Response to the Court of Auditors Report on the 1st Public Health Programme

The European Public Health Alliance was involved in the drafting of this text and fully endorses the position of the EU Health Policy Forum.

Opinion to the EU institutions concerning the Report of the Court of Auditors on the First EU Public Health Programme

The EU Health Policy Forum (EUHPF) has considered with concern the Report of the Court of Auditors on the Public Health Programme 2003-7, in which many EUHPF partners have participated. It recognises that many valuable points have been made and criticisms of some aspects of initial effectiveness of the overall programme are justified. It is aware that some of the specific projects directly referred to in the Report continue to refute some findings. It also welcomes the responses of the European Commission (specifically DG SANCO) and the EU Health Council.

The EUHPF welcomes both the impending midterm review of the Second Action Programme and the invitation of the Council to the Court of Auditors to carry out a further audit of the Second Action Programme (2008-13) in due course. It confidently believes that such further reports would show:

 The increasing value of the Health Action Programme in providing a substantial body of evidence (case studies, reports, information, etc.) that already has, currently does and in future will contribute to protection and promotion of the health of many people within and beyond member states;

 The increasing value of the Health Action Programme in terms of supporting and helping to build effective cooperative networks internationally, nationally and within communities. The evidence for this would include the numbers of bodies able to participate in the EUHPF. The Report states that support for networking is shown to be one of the more important benefits of the Programme;

 The increasing value of the Health Action Programme in terms of the added EU value and visibility in member states and communities. Prior to the first Programme, in 1998 a survey was carried out of European public health officers in preparation for the Parliamentary Report on the programme proposal. It showed from over 200 responses a widespread lack of awareness of an EU role in public health. Ten years later it is unthinkable that similar findings would result because so many public authorities are actively engaged;

 The increasing value of the Health Action Programme through specific follow up of activities that would not have otherwise taken place without its support and stimulation, for example capacity building for health improvement in the newest EU member states.

The EUHPF therefore agrees that, while some criticism is justified, the EC is also justified in rebutting some of the report which is outdated and some elements which have been misunderstood or by investigators.

The EUHPF also makes the following observations about the operation of the successive programmes which should be taken into account:

1. While progress has been made in raising awareness about the programme, transparency can be improved in its planning, implementation and evaluation. The use of the DG SANCO online facilities to disseminate outcomes has improved, but an enhanced partnership approach with stakeholders, including more effective promotion by national focal points, greater regional involvement, and a more engaged approach by the EAHC, would bring cost effective benefits.

2. In particular, there remains a top down approach to planning the components of the annual work programme and calls for proposals. Now there is a Joint Action provision, the member states deciding on awards in the programme committee can also put forward proposals. If that is acceptable, the EUHPF could be consulted annually in advance on what stakeholders feel should be included in the Programme, and members are willing to contribute responsibly and openly. We should practice what we preach: evidence from Programme work shows that users should be involved in design and implementation of successful initiatives. The EUHPF calls on the executive bodies to do so.

3. It is a fair criticism that there are excessive “priorities” provided in the annual Programme. All the EU institutions (and some stakeholders) must take some responsibility for that problem – the initial list of priorities was expanded beyond the capacity of the resources; the programme committee has not prioritised sufficiently well; the executive bodies have allowed too many small bids to succeed. There is evidence that this is improving, but the EUHPF calls on the programme committee and Commission to ensure realistic annual work programmes in line with the overall strategic objectives.

4. The belated but welcome existence of the EU Health Strategy is important. Until 2007 there was insufficient clarity among stakeholders and institutions about priorities. Now it is the responsibility of the Strategy mechanisms – in which the EUHPF should be more strongly involved – to help ensure that objectives are focussed and the Programme contributes in clear ways.

5. The recent agreement of the Health Strategy shows the comparatively early stage of the health competence of the EU. The Report concentrated on approaches concerning determinants. It is worth noting that the influential report of the WHO Commission on Social Determinants of Health was entitled Closing the Gap in a Generation. In addressing complex multidisciplinary problems, it is unreasonable to expect major behavioural or systematic change in a short time period. While recognising that some concrete performance indicators are important and achievement of objectives is essential for value for public investment, valuable work in such fields requires time to flourish.

6. It also requires adequate resourcing. The decisions of the EU institutions and Member States to allocate insufficient funds to meet their stated Programme requirements are incompatible. Member states have signed the Lisbon Treaty restating the competence in public health in addition to core objectives which underpin public and population health improvement as well as protection. The Report of the Court of Auditors, far from suggesting further reductions, strengthens the case for more effective allocation of funds to successor Public Health Programmes based on increasing demands from citizens in the period following economic and social crises. The EUHPF recognises pressure on EU budgets and will engage vigorously, including with our membership organisations in member states, in the forthcoming debates about comparative allocations for the next budget period, when we firmly believe health should be given a strong priority.

The role of the executive agency EAHC has been generally positive in terms of organisation. There are however some matters of concern:

7. The process of evaluation, both in assessing proposals and in capturing learning from Programme work, is variable, inequitable and requires attention. Every evaluator apparently has just 90 minutes to assess a detailed proposal in a concentrated period, with limited and rushed discussion and cross checking even though the evaluator is often qualified in another field and has little direct knowledge. Greater time, transparency, expert input and referencing is needed, and evaluation of the financial components should be improved at an earlier stage to reduce the annual process of proposals withdrawn in negotiation. All projects should require external evaluation, and an annual report of collective outputs provided so knowledge and transparency is improved.

8. Before the EAHC was established strong links between projects and SANCO officials were frequent. Now that important link in the policy/programme chain has been disturbed if not broken. Attention should be given to how the horizontal Programme practically integrates with the EC work programme beyond occasional meetings of experts in a particular field.

9. It is understood that the Programme provides limited funding. But the Court of Auditors Report states that some of the most effective benefits are shown by sustained approaches in networking etc. However the core funding available for such actions is minimal. This should be reconsidered, as a clear outcome from the Court Report, as the cost benefits of sustained operations rather than frequent start up, short term projects and closure costs would be significant.

10. Lastly, the consistency between programmes is inequitable. The difficulty for stakeholders to provide 50% matching funding is prohibitive, a barrier to inclusive participation and a threat to quality outcomes. The comparison with sometimes similarly structured projects funded by the EU research frameworks where larger proportions are funded, for example, is striking. For more cost effective outcomes in this field too, the proportion should be increased significantly.

Therefore the EUHPF:

 Notes the Report of the Court of Auditors for future reference;

 Looks forward to the midterm review of the current Programme for Health, which it will wish to study carefully;

 Urges the EU institutions to take into account not only the Court of Auditors Report(s) but also the midterm review and stakeholder views in order to enable evidence led decisions on future Health Programme funding and content;

 Commits to work individually and collectively to support the executive bodies in improving the effectiveness of the current Health Action Programme;

 Expresses its willingness to bring a stakeholder dimension into discussions with EU institutions concerning the planning, performance, outputs and future of EU Health Programmes.

EUHPF Opinion on the Court of Auditors’ Report

EPHA related articles
 Comments on the implementation of the EU Health Strategy
 EU Health Policy Forum meeting - 16 October 2009
 EU Health Policy Forum, May 2009