto a livello europeo. Ad esempio saranno considerati i progetti che: contribuiscono alla comparabilità dei dati e dei metodi tra Stati membri; contribuiscono ad una uniformizzazione e al consenso tra Stati membri; forniscano una base di esperienza per la definizione di nuove strategie; definiscono l’importanza di problemi di sanità pubblica comuni agli Stati membri; contribuiscono allo scambio delle migliori pratiche; identificano i metodi efficaci di intervento relativi alle minacce per la salute e ai fattori determinanti per la salute. 97

Si tratta di attività che coprono una questione nel modo più ampio, coinvolgendo tutti i partners e le discipline rilevanti nel corso di più anni e con vasto campo di applicazione. Si tratta di attività che coprono una questione nel modo più ampio, coinvolgendo tutti i partners e le discipline rilevanti nel corso di più anni e con vasto campo di applicazione. 98

Possono cioè apportare un contributo durevole, sia agli obiettivi del programma, sia allo sviluppo della strategia comunitaria in materia di salute. Possono cioè apportare un contributo durevole, sia agli obiettivi del programma, sia allo sviluppo della strategia comunitaria in materia di salute.

valutazione esterna, effettuata da esperti qualificati indipendenti, dell’attuazione e dei risultati conseguiti nel

corso del primi tre anni del programma. Valuta anche l’impatto sulla salute e l’efficienza dell’uso delle risorse

nonché la coerenza e la complementarietà rispetto ad altri programmi, azioni e iniziative pertinenti, attuate nel

quadro di altre politiche ed attività comunitarie. I progetti sono finanziati in base al principio delle spese

ripartite: se l’importo concesso dalla Commissione è inferiore all’assistenza voluta dal soggetto proponente,

spetta a questo ultimo trovare finanziamenti supplementari o ridurre i costi globali del progetto senza

attenuarne gli obiettivi ed il contenuto.

Inoltre, l’importo del contributo finanziario può, in linea di massima, raggiungere il sessanta percento dei costi

ammissibili per i progetti considerati. Vi è da dire che l’importo normale sarà probabilmente inferiore al

sessanta percento ma la Commissione determinerà, in ogni specifico caso, la percentuale massima da

concedere.

Da ultimo vi è la fase di monitoraggio, valutazione e divulgazione dei risultati. La Commissione infatti, in

stretta cooperazione con gli Stati membri, procede, ove necessario coadiuvata da esperti, ad un monitoraggio

periodico dell’attuazione delle azioni del programma alla luce degli obiettivi prefissati. Una volta l’anno, essa

riferisce al riguardo al Comitato e trasmette copia delle sue principali conclusioni al Parlamento europeo ed al

Consiglio. Entro la fine del quarto anno del programma, è previsto inoltre che la Commissione proceda ad una

valutazione esterna, effettuata da esperti qualificati indipendenti, dell’attuazione e dei risultati conseguiti nel

corso del primi tre anni del programma. Valuta anche l’impatto sulla salute e l’efficienza dell’uso delle risorse

nonché la coerenza e la complementarietà rispetto ad altri programmi, azioni e iniziative pertinenti, attuate nel

quadro di altre politiche ed attività comunitarie (Camaioni, 2004).

II.2.2.10 EU health strategy 2005

This Communication sets out the Community's general strategy on health - how it is working to achieve a

coherent and effective approach to health issues across all the different policy areas. A key component of this

is a new public health framework which will enable the Community to fulfil its obligations more effectively

by setting out clear objectives and policy instruments.

II.2.2.10.1 Act

Communication from the Commission of 16 May 2000 to the Council, the European Parliament, the Economic

and Social Committee and the Committee of the Regions on the health strategy of the European Community

[COM(2000) 285 final -- Not published in the Official Journal].

II.2.2.10.2 Summary

European Union citizens rightly attach great importance to their health and expect to be protected from

possible dangers. The Community has a crucial role to play and is obliged to guarantee a high level of

protection for its citizens. Due to the emergence of new challenges and priorities in the field of health, such as

enlargement, the emergence of new illnesses, pressures on health systems and increased Community

obligations following the amendments to the Treaty (Articles 3 and 152), it is necessary to develop a new

strategy.

This new strategy is the result of the debate launched in 1998 with the communication of the Commission on

the development of public health policy. It takes account of the results of this debate as well as the experiences

of previous action programmes.

II.2.2.10.3 Main elements

The strategy consists of two main elements:

- a new framework for action in public health ("public health framework"), which includes the adoption

of a Community action programme in the field of public health (2001-2006);

- the development of an integrated health strategy. As a result of the Treaty provision which stipulates

that a high level of health protection must be ensured in the definition and implementation of

Community policies, health protection concerns all key areas of Community activity. This new strategy

contains specific measures to incorporate health protection into all Community policies.

The public health framework, which is the key element of the strategy, includes those measures which relate

specifically to public health. A new action programme is part of this framework for which three main strands

of intervention are identified:

- improving information on health for all levels of society;

- setting up a rapid reaction mechanism to respond to the major health threats;

- tackling health determinants, in particular harmful factors related to lifestyle.

By emphasizing the areas where Member States cannot be effective individually -- and where coordination at

Community level is therefore essential -- the Community intends to optimize its impact with a limited budget

and bring Community added value. It is planned to extend the existing programmes before the launch of the

new action programme until such time as this is established.

In addition to the public health programme, the public health framework contains other legislative measures in

a range of sub-areas which will be developed within the framework. These include:

- the prevention and monitoring of communicable diseases, notably through the network of

epidemiological surveillance and control of communicable diseases, set up in 1999;

- prevention of drug dependence: activities to supplement the Union's action plan to combat drugs 2000-

2004 will be launched;

- combating nicotine addiction: activities will be undertaken to supplement initiatives already adopted

(such as the proposal for a new directive on the manufacture, presentation and sale of tobacco products);

- the quality and safety of organs and substances of human origin: creation of a global strategy, which is

already being developed, on drafting legislation on this subject;

- blood and blood derivatives: several measures are planned, such as a proposal for a directive

establishing a framework for quality and safety standards, the creation of a Community haemovigilance

network and the promotion of optimum use of blood and blood derivatives;

- veterinary and phytosanitary measures: the measures to be taken in this field will be closely linked to

the policies developed within the new global strategy on food safety set out in the White Paper on Food

Safety;

- the European Health Forum: it is planned to set up this new mechanism to allow all those involved in

public health to play a part in drawing up health policy.

II.2.2.10.4 Preparation of an integrated strategy

To ensure that the Community's global health strategy is coherent, there has to be a close link between public

health measures and health-related initiatives taken in other policy areas such as the single market, consumer

protection, social protection, employment and the environment.

These links also have to be supported by new mechanisms and instruments guaranteeing the contribution of

other Community policies to health protection:

- as of 2001, proposals relating to health will include a statement explaining how and why health issues

have been taken into consideration, and describing the expected impact on health;

- a priority task of the public health programme will be to develop criteria and methods for assessing the

policies proposed and the way in which they are implemented, with the possibility of carrying out an in-

depth evaluation of the impact on certain measures or policies;

- the public health programme provides for the possibility of carrying out joint measures together with

other Community programmes and agencies;

- within the Commission, mechanisms which guarantee the coordination of health-related activities will

be strengthened.

This new strategy represents a major commitment on the part of the Community and shows the importance

which the Commission attaches to public health in Community policies.

II.2.2.10.5 Related acts

Decision No 1786/2002/EC of the European Parliament and of the Council of 23 September 2002 adopting a

programme of Community action in the field of public health (2003-2008) [Official Journal L271 of

09.10.2002].

The programme is an essential component of the European Community's health strategy. Its objectives are to

improve information and knowledge for the development of public health and healthcare systems, enhance the

capability of responding rapidly and in a coordinated fashion to health threats, and tackle health determinants.

II.2 .2 .11 The second programme of Community action in the field of Health (2008-2013)

The European Parliament and the Council of the European Union, having regard to the Treaty establishing the

European Community, and in particular Article 152 thereof, having regard to the proposal from the

Commission, having regard to the Opinion of the European Economic and Social Committee99

, having regard

to the opinion of the Committee of the Regions100

, Acting in accordance with the procedure laid down in

Article 251 of the Treaty101

, on 23 October 2007 took the Decision no 1350/2007/EC establishing a second

programme of Community action in the field of health (2008-13) (Text with EEA relevance).

II.2 .2 .11.1 The reasons

(1) The Community can contribute to protecting the health and safety of citizens through actions in the field of

public health. A high level of health protection should be ensured in the definition and implementation of all

Community policies and activities. Under Article 152 of the Treaty, the Community is required to play an

active role by taking measures which cannot be taken by individual Member States, in accordance with the

principle of subsidiarity. The Community fully respects the responsibilities of the Member States for the

organization and delivery of health services and medical care.

(2) The health sector is characterized on the one hand by its considerable potential for growth, innovation and

dynamism, and on the other by the challenges it faces in terms of financial and social sustainability and

efficiency of the health care systems due, among other things, to ageing of the population and to medical

advances.

(3) The programme of Community action in the field of public health (2003-08), adopted by Decision No

1786/2002/EC of the European Parliament and of the Council102

, was the first integrated Community

programme in this field, and it has already delivered a number of important developments and improvements.

(4) Continued effort is required in order to meet the objectives already established by the Community in the

field of public health. It is therefore appropriate to establish a second programme of Community action on

health (2008-13) (hereinafter referred to as ‘the Programme’).

(5) A number of serious cross-border health threats with a possible worldwide dimension exist and new ones

are emerging which require further Community action. The Community should treat serious cross-border

health threats as a matter of priority. The Programme should place emphasis on strengthening the

Community’s overall capacities by further developing cooperation between the Member States. Monitoring,

early warning and action to combat serious threats to health are important areas where an effective and

coordinated response to health threats should be promoted at Community level. Action to ensure high-quality

diagnostic cooperation between laboratories is essential in order to respond to health threats. The Programme

should encourage the establishment of a system of Community reference laboratories. However, such a system

needs to be based on a sound legal base.

20.11.2007 EN Official Journal of the European Union L 301/3

(6) According to the World Health Organization (WHO) European Health report 2005, in terms of Disability

Adjusted Life-Years (DALYs), the most important causes of the burden of disease in the WHO European

Region are non-communicable diseases (NCDs — 77 % of the total), external causes of injury and poisoning

(14 %) and communicable diseases (9 %). Seven leading conditions — ischaemic heart disease, unipolar

depressive disorders, cerebrovascular disease, alcohol use disorders, chronic pulmonary disease, lung cancer

and road traffic injuries — account for 34 % of the DALYs in the region.

Seven leading risk factors — tobacco, alcohol, high blood pressure, high cholesterol, overweight, low fruit and

vegetable intake and physical inactivity — account for 60 % of DALYs. In addition, communicable diseases

such as HIV/AIDS, influenza, tuberculosis and malaria are also becoming a threat to the health of all people in

Europe. An important task of the Programme, in cooperation, where appropriate, with the Community

Statistical Programme, should be to identify better the main health burdens in the Community.

99

OJ C 88, 11.4.2006, p. 1. 100

OJ C 192, 16.8.2006, p. 8. 101

Opinion of the European Parliament of 16 March 2006 (OJ C 291E, 30.11.2006, p. 372), Council Common Position of 22 March 2007 (OJ C 103 E, 8.5.2007, p. 11) and Position of the European Parliament of 10 July 2007 (not yet published in the Official Journal). Council Decision of 9 October 2007. 102

OJ L 271, 9.10.2002, p. 1. Decision as amended by Decision No 786/2004/EC (OJ L 138, 30.4.2004, p. 7).

(7) Eight leading causes of mortality and morbidity from NCDs in the WHO European Region are

cardiovascular diseases, neuropsychiatric disorders, cancer, digestive diseases, respiratory diseases, sense

organ disorders, musculoskeletal diseases and diabetes mellitus. The Programme, in synergy with other

Community initiatives and funding, should contribute to better knowledge of and information on the

prevention, diagnosis and control of major diseases. Accordingly, the Commission may submit, during the

course of the Programme, proposals for pertinent Council Recommendations. The Programme should also

foster appropriate coordination and synergies among Community initiatives regarding the collection of

comparable data on major diseases, including cancer.

(8) Microbial resistance to antibiotics and nosocomial infections are becoming a threat to health in Europe.

The lack of new effective antibiotics as well as the means to ensure the proper use of existing antibiotics are

major concerns. Therefore it is important to collect and analyze relevant data.

(9) Strengthening the role of the European Centre for Disease Prevention and Control established by

Regulation (EC) No 851/2004 of the European Parliament and of the Council103

is important in the fight

against communicable diseases.

(10) The Programme should build on the achievements of the previous Programme for Community action in

the field of public health (2003-08). It should contribute towards the attainment of a high level of physical and

mental health and greater equality in health matters throughout the Community by directing actions towards

improving public health, preventing human diseases and disorders, and obviating sources of danger to health

with a view to combating morbidity and premature mortality. It should further contribute to providing citizens

with better access to information and thereby increase their ability to make decisions which best cater for their

interests.

(11) The Programme should place emphasis on improving the health condition of children and young people

and promoting a healthy lifestyle and a culture of prevention among them.

(12) The Programme should support the mainstreaming of health objectives in all Community policies and

activities, without duplicating work carried out under other Community policies. Coordination with other

Community policies and programmes is a key part of the objective of mainstreaming health in other policies.

In order to promote synergies and avoid duplication, joint actions may be undertaken with related Community

programmes and actions and appropriate use should be made of other Community funds and programmes,

including the current and future Community framework programmes for research and their outcomes, the

Structural Funds, the European Solidarity Fund, the European strategy for health at work, the programme of

Community action in the field of consumer policy (2007-13)104

, the programme ‘Drugs prevention and

information’, the programme ‘Fight against violence (Daphne)’ and the Community Statistical Programme

within their respective activities.

(13) Special efforts should be undertaken to ensure coherence and synergies between the Programme and the

Community’s external actions, particularly in the areas of avian influenza, HIV/AIDS, tuberculosis and other

cross-border health threats. In addition, there should be international cooperation in order to promote general

health reform and general health institutional issues in third countries.

(14) Increasing Healthy Life Years (HLY) by preventing disease and promoting policies that lead to a

healthier way of life is important for the well-being of EU citizens and helps to meet the challenges of the

Lisbon process as regards the knowledge society and the sustainability of public finances, which are under

pressure from rising health care and social security costs.

L 301/4 EN Official Journal of the European Union 20.11.2007

(15) The enlargement of the European Union has brought additional concerns in terms of health inequalities

within the EU and this is likely to be accentuated by further enlargements. This issue should, therefore, be one

of the priorities of the Programme.

(16) The Programme should help to identify the causes of health inequalities and encourage, among other

things, the exchange of best practices to tackle them.

(17) It is essential to systematically collect, process and analyze comparable data, within national constraints,

for an effective monitoring of the state of health in the European Union. This would enable the Commission

and the Member States to improve information to the public and formulate appropriate strategies, policies and

actions to achieve a high level of human health protection. Compatibility and interoperability of the systems

and networks for exchanging information and data for the development of public health should be pursued in

the actions and support measures. Gender, socioeconomic status and age are important health considerations.

103

OJ L 142, 30.4.2004, p. 1. 104

Decision No 1926/2006/EC of the European Parliament and of the Council (OJ L 404, 30.12.2006, p. 39).

Data collection should wherever possible build on existing work, and proposals for new collections should be

costed and based on a clear need. The collection of data should be in compliance with the relevant legal

provisions on the protection of personal data.

(18) Best practice is important because health promotion and prevention should be measured on the basis of

efficiency and effectiveness, and not purely in economic terms. Best practice and latest treatment methods for

diseases and injuries should be promoted in order to prevent further deterioration of health, and European

reference networks for specific conditions should be developed.

(19) Action should be taken in order to prevent injuries by collecting data, analyzing injury determinants and

disseminating relevant information.

(20) Health services are primarily the responsibility of Member States but cooperation at Community level can

benefit both patients and health systems. Activities funded by the Programme as well as new proposals

developed as a result of these should have due regard to the Council Conclusions on common values and

principles in European Union Health Systems (1) adopted in June 2006 that endorse a statement on the

common values and principles of EU Health Systems and invite the institutions of the European Union to

respect them in their work. The Programme should take due account of future developments as regards

Community action on health services as well as the work of the High Level Group on Health Services and

Medical Care, which provides an important forum for collaboration and exchange of best practice between

Member States’ health systems. (15) The enlargement of the European Union has brought additional concerns

in terms of health inequalities within the EU and this is likely to be accentuated by further enlargements. This

issue should, therefore, be one of the priorities of the Programme.

(16) The Programme should help to identify the causes of health inequalities and encourage, among other

things, the exchange of best practices to tackle them.

(17) It is essential to systematically collect, process and analyze comparable data, within national constraints,

for an effective monitoring of the state of health in the European Union. This would enable the Commission

and the Member States to improve information to the public and formulate appropriate strategies, policies and

actions to achieve a high level of human health protection. Compatibility and interoperability of the systems

and networks for exchanging information and data for the development of public health should be pursued in

the actions and support measures. Gender, socioeconomic status and age are important health considerations.

Data collection should wherever possible build on existing work, and proposals for new collections should be

costed and based on a clear need. The collection of data should be in compliance with the relevant legal

provisions on the protection of personal data.

(18) Best practice is important because health promotion and prevention should be measured on the basis of

efficiency and effectiveness, and not purely in economic terms. Best practice and latest treatment methods for

diseases and injuries should be promoted in order to prevent further deterioration of health, and European

reference networks for specific conditions should be developed.

(19) Action should be taken in order to prevent injuries by collecting data, analyzing injury determinants and

disseminating relevant information.

(20) Health services are primarily the responsibility of Member States but cooperation at Community level can

benefit both patients and health systems. Activities funded by the Programme as well as new proposals

developed as a result of these should have due regard to the Council Conclusions on common values and

principles in European Union Health Systems105

adopted in June 2006 that endorse a statement on the common

values and principles of EU Health Systems and invite the institutions of the European Union to respect them

in their work. The Programme should take due account of future developments as regards Community action

on health services as well as the work of the High Level Group on Health Services and Medical Care, which

provides an important forum for collaboration and exchange of best practice between Member States’ health

systems.

(21) The Programme should contribute to the collection of data, the promotion and development of methods

and tools, the establishment of networks and various kinds of cooperation and the promotion of relevant

policies on patient mobility as well as on the mobility of health professionals. It should facilitate the further

development of the European e-Health Area, through joint European initiatives with other EU policy areas,

including regional policy, while contributing towards work on quality criteria for health-related websites and

towards a European health insurance card. Telemedicine should be taken into account as telemedicine

applications may contribute to cross-border care while ensuring medical care at home.

105

OJ C 146, 22.6.2006, p. 1.

(22) Environmental pollution is a serious risk to health and a major source of concern for European citizens.

Special action should focus on children and other groups which are particularly vulnerable to hazardous

environmental conditions. The Programme should complement the actions taken within the European

Environment and Health Action Plan 2004-10.

(23) The Programme should address gender-related and ageing-related health issues.

(24) The Programme should recognize the importance of a holistic approach to public health and take into

account, where appropriate and where there is scientific or clinical evidence about its efficacy, complementary

and alternative medicine in its actions.

(25) The precautionary principle and risk assessment are key factors for the protection of human health and

should therefore be part of further integration into other Community policies and activities.

(26) This Decision establishes, for the entire duration of the Programme, a financial envelope which

constitutes the prime reference within the meaning of point 37 of the Interinstitutional Agreement of 17 May

2006 between the European Parliament, the Council and the Commission on budgetary discipline and sound

financial management106

, for the budgetary authority during the annual budgetary procedure.

20.11.2007 EN Official Journal of the European Union L 301/5

(27) In order to ensure a high level of coordination between actions and initiatives taken by the Community

and Member States in the implementation of the Programme, it is necessary to promote cooperation between

Member States and to enhance the effectiveness of existing and future networks in the field of public health.

The participation of national, regional and local authorities at the appropriate level in accordance with the

national systems should be taken into account in regard to the implementation of the Programme.

(28) It is necessary to increase EU investment in health and health-related projects. In this regard, Member

States are encouraged to identify health improvements as a priority in their national programmes. Better

awareness about the possibilities of EU funding for health is needed. Exchange of experience between the

Member States on funding health through the Structural Funds should be encouraged.

(29) Non-governmental bodies and specialized networks can also play an important role in meeting the

objectives of the Programme. In pursuing one or more objectives of the Programme, they may require

Community contributions to enable them to function. Hence, detailed eligibility criteria, provisions regarding

financial transparency and the duration of Community contributions for nongovernmental bodies and

specialized networks qualifying for Community support should be set out in accordance with Council Decision

1999/468/EC of 28 June 1999 laying down the procedures for the exercise of implementing powers conferred

on the Commission107

. Such criteria should include the obligations of such bodies and networks in establishing

clear objectives, action plans and measurable results representing a strong European dimension and a real

added value for the objectives of the Programme. Given the particular nature of the organizations concerned

and in cases of exceptional utility, it should be possible for the renewal of Community support to the

functioning of such bodies and specialized networks to be exempted from the principle of gradual decrease of

the extent of Community support.

(30) Implementation of the Programme should be carried out in close cooperation with relevant organizations

and agencies, in particular with the European Centre for Disease Prevention and Control.

(31) The measures necessary for the implementation of this Decision should be adopted in accordance with

Decision 1999/468/EC, respecting the need for transparency as well as a reasonable balance between the

different objectives of the Programme.

(32) The Agreement on the European Economic Area (hereinafter referred to as ‘the EEA Agreement’)

provides for cooperation in the field of health between the European Community and its Member States, on

the one hand and the countries of the European Free Trade Association participating in the European

Economic Area (hereinafter referred to as ‘the EFTA/EEA countries’), on the other. Provision should also be

made to open the Programme to participation by other countries, in particular the neighbouring countries of

the Community and countries that are applying for, are candidates for, or are acceding to, membership of the

European Union, taking particular account of the potential for health threats arising in other countries to have

an impact within the Community.

(33) Appropriate relations with third countries not participating in the Programme should be facilitated in

order to help achieve the objectives of the Programme, taking account of any relevant agreements between

those countries and the Community. This may involve third countries taking forward complementary activities

106

OJ C 139, 14.6.2006, p. 1. 107

OJ L 184, 17.7.1999, p. 23. Decision as amended by Decision 2006/512/EC (OJ L 200, 22.7.2006, p. 11).

to those financed through the Programme on areas of mutual interest, but should not involve a financial

contribution under the Programme.

(34) It is appropriate to develop cooperation with relevant international organizations such as the United

Nations and its specialized agencies, in particular the WHO, as well as with the Council of Europe and the

Organization for Economic Cooperation and Development, with a view to implementing the Programme

through maximizing the effectiveness and efficiency of actions relating to health at Community and

international level, taking into account the particular capacities and roles of the different organizations.

(35) The successful implementation of the objectives under the Programme should be based on good coverage

of the issues included in the annual work plans, on selection of appropriate actions and funding of projects,

which all have an in-built appropriate monitoring and evaluation process in place, and on regular monitoring

and evaluation, including independent external evaluations, which should measure the impact of actions and

demonstrate their contribution to the overall objectives of the Programme. Programme evaluation should take

into account the fact that the achievement of the Programme objectives may require a longer time period than

the duration of the Programme.

(36) The annual work plans should cover the main foreseeable activities to be funded from the Programme

through all the different funding mechanisms, including calls for tender.

L 301/6 EN Official Journal of the European Union 20.11.2007

(37) Since the objectives of this Decision cannot be sufficiently achieved by the Member States due to the

transnational nature of the issues involved, and can therefore, by reason of the potential for Community action

to be more efficient and effective than national action alone in protecting the health and safety of citizens, be

better achieved at Community level, the Community may adopt measures, in accordance with the principle of

subsidiarity set out in Article 5 of the Treaty. In accordance with the principle of proportionality, as set out in

that Article, this Decision does not go beyond what is necessary in order to achieve those objectives.

(38) In accordance with Article 2 of the Treaty, which provides that equality between men and women is a

principle of the Community, and in accordance with Article 3(2) thereof, which provides that the Community

shall aim to eliminate inequalities, and to promote equality between men and women in all Community

activities including the attainment of a high level of health protection, all objectives and actions covered by the

Programme contribute to promoting a better understanding and recognition of men’s and women’s respective

needs and approaches to health.

(39) It is appropriate to ensure a transition between the Programme and the previous programme it replaces, in

particular regarding the continuation of multi-annual arrangements for its management, such as the financing

of technical and administrative assistance. As of 1 January 2014, the technical and administrative assistance

appropriations should cover, if necessary, the expenditure related to the management of actions not yet

completed by the end of 2013.

(40) This Decision replaces Decision No 1786/2002/EC. That Decision should therefore be repealed.

II.2 .2 .11.2 The decision

Article 1

Establishment of the Programme

The second programme of ‘Community action in the field of health (2008-13)’ covering the period from 1

January 2008 to 31 December 2013 (hereinafter referred to as ‘the Programme’) is hereby established.

Article 2

Aim and objectives

1. The Programme shall complement, support and add value to the policies of the Member States and

contribute to increased solidarity and prosperity in the European Union by protecting and promoting human

health and safety and improving public health.

2. The objectives to be pursued through the actions set out in the Annex shall be:

— to improve citizens’ health security,

— to promote health, including the reduction of health inequalities,

— to generate and disseminate health information and knowledge.

The actions referred to in the first subparagraph shall, where appropriate, support the prevention of major

diseases and contribute to reducing their incidence as well as the morbidity and mortality caused by them.

Article 3

Funding

1. The financial envelope for the implementation of the Programme for the period specified in Article 1 is

hereby set at EUR 321 500 000.

2. Annual appropriations shall be authorized by the budgetary authority within the limits of the financial

framework.

Article 4

Financial contributions

1. Financial contributions by the Community shall not exceed the following levels:

(a) 60 % of costs for an action intended to help achieve an objective forming part of the Programme, except in

cases of exceptional utility, where the Community contribution shall not exceed 80 %; and 20.11.2007 EN

Official Journal of the European Union L 301/7

(b) 60 % of costs for the functioning of a non-governmental body or a specialized network, which is non-

profit-making and independent of industry, commercial and business or other conflicting interests, has

members in at least half of the Member States, with a balanced geographical coverage, and pursues as its

primary goal one or more objectives of the Programme, where such support is necessary to pursue those

objectives. In cases of exceptional utility, the Community contribution shall not exceed 80 %.

2. The renewal of financial contributions set out in paragraph 1(b) to non-governmental bodies and specialized

networks may be exempted from the principle of gradual decrease.

3. Financial contributions by the Community may, where appropriate given the nature of the objective to be

achieved, include joint financing by the Community and one or more Member States or by the Community and

the competent authorities of other participating countries. In this case, the Community contribution shall not

exceed 50 %, except in cases of exceptional utility, where the Community contribution shall not exceed 70 %.

These Community contributions may be awarded to a public body or a non-governmental body, which is non-

profit-making and independent of industry, commercial and business or other conflicting interests, and pursues

as its primary goal one or more objectives of the Programme, designated through a transparent procedure by

the Member State or the competent authority concerned and agreed by the Commission.

4. Financial contributions by the Community may also be given in the form of a lump sum and flat-rate

financing where this is suited to the nature of the actions concerned. For such financial contributions, the

percentage limits stipulated in paragraphs 1 and 3 shall not apply, although co-financing is still required.

Article 5

Administrative and technical assistance

1. The financial allocation of the Programme may also cover expenses pertaining to preparatory, monitoring,

control, audit and evaluation activities required directly for the management of the Programme and the

realization of its objectives, in particular studies, meetings, information and publication actions, expenses

linked to informatics networks focusing on information exchange, as well as all other technical and

administrative assistance expense that the Commission may have recourse to for the management of the

Programme.

2. The financial allocation may also cover the technical and administrative assistance expenses necessary to

ensure the transition between the Programme and the measures adopted under Decision No 1786/2002/EC. If

necessary, appropriations could be entered in the budget beyond 2013 to cover similar expenses, in order to

enable the management of actions not yet completed by 31 December 2013.

Article 6

Methods of implementation

Actions in pursuit of the aim and objectives set out in Article 2 shall make full use of appropriate available

methods of implementation, including in particular:

(a) direct or indirect implementation by the Commission on a centralized basis; and

(b) joint management with international organizations, where appropriate.

Article 7

Implementation of the Programme

1. The Commission shall ensure the implementation, in close cooperation with the Member States, of the

actions and measures set out in the Programme in accordance with Articles 3 and 8.

2. The Commission and the Member States shall take appropriate action, within their respective areas of

competence, to ensure the efficient running of the Programme and to develop mechanisms at Community and

Member State level to achieve the objectives of the Programme. They shall ensure that appropriate

information is provided about actions supported by the Programme and that appropriate participation is

obtained.

3. For the attainment of the objectives of the Programme, the Commission shall, in close cooperation with the

Member States:

(a) pursue the comparability of data and information and the compatibility and interoperability of the systems

and networks for exchange of data and information on health;

and

(b) ensure the necessary cooperation and communication with the European Centre for Disease Prevention and

Control and other relevant EU agencies in order to optimize the use of Community funds.

L 301/8 EN Official Journal of the European Union 20.11.2007

4. In implementing the Programme, the Commission, together with the Member States, shall ensure

compliance with all relevant legal provisions regarding personal data protection and, where appropriate, the

introduction of mechanisms to ensure the confidentiality and safety of such data.

Article 8

Implementation measures

1. The measures necessary for the implementation of this Decision relating to the following shall be adopted in

accordance with the procedure referred to in Article 10(2):

(a) the annual work plan for the implementation of the Programme, setting out:

(i) priorities and actions to be undertaken, including the allocation of financial resources;

(ii) criteria for the percentage of Community financial contribution, including criteria for assessing whether or

not exceptional utility applies;

(iii) the arrangements for implementing the joint strategies and actions referred to in Article 9;

(b) selection, award and other criteria for financial contributions to the actions of the Programme in

accordance with Article 4.

2. Any other measures necessary for the implementation of this Decision shall be adopted in accordance with

the procedure referred to in Article 10(3).

Article 9

Joint strategies and actions

1. To ensure a high level of human health protection in the definition and implementation of all Community

policies and activities and to promote the mainstreaming of health, the objectives of the Programme may be

implemented as joint strategies and joint actions by creating links with relevant Community programmes,

actions and funds.

2. The Commission shall ensure the optimal synergy of the Programme with other Community programmes,

actions and funds.

Article 10

Committee

1. The Commission shall be assisted by a committee (hereinafter referred to as ‘the Committee’).

2. Where reference is made to this paragraph, Articles 4 and 7 of Decision 1999/468/EC shall apply, having

regard to the provisions of Article 8 thereof.

The period laid down in Article 4(3) of Decision 1999/468/EC shall be set at two months.

3. Where reference is made to this paragraph, Articles 3 and 7 of Decision 1999/468/EC shall apply, having

regard to the provisions of Article 8 thereof.

Article 11

Participation of third countries

The Programme shall be open to the participation of:

(a) the EFTA/EEA countries in accordance with the conditions established in the EEA Agreement; and

(b) third countries, in particular countries to which the European Neighbourhood Policy applies, countries that

are applying for, are candidates for, or are acceding to, membership of the European Union, and the western

Balkan countries included in the stabilization and association process, in accordance with the conditions laid

down in the respective bilateral or multilateral agreements establishing the general principles for their

participation in Community programmes.

Article 12

International cooperation

In the course of implementing the Programme, relations and cooperation with third countries that are not

participating in the Programme and relevant international organisations, in particular the WHO, shall be

encouraged.

Article 13

Monitoring, evaluation and dissemination of results

1. The Commission, in close cooperation with the Member States, shall monitor the implementation of the

actions of the Programme in the light of its objectives. It shall report yearly to the Committee on all actions

and projects funded through the Programme, and shall keep the European Parliament and the Council

informed.

20.11.2007 EN Official Journal of the European Union L 301/9

2. At the request of the Commission, which shall avoid a disproportionate increase in the administrative

burden of the Member States, Member States shall submit any available information on the implementation

and impact of the Programme.

3. The Commission shall submit to the European Parliament, the Council, the European Economic and Social

Committee and the Committee of the Regions:

(a) not later than 31 December 2010, an external and independent interim evaluation report on the results

obtained in relation to the objectives of the Programme and the qualitative and quantitative aspects of its

implementation as well as its consistency and complementarity with other relevant Community programmes,

actions and funds. The report shall in particular make it possible to assess the impact of measures on all

countries. The report shall contain a summary of the main conclusions, and it shall be accompanied by

remarks by the Commission;

(b) not later than 31 December 2011, a communication on the continuation of the Programme;

(c) not later than 31 December 2015, an external and independent ex-post evaluation report covering the

implementation and results of the Programme.

4. The Commission shall make the results of actions undertaken pursuant to this Decision publicly available

and shall ensure their dissemination.

Article 14

Repeal

Decision No 1786/2002/EC shall be repealed with effect from 1 January 2008.

The Commission shall adopt any administrative arrangement necessary to ensure the transition between the

measures adopted under Decision No 1786/2002/EC and those implemented under the Programme.

Article 15

Entry into force

This Decision shall enter into force on the day following its publication in the Official Journal of the European

Union.

Done at Strasbourg, 23 October 2007.

For the European Parliament For the Council

The President The President

H.-G. PÖTTERING M. LOBO ANTUNES

L 301/10 EN Official Journal of the European Union 20.11.2007

II.2 .2 .11.3 Annex

Actions referred to in Article 2(2)

1. Improve citizens’ health security.

1.1. Protect citizens against health threats.

1.1.1. Develop strategies and mechanisms for preventing, exchanging information on and responding to health

threats from communicable and non-communicable diseases and health threats from physical, chemical or

biological sources, including deliberate release acts; take action to ensure high-quality diagnostic cooperation

between Member States’ laboratories; support the work of existing laboratories carrying out work with

relevance to the Community; work on the setting up of a network of Community reference laboratories.

1.1.2. Support the development of prevention, vaccination and immunization policies; improve partnerships,

networks, tools and reporting systems for immunization status and adverse events monitoring.

1.1.3. Develop risk management capacity and procedures; improve preparedness and planning for health

emergencies, including preparing for coordinated EU and international responses to health emergencies;

develop risk communication and consultation procedures on counter-measures.

1.1.4. Promote the cooperation and improvement of existing response capacity and assets, including protective

equipment, isolation facilities and mobile laboratories to deploy rapidly in emergencies.

1.1.5. Develop strategies and procedures for drawing up, improving surge capacity of, conducting exercises

and tests of, evaluating and revising general contingency and specific health emergency plans and their inter-

operability between Member States.

1.2. Improve citizens’ safety.

1.2.1. Support and enhance scientific advice and risk assessment by promoting the early identification of risks;

analyze their potential impact; exchange information on hazards and exposure; foster integrated and

harmonized approaches.

1.2.2. Help to enhance the safety and quality of organs and substances of human origin, blood, and blood

derivatives; promote their availability, traceability and accessibility for medical use while respecting Member

States’ responsibilities as set out in Article 152(5) of the Treaty.

1.2.3. Promote measures to improve patient safety through high-quality and safe healthcare, including in

relation to antibiotic resistance and nosocomial infections.

2. Promote health.

2.1. Foster healthier ways of life and the reduction of health inequalities.

2.1.1. Promote initiatives to increase healthy life years and promote healthy ageing; support measures to

promote and explore the impact of health on productivity and labour participation as a contribution to meeting

the Lisbon goals; support measures to study the impact on health of other policies.

2.1.2. Support initiatives to identify the causes of, address and reduce health inequalities within and between

Member States, including those related to gender differences, in order to contribute to prosperity and cohesion;

promote investment in health in cooperation with other Community policies and funds; improve solidarity

between national health systems by supporting cooperation on issues of cross-border care and patient and

health professional mobility.

2.2. Promote healthier ways of life and reduce major diseases and injuries by tackling health determinants.

2.2.1. Address health determinants to promote and improve physical and mental health, creating supportive

environments for healthy lifestyles and preventing disease; take action on key factors such as nutrition and

physical activity and sexual health, and on addiction-related determinants such as tobacco, alcohol, illegal

drugs and pharmaceuticals used improperly, focusing on key settings such as education and the workplace,

and across the life cycle.

20.11.2007 EN Official Journal of the European Union L 301/11

2.2.2. Promote action on the prevention of major diseases of particular significance in view of the overall

burden of diseases in the Community, and on rare diseases, where Community action by tackling their

determinants can provide significant added value to national efforts.

2.2.3. Address the health effects of wider environmental determinants, including indoor air quality, exposure

to toxic chemicals where not addressed by other Community initiatives, and socio-economic determinants.

2.2.4. Promote actions to help reduce accidents and injuries.

3. Generate and disseminate health information and knowledge.

3.1. Exchange knowledge and best practice.

3.1.1. Exchange knowledge and best practice on health issues within the scope of the Programme.

3.1.2. Support cooperation to enhance the application of best practice within Member States, including, where

appropriate, supporting European reference networks.

3.2. Collect, analyze and disseminate health information.

3.2.1. Develop further a sustainable health monitoring system with mechanisms for collection of comparable

data and information, with appropriate indicators; ensure appropriate coordination of and follow-up to

Community initiatives regarding registries on cancer, based, inter alia, on the data collected when

implementing the Council Recommendation of 2 December 2003 on cancer screening (1); collect data on

health status and policies; develop, with the Community Statistical Programme, the statistical element of this

system.

3.2.2. Develop mechanisms for analysis and dissemination, including Community health reports, the Health

Portal and conferences; provide information to citizens, stakeholders and policy makers, develop consultation

mechanisms and participatory processes; establish regular reports on health status in the European Union

based on all data and indicators and including a qualitative and quantitative analysis.

3.2.3. Provide analysis and technical assistance in support of the development or implementation of policies or

legislation related to the scope of the Programme.

L 301/12 EN Official Journal of the European Union 20.11.2007

II.2 .2 .11.4 Trilateral declaration

The European Parliament, the Council and the Commission:

— share the view that the second programme of Community action in the field of health (2008-13) must be

provided with financial means that allow fully for its implementation;

— recall Article 37 of the Interinstitutional Agreement on budgetary discipline and sound financial

management108

stating that the budgetary authority and the Commission undertake not to depart by more than

5 % from the budget unless new, objective, long-term circumstances arise for which specific reasons are

given. Any increase resulting from such variation must remain within the existing ceiling of the heading

concerned;

— assure their willingness to evaluate in a sound manner the specific needs and circumstances of the health

programme in the annual budget procedure.

II.2.2.11.5 Commission declaration

1. On 24 May 2006, the Commission issued an amended proposal for a second programme of Community

action in the field of health (2007-13)109

. In Article 7, the reference amount of the programme was proposed to

be set at EUR 365,6 million for the period starting in 2007 and ending in 2013.

2. Because of delays in the legislative procedure, on 23 March 2007 the Commission informed the Budget

Authority that the start of the new public health programme will have to be postponed to budget year 2008110

.

As a consequence, the envelope of the new public health programme 2008-13 would need to be adjusted to the

level of EUR 321,5 million.

3. An amount of EUR 44,1 million will be used in the 2007 budget year under the present public health

programme111

in order to ensure maximum continuity concerning public health actions. Therefore, the total

envelope for public health actions financed from the programmes over the period 2007-13 sums up to EUR

365,6 million.

20.11.2007 EN Official Journal of the European Union L 301/13

II.2.2.12 L’integrazione della politica sanitaria europea: considerazioni finali

Sono stati analizzati l’evoluzione e i meccanismi di implementazione della politica sanitaria europea. In primo

luogo si è messo in luce il ruolo giocato dall’Unione nel tentativo di ampliare le proprie competenze

legislative in materia sanitaria. Successivamente è stato descritto il procedimento seguito dai principali attori

della politica sanitaria europea nei primi due anni d’attuazione della strategia definita dalla Commissione.

Ciò che emerge dal quadro di sintesi è che le riforme dei sistemi di protezione sociale (e in particolare dei

modelli sanitari) sono rimaste di competenza degli Stati membri, nonostante a partire dalla seconda metà degli

anni Novanta le istituzioni comunitarie abbiano promosso l’avvio di processi di coordinamento tra i paesi

membri per sostenere la politica sociale e sanitaria e favorirne l’armonizzazione.

Visto che le competenze dell’Unione europea nel campo della sanità non includono la gestione e

l’organizzazione dei servizi sanitari, l’intervento della Commissione (in campo sanitario) ha riguardato

prevalentemente la prevenzione delle malattie, la promozione della salute e le azioni di integrazione e

coordinamento delle politiche dei paesi membri.

Tuttavia, sebbene non si possa affermare che l’azione dell’Unione Europea sia stata l’unica determinante delle

riforme dei sistemi sanitari nazionali, nel corso dell’ultimo quindicennio – e a partire dall’approvazione del

Trattato di Maastricht – è andata crescendo l’attenzione della Comunità nei confronti della convergenza dei

modelli sanitari.

In particolare, ciò che maggiormente spinge l’integrazione delle politiche sanitarie nazionali verso la direzione

unica tracciata dalla strategia comunitaria è il processo di decentramento sanitario (comune a molti dei Paesi

membri). Infatti un maggiore coordinamento da parte dell’Unione che eviti il proliferare di differenziazioni

territoriali con effetti disastrosi sul piano dell’equità dei sistemi sanitari nasce dalla creazione di livelli di

108

OJ C 139, 14.6.2006, p. 1. 109

COM(2006) 234. 110

COM(2007) 150. 111

Decision No 1786/2002/ΕC of the European Parliament and of the Council of 23 September 2002 adopting a programme of Community action in the field of public health (2003-08) (OJ L 271, 9.10.2002, p. 1).

governo sub-nazionali (es. aziende sanitarie) in applicazione del principio di sussidiarietà e della relativa

deresponsabilizzazione del livello di governo centrale.

Il coinvolgimento dell’Unione può costituire un ottimo strumento per sfruttare in positivo sia il processo di de-

responsabilizzazione dei livelli centrali di governo che la richiesta di maggiore autonomia proveniente dai

livelli subnazionali di governo.

Lo sviluppo dell’integrazione delle politiche sanitarie europee richiede, dunque, forme “evolute” di

coordinamento fra i Paesi, che tengano conto del nuovo contesto di mobilità dei cittadini europei e della

necessità di armonizzare i sistemi di protezione sociale.

Rimane infine ancora dubbia la questione se la metodologia di coordinamento aperto (modello della soft law)

recentemente proposta dalla Commissione per l’implementazione della strategia sanitaria sia idonea a

perseguire il livello sperato di integrazione delle politiche sanitarie dei Paesi membri o comunque se essa

possa fungere da anticamera per una regolamentazione comunitaria di tipo vincolante verso la quale, tuttavia, i

Governi nazionali hanno già dimostrato la propria resistenza in occasione dell’implementazione dell’Agenda

sociale (2000).

Quanto affermato ha dovuto tuttavia essere rivisto, alla luce della evoluzione dei tempi, per la crisi mondiale

tuttora in corso. Come già evidenziato in apertura, il quadro internazionale è mutato. Si mostrerà quindi nei

prossimi paragrafi come l’Europa stia rispondendo al tempo di crisi e l’impatto di tali concezioni a livello

locale.

II.2.3 Europe 2020

“Europe 2020 is the EU's growth strategy for the coming decade112

.

In a changing world, we want the EU to become a smart, sustainable and inclusive economy. These three

mutually reinforcing priorities should help the EU and the Member States deliver high levels of employment,

productivity and social cohesion.

Concretely, the Union has set five ambitious objectives - on employment, innovation, education, social

inclusion and climate/energy - to be reached by 2020. Each Member State has adopted its own national targets

in each of these areas. Concrete actions at EU and national levels underpin the strategy”.

II.2.3.1 Smart growth

Smart growth means improving the EU's performance in:

- education (encouraging people to learn, study and update their skills)

- research/innovation (creating new products/services that generate growth and jobs and help address social

challenges)

- digital society (using information and communication technologies).

EU targets for smart growth include:

1. combined public and private investment levels to reach 3% of EU's GDP as well as better conditions for

R&D and Innovation

2. 75% employment rate for women and men aged 20-64 by 2020– achieved by getting more people into

work, especially women, the young, older and low-skilled people and legal migrants

3. better educational attainment – in particular:

– reducing school drop-out rates below 10%

– at least 40% of 30-34–year-olds with third level education (or equivalent)

II.2.3.1.1 How will the EU boost smart growth?

Through 3 flagship initiatives:

1. Digital agenda for Europe

Creating a single digital market based on fast/ultrafast internet and interoperable applications: by 2013:

broadband access for all

by 2020: access for all to much higher internet speeds (30 Mbps or above)

by 2020: 50% or more of European households with internet connections above 100 Mbps.

112

The European Commission President’s speech is reported.

2. Innovation Union refocusing R&D and innovation policy on major challenges for our society like climate

change, energy and resource efficiency, health and demographic change strengthening every link in the

innovation chain, from 'blue sky' research to commercialization

3. Youth on the move, helping students and trainees study abroad equipping young people better for the job

market enhancing the performance/international attractiveness of Europe's universities improving all levels

of education and training (academic excellence, equal opportunities)

II.2.3.1.2 Why does Europe need smart growth?

Europe's lower growth than its main competitors is largely due to a productivity gap caused in part by:

- lower levels of investment in R&D and innovation

- insufficient use of information/communications technologies

- difficult access to innovation in some sections of society.

For example:

European firms currently account for just a quarter of the €2 trillion global market for

information/communication technologies.

Slow implementation of high-speed internet affects Europe's ability to innovate, spread knowledge and

distribute goods and services, and leaves rural areas isolated.

Two main features will be investigated: education and ageing.

a) Education/training

Some 25% of European school children have poor reading skills

Too many young people leave education/training without qualifications

Numbers attaining medium-level qualifications are better, but the qualifications often fail to match

labour market needs

Under a third of Europeans aged 25-34 have a university degree (40% in the US, over 50% in Japan)

European universities rank poorly in global terms – only 2 are in the world top 20 (see Shanghai index

(ARWU))

b) Ageing populations

As Europeans live longer and have fewer children, fewer people in work have to support higher

numbers of pensioners, as well as fund the rest of the welfare system.

The number of over-60s is now increasing twice as fast as it did before 2007 – by some 2 million a year

instead of 1 million previously.

A better knowledge economy with more opportunities will help people work longer and relieve the

strain.

II.2.3.2 Sustainable growth

II.2.3.2.1 What does sustainable growth mean?

Sustainable growth, for a resource-efficient, greener and more competitive economy, means building a more

competitive low-carbon economy that makes efficient, sustainable use of resources protecting the

environment, reducing emissions and preventing biodiversity loss, capitalizing on Europe's leadership in

developing new green technologies and production methods introducing efficient smart electricity grids

harnessing EU-scale networks to give our businesses (especially small manufacturing firms) an additional

competitive advantage improving the business environment, in particular for SMEs helping consumers make

well-informed choices.

EU targets for sustainable growth include:

1. reducing greenhouse gas emissions by 20% compared to 1990 levels by 2020. The EU is prepared to go

further and reduce by 30% if other developed countries make similar commitments and developing

countries contribute according to their abilities, as part of a comprehensive global agreement

2. increasing the share of renewables in final energy consumption to 20%

3. moving towards a 20% increase in energy efficiency

II.2.3.2.2 How will the EU boost sustainable growth?

The European Union will boost sustainable growth through 2 flagship initiatives:

1. Resource-efficient Europe

To support the shift towards a resource-efficient, low-carbon economy, our economic growth must be

decoupled from resource and energy use by:

- reducing CO2 emissions

- promoting greater energy security

- reducing the resource intensity of what we use and consume

2. An industrial policy for the globalization era

The EU needs an industrial policy that will support businesses – especially small businesses – as they respond

to globalization, the economic crisis and the shift to a low-carbon economy, by: supporting entrepreneurship –

to make European business fitter and more competitive covering every part of the increasingly international

value chain – from access to raw materials to after-sales service.

This policy can only be devised by working closely with business, trade unions, academics, NGOs and

consumer organizations.

II.2.3.2.3 Why does Europe need sustainable growth?

Several factors influence growth, indicated below:

a) Over-dependence on fossil fuels

Our dependence on oil, gas and coal:

- leaves consumers and businesses vulnerable to harmful and costly price shocks,

- threatens our economic security

- contributes to climate change.

b) Natural resources

Global competition for natural resources will intensify and put pressure on the environment. The EU can

help reduce these pressures through its sustainable development policies.

c) Climate change

To achieve our climate goals, we need to reduce emissions more quickly and harness new technologies

such as wind and solar power and carbon capture and sequestration.

We must strengthen our economies' resilience to climate risks, and our capacity for disaster prevention and

response.

d) Competitiveness

The EU needs to improve its productivity and competitiveness. It must maintain its early lead in green

solutions, especially in the face of growing competition from China and North America.

Meeting our energy goals could save €60 billion on Europe's bill for oil and gas imports by 2020 – essential

for both energy security and economic reasons.

Further integration of the European energy market can boost GDP by 0.6% to 0.8%.

Meeting 20% of Europe's energy needs from renewable sources could create over 600 000 jobs in the EU –

and an additional 400 000 if we meet the 20% energy-efficiency target.

Our emission-reduction commitments should be met in a way that maximizes benefits and minimizes costs

– including through the spread of innovative technological solutions.

II.2.3.3 Inclusive growth

II.2.3.3.1 What does inclusive growth mean?

Inclusive growth, a high-employment economy delivering economic, social and territorial cohesion, means

raising Europe’s employment rate – more and better jobs, especially for women, young people and older

workers helping people of all ages anticipate and manage change through investment in skills & training

modernizing labour markets and welfare systems ensuring the benefits of growth reach all parts of the EU

EU target for inclusive growth include:

1. 75% employment rate for women and men aged 20-64 by 2020– achieved by getting more people into

work, especially women, the young, older and low-skilled people and legal migrants

2. better educational attainment – in particular:

– reducing school drop-out rates below 10%

– at least 40% of 30-34–year-olds completing third level education (or equivalent)

3. at least 20 million fewer people in or at risk of poverty and social exclusion.

II.2.3.3.2 How will the EU boost inclusive growth?

The European Union will boost inclusive growth through 2 flagship initiatives:

1. Agenda for new skills and jobs for individuals – helping people acquire new skills, adapt to a changing

labour market and make successful career shifts collectively – modernizing labour markets to raise

employment levels, reduce unemployment, raise labour productivity and ensuring the sustainability of our

social models.

2. European platform against poverty ensuring economic, social and territorial cohesion both guaranteeing

respect for the fundamental rights of people experiencing poverty and social exclusion, and enabling them to

live in dignity and take an active part in society and mobilizing support to help people integrate in the

communities where they live, get training and help to find a job and have access to social benefits.

Regional development and investment also support inclusive growth by helping disparities among regions

diminish and making sure that the benefits of growth reach all corners of the EU.

II.2.3.3.3 Why does Europe need inclusive growth?

A lot of reasons could be considered to answer that question. Some of them will be indicated below as the

most important in the priorities scale: employment, skills, fighting poverty.

a) Employment

Europe’s workforce is shrinking as a result of demographic change –a smaller workforce is supporting a

growing number of inactive people.

The EU must increase its overall employment rate: The employment rate is particularly low for women (63%

against 76% for men aged 20-64) and older workers, aged 55-64 (46% against 62% in the US and Japan).

Europeans work short hours – 10% less than their US or Japanese counterparts.

The economic crisis has brought high youth unemployment – over 21% – and made it harder for out-of-work

people to find jobs.

b) Skills

The EU has around 80 million people with low or basic skills – benefiting less from lifelong learning than

more educated people.

By 2020, 16m more jobs will require high qualifications, with 12m fewer jobs requiring low skill-levels.

Acquiring and building on new skills is ever more important.

c) Fighting poverty

Even before the crisis, there were 80m people at risk of poverty, including 19m children.

8% of working people do not earn enough to make it above the poverty line.

II.2.3.4 Health for Growth Programme (2014-2020)

Proposal on establishing a Health for Growth Programme has been presented on December 8th 2011 as the

third programme of EU action in the field of health (2014-2020). The European Parliament and the Council of

the European Union have adopted its regulation on December 9th 2011, COM(2011) 709 final 2011/0339

(COD).

II.2.3.4.1 Context of the proposal

Health is not just a value in itself - it is also a driver for growth. Only a healthy population can achieve its full

economic potential. The health sector is driven by innovation and a highly qualified workforce. Health-related

research and development has the potential to reach 0.3% of GDP. The healthcare sector is one of the largest

in the EU: it accounts for approximately 10% of the EU’s gross domestic product and employs one in ten

workers, with a higher than average proportion of workers with tertiary-level education.

Health therefore plays an important role in the Europe 2020 agenda. In its Communication of 29th June 2011

‘A budget for Europe 2020’113

the Commission stressed that ‘promoting good health is an integral part of the

smart and inclusive growth objectives for Europe 2020. Keeping people healthy and active for longer has a

positive impact on productivity and competitiveness. Innovation in healthcare helps take up the challenge of

113

COM(2011)500 Final.

sustainability in the sector in the context of demographic change’, and action to reduce inequalities in health is

important to achieve ‘ inclusive growth ’.

The proposed third programme of EU action in the field of health (2014-2020), ‘Health for Growth’,

strengthens and emphasizes the links between economic growth and a healthy population to a greater extent

than the previous programmes. The Programme is geared towards actions with clear EU added value, in line

with the Europe 2020 objectives and current policy priorities.

The financial crisis has further highlighted the need to improve the cost-effectiveness of health systems.

Member States are under pressure to strike the right balance between providing universal access to high-

quality health services and respecting budgetary constraints. In this context, supporting Member States’ efforts

to improve the sustainability of their health systems is crucial to ensure their ability to provide high quality

healthcare to all their citizens now and in the future. The Health for Growth Programme contributes to finding

and applying innovative solutions for improving the quality, efficiency and sustainability of health systems,

putting the emphasis on human capital and the exchange of good practices.

Key goals, set out in the "Europe 2020 – A strategy for smart, sustainable and inclusive growth"114

, all hinge

on increasing innovation in healthcare as reflected in flagship initiatives such as the Innovation Union and the

Digital Agenda. However, innovation is not just about technology and new products. It is also about

innovating in how healthcare is organized and structured, how resources are used, how systems are financed.

As such, innovation in health has the potential to help reduce healthcare costs and improve the quality of care.

Many areas of the proposed Health for Growth Programme, such as health technology assessment (HTA),

medical devices, clinical trials and medicinal products, as well as the European Innovation Partnership on

Active and Healthy Ageing, aim to strengthen the link between technological innovation and its uptake and

commercialization; while fostering security, quality and efficiency of healthcare. Other initiatives focus on

promoting the uptake and interoperability of e-Health solutions, to improve for example cross-border use of

patient registers.

The Programme will further support better forecasting, planning of needs and training of health professionals,

which will contribute to both organizational innovation and inclusive growth. This is in line with the EU 2020

flagship initiative for New Skills and Jobs and its focus on flexibility and security, equipping people with the

right skills for the jobs of today and tomorrow, better working conditions and improving job creation. As the

population ages and demand for healthcare grows, the health sector has great potential to create new jobs.

Health problems are one of the major causes of absenteeism from work and early retirement. Keeping people

healthy and active for longer has a positive impact on productivity and competitiveness. Increasing the number

of healthy life years is a prerequisite if Europe is to succeed in employing 75 % of 20-64 year-olds and

avoiding early retirement due to illness. In addition, keeping people over 65 years of age healthy and active

can impact on labour market participation and lead to potential important savings in healthcare budgets.

The general objectives of the Health for Growth Programme shall be to work with Member States to

encourage innovation in healthcare and increase the sustainability of health systems, to improve the health of

the EU citizens and protect them from cross-border health threats.

It focuses on four specific objectives with a strong potential for economic growth through better health:

1. to develop common tools and mechanisms at EU level to address shortages of resources, both human and

financial and to facilitate up-take of innovation in healthcare in order to contribute to innovative and

sustainable health systems;

2. to increase access to medical expertise and information for specific conditions also beyond national borders

and to develop shared solutions and guidelines to improve healthcare quality and patient safety in order to

increase access to better and safer healthcare for EU citizens;

3. to identify, disseminate and promote the up-take of validated best practices for cost-effective prevention

measures by addressing the key risk factors, namely smoking, abuse of alcohol and obesity, as well as

HIV/AIDS, with a focus on the cross border dimension, in order to prevent diseases and promote good

health; and

4. to develop common approaches and demonstrate their value for better preparedness and coordination in

health emergencies in order to protect citizens from cross-border health threats.

This proposed Regulation sets out the general provisions governing the Health for Growth Programme and

repeals Decision (EC) No 1350/2007.

II.2.3.4.2 Objectives

114

COM(2010)2020 Final.

The challenges outlined above first and foremost require Member States to take direct action at national level.

The aim of EU health policy, as stated in the Treaty, is to complement and support these national policies and

encourage cooperation between Member States. The Programme provides possibilities to build and strengthen

cooperation mechanisms and coordination processes between Member States with a view to identifying

common tools and best practices that create synergies, bring EU added value and lead to economies of scale,

thus supporting reform under challenging circumstances.

Developing common tools and mechanisms at EU level to address shortages of resources, both human and

financial and facilitating up-take of innovation in healthcare in order to contribute to innovative and

sustainable health systems

For many years, Member States have been facing budget constraints with regard to the sustainability of their

health budgets, which represent up to 15% of public expenditure in some Member States115

.

This is further compounded by an ageing population, rising expectations for high quality services and the

emergence of new, more effective but more expensive technologies. The challenges have increased with curbs

on public spending in the wake of the financial crisis. Evidence116

suggests, however, that effective health

system reforms have the potential to contain ‘excess cost growth’, i.e. keep health spending in line with GDP

growth.

By supporting Member States’ efforts to improve the efficiency and financial sustainability of health care, the

programme aims to encourage a significant shift of resources in this sector towards the most innovative and

valuable products and services, which at the same time offer the best market potential and cost savings in the

longer term. It also seeks to support innovation in how healthcare is organized, to foster for example a greater

shift towards community care and integrated care. Health system reform must clearly consist of a mix of

immediate efficiency gains and longer-term strategic action addressing key cost drivers. For example,

European cooperation on health technology assessment will not only reduce duplication and pool expertise,

but can also unlock the potential for sustainable innovation in health products and services.

Health-related investments under the Structural Funds can play a particularly important role in helping

Member States reform their health systems at national and regional level, and in meeting the four specific

objectives under this Programme, drawing from best practice and pilot project experience acquired through the

Health for Growth Programme. As such, co-operation and synergies between the Health for Growth

programme and the Structural Funds will be reinforced.

With an ageing population and changing family structures, the demand for formal, professionalized care is

increasing as the availability of informal care in the family environment is declining. Healthcare has also

become more specialized and requires more intense work and longer training. By 2020 there will be a shortage

of one million health workers in the EU and, should no action be taken, 15% of necessary care will not be

covered. If successfully addressed, however, this would create significant employment and growth

opportunities.

To achieve this, the Programme will develop common tools and mechanisms at EU level to help national

health systems deliver more care with fewer resources. Innovative solutions are needed to tackle workforce

shortages and to maximize the efficiency of health systems through the use of innovative products, services,

tools and models. Successful implementation of such solutions will also require overcoming barriers such as

public procurement and lack of user involvement in innovation.

In this context, actions planned under this objective aim for example to foster European cooperation on Health

Technology Assessment (HTA) and explore the potential of e-Health and ICT for Health, including a

dedicated e-Health network and cooperation among electronic patient registries, as part of the implementation

of the Directive on patients' rights in cross border healthcare117

. Actions will also address shortages in the

health workforce and assist Member States in reforming their health systems through the pooling and

strengthening of expertise on technical evaluation of policy action.

They will also support measures setting high standards of safety, quality and efficacy for devices for medical

use required by or contributing to the objectives of EU legislation in this field, as well as contributing to

provisions on e-Health and HTA of the above mentioned Directive.

115

Source: extracted from Eurostat online database in July 2011 ‘General expenditure by function - health compared to total’. 2009: 14.63 %; http://appsso.eurostat.ec.europa.eu/nui/show.do?dataset=gov_a_exp&lang=en. 116

IMF 2011 and Joumard et al., 2010, i.e. the rise in public health spending over GDP in excess of what is due to population ageing (this excess cost growth is estimated at an average of about 1 % for the OECD). 117

Directive 2011/24/EU of the European Parliament and the Council of 9 March 2011.

The programme may also provide support, under its different objectives, to specific actions under the

European Innovation Partnership on Active and Healthy Ageing in its three themes: innovation in awareness,

prevention and early diagnosis; innovation in cure and care and innovation for active ageing and independent

living.

Increasing access to medical expertise and information for specific conditions also beyond national borders

and developing shared solutions and guidelines to improve healthcare quality and patient safety in order to

increase access to better and safer healthcare for EU citizens

Improving access to healthcare for all citizens regardless of income, social status, location and nationality is

key to bridging the current substantial inequalities in health. All EU citizens should have access to safe and

high-quality healthcare regardless of their circumstances. However, in reality, access to healthcare still varies

significantly in the EU. Poor health status often has a substantial impact on accessibility to effective healthcare

and the possibilities of citizens to act on health information. People with low income, the socially excluded

and those living in depressed or micro regions can experience specific difficulties in accessing healthcare.

Action under all the objectives of the programme should help contribute to bridging such inequalities by

addressing various factors that give rise to and increase inequalities, as well as complement action under other

programmes aimed at addressing social and regional differences within the EU.

To improve access to healthcare, in particular for specific conditions where national capacity is scarce, there is

clear added value in fostering the networking of specialized European centres of reference accessible to all

citizens across the EU.

In addition, to help Member States further improve the quality and safety of healthcare, the programme will

consolidate and continue on-going action to identify, exchange and disseminate good practices in this area.

The programme will increase access to medical expertise by supporting the establishment and setting up of a

system of European reference networks defining their criteria and conditions and by developing shared

solutions and guidelines for healthcare quality and patient safety across the EU, tackling a range of issues

including antimicrobial resistance.

Actions under this objective will also support measures setting high standards of safety, quality and efficacy of

blood, organs, tissues and cells, of pharmaceutical products and patients' rights in cross border health care

required by or contributing to the objectives of EU legislation in these fields.

Identifying, disseminating and promoting the up-take of validated best practices for cost-effective prevention

measures by addressing the key risk factors, namely smoking, abuse of alcohol and obesity, as well as

HIV/AIDS, with a focus on the cross border dimension, in order to prevent diseases and promote good health

Life expectancy has been progressing over the last decades in an unprecedented way and was 76.4 years for

men and 82.4 years for women in the EU in 2008. By contrast, the average number of healthy life years has

been progressing at a much slower pace and was 60.9 years for men and 62 years for women.

This means that a greater part of a longer life is being spent in ill health, which is one of the factors driving

spiralling health costs and hampering participation in the labour market. Ill health adversely affects the

development of human capital, which is crucial for developing a knowledge-based economy.

Chronic diseases are the main cause of death and poor quality of life in Europe. Over 4 million people in the

European Union die every year because of chronic diseases, which represent 87% of premature mortality in

the EU. Chronic diseases also represent a huge economic burden through loss of people’s capacity to work in

the prime of their lives. The programme includes action to support the efforts of Member States aimed at

prolonging the healthy and productive life years of their population by preventing chronic diseases.

Many chronic diseases are preventable. They are often the result of smoking, harmful alcohol consumption,

poor diet and insufficient physical activity. These risk factors are further compounded by underlying socio-

economic factors as well as environment factors.

This is not just a major health challenge, but also a substantial economic opportunity. The right investments

will lead not only to better health, but also to longer and more productive lives and lower labour shortages. If

Europeans live in better health, they will be able to continue contributing to the economy as they grow older,

as workers, volunteers and consumers. The expertise of the elderly will also be needed even more in a

population with low birth rates and a lack of skilled labour.

The programme will address the challenges in these areas by fostering best practice in health promotion and

cost-effective prevention targeting key health determinants namely smoking, abuse of alcohol and obesity, as

well as HIV/AIDS, with a focus on cross border issues. It will support European cooperation and networking

on preventing chronic diseases, including guidelines on quality cancer screening. Actions under this objective

will also support measures which have as their direct objective the protection of public health regarding

tobacco products and advertisement required by or contributing to the objectives of EU legislation in this field.

Developing common approaches and demonstrating their value for better preparedness and coordination in

health emergencies in order to protect citizens from cross-border health threats

In the recent past, the EU has faced several major cross-border threats to health, such as pandemic influenza or

SARS. EU competence as regards coordinating preparedness for and response to serious cross-border health

threats is enshrined in the Lisbon Treaty. By their very nature, such health threats are not confined to national

borders and cannot be effectively addressed by any Member State or by the Union alone. The EU needs to be

well prepared against these threats, which can have a heavy impact not just on the health and life of citizens,

but also on the economy.

Actions planned under this objective will help develop common approaches to prepare for possible health

emergencies, to co-ordinate a response to such health emergencies at European level, and to support national

capacity building in preparedness and management of health crises taking into account international initiatives.

The aim is to support preparedness planning, including for pandemic influenza, address gaps in risk

assessment capacities between Member States and support capacity building against health threats in Member

States as well as promoting the capacity at global level to respond to health treats.

Actions will also support measures designed to protect and improve human health against communicable

diseases, major cross-border health scourges, measures concerning monitoring, early warning of and

combating serious cross-border threats to health required by or contributing to the objectives of EU legislation

in these fields.

Under all four objectives mentioned above, the Programme will support actions on Health information and

knowledge to contribute to evidence-based decision making, including collecting and analysing health data

and wide-ranging dissemination of the results of the Programme. It will also support the activities of the

Scientific Committees set up in accordance with Commission Decision 2008/721/EC.

II.2.3.4.3 Results of consultations with the interested parties and impact assessments

II.2.3.4.3.1 Consultation and expert advice

The consultation targeted in particular Member States' representatives, National Focal Points, the Council

working party on Public health at Senior Level and the informal Health Council. Additional expert advice was

provided through the EU Health Policy Forum, health professionals and patients associations. Other

programme stakeholders, especially beneficiaries, have expressed their views in the recent programme

evaluations.

All participants in the various consultations strongly supported the Health Programme. Some Member States

concurred with the view that it should be more focused, cost-efficient and based on action with proven EU

added value, whereas others were of the opinion that it should continue to support the existing objectives and a

wide range of actions.

National Focal Points designated by Member States’ authorities mentioned that the programme could help to

shape national policies by providing best practices, sharing and exchanging practical experience, expertise and

knowledge and giving support on health issues on the national political agenda. The EU Health Policy Forum

argued that strong emphasis should be put on health determinants and a patient-centred focus. It also

recommended that the programme address the role of social determinants.

Furthermore, Member States and stakeholders alike mentioned the need for more active participation in the

programme by all EU Member States and emphasized that the programme should be more closely linked to

the Treaty on the Functioning of the European Union, to the Europe 2020 agenda and to the existing

legislation.

II.2.3.4.3.2 Impact Assessment

The Impact Assessment report analyzed various options for the programme. It identified the preferred option,

from a cost/benefit point of view, as corresponding to a well structured programme, with specific, measurable,

attainable, relevant and time-bound (SMART) objectives, prioritized actions, creating EU added value and

with better monitoring of outcomes and impacts. The programme will focus on:

- contributing to facilitate the up-take of innovative solutions for improving the quality, efficiency and

sustainability of health systems and increasing access to better and safer healthcare;

- promoting good health and preventing diseases at EU level by helping and complementing Member States’

efforts to increase their citizens’ number of healthy life years;

- supporting solutions for cross-border health threats;

- supporting actions required by the current EU legal obligations.

The budget under this option is approximately 57 million Euro annually (in 2011 prices), which is in line with

the proposed budget allocation for the Health for Growth Programme in the Communication ‘A Budget for

Europe 2020’ of June 2011.

II.2.3.4.3.3 Delivering European added value

As stated in Article 168 of the Treaty on the Functioning of the European Union, EU action must complement

national policies and encourage cooperation between Member States. The programme should contribute only

where Member States cannot act individually or where coordination is the best way to move forward.

The programme puts forward actions in areas where there is evidence of EU added-value on the basis of the

following criteria: fostering best practice exchange between Member States; supporting networks for

knowledge sharing or mutual learning; addressing cross-border threats to reduce risks and mitigate their

consequences; addressing certain issues relating to the internal market where the EU has substantial legitimacy

to ensure high-quality solutions across Member States; unlocking the potential of innovation in health; actions

that could lead to a system for benchmarking; improving economies of scale by avoiding waste due to

duplication and optimising the use of financial resources.

II.2.3.4.3.4 Increasing the performance of the programme

The Programme builds on the results of the first Public Health Programme (2003-2008) and the second Health

Programme (2008-2013), in line with the conclusions and recommendations made in the different evaluations

and audits performed on these programmes.

The new programme aims to focus on fewer actions, of proven EU added value, that deliver concrete results,

and respond to identified needs or gaps. The programme seeks to improve the way Member States cooperate in

the area of health and to provide leverage for reform of national health policies.

Activities over the seven years period and annual work plans should be based on multi-annual programming of

a limited number of actions per year. In addition, building on lessons learnt and the results of various

evaluations, the programme introduces a number of new elements:

- progress indicators to measure and monitor the objectives and the impact of the programme;

- EU added value as a key determinant in setting the priorities for the annual work plans;

- better dissemination and communication of the results of the projects to policy makers;

- incentives to encourage greater participation of Member States with lower Gross National Income (GNI) in

the programme. This will include a higher co-financing rate for those Member States.

II.2.3.4.3.5 Simplification

The revision of the Financial Regulation will contribute to facilitate participation in EU programmes, for

example by simplifying rules, reducing the costs of participation, accelerating award procedures and providing

a "one-stop shop" to make it easier for beneficiaries to access EU funding. The Programme will make a

maximum use of the provisions of the revised EU Financial Regulation, in particular by further simplifying

reporting requirements, including a more extensive use of online reporting.

The design of the new programme involves simplifying its implementation and management:

1. The level of Union co-financing for grants for actions, actions co-financed by the competent authorities of

the Member States or third countries, or by non-governmental bodies mandated by these authorities and

operating grants will be harmonized at 60% of eligible costs and up to 80% in cases of exceptional utility.

2. The long-term programming of strategic actions under the programme will help reduce their overall number

per year and avoid repetitive work in application, evaluation, negotiation and contracting procedures. In

addition, this will allow greater focus on the priority areas and better use of human and financial resources.

The funding process will be simplified in particular through the use of framework contracts for operating

grants, and the possibility of using lump sums will be examined whenever possible so as to reduce the

administrative burden.

3. The new monitoring and evaluation indicators rely on effective dissemination of Programme results and will

trace their use in Member States with the assistance of the National Focal Points network. It is therefore

expected to have a simplified approach to Programme outcomes; their uptake from the end-users should

increase the visibility and impact of the Programme.

4. In accordance with the Council Regulation (EC) No 58/2003 of 19 December 2002 laying down the statute

for Executive Agencies to be entrusted with certain tasks in the management of Community programmes,

the Commission has entrusted the Executive Agency for Health and Consumers with implementation tasks

for the management of the Programme of Community Action in the field of Health since 2005. The

Commission may use, on the basis of a cost-benefit analysis, an existing executive agency for the

implementation of the Health for Growth Programme.

II.2.3.4.4 Legal elements of the proposal

EU action is justified on the grounds both of the objectives laid down in Article 168 of the Treaty and the

subsidiarity principle. ‘Union action shall complement the national policies and the Member States’ action.’

The Union can also ‘lend support to their action’.

The second subparagraph of Article 168(2) states that ‘ The Commission may, in close contact with the

Member States, take any useful initiative to promote such coordination, in particular initiatives aiming at the

establishment of guidelines and indicators, the organization of exchange of best practice, and the preparation

of the necessary elements for periodic monitoring and evaluation ’; and the third paragraph stipulates that ‘

The Union and the Member States shall foster cooperation with third countries and the competent international

organizations in the sphere of public health.’

Against this background, Article 168(5) TFEU empowers the European Parliament and the Council to adopt

incentive measures designed to protect and improve human health.

II.2.3.4.5 Budgetary implication

The financial appropriations for implementing the programme over the period from 1 January 2014 to 31

December 2020 will amount to 446 million euro (in current prices). This corresponds to the proposed budget

allocation for the Health Programme in the Communication ‘A Budget for Europe 2020’ of June 2011.

II.2.4 Horizon 2020

II.2.4.1 What is Horizon 2020?

The European Commission released Horizons 2020, which will be the financial instrument for research and

innovation funding from 2014-2020: €31.7 billion will be allocated to tackling the major issues affecting the

lives of European citizens and €8.5 billion Euro are earmarked to health.

According to the European Commission, Horizons 2020 will “ensure a broad approach to innovation, which is

not only limited to the development of new products and services on the basis of scientific and technological

breakthroughs... continuous improvement, non-technological and social innovation."

The first objective is dedicated to supporting an ’Excellent science’ in Europe with a budget of €24.6 billion to

improve excellence in science and train researchers.

The second objective, ’Industrial leadership’, with a budget of €17.9 billion, will aim to attract investments in

research and innovation.

The third objective, ’Societal challenges’ will see €31.7 billion allocated to tackling the major issues affecting

the lives of European citizens. Under the priority Food security, sustainable agriculture, marine and maritime

research and the bio-based economy, there is a theme on “healthy and safe foods and diets for all.”

II.2.4.2 Horizon 2020: will broader innovation improve health and wellbeing?

The inclusive society strand will support the measurement of progress beyond the commonly used GDP

indicators as well as ensuring societal engagement in research and innovation.

a) Health priorities

8,5 Billion will be earmarked (of 80 Billion) to the health theme with the following priorities:

Understanding the determinants of health, improving health promotion and disease prevention.

Environmental, behavioural (including life-style), socio-economic and genetic factors, in their broadest

senses will be studied.

b) Developing effective screening programmes and improving the assessment of disease susceptibility

c) Improving surveillance and preparedness

d) Understanding diseases

e) Using in-silico medicine for improving disease management and prediction

f) Treating disease (communicable, rare, major and chronic diseases) supporting the improvement of cross-

cutting support technologies for drugs, vaccines and other therapeutic approaches, including

transplantation, gene and cell therapy;

g) Transferring knowledge to clinical practice and scalable innovation actions

h) Better use of health data

i) Improving scientific tools and methods to support policy making and regulatory needs

j) Active ageing, independent and assisted living

k) Individual empowerment for self-management of health

l) Promoting integrated care

m) Promoting partnership with civil society

In terms of promoting partnership with civil society, the following references were included:

"In all forms of innovation, strengthening the participation of civil society will be supported."

"Expert group shall show the appropriate level of expertise and knowledge in the covered areas and a

variety of professional backgrounds, including industry and civil society involvement."

"Regular interactions with end-users, citizens and civil society organizations, through appropriate

methodologies such as consensus conferences, participatory technology assessments or direct engagement

in research and innovation processes, will also be a cornerstone of the priority setting process."

II.2.5 Active and Healthy Ageing: the sounding board of Social, Technological and Integrated Innovation

II.2.5.1 European Innovation Partnership on Active and Healthy Ageing (EIP-AHA)

As we said before, recently, inside the Europe 2020 Flagship Initiative “Innovation” was promoted the

“European Innovation Partnership on Active and Healthy Ageing” as first EIP. It is a good example of how

Public-Private-Partnership (PPP) and Public-Public-Partnership (P2P) could move towards new a collaborative

pathway in respect of true implementation efforts.

The passage from the concept of Active and Healthy Ageing to its true implementation does really constitute a

huge challenge under many points of view: methodological, scientific, organizational, economic, political,

financial.

“With its Strategic Implementation Plan, the Steering Group of the European Innovation Partnership on Active

and Healthy ageing delivers its rationale, its vision and its suggestions for addressing the challenge of active

and healthy ageing.

The Partnership aims to identify and remove persisting barriers to innovation across the health and care

delivery chain, through interdisciplinary and cross-sectorial approaches.

This Partnership has already delivered added value. Indeed, it has brought a very wide range of stakeholders

into close cooperation. Valuable lessons have been learnt about the challenge of European collaboration in and

across the fields of innovation, health, social care and ICT.

It is the first time that such a broad range of stakeholders – from health and social care sectors as well as

business and civil society – have agreed on a shared vision and a comprehensive framework for action. The

latter is underpinned by innovation and is expected to radically improve active and healthy ageing in Europe.

The Partnership identifies a set of actions that can start as early as 2012 and deliver measurable outcomes

within the 2012 – 2015 timeframe. The Strategic Implementation plan sets outs more detailed explanations on

the work of the Steering Group and its suggestions for the way ahead.

Ageing societies are an emerging and seemingly irrevocable trend in Europe, but also in the US, Japan and

China. Progress in health care, an increase in levels of wealth, improvements in standards of living and better

nutrition, also combined with reduced fertility rates, have contributed to an increase in the number of citizens

over 65 years old. According to recent projections, the number of Europeans aged 65+ will almost double over

the next 50 years, from 85 million in 2008 to 151 million in 2060.

This trend represents a challenge for public authorities, policy makers, businesses and the no-profit sector;

especially as it comes at a time of steady decline in the number of health professionals (nurses and doctors)

and increases in the availability of healthcare products and services.

II.2.5.2 Active and Healthy Ageing. Challenge of ageing –the key role of innovation

Societal challenges like ageing societies require a timely and well-planned response containing its negative

social and economic effects and eventually turning the challenge into an economic opportunity, capable of

offering better prospects for the ageing population when it comes to quality of life and overall health and well-

being.

New solutions and approaches are needed and innovation can play a key role in rethinking and changing the

way we organize, deliver, finance and design care and social services.

However, the successful and efficient introduction of innovative solutions requires more than just a proven

idea. Several barriers and bottlenecks first need to be overcome. These do not only concern health and care

systems, but also affect other important sectors influencing people's health or quality of their daily lives like

housing and transportation.

Amongst the top ones are lack of user involvement in research and innovation, lack of cooperation and poor

communication among care players, fragmented and innovation – averse financing, lack of interoperability

and standards, and inflexible or inadequate legislation.

Through the Europe 2020 strategy framework and its "Innovation Union" flagship initiative, the European

Commission has committed to overcome the barriers to innovation, especially for addressing the main societal

challenges. It put forward the novel concept of European Innovation Partnerships. Active and Healthy Ageing

(AHA) was chosen as the trial focus area.

This document, notably the Strategic Implementation Plan prepared by the Steering Group of the Partnership

constitutes a first delivery of this initiative.

II.2.5.3 Vision of health and active ageing

Healthy and active ageing despite its importance happens to be perceived and understood differently. Hence

the key building blocks encompassing a vision for the future of health, ageing and innovation policies need to

be identified.

II.2.5.4 Definition of active and healthy ageing

Based on the WHO definition, active and healthy ageing is the process of optimizing opportunities for health,

participation and security in order to enhance quality of life as people age. It applies to both individuals and

population groups.

“Healthy” refers to physical, mental and social well-being. The “Active” refers to continuing participation in

social, economic, cultural, spiritual and civic affairs, not just simple ability to be physically active or to

participate in the labour force. Therefore active ageing also links to maintaining autonomy and independence

for the older people.

This definition also determines the meaning of an 'elderly' or older person. Usually it is related to the age at

which a person became eligible for statutory and occupational retirement pensions. However, in the context of

EIP and its broad active and healthy ageing definition, meaning of old age can vary, based on people's health,

social, functional or even economic status, and therefore varied geometry approach is followed.

In conclusion, in the context of the EIP active and healthy ageing focuses on extending healthy life expectancy

and quality of life for all people as they age.

II.2.5.5 New paradigm of ageing

Ageing, though one of the greatest societal challenges influencing the outlook of European economies and

societies, should be considered an opportunity rather than a burden; a positive vision which values older

people and their contribution to society; where they are empowered to influence and benefit from user centred

innovation in active and healthy ageing.

Older generations represent great social and economic opportunity which can be tapped into via a new

approach to the ageing challenge. This involves changing our perception of older individuals, beyond their

predominant position in society as patients and recipients of benefits. They should also be considered in equal

measure as empowered consumers and active participants of the societies and labour markets that bring value

to economy and prosperity of the communities they live in.

II.2.5.6 Innovation serving the older generation

Innovation, in all its forms – spanning across technology, process and social innovation – can be a crucial

contributing factor to improving the health and well-being of citizens as well as the sustainability of care

systems and to enhancing Europe's global competitiveness and growth.

Innovation in health and ageing may require high investments. However, when user centred and focused on

the most effective and cost-efficient evidence based solutions, it can bring multiple returns above all through

better outcomes for older people and increased work satisfaction of health professionals, care personnel and

informal/family carers, as well as through improved efficiency and increased productivity.

The Steering Group believes that the partnership should respond to the challenge of active and healthy ageing

by harnessing innovation, testing new organizational frameworks, stimulating new forms of entrepreneurship,

promoting new work practices, encouraging creativity and sharing of experience.

II.2.5.7 Focus on a holistic and multidisciplinary approach

In order to respond effectively to the societal challenge of ageing, new methods and innovative approaches

need to be developed and applied in addition to traditional policies. This shift in focus calls for a more holistic

and multidisciplinary approach with strong user involvement, requiring not only a new way of thinking about

demographic ageing, but developing a framework to harness these opportunities.

The European Innovation Partnership should aim to encourage collaboration among a wide range of relevant

public and private actors across borders, sectors and systems and involve older persons and patients as co-

designers of services they will benefit from.

The Steering Group emphasizes the significance of active involvement of all partners, both public and private,

across the entire innovation value chain, in the shaping and implementation of active and healthy ageing

policy. It should lead to the development of a holistic and coordinated approach across different stakeholders,

systems, disciplines, sectors and institutions with a strong involvement of end users” (Source: European

Commission, on the basis of "Active ageing - a Policy Framework", WHO 2002)

II.2.5.8 Working and Ageing

“The emerging pensions crisis associated with an ageing population across the EU poses particular problems

especially to intergenerational solidarity. It is estimated that by 2050 the number of people in the EU aged 65

and over will grow by 79%, the 80 + age group will grow by 181% (Thomson et al, 2009). A 2006 report

states “the pure demographic effect of an ageing population is projected to increase (public) health care

expenditure by between 1 and 2% of GDP in most EU Member States” (European Commission, 2006). That

seems an underestimate. The IMF has said that some countries will need further adjustments of about 4 to 5

percentage points of GDP to cope with growing expenditures for pensions and health care. But other

economists suggest that it will take somewhere between 12 and 15% of GDP to cope with the pensions time

bomb over the next few decades. Few if any countries are prepared for that.” (Source: Jonathan Watson,

Health ClusterNET Executive Director, Euregio III Project Director, HealthEquity-2020 Project Director,

STF-INNOINTEGRA Partner)

Promoting an inclusive labour market for ageing workers is another challenge. The economic consequences of

an ageing population are seen as interacting with the growth potential, constraints on competitiveness,

accumulation of savings, and current accounts. This interaction largely depends on the social model employing

an integrated approach to the role of older age groups in the economy, including various types of informal

work and its impacts.

Here again, transforming concepts into services is the key word: investments in Long Life Learning, for

example, are commonly seen not as a stable part of Common Good, but as occasional intervention. They aren’t

planned on a large scale so that while on one hand they are useful to affirm the concept, on the other hand

they’re not useful to implement it.

Older workers in the recession: the recession has made the European workforce older. The recession shows a

significant increase in employment among those aged between 50 and 64 years, while younger workers’

number is declining at all wages levels.

Some pensioners work because they want to, others because they cannot afford to live adequately on their

retirement income. The need to work can stem from low income and high expenses. Current decrease in public

spending have reduced public services so reducing quality of life of old people.

Common Good is the extra salary/pension income for millions of people. Investing in Common Good

Innovation could be the future of a true redistribution model, able to save internal market and economy.

It is a research of methodology of analysis producing a model to better understand a more complex

phenomenon : the widespread underevaluation of implementation , not only in terms of financing, but first of

all in terms of cultural, scientific and technological approach : implementation is Cinderella. But her Prince

Charming is arriving , pushed by the Crisis. Of course we speak about Ageing population, but it is a general

truth.

II.2.6 European Commission Regional policy – InfoRegio

European Commission also decided to invest in the regional policy. Its main instrument is InfoRegio.

What is regional policy? EU regional policy is an investment policy. It supports job creation, competitiveness,

economic growth, improved quality of life and sustainable development. These investments support the

delivery of the Europe 2020 strategy.

The Directorate General for Regional policy (DG Regional Policy) is the Commission's department

responsible for developing and pursuing actions leading to the strengthening of the European Union's

economic, social and territorial cohesion, with the objective of promoting smart, sustainable and inclusive

growth for the benefit of EU citizens.

To this end, DG Regional Policy manages regional development programmes in partnership with national,

regional and local actors, to deliver EU policy priorities on the ground throughout the European Union,

particularly in the least favoured regions, reflecting the principle of solidarity. It does this through the

following financial instruments: the European Regional Development Fund (ERDF)1, the Cohesion Fund and

the Instrument for Pre-Accession Assistance (IPA) - Regional Development / Cross-Border Cooperation

components. DG Regional Policy also manages the EU Solidarity Fund (EUSF). The Directorate General is

responsible for the coordination of EU policies on territorial and urban affairs and on the outermost regions.

The mission of the European Commission's Directorate General (DG) for Regional Policy is to strengthen

economic, social and territorial cohesion by reducing disparities between the levels of development of regions

and countries of the European Union. In this way the policy contributes positively to the overall economic

performance of the EU.

Reducing disparities requires a cohesion policy promoting constant improvements in competitiveness and

employment. By co-financing infrastructure projects, developing the information society, accelerating the

transfer of know-how, supporting investments in people and stimulating cross-border cooperation, the

Directorate General for Regional Policy helps regions that are less prosperous or are suffering from structural

problems to improve competitiveness and to achieve a faster rate of economic development in a sustainable

way. The policy is thus an important expression of the solidarity of the European Union.

The Directorate General manages three major Funds:

•the European Regional Development Fund, which operates in all Member States, cofinances investments -

this fund is heavily concentrated in the regions with lowest GDP/head;

•the Cohesion Fund, which co-finances transport and environment projects in Member States whose GNP is

less than 90% of the Community average;

•the Instrument for Pre-Accession Assistance (IPA), which helps candidate countries to develop transport

networks and improve environmental infrastructure.

Apart from these three funds, the DG is also responsible for:

•the implementation of the European Union Solidarity Fund (EUSF), which is dedicated to speedy intervention

in the case of major disasters, to provide aid as quickly as possible;

•the co-ordination group on ultra-peripheral regions, whose remit is to encourage Community actions to

implement measures compensating for the disadvantaged situation of the outermost regions, according to

Article 299 (2) of the Treaty;

•the management of the EC contributions to the International Fund for Ireland which, together with the

PEACE programme included in the Structural Funds, aims at peace and reconciliation in Northern Ireland.

DG Regional Policy aims to deliver (1) efficient and effective structural policies that (2) bring benefits to, and

are understood by, Europe’s citizens on the ground, (3) contribute directly to creating the conditions for the

successful enlargement of the European Union and (4) are consistent with the principle of sound financial

management.

Commissioner Johannes Hahn has the political responsibility for regional policy.

Regional policy is delivered through shared management with agreement on multi-annual development and

investment programmes between the Commission, Member States and regions every seven years. These

agreed programmes ensure that sufficient resources are made available in good time to the right objectives.

Regional policy is funded by the Structural and Cohesion Funds (European Regional Development Fund –

ERDF- and the Cohesion Fund –CF- and invest in a variety of social and economic activities ranging from

large infrastructure projects to small-scale support services for SMEs. The forms of assistance also vary from

grants to more sophisticated financial engineering instruments and public-private partnerships.

Regional policy represents one of the core policies of the Union and accounted for almost 25% of the total EU

budget in 2010. It is therefore essential that the resources devoted to it are used to best effect, and in

accordance with the principle of sound financial management.

In 2010, the Directorate General (DG) for Regional policy achieved its annual objectives to help Member

States and regions to recover from the crisis, to consolidate evidence on the added value of the EU Regional

policy and to launch an informed debate on the reform of the policy.

Budgetary execution was very good with more than EUR 30 billion paid representing 106% of the budget

originally allocated. In some Member States programme execution on the ground progressed very favourably

while others experienced difficulties, amplified by the context of the economic and financial crisis.

In this context, Regional policy resources have been mobilized to support national recovery efforts, even

providing decisive help in breaking the vicious circle created by the credit crunch.

Regional policy evaluation capacity has increased in quality and presented in 2010 robust evidence of the

impacts and results. Some key achievements for the 2000-2006 period include: 1.4 million jobs created; 2000

Km of motorway constructed; 4000 km of rail; 14 million people gained access to cleaner water; 38.000

research projects were supported and over 800.000 SMEs were aided. Evidence was provided that the

multilevel governance of Regional policy has had positive spill-over effects on national and regional

administrative systems.

The 2010 Fifth Report on Economic, Social and Territorial cohesion launched the debate on future options for

Regional policy to enable it to contribute even more effectively to create better jobs and sustainable growth.

Different sources of information are used to build up the Director General's annual declaration of assurance

that the resources assigned to the activities have been used for the intended purpose and in accordance with the

principle of sound financial management, and that the control procedures put in place give the necessary

guarantees concerning the legality and regularity of the underlying transactions. The assurance is built on a

comprehensive assessment by all parties involved in the management and control of every programme.

The first source of information are the annual control reports and the opinions submitted by the National Audit

authorities (2007-13 programming period). They were for the first time in 2010 quite comprehensive, even

though not all the individual control mechanisms have been able to play their full role within the overall

process. In particular the audit of operations carried out by the national audit authorities related to payments

made in 2009 to a sample of operations which, due to the early stage of programme life, were not fully

representative of the 2010 more complex operations.

As complementary sources of information to build up the annual declaration of assurance, DG Regional policy

has used the results of the Commission's own audit work, the opinions of the Directors managing the

programmes and the experience learnt from previous years.

Putting together these sources of information, DG Regional policy has made an assessment of the functioning

of the national management and control systems and has on this basis classified all programmes in four

categories. It has then estimated the total amount of 2010 payments at risk. In doing so DG Regional Policy

takes full account of the fact that the control systems and processes for Structural Funds operate on a multi-

annual basis, which means that the Commission and Member States can apply corrective recovery measures to

protect the EU financial interests up to several years after a payment is made.

The Director General has given a reasonable assurance on the use of the resources in 2010 including on the

appropriateness of the control procedures put in place to guarantee the legality and regularity of the underlying

transactions.

However he noted reservations concerning both programming periods 2007-2013 and 2000-2006. The

reservations are made in respect of significant deficiencies in the systems in the Member States where the

resulting risk to the EU budget is relevant. The specific reasons of the reservations are listed below.

� For the period 2007-2013, the reasons include (i) a delay in the implementation of the national audit

strategies leading to insufficient coverage in terms of both system audit and audit of operations on the ground,

(ii) the identification by National audit authorities or the DG for Regional policy of serious deficiencies in the

management and control systems with regard to the compliance of the operations with the public procurement

rules, or with regard to insufficient management verifications before making payments, (iii) high error rate

reported by the National audit authorities and (iv) very late submission to the Commission of the description

of the management and control systems which has led to a late approval.

� For the period 2000-2006, programmes are being examined to come to a conclusion on final payments;

reservations are on those programmes which have not been subject to sufficient control and corrective

measures by the National authorities and that will be treated in the closure process; even though payments to

these programmes was negligible in 2010, the deficiencies may still have an impact on previous years'

expenditure.

For the 2007-13 period, the number of ERDF and CF programmes under reservation in 2010 is higher than in

2009 (69 and 51 respectively out of 317) and affect a larger number of Member States (including both old and

new Member States). These increases result from two main causes: a higher volume of operations in 2010 with

a higher complexity and the more effective capacity of DG Regional Policy in cooperation with Member

States through the single audit approach to detect weaknesses at an early stage.

The increased control capacity is based on many new control mechanisms at Member States and Commission

levels which were fully deployed for the first time in 2010 (detailed audit opinions on the functioning of the

systems and first audits of operations at national level and, at Commission level complementary audit work

and payment interruptions).

However these specific difficulties should not overshadow the good results in the majority of Member States,

including some that are large beneficiaries and thus manage a large amount of funds, proving that when the

regulatory framework is applied properly it delivers satisfactory results.

The amount of payments quantified as "at risk" is between 0.8% and 1.7% of ERDF / Cohesion Fund

payments in 2010 (the quantification for the 2000-06 programmes is not representative as most of the

remaining irregularities have already been compensated). Thus, these percentages represent the remaining risk

of irregular expenditure in the 2010 intermediate payments in those programmes for which DG Regional

Policy has a limited or no assurance due to material deficiencies in the functioning of the national management

and control systems. This percentage cannot be compared with the error rate determined by the European

Court of Auditors for the Cohesion policy in its annual report. Whilst in both cases the figures are an estimate,

they are founded on different elements and measure different concepts.

In early 2011, DG Regional Policy has taken immediate actions for the 2007-13 programmes under

reservation, proposing an interruption of payment deadlines for programmes where the risks are high,

considering that it is preferable to correct deficiencies as soon as possible to ensure improvements throughout

the implementation period until 2015. 20002006 programmes are being scrutinized in the so called "closure"

process and payments are de facto stopped until an agreement is found with the Member States on the final

amount to be paid or recovered.

At the same time DG Regional Policy is acting in cooperation with the Member States and regions concerned

to redress residual structural weaknesses in their management and control systems. Agreed actions should be

executed swiftly so that programmes execution can go ahead and to meet the expected objectives in favour of

growth and jobs for the citizens and businesses (European Commission, DG Regional Policy, 2010 Annual

Activity Report).

II.2.7 A European non-discrimination law

A European non-discrimination law

In January 2010, the European Court of Human Rights and the European Union Agency for Fundamental

Rights decided to collaborate on the preparation of a Handbook118

on European case-law concerning non-

discrimination.

118

With the impressive body of case-law developed by the European Court of Human Rights and the Court of Justice of the European Union in the field of non-discrimination, it seemed useful to present, in an accessible way, a handbook with a CD-Rom intended for legal practitioners in the EU and Council of Europe Member States and beyond, such as judges, prosecutors and lawyers, as well as law-enforcement officers. Being at the forefront of human rights protection, they, in particular, need to be aware of the non-discrimination principles in order to be able to apply them effectively in practice. For it is at the national level that non-discrimination provisions come to life and there on the front line that the challenges become visible.

With the entry into force of the Lisbon Treaty, the Charter of Fundamental Rights of the European Union

became legally binding. Furthermore, the Lisbon Treaty provides for EU accession to the European

Convention on Human Rights. In this context, increased knowledge of common principles developed by the

Court of Justice of the European Union and the European Court of Human Rights is not only desirable but in

fact essential for the proper national implementation of a key aspect of European human rights law: the

standards on non-discrimination.

2010 marked the 60th anniversary of the European Convention on Human Rights, which sets out a general

prohibition on discrimination in its Article 14, and the 10th anniversary of the adoption of the two fundamental

texts in the fight against discrimination at EU level – the Racial Equality and Employment Equality Directives.

II.2.7.1 Introducing European nondiscrimination law: context, evolution and key principles

It is useful to explain the origins of non-discrimination law in Europe, as well as current and future changes in

both the substantive law and the procedures for protection.

It is important from the outset to note that both judges and prosecutors are required to apply the protections

provided for under the Convention for the Protection of Human Rights and Fundamental Freedoms (ECHR)

and those under the European Union (EU) non-discrimination directives irrespective of whether a party to the

proceedings invokes them. The national courts and administrators of justice are not limited to the legal

arguments advanced by the parties, but must determine the applicable law based on the factual matrix

forwarded by the parties involved; essentially, this means that the parties to a case effectively choose how to

present a non-discrimination claim through the arguments and evidence that they advance. This is consequent

to the governing legal principles evident in each respective system, for example, the direct effect of EU law in

the 27 Member States that make up the EU and the direct applicability afforded to the ECHR, which means

that it must be complied with in all EU and Council of Europe (CoE) Member States.

However, there is one significant constraint on this requirement and this is in the form of any applicable

limitation period. Before considering applying the non-discrimination protections, practitioners will have to

familiarize themselves with any relevant limitation period applying to the jurisdiction being considered and

determine whether the court in question can deal with the issue.

The practical consequences of this are that practitioners, where appropriate, are able to invoke the relevant

non-discrimination instruments and pertinent case-law before national courts and authorities.

This makes it imperative that practitioners understand the systems that are currently in place in the area of

non-discrimination, their application, and how they apply in given situations.

II.2.7.2 Context and background to European non-discrimination law

The term ‘European non-discrimination law’ suggests that a single Europe-wide system of rules relating to

non-discrimination exists; however, it is in fact made up of a variety of contexts. The Handbook draws mainly

from the ECHR and EU law.

These two systems have separate origins both in terms of when they were created and why.

II.2.7.2.1 The Council of Europe and the European Convention on Human Rights

The CoE is an inter-governmental organization (IGO) that originally came together after the Second World

War with the aim of promoting, among other things, the rule of law, democracy, human rights and social

development (see Preamble and Article 1 of the Statute of the Council of Europe). The CoE Member States

adopted the ECHR to help achieve these aims, which was the first of the modern human rights treaties drawing

from the United Nations Universal Declaration of Human Rights. The ECHR sets out a legally binding

obligation on its members to guarantee a list of human rights to everyone (not just citizens) within their

jurisdiction. The implementation of the ECHR is reviewed by the European Court of Human Rights (ECtHR)

(originally assisted by a Commission), which hears cases brought against Member States. The Council of

Europe currently has 47 members and any State wishing to join must also accede to the ECHR.

The ECHR has been altered and added to since its inception in 1950 through what are known as ‘Protocols’.

The most significant procedural change to the ECHR was Protocol 11 (1994), which turned the ECtHR into a

permanent and full-time body and abolished the Commission. This Protocol was designed to help the ECHR

mechanisms cope with the growth in cases that would come from States in the east of Europe joining the

Council of Europe after the fall of the Berlin Wall and the break-up of the former Soviet Union.

The prohibition on discrimination is guaranteed by Article 14 of the ECHR119

, which guarantees equal

treatment in the enjoyment of the other rights set down in the Convention. Protocol 12 (2000) to the ECHR,

not yet ratified by all EU Member States120

, expands the scope of the prohibition of discrimination by

guaranteeing equal treatment in the enjoyment of any right (including rights under national law).

According to the Explanatory Report to the Protocol, it was created out of a desire to strengthen protection

against discrimination which was considered to form a core element of guaranteeing human rights. The

Protocol emerged out of debates over how to strengthen sex and racial equality in particular.

Although not a primary focus of this Handbook, it is worth noting by the reader that the principle of non-

discrimination is a governing principle in a number of CoE documents. Importantly, the 1996 version of the

European Social Charter includes both a right to equal opportunities and equal treatment in matters of

employment and occupation, protecting against discrimination on the grounds of sex121

. Additional protection

against discrimination can be witnessed in the Framework Convention for the Protection of National

Minorities122

, in the CoE Convention on Action Against Trafficking in Human Beings123

, and in the CoE

Convention on the Access to Official Documents. There is also protection against the promotion of

discrimination in the Additional Protocol to the Convention on Cybercrime. The issue of non-discrimination

has clearly been influential in the shaping of the legislative documents produced by the CoE and is seen as a

fundamental freedom that needs to be protected.

II.2.7.2.2 The European Union and the non-discrimination directives

The European Union (EU) was originally an inter-governmental organization, but is now a separate legal

personality. The EU is currently made up of 27 Member States.

It has evolved from three separate IGOs established in the 1950s that dealt with energy security and free trade

(collectively known as the ‘European Communities’).

The core purpose of the European Communities was the stimulation of economic development through the

free movement of goods, capital, people and services.

In order to allow for a level playing field between the Member States, the original Treaty Establishing the

European Economic Community (1957) contained a provision prohibiting discrimination on the basis of sex in

the context of employment. This would prevent Member States gaining a competitive advantage over each

other by offering lower rates of pay or less favourable conditions of work to women.

Although this body of law evolved considerably to include areas such as pensions, pregnancy and statutory

social security regimes, until 2000 non-discrimination law in the EU applied only to the context of

employment and social security and only covered the ground of sex.

During the 1990s, significant lobbying was carried out by public interest groups calling for the prohibition on

discrimination to be extended in EU law to cover other areas such as race and ethnicity, as well as sexual

orientation, religious belief, age and disability. Fears of resurgent extremist nationalism among some EU

Member States stimulated sufficient political will among leaders to allow for the European Community Treaty

to be amended, giving the Community the competence to legislate in these areas.

In 2000, two directives were adopted: the Employment Equality Directive prohibited discrimination on the

basis of sexual orientation, religious belief, age and disability in the area of employment; the Racial Equality

Directive prohibited discrimination on the basis of race or ethnicity in the context of employment, but also in

accessing the welfare system and social security, and goods and services. This was a significant expansion of

the scope of non-discrimination law under the EU, which recognized that in order to allow individuals to reach

their full potential in the employment market, it was also essential to guarantee them equal access to areas

such as health, education and housing. In 2004, the Gender Goods and Services Directive expanded the scope

of sex discrimination to the area of goods and services. However, protection on the grounds of sex does not

119

A training guide in the form of a PowerPoint presentation offering guidance on the application of Article 14 of the ECHR can be found on the Council of Europe Human Rights Education for Legal Professionals website: www.coehelp.org/course/view.php?id=18&topic=1. 120

For the actual number of EU Member States that ratified Protocol 12, see: www.conventions.coe.int/Treaty/Commun/ChercheSig.asp?NT=177&CM=7&DF=16/07/2010&CL=ENG. 121

See Article 20 and Article E in Part V of the European Social Charter. See Article 20 and Article E in Part V of the European Social Charter. 122

See Articles 4, 6(2) and 9 in the Framework Convention for the Protection of National Minorities. 123

See Article 2(1) in the CoE Convention on Action Against Trafficking in Human Beings.

quite match the scope of protection under the Racial Equality Directive since the Gender Social Security

Directive guarantees equal treatment in relation to social security only and not to the broader welfare system,

such as social protection and access to healthcare and education.

Although sexual orientation, religious belief, disability and age are only protected grounds in the context of

employment, a proposal to extend protection for these grounds to the area of accessing goods and services

(known as ‘Horizontal Directive’) is currently being debated in the EU institutions.

II.2.7.3 Current and future developments in European protection mechanisms

II.2.7.3.1 EU Charter of Fundamental Rights

The original treaties of the European Communities did not contain any reference to human rights or their

protection. It was not thought that the creation of an area of free trade in Europe could have any impact

relevant to human rights. However, as cases began to appear before the European Court of Justice (ECJ)

alleging human rights breaches caused by Community law, the ECJ developed a body of judge-made law

known as the ‘general principles’ of Community Law124

.6 According to the ECJ, these general principles

would reflect the content of human rights protection found in national constitutions and human rights treaties,

in particular the ECHR. The ECJ stated that it would ensure the compliance of Community Law with these

principles.

In recognizing that its policies could have an impact on human rights and in an effort to make citizens feel

‘closer’ to the EU, the EU and its Member States proclaimed the EU Charter of Fundamental Rights in 2000.

The Charter contains a list of human rights, inspired by the rights contained in the constitutions of the Member

States, the ECHR and universal human rights treaties such as the UN Convention on the Rights of the Child.

The Charter, as adopted in 2000, was merely a ‘declaration’, which means that it was not legally binding,

although the European Commission (the primary body for proposing new EU legislation) stated that its

proposals would be in compliance.

When the Treaty of Lisbon entered into force in 2009, it altered the status of the Charter of Fundamental

Rights to make it a legally binding document. As a result, the institutions of the EU are bound to comply with

it. The EU Member States are also bound to comply with the Charter, but only when implementing EU law. A

protocol to the Charter was agreed in relation to the Czech Republic, Poland and the UK which restates this

limitation in express terms. Article 21 of the Charter contains a prohibition on discrimination on various

grounds, which will be returned to later in this Handbook. This means that individuals can complain about EU

legislation or national legislation that implements EU law if they feel the Charter has not been respected.

National courts can seek guidance on the correct interpretation of EU law from the ECJ through the

preliminary reference procedure under Article 267 of the Treaty on the Functioning of the EU.

II.2.7.3.2 UN human rights treaties

Human rights protection mechanisms are, of course, not limited to Europe. As well as other regional

mechanisms in the Americas, Africa and the Middle East, there is a significant body of international human

rights law that has been created through the United Nations (UN). All EU Member States are party to the

following UN human rights treaties, all of which contain a prohibition on discrimination: the International

Covenant on Civil and Political Rights (ICCPR)125

, the International Covenant on Economic Social and

Cultural Rights (ICESCR)126

, the Convention on the Elimination of All Forms of Racial Discrimination

(ICERD)127

, the Convention on the Elimination of Discrimination Against Women (CEDAW)128

, the

Convention Against Torture129

and the Convention on the Rights of the Child (CRC)130

. The most recently

124

The European Court of Justice is now referred to as the ‘General Court’ after amendments introduced by the Lisbon Treaty. However, the Handbook continues to refer to the ECJ in order to avoid confusion since most existing literature that practitioners may wish to consult was published before the entry into force of the Lisbon Treaty in December 2009. 125

999 UNTS 171. 126

993 UNTS 3. 127

660 UNTS 195. 128

1249 UNTS 13. 129

1465 UNTS 85.

created human rights treaty at UN level is the 2006 Convention on the Rights of Persons with Disabilities

(UNCRPD)131

. Traditionally, human rights treaties have been open to membership only for States. However,

as States cooperate more through inter-governmental organizations (IGOs), to which they delegate significant

powers and responsibilities, there is a pressing need to make sure that IGOs also commit themselves to give

effect to the human rights obligations of their Member States.

The UNCRPD is the first UN level human rights treaty that is open to membership by regional integration

organizations, and which the EU ratified in December 2010.

The UNCRPD contains an extensive list of rights for persons with disabilities, aimed at securing equality in

the enjoyment of their rights, as well as imposing a range of obligations on the State to undertake positive

measures. Like the Charter, this binds the EU institutions, and will bind the Member States when they are

applying EU law.

In addition individual Member States are currently in the process of acceding to the UNCRPD in their own

right, which will also impose obligations upon them directly. The UNCRPD is likely to become a reference

point for interpreting both EU and ECtHR law relating to discrimination on the basis of disability.

II.2.7.3.3 European Union accession to the European Convention on Human Rights

Currently EU law and the ECHR are closely connected. All Member States of the EU have joined the ECHR.

As noted above, the ECJ looks to the ECHR for inspiration when determining the scope of human rights

protection under EU law. The Charter of Fundamental Rights also reflects (though is not limited to) the range

of rights in the ECHR. Accordingly, EU law, even though the EU is not yet actually a signatory to the ECHR,

is largely consistent with the ECHR. However, if an individual wishes to make a complaint about the EU and

its failure to guarantee human rights, they are not entitled to take the EU, as such, before the ECtHR. Instead

they must either: make a complaint before the national courts, which can then refer the case to the ECJ through

the preliminary reference procedure; or complain about the EU indirectly before the ECtHR while bringing an

action against a Member State.

The Lisbon Treaty contains a provision mandating the EU to join the ECHR as a party in its own right and

Protocol 14 to the ECHR amends it to allow this to happen. It is not yet clear what effect this will take in

practice, and in particular what the future relationship between the ECJ and the ECtHR will be, as the

negotiations for EU accession may take several years. However, it will at the very least allow individuals to

bring the EU directly before the ECtHR for failure to observe the ECHR.

Key points

• Protection against discrimination in Europe can be found within both EU law and the ECHR. While to a

great degree these two systems are complementary and mutually reinforcing, some differences do exist which

practitioners may need to be aware of.

• The ECHR protects all individuals within the jurisdiction of its 47 States parties, whereas the EU non-

discrimination directives only offer protection to citizens of the 27 EU Member States.

• Under Article 14 of the ECHR, discrimination is prohibited only in relation to the exercise of another right

guaranteed by the treaty. Under Protocol 12, the prohibition of discrimination becomes free standing. Under

EU non-discrimination law, the prohibition on discrimination is free standing, but limited to particular

contexts, such as employment.

• The EU institutions are legally bound to observe the Charter of Fundamental Rights of the European Union,

including its provisions on non-discrimination. EU Member States must also observe the Charter when they

are implementing EU law.

• The European Union will join the UNCRPD and the ECHR. This will place the EU under the supervision of

external monitoring bodies, and individuals will be able to complain of violations of the ECHR by the EU

directly before the ECtHR.

130

1577 UNTS 3. In addition, some Member States are also party to the UN Convention on the Rights of Persons with Disabilities (UN Doc. A/61/611, 13 December 2006) and the International Convention for the Protection of All Persons from Enforced Disappearance (UN Doc. A/61/488, 20 December 2006); however, none are yet party to the International Convention on the Protection of the Rights of All Migrant Workers and Members of their Families (UN Doc. A/RES/45/158, 1 July 2003). 131

UN Doc. A/61/611, 13 December 2006.

II.2.7.4 Discrimination categories and defences

The aim of non-discrimination law is to allow all individuals an equal and fair prospect to access opportunities

available in a society. We make choices on a daily basis over issues such as with whom we socialize, where

we shop and where we work. We prefer certain things and certain people over others. While expressing our

subjective preferences is commonplace and normal, at times we may exercise functions that place us in a

position of authority or allow us to take decisions that may have a direct impact on others’ lives. We may be

civil servants, shopkeepers, employers, landlords or doctors who decide over how public powers are used, or

how private goods and services are offered. In these non-personal contexts, nondiscrimination law intervenes

in the choices we make in two ways: Firstly, it stipulates that those individuals who are in similar situations

should receive similar treatment and not be treated less favourably simply because of a particular ‘protected’

characteristic that they possess. This is known as ‘direct’ discrimination. Direct discrimination, if framed

under the ECHR, is subject to a general objective justification defence; however, under EU law defences

against direct discrimination are somewhat limited.

Secondly, non-discrimination law stipulates that those individuals who are in different situations should

receive different treatment to the extent that this is needed to allow them to enjoy particular opportunities on

the same basis as others.

Thus, those same ‘protected grounds’ should be taken into account when carrying out particular practices or

creating particular rules. This is known as ‘indirect’ discrimination. All forms of indirect discrimination are

subject to a defence based on objective justification irrespective of whether the claim is based on the ECHR or

EU law.

This chapter discusses in greater depth the meaning of direct and indirect discrimination, some of their specific

manifestations, such as harassment or instruction to discriminate, and how they operate in practice through

case-law. It will then examine how defences to discrimination operate.

Non-discrimination law prohibits scenarios where persons or groups of people in an identical situation are

treated differently, and where persons or groups of people in different situations are treated identically132

.

II.2.8 Europe for the Millennium Development Goals (MDGs)

II.2.8.1 Foreword

In 2007 Ban Ki-moon, Secretary-General of United Nations, during his speech about the Millennium

Development Goals, said:

“Since their adoption by all United Nations Member States in 2000, the Millennium Declaration and the

Millennium Development Goals have become a universal framework for development and a means for

developing countries and their development partners to work together in pursuit of a shared future for all.

We are now at the midpoint between the adoption of the MDGs and the 2015 target date. So far, our collective

record is mixed. The results presented in this report suggest that there have been some gains, and that success

is still possible in most parts of the world. But they also point to how much remains to be done. There is a

clear need for political leaders to take urgent and concerted action, or many millions of people will not realize

the basic promises of the MDGs in their lives.

The MDGs are still achievable if we act now. This will require inclusive sound governance, increased public

investment economic growth, enhanced productive capacity, and the creation of decent work. Success in some

countries demonstrates that rapid and large-scale progress towards the MDGs is feasible if we combine strong

government leadership, good policies and practical strategies for scaling up public investments in vital areas

with adequate financial and technical support from the international community.

To achieve the Goals, nationally-owned development strategies and budgets must be aligned with them.

This must be backed up by adequate financing within the global partnership for development and its

framework for mutual accountability.

The world wants no new promises. It is imperative that all stakeholders meet, in their entirety, the

commitments already made in the Millennium Declaration, the 2002 Monterrey Conference on Financing for

Development, and the 2005 World Summit. In particular, the lack of any significant increase in official

development assistance since 2004 makes it impossible, even for well-governed countries, to meet the MDGs.

132

See, for example, ECtHR, Hoogendijk v. the Netherlands (dec.) (No. 58641/00), 6 January 2005.

As this report makes clear, adequate resources need to be made available to countries in a predictable way for

them to be able to effectively plan the scaling up of their investments.

Yet, these promises remain to be fulfilled.

I commend this report as a key resource to help show what can be achieved and how much still needs to be

done. Reliable and timely information is key to formulating the necessary policies and strategies to ensure

progress, monitor development and make the MDGs achievable”.

II.2.8.2 An overview

An overview and the progress at the MDG mid-point was made by José Antonio Ocampo, Under-Secretary-

General for Economic and Social Affairs:

“The Millennium Declaration set 2015 as the target date for achieving most of the Goals. As we approach the

midway point of this 15-year period, data are now becoming available that provide an indication of progress

during the first third of this 15-year period.

This report presents the most comprehensive global assessment of progress to date, based on a set of data

prepared by a large number of international organizations within and outside the United Nations system.

The results are, predictably, uneven. The years since 2000, when world leaders endorsed the Millennium

Declaration, have seen some visible and widespread gains. Encouragingly, the report suggests that some

progress is being made even in those regions where the challenges are greatest. These accomplishments testify

to the unprecedented degree of commitment by developing countries and their development partners to the

Millennium Declaration and to some success in building the global partnership embodied in the Declaration.

The results achieved in the more successful cases demonstrate that success is possible in most countries, but

that the MDGs will be attained only if concerted additional action is taken immediately and sustained until

2015. All stakeholders need to fulfil, in their entirety, the commitments they made in the Millennium

Declaration and subsequent pronouncements.

The following are some measures of the progress that has been achieved:

• The proportion of people living in extreme poverty fell from nearly a third to less than one fifth between

1990 and 2004. If the trend is sustained, the MDG poverty reduction target will be met for the world as a

whole and for most regions.

• The number of extremely poor people in sub-Saharan Africa has levelled off, and the poverty rate has

declined by nearly six percentage points since 2000. Nevertheless, the region is not on track to reach the Goal

of reducing poverty by half by 2015.

• Progress has been made in getting more children into school in the developing world. Enrolment in primary

education grew from 80 per cent in 1991 to 88 per cent in 2005. Most of this progress has taken place since

1999.

• Women’s political participation has been growing, albeit slowly. Even in countries where previously only

men were allowed to stand for political election, women now have a seat in parliament.

• Child mortality has declined globally, and it is becoming clear that the right life-saving interventions are

proving effective in reducing the number of deaths due to the main child killers – such as measles.

• Key interventions to control malaria have been expanded.

• The tuberculosis epidemic, finally, appears on the verge of decline, although progress is not fast enough to

halve prevalence and death rates by 2015.

By pointing to what has been achieved, these results also highlight how much remains to be done and how

much more could be accomplished if all concerned live up fully to the commitments they have already made.

Currently, only one of the eight regional groups cited in this report is on track to achieve all the Millennium

Development Goals. In contrast, the projected shortfalls are most severe in sub-Saharan Africa. Even regions

that have made substantial progress, including parts of Asia, face challenges in areas such as health and

environmental sustainability. More generally, the lack of employment opportunities for young people, gender

inequalities, rapid and unplanned urbanization, deforestation, increasing water scarcity, and high HIV

prevalence are pervasive obstacles.

Moreover, insecurity and instability in conflict and postconflict countries make long-term development efforts

extremely difficult. In turn, a failure to achieve the MDGs can further heighten the risk of instability and

conflict. Yet in spite of a technical consensus that development and security are mutually dependent,

international efforts all too often treat them as independent from one another.

The following are some of the key challenges that have to be addressed:

• Over half a million women still die each year from treatable and preventable complications of pregnancy and

childbirth. The odds that a woman will die from these causes in sub-Saharan Africa are 1 in 16 over the course

of her lifetime, compared to 1 in 3,800 in the developed world.

• If current trends continue, the target of halving the proportion of underweight children will be missed by 30

million children, largely because of slow progress in Southern Asia and sub-Saharan Africa.

• The number of people dying from AIDS worldwide increased to 2.9 million in 2006, and prevention

measures are failing to keep pace with the growth of the epidemic. In 2005, more than 15 million children had

lost one or both parents to AIDS.

• Half the population of the developing world lack basic sanitation. In order to meet the MDG target, an

additional 1.6 billion people will need access to improved sanitation over the period 2005-2015. If trends since

1990 continue, the world is likely to miss the target by almost 600 million people.

• To some extent, these situations reflect the fact that the benefits of economic growth in the developing world

have been unequally shared. Widening income inequality is of particular concern in Eastern Asia, where the

share of consumption of the poorest people declined dramatically between 1990 and 2004.

• Most economies have failed to provide employment opportunities to their youth, with young people more

than three times as likely as adults to be unemployed.

• Warming of the climate is now unequivocal. Emissions of carbon dioxide, the primary contributor to global

climate change, rose from 23 billion metric tons in 1990 to 29 billion metric tons in 2004. Climate change is

projected to have serious economic and social impacts, which will impede progress towards the MDGs.

This report also points to disparities within countries, where particular groups of the population – often those

living in rural areas, children of mothers with no formal education and the poorest households – are not

making enough progress to meet the targets, even where the rest of the population is. This is particularly

evident in access to health services and education. In order to achieve the MDGs, countries will need to

mobilize additional resources and target public investments that benefit the poor.

Rapid and large-scale progress is feasible Several developing countries are demonstrating that rapid and large-

scale progress towards the MDGs is possible when strong government leadership and policies and strategies

that effectively target the needs of the poor are combined with adequate financial and technical support from

the international community.

In particular, impressive results have been achieved in sub-Saharan Africa in areas such as raising agricultural

productivity (in Malawi, for example), boosting primary school enrolment (as in Ghana, Kenya, Uganda and

the United Republic of Tanzania), controlling malaria (as in Niger, Togo, Zambia, Zanzibar), widening access

to basic rural health services (Zambia), reforesting areas on a large scale (Niger), and increasing access to

water and sanitation (Senegal and Uganda). These practical successes now need to be replicated and scaled-up.

With support from the United Nations, many developing countries – particularly in Africa – have advanced in

preparing strategies to achieve the MDGs. As of mid-2007, 41 countries in sub-Saharan Africa had started the

process of preparing national development strategies aligned with the MDGs and other development goals

agreed upon through the United Nations. During this mid-point year, the international community needs to

support the preparation of these strategies and to accelerate implementation of the MDGs.

In general, strategies should adopt a wide-ranging approach that seeks to achieve pro-poor economic growth,

including through the creation of a large number of additional opportunities for decent work. This, in turn, will

require comprehensive programmes for human development, particularly in education and health, as well as

building productive capacity and improved physical infrastructure. In each case, an effort should be made to

quantify the resources required to implement these programmes. Implementation should be based on a

medium-term approach to public expenditure. A sound national statistical system and enhanced public

accountability are necessary to support all these efforts.

The MDGs should also be systematically integrated into post-conflict recovery strategies by coordinating

security and humanitarian operations with long-term development efforts.

The MDGs provide outcome objectives that countries can use as benchmarks for the transition from relief and

recovery to long-term development.

Success in achieving the MDGs in the poorest and most disadvantaged countries cannot be achieved by these

countries alone. Developed countries need to deliver fully on longstanding commitments to achieve the

official development assistance (ODA) target of 0.7 per cent of gross national income (GNI) by 2015. It

requires, in particular, the Group of 8 industrialized nations to live up to their 2005 pledge to double aid to

Africa by 2010 and European Union Member States to allocate 0.7 per cent of GNI to ODA by 2015. In spite

of these commitments, ODA declined between 2005 and 2006 and is expected to continue to fall slightly in

2007 as debt relief declines.

Aid has to be improved by ensuring that assistance is aligned with the policies that recipient countries have

adopted, and that flows to individual countries are continuous, predictable and assured and are not tied to

purchases in the donor country. To this end, donors should reduce the present unpredictability of aid by

providing multi-year schedules of aid flows to each recipient country. One of the uses of the additional

resources should be to multiply, within and across countries, the number of “quick impact” initiatives that

have proven their efficacy in the past few years.

As a further element of their development partnership, and as agreed to in Doha in 2001, all governments

should redouble their efforts to reach a successful and equitable conclusion to the present trade negotiations –

an outcome that ensures that the international trading system and global trading arrangements become more

conducive to development in all developing countries. Addressing the challenge of climate change has to be a

new but integral element of each country’s development strategy. More importantly, however, it should

become an enhanced part of the international development agenda: all development partners should

collaborate intensively in devising a shared global strategy to address this global problem”.

II.2.8.3 Toward Domains of Core Competency for Building Global Capacity in Health Promotion

II.2.8.3.1 The Challenge: Addressing Urgent Health Needs

Health is necessary to achieve the global agenda for social progress. The Ottawa Charter (World Health

Organization, 1986) identified peace, shelter, education, food, income, a stable eco-system, sustainable

resources, social justice and equity as the fundamental conditions and resources that underlie health. However,

alarmingly, there is mounting evidence that the gap separating the rich and the poor is widening between and

within countries all around the globe. Clearly, the social and economic determinants of health—and the social

circumstances that must be created to promote health—have not been adequately addressed (Commission on

Social Determinants of Health, 2008).

In addition, there is deepening concern about the global burden of diseases and health-related problems that

continue to plague the world’s population, notably chronic diseases, infectious diseases, environmental threats,

and injuries. Such health problems result, in part, from the failure to develop and enact policies that support

and maintain the societal infrastructure that promotes health. Health promotion is a vital strategy by which

improvement in global health can be realized because of its emphasis on health literacy and advocacy for

policies that support creating conditions that foster health. Health promotion and health education are thus

uniquely poised to provide the vision and leadership to have a significant impact on global population health.

The Bangkok Charter for Health Promotion in a Globalized World (World Health Organization, 2005) has

affirmed that policies and partnerships that are organized to empower communities and to improve health and

health equity should be at the center of global and national development efforts. Moreover, building the

capacity to achieve health improvements called for in the Ottawa Charter, the Bangkok Charter and the United

Nations Millennium Development Goals (UN Millennium Development Goals Report, 2007), as well as by the

International Union for Health Promotion and Education, will require the global expansion of a competent

health promotion and health education workforce (International Union for Health Promotion and Education &

Canadian Consortium for Health Promotion Research, 2007).

To develop and strengthen workforce capacity to improve global health in the 21st century, health promotion

and health education must identify and promulgate the core competencies, standards, and quality assurance

systems for use in workforce training of all kinds.

II.2.8.3.2 The Galway Consensus Conference Statement

The purpose of the Galway Consensus Conference was to promote dialogue and an exchange of understanding

among international partners regarding domains of core competency, standards and quality assurance

mechanisms in the professional preparation and practice of health promotion and health education specialists.

The Consensus Conference was designed to provide a forum for discussion to identify the credentialing

practices necessary to build capacity for health promotion, as well as systems that can assure quality in

practice, education, and training. Developing a shared vision for workforce capacity-building and standards is

a critical foundation for subsequent strategic plans of action, which can be developed by many stakeholders

and partners (Allegrante, Barry, Auld, Lamarre, & Taub, 2009; or Barry, Allegrante, Lamarre, Auld, & Taub,

2009, for additional details of the background and process of the Galway Consensus Conference).

II.2.8.3.2.1Intended Audiences

This Consensus Statement is intended for several audiences: practitioners, researchers and academics in health

promotion and health education; policy and decisionmakers in government and non-governmental entities;

employers; international organizations and other institutional authorities who have a stake and a responsibility

in promoting the health of the public. In addition, the core values and principles, domains of core competency

and the statement regarding standards and quality assurance mechanisms, as well as the recommendations and

key actions that are contained in this Consensus Statement are intended to be relevant for all countries.

II.2.8.3.2.2 Health Promotion and Health Education

The terms health promotion and health education as used in this Consensus Statement have a high degree of

shared meaning, even if they are not synonymous. Both terms refer to efforts that enable and support people to

exert control over the determinants of health and to create environments that support health. In different parts

of the world, one or the other term may be preferred, but this should not distract those who are engaged in

health promotion and health education from recognizing and appreciating their shared values, strategies and

ambitions.

Health promotion and health education orchestrate a wide range of complementary actions at the individual,

community and societal levels. This Consensus Statement underscores that while health promotion is now

established as a recognized field in many parts of the world, it is only emerging in others where the political

will and resources to support capacity for health promotion are scarce and thus undermine its development

(International Union for Health Promotion and Education & Canadian Consortium for Health Promotion

Research, 2007). Health promotion works at many levels, is unique in the ways it can contribute to society and

is characterized by an essential set of competencies and skills that involve integrating theories and practices

from multiple disciplines and professions.

II.2.8.3.2.3 Core Values and Principles

Health promotion is guided by a set of core values and principles. These values and principles form the habits

of mind that provide a common basis for the practice of health promotion. These include: a social-ecologic

model of health that takes into account the cultural, economic and social determinants of health; a commitment

to equity, civil society and social justice; a respect for cultural diversity and sensitivity; a dedication to

sustainable development; a participatory approach to engaging the population in identifying needs, setting

priorities, and planning, implementing, and evaluating the practical and feasible health promotion solutions to

address needs.

II.2.8.3.2.4 Domains of Core Competency

Numerous efforts have been undertaken to identify the key competencies in health promotion and health

education. These efforts have resulted in the recognition of core competencies now in use in many countries.

This Consensus Statement, however, is not concerned with specific competencies but, rather, distinctly

focused on the broader domains of core competency, which are critical to achieving improvements in health.

In addition, their application is performed at varying levels of implementation. Finally, what is unique about

health promotion is the combined application of the domains of core competency and their integration with

knowledge from other disciplines in health promotion practice.

The competencies required to engage in health promotion practice fall into eight domains:

1. Catalyzing change – Enabling change and empowering individuals and communities to improve their

health.

2. Leadership – Providing strategic direction and opportunities for participation in developing healthy public

policy, mobilizing and managing resources for health promotion, and building capacity.

3. Assessment – Conducting assessment of needs and assets in communities and systems that leads to the

identification and analysis of the behavioral, cultural, social, environmental and organizational determinants

that promote or compromise health.

4. Planning – Developing measurable goals and objectives in response to assessment of needs and assets, and

identifying strategies that are based on knowledge derived from theory, evidence, and practice.

5. Implementation – Carrying out effective and efficient, culturally-sensitive and ethical strategies to ensure

the greatest possible improvements in health, including management of human and material resources.

6. Evaluation – Determining the reach, effectiveness, and impact of health promotion programs and policies.

This includes utilizing appropriate evaluation and research methods to support program improvements,

sustainability, and dissemination.

7. Advocacy – Advocating with and on behalf of individuals and communities to improve their health and

well-being and building their capacity for undertaking actions that can both improve health and strengthen

community assets.

8. Partnerships – Working collaboratively across disciplines, sectors, and partners to enhance the impact and

sustainability of health promotion programs and policies.

II.2.8.3.2.5 Standards and Quality Assurance

Acquiring proficiency in the domains of core competency will require setting standards and developing quality

assurance mechanisms that are practice-based and periodically updated. Thus, standards and quality assurance

mechanisms—preferably utilizing an independent administrative structure—need to be in place at training

institutions wherever in the world they are located. Every relevant training authority should strive to develop

quality assurance mechanisms appropriate to the prevailing political, economic and cultural circumstances.

Where a train-the-trainer model is employed at the level of practice, the trainers should have formal

preparation in health promotion and demonstrate proficiency in the domains of core competency.

II.2.8.3.2.6 Recommendations and Key Actions

The Galway Consensus Statement also identifies several recommendations and key actions that will be

necessary to strengthen and secure a global commitment to improving health promotion practice by further

advancing the field and providing direction for enhancing the academic preparation of health promotion

practitioners. These include:

1. Stimulating dialogue about the domains of core competency, standards and quality assurance mechanisms

by engaging key stakeholders at regional and sub-regional meetings and through other consultative processes.

2. Moving towards global consensus regarding competencies, standards and quality assurance systems.

3. Developing a comprehensive plan for communicating the results of the Galway Consensus Statement to

diverse audiences.

II.2.8.3.2.7 Moving forward

This Consensus Statement is intended as a stimulus to dialogue and a call to action involving the global health

promotion and health education community. Broad agreement on professional standards can only emerge

through energetic exchange of ideas on the issues, and standards must evolve continuously as the knowledge

base expands and as we learn from practice. The Galway Consensus Conference participants urge all relevant

institutions and all interested individuals to use meetings, conferences, journals and Internet resources to

continue a lively dialogue on these important issues (The Galway Consensus Conference Statement, 2009).

II.2.8.3.3 International Union for Health Promotion and Education (IUHPE)

The Global Programme for Health Promotion Effectiveness provides a blueprint for how the IUHPE can

effectively participate in, and lead, global networks for health. Health promotion research is well organized

and productive in most of the Northern hemisphere, but important wells of health promotion knowledge in the

Southern hemisphere are not widely-enough disseminated.

The IUHPE needs to help liberate knowledge producers everywhere from unnecessary structures, and find

innovative ways to illuminate knowledge for all to see. The effectiveness of a range of technologies such as

settings-based health promotion has been developed and proven. However, the vast majority of communities

are untouched and the IUHPE, in order to be a leader in finding ways to better disseminate effective health

promotion practice, became a vigorous and effective advocate for health promotion training, practice and

research. Now we need to expand our advocacy for equity in health, building on our effective work on social

clauses in trade agreements and on tobacco control.

II.2.8.3.3.1 IUHPE initiatives for quality, effectiveness and equity

Debate is encouraged about what counts as evidence of health promotion effectiveness. Inappropriate

standards are challenged and alternative standards are developed. In Europe, for example, six conferences

explicitly on the theme of health promotion quality and effectiveness have been held since the first one in

Rotterdam in 1989. Abundant research makes a convincing case for the effectiveness of health promotion.

However, the field of health promotion has not communicated well enough to completely allay decision-

makers’ doubts about the wisdom of investing in health promotion.

Therefore, the IUHPE puts as one of its central tasks the development of clearer and more compelling ways to

summarize and to disseminate evidence about health promotion’s effectiveness. In pursuit of this, the IUHPE

draws on the multiple skills and competencies of our global network.

II.2.8.3.3.2 Fundamental challenges

One of the most fundamental challenges that the IUHPE faces today is that the health promotion knowledge

base is very unevenly developed across the globe.

Today’s IUHPE global effectiveness initiative used the European experience as a launching pad, but in each

region of the world, the work has taken on flavors appropriate to the diverse contexts of the regions. However,

the programme as a whole does share three hallmarks:

• The GPHPE illuminates evidence of effectiveness–we emphasize what is known, rather than what is not

known;

• Inappropriate standards for judging the quality of evidence have been set aside–rigid attitudes placing the

randomized controlled trial at the centre have no place in our framework;

•Wide-scale dissemination efforts breach geographic, linguistic, cultural and professional boundaries.

II.2.8.3.3.3 Health promotion’s proven technologies

The effectiveness of some health promotion practices is so well documented, that they can be recommended

with confidence.

Here, such practices are referred to as technologies. In its simplest sense, technology is the application of

knowledge to solve problems, and using the term to describe proveneffective health promotion methods has

advantages. Many who are outside of health promotion are puzzled by health promotion’s ‘insider’

terminology, and that makes it harder to communicate with decision-makers than it needs to be– but everyone

is comforted knowing that cutting-edge technology is being applied to their problems!

So, what is meant by the term health promotion ‘technology’? One example is that of health impact

assessment (HIA), by which policies and programmes, at all levels from national to local, can be

systematically and rigorously evaluated for their positive, neutral and negative impacts on health. HIA can be

used to document the need for healthy policy, both public and private. Another example is that of community-

based public health action, to strengthen communities’ ability to take effective action at the local level,

including methods to map and mobilize local resources, activate citizens, governments and the commercial

sectors, manage positive change and transform homes, schools, hospitals and work places into health

promoting environments.

Perhaps the best developed amongst health promotion’s technologies is settingsbased action, in places such as

schools, workplaces and hospitals. When this technology is applied with high quality, it works. Yet the vast

majority of settings have not had the advantage of systematic application of this technology and a challenge

for health promotion is its more equitable use in communities where it is needed most.

Settings are ubiquitous in our lives, as they are the physical and social environments within which we carry

out our daily activities, and settings themselves can influence our health directly and indirectly. Individual

settings (such as a single school or workplace or church or sporting club) are microcosms of society–

structures within which tasks are carried out, places within which individuals and groups negotiate social

relationships and carry out the actions mandated by society to achieve specific goals. The technology of health

promotion in settings includes participative processes that help organizations decide on and implement their

policies, use research-derived evidence to inform policy development and undertake routine measurement of

progress and outcomes.

The problem of exclusion Health promotion in settings has been developed in scattered, relatively small-scale

local projects and programmes. Exemplars can be found today all around the world, but the vast majority of

settings are untouched.

The goal now is to spread the technology to all schools and all workplaces, but no matter the degree of success

in reaching this goal, many people will be excluded from health promotion because there are no schools and

workplaces for them. Children who have no school to attend, and adults who have no workplace, can hardly

benefit from even the most successful settings-based health promotion programme. Human development

initiatives that create schools and create jobs are fundamental. The best approach is one in which these new

creations are established from the start as health promoting environments, using the lessons learned from

converting existing settings into health promoting places.

Changing systems and settings on the scale and in the ways required to achieve equity requires effective action

at all political levels. Success in influencing the goals, policies, practices of the education, health and

employment sectors requires the engagement of practitioners and researchers who understand — and are

willing to engage in — the politics of building and implementing public policy for health in all policy arenas.

This last point is vital: health promotion cannot succeed in its aim to achieve equity in health based on the

efforts of professional health promoters alone. We need to train professionals in education, welfare,

economics, public administration, to name but a few fields, so that health promotion becomes partand-parcel

of their professional lore. This would not require particularly dramatic changes in curricula, and the feasibility

of such change is evident: today, every business management school in the world includes courses on

corporate social responsibility, a result of decades of pressure to produce business leaders who take social

responsibility seriously. Advocacy to require some training in health promotion in all the professions is

required, but no organized efforts are yet underway, signaling an unmet need that should be prioritized. Since

all professions have requirements of one sort or another for continuing education, the development of model

curricula for short courses suitable for continuing education could be a reasonable way to launch efforts.

II.2.8.3.3.4 Advocacy

The IUHPE has since 1998 been actively involved in advocacy for the inclusion of social clauses in trade

agreements. The work is done by the IUHPE Working Group on Social Clauses and Advocacy.

At the core of all IUHPE advocacy efforts is our aim to contribute to equity in health within and among

nations. We hold ourselves accountable to contribute to this aim, and a high priority in the coming period will

be to document how and to what degree we are succeeding.

The quest for effective health promotion should not be limited to interventions, projects and programmes. The

organizations for health promotion, governmental and nongovernmental alike, should strive for effectiveness

and efficiency in everything they do.

The resources devoted to health promotion are extraordinarily meager, considering the ambition to contribute

to equity in health at local, national and global levels, so making resources count to the maximum is not just a

matter of practicality, but also a matter of ethics. The IUHPE response has to be twofold: to do more of

everything we do well and to improve that which can be improved.

II.2.8.4 Values, principles and objectives of health policy in Europe133

II.2.8.4 Introduction

A new focus and debate on ethics and values is occurring in the health field. After a decade of economic

debate, professionals are beginning to think more critically about the values that drive health action. This

debate is as relevant to the changing European context as it is to the resolution of global challenges. Do

“European values on health” exist, and if so, how do they affect health policy-making – nationally, regionally

and globally? Are they reflected in the European Constitution or in other documents? Are they clearly stated

or they constitute a subtext? Does consensus still need to be established, particularly after the recent expansion

of the Union and its growing global role?

133

Kickbusch I.: The European Challenge: balancing solidarities in health - The need for common values, principles and objectives for health policy in a changing Europe. 7th European Health Forum Gastein 2004, Parallel Forum A1 - Values, principles and objectives of health policy in Europe, 6th and 7th October 2004.

Values take their most concrete expression in rights. For Jurgen Habermas, the new European citizenship

could be rooted in notion of “constitutional patriotism” in which diverse cultural identity and practices coexist

but do not define citizenship. According to Habermas, the nation-state gains its identity from “the praxis of

citizens who actively exercise their civil rights134

.” It follows then that European citizenship should be rooted

in its constitutional principles rather than its cultural orientations. Such principles guarantee citizen’s rights

and freedoms in the multicultural European society. Constitutional patriotism would replace the ethnic

nationalism that is still a key factor in many European nation states and promote a Europe that is “united in its

diversity” (which is the motto of the Union as expressed in Article IV-1 of the Constitution).

Historically health has developed into a right of citizenship in European nation states as represented in the

universality of access and solidarity in financing (despite very different approaches to organizing and

financing health systems). The health discourse in Europe took its starting point with the enlightenment and

has always been at the intersection of values assigned to two spheres: the public and the private, the personal

and the political, the public good and individual rights. This historical dimension with its roots in a view of

health as a means of empowerment for individual citizens and a responsibility of the state for the health of the

public is critical to any discussion of European values in health and health policy. The right to health and

medical care was and is an integral part of the claims to rights and citizenship of many of the social and

political movements of the last 150 years. Women’s health rights remain to this day the most explicit example

of this link.

“In modernity – so Foucault - the sharpest discourse on difference always takes its starting point from the

body.” Major health differences exist within and between countries in the new expanded European Union and

addressing them will be a challenge that goes beyond individual member states. Just as health played a major

role in establishing citizenship, identity and allegiance at the level of the nation state, it could play a major role

in the establishment of citizenship, identity and allegiance to the modern European Union (EU). Health is an

area that very concretely affects people’s wellbeing and feelings of security. Indeed a strong commitment of

the European Union to health could be seen as a concrete expression of the potential that lies in the EU’s

commitment to wellbeing and social justice. But at present, health remains an area that member states are

highly ambiguous about – with the area of health care jealously guarded by the member states of the Union

and the areas of public health kept weak within the Union responsibilities.

Also, there is not yet a strong citizen’s movement that advocates for a new approach to sharing access to

health rights throughout the Union.

This paper examines the values debate in the realm of health and its applications to policy making in Europe.

It discusses the issue of health as a value in itself, as well as other values like equity, dignity, solidarity and

diversity that are relevant to the European context. The paper continues by analyzing the values common to

the public health and health policy arenas as well as some of the applications for governance, including health

targeting and evidence. It discusses participation and accountability as values, followed by questions for future

debate and dialogue on this vast topic. Its key intention is to help initiate a systematic debate on European

values in health. This is crucial not just for Europe itself but also for its role in relation to global developments.

II.2.8.4.1 The Values Debate in Health: Key Dimensions

Values in health are ubiquitous. They frame European debates and shape evidence that informs health policy

and goals. A discussion on the underlying values in health within a new context and framework is timely, as

the success of public health in Europe has changed the very nature of modern societies. They have become

health societies. Health has expanded into ever-wider realms of life and policy, and has become increasingly

do-able. Health societies are defined by five major characteristics135

:

• a high life expectancy and ageing populations,

• an expansive health and medical care system,

• a rapidly growing private health market,

• health as a dominant theme in social and political discourse and

134

Habermas, J. “Citizenship and National Identity: Some Reflections on the Future of Europe” Praxis International, 12 (1), 1992, p. 3. Habermas, J. “Citizenship and National Identity: Some Reflections on the Future of Europe” Praxis International, 12 (1), 1992, p. 3. 135

Kickbusch, I. “The End of Public Health As We Know It: Constructing Global Health in the 21st Century” Hugh R. Leavell lecture, World Federation of Public Health Associations’ 10th International Congress on Public Health in Brighton, U.K, April 2004.

• health as a major personal goal in life.

Each of these five characteristics (and perhaps even more their synergies) presents a challenge to public health

and changes its nature and the extent of its remit. As in the 19th and 20th centuries, the resolution that is

adopted will define the progress of 21st century society. How will we treat the old? How will we pay for

health? Who has a right to care? To what extent will we enhance our biological capabilities? How do we

approach risk solidarity, generational solidarity or global solidarity? Or as Ulrich Beck would frame it “How

do we want to live?” The answers to this debate will only be found in a European-wide debate involving a

wide range of stakeholders and conducted over at least a decade with the aim of developing a new public

health ethic within a European democratic public space.

II.2.8.4.1.1 Health as a Value in Itself

II.2.8.4.1.1.1Health as an intrinsic value: an end not only a means

Health itself is often identified as a value. The World Health Organization’s Task Force on Health in

Development had as a key aim to achieve global recognition of the value of health in itself136

. Amartya Sen,

the 1998 Nobel Laureate in economics, also advocated this position by emphasizing health, not only a means,

but also as an end of political and societal activity, thereby reinforcing the intrinsic value of health. Various

types of capabilities (such as the capability to avoid preventable morbidity and premature mortality, or to be

literate and numerate) are considered both as ends in themselves, but they are also key to the achievement of

other intrinsically valued ends, such as political freedoms and capability to participate in trade and production.

Health and its social determinants, therefore, have both constitutive and instrumental value137

- they contribute

to capability of a person to live more freely, but they also complement one another138

.

In many countries, the commitment to a certain system of improving health is seen as a value in itself.

The Canadian report “Medicare: A Value Worth Keeping” asserts, “Canada’s health care system is one of this

country’s foremost social accomplishments, a core value that helps define our national identity139

.”

Sorrell claims, “NHS functions in the UK not only as a source of medical treatment but as a prime medium of

national solidarity and national identity140

.” At this level, health and the health system as values are “part of

the cultural fabric that allows people to engage each other with language, develop their institutions, maintain

the social order necessary for survival and prosperity, play social roles, and assume personal identities141

.”

II.2.8.4.1.1.2 Health as a public good

The discussion on health as a global public good has also given new impetus to the discussion of health as a

public good at other levels of governance. Public goods are non-excludable and are available in the public

domain for all to enjoy142

. The public good concept implies that health cannot be reduced to a commodity and

needs political will and a “public push”. It must be supported by a governance infrastructure with public

financing mechanisms. In this sense, health is also a public value. Public values are “concerned with State

intervention to promote morally desirable ends143

.” Public values extend beyond both individual preferences

and the private realm and, in terms of health, increasingly expand from regarding only medical care provision

into including the realm of social determinants of health. A renaissance of Geoffrey Rose’s public health

dictum is taking place at national and international levels.

136

“The WHO Task Force Calls for Innovative Strategies in Health Development”, World Health Organization press release, 17 December 1994. WHO Press Release WHO/97. 137

Ruger, J. P. “Health and social justice” The Lancet, 364, 2004. 138

Sen, A. Development as Freedom. Knopf: New York, 1999. Sen, A. Development as Freedom. Knopf: New York, 1999. 139

Medicare: A Value Worth Keeping. Health Action Lobby, 1992, p.1. 140

Sorrell, T. “Health Care Provision and Public Morality: An Ethics Perspective” in Oliver, A. (ed.) Equity in Health and Healthcare: Views from Ethics, Economics and Political Science, The Nuffield Trust, 2003, p. 11. 141

Giacomini, M., Hurley, J., Gold, I., Smith, P. & Abelson, J. “‘Values’ in Canadian Health Policy Analysis: What Are We Talking About?” Canadian Health Services Research Foundation, 2001, p. 13. 142

Kaul, I. & Faust, M. “Global public goods and health: taking the agenda forward” Bulletin of the World Health Organization, 79, 2001, p. 2. 143

Staley, K. “Voices, Values and Health: Involving the public in moral decisions” King’s Fund, 2001, p. 2.

“The primary determinants of disease are mainly economic and social; therefore its remedies must also be

economic and social144

.”

This concept forms the foundation of a new and broader public health field and expands it into a wide area of

economic and social rights. The new debate on basing health policies on a health determinants approach also

reflects this. But the concept of health as a public good and a public value is clearly under threat both from

economic developments, such as the growth of the private health care market, but also from social trends such

as increasing individualization. In consequence, European societies must debate the values they assign to

health: as a right of citizenship and empowerment, as a private product on the market or as an ultimate

value145

.

II.2.8.4.1.1.3 Health as a human right

As inequities in health become more and more obvious, the notion of health as a human right is gaining new

support. The right to health was codified as a human right in the Declaration of Human Rights in 1948 and is

stated in the constitution of the WHO. This raises the issue of the interface between European values and what

has been termed universal values. Nigel Dower points out, “If citizens are increasingly motivated by global

concerns then cosmopolitan goals enter domestic policy in that way and people can be effective global citizens

by being effective globally oriented citizens of their own states.” In particular, this would imply a common

notion of social justice and a system of international law where human rights, and in particular the right to

health, constitute a legal claim. The right to health approach moves health policy making into the arena of

international legal entitlements146

. It is relevant to the European Union in terms of access rights of third

country nationals within Europe as well as the global social contract that is implicit in the acceptance of health

as a human right.

II.2.8.4.1.2 Values in Health

II.2.8.4.1.2.1 Schools of thought

As already stated, values are inherent in health policies, programs and advocacy. Yet, these values in health

are seldom explicit. Clarity on the values and schools of thought underlying the formulation of health goals

and targets creates an understanding of the reasons for undertaking the initiative and also helps to determine

appropriate strategies and scope of the program. Alkire and Chen argue that a rightsbased approach (“fulfilling

our obligations so others are dignified”) or an equity approach (“achieving a fairer distribution of health

capabilities”) differs from one that is utilitarian (“maximizing aggregate subjective happiness”) or

humanitarian (“acting virtuously towards those in need”). Frequently, health advocates from various schools

of thought do not clearly elucidate their platform in an attempt to keep the discussions more superficial,

thereby appealing to a wider audience and generating more agreement147

.

II.2.8.4.1.2.2 Equity and social justice

From the very beginning of modernity, health has been at the center of debates on inequity, initially within the

context of the nation state and today as a key dimension of globalization. Health governance debates are

predominantly about social justice. The value of equity commonly arises in relation to access, utilization or

financing of health services and also in regards to health outcomes and health status. Two main forms of

health equity can be identified: vertical equity (preferential treatment for those with greater health needs) and

144

Rose, G. The Strategy of Preventive Medicine. Oxford University Press: Oxford, 1992, p. 129. 145

Kickbusch, I. “The Future Value of Health” in Perspectives in Health. The magazine of the Pan American Health Organization, 7 (2), 2002. 146

“Follow-up to previous sessions of the WHO Regional Committee for Europe” World Health Organization, 2004. EUR/RC54/12. 147

Alkire, S. & Chen, L. “Global health and moral values” The Lancet, 364, 2004.

horizontal equity (equal treatment for equivalent needs). Published literature focuses more heavily on

horizontal equity148

.

In the 1990s, new political and moral trends surfaced in the world that emphasized health and equity149

.

John Rawls’ work on the universal principles of social justice as set forward in “The Law of Peoples” takes

the issue of justice and fairness beyond states to peoples. Amartya Sen developed the “capabilities approach”,

partly based on Aristotle’s theories, which asserts that health has a special and moral importance in society. As

mentioned earlier, Sen values health intrinsically and maintains that different kinds of capabilities (such as the

ability to participate actively in life) are regarded as both ends in themselves and means for the achievement of

other ends (such as achieving good health). It is the expansion of these human capabilities that are the real

freedoms of life and the ultimate end of public policy150

. David Held in turn stresses the need to keep the focus

on “public goods” in relation to health, welfare and the environment including new global mechanisms to

finance them151

.

II.2.8.4.1.2.3 Dignity

Another value commonly evoked in the general health debate is dignity152

. Immanuel Kant defined dignity “an

absolute inner worth [of a man] whereby he exacts the respect of all other rational beings in the world, can

measure himself against each member of his species, and can esteem himself on a footing of equality with

them153

.” In 1997, the Council of Europe adopted the Convention for the Protection of Human Rights and

Dignity of the Human Being with regard to the Application of Biology and Medicine.

Article one states that Parties to the Convention “shall protect the dignity and identity of all human beings and

guarantee everyone without discrimination, respect for integrity and other rights and fundamental

freedom…154

” And Article two states, “The interests and welfare of human beings shall prevail over the sole

interest of society or science155

.” The value of dignity is becoming increasingly important in relation to the

ageing of European populations in terms of long-term care as well as death and dying. But it also plays a role

at the global level. According to Richard Horton, “A goal for those concerned with global health might

reasonably be to create setting that foster the conscious awareness and expression of dignity156

.” Given the

reports in AIDS patients in the developing world, mental health patients in many parts of Europe, older people

throughout health systems in the EU, the value of dignity will need to gain increasing importance.

II.2.8.4.1.3 Health as a European value

European values, in comparison to other parts of the world, are usually equated with commitments to welfare

state policies and frequently include reference to solidarity. Schwartz defines values as “principles, or criteria,

for selecting what is good (or better, or best) among objects, actions, ways of life, and social and political

institutions and structures. Values operate at the level of individuals, of institutions, and of entire societies157

.”

Within a short time span of about 50 years, universal medical care has become a trademark of European

welfare states. Martin McKee claims, “European societies have deeply held beliefs that the state has a

responsibility for the health of its population. The existence of these beliefs implies an acceptance of policies

148

Macinko, J.A. & Starfield, B. “Annotated Bibliography on Equity in Health, 1980-2001” International Journal for Equity in Health, 1(1), 2002. Macinko, J.A. & Starfield, B. “Annotated Bibliography on Equity in Health, 1980-2001” International Journal for Equity in Health, 1(1), 2002. 149

Berlinguer, G. “Bioethics, health, and inequality” The Lancet, 364, 2004. 150

Sen, A. Development as Freedom. Knopf, New York, 1999. 151

Archibugi, D. and Held, D. (eds.) Cosmopolitan Democracy: An Agenda for a New World Order. Polity Press: Cambridge, 1995. 152

Horton, R. “Rediscovering human dignity” The Lancet, 364, 2004. 153

Kant, I. The Metaphysics of Morals. Cambridge University Press, United Kingdom, 1996. 154

“Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine” Council of Europe, 1997, p. 2. 155

“Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine” Council of Europe, 1997, p. 2. 156

Horton, R. “Rediscovering human dignity” The Lancet, 364, 2004, p. 1084. 157

Schwartz, B. “On the creation and destruction of value” in Hechter, M., Nadel, L. & Michod, R.E. (eds.) The Origins of Values. Adline de Gruyter: New York, 1993, p. 155.

that seek to enhance population health158

.” Recent statements by Commissioner David Byrne support this

notion. In a Europe of the future, “Everybody has easy and prompt access to affordable, high quality health

care – whoever and wherever they are… people will have no trouble finding clear and reliable information on

how to be in good health and about diseases and treatment options159

.” Yet little is said about the mechanisms

of solidarity to achieve these goals. How will the three solidarities that need to be developed and clarified

interface? These three solidarities include: 1) the still existent but partly eroding national solidarity in health,

2) the European health solidarity through cooperation, redistribution of resources and granting of access to

citizens throughout the Union, and 3) global health solidarity.

Part of the debate about European values holds that the diversity of Europe itself constitutes a value to be

upheld. This diversity, which is based in the political, cultural, and religious inheritance of each country, is not

adequately understood. Given the diversity of values across Europe, a key issue for further exploration is how

beliefs in one country might influence the adoption of health policy developed elsewhere160

. Within the

European Union the system of “open coordination” and the increasing number of policy networks on health161

that have emerged throughout the European Union are contributing to the regular exchange of values.

The work of the European Regional Office of World Health Organization (WHO) has been the consistent

attempt to gain a common language and approach to key values driving European health policy. So to some

extent, the values reflected in the WHO European Health For All policy shed light on European values in

health – but on the whole they have been developed with nation state stakeholders only – not with the broad

involvement of European citizens. They include good governance, participation, solidarity, equity and human

rights162

.

The Health For All toolbox provides policy makers with the effective means with which to implement these

values. The tools for implementing Health For All values are divided into three categories: 1) Sustaining and

improving the ethical framework, 2) Basing policy on observation, knowledge and expertise, and 3) Improving

decision-making163

.

II.2.8.4.1.4 Values, Health and the European Constitution

II.2.8.4.1.4.1 The European Constitution on values

• The Preamble of the European Constitution emphasizes the need to draw “inspiration from the cultural,

religious and humanist inheritance of Europe, the values of which, still present in its heritage, have embedded

within the life of society the central role of the human person and his or her inviolable and inalienable rights,

and respect for law.”

• Article 2 sets forth the Union’s values. It states, “The Union is founded on the values of respect for dignity,

liberty, democracy, equality, rule of law and respect for human rights. These values are common to the

member states in a society of pluralism, tolerance, justice, solidarity and nondiscrimination.”

• Article 3 outlines the Unions objectives: “The Union’s aim is to promote peace, its values and the well being

of its peoples….It shall combat social exclusion and discrimination, shall promote social justice and

protection, equality between men and women, solidarity between generations and protection of children’s

right’s….It shall promote economic, social and territorial cohesion and solidarity among member states.”

II.2.8.4.1.4.2 The European Constitution on health

The commitment to the wellbeing of citizens is seen as a core value of the European Union. Article 3 states,

“The Union's aim is to promote peace, its values and the well-being of its peoples.” Health is not explicitly

158

McKee, M. “Values, beliefs, and implications” in Marinker, M. (ed.) Health Targets in Europe: Polity, progress and promise. BMJ Books: London, 2002, p. 181. 159

Byrne, D. “Enabling Good Health for All: A reflection process for a new EU Health Strategy” European Commissioner for Health and Consumer Protection, 15 July 2004, p. 10. 160

McKee, M. “Values, beliefs, and implications” in Marinker, M. (ed.) Health Targets in Europe: Polity, progress and promise, BMJ Books: London, 2002. 161

Slaughter, A. A New World Order. Princeton University Press: Princeton, 2004. 162

Danzon, M. “Updating Health For All: The European Perspective” Health Targets: News & Views, 7 (1), 2004. 163

“Follow-up to previous sessions of the WHO Regional Committee for Europe” World Health Organization, 2004. EUR/RC54/12.

mentioned in this article but by applying the WHO’s definition of health, wellbeing includes health. WHO

states, “Health is a state of complete physical, mental and social well being, and not just the absence of

disease.”

The EU’s formal position on health is outlined in the following way in the European Constitution:

• Article 16 includes the protection and improvement of human health as one area of supporting, coordinating

or complementary action. It states:

- “A high level of human health protection shall be ensured in the definition and implementation of all the

Union's policies and activities.”

- “Action by the Union, which shall complement national policies, shall be directed towards improving public

health, preventing human illness and diseases, and obviating sources of danger to physical and mental health.

Such action shall cover the fight against the major health scourges, by promoting research into their causes,

their transmission and their prevention, as well as health information and education.”

- “The Union shall encourage cooperation between the Member States in the areas referred to in this Article

and, if necessary, lend support to their action.”

- “The Union and the Member States shall foster cooperation with third countries and the competent

international organizations in the sphere of public health.”

- “European laws or framework laws shall contribute to the achievement of the objectives referred to in this

Article by establishing the following measures in order to meet common safety concerns.”

- “European laws or framework laws may also establish incentive measures designed to protect and improve

human health and to combat the major cross-border health scourges.”

• Article II-31 discusses fair and just working conditions: “Every worker has the right to working conditions

which respect his or her health, safety and dignity.”

• Article II-35, which comments on health care, states, “Everyone has the right of access to preventive health

care and the right to benefit from medical treatment under the conditions established by national laws and

practices. A high level of human health protection shall be ensured in the definition and implementation of all

Union policies and activities.”

• Article III-132 is on consumer protection. “In order to promote the interests of consumers and to ensure a

high level of consumer protection, the Union shall contribute to protecting the health, safety and economic

interests of consumers, as well as to promoting their right to information, education and to organize

themselves in order to safeguard their interests.”

II.2.8.4.1.5 European Citizenship and Health

Two views dominate the discussion European citizenship and health: one focuses on cultural identity and one

on citizens’ rights. Both views have implications for a debate on European values and health particularly since

with European expansion significant differences in health status now exist within the EU. II.2.8.4.1.5.1 Citizenship as culture

European citizenship, as a new kind of citizenship, cannot derive its sole meaning from national citizenship.

National identity, rights and responsibilities are important in their own right; yet European citizenship is more

than the sum of its parts. Since citizenship and identity are closely linked, the development of a meaningful

understanding of European citizenship is dependent on the creation of a European identity, which in turn

implies the commitment to a common set of values. The notion of a European identity, however, seems

problematic due to the linguistic, economic, ethnic and cultural heterogeneity of the EU. This diversity in

Europe intensifies even further with the influx of third country nationals who now are a significant element of

Europe164

. If the European identity is characterized by increasing heterogeneity, how should European

citizenship be understood?

Some argue that cultural citizenship is most appropriate in the European context. Distinct from the

Habermasian notion of citizenship, this view stresses the centrality of culture for an adequate understanding of

citizenship165

. It is closely aligned with multiculturalism and embraces cultural differences rather than

164

“Citizenship and Identity” El sitio web de la historia del siglo XX, Retrieved on September 29, 2004 from <www.historiasiglo20.org> 165

Delanty, G. “Two Conceptions of Cultural Citizenship: A Review of Recent Literature on Culture and Citizenship” The Global Review of Ethnopolitics, 1 (3), 2002.

promoting assimilation. Cultural citizenship makes cultural identity, not national identity or constitutional

principles, the core of citizenship.

II.2.8.4.1.5.2 Citizenship as rights

Concepts of citizenship relevant to understanding European values in health include: theoretical/soft

citizenship, practical/strong citizenship, active citizenship and social citizenship. According to Ralf

Dahrendorf, European citizenship lies between theoretical/soft citizenship (such as feeling part of a

community, having common goals and values) and practical/strong citizenship, which encompasses real rights

(such as voting, fair trials, expression and association).33

Active citizenship, frequently mentioned in citizenship literature, refers to citizens who actively participate in

political and social discourse. Historically, national citizenship has been constructed through social

participation.34 Active citizenship in the EU means that citizens defend human, political, economic and social

rights – including the right to health and health care.

Finally, social citizenship is relevant to the European context because it constitutes the core idea of a welfare

state. According to Gosta Esping-Andersen social rights are granted based on citizenship, not performance in

the market.35 Social services are available as a right, and therefore health is not a commodity. Concepts of

citizenship relevant to understanding European values in health include: theoretical/soft citizenship,

practical/strong citizenship, active citizenship and social citizenship. According to Ralf Dahrendorf, European

citizenship lies between theoretical/soft citizenship (such as feeling part of a community, having common

goals and values) and practical/strong citizenship, which encompasses real rights (such as voting, fair trials,

expression and association)166

.

Active citizenship, frequently mentioned in citizenship literature, refers to citizens who actively participate in

political and social discourse. Historically, national citizenship has been constructed through social

participation167

. Active citizenship in the EU means that citizens defend human, political, economic and social

rights – including the right to health and health care.

Finally, social citizenship is relevant to the European context because it constitutes the core idea of a welfare

state. According to Gosta Esping-Andersen social rights are granted based on citizenship, not performance in

the market168

. Social services are available as a right, and therefore health is not a commodity.

II.2.8.4.2 Applications to Health Policy

As can be seen from the above discussion, values in health policy are ambiguous and complicated. This is due

in part to the fact that research on values in the health realm is very underdeveloped but also because values

are inherently complex. And while it is not possible to encapsulate all values into one grand theory, some

reflections can be made. II.2.8.4.2.1 Values in Health Policy and Public Health

Different sets of values appear in discussions on health care versus discussions on public health. When

referring to values in public health, the domain of the public (thus implying the role of the state) and the

domain of health (as a more inclusive concept than health care) are present at the outset; action on

determinants of health is relevant in this case. Concerning health care, the core issues that seem to emerge are

access to health care and universality. Both discussions- whether about public health or health care are driven

by the notion of equity. The importance assigned to one over the other is not necessarily a reflection of values

but of interest.

II.2.8.4.2.1.1 Values in health policy

166

“Citizenship and Identity” El sitio web de la historia del siglo XX, Retrieved on September 29, 2004 from <www.historiasiglo20.org> 167

“Citizenship and Identity” El sitio web de la historia del siglo XX, Retrieved on September 29, 2004 from <www.historiasiglo20.org> 168

Esping-Andersen G. The Three Worlds of Welfare Capitalism. Princeton University Press: Princeton, 1990.

Giacomini et al.169

conducted a very helpful analysis of values in Canadian health policy. Their research found

that most stakeholders agree that values drive policy goals, decision-making and conduct, but disagree on

which values matter most. Health professionals do not share a precise understanding of what values even are.

Canadian health professionals call a variety of things “values”, including the health system (health care,

prevention-oriented system), health states (health, wellbeing, quality of life), equity (fairness, social justice,

equality), access (in conjunction with equity- i.e. universal accessibility), economic viability (cost-

effectiveness, efficiency), and relationships (caring, inclusiveness, rights), among others170

.

Many seemingly objective things contain values. Evidence, for instance, is not free of values. The questions

posed by a researcher, the transformation of answers into reported facts and the creation of an audience for

research reports are all influenced by values171

. Terminology like “ought” or “should”, or words with

positive/negative connotations (like health/mortality) are embedded with values. Additionally, what goods

society views as “public” versus “private” is often a reflection of its values. “The privateness or publicness of

a good is rarely an innate property. In most instances, it is a policy choice – our policy choice – to make a

good more or less public or private172

.” The trend towards privatization of health and health care, for example,

is one expression of larger neo-liberal values in modern societies. In the United States alone, the sales of the

wellness industry have already reached approximately US$200 billion and that it is set to achieve sales of

US$1 trillion within 10 years, thus matching the health care industry173

.

Meanwhile the public health sector faces the crisis of a severe shortage of public funding at local, national and

global levels.

Discussions of values rarely include explicit talk of the negative side of values, or their antonyms, also called

“disvalues”. Negative values are seldom called values despite the fact that they are equally normative and

judgmental as their positive counterparts174

. In a case of competition between values, dissenting individuals do

not typically advocate a disvalue but instead minimize a value’s importance or just omit mentioning it

altogether. “Negative values language carries a stiff price: it not only judges but also has an accusatory tone

that positive talk avoids175

.”

II.2.8.4.2.1.2 Values in public health

Public values, as described above, relate to state activity. A report by Staley of the King’s Fund176

in the UK

suggest seven public health values:

- “Equity reflects the understanding that everybody should get their fair share and that people should only have

what is their ‘due’.

- Compassion and altruism reflects the importance we place on selflessness and putting others before oneself.

- Security reflects the importance we place on controlling the future, minimising risk and reducing anxiety.

- Efficiency reflects a desire to get the most out of the resources available, always paying attention to the costs

of actions and decisions.

- Choice and autonomy reflects the freedom to act and make decisions on the basis of one’s own desires, in the

absence of State-imposed restraints.

- Health reflects a wide conception of what is ‘good’ for people in terms of how they treat their own bodies.

- Democracy underpins the authority of the Government to act, on the understanding that policy

implementation requires the consent of the people.”

169

Giacomini, M., Hurley, J., Gold, I., Smith, P. & Abelson, J. “‘Values’ in Canadian Health Policy Analysis: What Are We Talking About?” Canadian Health Services Research Foundation, 2001. 170

Alkire, S. & Chen, L. “Global health and moral values” The Lancet, 364, 2004. 171

Giacomini, M., Hurley, J., Gold, I., Smith, P. & Abelson, J. “‘Values’ in Canadian Health Policy Analysis: What Are We Talking About?” Canadian Health Services Research Foundation, 2001. 172

Kaul, I. “Financing Global Public Goods: A Discussion Note” United Nations Development Program, 2001, p. 4. 173

Pilzer, P. Z. The Wellness Revolution: How to Make a Fortune in the Next Trillion Dollar Industry. John Wiley and Sons: New York, 2002. 174

Giacomini, M., Hurley, J., Gold, I., Smith, P. & Abelson, J. “‘Values’ in Canadian Health Policy Analysis: What Are We Talking About?” Canadian Health Services Research Foundation, 2001. 175

Giacomini, M., Hurley, J., Gold, I., Smith, P. & Abelson, J. “‘Values’ in Canadian Health Policy Analysis: What Are We Talking About?” Canadian Health Services Research Foundation, 2001, p. 7. 176

Staley, K. “Voices, Values and Health: Involving the public in moral decisions” King’s Fund, 2001.

In analyzing the above values, one can conclude that efficiency not a value in itself but is a means to an end.

Also, in this list the concept of health as a value re-emerges. The importance given to equity is reinforced, as it

is listed first. And security and choice/autonomy, which are often conflicting, are both listed.

Democracy is a value that can be created through public participation in debates around public values.

Involving the public brings legitimacy, limits conflict and encourages consideration of collective concerns177

.

It may also help policy-makers identify and prioritize the relevant competing values so that they are better able

to act on behalf of their constituents. “It is possible to imagine that public consultation could serve as such a

statement of preferences. QALY [Quality Adjusted Life Year] estimates, for example, require some

understanding of the relative value that individuals place on various combinations of disease/disability states.

One can think of public consultation as a way of providing this sort of information178

.”

As example of focusing on determinants of health, we bring the Swedish Public Health Policy. The new

Swedish Public Health Policy, adopted in 2003, aims to create equity in health. In the 1980s, there were large

health inequalities in Sweden, and so a parliamentary commission was formed to create a strategy to create

equal conditions for good health through a focus on the structural determinants of health. The main objectives

include, but are not limited to, economic and social security, secure and favourable conditions during

childhood and adolescence, participation and influence in society, healthier working life and increased

physical activity179

. Many ministries and governmental agencies have to become involved in the

implementation of Swedish Health Policy due to its focus on determinants of health. Policy-makers in Sweden

have concluded that economic policy (redistribution between income groups, age groups and regions), social

welfare policy (accessibility of basic social services), labor policy (employment rate), secure growing up

conditions (quality of schools and day care), environmental policy, food and agricultural policy (food

subsidies), and alcohol policy (reducing supply) are all integral to creating equity in health in Sweden180

. Yet,

in all of these sectors, there is political resistance to the foundations of the new Public Health Policy in large

part due to differences in values. Neo-liberal forces, for instance, counter redistributive economic policies and

the accessibility of social services (through increased privatization). The Swedish National Institute of Health

in Sweden asserts, “There is strong popular opinion for defending and developing the social welfare. On the

other hand there are strong opposing forces, especially on the international level181

.”

Therefore, Ministers in Sweden are required to challenge the dominant neo-liberal paradigm in the world

today. The underlying issue in this case is expressed by McMichael and Beaglehole, “Tension persists

between the philosophy of neo-liberalism, emphasizing self-interest of market-based economies, and the

philosophy of social justice that sees collective responsibility and benefit as the prime social goal. The practice

of public health, with its underlying community and population perspective, sits more comfortably with the

latter philosophy182

.”

II.2.8.4.2.2 Values and Health Governance

II.2.8.4.2.2.1 Governance and health targeting

Values, unlike goals, do not necessitate particular policies. Yet values do serve a range of other objectives.

Three key aspects of values include the developmental (i.e. creating, cultivating, changing values),

philosophical (i.e., apprehending possible values, critically interpreting values), and discursive (i.e.,

conversing, deliberating, and persuading)183

. This explains why, when discussing target setting in health,

177

Staley, K. “Voices, Values and Health: Involving the public in moral decisions” King’s Fund, 2001. 178

Weale, A. “Democratic Values, Public Consultation and Health Priorities” in Oliver, A. (ed.) Equity in Health and Healthcare: Views from Ethics, Economics and Political Science. The Nuffield Trust: London, 2003, p. 49. 179

Agren, G. “The New Swedish Public Health Policy as a tool to improve equity in health” Swedish National Institute of Public Health, Powerpoint Presentation, 2004. 180

Agren, G. “The New Swedish Public Health Policy as a tool to improve equity in health” Swedish National Institute of Public Health, Powerpoint Presentation, 2004. 181

Agren, G. “The New Swedish Public Health Policy as a tool to improve equity in health” Swedish National Institute of Public Health, Powerpoint Presentation, 2004. 182

McMichael, T. & Beaglehole, R. “The Global Context for Public Health” in Beaglehole, R. (ed.) Global Public Health: a new era. Oxford University Press, Oxford: 2003, p. 10. 183

Giacomini, M., Hurley, J., Gold, I., Smith, P. & Abelson, J. “‘Values’ in Canadian Health Policy Analysis: What Are We Talking About?” Canadian Health Services Research Foundation, 2001.

individuals involved so frequently mention the importance of the process of target setting, which serves to

clarify and reiterate common concepts, approaches, values and learning. “Developing targets – at whatever

level of governance from international to organizational – provides a ‘common context of interpretation’ and

broadens the legitimacy base for critical choices…”184

In this way, values are both a means and an end, which

goes back to the aforementioned capabilities approach by Sen.

Values in health policy can be viewed on a continuum. Ultimate values, or those that are moral and abstract

and do not direct activities clearly (such as equality or health for all) are on end, and instrumental values (such

as universal access to health care) are on the other. The values that lie in between “operationalize” the ultimate

and instrumental values185

. Being involved in setting health targets as a broad inclusion process creates a

political space to actually consider the values along the continuum between the ultimate values on one end and

the instrumental values on the other.

Policy makers involved with instrumental values make choices and take specific action. They deal less with

what matters and more with what must be done, such as in health care financing. In comparing the policy

processes in Germany and Sweden, one can see that policy makers in Europe deal with both ultimate and

instrumental values. There are little to no debates in Germany about the ultimate, or fundamental values,

except in extremely hot debates over party politics. Yet, as described above, the Swedish Public Health Policy

is first and foremost focused on an ultimate value- that is, achieving equity in health.

II.2.8.4.2.2.2 Values and evidence

Translating the evidence or facts into policy requires also value trade-offs (not to mention that the evidence

itself is not free of values)186

. Policy decisions involve giving more weight to one value over another.

Sometimes values can work synergistically. For example, policies that reduce inequalities in health can also

increase security by reducing risks of life-threatening diseases. More commonly, however, values conflict in

health policy making187

. “Conflicts between autonomy and other public values are the most common, since the

Government’s desire to promote the health of the population often comes at a cost to individual freedom188

.”

No hierarchy of values exists, and so individuals will trade-off values in a way that reflects their priorities.

Values basically reflect how one thinks the world should be organized, and this becomes particularly

important when final evidence is not available. The everlasting debate between equity and efficiency is one

such example189

. Prioritizing public values can give rise to political controversies in public health because

values are often deeply held and individuals have conflicting beliefs on what values are most important. Often,

policy-makers hide behind technical evidence because tough decisions that might seem to counteract

supposedly held (or really held) values might need to be explained politically.

In order to achieve support, “health programmes also must build consensus among a diverse constituency of

resource-holders as to the central value of the initiative190

.”

One example is the fact that the majority of policy makers continue to frame health in terms of expenditure

and consumption of health care services. Very few institutions, organizations and funding programs clearly

differentiate between programs that focus on health and its determinants and those that focus on health care.

One potential reason for this gap, among many others, is that little Cochrane-type evidence exists on what are

successful interventions to address the determinants191

. The historical and common sense evidence, of course,

abounds but is not utilized. As Kimmo Leppo so eloquently stated, “One of the great paradoxes in the history

of health policy is that, despite all the evidence and understanding that has accrued about determinants of

health and the means available to tackle them, the national and international policy arenas are filled with

184

Kickbusch, I. “Perspectives on health governance in the 21st Century” in Marinker, M. (ed.) Health Targets in Europe: Policy, progress and promise. BMJ Books: London, 2002, p. 220. 185

Giacomini, M., Hurley, J., Gold, I., Smith, P. & Abelson, J. “‘Values’ in Canadian Health Policy Analysis: What Are We Talking About?” Canadian Health Services Research Foundation, 2001, p. 13. 186

Staley, K. “Voices, Values and Health: Involving the public in moral decisions” King’s Fund, 2001. 187

Giacomini, M., Hurley, J., Gold, I., Smith, P. & Abelson, J. “‘Values’ in Canadian Health Policy Analysis: What Are We Talking About?” Canadian Health Services Research Foundation, 2001. 188

Staley, K. “Voices, Values and Health: Involving the public in moral decisions” King’s Fund, 2001, p. 3. 189

Staley, K. “Voices, Values and Health: Involving the public in moral decisions” King’s Fund, 2001. 190

Alkire, S. & Chen, L. “Global health and moral values” The Lancet, 364, 2004, p. 1073. 191

Macintyre, S. “Evidence based policy making” British Medical Journal, 326, 2004.

something quite different192

.” It is in exactly this area that a new type of European debate spearheaded jointly

by the EU and the WHO regional office should move forward. The WHO has now created a new Commission

on social determinants and health chaired by one of the leading academics in Europe. Herein lies the

possibility of developing a new health policy model based on European values and bringing it into the global

debate as a guide for health development.

II.2.8.4.2.2.3 Fairness as an instrumental policy value

Health inequities exist due to unequal access to resources, including education, health care, job security and

clean air and water193

. Inequalities that are unfair, or arise from social injustices, and are also avoidable are

considered inequities. Fairness is used in this context to describe the unacceptable disparities in health194

.

As regards determining the inequity of health outcomes, benchmarks published in the WHO Bulletin195

contain criteria for evaluating specific aspects of fairness of health reform proposals. Relevant in a developing

country context, the benchmarks include analysis of intersectoral public health, financial barriers to equitable

access, non-financial barriers to access, comprehensiveness of benefits and tiering, equitable financing,

efficacy, efficiency and quality of care, administrative efficiency, democratic accountability and

empowerment, patient and provider autonomy. These benchmarks to not attempt to provide a universal scale

of fairness across health systems but instead emphasize the need to be context-specific. They are meant to be

supplementary to other efforts of monitor equity in health systems.

II.2.8.4.2.3 Participation and Accountability as Values

II.2.8.4.2.3.1 Do-ability and accountability

Public health is about collective efforts. This is of importance because, as Europe becomes increasingly

interdependent, there is an expansion of the territory of health into an increasing array of personal and political

spaces and a concurrent expansion of the do-ability of health. This do-ability raises the issue of responsibility

and accountability. Because health is do-able, whose responsibility is it to promote and provide it? Who is

accountable for the individuals lacking access to health and health services?

Knowledge and power in contemporary societies are so widely distributed that cooperation becomes “a new

categorical imperative196

.” It follows that accountability needs extend horizontally just vertically. This is

expressed, for instance, through the Verona Benchmarks, which relate best practice to partnership building197

.

II.2.8.4.2.3.2 Role of the citizen

As health expands in modern societies, the role of the citizen in health does as well. The citizen becomes an

individual who takes care of her own health, as a consumer in the health market place, as a patient in the

health care system, as a voter on health care issues, and as a social actor together with others in NGOs and

social movements. As this critical role of the citizen/consumer/patient gains in importance, participation and

accountability become key values in health governance.

II.2.8.4.2.4 Future European Dialogue on Health and Values

192

Leppo, K. “Introduction” in Koivisalo, M. & Ollila, E. (eds.) Making a Healthy World. Zed Books: London, 1998, p. 3. 193

Evans, T., Whitehead, M., Diderichsen, F., Bhuiya, A. & Wirth, M. (eds.) Challenging Inequities in Health: From Ethics to Action. Oxford University Press, New York, 2001. 194

Peter, F. & Evans, T. “Ethical dimensions of health equity” in Evans, T., Whitehead, M., Diderichsen, F., Bhuiya, A. & Wirth, M. (eds.) Challenging Inequities in Health: From Ethics to Action. Oxford University Press: New York, 2001. 195

Daniels, N., Bryant, J., Castano, R.A., Dantes, O.G., Khan, K.S. & Pannarunothai, S. “Benchmarks of fairness for health care reform: a policy tool for developing countries” Bulletin of the World Health Organization, 78 (6), 2000. 196

Paquet, G. “The new governance, subsidiary and the strategic state” in Governance in the 21st Century. OECD: Paris, 2001. 197

Kickbusch, I. “Perspectives on health governance in the 21st Century” in Marinker, M. (ed.) Health Targets in Europe: Policy, progress and promise. BMJ Books, London: 2002.

In the 21st century, the increasing overlap between government, civil society and the market pervades all

debates on new governance. Definitions of social justice, public and private goods, and the new social contract

between the state and the citizen are issue that commonly surface198

. And indeed this is the case here. The

values debate in health reflects this trend, a natural evolution in modern society. In response to this, Europe

needs to widen the health debate with many stakeholders about the role of health and the values of health in

the European Union. Health can become a positive force of European citizenship. The expansion of health into

areas other than the health sector implies that there needs to be a new and broader dialogue at the European

level. It is not enough to have agreement on values with regard to health within the health sector alone.

Light areas for further exploration and discussion in the values debate in Europe stand out. How are values

manifested in European health policy? Does it help to make these values explicit? Whose values matter? How

can policy makers take public values into account? Is this possible given the diversity in the EU? How are

values manifested in technical goals? Are there “priority values” by which European policy makers should

follow in policy making and target setting? If evidence is not value free, what does that mean for evidence-

based policy making? How are values manifested in the implementation process of target setting? How can

conflicts of value prioritization in target setting be resolved? How does the distinction of “old” versus “new”

Europe impact the values discussion? What kind of frameworks can be constructed to help guide policy

making and target setting? What are relevant mechanisms through which to implement health values in

Europe?

A key ambiguity in this assessment seems to be the difference in what professionals consider a value versus an

interest. Perhaps this could be an area of future review. A comparative value study of European health

documents as undertaken by the Canadians would probably reveal, just as the Canadian study did, that

European health policy makers call a great variety of things “values”. Also, a process to develop European

health goals and targets would create the political space to discuss the common European core and also the key

values relevant to European public health policy. Europe cannot escape the debate that builds on moral

philosophy as in efforts to build a healthy Europe and healthier world. Yet it is essential to find ways to

instrumentalize the values that come to the fore and make them reference points. This means taking values out

of the realm of moral speculation and putting them into the realm of rights at all levels of governance.

The key complexity is that in an interdependent world no national approach will be sufficient. Equity,

solidarity, universality and dignity will need to be matched at European and at the global level. Indeed what is

needed is a new global social contract. Elements of this are under way as the rich states examine their

approach to debt relief, trade and development policies. But it will be crucial that European citizens

themselves engage in this debate.

Europe has the potential to be an international leader in shaping policies that promote health through the

global acceptance of responsibility. Health, first and foremost, needs to be at the centre of EU policymaking199

,

66 especially in relation to citizens’ needs and rights. The social Europe of the future requires a focus on

European identity in which health is inextricably linked to the concept of modern European citizenship. Such a

concept of citizenship also accepts a commitment to global solidarity. Europe needs to apply the lessons

learned in the historical development of public health in Europe to its global responsibilities.

II.2.8.4.2.5 Assets for Health and Wellbeing Across the Lifecourse

Asset based approaches are concerned with identifying the protective factors that create health and well-being.

They offer the potential to enhance both the quality and longevity of life through focusing on the resources

that promote the self-esteem and coping abilities of individuals and communities. Researchers, practitioners,

commissioners and policy makers with an interest in assets based approaches are invited to actively

participate.

II.2.8.4.2.5.1 Health Assets for Young People’s Wellbeing

The first in a series of events to translate the asset model into policy research and practice was held in Seville,

Spain, on 28-30 April 2010.

198

Kickbusch, I. “Perspectives on health governance in the 21st Century” in Marinker, M. (ed.) Health Targets in Europe: Policy, progress and promise. BMJ Books: London, 2002, p. 218. 199

Byrne, D. “Enabling Good Health for All: A reflection process for a new EU Health Strategy” European Commissioner for Health and Consumer Protection, 15 July 2004.

As global health inequities continue to widen, policymakers are redoubling their efforts to address them. Yet

the effectiveness and quality of these programs vary considerably, sometimes resulting in the reverse of

expected outcomes. While local political issues or cultural conflicts may play a part in these situations, the

over predominant deficit approach of assessing health needs, which puts disadvantaged communities on the

defensive while ignoring their potential strengths, maybe the universal factor which hinders progress in this

area. The asset model proposed in the volume ‘Health Assets in a Global Context: Theory Methods Action200

offers an opportunity to unlock some of the difficulties associated with the health inequities agenda by posing

a necessary complement to the problem-focused framework that provides a new, positive lens for viewing the

world’s most resistant public health crises.

The ideas and themes of this book were launched at a unique event held in Seville between 28th and 30th

April 2010 and focused on the best ways of promoting wellbeing among young people. The event was

organized by the University of Seville (Spain) and the University of Hertfordshire (England) in collaboration

with the World Health Organization and the Health Behaviour in School-Aged Children (HBSC) study

(www.hbsc.org) to illustrate the actions required by policy makers, researchers and practitioners to make the

asset model a reality.

The overall goal of the Symposium is to contribute to the advancement of asset based approaches to young

people’s wellbeing by highlighting the actions required by researchers, policy makers and practitioners to

make it a reality. In so doing, it will start the process of building a case for why investments in the approach

can have benefits across a wide range of health and development outcomes in many different contexts.

The Seville Symposium was the first in a series of events aiming to advance the science and practice of asset

based approaches and so fits with the theme of the EU Spanish Presidency ‘Moving forward equity in health’

and specifically the objective ‘contribute to innovation in public health by emphasizing the relevance of:

monitoring social determinants of health follow-up and evaluation of policies and interventions’.

The symposium provided the rationale and methodologies required for asset based approaches and brought

together experts from around the world already working with the related concepts of salutogenesis, resilience

and social capital. It used evidence from the WHO Health Behaviour in School-Aged Children study

(www.hbsc.org) to demonstrate the importance of investing in the asset approach for the health and

development of young people and provided real life examples of the asset model already operating in different

contexts across the world. Examples of inputs included:

•Strengthening the assets of disadvantaged women (Germany).

•Sustainable community-based development programs (India).

•Using parental assets to control child malaria (West Africa).

•Asset/evidence-based health promotion in the schools (Romania).

•Evaluating asset-based programs (Latin America).

•Using social capital to promote health equity (Australia).

II.2.8.4.2.5.2 Assets for health and wellbeing across the lifecourse

On 26th and 27th September 2011 the International Conference 2011 titled “Assets for health and wellbeing

across the lifecourse” was held at the British Library Conference Centre in London.

Following the successful first symposium, held in Seville 2010, which focused on young people and youth

health, the aim of this conference was to increase the dialogue between public health, health policy, health

practitioners, commissioners, social care, the voluntary sector and the research community on key issues

relating to health assets across the life course.

Asset based approaches are concerned with identifying the protective factors that create health and well-being.

They offer the potential to enhance both the quality and longevity of life through focusing on the resources

that promote the self-esteem and coping abilities of individuals and communities.

Drawing on concepts that include salutogenesis, resilience and social capital, asset approaches create the

potential for unlocking some of the existing barriers to effective action on health inequities, so far

characterized by more risk-based or deficit approaches.

Dr Erio Ziglio, already Responsible for the WHO European Region, supports assets-based approaches and will

outline how such an approach fits in with the WHO’s attempts to improve global health.

II.2.8.4.2.5.3 Recommendations

200 Morgan A, Davies M. and Ziglio E.: Health assets in a global context: theory, methods, action. Springer, 2010.

The main areas for recommendations which arose from the symposium can be summarised as follows: for

policy and practice and for research and evaluation.

II.2.8.4.2.5.3.1 For policy and practice

1.Programmes set up to promote the health and wellbeing of young people should be reviewed that an

appropriate balance is reached between those aiming to reduce risk and those aiming to increase the

accumulation of protective factors during early child and mid adolescence.

2.A core set of asset based indicators should be agreed to ensure monitoring activities include measures which

reflect positive youth development. As a starting point a review of existing indicators already in use in

different country contexts should be carried out.

3.Methods and processes should be developed to ensure the regular and appropriate involvement of young

people is achieved to assess their views and roles in promoting wellbeing at key development stages.

II.2.8.4.2.5.3.2 For research and evaluation

1.Further research is required to understand the most important key assets for people’s wellbeing; the relative

cumulate effect of acquiring key assets at different development stages; the interaction between different

assets and between assets and risk factors; and an assessment of how relative importance of different assets

to different cultural contexts.

2.Frameworks for testing asset based approaches in evaluation studies to assess the effectiveness and cost

effectiveness of these approaches of different country and cultural contexts and with respect to reducing

health inequities.

CHAPTER III

IMPACT BETWEEN EUROPEISTIC AND LOCALISTIC CONCEPTS

III Introduction. III.1 The impact of health on the economy: empirical evidence. III.2 The Commission on Macroeconomics and Health

and beyond. III.3 The economic impact of health at the level of the individual. III.3.1 Labour market impacts of health. III.3.1.1 The

impact of health on earnings and wages. III.3.1.2 The impact of health on labour supply. III.3.1.2.1 The effect of health on labour force

participation. III.3.1.2.2 The effect of health on early retirement. III.3.1.2.3 Responsibility for others: the impact of health on labour

supply by those giving care to others. III.3.1.2.4 Methodological issues in estimating the causal effect of health on labour market

outcomes. III.3.2 The impact of health on education. III.3.3 The impact of health on saving. III.4 The impact of health on the

macroeconomy. III.4.1 The impact of historic health improvements in determining contemporary national wealth. III.4.2 Health as a

determinant of economic development. III.4.2.1 Macroeconomic studies using a worldwide sample of countries. III.4.2 .2

Macroeconomic studies focusing on high-income countries. III.4.3 The direct impact of the health system on the economy: an

accounting approach III.4.4 The contribution of health to ‘full income’: taking a welfare approach. III.5 Investing in health. III.5.1 An

integrated policy response. III.5.2 Investing in health via the health system. III.5.2.1 The impact of the health system on population

health. III.5.2.2 How much to spend on the health system? III.5.2.2.1 Health expenditure as a function of the level of economic

development. III.5.2.2.2 An alternative way to decide how much to spend on the health system. III.5.2.2.3 Financing of health care.

III.5.2.2.4 Health and healthcare expenditure in the context of an ageing population. III.5.3 Cost-effectiveness of investment in

healthcare and health promotion. III.5.4 Implications for the new EU Member States. III.6 The dialogue between regional and national

actors with European institutional actors. III.6.1 European Territorial Co-operation. III.6.1.1 Introduction. III.6.1.2 Solidarity and

cohesion. III.6.1.3 Inequality reasons. III.6.1.4 Success price. III.6.1.5 How funds are spent. III.6.1.6 Growth and employment creating

III.6.1.7 Interregional co-operation. III.6.1.8 Co-operation across borders. III.6.1.9 Transnational co-operation programmes. III.6.1.10

Regional development co-operation programmes outside the EU. III.6.1.11 European Grouping of Territorial Cooperation (EGTC).

III.6.1.12 Regions for Economic Change. III.6.1.12.1 Exchanging good practice between Europe's regions. III.6.1.12.1.1 INTERREG

IVC ‘Good Practice Fair 2011’ in Krakow. III.6.1.12.1.2 Policy Learning Database. III.6.1.13 Examples of regional innovation

projects. III.6.1.13.1 Foreword. III.6.1.13.2 Examples of regional innovation projects. III.6.1.14 RegioNetwork. III.6.1.14.1

RegioNetwork 2020 networking platform. III.6.1.14.2 Main features. III.6.1.14.3 Supporting the Europe 2020 strategy. III.6.1.15

Inspiring non-EU countries. III.6.1.15.1 International Affairs International Affairs. III.6.1.15.2 Regional Policy Dialogues. III.6.1.16

Interact. III.6.1.16.1 Strategic Programming Process. III.6.1.16.2 What lies ahead? III.6.2 Mattone Internazionale Project in Europe.

III.6.2.1 General frame work. III.6.2.2 General objective. III.6.2.3 Specific objectives. III.6.2.4 The five pillars of “Mattone

Internazionale”. III.6.2.5 Mattone Internazionale Project in Europe. III.6.3 Open call for proposals / Tender Second Programme of

Community Action in the field of Health (2008-2013). III.6.4 European Regional and Health Authorities Association (EUREGHA).

III.6.4.1 What EUREGHA is. III.6.4.2 Objectives. III.6.4.3 Consultative Group. III.6.4.4 Work Programme. III.6.4.4.1 2011 Work

Programme. III.6.4.4.2 New Health and Consumer Programmes. III.6.5 AGE Platform Europe. III.6.5.1 Bridging the Age Gap:

working together to develop rural communities. III.6.6 VII Framework Programme – Health. III.6.6.1 What is FP7? III.6.6.2 Which are

its main objectives? III.6.6.3 What is the overall budget for FP7? III.6.6.4 How does the Framework Programme work? III.6.6.5 Who

decides which areas will be financed under FP7, and on what basis? III.6.6.6 How is FP7 structured? III.6.6.7 Which themes have been

identified for FP7? III.6.6.8 What are the differences between FP7 and its predecessors? III.6.6.9 What are the next steps? III.6.6.10

How and when can I register as an independent expert for FP7? III.6.6.11 What are calls for proposals? III.6.6.12 In which languages is

FP7 available? III.6.6.13 What are work programmes? III.6.6.14 What are 'Third countries' and other non-EU entities that can

participate in FP7? III.6.6.15 Where help could be found? III.6.6.16 Ideas: Call for proposals for ERC Advanced Investigators Grant

(ERC-2012-AdG). III.7 Conclusions

III Introduction

In 2001, the Commission on Macroeconomics and Health (CMH) (1) made a strong economic case for

investing in health. Although confined primarily to evidence from low- and middle-income countries, it helped

bring about a shift in the prevailing paradigm: health was no longer seen as a mere by-product of economic

development, but as one — of several — key determinants of economic development and poverty reduction.

This has helped pave the way for health to be included in national development strategies and policy

frameworks in poor countries, exemplified by the poverty reduction strategy papers (PRSPs) and the

millennium development goals (MDGs). While these instruments are not without limitations, they do

demonstrate the commitment of the international community to acknowledge investment in health as a means

to promote economic development.

In contrast, the potential contribution of health to the economy has received rather less attention in high-

income countries. While policy-makers in high-income countries might rarely disagree, in general terms, with

the proposition that the health of their populations does contribute positively to the national economy, in

reality health has not made its way into national economic development strategies and plans. In most of these

countries, the thrust of contemporary discussions on health reform typically sees interventions that promote

health and the delivery of healthcare as costs that need to be contained. In most countries, health is among the

weakest of ministries and there are only a few examples of finance ministries having engaged with health

ministries in discussions about how the latter could contribute to national economic outcomes through

activities that improve health, rather than exhorting them to cut costs.

This situation is reflected at an international level. Even those key international economic and financial

organizations that are seen as health-promoting, e.g. the World Bank, frequently fail to mention the potential

role of health when they assess future prospects of economic growth. Likewise, within the European Union,

the strategy for economic development — the Lisbon strategy — so far says very little about health.

We ask whether this relative neglect of the economic importance of health in high-income countries is

justified. We ask specifically what, if anything, the high-income countries can learn from the economic case

that has been made for promoting health in poor countries. We conclude, based on an extensive review of the

available evidence, that the relative neglect of health is not justified. While the economic argument for health

in high-income countries may differ from the argument in poor-country settings, there is already sufficient

evidence that improving health can yield significant economic benefits, notwithstanding the remaining

research gaps. This has immediate policy implications, in that it provides a rationale for economic policy-

makers to use health investment, within and outside the health sector, as one additional means of achieving

their economic objectives.

In this light, health comes to be considered as an investment that brings an economic return, and not merely as

a cost.

In examining the evidence for the economic impact of investing in health, we are aware that the relationship

between health and wealth is bi-directional (Smith 1999). It is not our purpose to argue that the contribution of

health to the economy is any more important than the contribution of the economy to health. Whether one is

more important than the other is a question that may be unanswerable and is anyway unnecessary to ask. For

the present purposes it is sufficient to show that there is also a pathway going from health to the economy. It is

this mutually reinforcing relationship between health and the economy that provides a higher return from

investing a given amount in both compared with investing the same amount in one or the other.

III.1 The impact of health on the economy: empirical evidence

This chapter presents the empirical evidence on the impact of health on the economy, as it is considered

relevant to the EU Member States. While the focus of the book is on EU Member States, it was necessary to

include evidence from other countries, as the majority of research in high-income countries has been carried

out outside the EU, mainly in the USA. In some cases, such as the economic growth literature, we included

studies that examined low- and high-income countries in one common sample. Again, it would have been

preferable to limit our analysis to studies of the contribution of health to economic growth in high-income

countries, but there are only a few studies that do so.

The first part starts from a brief review of the work of the Commission on Macroeconomics and Health, given

that its work represents the most recent and comprehensive effort to assemble the evidence on the impact of

health on the economy. It also discusses the constraints in applying its findings to high-income countries and it

reviews some of the criticisms to which it has been subject.

In the second part we turn specifically to high-income countries, reviewing selected results from costof-illness

(COI) studies. This is a useful starting point in that COI studies provide an estimate of the quantity of

resources (in monetary terms) used to treat a disease as well as of the size of the negative economic

consequences (in terms of lost productivity) of illness to the society.

While COI studies do not claim to prove causality from illness to costs, other research referred to in the latter

part of the present chapter does explore the evidence that this relationship can at least in part be considered as

causal. This research can be divided into ‘micro-’ and ‘macro-’ categories. The first category comprises

studies at the individual or household level. Research in high-income countries adopting this approach has

largely focused on the impact of (ill) health on labour productivity and supply, e.g. in the form of earnings,

participation and early retirement. Reviewing this literature we find substantive support for an important role

of health in determining labour market performance at the micro level. The second category comprises

country-level historical case studies that are more or less quantitative. This research unequivocally

demonstrates that the countries that are now high-income owe a large part of their current economic wealth to

past achievements in health. The third category also assumes a macro perspective and utilizes cross-country

data to assess the impact of measures of health at the national level on the level of income or on income

growth rates. While most of the literature on this topic focuses on developing countries, we nevertheless find

some support for the argument that health can be a driver of economic growth in high-income countries. At the

same time, we point to the urgent need for further research on the contribution of health to economic growth in

rich countries. The subsequent section focuses on the direct impact of the health system on the economy,

irrespective of the ways in which the health system affects health, before the last section applies a broader

measurement concept of the welfare or ‘full income’ impact of health.

III.2 The Commission on Macroeconomics and Health and beyond

The work of the Commission on Macroeconomics and Health (CMH) has made an important contribution to

making the economic case for health in developing countries. However, the work as it stands is of limited

relevance to the EU countries as they are facing a very different health pattern the economic implications of

which are not immediately clear.

The starting point for this study is the report of the CMH. The CMH was an independent expert group chaired

by Professor Jeffrey Sachs that was given the task by the World Health Organization (WHO) to assemble the

evidence of the economic benefits attributable to better health in developing countries and to make

recommendations on how to act upon this evidence. The final report of the Commission was published in

December 2001 and it was seen as the beginning of a process that would be taken further at country level

through the development of national health investment plans.

The work of the CMH has been central to making the economic case for investment in health. Its report

concluded that investing in people’s health in developing countries — in addition to being a worthwhile goal

in itself — produces enormous economic benefits, both for the people concerned and for the countries as a

whole. This has helped bring about a paradigm shift according to which health is not merely seen as an end in

itself, but — in addition — can be considered a means that brings further benefits, especially to the economy.

The focus of the CMH has been on the developing world.

However, some of the empirical evidence collected does refer to industrialized countries and is part of the

evidence reviewed below. Moreover, the fundamental idea that health could contribute positively to the

economy should in principle be applicable to all regional and economic contexts.

The report identified a number of cost-effective investments that will save millions of lives and result in

billions of dollars worth of economic growth. It concluded that investing in essential healthcare for the poor

would help millions of people to emerge from poverty, as well as contribute in important ways to overall

economic growth.

In the analyses undertaken for the report, the typical quantitative impact of life expectancy on economic

growth was estimated to be of the following magnitude: a 10 % increase of life expectancy at birth increases

economic growth at least by 0.3 to 0.4 percentage points of GDP per year201

. This translates into a growth

differential between an average high-income and least-developed country of 1.6 points of GDP per year. When

compound interest rates are applied, this annual growth difference, on top of initially unequal starting points,

reinforces the wealth gap between rich and poor countries.

The vast majority (and the poorest) of the countries the CMH focused on are located in Africa. The CMH

report on developing countries justifies its main (though not exclusive) focus on communicable diseases as

well as on maternal and prenatal health in terms of intervention priorities. More specifically, the report

identifies the following key health intervention targets: HIV/AIDS, malaria, tuberculosis, maternal and

prenatal conditions, major causes of child mortality (including measles, tetanus, diphtheria, acute respiratory

infection, and diarrhoeal disease), malnutrition, other vaccinepreventable illnesses and tobacco-related disease

(its sole example of non-communicable disease).

When attempting to apply the results of the CMH report to EU countries, it is obvious that this list of priority

interventions would not address the burden of disease in Europe, which differs in several respects from

developing countries. This point shows the burden of disease in disability-adjusted life years (DALYs) in the

three European subregions (classified by WHO mortality strata) in comparison with four non-European

subregions that are typically considered as part of the ‘developing’ world.

III.3 The economic impact of health at the level of the individual

201

See CMH (2001).

A significant amount of evidence exists to support the economic importance of health in the labour market in

rich countries. We present evidence that health matters for a number of economic outcomes: wages, earnings,

the amount of hours worked, labour force participation, early retirement, and the labour supply of those giving

care to ill household members. The impact of health on education — an issue widely researched and supported

in the developing country context — has received much less attention in the high-income country context. The

impact of health on savings has likewise only received limited attention in rich countries, despite the highly

policy-relevant insights that could potentially be gained from studying these relationships.

III.3.1 Labour market impacts of health

It is intuitively obvious to argue that an individual’s health status impacts upon one’s labour supply and labour

productivity. One would expect that health affects not only the number of hours or days that an individual

would dedicate to his or her work, but also the very decision of participating in the labour force. Similarly, the

choice of early retirement from the labour force may at least partly be driven by an individual’s poor or

declining health status. All these choices are likely contributors to the overall labour supply choice of an

individual.

It is also common sense to expect that, given the amount of an individual’s labour supply, the quality of that

labour supply or its productivity, i.e. the output produced per unit of labour input, is determined by the

individual’s health status. This is easiest to imagine in the case of heavy physical works, but also applies to

non-manual work. An individual’s labour productivity is generally proxied by the wage rate, because under

the assumption of perfectly competitive markets the wage rate reflects marginal productivity. One would

expect, hence, to find a negative impact of ill health on the wage rate.

Overall, by reducing labour supply and/or productivity, poor health status would be expected to affect an

individual’s earnings negatively, i.e. the wage rate times the actual labour supplied in a given period202

. While

it would be desirable to separate out the effects of health on labour productivity on the one hand and on labour

supply on the other, in the practice of empirical research this has rarely been possible, as many studies have

looked at the effect of health on earnings (which captures both labour productivity and supply at the same

time). Therefore, the following sections distinguish — necessarily somewhat artificially — between the results

describing the economic impact of health on earnings and wages and then on labour supply.

III.3.1.1 The impact of health on earnings and wages

Several studies from high-income countries show that poor health negatively affects wages and earnings.

The magnitude of the impact obviously differs across studies (given different health proxies and

methodologies) and direct cross-country comparability of results is therefore limited. While a significant

number of studies have analyzed the impact of health on earnings and wages in high-income countries, overall

there appears to be relatively little evidence from EU countries directly.

The Grossman (1972) model of the demand for health first captured the complex interrelation among work

time, wages and health. Subsequently, many studies (mainly using American data) focused on the

interlinkages between work, wages and health. Grossman and Benham (1974) used the household production

model to examine the effect of health on wages (weekly wage) and on weeks worked, treating health as an

endogenous variable. The estimated structural equations for wage determination and labour supply indicated

that good health had a positive effect on earnings (wages times weeks worked). Contoyannis and Rise (2001)

restate the fact that there is little evidence on the impact of health on wages, particularly for developed

countries.

Luft (1975)203

investigated several aspects of the impact of health status on earnings in the USA, and calculated

the overall loss of earnings to the economy in 1967. He measured the effects of health status by comparing the

different components of earnings (labour force participation, hourly wage, and hours worked per week) of

persons who were healthy with those in bad health204

. Overall, he finds a rather sizeable effect of bad health,

202

Note that from a theoretical perspective one may also obtain opposite results, with labour supply increasing in response to health deterioration. 203

As quoted in Andrén and Palmer (2001). 204

A person in bad health was defined as a respondent who agreed with the statements ‘there is a health problem which influences work’ and ‘there is a health problem which influences housework (questioned only to women)’.

accounting for a loss of 6.2 % of total earnings, compared with a person who was not in bad health as defined

in the study. Splitting the samples by gender and ethnicity, he identifies ways in which disability affects

different groups. For example, black males turned out to be more likely to drop out of the labour force or work

fewer weeks than white males, while the latter take larger cuts in hourly wages and annual earnings.

Fukui and Iwamoto (2003) examined Japanese working-age (30-54) males by using data from the

Comprehensive Survey of Living Conditions for 1989, 1992 and 1995. The authors estimate that about 1 % of

total earnings are lost due to bad health, a value that is much lower than that estimated by Luft (1975), but still

significant. The authors also find that subjective indicators such as work limitations or self-rated health state

display a clearer relationship with earnings and labour force participation than more objective ones, such as

having been diagnosed with a particular disease or a symptom.

Bartel and Taubman (1979) estimated the effect of specific diseases (physician-diagnosed) on wage rates and

hours worked. Their sample is drawn from a population of white, veteran, male twins born in the continental

United States between 1917 and 1927. The study was performed in 1974 (with 2 500 pairs). The authors assess

the relative contribution of specific diseases to current earnings as well as the persistence of the effects over

time. There is a strong effect on earnings (20–30 % reductions) around age 50 of certain diseases contracted

during the preceding 10 years, i.e. heart disease and hypertension, psychoses and neuroses, arthritis and

bronchitis, emphysema and asthma. The diseases are found to reduce both the individual’s wage rate and

his/her labour supply although the relative effects differ by diseases.

Chirikos and Nestel (1985) examined the effect of health problems in the preceding 10-year period on current

economic welfare, using a two-equation model, estimated with the National Longitudinal Surveys (USA), of

older men in 1966–76 and mature women in 1967–77. Controlling for gender, race and current health status,

past health problems (up to 10 years) are found to adversely affect current earnings. The average reduction in

earnings, caused by having had health problems is roughly the same for both white and black men and

represents a loss of about 20 % of the earnings reported by the continuously healthy.

The question of whether sickness history affects annual earnings and hourly wages is also addressed by

Andrén and Palmer (2001). The empirical part is based on data from Sweden (data from Swedish National

Social Insurance Board, 1983–91, for people in working age 16–64). Using a longitudinal survey to examine

the effect of sickness on the individual, Andrén and Palmer estimated both (annual) earnings and (hourly)

wage equations, and found that people who are healthy in the current year, but who have had long-term

sickness in the previous five years have lower earnings in the following years than persons without long-term

sickness, even if they did not experience a new spell of longterm sickness.

Another study by Hansen (2000) from Sweden explored the effect of work absence — in particular due to

illness — on wages. The results indicate that women’s wages are significantly reduced by work absence

caused by their own sickness, while absence to care for a sick child appears to have no significant wage effect.

Taken literally this means that caring for a sick child is be considered more ‘legitimate’ than being sick

oneself. The data205

indicate that women are significantly more likely to be absent than men, both because of

their own sickness and because of caring for a sick child. For men, no significant effect of illness-related work

absence on wages was found.

Contoyannis and Rise (2001) examined the effects of self-assessed general and psychological health on hourly

wages — separately for males and females — by using longitudinal data from six waves of the British

Household Panel Survey206

. The results of the study suggest that reduced ‘psychological health’ — a variable

defined by the authors — in the case of males leads to a decrease in hourly wages, while excellent self-

assessed health increases the hourly wage for females.

The results change in interesting ways, once the sample is split further into fully and partly employed

respondents (again by gender). As for males, the gradient in self-assessed health is maintained, but the

magnitudes of the coefficients on both the excellent and good self-assessed health variable are reduced

205

Data obtained from the Swedish National Social Insurance Board (for the period 1991–92) as well as household data from Statistics Sweden; approximately 7 000 households were used for the study. 206

The British Household Panel Survey is a longitudinal survey of private households in Great Britain (England, Wales, Scotland), designed as an annual survey with the first wave conducted in 1991. In the survey, the self-assessed health question asks the individual to rate their health on average over the last 12 months relative to someone of their own age. This variable is coded as excellent, good, fair, poor, and very poor. Three dummy variables were created, equaling one if an individual has excellent health, has good health, or has fair health or worse. In addition a Likert scale indicator (from one to five) is used to capture more generally the respondent’s psychological well-being. The use of the Likert scale in the estimations makes the interpretation of the respective coefficient less intuitive.

substantially. In contrast, the gradient on self-assessed health is now more pronounced (and significant) for

full-time employees compared with part-time employees.

The British Household Panel Survey (BHPS) has also been used by Gambin (2004) who examined the impact

of health on wages, including a number of health indicators and estimating the equations for men and women

using 11 waves of the BHPS (1991–2001). The sample is restricted to respondents indicating that they are

employed at the time of the survey. Both part-time and full-time workers are included and an estimation is

performed using the full sample as well as the sample consisting only of the full-time employees. Gender

differences in the effect of health on wages are the particular focus of Gambin. Using the same self-assessed

health variables as Contoyannis and Rise (2001), she finds that self-assessed health impacts upon wages more

for women than for men.

Holding all other variables constant, excellent health for males — compared with less than excellent

health207

— increases the hourly wage by on average GBP 1.027 per hour while for women the impact would

be around GBP 1.040. (The average wage for men in the sample is GBP 8.284 and GBP 6.419 for women.)

Thus, the impact of health is found to differ slightly by sex and is more strongly related to women’s wages

than to men’s.

Pelkowski and Berger (2004) examined the effect of health problems on employment, annual hours worked

and hourly wages by using the US Health and Retirement Survey data (which contains retrospective and

current health information on the individuals surveyed) and conclude that permanent health conditions have

negative effects on labour market outcomes. The respondents of the survey are men and women born between

1931 and 1941 residing in the United States (and not in institutional care)208

. Poor health again has different

consequences for males and females. Women face a slightly larger percentage reduction in wages than males

as a result of permanent health conditions.

Females are found to have reductions in wages, but males have bigger decreases in hours worked.

Temporary health conditions have little impact on hourly wages or hours worked. The onset of health

problems in the 40s produces the largest negative consequences for males, while for females negative effects

peak in the 30s. In the authors’ view this may be due to the severity of the health shocks experienced in those

age groups, so that relative to healthy individuals, the biggest declines in wages and hours worked are

observed for individuals whose health problems started at those ages, near the peak of their life-cycle earnings.

Gustman and Steinmeier (1986) (22) use data for the years 1969 to 1975 from the US Retirement History

Survey (RHS) and the Panel Study of Income Dynamics (PSID) for white males to determine if short-term and

long-term illnesses have different impacts on real hourly wages of individuals.

When the illness occurred before the age of 55, the long-term illness reduced the wages of full-time workers

by 3.1 % and part-time workers by 4.9 %. For this same age category, short-term illness had a smaller negative

impact on full-time workers (0.7 %) but had a larger negative impact on part-time workers amounting to a 12

% reduction in wages. When the illness occurred after the age of 55, the long-term illness reduced the wages

of full-time workers by 8.4 % and part-time workers by 7.2 % while the short-term illness had a smaller

negative impact on both full-time workers and part-time workers of 4.2 % and 3.7 %, respectively.

Impairment of mental health has been shown to have a major impact on earnings in a study by Currie and

Madrian (1999) using data from the USA. This may be in part because psychiatric disorders affect workers at

the peak of productive life whereas other measures such as limitations on activities of daily living affect

primarily elderly people who already have a reduced labour force attachment.

Bartel and Taubman (1986), building on earlier work using the NAS-NRC twin data by Bartel and Taubman

(1979) — in the study already referred to above — report that the onset of mental illness reduces earnings

initially by as much as 24 %, and that negative effects can last for as long as 15 years after diagnosis. Benham

and Benham (1981) also find that having ever been diagnosed as psychotic reduces earnings by 27–35 %.

III.3.1.2 The impact of health on labour supply

A standard, if imperfect, illustration of the effect of illness on the labour supply of individuals is absenteeism

from the workplace due to illness. In the EU-15, for instance, around 40 % of EU-15 workers reported having

been absent from work at least once in the last 12 months due to health problems, according to the results of

207

As described above in the discussion of the results of Contoyannis and Rise (2001), the self-assessed health question uses five categories into which respondents can group themselves. ‘Excellent’ is the highest possible. 208

Partners (spouses or cohabitors) of the original targeted sample are also interviewed even if not initially age-eligible. The first wave was conducted in 1992–93. A total of 12 654 respondents from 7 703 households were interviewed.

the Third European Survey on Working Conditions conducted in 2000 (European Commission and Eurostat

2004). According to responses to this survey, these absences represent an average loss of 7.3 working days per

EU-15 worker due to occupational accidents, work-related health problems and other health matters (European

Foundation for the Improvement of Living and Working Conditions 2001).

Sickness absences have the direct cost of the sickness benefits to be paid to absent employees (when

applicable) and the indirect cost of the lost productivity during the days of work absenteeism. The lost

productivity due to sickness absence in the UK was assessed at over GBP 11 billion in 1994. In Portugal, 5.5

% of all working days in the 2 000 largest enterprises were assessed to have been lost as a result of illness and

accidents in 1993. In Belgium, EUR 2.8 billion was paid in 1995 on sickness benefits and benefits on work

accidents and occupational diseases. In 1993, payments to cover absence of work were assessed to be up to

EUR 30.6 billion in Germany and EUR 15.8 billion in the Netherlands (EUR 3.9 billion for benefits on

sickness absenteeism and EUR 11.9 billion for disability benefits)209

.

While this indicator has the disadvantage of also being determined by the incentives set by the policy

environment, it may nevertheless serve as a first, simple approximation. More in-depth microeconomic

research has focused on the extent to which less than full health reduces supply of labour. The following

sections look at three different aspects of the potential labour supply effects of health: labour force

participation, early retirement, and the labour supply of caregivers.

III.3.1.2.1 The effect of health on labour force participation

An extensive empirical literature, mainly from the USA but recently also from Europe, confirms that health

increases the probability of participating in the labour force. Again there is no consensus about the magnitude

of this effect and the comparison of results from different studies is difficult, as they use different measures of

health, model forms and estimation techniques.

Chirikos and Nestel (1985), for instance, find strong evidence of the impact of health problems on labour

supply. They distinguish the ‘direct effect’ of health on the annual hours of work (due to changes on the

preferences between leisure and market work) from the ‘indirect effect’ through the impact of health on

wages. Their analysis is based on data from the US National Longitudinal Surveys (NLSs)210

. Information on

health211

over a 10-year period was combined to construct four health categories under which all individuals

could be classified: ‘continuously healthy’; ‘continuous poor health’; enjoying ‘improving health’; and

‘deteriorating health.’ Estimates were made separately for women and men, and for black and white people,

giving rise to four sex-race groups. Those in ‘deteriorating health’ or ‘continuous poor health’ work less hours

per year than those ‘continuously healthy’ over the same time period212

. Also black men and women in

‘improving health’ supply less hours of work than those who are ‘continuously healthy’. The opposite is,

however, the case for white men and women. In general, the negative impact of poor health on labour supply

is higher for black people than for white people. However, while for white men and women, the effect of poor

health on labour supply is mainly due to its indirect effects via reduced wages, for black men and women

direct reductions in work effort due to changes in preferences are dominant. White people who had health

problems during the previous 10 years, including those with ‘improving health’, had significantly lower wages

than the ‘continuously healthy’ groups213

. This is particularly so for those in ‘continuous poor health’ whose

wages were 36 % lower in the case of men and 48 % in the case of women.

209

Data on costs of absenteeism from the European Foundation for the Improvement of Living and Working Conditions (1997). 210

Data on wages and annual hours worked come from the 1976 survey for men and from the 1977 survey for women. Data on health come from the NLSs over a 10-year period (1966–76 for men and 1967–77 for women). 211

Including self-reports of functional limitations or impairments, self-ratings of general health status, retrospective assignments of health as having improved, deteriorated or remained unchanged over various time periods, and selfreports of whether health affects work effort. Including self-reports of functional limitations or impairments, self-ratings of general health status, retrospective assignments of health as having improved, deteriorated or remained unchanged over various time periods, and selfreports of whether health affects work effort. 212

Controlling for other factors likely to affect labour supply such as other family income, class of the worker, age, and children less than six at home for women. 213

Controlling for other human capital characteristics.

The average214

annual hours of work lost due to a history of any poor health represents 13.4 % of the hours

worked by the ‘continuously healthy’ in the case of white men, 6.3 % for white women, 20.6 % for black men

and 27 % for black women. The use of a historical measure of health can be expected to reduce the

endogeneity bias that exists in the health–labour market relationship, although it does not completely eliminate

it (as these health measures can be influenced by permanent wages or previous labour supply decisions, on

which current labour market status might depend).

In a paper by Pelkowski and Berger (2004), the authors use data from the Health and Retirement Survey

(USA) to distinguish between the labour market impact of permanent and temporary health conditions. The

Health and Retirement Survey, the first wave of which was conducted in 1992–93, contains retrospective and

current health and employment information that allows constructing health and employment experience

profiles over the lifetimes of individuals. First of all, the authors find that permanent health illnesses have a

stronger impact on the number of hours worked in males than in females. According to one of the estimates

that controls for fixed individual effects (correcting for unobserved heterogeneity), a permanent illness

reduced hours worked by 6.9 % for men and by 4.5 % for women. Secondly, the impact of temporary

illnesses215

on the number of hours worked is insignificant for both men and women. Thirdly, the authors

distinguish between permanent illnesses by age of onset. Estimates controlling for the sample selection bias

(as the probability of being employed could be different for individuals having health problems and could

depend on the type of problems and their age of onset) show that when a permanent illness appears between

ages 30 and 39, men reduce the number of hours worked by approximately 9.5 % compared with healthy men.

This reduction is lower, 6.9 %, when the illness appears at ages 50 and older. According to the authors, this

might be related to the different degree of severity of the health shocks that are experienced by different age

groups.

Turning now to the evidence in European countries, in a study based on data from Ireland, Gannon and Nolan

(2003) found that the probability of labour force participation was 61 % lower for men and 52 % lower for

women who had a chronic illness or a disability ‘severely’ hampering their daily activities compared with men

and women without such a chronic condition, after controlling for differences in age, education and marital

status. The presence of a chronic condition hampering ‘to some extent’ daily activities reduced the probability

of labour force participation by 29 % for men and 22 % for women. These estimates were obtained using a

probit model and data from the 2000 Living in Ireland Survey (the Irish component of the ECHP216

for

individuals of working age (between 16 and 64 years of age). Similar results were obtained using data for

2002 from the Quarterly National Household Survey, looking at individuals reporting a long-standing health

problem or disability that severely restricted the kind of work they could do: for this group, the probability of

labour force participation was reduced by 66 % for men and by 42 % for women. The impact of a long-

standing illness restricting ‘to some extent’ the kind of work the individual could do had a smaller, but still

significant, impact on the probability of labour force participation, which was reduced by 12 % for men and by

14 % for women.

214

Obtained weighting differences attributable to each of the four health histories by their prevalence. Obtained weighting differences attributable to each of the four health histories by their prevalence. 215

distinction between temporary and permanent illnesses is based on the answer to the question ‘Is (was) the illness temporary (lasts three months or less)?’, only completed temporary illnesses are included in the analysis. distinction between temporary and permanent illnesses is based on the answer to the question ‘Is (was) the illness temporary (lasts three months or less)?’, only completed temporary illnesses are included in the analysis. distinction between temporary and permanent illnesses is based on the answer to the question ‘Is (was) the illness temporary (lasts three months or less)?’, only completed temporary illnesses are included in the analysis. 216

The European Community Household Panel (ECHP) is a longitudinal survey based on a standardized questionnaire that involves annual interviews of a representative panel of households and individuals in each country, covering a wide range of topics: income, health, education, housing, demographics and employment characteristic, etc. It ran from 1994 to 2001. The then 12 Member States participated in the first wave. Austria (1995) and Finland (1996) have joined the project since then. Data for Sweden are available as of 1997, and have been derived from the Swedish Living Conditions Survey and transformed into ECHP format. The European Community Household Panel (ECHP) is a longitudinal survey based on a standardized questionnaire that involves annual interviews of a representative panel of households and individuals in each country, covering a wide range of topics: income, health, education, housing, demographics and employment characteristic, etc. It ran from 1994 to 2001. The then 12 Member States participated in the first wave. Austria (1995) and Finland (1996) have joined the project since then. Data for Sweden are available as of 1997, and have been derived from the Swedish Living Conditions Survey and transformed into ECHP format.

In their estimates of the impact of the degree of disability on employment of men with disabilities in Spain,

Pagán and Marchante (2004) find that being severely disabled has an important and significant negative effect

on the probability of being employed. These authors base their analysis on the self-assessed disability data for

men in the ECHP from year 1995 to 2000. According to these data, only a quarter of men with disabilities are

employed, compared with approximately three quarters of people without disabilities.

People with limiting long-standing illness are found to have a higher probability of being unemployed and

inactive in Sweden in a study by Lindholm et al. (2001). The authors base their findings on the analysis of data

from the Swedish Surveys of Living Conditions for a sample of people interviewed twice with an interval of

eight years, the first interview taking place in the period 1979–90 and the second one between 1986–97. Men

and women included in the sample are aged 25–64 years, at the time of the first interview do not have any

limiting long-standing illness (self-reported) and are employed. Odds ratios are calculated for those who

become ill at the time of the second interview, controlling for differences in age, gender and socioeconomic

group217

. The results show that the probability of economic inactivity, unemployment and long-term

unemployment is significantly higher for those who have a limiting long-standing illness. A problem for

interpretation of these results as evidence of causation is that the interval between the two interviews is very

long (eight years), and we are not able to know whether it is illness that precedes economic inactivity (or

unemployment), or the other way round. Moreover, the social context (average unemployment and labour

force participation rates) changed dramatically at the end of year 1991, with some second interviews taking

place before this change, and some after, so the results might be biased by a confounding effect of time.

In order to avoid the potential bias arising from the endogeneity in the relationship between labour market

participation and health status, Riphahn (1998) focused on sudden deteriorations of health, or health shocks,

arguing that labour-attributable health deterioration can be expected to act over a longer time period. Her

analysis is based on pooled data from the first 11 waves of the German Socio-Economic Panel (1984–94), and

on a sample of full-time employed West German individuals aged 40 to 59 (since at age 60 individuals might

be entitled to retirement benefits). Riphahn defines a health shock as a drop of at least five points on the level

of health satisfaction within one year (based on a scale from 0 to 10)218

. She finds that 13 % of those suffering

a health shock were no longer fully employed in the next period, compared with 5.3 % in the overall sample.

The percentage increases to 17.5 % after two years of suffering the health shock. Importantly, the impact of a

reduction in health is much greater among women, 20.5 % of whom leave full-time employment after

experiencing a sudden health deterioration. In addition, a greater proportion of women move into part-time

employment after suffering a health shock. Using a multinomial logit model, Riphahn estimates the probability

of labour transition after suffering a negative health shock219

. She finds that suffering a negative health shock

increases the probability of entering part-time employment by about 60 %, unemployment by 90 % and of

leaving the labour force by more than 200 %.

Moreover, among all the characteristics examined, a health shock is found to be the most important

determinant of dropping out of the labour force. Riphahn concludes that these results demonstrate the scope

for public policies to retain older workers in work by, for example, offering incentives to employers to

accommodate workers whose health is impaired or promoting more intensive use of rehabilitation

programmes.

Lechner and Vazquez-Alvarez (2004) also use the data from the West Germany sample of the German Socio-

Economic Panel, but focus on disability indicators. Their results suggest that becoming disabled can lead to a

significantly lower probability of being in employment, which can be as much as 9.6 % lower. They use data

from waves of years 1984 to 2001 for people between 17 and 60 years of age. The 18-waves sample is divided

in sequences of observations in three consecutive years for a same individual. Individuals are divided in two

groups: (1) a treatment group, that is observed to be non-disabled in the first year of a sequence of three

consecutive years and then disabled in the following two years; and (2) a control group, that is observed to be

non-disabled during three consecutive years. The labour market outcomes of the treatment and control group

217

Five socioeconomic groups are used: unskilled manual workers, skilled manual workers, lower non-manual employees, intermediate non-manual employees and upper non-manual employees. The intermediate and upper non-manual employees were taken as the reference group. 218

A caveat of this measure is that it does not differentiate between temporary and permanent health problems. 219

Controlling for demographic and human capital measures, characteristics of current employment and labour demand effects. Controlling for demographic and human capital measures, characteristics of current employment and labour demand effects. Controlling for demographic and human capital measures, characteristics of current employment and labour demand effects.

in the third year of each sequence are compared using two different matching techniques according to each

individual’s propensity score220

in the first year of the sequence. In this study, individuals are identified as

being disabled if they declare a degree of disability equal to or greater than 30 % (however, in the used

sample, the majority of individuals becoming disabled had a zero degree of disability in the first year of the

observed sequences). The authors control for the observable characteristics of the disabled and non-disabled

individuals that can affect both their probability of becoming disabled and their probability of employment.

The authors do the same analysis for a restricted part of the sample, those who declare to be full-time workers

in the first year of each three-year sequence. These individuals might be expected to be better informed about

disability policies and the labour market, and therefore suffer less than the whole sample in terms of

employment when becoming disabled. However, the study shows that the effect is similar in this more

restricted group of individuals, where the probability of being out of work is estimated to be between 8.5 %

and 9.2 % higher for those becoming disabled than for those who remain non-disabled.

In the Netherlands, Van de Mheen et al. (1999) find that health problems in 1991 were significantly associated

with a higher risk of mobility out of employment and a lower probability of mobility into employment in

1995. Their study is based on data from the ‘Longitudinal study on socio-economic health differences in the

Netherlands’, for a sample of men and women aged 15–59 in 1991, and interviewed again in 1995. The

authors use three indicators of health status in 1991: perceived general health, health complaints (from a list of

23 items) and chronic conditions (from a list of 23 conditions).

Regarding labour market position, people are categorized into paid employed on one hand and unemployed

and economically inactive on the other hand (unemployed, disability pension, housewives/househusbands and

early retirement). This study uses odds ratios to compare the probability of being out of employment or in

employment in 1995 to those with and without health problems in 1991 (adjusting for differences in age, sex,

educational level and marital status). The results show that among those employed in 1991, the probability of

being out of employment in 1995 is significantly higher for persons suffering from health problems in 1991,

whether measured by general perceived health, chronic conditions (reporting one or more), or health

complaints (reporting four or more). In addition, among those out of employment in 1991, those with health

problems have a lower probability of being employed in 1995 than those without health problems.

III.3.1.2.2 The effect of health on early retirement

A relatively large number of studies from high-income countries find a significant and robust role of ill health

in anticipating the decision to retire from the labour force. The relationship has been more extensively

researched in the USA than in Europe. When interpreting the results from different countries one should keep

in mind that they are likely to be very sensitive to the institutional framework (e.g. pension rules221

,

availability of disability benefits, occupational insurance arrangements).

Most empirical studies have focused on the influence of health on decisions concerning workforce

participation at older ages, and more particularly on the decision to retire. Following a review of research in

the USA, Sammartino (1987) concludes that a significant effect of health on the probability to retire has been

established. This is also the conclusion of a recent literature review by Deschryvere (2004) that includes

evidence from European countries.

Sammartino (1987) concludes that those in poor health are likely to retire between one to three years earlier

than workers in good health with similar economic and demographic characteristics. Gordon and Blinder

(1980), who considered the impact of health on both the relative marginal utility of leisure and consumption

and on the expected wage, found that in white male workers aged 60 to 67 poor health increased the

probability of retirement by 14–18 %. Gustman and Steinmeier (1983) estimated that a long-term health

problem beginning at age 55 reduced the average age of final retirement by 2.8 years. Most of this effect was

220

Propensity to becoming disabled that is estimated according to a series of characteristics of individuals that might have an effect on their probability of becoming disabled. Propensity to becoming disabled that is estimated according to a series of characteristics of individuals that might have an effect on their probability of becoming disabled. 221

Gruber and Wise (1999) found a strong link between the level of participation of older people and the opportunity cost of continuing to work after early retirement age imbedded in the pension system (and measured as the percentage of total net loss of pension benefit for the years from early retirement age until age 69 for working an additional year, over the net wage earned in that additional year). They argued that about 81 % of the variation in participation of older people (aged 55–65), among 11 OECD countries, could be explained by the system’s opportunity cost.

due to the impact of health on changes in leisure/consumption preferences (2.7 years), with only a minor effect

via changes in wages222

.

Sickles and Taubman (1984) find a strong effect of health on male retirement decisions. Based on data from

the US Retirement History Survey (years 1969 to 1977), they generated a model that includes an equation

linking health status to retirement as well as an equation determining health stock (considered as a form of

human capital) on the basis of individual characteristics.

Coile (2003) finds that health shocks have a large effect on labour supply decisions by both men and women

between the ages of 50 and 69, mainly when accompanied by major changes in functional status. For example,

the onset of a heart attack or stroke accompanied by an important deterioration in the ability to perform

activities of daily living223

was estimated to reduce the number of work hours supplied by men per year by 1

030 or to raise the probability of leaving the labour force by 42 %. A comparable effect of 654 hours’ decrease

or a 31 % increase in the probability of leaving the labour force was found for women.

Bound et al. (2003), using data from the US Health and Retirement Study, estimate that a representative

individual in poor health is 10 times more likely than a similar person in average health to retire before

becoming eligible for pension benefits. In another study, Bound et al. (1999) found that not only

contemporaneous health affected labour force behaviour, but also past health shocks224

. Their study is based

on data from the first three waves of the US Health and Retirement Survey (covering people aged 50–62 in the

first wave in year 1981). The authors tried to address the limitations of selfreported health measures by

constructing a health index that depends on a series of exogenous factors (such as age and education) and on a

measure of functional health. The authors estimate that only 30 % of men whose health deteriorated in the last

year remained in the labour force, compared with 87 % of those who continued in good health. Estimates for

women show a similar pattern: 33 % of those whose health deteriorated remained in the labour force, against

82 % of those in continued good health. A similar pattern is found for women: 33 % of those whose health

deteriorated against 82 % of those in continued good health. They also found that the earlier a health shock

occurs, the less likely it is to lead to labour force exit, and the more likely that individuals will change job,

suggesting a strategy of adaptation. Yet even those who suffer a shock at an early age had lower labour force

participation than those who were always in good health. The authors also control for the selection bias that

arises because those continuing to work after having suffered a first negative health shock are less likely to

leave work due to poor health in the future. Doing so increases the likelihood that a negative

health shock will lead to exit from the labour force.

Turning to evidence from European countries, Jiménez-Martín et al. (1999) found that health225

, particularly

among males, was a very important factor in the decision of an individual to retire as well as that of their

spouse to retire with them. The authors use information on labour market transitions between 1994 and 1995

from the ECHP, pooling data from across the EU, to analyse retirement patterns of individuals and couples in

a sample of men older than 54 years and women older than 49.

Considering men and women separately, poor health status is found to have a positive effect on the probability

for own retirement226

. When couples are considered together, having serious health problems227

raises the

probability that men will retire by 289 % (compared to the reference couple228

when the wife is already out of

the labour force and by 1 375 % 229

when she is still working.

222

The results of the studies by Gordon and Blinder (1980) and Gustman and Steinmeier (1983) are quoted in Sammartino (1987). 223

New four or more limitations in activities of daily living. 224

Controlling for contemporaneous health status. Controlling for contemporaneous health status. Controlling for contemporaneous health status. 225

The health variables refer to year 1994 (to minimize the endogeneity bias) and include the following indicators: selfreporting good health; self-reporting a chronic physical or mental health problem (data only available for 1995); having been admitted as an in-patient during the previous year; having visited a doctor between one and five times in the year; having visited a doctor more than five times in the year. 226

Controlling for different demographic and socioeconomic characteristics in the year 1994 and for differences between countries. The significant health variables for men are: having a chronic health problem, having been admitted to hospital in the previous year, having visited a doctor more than five times per year. For women: self-reporting good health status (which reduces probability to retire) and reporting a chronic health problem. 227

Having a chronic condition, having been admitted to hospital in the previous year and visiting a doctor more than five times a year. 228

Among other characteristics of the reference couple, the husband is 55 years old and the wife 52. 229

The probability that the husband in the reference couple retires is very low.

For women, having serious health problems increases the probability of retirement by 324 % when the

husband has left the labour force, but only by 58 % when he is still working.

Strong evidence of the influence of health status on the retirement decision is reported by Siddiqui (1997),

using data from the German Socio-Economic Panel to look at men in West Germany who have reached the

minimum retirement age (which is at 58 years in the German institutional framework)230

. The author analyses

retirement behaviour using a model that describes an individual’s retirement decision as a trade-off between

the gain in income from postponing retirement and the gain from leisure obtained by early retirement. It

estimates the influence of several explanatory variables, including two measures of health status231

, on an

individual’s preference for leisure. including two measures of health status75

, on an individual’s preference for

leisure.

The health measures used are: the degree of disability based on a physician’s assessment of the capacity to

fulfil the job requirements; and a dummy variable indicating whether the person suffers from a chronic disease

(self-assessed). The regression results show that being disabled or suffering from a chronic disease

significantly increases the probability of early retirement. Indeed, the degree of disability seems to be the

dominant factor explaining early retirement, with the probability of leaving the labour force at the earliest

possible age for disabled men being four times that of men without disability. As the author notes, these results

suggest that improving employees’ health could be a highly effective measure to raise the actual age of

retirement.

Deterioration in an individual’s ‘health stock’ is found to be an important predictor of retirement in a study

undertaken in Great Britain232

by Disney et al. (2003). The authors find some evidence of asymmetry in the

effect of health variations: the impact of improving health on transition into economic activity is weaker than

the impact of deteriorating health on the transition into inactivity. The study uses data from the first eight

waves of the British Household Panel Survey (1991–98) for people aged 50 to 64 in 1991. This survey

includes a standard measure of general health status: ‘Over the last 12 months and compared with other people

of your own age, would you say that your health on the whole has been: excellent; good; fair; poor; very poor;

don’t know’. In order to avoid potential reporting biases, an instrumental variable (‘health stock’) is

constructed. This variable is calculated from a set of individual characteristics and some more objective health

indicators: (1) whether the individual is registered as disabled or not; (2) whether the individual feels that

health limits his or her ability to perform the following daily activities compared with most people of his or

her age: doing housework, climbing stairs, dressing oneself, walking for at least 10 minutes, and (3) whether

the individual does or does not have a series of health problems and disabilities233

. A reduced form model of

labour market activity/inactivity is then estimated using the ‘health stock’ variable as well as the following

variables: age, state pension age reached or not, marital status, regional unemployment rate, house ownership.

The model is estimated for individuals that transit the states of economic activity and inactivity, avoiding

individuals who may have never worked. The results show that an improvement (or deterioration) of an

individual’s relative health status is strongly and positively associated with economic activity (or inactivity).

III.3.1.2.3 Responsibility for others: the impact of health on labour supply by those giving care to others

Ill health matters not only for the labour market performance of the individual directly concerned but also for

that of his/her household members, who have been found to adjust their labour market behavior in response to

another household member’s illness. In the studies reviewed men appear to reduce their own labour supply by

substantial amounts in the event of their wives’ illness, while in the reverse case women tend to increase their

labour supply.

This can partly be explained by the unequal distribution of gender roles within the family and the different

situation of men and women in the labour market. The availability of health insurance can critically affect the

response to a spouse’s health conditions.

230

The self-employed are withdrawn from the sample due to their different pension systems. 231

Marital status and educational status are included among the other explanatory variables. 232

England, Wales and Scotland. 233

These include: problems with arms, legs, hands, feet, back or neck; difficulty seeing; difficulty hearing; skin conditions and allergies; chest or breathing problems including asthma and bronchitis; heart problems and blood pressure or circulation problems; stomach, liver, kidney or digestive problems; diabetes; anxiety, depression or bad nerves; alcohol or drug-related problems; epilepsy; migraine or frequent headaches; other health problems.

The deterioration in an individual’s health does not only influence his or her own labour force participation,

but also the labour force participation of those who care for him/her. The effect on a third person’s labour

supply is, however, theoretically ambiguous (Coile 2003). On the one hand, if an individual decides to leave

work due to deterioration in his or her own health, this could cause a drop in household income that other

family members might try to compensate for by increasing their labour supply. This could also be the case if

the onset of a health problem increases financial needs (for example, due to increased need for healthcare not

publicly provided or for which the individual is not insured). On the other hand, if due to health deterioration

an individual needs to be taken care of, other family members may decide to reduce their labour supply or to

leave the labour force. The need to care for others could also deter the entrance into the labour market.

In the studies undertaken in the USA, it is important to take account of the fact that a partner leaving

employment may have health insurance coverage removed from the whole family, which may be a significant

deterrent. It is also important to note that the compensating behaviours of different family members might not

make it possible to observe the effect of health on labour supply at the household level. The reduction of

labour supply arising from an ill family member might be compensated by healthy family members working

(and earning) more. These compensating responses do not, however, come without a cost, as the healthy

family member might be giving up competing investments, such as education.

Some studies have focused on the impact of health on a spouse’s labour behaviour. For example, the above

mentioned study by Jiménez-Martín et al. (1999) found that, for men with wives outside of the labour force,

the fact that their wife had a chronic condition increased the probability that they would retire by 13 %. The

opposite was the case for women whose husband was inactive, for whom the probability that they would retire

reduced by 24 % when the husband had a chronic condition. This study used ECHP data to estimate the impact

of spouses’ health status on each other’s probability of retirement. When both spouses were working in the

first year, the probability that both decided to retire in the second year changed from 0.1 % for the reference

couple234

to 5.5 % when the husband had a serious health problem, while it slightly decreased to 0.08 % when

it was the wife who had the serious health problem.

Evidence of significant reactions to spousal bad health is found by Charles (1999), using data from the

American Health and Retirement Survey (HRS), who reports that men reduce labour supply by substantial

amounts in response to their partner’s poor health, whereas wives of ill husbands significantly increase theirs.

The author explains these results by arguing that husbands and wives specialize in market and home

production, and that illness of a partner makes the other take up more of the activity typically done by the ill

person.

In addition, Berger (1983), using data from the USA, found that a spousal illness increased market work time

of women, while reducing market work time of men. Parsons (1977) finds that men increase home production

time and women market work time when a spouse becomes ill, but in both cases these increases come out of

leisure time, so they do not imply a reduction in working time by men235

.

Although Coile (2003) does not find a significant effect of health shocks on a spouse’s retirement, her results

based on American data suggest that this might be partly due to offsetting responses of different groups of

people. For example, according to her estimates, if a man’s wife has an acute health problem236

and receives

disability benefits, the husband’s annual labour supply reduces by 813 hours, and he has a 20 % increased

probability of leaving the labour force. However, if the wife applies for disability benefits but does not receive

them, the husband’s work hours rise by 651 hours and his probability of leaving the labour force falls by 22 %.

These results suggest that a spouse’s labour response is affected by the need to provide health insurance, the

presence of other potential caregivers, the importance of the lost income, and the availability of disability

benefits.

The results for both the EU and the USA suggest that men and women react differently to spouses’ illness,

with men generally reducing labour supply and women increasing it. This seems to be related to gender

differences in the pattern of occupations of men and women and the availability of insurance and related

234

The reference couple has the following characteristics: husband 55 years old and wife 52, none of them with higher education, none unemployed in the initial period, both starting their working lives at 18, with no part-time job, none working in the public sector, none self-employed, living independently and without any other family member. The shares of the household income for the reference couple are: 25 % wife income, 50 % husband income and no capital income. 235

These two studies, Berger (1983) and Parsons (1977), are quoted in Currie and Madrian (1999). 236

Heart attack, stroke, new cancer.

benefits linked to them. The results obtained by Coile (2003) confirm the role that the availability of these

resources plays on the partner’s employment decisions.

The reaction to illness of any family member is studied by Roberts (1999) using data from the 1987 US

National Medical Expenditure Survey. In this case, it is men who are found to have a higher probability of

labour force participation in the presence of mental illness in the family, when this is accompanied by a

chronic physical illness, while women’s probability of labour participation is not affected. However, for both

men and women, the number of weekly hours of work is substantially reduced in the presence of a mentally ill

family member when he/she also has difficulties with an ADL237

or is afflicted by an additional physical or

mental illness.

The need to care for one’s parents is an example of how a family member’s health could influence an

individual’s labour decisions. Ettner (1996) found that care-giving had a large negative impact on the number

of weekly hours of work supplied by women providing care to parents residing outside the household. A

significant effect was not, however, found when care was provided to disabled parents living at home. But, as

noted by the author, the true labour supply effect could have been underestimated as, due to limitations of the

data, it was assumed that all children living with a disabled parent provided care. This study is based on data

from the 1987 National Survey of Families and Households, which covers non-institutionalized US population

aged 19 and over. In order to correct for endogeneity bias, care-giving by parents was instrumentalized by

combining a series of related variables. Also in the USA, simulations by Stern (1996) suggest that caring for

an elderly parent reduces the probability of labour force participation by 18–22 %, for both men and

women238

.

The study of the impact of the need to provide care on women’s labour decisions is particularly relevant, as

female employment is lower than male employment in all EU countries. Moreover, women are more likely to

engage in care-giving (7.2 % look after an old person compared with 3.8 % of men) and provide more time-

intensive support than men (between one and two weekly hours more than the average population in most EU

countries). In particular, the probability that someone will be a care-giver is highest among women aged 45–

59, 12.1 % of whom look after an old person (Schulz 2004).

Spiess and Schneider (2004), using ECHP data, analyze simultaneous decisions about work hours and care

hours taken by women in mid-life (aged 45 to 59) in Europe. Spiess and Schneider estimated the correlation

between changes in weekly work hours and changes in weekly care hours over a two-year period (from 1994

to 1996), pooling data for 12 EU countries. Their results show that commencing care-giving and increasing the

hours spent on informal care are significantly and negatively correlated with a change in the number of hours

worked by women. The opposite effect is, however, not found. Ceasing care-giving or reducing the number of

care hours do not have a significant impact on hours worked239

. This asymmetrical effect suggests that women

who reduce work hours or exit from the labour force are not likely to recover after giving up caring activities.

There is a difference between northern and southern European countries. Commencing care-giving is

negatively associated with women’s labour supply in northern European countries, but there is no significant

association in southern European countries.

III.3.1.2.4 Methodological issues in estimating the causal effect of health on labour market outcomes

The attempt to detect a causal impact of health on labour market outcomes faces certain methodological

challenges, but this is no different from other areas of empirical research in the social sciences.

Empirical methodologies — also widely applied in other fields — have been used in the literature in order to

separate the effect of health on economic outcomes from the potentially simultaneous impact of economic

outcomes on health. Some specific challenges regarding the correct measurement of health in surveys form

part of a future research agenda.

Two main issues that arise when trying to estimate the true impact of health on labour market outcomes are:

(1) possible reporting errors in the subjective self-reported health measures, and (2) possible endogeneity in

the health–labour market status relationship. Both could create estimation biases.

Different strategies and techniques have been proposed to avoid or at least minimize these biases.

Regarding reporting errors, some authors have criticized the use of subjective indicators of health to assess the

impact of health on labour force participation, arguing that they do not reflect true differences in health status.

237

Activities of daily living. 238

As quoted in Currie and Madrian (1999). 239

It should, however, be noted that the model has a low explicative power.

The main problem with errors in subjective health measures is that they are not likely to be random, but to

depend on a person’s labour situation. An individual could, for example, have incentives to declare his/her

health worse than it truly is if poor health status gives access to special benefit schemes. A person could also

use health to justify his/her behaviour if there is social prejudice against those who do not work but are fit

enough to do so (referred to in the literature as the justification bias).

The existence of a justification bias affecting self-assessed health measures has, for example, been suggested

by Ahn (2003). He suggests that this might be the reason why the proportion of men reporting disability, bad

health and very bad health in Spain is lower in the age group 65–69 than in the age group 60–64, 65 years

being the normal retirement age for men in Spain240

. This fall in disability prevalence with age is not found in

any other age group, and does not appear for women (who have a lower labour force participation rate and

experience less social prejudice against not working). Ahn, however, also suggests that the observed

phenomenon might be due to a true improvement in health status of those retired if they are able to devote

more time to health-promoting activities or are free from working activities that are detrimental to their health.

The errors linked to the use of subjective health measures can also lead to under-reporting of health problems.

In some surveys, the individual is asked directly whether he/she has health problems that limit his/her capacity

to work. Individuals with health problems might choose jobs where these problems do not limit their capacity

to work, problems that will then not be reported. Despite this, some authors argue that such questions provide

better measures of ‘work capacity’ than more objective measures of health, and are therefore more appropriate

when trying to assess labour outcomes.

Thus, reporting errors could, in principle, lead to both overestimation and underestimation of the impact of

health on labour force participation status.

In addition, the relationship between health and labour market status could be endogenous, as each of them

may influence the other or both might be influenced by common third factors. There is no consensus about the

direction of the influence of labour status on health. The most common hypothesis in the literature is that due

to boredom, a general lack of activity and a low self-esteem, health deteriorates in individuals that exit the

labour market. Yet it could also be argued that bad working conditions or work-related stress cause

deterioration in health. For example, the study by Kerkhofs et al. (1999), reviewed below, finds that health

improves among non-workers. Evidence of a deleterious effect of work on health241

is also found by Stern

(1989) and is consistent with recent results by Ruhm (2003), although this is contrary to the extensive

evidence of a negative impact of unemployment on health242

. As a result of endogeneity, the impact of health

on labour force participation could therefore be either underestimated or overestimated, depending on whether

working has a negative or a positive effect on health.

A study by Kerkhofs et al. (1999) shows how the size of the estimated effect of health on the retirement

decision can vary depending on the health measure used. The authors use a dynamic model for retirement

behaviour to analyse the factors underlying the decision to take three alternatives routes out of the labour

market in the Netherlands: early retirement schemes, disability insurance and unemployment insurance. The

retirement model is estimated using panel data on wage income and labour force participation over the period

1991 to 1995243

. Health data are obtained from two waves of the CERRA panel survey244

conducted in 1993

and 1995.

This survey provides information on a subjective measure of health ‘does your health limit you in your ability

to work?’ and on a more objective measure: the Hopkins Symptom Checklist245

. Health instruments are also

constructed using a health dynamics model estimated on CERRA panel data. According to their estimates,

240

According to the ECHP data for 1994. This is a cross-sectional comparison and age and cohort effects might be confounded. However, the author finds unlikely that the cohort effects are the cause of the decrease in disability observed in the age group 65–69. 241

In a later study (Lindeboom and Kerkhofs 2002), this is estimated to happen only beyond 25 years of work experience. 242

Review of evidence on the impact of unemployment in health by Mathers and Schofield (1998). 243

For more information see Heyma (1999). 244

CERRA is a Dutch panel survey designed for the analysis of health and retirement issues. The first wave conducted in 1993 included 4 727 households in which the head was between 43 and 63 years old. Both the head of the household and partner, if present, were interviewed. 245

This test includes 57 questions, the responses to which provide a mental score, a physical score and a total health score. This study uses the total health score.

health improves for non-workers, and therefore endogeneity leads to an underestimation of the impact of

health on retirement when this effect is not taken into account.

Comparing the results with different health measures, the authors find important effects of endogeneity on the

estimates of both the probability of early retirement and the probability of receiving unemployment benefits.

The effect of reporting errors in the estimation of these probabilities is, however, negligible. On the contrary,

the probability of receiving disability benefits is strongly affected by reporting errors (overestimating the

impact of health), while in this case endogeneity plays a minor role. Controlling for the effects of endogeneity

and reporting errors, health is found to be highly significant and the dominant factor explaining the receipt of

disability and unemployment benefits246

.

In the case of early retirement, after controlling for the impact of endogeneity, health is also found to have an

important effect (significant at the 10 % level), although the financial incentives seem to be the most important

factor in the decision to retire early.

Bound (1991) shows that neither self-reported measures nor more objective measures of health provide

unbiased estimates of the impact of health on labour force participation of older men. However, the biases that

result from both types of measures go in opposite directions (overestimation in the case of subjective health

measures and underestimation using mortality information). The author therefore suggests that both types of

measures could be used to obtain a high and low bound of the real effect of health on labour force

participation. His estimates are based on data from the US Retirement History Survey covering the years

1969–79.

Most of the studies on the impact of health on labour force participation in developed countries use self-

reported indicators of health, as these are the most widely available. There is no consensus in the literature

about whether the use of these measures leads to significant biases in the estimates, and about the direction of

these biases. However, when assessing the estimates of the impact of health on labour supply in any particular

study, one must keep in mind that these ‘estimates may be very sensitive to the measure of health used, and to

the way in which the estimation procedure takes account of potential measurement error’ (Currie and Madrian

1999).

III.3.2 The impact of health on education

Human capital theory predicts that more educated individuals are more productive (and obtain higher

earnings). Good health in childhood enhances cognitive functions and reduces school absenteeism and early

drop-outs. Hence, children with better health can be expected to reach higher educational attainments and be

therefore more productive in the future. Moreover, healthier individuals, with a longer lifespan in front of

them, would have greater incentives to invest in education and training as they can harvest the associated

benefits for a longer period. While theoretically plausible and empirically supported in the case of developing

countries, there has been relatively little work exploring this link in high-income countries.

Nevertheless, there is reason to believe that at least part of the association between health and education is due

to a casual impact of the former upon the latter.

A large body of literature has provided evidence of a strong positive correlation between adult health and

education (Freedman and Martin 1999). Most of the studies have attributed this correlation to the impact of

education on health outcomes. This explanation corresponds to the prediction by Grossman (1972) who

assumes that education increases the efficiency of producing health (and other goods), and that more educated

people would therefore choose higher levels of health capital.

Strauss and Thomas (1998), for example, found that among men between 25 and 34 years, a 10 cm gap in

height was associated with one additional year of schooling in the USA (a 8 % increase) and 1.5 years in

Brazil (a 25 % increase)247

. Perri (1984) estimates the number of completed years of schooling using a simple

model of schooling choice that maximises lifetime earnings, considering health status as an exogenous

variable and earnings dependent on both health status and education.

246

Other factors considered are: gender, married or not, educational level, white collar worker or not, age, replacement rates of three alternatives schemes (early retirement, disability insurance and unemployment insurance), and calendar time effects. Other factors considered are: gender, married or not, educational level, white collar worker or not, age, replacement rates of three alternatives schemes (early retirement, disability insurance and unemployment insurance), and calendar time effects. 247

US data from the second National Health and Nutrition Examination Survey (1976–80). Data for Brazil from the ENDEF (National Study of Family Expenditure) conducted in 1974–75.

Using data from the US National Longitudinal Survey of Male Youth for 1971, and the index of functional

limitations constructed at Ohio State University248

, the author distinguishes four categories of health status.

Those individuals with health problems limiting their activities are classified, according to functional

limitations, as having: ‘fair’, ‘moderate’ or ‘poor’ health. Most of them fall under the ‘fair’ category.

Individuals without health problems are categorized as having an ‘excellent’ health. Perri finds that having a

limiting health problem reduces the probability that an individual will be enrolled in school by 5–6 %. This

probability is reduced by 25 % for those who have poor health compared with individuals in excellent health,

and by 19 % for those in moderate health249

.

Regarding the effect on the years of schooling, the author estimates that those in poor health have on average

2.4 years less of schooling completed than those in excellent health, those in moderate health 1 year less, and

those in fair health 0.3 years less250

. Adult men with limiting health problems have on average 0.7 years less of

schooling that those with no health limitations. The results of these studies do not, however, allow us to infer a

causal relationship running from health to education.

A study by Berger and Leigh (1989) examined the alternative explanations for the observed positive

correlation between schooling and good health. First of all, the authors used data from the US National

Longitudinal Survey of Young Men (NLS), which included a sample of men aged between 14 and 24, to

estimate the number of completed years of schooling in 1976 on the value in 1966 of a number of variables251

,

which included a measure of ‘whether health limits work, school, or other activities’. Berger and Leigh found

a significant and negative impact of poor health in 1966 on the number of completed years of schooling in

1976. This suggests that part of the correlation between schooling and health is due to the fact that those who

are less healthy invest less in schooling.

The authors were particularly interested to test the hypothesis that the strong correlation between schooling

and good health might be because both are influenced by some common unobserved factors like genetics,

personality or preference variables (such as rate of time discount).

To do so, they estimated health status in 1976 in two different ways: (1) using an instrumental variable for the

level of schooling, and (2) using a self-selection model that allowed separating the partial effect of schooling

on health from the effect of common unobservable factors (affecting both health and schooling) on health.

Two measures of health status were available in the NLS252

for year 1976: a measure of presence or absence of

functional limitations, and a measure of presence or absence of work limiting disabilities.

Both the effect of the predicted value of schooling (using an instrumental variable) and the partial effect of

schooling (using the ‘self-selection model’) are found to be significant and have a negative effect on the two

measures of health limitations. This effect is only slightly lower (between 11 and 29 % lower) than what

results using directly the number of completed years of schooling observed in 1976. Moreover, the impact of

other common variables on health, and of their interaction with schooling, is found to be insignificant. The

authors therefore conclude that the direct effect of schooling on health is more important than the effect of

unobserved third variables, such as the rate of discount.

Their conclusion corresponds to the findings in a study by Fuchs (1980), according to which the effect of time

preference on health behaviour and health status was not always significant, and, even when statistically

significant, was frequently small.

Using data from Great Britain, Case et al. (2004) find that children with poor health have significantly lower

educational attainment. Exploring alternative explanations for the widely documented positive association

between good health and higher economic status in adulthood, these authors analyze the impact of health and

economic circumstances in childhood on adult health, employment and socioeconomic status. One of the

channels the authors explore is precisely the impact of health on educational attainment. Their study makes

use of the panel data from the 1958 National Child Development Study (NCDS), which followed all children

248

Center for Human Resources Research. 249

Also controlling for age and proxies of family earnings. 250

Controlling for age and proxies of family earnings. 251

Other variables include: age, marital status, race, household size, whether the individual is a household head, whether he lives in an SMSA (standard metropolitan statistical area), ability measures, and measures of family background. 252

The authors conducted the same estimates on a second set of cross-sectional data, on which we do not report here. The results with this second data set were similar to those reported here.

born in Great Britain (Scotland, England and Wales)253

in the week of 3 March 1958 from birth until age 42,

with follow up interviews conducted also at ages 7, 11, 16, 23 and 33.

The measures of prenatal and childhood health used are: low birth weight (less than 2 500 grams), indicators

of how much the child’s mother smoked during pregnancy (moderately, heavily, variable), the number of

physician-assessed chronic health conditions observed at ages 7 and 16 (differentiating between physical

impairments, mental and emotional conditions, and other ‘systems’ conditions), and height at age 16. For this

analysis, the measure of education used is the number of O-level (school) exams passed at age 16254

.

Controlling for different factors of family background and for the height of the child’s mother and father, Case

et al. find that children with low birth weight passed on average 0.5 fewer O-level exams. A mother’s smoking

during pregnancy is also associated with significantly fewer O-level passes, 0.4 fewer for heavy smokers.

Each chronic condition at age 7 is associated with a 0.3 reduction in the number of O-levels passed, and each

condition at age 16, with an extra 0.2 reduction. Height at age 16 has a significant and positive relation with

the number of O-level exams passed.

Mental and emotional conditions in childhood are, among the three types of conditions distinguished, those

more strongly related with educational attainment, as measured by the number of O-level exams passed. The

authors note that estimates done with other measures of educational outcomes (passing the English O-level at

age 16, passing the Math O-level at age 16, and the highest educational qualification at age 23) yield very

similar results.

The same UK data set is used by Gregg and Machin (1998), who among other things estimate the effect of

whether a child has ever been sick (because of ‘minor ailments’ or because of ‘more serious ailments’) in the

last school year (age 15–16) on two outcomes: school attendance in the autumn term and the probability of

staying on at school after the compulsory school leaving age. The authors find that for both males and females,

not only is school attendance lower for those who were ever sick, what might seem more obvious, but also that

having suffered either minor or more serious ailments in the last school year reduced the probability of staying

on at school after compulsory school leaving age.

The relationship between health in childhood and cognitive development has been the subject of several

studies in the USA. Edwards and Grossman (1980) find a significant correlation between two indicators of

cognitive development (an IQ measure, and a measure of school achievement) and several health indicators.

The authors use cross-sectional data from the Cycle II of the Health Examination Survey (HES) which covers

children aged 6 to 11 years over the period 1963–65. They estimate the effect of 13 health-related dimensions

(four related to past health status and nine related to current health status) on two measures of the children’s

cognitive development. The impact of a series of non-health variables255

is controlled for.

Their results show a significant correlation between the two measures of cognitive development used (the IQ

measure and the measure of school achievement) and the following health-related variables: low birth weight

(negative), being breast-fed (positive), having a ‘significant abnormality’256

(negative), height (positive effect),

and the number of decayed teeth (negative). The measure of school achievement was also found to be

significantly and negatively correlated with having hearing problems and with health being assessed as poor or

fair by the child’s parents. Finally, the IQ measure was lower for children whose mother was younger than 20

years at birth and higher for those whose mother was older than 35 years compared with those whose mother

was between 20 and 35 years old.

However, as noted by the authors, these findings cannot be interpreted as evidence of a causal relationship

running from health to cognitive development, for at least the following three reasons: (1) the results might be

partially due to causality running from cognitive development to health, (2) the relationships could be due to

third factors (genetic or environmental factors) omitted from the analysis, and (3) some of the health indicators

253

There has been attrition from the original sample of 17 409 children. Around 700 children born during the same week who immigrated to Great Britain prior to age 16 have also been added to the survey. 254

Information on the British school system can be found in the appendix of Case et al. (2004). Information on the British school system can be found in the appendix of Case et al. (2004). 255

Sex of the child, whether the child is the first born in the family, whether the child is a twin, whether the child attended kindergarten or nursery school, size of the family, years of formal schooling completed by the mother and by the father, labour force status of the mother, family income, whether a foreign language is spoken at home, region of residence, and size of place of residence. 256

Significant abnormalities reported by the examining physician include heart disease (congenital or acquired); neurological; muscular, or joint conditions; other congenital abnormalities; and other major diseases.

used might be proxies for other non-health related factors (for example, breast-feeding could be a proxy for

mothers’ allocation of time to children).

Using a longitudinal sample of children and adolescents257

, Shakotko et al. (1980) find a significant negative

effect of having one or more significant health abnormalities258

and of high diastolic blood pressure in

childhood, on the IQ measure in adolescence. Mental and emotional conditions in childhood are, among the

three types of conditions distinguished, those more strongly related with educational attainment, as measured

by the number of O-level exams passed. The authors note that estimates done with other measures of

educational outcomes (passing the English O-level at age 16, passing the Math O-level at age 16, and the

highest educational qualification at age 23) yield very similar results.

The same UK data set is used by Gregg and Machin (1998), who among other things estimate the effect of

whether a child has ever been sick (because of ‘minor ailments’ or because of ‘more serious ailments’) in the

last school year (age 15–16) on two outcomes: school attendance in the autumn term and the probability of

staying on at school after the compulsory school leaving age. The authors find that for both males and females,

not only is school attendance lower for those who were ever sick, what might seem more obvious, but also that

having suffered either minor or more serious ailments in the last school year reduced the probability of staying

on at school after compulsory school leaving age.

The relationship between health in childhood and cognitive development has been the subject of several

studies in the USA. Edwards and Grossman (1980) find a significant correlation between two indicators of

cognitive development (an IQ measure, and a measure of school achievement) and several health indicators.

The authors use cross-sectional data from the Cycle II of the Health Examination Survey (HES) which covers

children aged 6 to 11 years over the period 1963–65. They estimate the effect of 13 health-related dimensions

(four related to past health status and nine related to current health status) on two measures of the children’s

cognitive development. The impact of a series of non-health variables99

is controlled for.

Their results show a significant correlation between the two measures of cognitive development used (the IQ

measure and the measure of school achievement) and the following health-related variables: low birth weight

(negative), being breast-fed (positive), having a ‘significant abnormality’100

(negative), height (positive effect),

and the number of decayed teeth (negative). The measure of school achievement was also found to be

significantly and negatively correlated with having hearing problems and with health being assessed as poor or

fair by the child’s parents. Finally, the IQ measure was lower for children whose mother was younger than 20

years at birth and higher for those whose mother was older than 35 years compared with those whose mother

was between 20 and 35 years old.

However, as noted by the authors, these findings cannot be interpreted as evidence of a causal relationship

running from health to cognitive development, for at least the following three reasons: (1) the results might be

partially due to causality running from cognitive development to health, (2) the relationships could be due to

third factors (genetic or environmental factors) omitted from the analysis, and (3) some of the health indicators

used might be proxies for other non-health related factors (for example, breast-feeding could be a proxy for

mothers’ allocation of time to children).

Using a longitudinal sample of children and adolescents101

, Shakotko et al. (1980) find a significant negative

effect of having one or more significant health abnormalities102

and of high diastolic blood pressure in

childhood, on the IQ measure in adolescence.

The authors compile data from a 1963–65 survey and a 1966–70 survey. Individuals in the sample are aged

between 6 and 11 years in the 1963–65 period and between 12 and 17 years in the 1966–70 period. The

authors use the same two measures of cognitive development as Edwards and Grossman (1980): an IQ

measure and a school achievement measure. Using an ordinary least squares regression method, this paper

estimates the measures of adolescent cognitive development on measures of childhood health, childhood

cognitive development, and on a series of variables regarding family background.

The authors also regress adolescent health on several measures of childhood health, childhood cognitive

development, and family background. Their analysis finds that higher school achievement in childhood is

significantly and positively correlated with health in adolescence for four out of six health indicators used259

.

257

Compiled from two nationally representative cross-sections of children: Cycles II (years 1963-65) and III (years 1966-70) of the Health Examination Survey (HES). 258

Heart disease; neurological, muscular, or joint conditions; other major diseases. 259

A periodontal index; the presence or not of one or more significant abnormalities as reported by the examining physician; parent’s assessment of the adolescence overall health; and excessive school absence for health reasons during the past six months or not.

Two indicators of health in childhood260

(out of six) are also significantly correlated to the measure of IQ in

adolescence. The authors therefore conclude that there is feedback both from health to cognitive development

and from cognitive development to health, but that the latter of these relationships seems stronger. Their

results suggest that there is a continuous interaction between health and cognitive development over the life

cycle. The authors also find a significant and strong positive correlation between cognitive development in

childhood and cognitive development in adolescence.

In a more recent study conducted in a large north-eastern city in the USA, Del Gaudio Weiss and Fantuzzo

(2001) find that two health risks (low birth weight and lead poisoning) increased the risk of poor school

adjustment in children of first grade. The study was done on a sample of 9 088 students enrolled in first grade

during 1995–96. The mean age of the students at the end of first grade was 7.1 years. The authors sought to

examine the relationship between seven risk factors (three related to the child’s health and four related to the

child’s caretaking environment) on the adjustment of children to the first year of elementary school.

According to the authors, it is relevant to look at early achievement, as the patterns of educational achievement

are quite stable over time, and ‘early school achievement patterns are likely to persist’.

For each of the risk factors under analysis, the authors choose a threshold beyond which a child is considered

to be at risk. The health risks studied are: low birth weight (less than 2 500 gr.), lead poisoning (10 μg/dl of

lead in blood), and the Apgar score261

(risk at scores ≤ 6). The indicators of school adjustment used are: an

indicator of school performance, an indicator of school behaviour, grade retention (not meeting the criteria to

pass first grade at the end of the year) and an indicator of school attendance262

. Controlling for age and poverty

concentration in the child’s area of residence, logistic regression analyses were conducted for each of these

outcome variables. The results suggest

that low birth weight increases the probability of poor academic performance by 34 % and of grade retention

by 32 %. Moreover, lead poisoning increased the probability of poor school behaviour by 16 %.

On the contrary, risk as measured by the Apgar score was found to have a positive impact on On the contrary,

risk as measured by the Apgar score was found to have a positive impact on school behaviour, reducing the

probability of poor school behaviour by 50 %. None of these health risks was, however, found to have a

significant effect on school attendance.

The evidence presented here suggests that, although the strong positive correlation between health and

education might be mostly due to the impact of education on health, at least part of this relationship could be

due to the impact of health on education, mainly through the effect of health conditions in childhood in

cognitive development. This provides an additional argument in favour of investing in children’s health.

III.3.3 The impact of health on saving

It is highly plausible that savings will increase with the prospect of a longer and healthier life. The idea of

planning and, hence, saving for retirement would be expected to occur only when mortality rates become low

enough for retirement to be a realistic prospect. Some work confirms such an effect in the case of developing

countries. In the high-income country context, our review found comparatively little published research in this

area263

.

As Smith (1999) argues, there would be important insights to be gained from studying the effect of health on

savings behaviour, for ‘as people age, the evolving variation in their health offers statistical information to

estimate parameters of household savings and consumption behaviour that so far have proven to be somewhat

elusive’ (Smith 1999, p. 146). Given the relative shortage of empirical literature on this issue, we limit

ourselves to a brief description of the main potential channels that could account for an impact of health on

saving, and complement this by some empirical illustration.

Arithmetically, savings would fall as current health deteriorates because poor health reduces current period

income or increases either consumption or out-of-pocket medical expenses. A striking result of a study

260

As mentioned previously, these were: having one or more significant abnormalities and having high diastolic blood pressure. (78) As mentioned previously, these were: having one or more significant abnormalities and having high diastolic blood pressure. 261

The five-minute Apgar score is a measure that discriminates infants in need of resuscitation at birth from those who do not need medical intervention. Newborns are rated on five physical signs and scores range from 0 to 10. 262

An indicator of presence or absence of ‘special education’ was initially also included, but there were very few children receiving this sort of education, and no risk factor appeared as significant. 263

Some exceptions are Hubbard et al. (1994), Lillard and Weiss (1996), and Palumbo (1998).

reported by Smith (1999) is how modest out-of-pocket medical costs are for the average person in a high-

income country, such as the USA, and how relatively insensitive costs are to the onset of even serious

illnesses, in contrast to the situation in low-income countries.

Individuals or households may well adjust in more subtle ways to present or anticipated changes in health. If

the marginal utility of consumption is a function of health status (i.e. the utility of consuming one additional

unit increases with the health status), then individuals will seek to consume more when they are healthy than

when in ill health. If so, savings will rise when the prospect of poor health increases264

.

Some households may also adjust to new or anticipated health events not by reducing current or future

consumption, but instead by decreasing financial transfers to their heirs. This hypothesis finds some initial

empirical support in the US context. More than half of the survey respondents in poor health report they are

certain they will not leave an inheritance larger than USD 10 000, while more than half of households in

excellent health are just as certain that they will leave such an inheritance (Smith 1999).

The onset of ill health may also affect savings by reducing the amount of labour supplied. This channel takes

the abovementioned impact of ill health on labour supply one step further. In the research by Smith (1999), the

labour supply effect accounted for a substantial amount of the income effect caused by a new and severe

health problem.

Overall, the evidence presented in this section does support the hypothesis of a positive economic impact of

health on economic outcomes on the individual or household level. Certain methodological challenges remain,

such as the ‘right’ measurement of health, or the question of how to tackle endogeneity, but they are not very

unique to this field of research and there are ways of overcoming them. The following section turns to the

review of the macroeconomic evidence.

III.4 The impact of health on the macroeconomy

The key question is whether the micro effects discussed above translate into an aggregate effect on the country

level in terms of GDP or the GDP growth rate. This will be discussed in the subsequent sections. The first

section looks at the contribution of historic achievements to contemporary economic wealth, as reported by

more or less quantitative studies of single countries. The second section reviews the results of studies that have

used more extensive quantitative methods in order to determine the contribution of health to economic growth

across a larger set of countries.

III.4.1 The impact of historic health improvements in determining contemporary national wealth

Historical studies exploring the role of health in a specific country over one or two centuries have shown that a

large share of today’s economic wealth is directly attributable to past achievement in health.

Several important historical studies have examined the contribution of health improvement to the economic

development of one or more countries over one or two centuries. This approach has been pioneered by the

Nobel laureate Robert Fogel265

. While a description of the detailed methods used goes beyond the scope of this

book, for our present purposes the key finding is the overwhelming strength of evidence that health has made a

substantial contribution to the current level of economic development in industrialized countries.

Fogel (1994) reported that improvements in health and nutrition have accounted for about 30 % of income

growth in the United Kingdom, or about 1.15 % per capita per annum in the 200-year period from 1780 to

1980. The author pointed out that what he terms the average efficiency of the human engine in the United

Kingdom, by which he meant the ability to convert energy into work, increased by about 53 % between 1790

and 1980. He concluded that the combined effects of the increase in dietary energy available for work (as less

was required for domestic tasks), and of increased human efficiency in transforming dietary energy into work

output, to account for about 50 % of the British economic growth since 1790.

In a more recent study, Arora (2001) argues that the assessment of the influence of health on economic growth

requires longer sample periods.

264

Whether or not the marginal utility of consumption is increasing in health is an empirical question though, and different authors have found conflicting results (see Smith 1999). 265

For an overview, see for example Fogel (1997). For an overview, see for example Fogel (1997). For an overview, see for example Fogel (1997).

The author investigates the influence of health266

on the growth paths of 10 industrialised countries over the

course of 100 to 125 years. The countries and the time spans selected are Australia (1881–1994), Denmark

(1870–1992), Finland (1881–1992), France (1870–1994), Italy (1875–1992), Japan (1891–1994), Netherlands

(1880–1992), Norway (1870–1992), Sweden (1870–1994) and the United Kingdom (1871–1992). Arora

concludes that improvements in health increased the rate of growth in these countries by 30 to 40 %, altering

permanently the slope of their growth paths.

III.4.2 Health as a determinant of economic development

Health — typically measured as life expectancy or adult mortality — emerges as a very robust and sizeable

predictor of subsequent economic growth in virtually all studies that have explored the issue in explaining

differences in growth between rich and poor countries. Researchers have focused much less on investigating

the specific role of health in economic growth in high-income countries only, and in the few cases in which

this was done, health was not always found to be positively related to economic growth, and in some case

there was even a negative relationship. We attribute these results partly to the use of health indicators that

imperfectly capture the existing health differences between high-income countries. This is confirmed by a very

recent analysis showing that if cardiovascular disease mortality is used as a health proxy, health does matter

significantly for subsequent economic growth in high-income countries. The institutional policy framework in

high-income countries, in particular through the definition of the retirement age might also prevent health (of

the elderly) from making its full beneficial impact on economic growth in high-income countries. If, as was

shown above, health is a major determinant of long-term economic growth, to what extent are contemporary

differences in the wealth of nations attributable to health? There are essentially two methods that have been

employed to assess empirically the macroeconomic impact of health gain: the aggregate production function

approach (which seeks explanations for variations in per capita income) and the economic growth regressions

approach. The aggregate production function approach is an adaptation of the firm-level production function at

the national level. Obviously, this assumes that there exists an aggregate production function that works in a

similar way as the firm level production function267

.

The economic growth regression approach is rooted in the broader literature on the determinants of economic

growth (see Barro and Sala-I-Martin (1995) for an overview) and has a more solid theoretical foundation than

the production function approach. Most of the studies use a global sample, including rich and poor countries.

The volume of this research focusing specifically on health as a determinant of growth in rich countries is

rather limited and there remains significant scope for further research.

Nearly all studies that have examined economic growth using one of these two methods have found evidence

of a positive, significant and sizeable influence of life expectancy or adult mortality (or other health

indicators) on the subsequent pace of economic growth (see, for example, Barro 1996, Barro 1991, Barro and

Lee 1994, Barro and Sala-I-Martin 1995, Bhargava et al. 2001, Easterly and Levine 1997, Gallup and Sachs

2000, Sachs and Warner 1995, and Sachs and Warner 1997)). In some studies, initial health even seems to be a

better predictor of subsequent growth than is initial education (Barro 1996).

While potentially delivering more powerful results, growth regression studies tend to suffer from problems of

multi-collinearity, leading to a large variation in the significance and size of the coefficient estimates. Hence,

in the economic growth literature only very few variables have been found to be robust predictors of economic

growth. In these circumstances, it is especially notable that two prominent studies that have attempted to

identify robust determinants of growth did find life expectancy to be part of this ‘exclusive’ set of variables

(Levine and Renelt 1992, and Sala-I-Martin et al. 2004).

As is noted above, most of these studies include rich and poor countries at the same time. Their findings may

or may not be directly applicable to rich countries alone. Below we review in more detail the results of a

selection of key studies that have used a global sample. A few of these studies find important differences in the

relationship between health and economic growth in poor and rich countries, although some find evidence of a

negative impact of certain health indicators on economic growth (or on income) in high-income countries but

266

The author used the following five health-related variables: life expectancy at: birth; 5 years old; 10 years old; 15 or 20 years old; and stature at adulthood. 267

Some of the production function studies reviewed below regress changes in the level of income (hence growth rates) on changes in the independent variables. This is, however, equivalent to the estimation of levels controlling for country-specific fixed effects, and it does therefore not make these studies comparable to proper economic growth studies.

not in low- and middle-income countries. As we argue below, however, such a result cannot lead us to

conclude that health is bad for growth in high-income countries for the reasons below.

The global studies did not specifically examine economic growth in high-income countries.

Where health indicators do seem to be negatively associated with economic growth in high-income countries,

this may be because increasing health in these countries increases the share of people beyond retirement age,

i.e. those outside the formal labour force, which in turn puts a burden on public budgets and thereby might

indirectly hamper economic growth prospects. If so, then the reason for the negative economic impact of

health is not improved health per se, but the consequence of having a too early retirement age. Should

retirement age be increased, bringing more and healthier older people into the workforce, this would most

likely allow health to ‘deliver’ its positive impact on the labour market and on the economy.

The most plausible explanation for the surprising finding that there may be a negative impact of health on the

economy is that it is an artefact, related to the choice of health indicator. It is apparent that life expectancy and

adult mortality vary more widely among low- and middle-income countries than in high-income countries

where there is some evidence of convergence at a high level. It is perhaps no great surprise that if the chosen

health indicator varies little between the sub-samples of rich countries, then it can hardly have much of an

explanatory power. A serious examination of the role of health in rich countries clearly requires the use of

health indicators that are better able to discriminate between levels of health among these countries.

A few studies have focused specifically on high-income countries. These will be reviewed further below.

There we shall also present the results of so far unpublished work by some of the authors of this book, which

seeks to address specifically the latter point.

III.4.2.1 Macroeconomic studies using a worldwide sample of countries

The cross-country studies of the impact of health on income levels and growth rates, as stressed by Strauss and

Thomas (1998), date back to the first of the World Bank’s reports on poverty (World Bank 1980). In 1993, the

World Bank’s World Development Report ‘Investing in health’ (World Bank 1993) reported strong economic

effects of health using an aggregate production function methodology.

More recent studies have examined the impact of life expectancy on economic growth in a worldwide set of

countries (see, for example, Barro 1996, Sachs and Warner 1997, and Bloom and Williamson 1998),

consistently finding strong positive effects of improved health on economic development.

Using a panel data set from about 100 countries for the period from 1960 to 1990, Barro (1996) has identified

the following variables as being the most powerful predictors of subsequent economic growth: lower initial

GDP; initial human capital, measured by male secondary and higher schooling and life expectancy; lower

fertility rate; lower government consumption ratio; rule of law; terms of trade; and a lower inflation rate. In

particular, Barro detected a significantly positive effect of health (measured by life expectancy) on economic

growth, and the size of the effect even appeared to be bigger than the effect of education. Holding the other

factors constant, a rise in life expectancy from 50 to 70 years (i.e. by 40 %) would raise the growth rate by 1.4

percentage points per year. Barro also notes that the link between overall health status and subsequent

economic growth runs both ways. Better health tends to enhance economic growth in various ways. At the

same time, economic advance encourages further accumulation of health capital.

From the work of Barro and other related research, it can be surmised, if all other conditions are equal, a five-

year advantage in life expectancy will give a country 0.3 to 0.5 % higher annual growth of GDP than its less

healthy counterparts. This would represent a significant boost to growth, given that in the last 25 years,

average per capita income growth in the world has been only 2 % per annum (Zamora 2000).

Essential evidence on the potential effect of health investment on economic growth has been provided by

Bloom, Canning and Sevilla (Bloom et al. 2001, Bloom and Canning 2000). Their main conclusion is that

good health has a positive, sizeable, and statistically significant effect on aggregate output for a broad range of

countries. They extend the conventional production function model by including work experience and health

(in addition to education)268

and analyze panel data for GDP for 104 countries for every 10 years from 1960 to

268

The approach used by Bloom et al. is to include health in a well-specified aggregate production function in an attempt to test for the existence of a true effect of health on labour productivity, and to measure its strength. However, because human capital is multidimensional, the model of growth has to include all its major components, in order to ensure that the contribution of a single component is not overestimated. For this reason, the authors of the model added work experience to the model, because considerable microeconomic evidence indicates that it has an impact on workers’ earnings (see, for example, Mincer 1974). The macroeconomic measures of health and work experience have

1990. The researchers use life expectancy as a proxy for health of the workforce. A key finding of their

research is that a one-year improvement in a population’s life expectancy contributes an increase of 4 % in

GDP. They stress that this is by most standards a very large effect, indicating that increased expenditures on

improving health might be justified purely on the grounds of their impact on labour productivity. However, the

authors note that accounting for economic growth is only the first stage in explaining the effect of health on

the economy.

Bhargava et al. (2001) use adult survival rates (i.e. essentially the inverse of adult mortality rates) between

ages 15 and 60 as a health proxy in order to assess the effect of health on economic growth in a worldwide

panel data set for the period 1965 to 1990. A novel aspect of the analysis is that the authors are sensitive to

potential non-linearities in the relationship between health and economic growth. By interacting the health

proxy with per capita income, they detect a threshold income level beyond which adult survival rates may

have negligible or even negative effects on growth rates.

Below the threshold income level, i.e. for the poorest countries, a 1 % improvement in the adult survival rate

was associated with an approximate 0.05 % increase in the growth rate. Beyond the threshold income, i.e. for

developed countries, the estimated effect of adult survival rates on growth rates tends to be negative.

Jamison et al. (2004), using data from more than 50 developing and developed countries, conclude that

improvements in health (as measured again by the adult survival rate) accounted for about one tenth of

economic growth in the period 1965–90269

. Countries with initially high levels of adult survival typically

achieved a more modest contribution to their growth rates from health improvements than did countries with

an initially lower initial adult survival rates. Decomposing income growth into its sources, the authors find that

increases in physical capital stock dominate (accounting for 67 % of total growth) but both educational

improvements (14 %) and health improvements (11 %) make up for an important share, too. Jamison et al.

(2004) find diminishing returns from investment in health, consistent with the previously reported ones by

Bhargava (2001). However, as the authors pointed out, these results should be interpreted with some caution

for several reasons. First, lack of data on morbidity or disability required use of mortality rates as a proxy for

overall health conditions but it is plausible that changes in morbidity may also be significant for income

growth while they are only partially correlated with mortality decline and they might lag mortality decline.

Second, health improvements above age 60 are likely to be important (in terms, for example, of age of

retirement) and may show scope for significant improvement well after the adult survival rate has reached high

levels.

Knowles and Owen (1995) examined the effects of incorporating a proxy for health capital in a human capital-

augmented economic growth model270

. A sample of 84 countries is used in the model. The results show a

strong and relatively robust relationship between life expectancy, as a proxy for health capital, and income per

capita.

Brinkley (2001) examines the health–wealth causality for the US only. GNP data since 1900 is used as a proxy

for wealth and are tested against four health variables, namely life expectancy, infant mortality rates, crude

death rates, and investment in medical research271

(89). The author tested both hypotheses: that health triggers

wealth and that wealth causes health. The results are unequivocal — for all four health variables, the causal

pathway runs from health to wealth. Given the long observation period, which is, depending on the variable,

from 1900, 1915 or 1948 until 1991, Brinkley considers his results as highly robust and thus he concludes that

governmental intervention should not focus on pro-growth but rather on health-enhancing policies. Improving

health thus becomes key to creating the conditions for sustainable economic growth.

III.4.2 .2 Macroeconomic studies focusing on high-income countries

Very few studies have focused on the role of health in determining income levels or economic growth in high-

income countries specifically. Exceptions include Knowles and Owen (1995), Knowles and Owen (1997),

been constructed to examine whether microeconomic evidence of their importance as forms of human capital carries over to a significant, positive macroeconomic impact. Other studies use a similar approach as Bloom et al. (2001, 2002). Strauss and Thomas (1998) list several studies where microeconomic evidence is used on factor shares and the effect of human capital on wages to calibrate production function models of aggregate output (Klenow and Rodriguez-Clare 1997, Prescott 1998, Weil 2004, Young 1994, 1995). 269

Data are extracted from PWT, version 5.6, WDI (World Bank 2001). 270

The basic data set is the one used in Mankin-Romer-Weil (MRW). 271

Granger-causality framework is applied.

Rivera and Currais (1999a, 1999b) and Beraldo et al. (2005). Knowles and Owen use life expectancy as a

proxy for health in the sub-sample of 22 high-income countries they specifically examine and find an

insignificant impact of that health indicator on economic growth (Knowles and Owen 1995) and on the level

of per capita income (Knowles and Owen 1997). The panel estimates used by the authors span the period

1960–85. As Tompa (2002) argues, the insignificant result is most likely due to the very limited variability of

life expectancy within the sample of rich countries.

In contrast, Rivera and Currais (1999a, 1999b) and Beraldo et al. (2005)272

use health expenditures (as a share

of GDP) as proxies for health in OECD countries. All three studies find a statistically significant impact of

health expenditures on economic growth and on income levels. While the authors make a case in favour of

their health proxy, at the same time it must be recognized that health expenditures are a rather questionable

proxy for health in high-income countries. They are not closely correlated with the more usual measures of

health such as life expectancy and child mortality, and it is perhaps questionable whether the marginal dollar

spent on medical care translates into morbidity reductions (Tompa 2002).

Bearing these reservations in mind, the results are nevertheless important. Beraldo et al. (2005) find the role of

spending on health to explain a much larger share (between 16 and 27 %) of growth rates than expenditures on

education (around 3 %). Similar results are found by Rivera and Currais (1999a, 1999b). Taking the results at

face value this suggests that (a) investing in health contributes to economic growth even in countries that

presumably already have a high health status, and (b) investing in health is at the very least as important, if not

more important, a contributor to economic growth than investing in education.

There is also a slightly different interpretation of these results, offered in particular by Beraldo et al. (2005).

Health (and education) expenditures may be seen as proxies for the size of the welfare state.

According to Beraldo et al., the result of a positive impact of health (and/or education) expenditures on

economic growth in high-income countries would therefore be consistent with the hypothesis that the

contribution of welfare expenditures more than compensates for the distortions caused by the tax system273

. It

may be worth elaborating on this interpretation and the highly controversial policy implications that flow from

it, such as the question of whether the welfare state is good for growth.

Mainstream economic reasoning would forcefully deny such a beneficial effect, because the financing of the

welfare state occurs via taxation, and taxation distorts the optimal allocation of goods, imposing an efficiency

loss upon the economy. Everyone would be better off, so goes the standard argument, if the tax burden were to

be reduced. On the other hand, as Atkinson (1995) suggests, this argument is in itself somewhat ‘distorted’, as

it highlights only one side of the coin. In fact, through the revenues generated via taxation, the welfare state

makes available potentially productive public expenditure that could reasonably have a positive impact on

people’s health, skills and knowledge, and, through this channel, on economic growth.

Naturally, it is important not to assume that all public expenditures traditionally included under the definition

of the welfare state would have a positive effect on human health (and skills). The argument should not be

extrapolated to justify massive levels of taxation and public expenditures. At the same time, the recent

remarkable economic performance of some of the Nordic European countries tends quite convincingly to

reject the hypothesis that high taxation and public expenditures inevitably represent a brake on dynamic

economic development.

Recent and ongoing work by Suhrcke and Urban (2005) has taken a different line in assessing the role of

health in economic growth in rich countries. Starting from the notion that non-communicable diseases (NCDs)

characterize the health pattern in high-income countries better than in low-income countries, they asked what

the role of the most important NCD, i.e. cardiovascular disease (CVD), would be in determining economic

growth. Using panel regressions for the period 1960 to 2000 for a worldwide set of countries, they find that,

when focusing on the sample of 26 high-income countries, CVD mortality (of the working-age population)

turns out to be a robust predictor of subsequent economic growth. In one specification, a reduction of CVD

mortality at working age of 10 % is associated with an increase in the growth rate of per capita GDP by 1

percentage point274

.

272

Beraldo et al. (2005) use a panel of 19 OECD countries for the period from 1971 to 1998. They apply a production function approach. 273

This interpretation brings the results very close to the findings and interpretations of Lindert (2004). For the theoretical arguments supporting the hypothesis, see also Atkinson (1995). 274

When looking at the sample of low- and middle-income countries only, the impact of CVD working-age mortality becomes insignificant. This is the converse result of other studies that have used life expectancy (e.g. Knowles and

These results underline the need to look for more appropriate health indicators when trying to assess the

impact of health on economic growth in rich countries. The mortality rate from CVD appears to be one such

indicator, not least because it displays more variability among the high-income country group than does life

expectancy. Other health indicators, for instance mental illness or morbidity indicators, might also be

important in the rich country context (Tompa 2002).

III.4.3 The direct impact of the health system on the economy: an accounting approach

While there is a direct effect of health on the economy as described in the previous section, there is also an

impact of the health system on the economy irrespective of the ways in which the health system directly

affects health. The health sector ‘matters’ in economic terms simply because of its size.

It represents one of the most important sectors in developed economies, representing one of the largest service

industries. Currently its output accounts for about 7 % of GDP in the EU-15, larger than the roughly 5 %

accounted for by the financial services sector or the retail trade sector275

.

Through its sheer accounting effect, trends in productivity and efficiency in the health sector will have a large

impact on these performance measures in economies as a whole. Moreover, the performance of the health

sector will affect the competitiveness of the overall economy via its effect on labour costs, labour market

flexibility and the allocation of resources at the macroeconomic level.

The economic importance of the health sector can be further illustrated by its direct labour market effect.

According to the Eurostat Labour Force Survey, the share of persons employed in the health and social sector

represented 8.8 % of all people employed in the EU-15 and 9.3 % of all those employed in the EU-25 in the

second quarter of 2003276

. As Table 7 shows, employment figures in the health and social care sectors are

growing in the USA and in Europe, even if rates of change vary significantly across countries.

Through its sheer economic size, developments in the health sector have significant consequences for the

macroeconomy. But the economic context of the health sector is very different from other sectors and this has

specific implications for the impact of the health sector on the economy: there is very little international trade

in health services and, hence, health providers in EU countries face little international competition. This

specific situation may become either a great opportunity or a risk for the overall economy. Unless appropriate

regulatory measures are in place, it may lead to inefficiencies that have a knock-on effect on the rest of the

economy, leading to the potential for misallocation of resources. This in turn may affect competitiveness at the

macroeconomic level by diverting resources away from other, potentially more productive, sectors of the

economy.

More specifically, there are two main channels through which the health sector can directly affect the

competitiveness of the overall economy. The first is the impact of the health system on labour costs, and hence

international competitiveness. The second is the effects the system will have on job mobility and hence on

labour market flexibility. If the health sector expands out of control, this will affect labour costs via tax rates

and insurance contributions. Labour costs are an important determinant of international competitiveness and

increased taxation or insurance contributions will affect it negatively, unless the increased health spending

brings with it a parallel increase in productivity, such as reductions in the number of days lost through ill

health. If there is over-consumption of healthcare services — due to problems of supplier induced demand for

example — the increase in costs is unlikely to result in such an increase in productivity (European

Commission 2004).

Evaluating performance in the health sector therefore becomes key to ensure that the outcomes of the health

system are optimized (i.e. that of maintaining and improving health in the first place).

However, evaluating performance in services, and the public sector in particular is fraught with difficulties

(O’Mahony and Stevens 2002). Doing so for the health sector is more difficult than in other service sectors

since both the system of provision and the nature of the production process have a number of unique features

(European Commission 2004).

III.4.4 The contribution of health to ‘full income’: taking a welfare approach

Owen 1997) which found a significant positive impact in the low- and middle-income sample, but an insignificant one in the high-income sample. 275

O’Mahony and Van Ark (2003). 276

For similar analysis and figures, see also Buchegger and Stoeger (2003).

The new approach presented here starts from the uncontroversial recognition that GDP is an imperfect

measure of social welfare because it fails to incorporate the value of health. The true purpose of economic

activity is the maximization of social welfare, not necessarily of the production of goods by itself. Since health

is an important component of properly defined social welfare, measuring the economic cost of ill health only

in terms of foregone GDP leaves out a potentially major part of its ‘full income’ impact, defined as its impact

on social welfare. Taking the welfare impact of health into account gives an even stronger illustration of the

‘true’ economic importance of health. Most of the existing studies have focused on the situation in the USA.

Health is clearly ‘valued’ very highly, and more than most other market or non-market goods, even if it cannot

typically be given a ‘market price’277

. Yet while health has no market price, this does not imply that health has

no value. When asked, people are ready to give up substantial income for better and longer health. Therefore,

even if no explicit value exists, there must be an implicit value that people attribute to health. While this value

is high, it is not infinite, since in the day-to-day context we are not willing to give up everything in exchange

for better health278

.

The challenge is to make the high value attributed to health more explicitly visible by measuring the extent to

which we are willing to trade-off health with specific market goods for which a price exists.

This is undertaken in willingness-to-pay (WTP) studies. WTP is often inferred from the existence of risk

premiums in the job market. Jobs that entail health risks, such as miners and construction workers in

hazardous industries, receive higher compensation in the form of a risk premium. There is now a large number

of WTP studies, making it possible to calculate a ‘value of a statistical life’ (VSL) that can in turn be used to

value changes in mortality. Usher (1973) first introduced the value of mortality reductions into national

income accounting. He did this by generating estimates of the growth in ‘full income’ (or ‘wealth’) — a

concept that captures the changes in life expectancy by including them in an assessment of economic welfare

— for six countries and territories (Canada, Chile, France, Japan, Sri Lanka, and Taiwan Province of China)

during the middle decades of the 20th century.

For the higher income countries in this group, about 30 % of the growth of full income resulted from declines

in mortality. Estimates of changes in full income are typically generated by adding the value of changes in

annual mortality rates (calculated using VSL figures) to changes in annual GDP per capita. Even these

estimates of full income are conservative in that they incorporate only the value of changes in mortality and do

not include the total value of changes in the health status.

For the USA, Nordhaus (2003) found that the economic value of increases in longevity in the last 100 years is

about as large as the value of measured growth in non-health goods and services. In a rediscovery of Usher’s

pioneering work, Nordhaus tested the hypothesis that improvements in health status have made a major

contribution to economic wealth (defined as full income) over the 20th century.

A more detailed assessment reveals that ‘health income’ probably contributed to changes in full income

somewhat more than non-health goods and services in the first half of the 20th century and marginally less

than non-health goods and services since 1950. If the results of this and other related studies (e.g. Costa and

Kahn 2003, Crafts 2003, Cutler and Richardson 1997, Miller 2000 and Viscusiand Aldy 2003)) are confirmed,

then the role of health (and of the activities that promote health, among others the healthcare system) should

be reconsidered. It raises the possibility that the social productivity of spending on health (via the health

system and via other sectors) might be many times greater than that of other forms of investment.

Most of this very recent research has focused on the USA. Similar studies from the EU context are rare, with

Crafts (2003) being one notable exception. Like Nordhaus (2003), he examines the value of life expectancy

improvements in the UK between 1870 and 2001 and concludes that these health improvements have had an

impact on full income that is equivalent to large additions in material consumptions.

Preliminary analysis by partners in the present project, carried out in parallel with the preparation of the book,

has applied the full income approach to selected EU countries (UK, Sweden, France, Italy and Spain) to assess

the value of changes in life expectancy between 1990 and 1998 (McKee et al. 2005). The value of a life year

used by Nordhaus ($2,600) was applied to the change in life expectancy at birth to calculate the gain in health

income. However, in a refinement of the method, the value of a life year gained was also applied to the gain in

life expectancy that is attributable to healthcare (based on an earlier study of mortality avoidable by timely and

277

The healthcare inputs are included in the measurement of GDP, but they represent only a small share of the true value of health, as argued further below. 278

We are describing here situations in which people face marginal trade-offs between health and other goods. We do not consider the far less representative situation in which people are facing an immediate death threat, the prospect of which would clearly increase the readiness to give in the maximum amount of other goods in order to prevent death.

effective care (Nolte and McKee (2004)). These are then compared with changes in expenditure on healthcare.

By these means, and for the sake of simplicity disregarding time lags, it can be shown that there are substantial

economic welfare returns to health. The value of life expectancy improvements amounts to between 60 and

almost 100 % of the increases in per capita GDP in that period. In addition, the authors propose an estimate of

the return to health expenditures in terms of that part of the resulting life expectancy improvements that can be

ascribed to improved healthcare provision. The results show rates of return between about 50 and 270 % — a

magnitude that is not matched easily by other types of investment. The study makes no comparison with the

returns from investment in broader population health interventions, for which the return is likely to be even

greater. Furthermore, as this analysis considers only mortality and not the less easily measured improvements

in quality of life, and as Nordhaus’s figure has not been updated to account for inflation, the gains are likely to

be a considerable underestimate.

We consider the development of a similar indicator for the EU countries279

as an approach that would give a

powerful quantitative argument to illustrate the contribution of health to economic welfare.

At the same time, it would overcome some shortcomings in the use of GDP as a measure of social welfare. It

could help reshape the way we think about health, health policy, and the associated returns.

III.5 Investing in health

The research reviewed supports the premise that improving the health status of a population can be beneficial

for economic outcomes at the individual and the national level.

There is indeed much evidence to suggest that the association between economic wealth and health does not

run solely from the former to the latter. An immediate, if general, policy implication that derives from this

conclusion is that policy-makers who are interested in improving economic outcomes (e.g. on the labour

market or for the entire economy) would have good reasons to consider investment in health as one of their

options by which to meet their economic objectives.

This raises the question of just how should we invest in health and how much does it cost for what return?

Investment in health includes spending on any activity whose main objective is the re-establishment,

maintenance, improvement and protection of health in a country during a defined period of time. Investment in

health takes place both outside and inside the ‘health system’280

. The resources that a country will assign to the

different sectors of its economy reflect both the needs of the country and the priorities of society, expressed

through the decisions of its government. Thus, the share of GDP allocated to healthcare and other activities

that promote health provides a means of identifying the priority given to health, especially when related to

indicators of health needs.

It is beyond the scope of this book to review and evaluate all the possible ways of investing in health — in and

outside the health sector. In what follows we limit ourselves to first describing the need for an integrated,

multi-sectoral policy response. Subsequently, we scrutinize one specific way of investing in health, which is

via investment in the health system. We do not elaborate on health investment taking place outside the health

sector, even though this is considered as an important part of investing in health. A new, independent

Commission on Social Determinants of Health (CSDH), set up by WHO, has recently started to collect and

produce the evidence on this subject.

III.5.1 An integrated policy response

279

Within the EU one could build on some studies referring to the UK context (see references in Costa and Kahn 2003). 280

We follow the definition proposed by the WHO (WHO 2000), according to which a health system comprises ‘all organisations, institutions and resources that are devoted to producing health actions’. A health action is further defined as any effort, whether in (1) personal healthcare, (2) public health services or (3) through intersectoral initiatives, whose primary purpose is to improve health. This definition goes beyond the narrower concept of the ‘healthcare system’, which only refers to the first two items. The wider definition explicitly excludes those actions that do impact upon health, but whose primary purpose is not health improvement. An example of the latter is the general education system, while specifically health-related education would be part of the health system. In the literature these two concepts are often used interchangeably and this may cause some confusion. In part this may be due to the fact that the narrow concept can be measured far more easily, so that even if one wanted to refer to the wider concept, measurement problems often pose a limit to this ambition.

It is important that governments establish an integrated policy framework by which they can assure themselves

that what is being done to achieve good health is appropriate and effective. This book argues the case for

mechanisms that will permit the assessment of the health needs of a population, the identification of effective

interventions to respond to those needs, and the monitoring of the results achieved.

Given that the burden of disease in developed countries is mainly due to lifestyle Given that the burden of

disease in developed countries is mainly due to lifestyle factors, health investment must inevitably involve

actions and measures addressing issues lying outside the reach of the traditional healthcare systems, requiring

action across government.

This section reviews the steps that might be taken by a country seeking to ‘invest’ effectively in the health of

its population. The first step is to determine the major causes of ill health afflicting one’s population. These

causes act at several levels281

.

First, there are the immediate causes, with the major examples common to all EU Member States including

cancer, cardiovascular disease, mental health problems and injuries. The inclusion of mental health acts as a

reminder of the need to go beyond narrow measures of mortality to include those causes that increase distress

and disability. Second, there are a series of individual determinants of health that are common to several

disease processes, related to lifestyle and living conditions (including access to healthcare), of which the main

examples in Europe are tobacco, poor nutrition (and lack of physical exercise), and hazardous drinking. Third

are the wider determinants of health, related to the general socioeconomic, cultural and environmental

conditions, which include poverty, poor education, unsafe environments, and more broadly defined social

exclusion. However, a comprehensive assessment of health needs should go beyond existing problems to

anticipate future developments, including both those that can be predicted, for example by extrapolation of

current disease trends, as well as those that are less predictable, such as infectious disease outbreaks. These

steps clearly imply that each country has put in place the necessary information systems to monitor the health

of its population and to analyze appropriately the resulting data.

The second step is to identify appropriate policy responses, based on the best available evidence.

These will inevitably span a range of activities from health promotion through disease prevention, treatment

and rehabilitation. Some will be the responsibility of the healthcare system, for others the healthcare system

can play either a leadership or a catalytic role by encouraging and supporting other sectors, and in some cases

the main responsibility will be in other sectors, such as transport or education.

The third step is to establish a system to monitor the impact of the policies being put in place, recognizing that,

as with any complex human system, there is a risk of unintended consequences and there is rarely a linear

relationship between the implementation of a policy and its outcome.

From this brief review it will be apparent that a pro-growth policy that includes a focus on health will require

action across government to tackle the main determinants of health. Many governments have already done

much to achieve this, as illustrated by the increasing numbers of countries that are banning smoking in public

places. It is, however, important not to overlook the contribution that the healthcare system can make. This is

considered in the following section.

III.5.2 Investing in health via the health system

What is the role that the health system plays in determining health? This is far from being the trivial question it

might look like. The contribution of the health system to population health has long been debated. We first

review briefly this discussion and conclude that the contribution of healthcare in promoting health is likely to

have increased over the last decades. We then take the discussion one step further by asking, what then could

be the ‘right’ level of spending on healthcare.

III.5.2.1 The impact of the health system on population health

Various commentators have argued that the role of healthcare was rather small and may even have been

detrimental (Illich 1976, McKeown 1979) back to the 1960s when healthcare offered much less than now. In

fact, the impact of ‘curative medical measures’ may reasonably be assumed to have had little effect on

mortality decline prior to the mid-20th century (Colgrove 2002). Since then, the scope and quality of

healthcare have changed almost beyond recognition.

281

See for a set of health determinants.

A reassessment of the contribution of healthcare to population health has followed the development of the

concept of ‘unnecessary untimely mortality’, or ‘avoidable’ mortality, first developed by Rustein et al. (1980)

and Rutstein et al. (1977). This work analyses mortality trends for a selection of conditions in which death can

be avoided by adequate preventive or therapeutic intervention. Most studies, in which socio-demographic

variables are used to control for the influence of external factors, have shown that healthcare interventions

have had a substantial effect on the decline in mortality, especially over the past 30 years: Poikolainen and

Eskola (1986), Charlton et al. (1983), Holland (1986), Jougla et al. (1987), Mackenbach et al. (1988).

Nolte and McKee (2004) have undertaken a systematic review of empirical and methodological studies using

the concept of ‘avoidable’ mortality and of its use in attributing health outcomes to healthcare.

This review confirmed the ability of ‘avoidable’ mortality to assess the contribution of healthcare to

population health. Building on this work, the authors used a modified version of this concept by updating the

list of conditions considered amenable to healthcare in the light of advances in medical knowledge and

technology and using a higher age limit of 75 years. This was then applied to routinely available data from

selected countries in the European Union to investigate the potential impact of healthcare on changing life

expectancy and mortality in the 1980s and 1990s. Importantly, they noted that the healthcare system now has a

role that goes beyond treating people who fall ill, but also encompasses development of a wide range of

preventive activities to reduce the risk of disease in the first place.

They showed that, since 1980 all European countries experienced increases in life expectancy between birth

and age 75 although the pace of change differed over time and between countries. Reductions in amenable

mortality made substantial positive contributions in the 1980s in all countries except for men in Italy. The

largest contribution was from falling infant mortality but also improvements among the middle-aged, for

example in Denmark, the Netherlands, the UK, France and Sweden. In many countries the pace of

improvement slowed in the 1990s although not in the Mediterranean countries, a finding that would imply a

continued catching up in the southern European countries. Overall, these findings support the notion that

improvements in access to effective healthcare had a measurable impact in many countries during the 1980s

and 1990s and, for the purposes of this book, confirm the potential for investment in health services to

improve population health outcomes.

The conclusion that healthcare matters for population health does, however, not give us much guidance as to

just how much should be spent on healthcare — a key question in today’s health policy discussions.

III.5.2.2 How much to spend on the health system?

If the health system matters for health, there is a case for spending money on the health system. But how much

should be spent? Obviously, there is no simple answer to this question, as health expenditures are driven —

legitimately or not — by a multitude of factors.

The following sections provide a very brief overview of some of the issues surrounding the factors that do or

should influence the level of health expenditures. The level of a country’s economic development is one

important determinant of health expenditures. This does not mean that countries should only decide their

health expenditure level according to some pre-defined function of their GDP per capita. In fact there are more

appropriate ways of determining the right level of expenditures. Last but not least there is the key issue of how

much improving the health of the elderly can or cannot contribute to easing some of the pressure on the

demand for rising health expenditures.

III.5.2.2.1 Health expenditure as a function of the level of economic development282

The notion of healthcare being a luxury good frequently underpins the debate on healthcare funding.

In this section we argue that this is based on a simplistic interpretation of the available evidence, which when

taken together shows that it is not at all inevitable that healthcare expenditure will increase and countries

become more wealthy. At the same time, many commentators have argued that additional health expenditure

brings little tangible benefit. This too is unsupported by the evidence.

By extension, these findings compel us, when asking how much a health system should spend, to first ask

what it is required to achieve, given factors such as the burden of disease confronting it.

Expenditure on healthcare in EU Member States typically accounts for about 9 % of GDP, having increased

from about 7 % in 1980. As a significant part of the economy, it is important to understand what factors

282

We are especially grateful to Dr Panos Kanavos for his advice on this section.

determine a country’s level of health expenditure. Is it driven by patterns of health, by political preferences, by

the cost of inputs, or is it, as some have argued, simply a reflection of national income? In other words, is

healthcare a ‘luxury good’ in that increasing wealth fuels higher expectations, so that the share of national

income spent on healthcare increases inexorably as national income increases? If this is the case, as some

argue, then the case for further increasing healthcare expenditure is weakened as it implies that rising

expenditures are simply a reflection of economic growth and not a legitimate response to health needs. Sound

fiscal policy should therefore seek to reduce this level of expenditure.

The earliest analyses of the determinants of health expenditure date from the early 1960s when Abel-Smith

attempted to standardise the sources of data used in cross-national comparisons. In an analysis of 15 countries,

he showed that, after adjustment for exchange rates, inflation and population size, and using a simple linear

model, GDP was a major determinant of health expenditure (Abel-Smith 1967). This was followed by a 1974

study by Kleiman, using a log-linear model with cross-sectional data, that reported that the income elasticity of

demand for healthcare was greater than 1 (Kleiman 1974). In other words, the increase in health expenditure

was proportionately greater than that of national income. A 1977 paper by Newhouse was extremely

influential (Newhouse 1977). It used a linear model to examine cross-sectional data from 13 countries for the

years between 1968 and 1972 (the years selected were not the same for each country) and found that GDP

explained a remarkable 92 % of variation in health expenditure and again reported an income elasticity of

greater than 1283

. Newhouse interpreted this finding as indicating that ‘medical care services at the margin

have less to do with common measures of health status … and more to do with … relief of anxiety, somewhat

more accurate diagnosis and heroic measures near the end of life’. There was no attempt to examine whether

the increased expenditure on healthcare was contributing to population health.

This research was, however, being undertaken shortly after the publication of McKeown’s report ‘The role of

medicine’, which argued that healthcare had contributed little to population health since the middle of the 19th

century (McKeown 1979) as well as Illich’s report ‘Medical nemesis’, which introduced the concept of

iatrogenesis, proposing that much healthcare was actually damaging to health (Illich 1976). Consequently,

Newhouse’s paper was used to argue in favour of containing rising costs on what was seen as somewhat

ineffective healthcare. This view was supported in a 1979 paper by Cullis and West who again reported that

healthcare was a luxury good and stated that ‘at the margin [healthcare] may contribute little to physiological

health’ (Cullis and West 1979).

At the same time, a body of literature was emerging, using household or subnational data that came to a rather

different conclusion. Research on the relationship between income and, variously, hospital, physician or total

health expenditure in American States (Baker 1997, Feldstein 1971, Fuchs 1980, Levit 1982) or Canadian

provinces (Di Matteo and Di Matteo 1998) found income elasticities of between 0.5 and 0.9, implying that

healthcare is not a luxury good, as did studies on household income and consumption (Gbsemete and

Gerdtham 1992, Wagstaff 1986).

What was by now becoming established wisdom that healthcare expenditure would rise inexorably with

growing national income, while bringing little benefit to population health, was challenged on two fronts. The

first was from an economic perspective. Parkin et al. (1987) noted that exponential models were viewed as

most appropriate for goods that are considered to be luxuries, making the finding of a large elasticity a self-

fulfilling prophecy (see Table 9). Subsequently, other researchers have explored the relationship using either

general purchasing power parities (derived from a broad range of goods from all sectors of the economy) or

health specific purchasing power parities (derived from a basket of health-related goods, although dominated

by pharmaceuticals) (Gerdtham and Jönsson 1991). Most found elasticities of greater than 1, although several

have been the subject of reanalysis to take account of statistical features of the data (such as

heteroscedasticity) (Murthy 1992) resulting in the identification of elasticities less than 1.

The second challenge came from the perspective of epidemiology. The concept of ‘avoidable mortality’ or

‘mortality amenable to medical/healthcare’ was developed (as discussed in the previous section), separating

those deaths that could not be avoided by timely and effective healthcare from those that could (Rutstein et al.

1977). Healthcare appeared to have contributed substantially to the observed gains in life expectancy in

Western industrialized countries (Charlton et al. 1983, Holland 1986, Mackenbach et al. 1988).

Recognition that factors other than national income are likely to play a role in determining health expenditure

has led to studies that use more complex multivariate models. Leu hypothesized that health expenditure would

283

Elasticity is the measure of responsiveness of demand to changes in prices or incomes, measured as the proportionate change in the quantity demanded divided by the proportionate change in income. Normal goods are those with positive income elasticity and inferior goods are those with negative income elasticity.

increase faster where the share of public expenditure was highest (Leu 1986). His analysis explored this

variable as well as national income, a range of demographic variables, and some system specific factors. He

was able to confirm his main hypothesis and demonstrate an income elasticity greater than 1 as well as

associations with the demographic variables that were in the directions predicted. He also showed that the

presence of a national health service model (as in the United Kingdom and New Zealand) reduced

expenditure, a finding attributed to the central control exerted on the system.

Subsequent researchers, using different years and functional forms, have not, however, been able to replicate

these findings. For example, Gerdtham et al. found that an increased share of public financing was associated

with a lower health expenditure whereas, as expected, fee for service payment was associated with higher

expenditure (Gerdtham et al. 1992). Another analysis by Gerdtham (1992) using data from 22 countries for the

period 1972–87, which also took account of demographic changes and the share of public financing, found an

income elasticity of less than 1, in contrast to that found by Leu, as well as identifying a series of country- and

period-specific effects. Hitiris and Posnett, using a larger data set, as well as additional statistical refinements,

found an income elasticity that was close to unity (1.026 when using exchange rate conversions and 1.16 with

purchasing power parities) (Hitiris and Posnett 1992).

Research using time series analyses confronts the problem of underlying trends that may introduce bias that

can occur if using cross-sectional data. Studies using time-series approaches have generally found income

elasticities of less than 1 or a non-significant association between GDP and health expenditure (Blomqvist and

Carter 1997, McCoskey and Selden 1998, Saez and Murillo 1994).

Analyses that have focused on the relationship between national income and health expenditure have thus

yielded conflicting results. While it is a widely held view that healthcare expenditure inevitably increases

faster than national income and the increased expenditure contributes little to population health, it is not a view

that is unequivocally supported by the available evidence. Any relationship that exists between national

income and health expenditure is influenced by the choice of years, countries and model form.

As a previous section showed, healthcare does contribute positively to population health and the appropriate

level of expenditure is that needed to deliver the amount and type of healthcare that is appropriate for the

needs of the population in question. This approach is elaborated in the following paragraphs.

III.5.2.2.2 An alternative way to decide how much to spend on the health system

There is no simple answer to the question of how much a country should spend on healthcare, as each country

faces a different burden of disease, its populations have differing expectations, and it faces different

geographical constraints on what it can do. Furthermore, the inputs required to provide an appropriate package

of care vary considerably, largely as a consequence of decisions taken in other sectors.

One of the few examples where an attempt has been made to relate the required level of healthcare expenditure

to health needs is in the United Kingdom, where the Treasury has commissioned two reports by a senior

executive from the financial services sector, Sir Derek Wanless. In his first report he was asked to estimate the

future cost of providing healthcare to the British population in 2020. To do this he began from the bottom up,

assessing what the health service was presently providing and what, on the basis of the best available

evidence, it should be providing. In doing so, he was greatly helped by earlier work developing a series of

National Service frameworks. These frameworks, produced by the British government’s National Institute for

Clinical Evidence, reviewed the evidence for cost-effectiveness of healthcare interventions used in the

management of common disease categories, such as cardiovascular disease and diabetes. These interventions

ranged from prevention through diagnosis and treatment to rehabilitation.

This approach has a compelling logic, in that rather than attempt to distil some figure from regressions of

frequently incomparable data where the association between inputs and outcomes is to say the least opaque, it

begins by asking what the healthcare system should actually be seeking to achieve. Having done this, it then

decides what it needs to achieve its objectives. This is exactly the same approach that is adopted in most other

sectors. We can only speculate why it has not been done previously in the health sector, although reasons are

likely to include both the complexity and the limited analytical capacity in many health ministries (and here it

is noteworthy that these reports were prepared under the auspices of a finance ministry).

Although the methods employed in the Wanless reports are the principal focus of interest here, the findings are

also important. The first report concluded that the future level of expenditure on healthcare was critically

dependent on investment now. He identified three possible scenarios, one of which, fully engaged, involved a

major investment in the promotion of health and the provision of effective healthcare. Specifically, it

recognized the long time horizons involved in healthcare investment, so that decisions were needed many

years in advance if necessary numbers of trained staff and appropriately designed facilities are to be in place

when they will be needed.

The Wanless reports provide a very solid basis for defining the appropriate level of healthcare expenditure.

However, they look at the situation in only one country while each country has a number of specificities. The

remainder of this section builds on that work to propose a schematic model of the key elements to be taken

into account when seeking to understand the need for financial resources for the health system within a

country. It uses a highly simplified model of the inputs into the production of health by a healthcare system.

The amount of money needed to fund a healthcare system adequately is a function of a large number of

variables. The first set relates to the demands placed upon the healthcare system. The most obvious, but one

that is often overlooked, is the burden of disease requiring treatment. A sicker population will require more

healthcare. However, there is no simple linear relationship between conventional measures of burden of

disease and the need for resources as the key issue is the nature of the disease. Some conditions can be treated

simply and at low cost while others that account for the same aggregate burden of disease may require a

complex and expensive package of care. A second factor is the extent to which care is provided informally, by

families and friends. In many countries a combination of ageing populations, greater female participation in

the workforce, and changing societal attitudes is causing much care that was once provided within the family

to be transferred to the health and social care sectors. A third is the nature of public expectations. These too are

changing, consistent with the growth of consumerism in other sectors. Finally, it is necessary to take account

of issues such as geographical dispersion. Thus, it is more expensive to provide care to a low-density

population, such as that in northern Sweden or Finland, as there is a need to provide many small facilities in

isolated areas, as well as mechanisms to enable the inhabitants to obtain care in specialized centres elsewhere.

The second set of factors relates to the supply of healthcare and in all cases these are to a considerable extent

determined by factors external to the health sector. The first is the cost of employing the staff that will provide

healthcare. The level of salary required to recruit and retain staff is a function of the labour market, which is

influenced by both the supply (for example, output of educational programmes, migration) and demand

(including in other sectors). The cost of recruiting staff is also influenced by skill-mix, for example the extents

to which tasks are undertaken by different types of health professionals. A second is the cost of

pharmaceuticals and technology. All EU Member States have imposed some form of price controls and, while

parallel trade has led to some degree of harmonization, there are still considerable variations among countries.

Athird is the cost of capital, influenced by factors such as interest rates and, in some countries, the use of new

models of capital financing.

Expenditure in an individual year is also influenced by the inherited stock of capital, an issue of particular

importance for the new Member States in central Europe where, prior to 1989, the model of care was based on

widespread substitution of cheap labour for what would have been expensive capital. Free movement of

professionals, who can now move to Member States where wages are higher, means that this model is no

longer sustainable. A fourth is the cost of research and development, with some countries investing in

indigenous medical and health services research while others take advantage of evidence obtained elsewhere.

It is also influenced by the extent to which countries engage in translational research and getting research into

practice. The cost of many of these inputs is affected by EU legislation, most of which has been decided by

ministers responsible for other sectors.

Examples include the European working time directive, which is having profound implications for staffing

healthcare facilities, and the European directive on clinical trials, which is increasing greatly the cost and

difficulty of undertaking clinical research in Europe.

III.5.2.2.3 Financing of health care

The inputs to healthcare systems require money, and countries vary in the way that they collect it.

The system in place in a particular country often reflects historical factors; the complexity of healthcare

financing means that countries never begin with a blank sheet when developing a financing system.

For the present purposes it is important to ensure that the funds that are necessary to provide healthcare are

raised in a way that promotes growth, drawing on a wide revenue base that does not discourage investment or

employment.

The issue of revenue generation was addressed by the UK Treasury’s Wanless report, which concluded that

there was no justification for changing the tax-based system of financing the British National Health Service to

any of the other possible models, in particular a social insurance system, which had been advocated by some

political commentators. In doing so, Sir Derek Wanless noted the disproportionate burden on employment

costs of social insurance, in contrast with the much broader revenue base available with taxation, which could

draw on not only income tax but also company tax, value added tax, and a wide range of other sources of

government revenue, including customs tariffs and the burgeoning number of taxes on specific activities and

goods (such as vehicle excise duty, transport surcharges, etc.). This echoed debates taking place in some other

countries, such as France, where there has been concern about the ability of a system based on social

insurance, which was established at a time when patterns of employment and family structures were quite

different from now, to respond adequately to changing circumstances.

It is then necessary to bring together the appropriate mix of inputs in ways that meet the demands on the

healthcare system. At the risk of simplification, there are essentially two approaches. One is to assume a

reactive approach, hoping that the sum of interactions between individual patients and health professionals

will lead to the delivery of an appropriate package of care that maximizes health.

However, there are many reasons why this is unlikely to happen. First, there is often unmet need for care, with

those at most need often failing to seek it as they face obstacles both within and outside the healthcare system.

Second, the care that is provided might not necessarily be appropriate, for example where providers respond to

inappropriate incentives. The alternative model is strategic purchasing, involving assessment of health needs,

identification of evidence-based models of care, and monitoring the impact of these interventions on health.

A health-promoting health system can be expected to reduce future costs by reducing the burden of disease

within the population. However, it can go beyond this by engaging in health promotion, both through its own

efforts and by catalysing the efforts of those in other sectors that have the ability to adopt policies that will

promote health.

III.5.2.2.4 Health and healthcare expenditure in the context of an ageing population

The population of Europe is ageing, as life expectancy increases and fertility declines. Consequently, in the

future there will be fewer people of working age to support those in retirement. What are the consequences for

healthcare expenditure?

Total public expenditure on healthcare represented 6.2 % of GDP in 2002 on average in the EU-15 countries

(including both curative activities and long-term care) (this figure is lower than that cited in the previous

section, which included expenditure from all sources). Research by the Netherlands Bureau for Economic

Policy Analysis (CPB), in the context of the AGIR project284

, indicates that this figure can be expected to

increase to 7.2 % in 2020 and to 8.9 % in 2050.

The increase in health expenditure is expected to be particularly dramatic in certain countries, and to reach the

10 % of GDP in countries such as Sweden, Finland and the Netherlands by 2050, under the current

institutional framework and expenditure patterns. These projections considered not only variations on health

expenditure by age, but also the different healthcare costs of survivors and decedents285

. The demographic data

were taken from the Eurostat 2000 population projections. CPB286

assumed that healthcare expenditures would

rise in line with GDP.

As the Wanless report noted, future needs for healthcare can be reduced if the population is not simply getting

older (as assumed in the Eurostat demographic projections) but also becoming healthier.

The impact of such a compression of morbidity hypothesis on expenditure was projected by CPB in an

optimistic ‘living in better health scenario’, which assumes that in the next 50 years the number of years lived

in bad health will be kept at the current level (and that therefore all improvement in life expectancy will be of

years lived in good health). CPB assumed that the elasticity of health expenditure to improvements in average

284

AGIR (acronym for ‘Ageing, health and retirement in Europe’) is the name of a three-year European research project on the economic consequences of ageing financed by the European Commission under the fifth research framework programme. Researchers from nine European economic policy research institutes have participated in this project. The AGIR project has explored all available information on the health developments in the EU-15 countries during the last 50 years, and analyzed how different future demographic and health scenarios could affect pension and healthcare expenditure in several EU countries. Further information on this project can be found at: http://www.enepri.org/Agir.htm 285

Healthcare costs are lower for survivors than for non-survivors, following recent evidence that the major expenditure on health happens in the last months of life. Profiles of expenditure on healthcare therefore vary according to both age and proximity to death. This approach forecasts a lower increase on healthcare expenditure than the approach followed by the EPC (Economic Policy Committee) considering only the relation between healthcare expenditure and age. 286

The report on CPB projections’ results is available at the ENEPRI website.

health status is of – 0.3 for people in ages 0–64 and of – 0.2287

for people aged 65 and older. According to their

calculations, the compression of morbidity scenario would correspond with a level of expenditure on

healthcare of 8 % of GDP in 2050 for the EU-15, this is, a 0.9 % of GDP lower than in the baseline scenario.

This further highlights the importance of investing in population health as a means of mitigating future

economic impacts of ageing populations.

The present section has shown that investing in healthcare can indeed be considered as one of several effective

ways of investing in health. Again, we emphasize that investing in healthcare is not the only way of investing

in health, since many of the determinants of health lie outside the health system. Moreover, the fact that

healthcare does matter for population health by itself does not answer the question of how much a country

should invest in healthcare. It does, however, suggest that the hypothesis that healthcare is a mere luxury good

producing little in terms of tangible results cannot be supported. We also showed briefly that, under certain

conditions, investing in the health of the elderly could reduce the rising healthcare costs associated with an

ageing society.

III.5.3 Cost-effectiveness of investment in healthcare and health promotion

The strength of the empirical evidence assembled to produce this book demonstrates the importance of

investment in health. The precise policies that Member States should consider will depend on their individual

circumstances. However, they all face the challenge of establishing mechanisms that can assess the health

needs confronting their populations, define interventions that respond effectively to those needs, and assess

progress towards better health. Although the volume of research on the cost-effectiveness of public health

programmes remains relatively small, what exists frequently shows that investments yield substantial positive

returns.

This section provides a brief, and of necessity highly selective, illustration of some interventions that have

been shown to be cost-effective in reducing the burden of disease in a population. Evidence on the cost-

effectiveness of health interventions is one of several key inputs into the decision-making This section

provides a brief, and of necessity highly selective, illustration of some interventions that have been shown to

be cost-effective in reducing the burden of disease in a population. Evidence on the cost-effectiveness of

health interventions is one of several key inputs into the decision-making process at the policy level, as it

provides information on those interventions that work and the resources required to implement them. In our

view the attempt to measure costs and effects (or benefits) associated with one or several narrowly or broadly

defined health interventions is crucial in helping to integrate health investments into national development

strategies, as they allow more direct comparison of the return from investing in health with potentially

competitive, ‘traditional’ economic investment outside the health domain. Perhaps because health has not been

seen primarily as an ‘investment’, the cost-effectiveness studies that exist at present are insufficient to provide

information on a sufficiently broad range of interventions.

Many of the interventions for which cost-effectiveness assessments exist focus on those at the individual level

rather than on populations as a whole, although the overall impact of the former on population health is

relatively small. Some types of population-based interventions with the potential to make very substantial

improvements in population health have either not been implemented very frequently or have rarely been

evaluated. While the evidence on cost and effectiveness of these interventions is less certain, it is important to

consider them because they have the potential to make very substantial differences in health outcomes.

Nevertheless, some evidence does exist. Perhaps the most comprehensive effort to assess cost-effectiveness of

a fairly comprehensive set of interventions over a large range of regional settings has been made by the WHO-

CHOICE project288

. In this section we focus on the representation of one influential study from Australia,

which has been at the forefront of economic evaluation of public health policies.

287

Derived from the results in Lubitz et al. (2003). 288

CHOICE: ‘Choosing interventions that are cost-effective’. Generally, WHO-CHOICE has been developing the tools and methods for generalized cost-effectiveness analysis (CEA). Its objectives are to: develop a standardized method for CEA that can be applied to all interventions in different settings; develop and disseminate tools required to assess intervention costs and impacts at the population level; determine the costs and effectiveness of a wide range of health interventions, undertaken by themselves or in combination; summarize the results in regional databases that will be available on the Internet; assist policy-makers and other stakeholders to interpret and use the evidence. For details, relevant papers and continuous updates see http://www.who.int/whosis/cea

Australia has adopted policies to reduce consumption of tobacco for many years, with considerable success.

The proportion of adult male smokers in the population fell from 75 % in 1945 to 45 % in 1974 and

subsequently to 27 % in 1995. Among adult women, the proportion declined from 33 % in 1976 to 29 % in

1986 and 23 % in 1995289

. Among smokers, the number of cigarettes smoked per day has also fallen

substantially since the 1960s, as has the real expenditure per adult on tobacco products.

This reduced tobacco consumption has given rise to major health benefits, with large reductions in premature

deaths from lung cancer, chronic obstructive pulmonary disease (COPD) and coronary heart disease. In 1998,

for example, an estimated 17 421 premature deaths were averted: 6 492 deaths from coronary heart disease; 3

998 deaths from lung cancer; 3 581 deaths from COPD; and 2 900 deaths from stroke and other cancers.

It has been estimated that the present value of the expenditure savings for government would provide savings

of about USD 2 for every USD 1 of expenditure on public health programmes to reduce tobacco

consumption290

.

Since the 1960s, most Australian States have implemented programmes to encourage women to have regular

cervical screening. The proportion of women aged 15 and above having cervical smears within the public

health system has increased markedly and, in 1997–98, reached 64 %. The cost per life saved by these

programmes is estimated to be approximately AUD 30 000 (NHMRC — National Health and Medical

Research Council 1997).

Australian governments at state and federal levels have engaged in sustained campaigns to reduce the toll from

road traffic injuries. The number of people killed per registered road vehicle has fallen steadily since 1970

even though the amount of road travel has almost doubled over this period (Abelson 2003). This trend reflects

improvements in roads (e.g. construction of high standard roads, skid resistant pavement, road delineation and

staggered T-intersections), vehicles (e.g. anti-burst door latches and hinges, energy absorbing steering

columns), driver skills, and road safety education.

Newstead et al. estimate that minor engineering works, declining alcohol sales, unemployment and road safety

programmes reduced serious crashes by 46 % below the expected trend in Victoria (Newstead 1995). They

also estimate that random breath testing, speed cameras, traffic infringement notices and supporting media

publicity were responsible for a 25–27 % reduction in serious crashes.

Road safety programmes are estimated to have saved governments AUD 750 million a year in the late 1990s

(Abelson 2003). The Traffic Accident Commission (TAC) in Victoria, which administers the no-fault accident

289

NHMRC — National Health and Medical Research Council (1997). 290

Since the 1960s, most Australian States have implemented programmes to encourage women to have regular cervical screening. The proportion of women aged 15 and above having cervical smears within the public health system has increased markedly and, in 1997–98, reached 64 %. The cost per life saved by these programmes is estimated to be approximately AUD 30 000 (NHMRC — National Health and Medical Research Council 1997). Australian governments at state and federal levels have engaged in sustained campaigns to reduce the toll from road traffic injuries. The number of people killed per registered road vehicle has fallen steadily since 1970 even though the amount of road travel has almost doubled over this period (Abelson 2003). This trend reflects improvements in roads (e.g. construction of high standard roads, skid resistant pavement, road delineation and staggered T-intersections), vehicles (e.g. anti-burst door latches and hinges, energy absorbing steering columns), driver skills, and road safety education. Newstead et al. estimate that minor engineering works, declining alcohol sales, unemployment and road safety programmes reduced serious crashes by 46 % below the expected trend in Victoria (Newstead 1995). They also estimate that random breath testing, speed cameras, traffic infringement notices and supporting media publicity were responsible for a 25–27 % reduction in serious crashes. Road safety programmes are estimated to have saved governments AUD 750 million a year in the late 1990s (Abelson 2003). The Traffic Accident Commission (TAC) in Victoria, which administers the no-fault accident compensation scheme and provides funds for specific enforcement activities, intensive media campaigns, school and traffic safety education and research, estimates that its prevention policies achieve a benefit–cost ratio of at least 3:1 (NHMRC — National Health and Medical Research Council 1997). There have been relatively few economic evaluations of prevention activities in Europe, with most coming from a few university departments. Thus, research undertaken in the United Kingdom has shown the cost-effectiveness of the English smoking cessation programme (Godfrey et al., 2005) and the benefits achieved by treating drug misuse in England, largely because of the reduction in the cost of crime (Godfrey et al., 2004). In The Netherlands, several studies have examined the economics of infectious disease control (Welte et al., 2004) and research from Sweden has assessed the cost-effectiveness of injury prevention (Lindqvist, 2001). These are, of course, purely illustrative examples but, in general, economic evaluation of prevention has been less well integrated with policy in Europe than in Australia.

compensation scheme and provides funds for specific enforcement activities, intensive media campaigns,

school and traffic safety education and research, estimates that its prevention policies achieve a benefit–cost

ratio of at least 3:1 (NHMRC — National Health and Medical Research Council 1997). There have been

relatively few economic evaluations of prevention activities in Europe, with most coming from a few

university departments. Thus, research undertaken in the United Kingdom has shown the cost-effectiveness of

the English smoking cessation programme (Godfrey et al., 2005) and the benefits achieved by treating drug

misuse in England, largely because of the reduction in the cost of crime (Godfrey et al., 2004). In The

Netherlands, several studies have examined the economics of infectious disease control (Welte et al., 2004)

and research from Sweden has assessed the cost-effectiveness of injury prevention (Lindqvist, 2001). These

are, of course, purely illustrative examples but, in general, economic evaluation of prevention has been less

well integrated with policy in Europe than in Australia.

III.5.4 Implications for the new EU Member States

The research reviewed in previous sections supports the premise that improving health of a population can be

beneficial for economic outcomes at the individual and the national level. There is indeed much evidence to

suggest that the association between economic wealth and health does clearly not solely run from the former to

the latter. An immediate, if general, policy implication that derives from this conclusion is that policy-makers

that are interested in improving economic outcomes (e.g. on the labour market or for the entire economy)

would have good reasons to consider investment in health as one of their options by which to meet their

objectives. This has particular relevance for the new Member States in central Europe where levels of both

health and economic performance lag behind the EU-15.

In many of the new Member States, investment in health has historically been given a relatively low priority.

This has continued at a time when the policy agenda was dominated by the process of EU accession, in which

health considerations played a minor role (Hager and Suhrcke 2001). As with all Member States, these

countries face major budgetary pressures, often exacerbated by the decision to adopt healthcare financing

systems based predominantly on employment-related contributions. In a period of relatively high official

unemployment, coupled in some countries with a large informal sector that does not contribute to the

healthcare budget, there is a risk of promoting a self-perpetuating cycle in which the necessary expenditure to

promote health adds disproportionately to the cost of employment as contributions fall on a narrow revenue

base, thus reducing competitiveness of economies and decreasing formal employment further, a situation

experienced in some western European welfare states over recent years (Alber and Köhler 2004, Esping-

Andersen 1996, Scharpf and Schmidt 2000).

Like all investments, the return on expenditure on health and healthcare is at some point in the future.

In this respect it is no different from a major infrastructure project. It is, however, an area where the potential

for return on investments, and the uncertainty associated with a return, has been less well understood than in

other sectors, and where fewer efforts have been undertaken to explicitly measure the returns to public health

investment in monetary terms so that they can be more directly compared with alternative investment projects.

The absence of a precise cost–benefit scenario may by itself have prohibited the inclusion of health investment

into national economic development plans.

III.6 The dialogue between regional and national actors with European institutional actors

III.6.1 European Territorial Co-operation

III.6.1.1 Introduction

Cohesion policy encourages regions and cities from different EU Member States to work together and learn

from each other through joint programmes, projects and networks. In the period 2007-13 the European

Territorial Co-operation objective (formerly the INTERREG Community Initiative) covers three types of

programmes:

•52 cross-border co-operation programmes along internal EU borders. ERDF contribution: €5.6 billion.

•13 transnational co-operation programmes cover larger areas of co-operation such as the Baltic Sea, Alpine

and Mediterranean regions. ERDF contribution: €1.8 billion.

•The interregional co-operation programme (INTERREG IVC) and 3 networking programmes (Urbact II,

Interact II and ESPON) cover all 27 Member States of the EU. They provide a framework for exchanging

experience between regional and local bodies in different countries. ERDF contribution: €445 million.

The European Territorial Co-operation objective is financed by the European Regional Development Fund

(ERDF) and supports cross-border, transnational and interregional co-operation programmes. The budget of

€8.7 billion for this objective accounts for 2.5% of the total 2007-13 allocation for cohesion policy, including

the allocation for Member States to participate in EU external border co-operation programmes supported by

other instruments (IPA and ENPI). For European Territorial Co-operation the European Regional

Development Fund (ERDF) regulation is applicable, in particular chapter 3.

The European Grouping for Territorial Cooperation (EGTC) is a new European legal instrument designed to

facilitate and promote cross-border, transnational and interregional cooperation. Unlike the structures which

governed this kind of cooperation before 2007, the EGTC is a legal entity and as such, will enable regional

and local authorities and other public bodies from different member states, to set up cooperation groupings

with a legal personality. More information about the EGTC.

Regional Policy Directorate General published in September 2011 a new publication entitled ' European

Territorial Cooperation: building bridges between people' . This publication will give you an insight into how

cooperation, including the European groupings for territorial cooperation and EU macro-regional strategies,

currently works, and what the future may hold. It brings you stories about people from all over Europe who

either have benefited from, or are somehow connected to, cooperation.

III.6.1.2 Solidarity and cohesion

Regional policy represents a financial solidarity instrument and a powerful cohesion force and economic

integration. Solidarity intends to bring concrete advantages to citizens and less favoured regions, while

cohesion answers to the principle that the income and well-being gaps existing among European regions

reduction is useful for all.

Wealth distribution is not homogeneous neither among member States, nor inside them. All the reachest

regions about pro capite GDP (standard well-being measure) are urban ones: London, Bruxelles and Hamburg.

The reachest country, that is Louxembourg, is seven times reacher than Romania and Bulgaria, the two poorest

countries recently joined the European Union.

The dynamic impulses coming from entering into EU, if sustained by a strong and aimed regional policy,

could produce results effectively. One of the priorities of regional policy is to bring as soon as possible the

standard of life of those countries which joined EU after 2004 closer to the others.

III.6.1.3 Inequality reasons

Regional inequalities have got different causes. They can depend on persisting disadvantages owing to

geographic distance or to more recent socio-economic changes, or to those factors combined. Disadvantage

situations often translate themselves into social withdrawal, inferior quality school systems, a higher

unemployment rate and inadequate structures. As regards some EU countries, these inequalities are partially

caused by the former centralized economies.

III.6.1.4 Success price

Regional policy invests in people.

The European Union seized the central and oriental European countries adherence as an opportunity to

reorganize and restructure its own regional financings. During the period 2007-2013 they will amount 36% of

the whole EU balance, about 350 Euro milliards, in order to concentrate on three prioritary objectives:

convergence, competitivity and cooperation, now collected in the so called “cohesion policy”.

Attention is mainly addressed to the new member States, as well as to other EU countries regions having

specific exigences. The twelve countries which have joined EU after 2004, even though they represent less

than 25% of European population, will receive 51% of regional financings between 2007 and 2013.

Financings come, on the ground of the assistance and beneficiary kind, from three different sources:

• the regional development European fund (RDEF), which finances programs having as a theme general

structures, innovation and investments. RDEF financings are destined to those poorest regions among all

the member States;

• the social European fund (SEF), which finances professional training projects and other kinds of program

in behalf of employment and work places creation. As RDEF, also SEF is destined to all member States;

• the cohesion fund, which finances environmental structures and transport and development projects on

renewable energies; financings are limited to those member States with a standard of life less than 90% of

EU average; thus beneficiaries are at present the twelve new member States, besides Portugal and Greece.

Spain, that was benefited by cohesion fund interventions in the past, will be progressively excluded.

III.6.1.5 How funds are spent

The major part of regional financings is riserve to regions with a GDP inferior than 75% of EU average, in

order to help them to improve their own structures and to develop their economic and human power.

Seventeen of the twentyseven EU countries are interested about. From the other side, all member States may

ask financings to promote innovation and research, sustainable development and professional formation in

their own less developed regions. A limited share is destined to transnational and interregional projects.

III.6.1.6 Growth and employment creating

The objective is to let flow together regional policy into the so called “Lisbon agenda”, in order to promote

growth and employment through the following initiatives:

• to let countries and regions to attract greater financings, improving accessibility, offering quality services

and safeguarding potentialities offered by environment;

• to promote innovation, undertaking and knowledge based economy through information and

communication technology development;

• to create better and more numerous employment places drawing more persons to the work market,

improving workers adapting capability and increasing human capital investments.

III.6.1.7 Interregional co-operation

Interregional cooperation works at pan-European level, covering all EU-27 Member States, and more. It builds

networks to develop good practice and facilitate the exchange and transfer of experience by successful regions.

It showcases what regions do well, to the benefit of those still investing.

The INTERREG IV C programme enables EU regions to work together and is structured around two

priorities, which address: innovation and the knowledge economy, and environment and risk prevention.

ERDF contribution: €321 million.

Countries: EU-27, Norway and Switzerland.

3 networking programmes:

•The URBACT II programme brings together actors at local and regional level to exchange experience and to

facilitate learning on urban policy themes. The programme supports thematic networks and working groups

between cities, conferences and the development of tools.

ERDF contribution: €53 million.

Countries: EU-27, Norway and Switzerland.

•The "European Spatial Planning Observation Network" (ESPON) provides scientific information for the

development of regions and larger territories through applied research, analysis and tools.

ERDF contribution: €34 million.

Countries: EU-27, Norway, Switzerland, Iceland and Liechtenstein.

•The INTERACT II programme provides training, services and tools to programme managers and

administrators of co-operation programmes in order to improve the management of these programmes.

Countries: EU-27,

ERDF contribution: €34 million.

Jointly with the URBACT II programme, the INTERREG IVC programme is the main vehicle for the EU

initiative ‘Regions for Economic Change’ which is designed to support regional and urban networks in

developing and spreading best practice in economic modernization. The most innovative projects can compete

for the annual RegioStars award.

III.6.1.8 Co-operation across borders

Cross-border cooperation is essentially about "filling the gaps". It does so through agreed cross-border

'analysis and response' strategies, formulated in each of the 52 cross-border programmes. It deals with a wide

range of issues, which include:

•Encouraging entrepreneurship, especially the development of SMEs, tourism, culture and cross-border trade;

•Improving joint management of natural resources;

•Supporting links between urban and rural areas;

•Improving access to transport and communication networks;

•Developing joint use of infrastructure;

•Administrative, employment and equal opportunities work.

Whether the challenge relates to infrastructure (building bridges), to markets and services (linking universities

to business to clients) or to cultural or linguistic barriers, cross-border co-operation is intended to address

them.

All 52 cross-border co-operation programmes are accessible through an interactive map.

The cross-border co-operation programmes under the Instrument for Pre-Accession are listed in a dedicated

section.

Annual meeting of cross-border cooperation programmes.

III.6.1.9 Transnational co-operation programmes

The transnational programmes add an important extra European dimension to regional development,

developed from analysis at a European level, leading to agreed priorities and a coordinated strategic response.

This allows meaningful work between regions from several EU Member States on matters such as

communication corridors, flood management, international business and research linkages, and the

development of more viable and sustainable markets. Themes covered include:

•Innovation, especially networks of universities, research institutions, SMEs;

•Environment, especially water resources, rivers, lakes, sea;

•Accessibility, including telecommunications, and in particular the completion of networks;

•Sustainable urban development, especially polycentric development.

There are currently 13 transnational co-operation programmes.

III.6.1.10 Regional development co-operation programmes outside the EU

There are also a number of new instruments available to support regional development along the EU’s external

borders with countries which are either candidates for EU membership or potential candidates, and also with

so-called third countries (i.e. non-EU members : Iceland, Norway, Switzerland, ...).

There are two instruments supporting cross-border co-operation along the external borders of the Union in

2007-13:

•The Instrument for Pre-Accession Assistance (IPA) is based on partnerships with the EU candidate countries

– the former Yugoslav Republic of Macedonia, Croatia, and Turkey – and potential candidate countries –

Albania, Bosnia and Herzegovina, Montenegro, and Serbia. It supports administrative, social and economic

reforms, as well as regional and cross-border co-operation. The IPA supports both cross-border co-operation

between Member States and candidate / potential candidate countries on the one hand, and among the

candidate / potential candidate countries themselves on the other. The first group is managed by Directorate-

General Regional Policy and further details can be found on this site. Details of the second group can be found

on the web pages of DG Enlargement. EU allocation: €11.47 billion, of which €600 million is earmarked for

cross-border co- operation.

•The European Neighbourhood and Partnership Instrument (ENPI) promotes co-operation and economic

integration between the EU and partner countries – Algeria, Armenia, Azerbaijan, Belarus, Egypt, Georgia,

Israel, Jordan, Lebanon, Libya, Moldova, Morocco, the Palestinian Authority, the Russian Federation, Syria,

Tunisia, and Ukraine. It supports partnerships encouraging good governance and social and economic

development. Included are 14 cross-border co-operation programmes which operate along EU external

borders. These programmes are managed by DG EuropeAid. Further details are available here.

EU allocation: €11.18 billion, of which ENPI-CBC programmes account for €1.18 billion.

III.6.1.11 European Grouping of Territorial Cooperation (EGTC)

The EGTC is an European legal instrument designed to facilitate and promote cross-border, transnational and

interregional cooperation. Unlike the structures which governed this kind of cooperation before 2007, the

EGTC is a legal entity and as such, will enable regional and local authorities and other public bodies from

different member states, to set up cooperation groupings with a legal personality. For example, an EGTC or

EGTC members can be:

•Member States

•Regional or local authorities

•Associations

•Any other public body

The EGTC is unique in the sense that it enables public authorities of various Member States to team up and

deliver joint services, without requiring a prior international agreement to be signed and ratified by national

parliaments. Member States must however agree to the participation of potential members in their respective

countries. The law applicable for the interpretation and application of the convention is that of the Member

State in which the official EGTC headquarters are located.

An EGTC convention sets out in particular:

•The name of the EGTC and its headquarters

•The list of members

•The area it covers

•Its objective

•Its mission

•Its duration

For more information:

•Regulation (EC) No 1082/2006 on a European grouping of territorial cooperation (EGTC)

•Committee of the Regions

•INTERACT EGTC

•(19/06/2008) European Grouping of Territorial Cooperation: Conference puts spotlight on new tool to help

regions team up for projects across borders

III.6.1.12 Regions for Economic Change

"Regions for Economic Change" is an initiative of the European Commission that aims to highlight good

practice in urban and regional development, with a particular focus on innovation, and to speed up the transfer

of good practices to enhance the quality and impact of the EU’s regional development programmes and their

implementation by the EU’s Member States and regions. It supports the EU policy objectives of smart,

sustainable and inclusive growth, as outlined in the EU’s 2020 strategy.

Regions for Economic Change is a learning platform for EU regions that includes the annual Regions for

Economic Change Conference and RegioStars Awards, a PolicyLearning Database and interregional fast track

networks, funded by the INTERREG IVC and URBACT II programmes. Those networks are testing

innovative ideas and working on their rapid transfer into regional policies and programmes. As such it will

also be instrumental to inspire ideas and concepts for regional ‘smart specialization’ strategies and to

maximize regional innovation potential.

III.6.1.12.1 Exchanging good practice between Europe's regions

Several examples could be brought about this theme. We shall show just two of them.

III.6.1.12.1.1 INTERREG IVC ‘Good Practice Fair 2011’ in Krakow

The INTERREG IVC ‘Good Practice Fair 2011’, was organised on 24 November 2011 in Krakow (Poland).

Interregional cooperation has brought many advantages to those organizations involved in partnerships.

Across 122 projects financed by the INTERREG IVC programme, over 1000 good practices have been

identified or transferred within cooperation projects. The knowledge gathered in 27 EU countries, Norway and

Switzerland is available to all and it is the right time to share:

•What effective techniques have been used to promote entrepreneurship in order to boost employment?

•What are the latest developments in sustainable public transport?

•How do regions deal with the emphasis on innovation and how can innovative ideas be brought to the

market?

•What works on a regional level when tackling climate change?

•How do regions face the challenges brought about by demographic change?

•How can improving energy use improve a region’s performance?

Policy-makers and practitioners from all over Europe have been invited for an intensive one-day event to share

experiences and encourage uptake of good practices identified or transferred with cooperation projects. The

day was a one-stop shop for regions who may be financially restricted but know that a good idea is worth gold.

For more information it is possible to connect to: goodpractice.interreg4c.eu.

III.6.1.12.1.2 Policy Learning Database

This searchable database has been developed primarily for project promoters, policy makers and other

practitioners to promote policy learning. During 2007-2009 it provided access to a growing collection of in-

depth project analyses to actively support the exchange of experience. In July 2010 it was expanded to include

specific ex-post regional analyses.

This searchable database therefore contains three types of documents:

•Case studies of specific projects funded under the EU's Cohesion policy from 2000 onwards. Designed

according to a case study methodology, the project specific case studies present the regional strategic context,

the activities and the results achieved, the partnership developed, the innovative dimension, the obstacles

encountered in implementing the innovation project and conclude with the lessons learnt and good practices

identified.

•Ex-post evaluation reports commissioned by DG REGIO on specific sectoral, regional or urban programmes

or sub-programmes. The overall synthesis reports under the different ex-post evaluation work packages are

not stored here but available on this link.

•Summaries of those RegioStars finalists pre-selected by independent juries (where a case study has not been

prepared).

The database is searchable by sector and sub-sectors, member states or regions. A short synthesis and project /

author contact details are provided on screen while the full case study or evaluation report (where available) is

linked for download.

This database is part of the communication effort foreseen under the Regions for Economic Change initiative

linked to spreading good practice, in particular on priority themes linked to innovation and modernisation

themes. While there is no standard way to improve regional competitiveness and develop effective public

policies there are many practical examples and evaluation outputs to learn from.

In addition to this database, several hundred short descriptions of Cohesion Policy funded projects in many

regions across all member states over several programming periods are available in the Success stories

database.

III.6.1.13 Examples of regional innovation projects

III.6.1.13.1 Foreword

More and better innovation in Europe is key to improving our competitiveness, increasing growth, and

promoting jobs. It is at the heart of Cohesion Policy for the period 2007-2013. Europe’s regions already have a

wealth of experience in this area, and sharing this experience is one of the most effective ways of helping

us understand the mechanisms of regional innovation. This is why we have produced this document which

brings together summaries of some 40 project case studies of good practice from the regional programmes of

innovative actions.

The full case studies can be found on our InfoRegio website. They form a contribution to the exchange of

experience between regions and Member States that I wish to encourage. More examples of innovative

projects, from mainstream operational programmes, will be published during the 2007-2013 programming

period. RegioStars – the innovative projects awards - will be held annually to identify and publicise the best

regional innovative projects and this will also contribute to the exchange of good practices across the

European Union. The awards are being launched at the first annual Regions for Economic Change conference

on 8 March 2007. The conference will focus on fostering competitiveness through innovative technologies and

products and healthy communities. Further conferences will be organized by my services on themes that are

important for regional development.

We all understand, and the regions in particular know this, that it is through informal contacts and within

networks created for regional cooperation, that discussion on regional approaches and practices can lead to

new ideas and thus enrich our thinking on strategies for regional development. I hope that the regions will find

an additional source of inspiration in the projects described in this publication.

(Danuta Hübner, Member of the European Commission responsible for Regional Policy)

III.6.1.13.2 Examples of regional innovation projects

This document contains summaries of case studies of good practice from the regional programmes of

innovative actions, 2000-2006. These programmes were co-financed by regional policy in the EU15 with the

aim of trying out new approaches, new partnerships and new ideas for development.

The full case studies are available on the INFOREGIO website. The case studies analyze the project objectives

and activities, the strategic context, innovation , partnership and obstacles in terms of design or

implementation. Results and impacts achieved are highlighted and sustainability is also considered. The case

studies conclude with the lessons learnt and good practices identified.

The case studies have been drawn up by the Innovative Actions Unit of the Directorate General for Regional

Policy in consultation with the regions and project managers concerned. The summaries are available in

English or French.

Contents regard tree main topics: the first is “knowledge transfer and technological innovation” and

experiences about clustering and business networking, creating links between research and enterprises and

bringing ideas to the market have been brought; the second one is “information society” and applications and

services for citizens and for SMEs belong to it; the last one is “innovation for sustainable development”.

III.6.1.14 RegioNetwork

III.6.1.14.1 RegioNetwork 2020 networking platform

RegioNetwork 2020 is an on-line collaboration platform for representatives of European regions and others

who are interested in the European Union's regional policy. It is an on-line professional networking platform

for cooperation and exchange of good practice between European regions.

Regions can use the site to tell the rest of the regional policy community about their priorities and

achievements. They can also interact with their counterparts in other EU countries. The regional profiles are

normally set up and managed by each region's Brussels office, or the Managing Authority in the region.

In addition to the official regional profiles, anyone who has an interest in EU regional policy can sign up,

create an individual profile on the site and join one of the workgroups. Just a few months after its launch, the

site has already grown into a lively on-line community of more than 1000 people (officials from the EU

institutions, regional offices, people managing EU-funded programmes and projects, researchers and experts,

etc.).

III.6.1.14.2 Main features

The site allows users to set up and contribute to thematic groups, share examples of good practice, create

profiles for a region, create profiles for an individual, follow the activities of regions and individuals.

Here are some examples of issues that are being discussed on RegioNetwork:

•Future EU cohesion policy

•Preparations for 2012 Open Days of Regions and Cities

•Smart growth and regions for economic change.

III.6.1.14.3 Supporting the Europe 2020 strategy

The Europe 2020 strategy aims to promote smart, sustainable and inclusive growth. The European

Commission hopes that RegioNetwork 2020 will contribute towards the Europe 2020 strategy by offering

local and regional stakeholders new opportunities to participate in the development and delivery of policy.

III.6.1.15 Inspiring non-EU countries

III.6.1.15.1 International Affairs International Affairs

In the international relations arena, the Directorate General for Regional Policy acts in support of, and in

cooperation with the External Relations family of Directorates General (European External action Service

EEAS and DEVCO) and with DG TRADE. There is a growing interest in different parts of world in the

process of European integration, not just from an institutional point of view but also in terms of the policies

that promote European cohesiveness. First and foremost among the latter is European regional policy which

seeks to ensure that the benefits of the single market in Europe based on the free movement of goods and

services, labour and capital, are as widely spread as possible.

Principal among the features of EU regional policy that are of interest to third countries such as China, Russia

and Brazil, as well as to international organizations such as MERCOSUR and ASEAN, are the financial

dimension and the geographical targeting of resources between Member States and regions; the geographical

and strategic objectives; and the different dimensions of the implementation system. So far as countries in the

European Neighbourhood are concerned the EU wishes to promote key concepts of EU regional policy such as

open markets, respect for the environment, participative democracy and partnership in the conception and

implementation of development policy.

This interest comes at a time when the policy has undergone substantial changes. In effect, EU regional policy

today is a means of delivering the Union's policy priorities across its territory. It does so by co-financing

integrated, national or regional investment programmes, where the Union's contribution to the programmes is

greatest in the least prosperous areas.

Today therefore, EU regional policy is an integral part of economic policy, but with the unique feature that it

is delivered with the consent and involvement of the grassroots through a multi-level governance system

where each level – European, national, regional and local – has a role to play. The involvement of the

grassroots, for example, in devising regional and local strategies and selecting projects creates a sense of

ownership of European policy and in that way contributes to territorial integration. It is these features that have

inspired interest in large countries with major territorial imbalances that are seeking to combine the pursuit of

a more even pattern of growth with governance systems that contribute to transparent public policies and that

help to further integration through decentralization.

As well as projecting notions of inter-regional solidarity and good governance, cooperation in the field of

regional policy also provides the opportunity to project other values such as respect for the free market

through competition, state aid and public procurement rules, for environmental rules and policies and for equal

opportunities and minority rights. These create the framework conditions under which EU financial support is

granted and provide positive incentives to achieving high standards in public policy.

III.6.1.15.2 Regional Policy Dialogues

The Commission, DG REGIO, has concluded Memoranda of Understanding on regional policy cooperation

with China , Russia , Brazil , and Ukraine all of which are confronted with wide regional disparities as well as

major challenges in terms of co-ordinating the different levels of government, and ensuring that

decentralization can be achieved without compromising efficiency.

The brochure “European Regional Policy, an inspiration for Countries outside the EU?” is available.

III.6.1.16 Interact

III.6.1.16.1 Strategic Programming Process

INTERACT was born to prepare for the programming process for the post 2013 period.

Programming, in view of the next programming period, became a prominent discussion topic in 2011.

INTERACT has been consulting European Territorial Cooperation stakeholders for their experience and,

through the Future Programme Management working group, providing a platform for discussions and

gathering of good practice for the upcoming period. The working group has involved colleagues from Member

State institutions responsible for programming, the Managing Authorities, the Joint Technical Secretariats, as

well as from the DG Regional Policy.

A first interim result, the draft Practical Paper on programming was available for consultation on Group

Spaces in the autumn of 2011. More information is available on the dedicated group space.

III.6.1.16.2 What lies ahead?

The first half of 2012 will see finalization of the Practical Paper based on comments and inputs received from

practitioners.

Based on this, as well as experience gathered, INTERACT will run a series of workshops to guide programme

actors through the main stages/processes of programming and focus on steps/logic that support the delivery of

a strategic programming approach. Further information on the planned workshops will be announced on

INTERACT’s website since March 2012.

III.6.2 Mattone Internazionale Project in Europe

Starting from the experience of the previous 15 Mattoni (bricks) of the Italian Health System

www.nsis.salute.gov.it, the Project Mattone Internazionale aims at increasing the role of the regional health

systems and policies in Europe by strengthening their competences in investigating opportunities offered by

the European Union and other international organizations ("bringing the health system and policies of the

Italian regions in Europe and Europe in the health systems of the Italian regions").

Under the auspices of the Italian Ministry of Health the Veneto Region is coordinating the project with the

support of the Tuscany Region (co-coordinator).

The project foresees the implementation of educational and information activities addressed to Ministry

organizations, Italian Regions, local social-health authorities, hospitals as well as other stakeholders involved

in health topics, in order to promote the dissemination of EU policies and opportunities to access EU financed

programs in the framework of health, research and innovation in the national territory.

In addition, the project will activate specific mechanisms for the promotion and participation of all qualified

stakeholders to European and international health policies.

III.6.2.1 General framework

Il Mattone internazionale rappresenta il 16° mattone del Progetto "MATTONI SSN".

Approvato in Conferenza Stato Regioni nella seduta del 10 Dicembre 2003, nasce da alcune considerazioni e

necessità di carattere generale:

•la necessità di costituire una presenza costante e qualificata dell’Italia nelle sedi europee ed internazionali;

•la partecipazione ai processi di formazione e di implementazione delle politiche comunitarie in

considerazione del fatto che lo sviluppo dei Sistemi sanitari dipende sempre di più dalla capacità di saper

rispondere alle nuove sfide europee;

•l’importanza di inserire l’esperienza del Sistema Sanitario Nazionale (SSN) nell’ambito del più ampio

contesto europeo, per contribuire sia alla fase ascendente che discendente del processo decisionale con una

posizione condivisa con le Regioni;

•la necessità di incrementare l’efficienza gestionale e migliorare la qualità dei servizi grazie al confronto

internazionale;

•la considerazione del fatto che la globalizzazione dei mercati e della ricerca rende più pressante un approccio

globale ai numerosi problemi sanitari;

•la necessità di valorizzazione del know-how e di diffusione delle buone pratiche anche nell’ambito della

cooperazione sanitaria decentrata e della salute globale;

•la necessità di promuovere la partecipazione dell’Italia ai finanziamenti e ai progetti europei e delle Agenzie

internazionali.

III.6.2.2 General objective

Portare la sanità delle Regioni italiane in Europa e nel Mondo e altresì l’Europa e il Mondo nei Sistemi

Sanitari delle Regioni italiane, nel quadro di una collaborazione sinergica con il Sistema Paese.

III.6.2.3 Specific objectives

1.promuovere la divulgazione sul territorio nazionale delle politiche comunitarie e delle possibilità di accesso

ai programmi europei per la ricerca e l’innovazione volendo interfacciare la dimensione nazionale con quella

comunitaria e partecipando al processo decisionale dell’Unione Europea in materia di sanità e di ricerca

medica;

2.coinvolgere attivamente le Regioni italiane nel dibattito sanitario internazionale;

3.promuovere la partecipazione dei Sistemi Sanitari Regionali alle politiche di salute dell’Organizzazione

Mondiale della Sanità e delle altre Agenzie internazionali, supportando il dialogo delle Regioni italiane con

le agenzie internazionali;

4.aumentare le competenze e la competitività delle Regioni italiane in ambito internazionale;

5.supportare e rendere competitiva la partecipazione delle Regioni italiane, così come delle Aziende sanitarie e

delle Aziende ospedaliere, ai finanziamenti europei e internazionali;

6.diffondere le opportunità derivanti dalla progettazione nel settore della cooperazione decentrata e delle

emergenze sanitarie.

III.6.2.4 The five pillars of “Mattone Internazionale”

1.Piano di formazione nazionale: intende essere la risposta efficace alla necessità di costituire una presenza

costante e qualificata dell’Italia nelle sedi europee ed internazionali, con l’obiettivo di offrire alle Regioni

italiane, alle Province autonome, alle Aziende sanitarie ed ospedaliere, un supporto all’aumento delle

competenze in ambito internazionale.

2.Database dei progetti europei ed internazionali: il database permetterà l’accesso ai progetti europei ed

internazionali realizzati dalle diverse Regioni italiane, Province autonome, Aziende sanitarie e ospedaliere.

3.Comunicazione e informazione: attraverso l’organizzazione di eventi legati a momenti chiave europei ed

internazionali.

4.Piani di formazione locale: : sulla base di una selezione regolamentata con avviso pubblico, tutte le Regioni

e le Province Autonome potranno accedere a finanziamenti dedicati all’attivazione di corsi formativi con il

coinvolgimento delle Aziende sanitarie e ospedaliere nonché di tutti gli attori attivi nel mondo sanitario.

5.Cantieri aperti per la sanità del futuro : sulla base di una selezione regolamentata con avviso pubblico, tutte

le Regioni e le Province Autonome, nonché le Aziende sanitarie e ospedaliere potranno accedere ai

finanziamenti dedicati alla realizzazione di corsi formativi per il personale e al supporto delle attività di

progettazione, in particolare relativamente ai Programmi comunitari.

III.6.2.5 Mattone Internazionale Project in Europe

On 7 December 2011, the Mattone Internazionale Project has coordinated a workshop at the Committee of

Regions focusing on the opportunities provided by the project to work more efficiently at EU level. The

launch of the project has been welcomed by MEP Mr. Antonio Cancian, who has emphasized the importance

of bottom-up projects that have an impact at EU level. – Nowadays, key elements such as knowledge-sharing,

synergy amongst different institutional stakeholders and lobbying exert a fundamental role in giving value to

the centres of excellence that exist at local level – has commented Mr. Cancian before concluding with a

remark on the necessity of improving the dialogue between regional and national actors with European

institutional actors, especially the European Parliament.

Additionally, the roundtable has touched upon various topics such as the implementation of the directive on

patients´ rights in crossborder healthcare, the priorities of the national prevention action plan, the priorities of

the 2012 Public Health call and the future Health for Growth Programme (2014-2020). The debate has

triggered interesting reflections on the importance of promoting strategic partnerships at regional and national

levels, with the ultimate objective of improving lobbying and coordination amongst Research Health Institutes

and regional and national authorities, within the Italian context.

In the afternoon session, it was discussed the role of the national seconded experts and the roundtable

concentrated on various topics such as the role of the Brussels-based regional offices and their collaboration

with territorial entities, in addition to the topic of participation in European networks as a means to promote

the collaboration amongst regions in the European context. The workshop was attended by the Brussels-based

regional representatives and the regional contact points of the Mattone Internazionale Project so as to incentive

the collaboration and exchange of information between the regional and European levels.

This event will be followed by a study visit that will be held in the first semester 2012 in Brussels in which all

regional contact points of the Mattone Internazionale Project will be involved. The visit aims to gain further

knowledge on the EU policy-making process and strengthen the relations with the EU institutions and the

Italian Permanent Representation.

Last November a working group has been set up following the suggestions coming from the contacts of Italian

Regions involved in the activities of the project MI. The working group will develop a database of EU projects

in the social and health sector implemented by the Italian regions, as foreseen in one of the five pillars (macro-

activities) of the Project MI. So far this group includes the following Italian regions: Basilicata, Friuli

Venezia-Giulia, Marche, Piedmont and Sicily. The database aims at collecting the EU and international

projects and cooperation initiatives implemented by Italian regions, Local Health Authorities and Hospitals,

thus promoting the development of targeted statistical studies (on the economies, resources, etc..). This

upgradeable database will favor the inventory of excellence working in the health sector, research and

cooperation thus promoting the identification of synergies in different areas, as well as European networks of

whom some Italian Local Health Authorities and Hospitals are members.

On December 20th the General Coordination Group (o Steering Group) of the Mattone Internazionale Project

approved the action plan for the implementation of the activities during the first semester of 2012. In

particular, we would like to highlight the agreement on the National Training Plan promoted and financed by

the project and including training packages with different components that will be replicated in all the Italian

Regions. The National Training Plan has already began to be presented to all regional representatives and the

activities have been starting in February 2012.

III.6.2.6 Priorities for 2012

Actions under this work plan 2012 aim at supporting the implementation of EU priorities set out in the Europe

2020 Strategy. In 2012, the health programme will contribute to the following objectives:

• to enable European citizens to lead active, healthy and independent lives for as long as possible by promoting

the physical and mental health (better nutrition and physical activity, and preventing behaviour that is harmful

to health);

• to prevent the onset of major and chronic diseases through action such as cancer screening;

• to create and maintain sustainable and efficient health care systems (to develop innovative products and

services that respond to the ageing challenge);

• actions envisaged under this work plan focused on exploring and setting up efficient mechanisms for

detecting and preventing the spread of various cross-border health threats, or minimizing their impact;

• safe and secure systems and mechanisms in support of EU legislation on the safety and quality of organs and

substances of human origin, blood, and blood derivatives;

• to support legislation in the area of cross-border healthcare;

• complementary action on the main risk factors for health such as nutrition, alcohol abuse and smoking as

well as in the area of major, chronic and rare diseases;

• to disseminate health information and knowledge (to collect data, pro-duce scientific evidence and

effectively process information to citizens, stakeholders and policy makers).

1. Actions under the first objective “Improve citizens’ health security”

1.1 Protect citizens against health threats — Develop risk management capacity and procedures, improve

preparedness and planning for health emergencies.

1.2 Protect citizens against health threats — Develop strategies and mechanisms for preventing, exchanging

information on and responding to health threats from communicable and non-communicable diseases and

health threats from physical, chemical or biological sources, including deliberate release acts.

1.3 Improve citizens’ safety — Scientific advice.

1.4 Improve citizens’ safety — Safety and quality of organs and substances of human origin, blood, and blood

derivatives.

2. Actions under the second objective “Promote health”

2.1 Increasing healthy life years and promoting healthy ageing.

2.2 Identifying the causes of, addressing and reducing health inequalities within and between Member States

in order to contribute to prosperity and cohesion; supporting cooperation on issues of cross-border care and

patient and health professional mobility.

2.3 Addressing health determinants to promote and improve physical and mental health and taking action on

key factors such as nutrition and physical activity, and on addiction-related determinants such as tobacco and

alcohol.

2.4 Prevention of major and rare diseases.

3. Actions under the third objective “Generate and disseminate health information and knowledge”

3.1 European Health Information System.

3.2 Dissemination, analysis and application of health information; provision of information to citizens,

stakeholders and policy makers.

3.3 Analysis and reporting.

For more information about the Second Programme of Community Action in the Field of Health:

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

III.6.3 Open call for proposals / Tender Second Programme of Community Action in the field of Health (2008-

2013)

The second programme of Community action in the field of health (2008-2013) was established by Decision

No 1350/2007/EC. The mission of the programme is to complement and support the policies of the Member

States in protecting and promoting human health and safety thus improving public health. The EU ac-tion in

the area of public health is designed to improve public health, prevent physical and mental illness and

diseases, and obviate sources of danger to physi-cal and mental health. The EU Health Strategy set out in

Commission White Pa-per Together for health: A strategic approach for the EU 2008-2013 (COM(2007) that

provides an overarching framework for all action under this programme.

The programme pursues the following objectives:

1. improving citizens health security

2. promoting health, including the reduction of health inequalities;

3. generating and disseminating health information and knowledge.

The health programme is open to the participation of EU Member States and third countries (EFTA/EEA

countries - Iceland, Liechtenstein and Norway; European neighbourhood policy countries, countries applying

for, countries that are candidates for, or are acceding to membership of the EU and the western Balkan

countries included in the stabilization and association process). The Executive Agency for Health and

Consumers (EAHC) assists the Commission in implementing this work plan.

The EU Commission adopt an annual work plan setting out priorities and specific actions to be implemented,

including the allocation of financial resources. On 1 December 2011 the EU Commission adopted the Work

Plan 2012, setting out the activities to be co-financed by different funding schemes (specifying the selection

and award criteria and the procedures for the participation to the different actions).

The total budget available is 27.521.820 €; it will be allocated to finance project proposals related to specific

actions under the following funding schemes:

• Project grants (tot. Budget 13,171.820 €) The maximum rate for EU co-financing is 60 %. However, this

may go up to 80 % if a proposal meets the criteria for exceptional utility.

http://ec.europa.eu/eahc/health/projects.html;

• Operating grants (tot. Budget 4,400.000 €) Operating grants may be awarded to renew operating grants

awarded to NGOs and specialized net-works under the work plan for 2011. New operating grants may be

awarded to NGOs and specialized networks active in areas corresponding to the three objectives of the health

programme http://ec.europa.eu/eahc/health/grants.html;

• Grants for joint actions (tot. Budget 8,950.000 €) Joint actions allow the competent authorities of the

Member States/other countries participating in the health programme and the European Commission to take

forward work on jointly identified issues. The maximum rate of EU co-financing is 50 %. However, this may

go up to 70 % in cases of exceptional utility. http://ec.europa.eu/eahc/health/actions.html;

4

• Conference grants (tot. Budget 800.000 €) the conferences,, apart from Presidency conferences, must take

place in 2013. Grants may be awarded to the organization of conferences related to the three objectives of the

health programme, and especially focused on: active and healthy ageing, including health promotion and

prevention of diseases; prevention of health inequalities, including ensuring better access to health care for all,

and questions relating to the health workforce. The Conferences must have a broad European dimension.

http://ec.europa.eu/eahc/health/conferences.html

The deadline for the submission of project proposals under the different funding schemes is 9 March 2012.

III.6.4 European Regional and Health Authorities Association (EUREGHA)

III.6.4.1 What EUREGHA is

EUREGHA represents the interest of regional and local authorities focused on public health. EUREGHA is an

open network and the membership is free of charge. To date, EUREGHA accounts more than 100 local and

regional authorities across 18 countries.

The EUREGHA Network was created on January 30th 2006 according to an opinion of the Committee of

Regions to meet the needs of the European Commission regarding patient mobility and open coordination on

health quality care in 2004. It represents a platform of dialogue between regional and local

authorities/organisations and the European Commission on health care issues.

III.6.4.2 Objectives

EUREGHA was created with some important objectives:

To improve the role of local and regional authorities at the European level

To share information and experiences on public health

To raise awareness on the role of regional authorities in implementing the EU health policy

To improve the collaboration among Brussels Regional Offices

To cooperate with relevant stakeholders such as NGOs and universities

To collaborate with the EU institutions, in particular the European Commission, Committee of Regions, the

EU presidency and MEPs.

The EUREGHA network is coordinated by a Consultative Group, whose role is to liaise with the European

Commission and other key partners. The EUREGHA network encourages the creation of Working groups

focused on specific public health issues.

Activities With the intent of improving the role and recognition of local and regional authorities at the

European level, the network promotes a series of initiatives emphasizing the regional dimension. Over the past

2 years EUREGHA has in fact organized a series of conferences on a wide range of issues pertaining the

public health field through the collaboration of different stakeholders such as the European Commission,

MEPs, pan-European NGOs and other regional networks. More information related to the upcoming

conferences are included in the homepage section "News".

Furthermore, EUREGHA enables the creation of interregional and cross-border partnerships by disseminating

project proposals and facilitating the partner search. In this regard, EUREGHA organizes, in correspondence

to the launch of public calls, info day and market places to better inform our members on the call’s specific

aspects and to facilitate the partner search.

III.6.4.3 Consultative Group

The Consultative Group, hereafter referred with its acronym CG, coordinates and ensures that the EUREGHA

network is working towards the fulfillment of its objectives. Being the decision-making body of the network,

the CG functions as a steering committee. Among its tasks, the CG identifies and selects relevant European

health issues for the EUREGHA network and approves all EUREGHA policy statements.

The General Assembly approves the members of the Consultative Group every year. There can be appointed

one regional/local representative and one regional/local alternate to represent each Member State in the

Consultative Group. The members are (listed by MS): Austria, Belgium, Czech Republic, Denmark, Finland,

France, Germany, Italy, Spain, Sweden, United Kingdom.

III.6.4.4 Work Programme

III.6.4.4.1 2011 Work Programme

2011 was a crucial year for EUREGHA. Nowadays, the network is recognized as a credible stakeholder by

regional and local health authorities as well as the European Institutions, notably DG Health and Consumers

and the Committee of Regions. Yet, we have learned that without a sustainable structure EUREGHA is at risk,

given that regions and local authorities in Brussels cannot ensure enough human and financial resources.

Therefore, important decisions about the network have to be made for the year 2011. We have to concentrate

on finding means for a sustainable network with the necessary resources in order to remain the major regional

and local network.

Hereafter the 2011 priorities set by Lower Austria, the Chair of the EUREGHA Network:

Development of a legal statute for the network, creation of a Belgian ASBL compounded by a one-person-

secretariat, a steering group, a high-level group of the Directors of the regional and local Health Authorities

and a broad membership with differenciated membership fees.

Application of the EUREGHA network for an Operating Grant in the framework of the Public Health

Programme 2011 under the condition of EUREGHA acquires a legal identity.

Organization of the General Assembly of the network to officially kick off the new EUREGHA structure at

the end of the year 2011.

Establishing and Maintaining EUREGHA Working Groups:

1. New Working Group on cross-border healthcare: database of current cross-border projects in Europe, study

visits in the regions, exchange of information/experience on different areas of cross-border health (training,

exchange of health professionals, e-health, etc.)

2.New Working Group on E-Health

3.Working Group on mental health and suicide prevention

4.Working Group on Cancer

Drafting and lobbying amendments for the SURE report of the European Parliament as regards the importance

of health in the context of the Multiannual Financial Framework (MFF) 2014 ff.

2011 planned activities were:

a) Cooperation with Committee of the Regions (CoR):

1. EUREGHA will be the secretariat for the new intergroup on health in the CoR and will be shaping its

agenda.

2. The network will also cooperate with the CoR for organizing the Technical Platforms (conferences on

specific health topics) and provide speakers.

3. During the Open Days, EUREGHA will be present with a workshop on the future of territorial

cooperation in health after 2013, Lead Partner Lower Austria.

b) Organizing meetings with DG SANCO to advocate for the future of the Public Health Programme and

funding for territorial cooperation as well any other topic of relevance for the members.

c) Participation in the Ministerial Conference on E-health and in the EHTEL workshop on sustainable e-health

development during the e-health week (Budapest, Hungary)

d) EUREGHA participation in the European Health Forum Gastein - Young Gasteiner Scholarship

e) Participation in the European Health Agora – experts meeting on health

f) Joint conference ERRIN-EUREGHA on Physical Activity, Sports and Health.

g) Joint Conference Flanders-EUREGHA 4th May on the perspectives for health after 2013 in diverse policy

areas and drafting a EUREGHA declaration on the topic.

III.6.4.4.2 New Health and Consumer Programmes

On 9 November 2011, the European Commission adopted proposals for the new Health for Growth and

Consumer Programmes. The two programmes aim to foster a Europe of healthy, active, informed and

empowered citizens, who can contribute to economic growth.

These new programmes will run from 2014-2020 with a budget of €446 million for the Health for Growth

Programme and €197 million for the Consumer Programme.

Focus will be on fewer concrete actions that offer clear EU added-value.

The Health for Growth Programme aims to support and complement the work of Member States to achieve the

following four objectives:

- Developing innovative and sustainable health systems;

- Increasing access to better and safer healthcare for citizens;

- Promoting health and preventing disease; and

- Protecting citizens from cross-border health threats.

This programme aims to build on the previous Health Programmes to support and deliver action aimed at

encouraging the uptake of innovation in health, fostering better and safer healthcare, promoting good health

and preventing diseases, and protecting citizens from cross-border health threats.

Examples on which further action will be built:

- co-operation on Health technology assessment (HTA), an EU-wide voluntary network of Member States'

HTA agencies to share information on the effectiveness of health technologies such as medicines, medical

devices, and preventive measures, to support national decision-making on technology;

- co-operation on rare diseases at European level to improve prevention, diagnosis and treatment for patients

with rare diseases across the EU, including the EU portal for rare disease (www.orpha.net), the world

reference database on rare diseases;

- cancer prevention and control, through EU-wide screening guidelines to improve early detection so that the

disease can be diagnosed at an early stage and lives can be saved; and through exchange of knowledge and

best practice on cancer prevention, research and care.

III.6.4.5 Euregha General Assembly

On 30 January 2012, EUREGHA – European Regional and Health Authorities Association (EUREGHA)

organized its Annual General Assembly at the Committee of the Regions. The morning session, open to all

interested parties, was focusing on the issues of sustainability, quality and accessibility, with a particular

attention to evidence-based regional success stories of integration of services and continuity of care. The first

roundtable included high-level speakers such as the Director of the Health Systems and Products Directorate

of DG Health and Consumers, the Danish health attaché, the vice-president of the interregional group on

health of the Committee of the Regions and regional health ministers and delegates. The second roundtable

was dedicated to the leaders of the working groups on mental health, crossborder hospital collaboration,

cancer screening and the project officers from the European Commission dealing with these topic areas. The

afternoon sessions were closed to EUREGHA members.

III.6.5 AGE Platform Europe

AGE Platform Europe is a European network of organizations of people aged 50+ and represents over 25

million older people in Europe. AGE aims to voice and promote the interests of the 150 million inhabitants

aged 50+ in the European Union and to raise awareness of the issues that concern them most.

AGE Platform Europeis leading theEY 2012 NGO Coalition.

III.6.5.1 Bridging the Age Gap: working together to develop rural communities

Rural Youth Europe, a Member of the European Youth Forum is hosting a seminar titled “Bridging the Age

Gap: Working Together to Develop Rural Communities”. This event will be held from 15-22 April 2012 at

the European Youth Centre Budapest. Its aim is to promote intergenerational solidarity in rural youth work as

part of the 2012 European Year of Intergenerational Solidarity and promote skill development in managing

cross-generational projects.

Rural Youth Europe is looking to have a true intergenerational dialogue with participants of all different ages

and backgrounds. Therefore AGE was asked to forward this invitation to its Members and invite them to

participate.

By working together across generations we can more effectively support sustainable rural communities and

create a better future for rural young people.

“Bridging the age gap” aims to promote the social inclusion of rural young people through cross-generational

projects. Participants will gain practical skills in project management as well as confidence to act as youth

actors in their local communities.

Aims are to promote intergenerational solidarity in rural youth work To promote the social inclusion of young

people through cross-generational projects

Objectives consist in learning about European policies and developments in the promotion of intergenerational

solidarity To exchange good practices on cross-generational project management To provide practical skills in

developing and managing cross-generational projects To support participants in building confidence as youth

actors and assisting self-development of personal competencies To develop new cross-generational projects on

the local, national, regional and European level To develop a series of e-tools which can be used by

participants and other young people in their home organizations.

The study session will use a variety of methods to achieve its aims. This will include small and large group

discussions, plenary sessions, simulation games and role-plays, workshops, individual reflection, individual

and group presentations and much more…

Intercultural learning, peer to peer learning, experience exchange will be the basis for the learning process.

The programme will have 3 key parts:

1. Information-sharing on intergenerational solidarity

What's happening on the European level? what's happening on the local level? Sharing best practices between

our organizations.

2. Developing cross-generational projects

Developing new projects and new skills – participants will divide into different groups and develop their own

project ideas through a series of workshops on project management (covering project conceptualization, needs

analysis, aims and objectives, preparation, fundraising and financial management, implementation, evaluation

and follow-up) discussing special issues related to managing cross-generational projects – checking the needs

and perspectives of different age groups and how these issues might impact on project management.

3. Summary & evaluation

Presentation of final project ideas Project action planning Personal development plans Designing a workshop

for your home organization The final programme will be sent to selected participants with the acceptance

letter.

III.6.6 VII Framework Programme – Health

III.6.6.1 What is FP7?

'Framework programmes' (FPs) have been the main financial tools through which the European Union

supports research and development activities covering almost all scientific disciplines. FPs are proposed by the

European Commission and adopted by Council and the European Parliament following a co-decision

procedure (view the FP7 approval process).

FPs have been implemented since 1984 and cover a period of five years with the last year of one FP and the

first year of the following FP overlapping. The current FP is FP6, which runs up to the end of 2006.

It has been proposed for FP7, however, to run for seven years. It will be fully operational as of 1 January 2007

and will expire in 2013. It is designed to build on the achievements of its predecessor towards the creation of

the European Research Area, and carry it further towards the development of the knowledge economy and

society in Europe.

III.6.6.2 Which are its main objectives?

Knowledge lies at the heart of the European Union's Lisbon Strategy to become the " most dynamic

competitive knowledge-based economy in the world". The ' knowledge triangle' - research, education and

innovation - is a core factor in European efforts to meet the ambitious Lisbon goals. Numerous programmes,

initiatives and support measures are carried out at EU level in support of knowledge.

The Seventh Framework Programme (FP7) bundles all research-related EU initiatives together under a

common roof playing a crucial role in reaching the goals of growth, competitiveness and employment; along

with a new Competitiveness and Innovation Framework Programme (CIP), Education and Training

programmes, and Structural and Cohesion Funds for regional convergence and competitiveness. It is also a

key pillar for the European Research Area (ERA).

The broad objectives of FP7 have been grouped into four categories: Cooperation, Ideas, People and

Capacities. For each type of objective, there is a specific programme corresponding to the main areas of EU

research policy. All specific programmes work together to promote and encourage the creation of European

poles of (scientific) excellence.

The non-nuclear research activities of the Joint Research Centre (JRC) are grouped under a specific

programme with individual budget allocation.

III.6.6.3 What is the overall budget for FP7?

In the Commission's amended proposals for FP7, it was proposed that the maximum overall amount for

Community financial participation in the EC Seventh Framework Programme should be EUR 50 521 million

for the period 2007 - 2013. For nuclear research and training activities carried out under the Euratom treaty

EUR 2751 million are foreseen for 2007-2011.

Visiting the budget section it is possible to compare the amounts and breakdown proposed in the

Commission's proposal of 2005, amended proposal in June 2006 and political agreement of the Council in July

2006.

III.6.6.4 How does the Framework Programme work?

In a series of interviews with some of the people working within FP6 and responsible for the development of

FP7, CORDIS News examined how ideas for research are generated in the first place, how the framework

programmes are adopted, how calls are timetabled, how proposals are assessed and how the European

Commission decides who receives funding. Particular attention has been put to investigating research.

III.6.6.5 Who decides which areas will be financed under FP7 and on what basis?

In the preparation of the present proposals, the Commission took into account the views expressed during a

very broad consultation with other EU institutions, in particular the European Parliament, and the EU Member

States, as well as by the scientific community, industry and all stakeholders in European research. The results

of the stakeholder consultation can be seen in the "Statistical overview of results and report on the results of

the consultation". This service includes a section that follows the policy debate towards FP7.

The proposals also rely on an in-depth Impact Assessment. This impact assessment was based upon inputs

from stakeholders, internal and external evaluation and other studies, and contributions from recognized

European evaluation and impact assessment experts.

III.6.6.6 How is FP7 structured?

The European Community part of FP7 is organized in four programmes corresponding to four basic

components of European research:

- Cooperation

Support will be given to the whole range of research activities carried out in trans-national cooperation,

from collaborative projects and networks to the coordination of national research programmes.

International cooperation between the EU and third countries is an integral part of this action.

This action is industry-driven and organized in four sub-programmes: a) Collaborative research will

constitute the bulk and the core of EU research funding; b) Joint Technology Initiatives will mainly be

created on the basis of the work undertaken by the European Technology Platforms; c) Coordination of

non-Community research programmes; d) International Cooperation

- Ideas

This programme will enhance the dynamism, creativity and excellence of European research at the frontier

of knowledge in all scientific and technological fields, including engineering, socio-economic sciences and

the humanities. This action will be overseen by a European Research Council

- People

Quantitative and qualitative strengthening of human resources in research and technology in Europe by

putting into place a coherent set of Marie Curie actions.

- Capacities

The objective of this action is to support research infrastructures, research for the benefit of SMEs and the

research potential of European regions (Regions of Knowledge) as well as to stimulate the realization of the

full research potential (Convergence Regions) of the enlarged Union and build an effective and democratic

European Knowledge society.

Each of these programmes will be the subject of a 'Specific programme. In addition, there will be a 'Specific

programme' for the Joint Research Centre (non-nuclear activities) and one for Euratom nuclear research and

training activities.

III.6.6.7 Which themes have been identified for FP7?

FP7 presents strong elements of continuity with its predecessor, mainly as regards the themes which are

covered in the Cooperation programme. The themes identified for this programme correspond to major fields

in the progress of knowledge and technology, where research must be supported and strengthened to address

European social, economic, environmental and industrial challenges.

The overarching aim is to contribute to sustainable development.

The ten high level themes proposed for EU action are the following:

- Health

- Food, Agriculture and Fisheries, Biotechnology

- Information & communication technologies (ICT)

- Nanosciences, nanotechnologies, materials & new production technologies

- Energy

- Environment (including climate change)

- Transport (including aeronautics)

- Socio-economic sciences and the humanities

- Space

- Security

In addition, two themes are covered by the Euratom Framework Programme: Fusion energy research and

Nuclear fission and radiation protection.

In the case of particular subjects of industrial relevance, the topics have been identified relying, among other

sources, on the work of different "European Technology Platforms".

III.6.6.8 What are the differences between FP7 and its predecessors?

While building on the achievements of its predecessor, the Seventh Framework Programme will not be "just

another Framework Programme". In its content, organization, implementation modes and management tools, it

is designed as a key contribution to the re-launched Lisbon strategy.

The new elements in FP7 include the following:

- Emphasis on research themes rather than on "instruments"

- Significant simplification of its operation

- Focus on developing research that meets the needs of European industry, through the work of Technology

Platforms and the new Joint Technology Initiatives

- Establishment of a European Research Council, funding the best of European science

- Integration of International cooperation in all four programmes

- Development of Regions of Knowledge

- A Risk-Sharing Finance Facility aimed at fostering private investment in research.

III.6.6.9 What are the next steps?

FP7 was presented in April 2005 and is in the final stage of the political procedure (co-decision) to be

approved. Obstacles in the way of FP7 were swept aside on the 24 July when the Council reached a political

agreement on FP7 [PDF]. The decision cleared the way for the second European Parliament reading to adopt

the FP7 proposals in November, on schedule for the timely launch of the programme on 1 January 2007. The

final adoption of FP7 by the European Council of Ministers, and of the work programmes by the Commission,

is scheduled for mid-December, with the first calls published on 22 December 2006.

III.6.6.10 How and when can one register as an independent expert for FP7?

The European Commission will contact FP6 registered experts and transfer their data to the FP7 database of

experts.

The registration service for FP7 experts is available on CORDIS.

Further information on the appointment of independent experts can be found in the CORDIS FP7 participation

section (see 'WHO - Appointment of independent experts').

III.6.6.11 What are calls for proposals?

The calls for proposals under FP7 will be set out in annual work programmes which will provide details about

topics, timing and implementation.

The proposal process is triggered by the call. Calls are published official invitations for researchers to submit

project proposals for a specific area of the Framework Programme by a specific date, usually about three

months after the call. Calls specify very clearly what is required. Proposals that do not meet the specifications

in the call will be disqualified.

Calls are announced in the Official Journal of the European Union, with the call and any documents relating to

it published on the Participant Portal.

Once there is agreement on FP7 between the EU institutions and the work programmes have been adopted by

the Commission, the Framework Programme will begin and calls will be issued. For FP7, the first calls were

published on 22 December 2006.

Please note that the so called 'Marie Curie' scheme (exchanges, fellowships and conferences to aid researcher

mobility) will be implemented under the FP7 People programme. This programme aims to support the

training, mobility and career development of researchers.

III.6.6.12 In which languages is FP7 available?

Currently, the FP7 service on CORDIS is available in 6 languages, but the official documents are available in

all EU official languages. Announcements of calls and other news related to FP7 are available on CORDIS in

German, English, Spanish, French, Italian and Polish, and it is planned to extend the CORDIS service into

other languages as FP7 moves into implementation.

III.6.6.13 What are work programmes?

The individual 'work programmes' are the detailed implementation plans for the specific programmes, research

themes and other activities under FP7. They specify the concrete scientific-technical, economic and societal

objectives of each activity, providing both a broad background and the detailed technical content.

They project a 'road map' of the planned calls for proposals. They also indicate for each call the instruments

that will be available and the evaluation criteria that will be applied. Understanding the objectives of the work

programme is essential for preparing a good proposal.

III.6.6.14 What are 'Third countries' and other non-EU entities that can participate in FP7?

'Third country' means a state that is not a Member State of the European Union - it also includes countries with

international cooperation agreements;

'Associated country' means a third country which is party to an international agreement with the European

Community, under which it makes a financial contribution to FP7;

'International organization' means an intergovernmental organization, other than the European Community,

which has legal personality under international public law, as well as any specialized agency set up by such an

international organization;

'International European interest organization' means an international organization, the majority of whose

members are EU Member States or associated countries, and whose principal objective is to promote scientific

and technological cooperation in Europe;

'International cooperation partner country' means a third country which the European Commission classifies as

a low-income, lower-middle-income or upper-middle income country and which is identified as such in the

FP7 work programmes;

'International organizations and legal entities established in third countries' - Participation in indirect actions

(such as collaborative research projects) is open to international organizations and legal entities established in

third countries after the minimum conditions specified in FP7's specific programmes or work programmes.

III.6.6.15 Where help could be found?

Network of National Contact Points (NCPs) in Member States and Associated States has been created in order

to answer the several questions that could present before, during or after the work.

If you have looked through the FAQs and they don't answer your questions, please contact your local National

Contact Point (NCP). NCPs are established to provide local guidance, practical information and assistance on

all aspects of participation in the framework programmes.

The NCP network is the main provider of advice and individual assistance in all Member States and

Associated States. By using this service you can easily find the contact details of the designated National

Contact Points for your country.

Since NCPs are appointed for each of the areas of FP7, when seeking support you should contact the NCP

relevant to your area of interest. If you have looked through the FAQs and they don't answer your questions,

please contact your local National Contact Point (NCP). NCPs are established to provide local guidance,

practical information and assistance on all aspects of participation in the framework programmes.

III.6.6.16 Ideas: Call for proposals for ERC Advanced Investigators Grant (ERC-2012-AdG)

This just represents an example of the possible calls.

The call has been published on 16 November in the framework of 7° PQ (Programme Ideas) and it aims at

financing excellent and leading advanced investigators to pursue ground breaking, high-risk/high gain research

projects in the following three main research domains: 1) Physical Sciences & Engineering; 2) Life Sciences;

3) Social Sciences & Humanities.

The ERC grants are open to researchers from any country in the world from, both public and private

institutions, with a track-record of significant research achievements in the last 10 years.

Deadlines: 1) Physical Sciences & Engineering: 16 February 2012; 2) Life Sciences: 14 March 2012; 3) Social

Sciences & Humanities: 11 April 2012

Total Budget available 679,95 M€: 1). Physical Sciences & Engineering: 299,18 M€; 2) Life Sciences: 265,18

M€; 3) Social Sciences & Humanities:: 115,59 M€.

Please see the Work Programme 2012 IDEAS.

For more information: http://ec.europa.eu/research/participants/portal/page/ideas?callIdentifier=ERC-2012-

ADG_20120411

III.7 Conclusions

Our main purpose has been to review the empirical evidence on the economic impact of health as it applies to

EU Member States. Our point of departure has been the work of the Commission on Macroeconomics and

Health, which has made a powerful economic case for investing in health in developing countries. A specific

question guiding our review of the evidence was to what extent a similar case could be made with respect to

high-income countries, such as the EU Member States. This is a far from trivial question, partly because one

might expect improved health to give rise to a lower pay-off in countries that are already very healthy

compared with countries in which disease is rampant. It is also a question that gives rise to potentially

important policy implications: if health were to become recognized as an investment that brings an economic

return, then this would be expected to strengthen the position of health ministries in rich countries’

governments where to date they often play only a marginal role. More broadly, it should strengthen the

position of health and might make other economic policy-makers seek to consider health as one, of several,

options by which to achieve their primarily economic objectives. In sum, we find that there is much evidence

documenting the positive contribution that health can make to the economy in EU Member States. At the same

time we have shown that it is a highly under-researched area, a factor that simultaneously reflects and

promotes an inadequate recognition that health can also be good for the economy in rich countries. Our

conclusions can be summarized as follows.

1. There is a sound theoretical and empirical basis to the argument that human capital matters for economic

growth, but for the most part human capital has traditionally been rather narrowly defined as education.

2. The idea of health representing — in addition to education — an important component of human capital

was introduced most prominently by Grossman in 1972 already, but has only recently been

acknowledged more widely.

3. Since human capital matters for economic outcomes and since health is an important component of human

capital, health does matter for economic outcomes, too. At the same time, economic outcomes matter

for health.

4. The work of the Commission on Macroeconomics and Health (CMH 2001) has made an important

contribution to making the economic case for health in developing countries. However, as it stands, the

work is of limited relevance to the EU countries that are facing a very different health pattern with

potentially very different economic implications that need to be worked out separately.

Review of existing empirical evidence

5. There are numerous cost-of-illness studies in high-income countries. The studies estimate the quantity of

resources (in monetary terms) used to treat a disease as well as the size of the negative economic

consequences (in terms of lost productivity) of illness that are incurred by society. They represent a

useful first step in developing an idea of the economic burden of ill health and they show that the

magnitude of the economic consequences is substantial. At the same time they are limited by certain

methodological problems and by their failure to differentiate the direction of causality in the

relationship between health and economic outcomes. This is why we subsequently look at more

‘structural’ analyses.

6. A significant amount of evidence exists to support the economic importance of health in the labour market

in rich countries. We present evidence that health matters for a number of economic outcomes: wages,

earnings, the number of hours worked, labour force participation, early retirement, and the labour

supply of those giving care to ill household members. In addition we reviewed the comparatively scarce

evidence of the effect of health on education and on savings in developed countries. The impact of

health on education — an issue widely researched and supported in the developing country context —

has received much less attention in the high-income country context. The impact of health on savings

has likewise only received limited attention in rich countries, despite the highly policy-relevant insights

that could potentially be gained from studying these relationships.

7. Several studies from high-income countries show that poor health negatively affects wages and earnings.

The magnitude of the impact obviously differs across studies (given different health proxies and

methodologies) and direct cross-country comparability of results is therefore limited. While a significant

number of studies have analyzed the impact of health on earnings and wages in high-income countries,

overall there appears to be comparatively less direct evidence from EU countries.

8. A number of studies find a significant impact of physiological proxies for health (e.g. height or body mass

index) on earnings and wages not only in developing but also in some high-income countries. Height

tends to positively affect these labour market outcomes, while a higher body mass index (linked to

overweight and obesity) appears to depress wages and earnings more for women than for men. It is

likely that some of the link between these physiological measures and labour market outcomes can be

accounted for by social perception of height, and by social stigma in the case of obesity, rather than by a

direct productivity effect.

9. An extensive empirical literature, mainly from the USA but recently also from Europe, confirms that health

increases the probability of participating in the labour force. Again there is no consensus about the

magnitude of this effect and comparison of results from different studies is difficult, as they use

different measures of health, model forms and estimation techniques.

10. A relatively large number of studies from high-income countries find a significant and robust role for ill

health in anticipating the decision to retire from the labour force. The relationship has been more

extensively researched in the USA than in Europe. When interpreting the results from different

countries one should keep in mind that they are likely to be very sensitive to the institutional framework

(e.g. pension rules, availability of disability benefits, occupational insurance arrangements).

11. Ill health matters not only for the labour market performance of the individual directly concerned but also

for that of the household members, who have been found to adjust their labour market behaviour in

response to another household member’s illness. In the studies reviewed, men appear to reduce their

own labour supply by substantial amounts in the event of their wives’ illness, while in the reverse case

women tend to increase their labour supply. This can partly be explained by the unequal distribution of

gender roles within the family. Access to health insurance can critically affect the response to a spouse’s

health condition.

12. As in most empirical research in the social sciences there are methodological challenges involved in the

attempt to detect a causal impact of health on labour market outcomes. Empirical methodologies —

widely applied in other fields — have been used in the literature reviewed in order to ‘purify’ the effect

of health on economic outcomes from a potential simultaneous impact from economic outcomes on

health. Some specific challenges regarding the most appropriate way to measure health in surveys

remain for a future research agenda.

13. Human capital theory predicts that more educated individuals are more productive (and obtain higher

earnings). Good health in childhood enhances cognitive functions and reduces school absenteeism and

early drop-outs. Hence, children with better health can be expected to achieve higher educational

attainments and be therefore more productive in the future. Moreover, healthier individuals with a

longer lifespan ahead of them have higher incentives to invest in education and training, as they can

harvest the associated benefits over a longer period. While theoretically plausible and empirically

supported in the case of developing countries, there has been relatively little work exploring and

confirming this link in high-income countries. More research is needed.

14. It is highly plausible that savings will increase with the prospect of a longer and healthier life. The idea of

planning and, hence, saving for retirement would be expected to occur only when mortality rates

become low enough for retirement to be a realistic prospect. Some work confirms the existence of such

an effect in developing countries. In the high-income country context, our review found comparatively

little published research in this area.

15. Turning to the effect of health in the long term, historical studies exploring the role of health in a specific

country over one or two centuries have shown that a large share of today’s economic wealth in

industrialized countries is directly attributable to past achievements in health.

16. Health — typically measured as life expectancy or adult mortality — emerges as a very robust and

sizeable predictor of subsequent economic growth in virtually all studies that have sought to explain

differences in economic growth between rich and poor countries. Researchers have focused much less

on investigating the specific role of health in economic growth in high-income countries only, and in the

few cases in which this was done, health was not always found to be positively related to subsequent

economic growth, and in some case there was even a negative relationship. We attribute these results

partly to the use of health indicators that imperfectly capture existing health differences between high-

income countries. This is confirmed by a very recent analysis showing that if cardiovascular disease

mortality is used as a health proxy, health does matter significantly for subsequent economic growth in

high-income countries. The institutional policy framework in high-income countries, in particular

through the current choice of retirement age, might also prevent health, in particular of the elderly, from

having its full beneficial impact on economic growth in high-income countries.

17. The use of a welfare or ‘full income’ measure, that takes health into account, gives an even stronger

illustration of the ‘true’ economic importance of health. This approach starts from the uncontroversial

recognition that GDP is an imperfect measure of social welfare because it fails to incorporate the value

of health. The true purpose of economic activity is the maximization of social welfare, not simply the

production of goods by themselves. Since health is an important component of properly defined social

welfare, measuring the economic cost of ill health only in terms of foregone GDP excludes a potentially

major part of its ‘full income’ impact, defined as its impact on social welfare. Most of the existing

studies in this domain have focused on the USA.

18. While there is a direct effect of health on the economy, as noted above, the health system has an impact on

the economy irrespective of the ways in which the health system affects health. The health sector

‘matters’ in economic terms simply because of its size. It represents one of the most important sectors in

developed economies, representing one of the largest service industries. Currently its output accounts

for about 7 % of GDP in the EU-15, larger than the roughly 5 % accounted for by the financial services

sector or the retail sector. Through its sheer accounting effect, trends in productivity and efficiency in

the health sector will have a large impact on these performance measures in economies as a whole.

Moreover, the performance of the health sector will affect the competitiveness of the overall economy

via its effect on labour costs, labour market flexibility and the allocation of resources at the

macroeconomic level.

Investing in health

19. The most important, if general, policy implication of the evidence synthesized in this book is that policy-

makers interested in improving economic outcomes would have good reasons to consider health

investment as one of their options by which to meet their economic objectives.

20. It is beyond the scope of this book to define which health and healthcare policies should be implemented.

What is important is for governments to establish an integrated policy framework by which they can

assure themselves that what is being done to achieve good health is appropriate and effective. This book

argues the case for mechanisms that will permit the assessment of the health needs of a population, the

identification of effective interventions to respond to those needs, and the monitoring of the results

achieved. This will enable resources to be targeted most effectively.

21. The fact that the disease burden in developed countries is mainly due to non-communicable diseases,

whose levels are largely determined by lifestyle-related factors and that, consequently, health, education

and culture are intimately related, implies that health investment must inevitably involve actions and

measures addressing issues lying outside the reach of the traditional healthcare systems. Health

investment therefore requires action across government.

Filling the evidence gap

The following priorities for future research emerged from the review of the existing evidence.

22. There are few microeconomic studies that compare the effect of (ill) health on the labour market in

different EU countries. Existing data sources, such as the European Community Household Panel, could

be usefully exploited to this effect. However, there is also a need for substantial investment in the

collection of comparable data sets from all Member States similar to that available in some other

industrialized countries, linked to investment in primary research on the relationship between health and

the economy in Europe. This has implications for the work of Eurostat as it seeks to harmonize the data

collected in Member States. These investments will anyway be important to assess progress towards

achievement of the Lisbon agenda.

23. There are gaps in our understanding of the relationship between health and education in EU Member

States. The increasingly popular educational performance surveys could be complemented by questions

that capture the health status of the child, in order to allow this relationship to be analyzed.

24. The effect of ill health or of the prospect of ill health on savings appears not to have been studied at all in

the EU context. There is reason to believe that the incorporation of health in models of savings has

much to offer in understanding patterns in household savings and consumption behaviour.

25. Both at the macro and micro level, there is a need to improve the quality of health indicators to permit

better discrimination of the diversity of health in developed countries. This requires the testing and

development of more contextually appropriate health indicators than those commonly used in the

worldwide cross-country regressions. Research in this area should also investigate further how far and

in what ways the ‘welfare state’, imperfectly proxied by health (and other social) expenditures in some

studies, contributes to economic growth.

26. Given that many of today’s health issues are driven by lifestyle factors, there is a need to establish more

explicitly the economic case for governments to intervene in areas that prima facie might be seen as

issues of individual choice. There is much to suggest that a case for doing so can be made using sound

economic reasoning. If so, this could provide a similar rationale for investing in health as already exists

for investment in road infrastructure or public schools.

27. As the key next step in developing further the economic argument, more research is needed to assess the

costs and benefits in particular of broader public health interventions. This would represent the ultimate

and necessary step in order to make a direct comparison of the returns to health investment with

alternative uses of the money involved. In doing so, it would further facilitate the integration of health

investment into overall national economic development plans.

CHAPTER IV

HEALTH POLICIES AT LOCAL LEVEL

IV.1 A concrete proposal as answer to the crisis: STF-INNOINTEGRA. IV.1.1 The project. IV.1.1.1 Objectives. IV.1.1.2 Consistency

and reliability of returns. IV.1.1.3 Investment Time Horizon. IV.1.1.4 Variety of Investment Options Variety of Investment Options.

IV.1.1.5 Low Risk Investment. IV.1.1.6 Concerns about Infrastructure Investing. IV.1.1.7 Conclusion. IV.1.1.8 Comments. IV.1.2

Progress beyond the state-of-the-art. IV.1.2.1 World evolves. IV.1.2.2 Facing economic and social scenarios of ageing population.

IV.1.2.2.1 Framework. IV.1.2.2.2 The added value of the elderly. IV.1.2.2.3 Financial support mechanisms. IV.1.2.2.4 Analysis of the

Economic Policy on the elderly. IV.1.2.2.5 Active aging and innovative care pathways. IV.1.2.2.6 Rights of elderly people . IV.1.2.3

The influence of technology on the future of long-term care systems. IV.1.2.3 Introduction. IV.1.2.3.1 Technology-based services as a

crucial support to the diverse stakeholders. IV.1.2.3.2 The magic word: integration. IV.1.2.3.3 Direct and indirect future influence of

the technologies on the LTC sector. IV.1.2.3.4 Systemic benefits and barriers to overcome. IV.1.2.3.5 Recommendations – I. IV.1.2.3.6

The mechanisms to influence the long term care processes. IV.1.2.3.7 The technology as a catalyst for new organizational models.

IV.1.2.3.8 The role of the Care Manager in an innovative care model. IV.1.2.3.9 A comprehensive information substrate on LTC

services. IV.1.2.3.10 Optimizing the usage of resources and the quality of care. IV.1.2.3.11 Recommendations – II. Section I - Improve

the outcome of the assessment methodologies. Section II – Increase the awareness on the opportunities offered by technology. Section

III – Turn on the right context for the development of technology. Section IV - Develop and maintain the Info-structure for semantic

interoperability. IV.1.2.3.12 Conclusions. IV.2 Interventi innovativi per la valorizzazione del patrimonio storico: small historical

towns for healthy ageing

IV.1 A concrete proposal as answer to the crisis: STF-INNOINTEGRA

IV.1.1 The project

IV.1.1.1 Objectives

The objective is to study deeply social, financial and technological innovation, so that a model on Active and

Healthy Ageing (AHA) could be defined.

We have in mind an operative assessment, by which we offer to Europe a new vision, a new initiative, a new

proposal,

Pension Fund Investment in Social Infrastructure

“Many pension funds have increased their allocation to alternative investments in an attempt to both reduce

risk through diversification and to generate higher risk-adjusted returns. Historically, the alternative asset

class, which includes private equity and private and public real estate, has provided positive returns with low

correlations to traditional public asset classes.

However, as the opportunity for worthwhile investments in this asset class has become more difficult to come

by, the need for new investment options has increased. Pension fund investors continue to look to other

avenues for high yielding and diversifying investments. The extension of the alternative asset class has

included investment in hedge funds, commodities and infrastructure.

Infrastructure investing, which includes investment in bridges, toll roads, airports, pipelines, utility towers, and

educational and healthcare facilities, is the most recent addition to this category and potentially the most

attractive to pension fund investors.

Investment in these real infrastructure assets is becoming a more popular investment choice because of the

diversification benefits and the predictable and reliable long-term cash flow streams.

Pension funds have made various attempts to minimize funded ratio risk - for example, by matching assets

more closely with liabilities. Infrastructure investments provide an opportunity to more closely link the asset

cash flows to liability cash flows.

Investment in infrastructure such as toll roads or bridges may have high upfront costs, but provides many

benefits to the long-term investor. The following are key characteristics of infrastructure investing that align

with the needs of a pension fund investor.

An investment in infrastructure assets can act as a risk reduction tool for a plan due to its low correlation to the

traditional public market asset classes. This can serve to reduce the volatility of returns and unsystematic risk

of the overall plan”.

IV.1.1.2 Consistency and reliability of returns

Another benefit to infrastructure investing is the fixed income nature of the return stream. Similar to many real

estate investments, a large part of the return from infrastructure investments is generated as income rather than

investment appreciation. This provides a greater reliability of the returns over time. The consistent positive

cash flow matches nicely with the needs of the long-term investor. Also, the returns for many of these

investments can be partially hedged for inflation. Due to the monopolistic structure of many of these assets,

the demand for the asset tends to be relatively price inelastic, so price increases linked with inflation should do

little to deter demand or use of the asset by the public. The use of utilities, mass transit facilities and public

buildings are typically unaffected by infrastructure cost increases.

In the table below, we summarize the return and standard deviation of three public asset class benchmarks and

two infrastructure benchmarks over the 1 year, 2 year and 3 year time periods.

IV.1.1.3 Investment Time Horizon

A critical characteristic of infrastructure for pension funds is the long-term lives of many of the investments.

Since pension funds are long-term investors due to the long-term nature of their liabilities, investing in assets

that generate cash flow over the long term aligns nicely with the pension fund's primary goal of meeting its

cash flow obligations.

IV.1.1.4 Variety of Investment Options

There are many global options for investment in infrastructure that run across a wide spectrum of choices

related to utility and facility operations. The numerous investment types provide flexibility in attempting to

match asset cash flow to liability cash flow. Investments will have varying maturities based on the specific

investments.

Global pension fund investment in infrastructure has been growing steadily and dates back to at least the early

1990s. The expansion and development of global economies such as China and India also provide a window

for market growth. As emerging market economies develop and prosper, there will be a growing need for

improved infrastructure, which will fuel the opportunities for future investment.

IV.1.1.5 Low Risk Investment

One of the more attractive characteristics for investing in infrastructure is the low risk of the investment.

Typically, infrastructure assets have high barriers to entry, and in some cases, a monopolistic positioning

within the society. For example, the investment in a major toll road is not likely to have to compete for income

from another major roadway. The lack of competition limits the risk that the asset will become supplanted by

another asset.

IV.1.1.6 Concerns about Infrastructure Investing

Infrastructure investing is a relatively new arena for pension funds, so it is important to understand the

drawbacks to investing in this asset type. There are two major concerns regarding infrastructure investing. The

first concern is whether the consistently positive and relatively low-risk returns can continue. Although this is

a concern across all asset classes, it is more difficult to gauge the potential volatility of infrastructure investing

because of the limited history of returns in this asset class. The second concern relates to the regulatory impact

of these global investments. Many infrastructure assets are impacted by local regulations, which can be

unpredictable. Investments in global and, in some cases, emerging markets can be dependent on somewhat

unstable regulatory oversight.

IV.1.1.7 Conclusions

As infrastructure investing grows across the global pension market, it may change the landscape of investment

in the alternative asset class. The infrastructure investment options seem to provide the appropriate

characteristics for the long-term pension investor. The low correlation and potential for consistent long-term

cash flow, along with the growing global opportunity for investment, makes infrastructure investing a viable

option for pension fund investors. However, it is important that the investor understand the specific

investments because of potential regulatory impact. If a detailed due diligence is performed, we may see a

shift in assets within the alternative asset class. ( Source Mark Huamani - JPMorgan Investment Analytics and

Consulting )

The investment policy should establish clearly the financial objectives of the pension fund and

the manner in which those objectives will be achieved. The investment objectives should be consistent

with the retirement income objective of the pension funds, and therefore, with the fund’s liabilities.

They should also satisfy the relevant legal provisions (prudent person standard and portfolio limits), and more

generally, the principles of diversification, and matching of assets and liabilities (maturity, duration,

currency, etc).

Pension fund investment policy depends critically on the type of plan: defined contribution versus defined

benefit.

Both types of plan normally are exempt from taxation, but defined benefit plans have unique features that can

lead their sponsors to pursue investment policies that differ radically from those of defined contribution plans.

The guiding principle is efficient diversification, that is, achieving the maximum expected return for any given

level of risk exposure. The special feature is the fact that investment earnings are not taxed as long as the

money is held in the pension fund.

STF-INNOINTEGRA wants to build a model interfacing Regional Active and Healthy Ageing Integrated

Innovation Plans with Pension Fund Investment in Social Infrastructure, so opening a possible pathway to re-

open a coagulated condition following Financial Crisis.

STF-INNOINTEGRA comes from a long preliminary stage with contacts with Presidency of EU Commission,

Commissioner for Health and Consumer, Commissioner for Regional Policies, DG Infso, DG Sanco, DG

Regio, DG Research, DG Enterprise, European Parliament, Committee of the Regions , EESC, EIB, EU

Pension Funds Associations, Public Research Centers, LSE, OECD, HCN, YF, SIE, EPHA, ECHAA, EFN,

Age Platform, FERPA, European Pension Funds Associations, Deloitte, FORTH, CONTINUA etc..

STF-INNOINTEGRA does really represent the first attempt to give an organic answer to Financial Crisis

through a implementation model based on Pension Fund Investment well discussed with Partners representing

14 Countries, Management Team , Steering Committee , Work Package Leaders and Advisory Board.

The project has been attached to the present work.

IV.1.1.8 Comments

Maria Iglesia-Gomez, Head of Unit Strategy and International, DG Health and Consumers (SANCO),

European Commission, said: ““I fully share the view that also non-technical innovation needs to be

implemented in order to successfully tackle societal challenges Europe is facing. I also support the view that it

is crucial to involve the regional actors in the innovation process in particular in areas such as health and

ageing. These considerations have also informed our work on the pilot Active and Healthy Ageing

Partnership”.

IV.1.2 Progress beyond the state-of-the-art

IV.1.2.1 World evolves

Investment in Common Good Innovation could mean not only an exit strategy from the Financial Crisis, but

an entering strategy in a new concept: we live in a planet full of financial resources as never happened in the

mankind history. The asymmetric distribution of resources is both the problem and the starting point of the

solution.

The state of the art is under our eyes. No words could describe it better than the daily lives of each of us.

Progress beyond the state-of-the-art in our project is to study and present a new model based on a new vision:

the necessity to start with a dialogue with Pension Funds for Long Term Investment in Public Common Good

Policy.

OECD presented in 2009 “Pension Fund Investment in Infrastructure”, a report that clearly showed through

some successful stories that this is a possible way.

On the other hand Pension Fund Associations promoted a Task Force on Pension Fund Investment in

promoting local economies.

This our project will try to move forward to a Model about Pension Fund Investment in Regional Innovation

Plan in AHA field.

Financial crisis will progressively lower the public budget sustainability with huge negative consequences in

social and health expenditure. Not only public long term commitments will be almost impossible, but a

reduction of services due to cutting of costs is expected. The cuts of the costs will happen without knowing the

costs of the cuts and a “crisis in the crisis” will occur.

Social Science and Humanities research could now play a pivotal role promoting the indispensable passage

from actions to interactions and from interactions to integrations.

Social Science and Humanities research could promote an integrated innovation coming from social,

technological and financial fields. These three fields cannot walk alone anymore: it is a luxury we cannot

afford. At all.

Social, Technological and Financial Integrated Innovation does really constitute a model out of traditional

paradigms, as financial crisis is out of traditional paradigms of development, progress and democracy.

Financing Social Innovation in respect of equity and excellence is quite an huge matter: and all kind of

resources must be considered, not only the fiscal ones. We’re not speaking of our destination, but about our

destiny.

A quantitative approach is strongly needed to understand and to manage the economical consequences of

evolving social needs. The passage from concepts to services is fundamental if we want to speak of Active and

Healthy Ageing as a concrete possibility given to the European ageing population each day, each week, each

month and each year long. This passage is perhaps very complicated and clearly indicates the quality of

democracy. Democracy needs continuous maintenance, control and surveillance.

Reading key consists in a few points:

- EIP-AHA exists (it is a datum)

- Implementation has got a key role (therefore the unavoidable labour in searching financing sources,

fundamental guarantee)

- Pension funds investment (we do not a platonic attempt; on the contrary we enter concrete issues)

- To obtain a model (it is needed to get provisions)

- by means of a written agreement with Pension funds a regional application could be activated;

- a regional rating agency model could support that resources flux.

On these main points the work packages and the whole work are based.

Europe decided to study how to help people gain two more years in their lives. To this aim we may use

several factors (device, etc.), which result from that research called innovation. It is producted by industry.

This one is in Europe. So prototypes born from the integration of different competences - especially coming

from industry, but starting from the public context (health services, etc.) – could then be reproduced into each

local reality. What can we do? An innovation partnership is a new and unique concept: we try to achieve in

network what cannot be done locally by single partnerships.

So we shall have a triple win: a) increased health; b) innovation; c) possibility of growth.

Three are the themes on which our attention must be focused on:

- Awareness

That means to be conscious, to give priority to prevention and early diagnosis. In Europe we are

unlettered as concerns health: the health knowledge is not the European citizen’s patrimony.

- Care and cure

The real problem is complexity of medicine. Comorbidity is not a simple addition of diseases in the

same patient, but is a person who has more diseases at the same time. So the intake of drugs for that

person increases, as well as the underprescription: in one word - with a home rule or through the general

practitioner - the patient puts one or more drugs away from therapy. At present no one is thinking of

creating a personal health technology assessment (HTA).

- Independent living

Innovation supporting independent living must be considered. ICT is available: it is transversal to all

kinds of projects. E-health theme is present besides: it regards both care and cure and social housing.

In order to conclude Europe commitments it is necessary:

- to change paradigm on how health is both provided and administered – the core of medicine today –;

- to change the kind of cooperation of all the stakeholders involved in the take in charge of patients.

It is a political project coveting to connect several fields concerning health, in order to support the health

programme to be realized. Particular regard will be given to efficacious public-private partnerships.

An important way to be pursued is ICT applied to housing (telemedicine, etc.), because of its several

favourable repercussions on home care and, therefore, its connections to welfare state.

Attendance to the retiring state must be an end of view. Persons can be accompanied to retirement with the

possibilities to be protagonist not only of pension funds, but also to continue working – gratuitously, as they

get their own pension salary anyway – to show a tutoring activity – therefore offering their expertise – just

using little low cost incentives – like theatre or cinema or gymnasium subscriptions -. That has a positive

impact on health: Sweden achieved great experience on this theme; an Italian experience conducted in the city

of Verona showed a 37% hospital shelters decrease.

In respect of the classic concept of medicine, nowadays medicine is becoming a life styles medicine.

Therefore, if we act on them – food and nutrition, physical exercise, environment – we shall be able to

interfere in the etio-pathogenetic factors. Besides, considering that more than 65% of drugs are prescribed to

persons over 65 years old, studies results show that only 60% of drugs is really used and, more over, only 30%

well used. The drug example succeeds in explaining how that world is complex.

Local-regional starting ideas can be expanded in other European countries. It is not a research, but a prototype

implementation. Therefore the dimension could even be little, because that same partnership may be exported

for those same dimension.

IV.1.2.2 Facing economic and social scenarios of ageing population

IV.1.2.2.1 Framework

Old age is not intended as a source of problems, but as a great opportunity.

From this project ideas, models, initiatives (e.g. investment in innovation common good, financial support

mechanisms, innovative care pathways, etc.) come. They will be primarily implemented at the regional level,

in order to create conditions to ensure that older people can be producers of wealth for themselves and the

community, allowing for greater sustainability of the welfare system.

This phenomenon, while it has long been an element of reflection and an effort to adapt to changing needs, on

the other hand is one of the most important challenges for the future in reference to national planning,

international public policy and dynamics of the markets.

Many considerations can be made made, not only in general about the status and condition of the elderly in the

society, but also more specifically, regarding needs and potential of the elderly. In other words, attention to the

widespread and diverse impact ageing population has on the structure, functioning and development of all

societies, as well as the emphasis on digital divide, should not be missed. And if in some circumstances may

have to increase or diversify the commitment of public and private sectors assuming some of the functions that

are performed by the family, in others it will be necessary to change policies for the family.

IV.1.2.2.2 The added value of the elderly

Older persons can be a more important economic resource in the future. In fact, in more developed countries,

as a consequence of the increased life expectancy, retirement is seen as the beginning of a “new life”, in which

people can pay more attention to themselves and feel a still dynamic part of the society, also making demand

for goods and services, information and cultural interests. So, new opportunities can be taken considering

livewire older people, but analysis of their specific characteristics in terms of needs and consumptions are

necessary and appropriate. This could allow companies to define new market targets, and to promote

innovation in order to create new products or services, or redirect the existing, according to senior needs; as a

result, the economic development outlook is interesting. In this sense, a new research approach that allows to

identify clusters by processing social health and marketing data is considered particularly useful.

How then not to think of the following themes?

IV.1.2.2.3 Financial support mechanisms

a) Financial support mechanisms for incentivising those people who, in the family environment,

systematically devote time to enhance a possible role of elders (at least of those amongst elders who are

in good health conditions), by implementing “pilot-experiences” which could be borrowed by local

communities especially in small towns; the design of possible rewarding mechanisms of financial nature

could be based on hypothesis of subsidies consisting of prizes – to be publicized through events

addressed to local communities and reported by the local media – to be granted to pilot-experiences

implemented during any specific period and would imply identifying the public body in charge of

awarding the subsidies/prizes, the structure of these incentives in terms of initial amount, the potential

extra-rewarding mechanisms for the repetition of successful experiences and the tax treatment of the

prizes.

b) Special tax treatment for those individuals who systematically devote time to the involvement of elders

in a range of activities that the latter are able to carry out, by offering such examples of enhancement of

elders’ role as to be “transferrable” within local communities. In this case, the conception of the

mechanism should envisage an ad hoc “register” of those who devote themselves to such involvement

of elders, of the requirements to be met by elders involved, of the taxes – either national or local taxes –

against which the special tax treatment could be claimed by the people concerned, and of the

implementing devices in terms of reduction of the taxable base or of the tax rate.

IV.1.2.2.4 Analysis of the Economic Policy on the elderly

The subject of the health care expenditure on the elderly seems to be the test pattern of the Western social

systems for what pertains to both their credibility and the sustainability of the economic development model

on which these post-industrial economies are based. In the last twenty years, despite the requirement of a new

social and economic paradigm that is able to face the ageing population trend as well as the increase of costs

for the long term care services, the major part of public policies on the elderly has essentially been shaped

around the cut of resources and the increase of the informal Family assistance. In the bargain, since the value

of this typology of “good” cannot be quoted in a real market, the number of scientific surveys that describe the

health care expenditure as a sum of costs are very numerous: they should be suitable for the society but they

must be tailored in order to achieve the equilibrium on the public finance. On the contrary the health care

expenditure on the elderly requires careful attention first of all from the normative economics point of view. In

this respect the possibility to define which should be the intervention of the policy maker especially for what

pertains to the mix between public and private sellers is of great importance. Secondly, from a quantitative

point of view the research on the elderly should analyze the impact of economic policy on the major socio-

economic indicators such as the level of employment, the level of wealth, the distribution of income among

the institutional sectors by income or age classes. At the same time it is crucial to quantify the impact of

several policies of reform onto composite indicators such as the incidence of the health care expenditure on the

gross domestic product (GDP). The multisectoral approach is the suitable framework in order to achieve that

goals, first by means of the Social Accounting Matrix (SAM). This is an advanced accounting tool also

recommended by the United Nations Organization as essential tool in order to analyse regional economies.

The SAM scheme allows to develop the multisectoral extended model which permits to simulate UE policies

but also National and Regional ones. Furthermore the model allows to identify the optimal policies with the

aim to identify a set of indicators to better evaluate policy on the health care for the elderly.

IV.1.2.2.5 Active aging and innovative care pathways

Transformations of epidemiological, sociological and social-political settings, in particular life extension, the

growing forms of disability and non self-sufficiency in the elderly and transformations of families structures

need a reorganization of the traditional discrepancy between formal and informal care and between

professional and lay knowledge. In social field there is an increasing need for the involvement of subjects and

of their own knowledge, both in the promotion of the quality of life during periods partially free from disease

and disability and in clinical pathways, especially in the case of extended ones. It can be interesting to analyse

the contribution and the dialogue between lay and professional knowledge, both in case of long-lived elderly

persons with a chronic disease and in case of healthy long-lived elderly persons. Regarding the first

dimension, the recognition of the role that lay knowledge plays for the management of health led to the

development of several initiatives aimed at enhancing self-management and lay knowledge sharing for those

living with chronic illness. As a matter of fact lay knowledge of health disease consists in all those

competences that are not a mere dilution or popularization of medical knowledge, but that are the whole series

of beliefs, knowledge, competences, forms of behaviour and decision making processes that lay people adopt

to face disease and to keep in good health. As such, they are forms of “local knowledge” , produced in specific

social, economic, political and cultural contexts created by specific historical and geographical situations. We

would like to get in depth into the analysis of innovative care pathways that could advance a real integration

between lay knowledge and professional one. In particular it will make reference to Family Learning

experience which consists in guided and mediated formation processes involving patients and their relatives,

together with professionals that accept to “sit at the same table” with the families to compare their

competences and experiences about a specific pathology. Especially it will be examine if it's possible, through

Family Learning, to get to a real exchange of “experiences” and competences. We think this is the fullest

meaning of the concepts of “expert patient” and “expert professional”: people who can reciprocally experience

each other's expertise. With regard to the second dimension of healthy elderly and active ageing initiatives we

consider the new concept of the longevous, healthy person, who is still able to look after himself/herself and is

active in the various dimensions of social life, can be scientifically studied according to the perspective of “

life course”, a relatively recent interdisciplinary field of study that seems to contradict any simplistic view in

terms of early determining factors of health in old age, pointing out the basic impact of “agency” - one of the

least studied among the “agency” factors is lay knowledge - and welfare systems in deeply changing health

trajectories in life courses. We would like to build up a common terminology for the study of old people's

health according to the interdisciplinary perspective of life course; to create a longitudinal model in order to

analyse the role that the various dimensions (biological, psychological, social, cultural, economic and

institutional) play in the life course, so as to explain the different longevity levels and in particular healthy

longevity; to verify empirically verification this model). Finally the indications and suggestions that research

can supply to social and health policies, in particular for the acknowledgement, the promotion and the

inclusion in the health systems of the role that lay knowledge of old people, of their families and proximity

social networks can play in people's life and care.

IV.1.2.2.6 Rights of elderly people

The rights of the elderly people in new scenarios defined by the crisis. Innovative ways of implementation of

the Charter of Rights for Older by local communities.

IV.1.2.3 The influence of technology on the future of long-term care systems

IV.1.2.3 Introduction

Typically the Long-Term Care (LTC) provision has been reactive and episodic, causing an avoidable use of

hospitals and residential facilities. The innovative organizational models that are being introduced to prevent,

alleviate and control the consequences of a compromised functional autonomy are intended to better meet the

holistic needs of health and wellness of the citizens. The meaningful use of the Information and

Communication Technology (ICT) and advanced home equipments may be crucial to help offer more services,

to make them more targeted and effective, to reduce the fragmentation of the interventions of social and health

operators and the geographical dispersion of citizens and professionals on the territory.

The greatest impact on the future of LTC will not be due to the spontaneous and scattered diffusion of some

tools among individual citizens-consumers, but rather by large-scale organizational changes of the entire

welfare system, supported by enabling technological services aimed at chronic diseases, fragility and healthy

aging. In fact, ICT and domotics may deeply influence the rising of new models of care by shifting the focus

from residential care to home, changing the roles of formal and informal carers and of the citizens-patients,

reducing the functional limitations and the frailness, lessening the burden for informal carers.

In future, coordinated care models with a proactive role of the citizens may be successfully deployed with an

appropriate technological support at an increasingly accessible cost, improving both the quality of life of

affected individuals and their families, and the economic sustainability of the overall system.

The effects of the technologies on the LTC sector will be added to the well-known socio-demographic

evolution, i.e. the increase of the number of elderly people, the reduction of the family size, the modifications

of lifestyles. To this end, two contexts should be considered:

• the direct opportunities to better adapt the individuals to their daily activities and their social context,

living at their best with the long-term conditions and recovering as possible from the related loss of

functionalities, with the consequent chances also to alleviate the burden for the informal carers and

restore in some measure their productive role in the society;

• the indirect effects that prevent or delay the future needs for LTC, e.g. by a focus to the risks for frail

elderly, timely interventions to avoid or reduce the consequences of health-threatening events or the

improvement of the care of the chronic diseases.

The European Union has implemented numerous initiatives in this area, including: AAL-Ambient Assisted

Living, ICT for Health and e-Inclusion, now integrated in the framework of the Digital Agenda and of the

European Innovation Partnership on Active and Healthy Ageing.

IV.1.2.3.1 Technology-based services as a crucial support to the diverse stakeholders

The appropriate technology can assist the citizens (and the carers who surround them: relatives, family-paid

workers, neighbours, volunteers) in order to restore or replace at least partially the compromised

functionalities, to enhance their skills in self-care, to increase the adherence to prescribed therapies, to reduce

waiting times and visits, to decrease morbidity and mortality. LTC may be increasingly carried out at home to

support the daily activities and the care processes, e.g. to communicate with remote formal carers or other

citizens, to measure biological and environmental parameters, to generate reports and alerts, to recall deadlines

and appointments, to look for information on available facilities and services, to carry out administrative

procedures, to receive instructions and on-line educational sessions.

The formal carers can perform a more regular follow-up with additional remote contacts. Operators may

reduce their isolation by improving their links with other colleagues; they can decrease their workload on less

compromised patients and reduce the risks of errors. Although scattered throughout the territory and having

different roles, objectives and tasks, all the actors could better communicate with each other, coordinate their

activities and share the corresponding documentation, according to the individual plan of care, which also

includes the activities performed at home by the citizen and the informal carers.

ICT will allow the managers to extract timely indicators related to the critical points in the care processes (e.g.

in the situations at risk of non-appropriateness or errors), possibly agreeing at a regional and national level on

standards about the routine data to be systematically observed and exchanged, to be also used for governance.

Managers can ensure a more appropriate allocation of resources, avoid hospital admissions (and particularly

by reducing inappropriate access to emergency rooms) and encourage earlier discharge of patients with the

guarantee of quality and appropriate management of home care.

Policy makers could deploy large-scale organizational changes, enabled by technology, to improve health and

wellness in case of disability and non-self-sufficiency: awareness has grown that the scale of the phenomena is

no more local and isolated, with spontaneous interventions on particular services, but it covers wide areas with

the involvement of appropriate regulatory and governance tools.

In addition, the nascent market of smart ‘networkable’ home devices offers significant opportunity for the

industry on LTC technologies, still underdeveloped in terms of products and services. Although the market is

potentially huge, the slow process of adoption has kept low the supply of the technology-based services.

IV.1.2.3.2 The magic word: integration

The technological services are intrinsically susceptible to various modalities of ‘integration’:

• integration of equipments and ICT solutions into comprehensive technology services;

• integration among the actors, including not only the formal carers, but also the care recipient and the

informal carers, into a sort of earmarked 'virtual team' built around the needs of each individual;

• integration of administrative, organizational, operational tasks and related documentation;

• integration of social and health care.

The deployment of this ‘ideal world’ is not hampered by a shortage of the potential technological solutions,

but by regulatory, economic, organizational and cultural issues, including the lack of a constructive debate to

spread awareness about the available opportunities and the chronic shortage of innovators to manage the

change processes. It is often difficult to transform the pilot experiences into a long-lasting routine with a

permanent reallocation of roles, responsibilities and resources; the evolution of the phenomenon cannot be left

to spontaneous local initiatives, but it must be coordinated and planned in a regional frame to obtain the

maximum of benefits for the individuals and the community.

IV.1.2.3.3 Direct and indirect future influence of the technologies on the LTC sector

The lessons learned e.g. from the incredibly quick diffusion of the Internet and mobile phones in the last

decade make it clear that every forecast on the future evolution of the technologies is quite hopeless. However,

it is still possible to envisage the mechanisms that may produce a direct influence of the technologies on the

recipient of care, on the informal and formal carers within the current LTC processes:

• to augment the opportunities to alleviate the dependency of the individuals after a loss of functions, by

self-care or by an appropriate replacement of the defective functions;

• to improve safety, timely detection of potential problems, and reduce the consequences of accidents, by

the surveillance on the environment, by the prevention of inappropriate actions of the individual and of

the informal carers and by immediate reactions to unforeseen events;

• to support the individuals and the informal carers on collateral activities, e.g. administrative procedures,

education about lifestyles;

• to orchestrate the collaboration of the formal carers among themselves as well as with the subject of

care and the informal carers.

Among the potential indirect influences on LTC processes, some mechanisms that do not involve the actual

care provision, but anyhow affect the activities performed within the LTC environment, are:

• the activities to promote the appropriate adoption of technologies, e.g. by portals with a description of

the available devices or services, by show-rooms and orientation centres to assist the consumer in the

selection of the most suitable equipments and services compatible with the economic constraints;

• the ICT services to support the managerial activities, e.g. to assist the decision makers in the set up of

the organizational model and in the governance of the system;

• the e-learning services to train voluntary and family-paid carers;

• the ICT services to facilitate the meeting between the families and the family-paid carers.

Additional indirect mechanisms acting on other sectors, which could have a relevant influence on LTC in the

medium-long term, may include:

• to assist in the care of the chronic conditions and their predictable consequences, in order to prevent or

slow down the evolution of the diseases and mitigate their (permanent) effects on the daily life;

• to improve the effectiveness of interoperable ICT solutions, e.g. to produce and maintain a body of

coding schemes and structured knowledge (info-structure) in a format suitable for computer processing,

to assure the semantic interoperability during the care process and the timely calculation of quality

indicators for the managers and the policy makers;

• to perform research on the optimal usage of the available technologies and to direct the efforts to fill in

the gaps and the bottlenecks in the continuum of the available LTC services.

Each kind of technological solution will have a different strategic and practical influence, depending also on

the local regulatory and organizational context; they allow, in most cases:

• to access current information on social care facilities and on services provided by them, to reduce the

time lost in the administrative steps (to download forms, to submit requests via the internet, to get

information on the progress of ongoing steps);

• for a citizen, to enjoy a greater continuity of care, thanks to an information system that facilitates

collaboration among operators and with him and the informal carers;

• for a citizen and his/her informal carers, to manage (also online, safely) personal health information, the

agenda and the deadlines, to receive recalls and warnings for the correct use of medications or for

performing measurements with equipments and instruments, to report problems to formal carers, to

improve data capture with an immediate assessment of data quality in relation to the parameters already

measured;

• to access authoritative knowledge in different languages (on diseases, medications, procedures, etc.) and

suggestions for an appropriate use of health facilities, providing audio-visual aids, including interactive

educational tools on the execution of activities by the citizens, for example motor rehabilitation or

changes in life styles;

• to provide tele-company services, in order to permit citizens to talk to operators, relatives, friends or

people with similar problems; to improve comfort, for example, automatically turning on lights,

controlling temperature and the air conditioning of a room; to provide an automatic reader of texts or

colours recognizer to the blind; to improve security through environmental surveillance and possibly

generating reports of faults and alarms.

Aids and services may be purchased by families or offered by providers and voluntary organizations; however

it would be useful for citizens, families and decision makers in the care organizations, to receive an

independent consulting assistance on how to select the most suitable technological support.

IV.1.2.3.4 Systemic benefits and barriers to overcome

The technological solutions available today can significantly help improving the quality of life of citizens and

their informal carers, allowing many of them to re-establish an active role in the community. The LTC system

will improve in the optimal management of the resources, increasing at the same time quality and

appropriateness of care. The industry also may have benefits both on the provision of services and on the

design and marketing of devices and ICT solutions.

Technology can massively impact on LTC by significantly alter the relations now existing among the various

actors. How? Rethinking roles and tasks of actors and giving a meaningful use of data for planning and

governance.

Of course several obstacles and barriers to innovation take often place. Different obstacles are slowing down

the process of change. The technological solutions should be selected downstream of strategic decisions on the

models of care, therefore the main barriers to technology adoption are due to leadership (or lack of) and not to

the specific technology. Other barriers are related to privacy and security and to the coherence with the

regulatory system. Finally, there are issues on data management accountability: Who is the “owner” of the

recipient’s data? Who is responsible for managing, updating and ensuring the completeness of data? Questions

like these need to be resolved in a participatory way by involving all the stakeholders in the care processes.

Most of the obstacles arising from the connectivity in remote areas seem now being overcome, even for the

fact that it is possible to obtain significant results even with the exchange of a small amount of data.

Furthermore the resistance to technology seems in the process of being overcome thanks to the growing

friendliness of the interfaces, although it is still quite critical for an elderly person in the absence of a skilled

informal carer.

IV.1.2.3.5 Recommendations - I

The recommendations fall into various lines: how to provide technological support to the various actors in a

favourable context, how to promote the growth of awareness in a country on the issues at stake and the

opportunities offered by technology, how to progressively produce a corpus of reference information (Info-

structure) to foster the pervasive and interoperable development of the sector.

Therefore the expected deliverables will be:

Turn the right context for the development of technology

Increase the awareness on the opportunities offered by technology

Improve the demand for the industrial solutions

Develop and maintain the Info-structure for semantic interoperability

The synergy between ICT and devices.

IV.1.2.3.6 The mechanisms to influence the long term care processes

The technologies themselves should not be the main driver of change, even if they could be an enabling factor

or a catalyser of phenomena being deployed in the health and social sectors: the technologies offer in fact the

opportunities to support and amplify relevant organizational changes, perhaps endorsed and made possible by

new approaches to regulations, i.e. by a reform of the (integrated ?) sectors of health and social care.

In other words, the deployment of the technologies must be considered in the systemic context of innovative

care models, in turn promoted as a consequence of the overall policies of a national or regional jurisdiction to

cope with the future sustainability of the health and social care.

Unfortunately, given the unusually large scale of the action plans, their novelty and their strong dependency on

the regulations and historical context of each concerned jurisdiction, the previous partial experiences cannot

provide a solid evidence base to predict obstacles, costs and benefits, making the related decision processes

very complex.

Therefore we here adopt a systemic approach focused on the health and social care models that can be

deployed (and enhanced by the available technologies), rather than to a “symptomatic” approach to the mere

social care, i.e. about the direct impact of each single technological solution either on the recipients of care or

on each formal or informal carer.

This result draws attention to the expectations raised by the advanced technological services and to the

potential mechanisms to enact their influence on LTC, confident that the efforts made in every country to

overcome the current barriers to a widespread diffusion of the technologies (e.g. the issues related to privacy,

security, safety, infrastructures and costs, already solved in most other economic sectors) will enable a

pervasive deployment also in the health sector.

We claim that the influence of the technologies on the LTC sector – to be added to the well-known socio-

demographic evolution, with their influence of the number of elderly people, the reduction of the family size,

the modifications of lifestyles, etc. – will come from the evolution of two contexts:

• the indirect effect from the progress of health care models, in particular with a proactive attention to the

risks for frail elderly, the timely intervention to avoid or reduce the consequences of health-threatening

events and the improvement of the care of the chronic diseases predictably leading to long term

conditions, able to reduce / delay their effects.

• the direct increase of the opportunities to adapt the individual to the daily activities and their social

context, living at their best with the long-term conditions and recovering as possible from the related

loss of functionalities, with a consequent chances for the informal carers to alleviate their burden and

restore in some measure their productive role in the society.

In synthesis, this deliverable envisages the combined impact of ICT and equipments (either at home or in

residential facilities), as an essential, enabling component of innovative care models in the provision of

a ‘Technology-Assisted Long Term Care’.

IV.1.2.3.7 The technology as a catalyst for new organizational models

The technologies could represent an enabling component for new care models, to significantly improve quality

and appropriateness of care, through various innovative mechanisms, e.g.:

• improve capture of the most relevant data for each condition, with an immediate check on their quality

and on their relations to available data and knowledge;

• perform a remote monitoring of data generated by smart devices, at home or in residential facilities

(either continuous, or on scheduled times, or on request), with or without a local intervention;

• offer the possibility to exchange structured administrative, organisational and clinical data among all the

actors that are involved around the same subject of care;

• facilitate the data analysis and the comparison among subjects of care for the self-audit of the

professionals and for the optimal management of the care plans;

• produce the proper routine data needed to generate timely governance indicators;

• enable tailored educational programs – based also on case-specific data – for all the professional and

non-professional actors.

IV.1.2.3.8 The role of the Care Manager in an innovative care model

Costs for the management of frail elderly and the elderly with chronic diseases had been spiralling. Various

organizational models were developed to reduce costs while improving quality and citizen satisfaction, which

allocate the activities to specific professional profiles and roles in relation to the application environment. A

new profile, the “care manager”, is emerging in different contexts, to assist the recipient of care and the

informal carer in their routine management of a long-term condition, with a special emphasis on the support

for self-care. The care manager should be the interface between the recipient of care and the different actors in

the care system, and should help the recipient of care (and the informal carers) in the implementation of a

predefined care plan and in the recognition of the situations that require an alert and a potential adaptation /

extension of the plan.

IV.1.2.3.9 A comprehensive information substrate on LTC services

The adoption of a coherent information substrate on LTC services in a large jurisdiction should be an essential

component of the appropriate implementation of the regulatory, organizational and cultural changes. It should

eventually involve all the entities that contribute to the provision and the governance of health and social care.

It may have a potentially huge impact on the role and on the responsibilities of all the stakeholders and thus on

the provision of LTC.

Its feasibility and effectiveness depends on the organizational coherence among the entities in the health and

wellness ecosystem (i.e. on their motivation towards cooperation), which in turn depends on the regulations

and on the cultural context within each jurisdiction.

Standards and reference material in a computable format should be widely used, named as “infostructure”,

including: definition of reference care plans; data sets and governance indicators; earmarked subsets of coding

schemes; guidelines about the production of each kind of documentation about the activities performed and the

conditions of the individual.

IV.1.2.3.10 Optimizing the usage of resources and the quality of care

Three major benefits on quality may be envisaged: increased adherence to guideline-based care, enhanced

surveillance and monitoring, and decreased medication errors. The main domain of improvement is preventive

health; the major efficiency benefit may result in a decreased utilization of care. Based on the review of the

literature, the project identified four dimensions of quality in LTC. Further studies should develop a robust and

comparable set of indicators to reach an adequate level of accuracy in the measure of the various dimensions.

The quality dimensions are:

1. Effectiveness. Effectiveness has been defined as a combination of concepts: effectiveness of care,

appropriateness, competence of health system personnel;

2. Safety, a dimension that is closely related to effectiveness, although distinct from it in its emphasis on

the prevention of unintentional adverse events for patients;

3. Patient value responsiveness. This also is the combination of different concepts which are aimed at

representing the patient point of view: patient value responsiveness, satisfaction, acceptability;

4. Coordination. Coordination was defined as the combination of timeliness, continuity, integration

between primary and secondary care, and between healthcare and social care.

IV.1.2.3.11 Recommendations - II

The studies performed allowed to produce some recommendations, which fall into four lines:

1. how to improve the assessment on technological services, and the criteria to select them in the context

of the deployment of innovative organizational models;

2. how to promote the growth of awareness in a country on the issues at stake and the opportunities offered

by technology;

3. how to set up a favourable context that will include a technological support into a well-defined path of

organizational change;

4. how to progressively produce a corpus of reference information (Info-structure) to foster the pervasive

and interoperable development of the sector.

The recommendations are discussed in detail in the following sections:

Section I - Improve the outcome of the assessment methodologies

The mechanism and the strength of the influence of technologies on each long-term condition are extremely

different across the various phases in its evolution and among the different conditions.

Valid technological solutions already exist and their benefits have been demonstrated in a number of

experiences (e.g. Department of Health, 2011); however, unlike other technologies (e.g. diagnostic technology

in health care), LTC technologies are still not fully integrated into the care processes and in the daily activities.

Researchers and decision-makers should investigate how to better assess the technologies, from the economic

and organizational points of view, in order for them to take more informed decision about how to renovate the

care models. Further studies are needed not only to improve the evidence of the benefits and their cost-

effectiveness (e.g. Renewing Health, 2011) but also to put them in practice, in order to best use the limited

resources available for LTC.

The comprehensive methodologies should be able to assist the decisions (in the various settings: the public

system, the insurances, the voluntary organizations and the families) by comparing different complementary

components to build complex strategies.

Section II – Increase the awareness on the opportunities offered by technology

A major factor that hinders the development of technology in the LTC sector is the mere lack of awareness on

all the opportunities offered by technology.

A first form of intervention is the development and coordination of a network of intra- and inter-regional

information centres providing assistance on the rights of citizens, helping in choosing the most suitable

devices to each individual, providing information on the social and health care organizations (including

volunteer organizations) and on their available services.

The centres could also produce and distribute (multilingual) material to compare different types of devices and

manage showrooms to offer the opportunity to test them. The network of centres could have a web portal, on

which documents can be made available to citizens in electronic format and where a discussion on the

problems in the LTC sector could take place.

A set of pre-competitive “living labs” may also be recommended. These centres would be an innovation space

where industries, authorities, organizations, gather their experiences, present national and international best

practices, identify new user requirements for the design of new technologies.

Finally, short training modules could be organized to increase the awareness among the intermediate-level

decision makers who cope daily with the organizational issues and the supervision of the care processes, as for

example the managers in the municipalities, in the local health authorities and in the voluntary organizations.

This activity would have two complementary goals:

• to prepare them to design a roadmap and to monitor its progress;

• to create a network among the intermediate-level managers, who can then exchange information and

updates and are able to support the top-level policy makers in setting priorities and strategies.

Section III – Turn on the right context for the development of technology

Many technological solutions now available are recognized as effective and sustainable in the international

literature. It is also clear that the most important factor for a successful implementation is a precise outline of

the role of technology within a well-defined path of organizational change and the presence of a strong

leadership commitment to drive the change process.

Without an implementation plan clearly redefining responsibilities, roles, and behaviours of each actor, a great

risk of resistance to change may occur, which hampers the opportunity to get the feeling of technology as an

essential component of a new care model and thus to establish a permanent solution.

Operators need to be motivated and reassured that the technological change has a positive return, not

necessarily in the form of economic incentive, but rather in a strategic and organizational development, to

become part of a coherent, accountable system.

Industry involvement in LTC is still underdeveloped, also for the inadequacy of the demand side, which is

highly fragmented and with specific difficulties in entering into long-term programs. Technologies are often

an issue directly left to the patient-consumer.

The outsourcing of some components of the services to external organizations can be better addressed with the

establishment of a regional or national pricelist.

Section IV - Develop and maintain the Info-structure for semantic interoperability

A coherent future application of the technologies in the LTC sector may be accelerated by the production and

maintenance of a robust Info-structure in a computable format, i.e. a systematic definition of the details about

the content shared between applications, made coherent at regional, national or international level.

That Infostructure, specific to the social and health sectors, includes:

• the systematic description of relevant care processes (with a precise definition of the actors typically

involved and their communication needs) and related exchanges of documentation among the actors,

with the criteria to select the information to be included in the various documents;

• a unique name and an identifier for the main parameters and variables to be collected and exchanged in

different contexts, each with the set of the allowed values and their respective codes;

• a definition of each indicator of process and outcome, useful to build a dashboard for decision-makers;

the adoption of clear and explicit definitions for indicators (uniform among healthcare organizations,

municipalities and regions) would allow managers to compare similar realities;

• the modalities of interaction between the home equipments and the rest of the information system.

International experience shows that to achieve the ‘semantic’ interoperability, a meaningful communication

between operators and citizens and the effective governance of the care system, it is necessary to develop and

maintain a reference ‘Infostructure’. The definitions are then made available in a format suitable for electronic

processing, both for systems developers and for the users, to allow for the optimal functioning of the overall

system together with the infrastructure and basic services for ‘technical’ interoperability (hardware, software,

secure networks, master index of citizens and care professionals, electronic cards, etc.).

The content can be built gradually, starting with well-selected target populations with the processes and data

considered as most appropriate by the policy-makers in each jurisdiction; the content can then be gradually

extended in accordance with the local development plans, also considering the relationship with the efforts on

Electronic Health Record (EHR), which is going to be implemented in several countries and regions. In

particular, the infrastructure of the EHR may be used also for social care processes other than health care.

In addition, a topic certainly useful to managers is the definition of detailed professional profiles for

technology managers and related training plans. In fact, to successfully exploit the technologies, innovators

need to be able to understand how to integrate them in the care processes, and how to manage the relationships

among all the stakeholders and players.

IV.1.2.3.12 Conclusions

We described multiple mechanisms by which the application of the technology, intended as the

complementary usage of equipments and ICT solutions, can influence the evolution in LTC from inside the

sector, including:

• changing the mutual roles of the professionals and of the informal carers, allowing each of them to

perform tasks currently performed by less skilled individuals (and thus moving the burden from

specialized facilities to less specialized ones and eventually to the home).

This phenomenon includes also the potential creation of new professional profiles, e.g. care managers, and

new jobs (e.g. increasing the number of non-medical professionals in the territory);

• optimizing the organization of LTC, by better synchronizing the activities of the different formal and

informal carers involved, increasing the awareness of each other, reducing the time of their

communication (and thus providing better care with fewer resources, with a positive influence on the

evolution of the subject’s status);

• optimizing the accuracy of the LTC processes by better monitoring and more timely reactions to the

events happened to the subject (again improving the quality of care and the subject’s status).

In a more indirect way, two more mechanisms – external to the actual LTC processes – should be considered

to study the future evolution of LTC, namely:

• the improvement of the healthcare outcomes (e.g. in the case of diabetes) and

• the support to the industry to provide more effective solutions (e.g. by promoting the set-up,

verification, and diffusion of the info-structure).

The case studies show the extreme difference of the potential influence that can be provided by the various

technologies on each stage of the long-term condition. It is impossible to generalize, without considering the

stratification of the individuals with respect to the disease stage.

The final effect in the years to come will be to reduce the burden of LTC on the (public) system, in two major

ways: by increasing the efficacy and the quality, but also by transferring the burden to the individuals (the

recipient of care and the informal carers).

However there is also a potentiality for benefits for the recipient of care and the informal carers, which may

use the current low-tech tools to alleviate the effect of the existing impairments, and advanced technologies to

improve the effectiveness of self-management. These mechanisms may allow them to be able to go back to an

active life or to take a suitable place in a working environment.

We are all accustomed to a large number of equipment (and more is going to appear) that “interacts” with the

most common human activities, including e.g. cars to facilitate transportation and glasses to alleviate the

vision defects.

Some is general purpose tools that may be used either for defective functions (perhaps after some adaptation),

either for comfort or efficiency (e.g. cars). Several of them are specifically conceived to cope with missing or

defective functions (e.g. glasses, wheelchairs).

Information Technology is having a pervasive impact on all the sectors of our life, mainly through

communication devices and infrastructures (internet, mobile phones, smartphones, etc.) and through the

selective access to information and knowledge.

In addition to the above earmarked devices and to information technology, a new generation of devices is

appearing, which can be placed at home or in LTC facilities, which are able to perform measurements,

generate alarms, capture videos. These devices can be remotely controlled and can send data to remote places

for appropriate interpretation by skilled people.

In the medium-long term we can envisage a revolution in the organization of care provision, facilitated by –

the perhaps massive – adoption of technology. It will have a strong impact on the management of the LT

conditions: slowing down consequences, allowing effective organizational changes from hospital to the

territory and from LT facilities to home.

More frail people with stable LT diseases (that need to be cured) will live well outside the hospitals, i.e. at

home or LT facilities, perhaps for a longer period; an increased percentage of recipients of care will be able to

stay at home (i.e. not in LT facilities).

Each actor will be able to perform additional activities related to care that are currently performed by more

skilled people:

• frail subjects of care will have the opportunity to be more autonomous on their routine activities

(including ADL and IADL) ;

• they will require less support by the non-professional people around them (mostly informal carers);

• a number of those recipients of care will go under the threshold of LTC needs which was requiring the

intervention of a formal carer;

• a number of tasks will be passed from professionals to non-professional people, including the recipients

of care themselves, perhaps under the (remote) supervision of more skilled people.

For example, the usual telephone device can be replaced by a specialized, friendly display with a webcam for

video-communication with a remote care manager or with a specific relative (a modern version of this device

is just appearing on the market, produced by Intel and other big companies).

Several devices are purpose-specific, i.e. each type of device is conceived for a specific defective function;

therefore it produces a very circumscribed impact and a general theory is not possible. However, a small

amount of them can be selected in the context of the case studies (i.e. obesity and dementia). More in general,

the effects of most defective functions (beyond ADL and IADL) may be alleviated by specific devices or the

involved processes may be replaced by suitable alternate processes with similar objectives, assisted by

appropriate technological solutions.

Organizational issues (involving the recipient of care as well as formal and informal carers) could be often

more relevant than the direct effect on the defective functions.

Another significant effect could be envisaged on the governance of the caring system and on the optimization

of the LTC provision. Particular attention should be devoted to the effects of the domotic devices (surveillance

and alarms), of the register of contacts and of the indicators for the proper governance of the system.

Finally, we should also consider indirect mechanisms, e.g. on the education of the recipient of care and of the

caregivers, and on their access to knowledge (topics include the management of the LT condition, the patient’s

rights, the administrative issues, etc.).

Therefore the effect that is more interesting for policy makers will be due to the systemic organizational

changes and not to the increase of the market of the devices or to a better coping with defective functions (by

independently assisting each subject of care to cope with the daily activities).

The main focus of the analysis should not be on the technology, but on the organizational changes in the whole

health and social system (facilitated / allowed by the technologies), in particular the ones dealing with chronic

conditions, that in turn will be related to new laws and regulations and will influence the future of LTC.

The above scenario about the future can be mainly qualitative: it is very hard to define, for each country or

region and for each kind of technological solution, the potential speed of adoption of the technology, the

incentives that will be put in place, the benefits / cost ratio of new technologies that will be put on the market

in the next years.

In other words, the studies about the past are of limited use here: look for example at the speed of the diffusion

of the internet, or at the increased speed of diffusion of cellular phones and - more recently – of smartphones.

Nevertheless, it is possible to work out a reasonable range of values for the main indicators on the evolution of

the sector.

IV.2 Interventi innovativi per la valorizzazione del patrimonio storico: small historical towns for healthy

ageing

In un contesto denso di storia, nel cuore della città antica di Bologna, nel complesso delle Sette Chiese e nel

Palazzo Isolani in Piazza Santo Stefano, il 9 novembre 2011 si è svolto nell’ambito della VIII Edizione di

Urbanpromo il Convegno nazionale “Interventi innovativi per la valorizzazione del patrimonio storico: small

historical towns for healthy ageing (I borghi della salute)”, organizzato dal Centro ricerca Fo.Cu.S

dell’Università degli studi “La sapienza” di Roma, in collaborazione con l’Equity in Health Institute (Ehinst) e

l’Associazione Nazionale Piccoli Comuni d’Italia (ANPCI).

Sono state presentate le esperienze realizzate in Puglia e in Sardegna, nonchè quelle a cura della Provincia di

Terni, accomunate dal concetto di “Territorio socialmente responsabile” e in linea con il programma European

Innovation Partnership on Active and Healthy Ageing (EIP-AHA). L’attenzione che l’Europa ha deciso di

dedicare all’invecchiamento attivo e alla solidarietà fra generazioni ha infatti condotto a dedicare il 2012 a tale

tema. Gli anziani sono non tanto forma costruita, quanto forma di memoria291

. Il servizio sanitario non è più

inteso solo come cura e mera erogazione di prestazioni, ma come strumento di promozione della salute e di

una nuova cultura del ben-essere, in cui l’idea di prevenzione sia promossa anche attraverso la diffusione di

stili di vita più sani. Ecco allora che i centri di dimensione minore, diffusi capillarmente sull’intero territorio

nazionale, possono valorizzare gli elevati livelli di valore ambientale e storico-architettonico e la qualità della

vita e di relazioni sociali, mettendoli a disposizione di tutti e, integrandoli con attività di assistenza, cura292

e

wellness, rappresentare quindi luoghi di “presidio della salute”.

In tale cornice è stato presentato anche il progetto “SensoriABILIS”293

, a cura di Confindustria Ancona:

cultura, ospitalità, organizzazione e tecnologia integrate in modo organico divengono i presupposti per un

territorio di qualità per il turista e il cittadino di ogni giorno, verso un territorio sempre più accessibile,

disponibile e aperto all’accoglienza, sottolineando l’importanza di realizzare un insieme di servizi e di

strutture che permettono a tutti di poter sfruttare al meglio gli spazi urbani e non, abbattendo barriere

tecnologiche e sociali.

Il naturale luogo di scambi e di incontri ha consentito al convegno di intersecare gli interessi dei diversi

protagonisti e indicare con percorsi variamente strutturati la riprogettazione dei piccoli Comuni, a misura

d’uomo, in maniera integrata, al fine di migliorare gli stili di vita nei diversi aspetti – nutrizionale, sociologico,

medico – e, quindi, produrre salute. Per raggiungere tale traguardo si è concordato di concentrare le iniziative

oggi frammentate e definire un modello regionale/interregionale di promozione della salute su larga scala, da

presentare ai fondi pensione per riuscire a modificare lo squilibrio attualmente esistente nella destinazione

delle risorse, pari al 97% per la cura e solo al 3% per la promozione della salute.

Il centro storico va quindi inteso non in modo ristretto come “borgo”, ma come “terra di sviluppo” e, grazie a

un Piano Territoriale attivo che si appella direttamente alle comunità, si può innescare un meccanismo

partecipativo che ponga attenzione al riconoscimento di valori condivisi e delineare le “mappe di comunità”

(un esempio per tutti quella del Comune di Parrano in provincia di Terni, ove sono stati stipulati “contratti di

paesaggio” e “contratti di fiume”); si ottiene così la valorizzazione delle diversità e della complessità dei

patrimoni culturali locali che si esprimono nelle memorie e nei segni storici, nei saperi e nel “saper fare”

locali.

Elemento strategico è stato giudicato l’aspetto formativo di operatori altamente qualificati (Direttori generali e

di distretto delle aziende sanitarie, dirigenti medici di prevenzione, assistenti sociali, psicologi), che a cascata

possano poi implementare la formazione ai cittadini in genere, con particolare riferimento sia alle associazioni

291

Si conferisce nuovamente alla persona anziana il ruolo di vecchio saggio, dall’antico greco “presbùteros”, che diviene quindi una risorsa preziosa per l’intera comunità. 292

La connessione fra il concetto di cura e l'essenza primaria dell’essere umano affonda le proprie radici nel mito: si narra infatti che Cura abbia creato la figura umana modellando fango cretoso, a cui il dio Giove infonde lo spirito . Fra i due sorge una diatriba su chi possa decidere a maggiore ragione il nome della nuova creatura. Alla disputa si aggiunge la Terra, rivendicando anche lei tale diritto in virtù della materia della creazione che da lei proviene. Saturno, dio del Tempo, interviene a regolamentare la lite: “Tu, Giove, hai dato lo spirito e al momento della morte riceverai lo spirito. Tu, Terra, hai dato il corpo e riceverai il corpo; poiché per prima fu Cura a dare forma a questo essere, finché esso vive lo possiede Cura. Per tutta la vita l’uomo è l’essere della Cura e visto che proviene dalla terra, dall’humus, il suo nome è homo”. (Liber Fabularum, Higynius, I sec. d.c.). 293

SensoriABILIS si pone come PUNTO DI RIFERIMENTO PER LA FRUIZIONE UNIVERSALE: i Comuni devono avere la capacità di accogliere tutti, con particolare riguardo a chi proviene da una devastazione (valoriale, emozionale, motivazionale, relazionale); i princìpi che sottendono Sensoriabilis sono significati che permettono non solo l'erogazione di un posto letto, ma anche un'accoglienza umana, in linea con la concezione solidaristica e universale del Sistema Sanitario Nazionale; SensoriABILIS propone un MARCHIO DI QUALITA': di qualità della vita (dall'aria pura alle condizioni ambientali in toto), della ristorazione, dei valori storico-culturali tutti (musei, biblioteche, monumenti e chiese, etc.), delle relazioni sociali, etc.; Sensoriabilis garantirà TUTTO IL SISTEMA DI AGENZIA necessario a rendere completa l'offerta di accoglienza: con i proventi sarà possibile finanziare i trasporti e la recettività per i più poveri; SensoriABILIS rappresenterà quindi uno STANDARD DI ACCOGLIENZA, visto come un valore aggiunto al prodotto sociale: la sussidiarietà dev'essere proporzionale alla quantità del bisogno, così che l'equazione si trasformi da "Non hai una lira, allora sei escluso da tutto" a "Non hai una lira, allora sarai avvantaggiato rispetto agli altri".

di anziani che a studenti e altri gruppi giovanili, che si sentano protagonisti attivi del proprio paese e

divengano quindi motore di rinnovamento.

L’Università degli studi “La sapienza” sta coordinando su un tema così complesso più tesi di laurea, con la

caratteristica comune di approfondire tre filoni: urbanistico, tecnologico, di fattibilità, cui si aggiunge in modo

trasversale quello medico; l’aspetto architettonico visto in maniera innovativa, tecnologica, assume un rilievo

fondamentale nei lavori succitati, i cui risultati, integrati, costituiranno un modello di riferimento per la

capacità di riconoscere i bisogni attraverso una lettura basata sulla innovazione integrata – sociale, tecnologica

e finanziaria –.

CHAPTER V

FINAL CONSIDERATIONS

V.1 Considerations. V.1.1 Seven maxims. V.2 Conclusions. V.3 Quotations

V.1 Considerations

Marshall Marinker (2006) indicates in the “constructive conversationalist” the key figure for health policy.

“Policies – he says – arise in the first instance from some initiating impetus, from new research findings, from

epidemiological data monitoring trends, perceptions of needs, risks, threats, from evidence of public

dissatisfaction with the status quo, the campaigns by special interest groups, political parties, the instant

agendas of the media. For policy to ensue, these things must be talked about.

At some point the policy makers, groups of experts, health and social scientists, politicians and public

servants, special interest representatives, public and corporate administrators, have to sit together and

deliberate. This may occur at the highest levels, the WHO, the World Bank, the European Union, or the nation

states, and at the most local levels, the smallest municipal districts or health authorities. What is the process of

these deliberations? How is the initial impetus transformed into directives and then managerial plans for

implementation? Derek Yach (Yach, 2006) suggests that at the very highest global level of decision taking, the

power of advocacy can overwhelm and override the evidence.

In recent years the aspiration has been that health policy be 'evidence based'. However policy is not the

product of the data alone. It emerges from group interaction. In this, the light of evidence and reason is

inevitably deflected through the prism of the values, preferences, emotions, intellect and personality of all the

individuals who take part. The term conversation implies far more than 'speaking together'. The OED

definition refers to 'having dealings with others', 'living together', and also to 'society' and 'intimacy'. The

constructive conversationalist is a negotiator, an interpreter, and an explorer. How is `constructive

conversation' to take the place of partisan lobbying and special pleading? Or, if not to take its place that may

be asking too much of human nature how is it to enable solidarity and moral efficiency in the choice of

policies and in their ends?

Table 1. illustrates the different characteristics of committee process and the process of 'workshops' or 'think

tanks' (Marinker, 1994).

Workshop members are either self selected, or brought together on the basis of judgements about their

personal fitness for, and commitment to, the task in hand.

Table 1

Group work Committee work

Characteristics Social Political

Internal affiliation External affiliation

Process-oriented Result-oriented

Cooperative Adversarial

Tasks Explore differences Decide intentions

Define paradox Reach agreement

Consequences Focus on principles Focus on actions

Set limits to compromise Generate rules

Dominant values Beneficence Non maleficence

Autonomy Efficiency

Advocacy Justice

End points Judgement Agreement

(Reproduced from Marinker (1994) with permission from Blackwell Publishing.)

They interact socially, in the sense that their personal values and prejudices are close to the surface of their

deliberations, and legitimately so. Their commitment is to the group and its processes. For this reason their

affiliations may be described as internal, and their mode cooperative.

Committee members are appointed by bureaucratic processes, to be representatives, or even delegates, of

organizations or interests. They interact politically, and their personal values and prejudices, although

inevitably in evidence, must always be subordinated to the committee's tasks, and to the agendas of the

organizations and interests in whose name they attend. For this reason their affiliations may be described as

external, and their mode adversarial.

Participants in workshops are encouraged to explore and define the paradoxes that abound, and to examine

them, in terms of the principles and values that individual members bring to the table. Consequently, the

predominant values expressed are more likely to be the liberal and permissive ones of beneficence, choice and

advocacy. The intention of the group's work is to produce judgement and reflection.

Committee members, when they encounter a paradox, are enjoined to decide between its conflictual elements,

sometimes even to vote on them. Their job is to reach clear agreement, to take action and to generate rules.

Consequently the predominant values expressed will be the more prudent and conservative ones of non

maleficence, efficiency and justice. The intention of the committee's work is to produce agreement and action.

The challenge is to reconcile the strengths of both approaches, and their mutual contradictions. Much of the

literature on consensus in medicine refers to the function of ethics committees (Veath and Moreno, 1991). This

is helpful, since what Handy` calls the management of paradox is little different from what medical ethicists

have called the resolution of dilemmas. Jennings (Jennings, 1991) urges us to think of consensus not as a

thing, or a goal, but rather as an activity. He regrets the lack of a gerund form of the word (gerund: a form of a

verb capable of being construed as a noun). In English the word would be 'consensing'. Jennings asserts that

consensus enjoys moral weight in decision making only when it reflects 'a healthy community of open,

inclusive moral discovery and growth'. But consensus speaks of compromise. Reflecting on the hard realities

of policy making and implementation, Hans Stein (Stein, 2006) remarks 'If the choice you must make is

between taking the left or the right road, to compromise by choosing the middle one won't get you anywhere,

or at least not to the place that you originally had in mind.'.

In an inescapable sense, a consensus must always be false. In the bargaining and the negotiations of policy

making, some ideas succeed, others fail. More robust than consensus is the notion of keeping the differences in

productive tension. Giovanni Moro (Moro, 2006) says that policies '... must essentially be a matter of

managing diversity'.

Constructive conversation will require something more open and flexible than the implied rules of the

committee, the arena in which most health policy is made. Crucially, Per Carlsson and Peter Garpenby

(Carlsson and Garpenby, 2006) observe: “Participants in the deliberative democracy model are expected to act

without any predetermined opinions. The idea is that the discussion itself, and the arguments that are put

forward, will contribute to reshaping preferences, and that following such discussion it should be possible to

achieve a cooperation that includes the broad majority.'

We may need to invent new arenas for the discussion itself', for constructive conversation, new metaphors of

discourse, much as Morgan 34 urges the invention of new metaphors for organizations. These, he suggests,

will be the product of our ability to imagine them, a process that Morgan describes as 'imaginization'.

V.1.1 Seven maxims

Committees are bound by conventions and rules the rhythm of agendas, who speaks and when, how decisions

are proposed, challenged, reached and minuted. There are no such generally recognized rules of engagement in

the case of constructive conversation. Marinker (Marinker, 2006) suggests that it might be helpful to adduce

some maxims to guide us through the policy discourse, and offer the following list for critique, improvement

and expansion.

1 Search for the absent dimensions: The Madrid Framework attempts to make explicit both the

interconnectedness of, and the conflicts within and between, all of its dimensions. Discussions that

habitually avoid one or other dimension may suggest an unconscious, or even a deliberate, avoidance by

the policy makers. Any such persistent absence of issues may also suggest that the policy group lacks

individuals with the relevant professional expertise or motivation, such that the balance of discussion in the

group becomes constitutionally distorted.

2 Resist 'stakeholder capture': Discussions are inevitably driven by the professional or political or corporate

imperatives of the participants. Constructive conversation requires the moderation of such self interests or

special pleadings, and the validity of the discussion may be tested by the degree to which participants are

prepared to speak at variance from their expected partisanship.

3 Expect the unanticipated: Policies grow, evolve, adapt to changing circumstance, are blown off course by

events, are capable of adapting to explore and exploit ecological niches in the health system. Uncertainty is

the only certainty. There is no place for the constructive conversationalist in a discourse based on the

fiction that every effect can be the precisely predicted product of a particular cause.

4 Beware the claims of a common metric: You cannot make quantitative comparison between custard and

Tuesdays. Aristotle pictures choice as a quality based selection among heterogeneous goods. Consequently,

the following claims should be resisted. Firstly, the belief that in every situation of choice there is one value

common to all the alternatives, and that this varies only in quantity. Secondly, the claim that in all

alternatives, there is one and the same metric. Thirdly, that ‘means' have values only in relation to the good

consequences, the ‘ends', that they produce. Fourthly, the myth of a common metric in all things belonging

to the ultimate end in our case to 'health' or 'equity', and so on.

5 Distrust de fide claims of moral superiority: Most of the dimensions imply ethical positions. These are often

"played' in debate as though 'equity' or 'choice' or 'evidence' and so on were the ace of trumps in a political

card game. Such claims of de fide moral superiority are hard to resist, but they should be challenged

(Zeldin, 1998).

Daniels (2003) compares a foundationalist with a relativist approach to discourse. In the former certain

moral positions, values, are taken to be self evident, fixed and unrevisable, because they derive from some

absolute structures of value that reflect religious revelation or metaphysical theory. In health policy

discourse the pursuit of equity or freedom of choice or quality of service are often presented in this way.

Rawls (1999) refers to these as 'fixed points'. Daniels argues for a relativist approach that he calls

“reflective equilibrium”. This 'consists in working back and forth among our considered judgments (some

say our intuitions) about particular instances or cases ... revising any of these elements wherever necessary

in order to achieve an acceptable coherence among them.' Whether we claim authority for our values from

revelation or from reason, whether we believe them to derive from a universal reality or to be contingent on

the insights of a particular moment in history, we argue for them on the basis that one is superior to

another. Reflective equilibrium, constructive conversation, posits a dialogic, and not a dogmatic, resolution

to the conflicts between the values implied in our policies.

6 Shun easy consensus: Consensus can be the lowest common denominator of agreement between the policy

makers and stakeholders. The quest for this enfeebles robust debate and challenge. All the essays in this

book reveal the complexities, the intra dimensional conflicts within, and inter dimensional conflicts

between, such goods as ‘health' or sustainability' or `democracy'. Attempts to reach easy consensus by

over simplification of the real conflicts and paradoxes obscures the need for hard political choices. There is

no consensus without loss. This should be faced and the cost counted.

7 Consider your metaphors: The various metaphors we use imply different ends, means and cultures. It's

important to know in what metaphors we fashion our policies. If they seem inappropriate to the tasks, we

can try to change them, to operate in alternative imaginations. In literature, mixing metaphors is deemed a

vice; in constructive conversation about health, it can be a virtue.

Richard Rorty (1989) resists the notion of foundationalist beliefs in a universal obligation on all humankind.

Instead, he suggests that our sense of solidarity is grounded not in metaphysical absolutes, but in the

particulars of how we have come to live in a liberal society. He holds that since our moral positions are

contingent on our histories and our contemporary situations - it does not help to try to express an essence of

human solidarity (for example, with such collectives as 'all humankind' or 'all rational beings`). Rather, he

believes that we express our liberal sentiments and aspirations more securely and more practically by

‘reminding ourselves to keep trying to expand our sense of us as far as we can'. Rorty says that what is

important is to separate out the question, ‘Do you believe and desire what we believe and desire?' from the

question ‘Are you suffering?' The former seeks to define the boundaries of our obligations. The latter invites

answer from across all the frontiers of our partialities and our prejudices” (Marinker, 2006).

V.2 Conclusions

This initiative with a founding, refounding and reconstituent taste seems to be as ever proper in a historical

moment marked by the mundial crisis at all levels. So while courage appears as the great absentee and the fear

of sticking one’s neck out is spreading, for the common benefit we are able to dare.

Collectivity has got an own meaning: it amplifies the single’s potentialities and allows to dare in a major

measure than a simple individual could do. That’s therefore the ambition to lead all together a more incisive

action on whom holds the decisional power. As expression of a shared governance, through the study of

political programs and execution by involving both public and private actors joined with the aim to influence

policies and programmes results and impacts. It is a process by which problems are solved collectively

answering to society needs. We are talking about democracy.

V.3 Quotations

"Who starts from a dream can never fail" (Nicholas Shakespeare)

“Patience is a virtue, persistence to the point of success is a blessing” (Peter Safar)

“Maybe today the main objective is not to discover what we are, rather to deny what we are. We have to

imagine and build what we could become” (Michel Foucault)

"Ora il futuro determina il presente" (Franck Biancheri)

“We are at a life crossing, in an economic scenery which does not accept compromises, deeply reach of

challenges and opportunities” (Gabriele Micozzi)

“An action without thought is a deed that dies in the darkness, a thought forming an action brights light

intensely. Future horizon shape will only depend on our steps’ pathway” (Gabriele Micozzi)

“Man often becomes what he believes to be. If he continues telling he is not able to do a certain thing, it is

possible him to become really unable to do it at last. On the contrary, if I have confidence to can do it, I shall

surely acquire the capacity doing it, even though, at the beginning, I could not be able to do it” (Mohandas

Karamchand Gandhi, detto il Mahatma Gandhi) (Mohandas Karamchand Gandhi, said the Mahatma Gandhi)

Paolo VI ha sottolineato la forza rivoluzionaria dell’«immaginazione prospettica», capace di percepire nel

presente le possibilità in esso inscritte e di orientare gli uomini verso un futuro nuovo: “Liberando

l’immaginazione, l’uomo libera la sua esistenza”.

ANNEX 1

Draft Agenda Preparatory Meeting EIP

Prermises Rue Montoyer 24 , Brussels

February 13th 2012, 9.00 am - 1.00 pm

"TOWARDS PENSION FUND INVESTMENT

IN REGIONAL HEALTH SYSTEMS INNOVATION PLANS"

Participants:

Francesco Briganti AEIP General Director (confirmed)

Matti Leppala EFRP General Secretary (tbc)

Hagen Huegelschaeffer EAPSPI General Secretary (tbc)

Jonathan Watson Health ClusterNET Executive Director, Euregio III Project Director, HealthEquity-2020

Project Director (confirmed)

Steve Wright EAHAA Executive Director and former EIB Deputy Director (confirmed)

Fausto Felli President of Equity in Health Institute, Member Health Expert Group Age Platform Europe

(confirmed)

Vincenzo Costigliola President of European Medical Association (confirmed)

First Session 9.00 - 10.15

a) Analizyng the point of view of Regions : Innovation Plans in Health System under the crisis and

reconfiguration of care to provide for ageing societies. The strategic relevance of Investments in II

b) Exploring the point of view of PF . Investment in Common Good , beyond risk management and

prudential principles of security, profitability, and liquidity : the two pockets theory.

Consistency and Reliability of Returns : PF+SF ? (for public)

c) Hearing the point of view of Banks : How to act

d) STF short presentation ( they're in the AB)

Second Session 10.30 - 12.30

e) Social , Technological and Financial Integrated Innovation. Let's dream : how to start ?

f) European Commission: short report on first attention from President Barroso, Commissioner Dalli

(Health & Consumer) and Commissioner Hahn (Regional Policy)

g) Some new ideas for a a good feasibility plan:

RATING AGENCY FOR PF INVESTMENTS IN

REGIONAL HEALTH SYSTEMS INTEGRATED INNOVATION

h) Consensus Conference "INVESTMENT IN COMMON GOOD INNOVATION" Brussels 2013

i) AOB

l) Next steps :

1. Meeting with EU Commission experts (May 2012 ?)

2. Presentation of the draft of the Green Paper on

PENSION FUND INVESTMENT IN REGIONAL HEALTH SYSTEMS INTEGRATED

INNOVATION ( October 2012 ? )