Event Report

Austerity-era cuts have undermined Europe’s healthcare systems. The Vilnius Declaration, set down in November 2013 during the Lithuanian Presidency of the EU, was a call from stakeholders including patients, civil society, clinicians, academics and industry, to end this attrition. In its EU Presidency in the first half of 2015, Latvia took the agenda forward in a number of high-profile health events that culminated in the Universal Health Conference, providing an opportunity to take stock of progress and suggest new objectives and ambitions to improve health systems for the future.

The overall aim of the two days of discussion was to identify ways in which citizens can actively participate in making health systems more efficient, sustainable and inclusive.

When the Vilnius Declaration was set down, Mr Vytenis Andruikaitis was Health Minister of Lithuania. Now as EU Commissioner for Health & Food Safety he made the keynote address to the conference, telling delegates Europe needs a plan for action to invest in health for all.

“The state of health systems affects all of us,” the Commissioner said. There is a need to reduce the toll of early death and relieve the pressure of chronic disease, and in doing so, to make Europe’s health systems more effective and sustainable.

The Commissioner said the Vilnius Declaration’s call for action – based on the views and opinions of all stakeholders – has been heard in Brussels. The European Commission is now responding with a number of policy initiatives that highlight the opportunity for cooperation at an EU level in areas including health technology assessment, eHealth, patient safety and the effective use of medicines.

“For me also, the Declaration was a source of inspiration when I was framing my priorities as Health Commissioner,” Mr Andriukaitis said, pointing to his ambition to increase investment in health promotion and disease prevention, and in public health. In particular, the Commissioner cited the need for action on childhood obesity and in reducing alcohol- and tobacco-related harm. “The benefit will be in personal health, in the health of health systems and in the health of Member State economies,” said Mr Andriukaitis.

To be really effective, such measures need to be integrated in all policies in a coordinated manner. In addition, there needs to be coordination of relevant budgets from a local, to regional, national and EU level, the Commissioner said.

“I think the past two years since the Vilnius Declaration have seen some important progress on the path to ‘Health systems for inclusive growth’. Now is the time – after the call for action – to come up with a plan for action and to define more precisely how Member States, EU institutions and stakeholders should invest in health and wellbeing for all,” Mr Andruikaitis said, adding, “We still await that much needed paradigm shift in EU health policy.”

Health systems need to reduce inequalities in health status, and empower people as patients and as citizens. “The future of our health systems affects everybody – politicians, stakeholders, and last but not least every one of us as citizens and patients,” said Mr Andruikaitis.

The Commissioner concluded, “So let’s not lose sight of our objectives – reduce the number of early deaths, lift some pressure from public spending related to chronic diseases, and make healthcare more effective”.

Guntis Belevics, Minister for Health for Latvia, agreed that tackling childhood obesity and tobacco and alcohol misuse should be priorities. On childhood obesity it is necessary to look across all policies and measures, from education, to the use of modern technologies to promote healthy choices in relation to exercise and nutrition, to working to spread healthy lifestyle habits at school. “Healthy life starts in childhood. We should promote healthy habits early on,” Mr Belevics said.

Whilst health promotion and protection is obviously central to preventing disease in the future, it is also important to address the needs of those who are currently dependent on healthcare services, Mr Belevics, said. There should be tailor-made services that aid individuals in rapidly and sustainably regaining health.

“The goal of safe and quality medical services at sustainable costs can best be achieved by tailoring and actively involving patients,” said Mr Belevics, adding, “Money spent on health is a long-term investment, rather than an expenditure in the classical use of the word.”

Laimute Vaideliene, Vice Minister for Health in Lithuania, said the Vilnius Declaration has inspired new healthcare policy initiatives in Lithuania, with targets to increase life expectancy, further reduce infant mortality rates, cut consumption of alcohol and to increase total expenditure on health as a percentage of GDP to eight percent by 2020.

These targets are being pursued through a health-in-all-policies approach and by promoting integrated care. In addition, Mrs Vaideliene said Lithuania is determined to deploy eHealth. “We want to use eHealth to improve the quality of, and access to the healthcare system, and to ensure the necessary information exchange,” she said.

For Andrey Kovatchev, Member of the European Parliament, the Vilnius Declaration has had the positive effect of bringing patients and patient advocates into closer contact with the European Parliament.

This is important because while health is a Member State responsibility, there is an issue for Europe as a whole if some national healthcare systems are underperforming. “It promotes migration of patients and of healthcare professionals, and as a result health needs are not equally addressed across the EU,” Mr Kovatchev said.

Policy makers at a European level – as much as at a national level – need information from stakeholders to understand the position of patients. Given this, “There is a strong case for more coordination in approach to patient engagement,” said Mr Kovatchev.

Despite austerity-era cuts, Europe’s health systems command significant budgets. Now Member States need to find ways to deploy these resources in a smarter, evidence-based way to extract greater value, increase efficiency, and reduce inequalities within and between nations.

In common with other health systems across Europe, the UK is facing a falling budget in real terms at a time of increasing demand, higher expectations and a huge burden of chronic disease, with long-term conditions now accounting for 70 percent of the National Health Service’s £147 billion annual budget, said Gillian Leng, Deputy Chief Executive and Director of Health and Care at the UK’s National Institute for Health and Care Excellence.

There are practical measures in hand to try and get more value from this considerable sum, such as national drives to improve procurement and to cut waste. There is also a programme tracking variation in care in areas such as hip replacement, diabetes, uptake of new medicines and mortality rates, to identify and explain inefficiencies, and try to bring the worst performers up to the level of the best.

But even when inefficiencies are identified, they can be difficult to address,. “It isn’t easy to change things. Even if it’s going to be better, it is resource-intensive to get there,” Mrs Leng said. “You need to have some space and some resources to make changes.”

For Jo de Cock, CEO of the National Institute of Health and Disability Insurance in Belgium, the case for enshrining health systems performance as an essential driver of more efficient health systems has already been made. “Now we need a real action plan to get rid of health inequities – which are more avoidable than we think.” The aim should be to develop a portfolio of instruments and tools and to demonstrate efficiency can improve solidarity, Mr de Cock said.

Adrian van den Hoven, Director General of the European Generic and Biosimilar Medicines Association, described how generics contribute to reducing inequalities and improving outcomes. Generic anti-hypertensive drugs have saved 1.7 million patient years of life, for example, while of 36 million diabetics across Europe, 20 million are treated with generic medicines. And now biosimilar versions of innovative biologic drugs are beginning to make a similar impact.

“It is not about savings, it is about increasing and improving treatment,” Mr van den Hoven said. “I believe you can’t have universal access without generics.”

The question of whether increasing the efficiency of health systems will reduce inequalities depends on what aspect of care is under consideration, and how efficiency is assessed, said Josep Figueras, Director of the European Observatory on Health Systems and Policies.

In efficiency drives there is a tendency to focus on costs rather than benefits. “If you looked from the point of view of benefits, you would be getting results,” Mr Figueras said. For example, redistributing resources to encourage vulnerable groups to access primary healthcare increases efficiency, because this is where the highest burden of disease lies.

However, new technology may make systems more efficient without reducing inequality. “For example, mobile health increases efficiency, but it is not redistributive – it is more likely to be the opposite,” Mr Figueras said.

For Stanimir Hasurdjiev of the Patient Access Partnership, removing the barriers to access is key to reducing inequalities. However, he noted, there is no standard definition of access, making it hard to measure it objectively. “If you can’t measure something, you can’t improve it,” Mr Hasurdjiev said.

This has prompted the Patient Access Partnership to set up a project to define access. As a result, five access principles – of availability, adequacy, accessibility, appropriateness and affordability – have been set out and are now being tested to see if they provide an adequate basis for measuring access.

Research to date indicates there are divergent views. “Perception of access is totally different depending on who you are. You need to get the views of all stakeholders; you need a comprehensive evidence-based tool to measure access,” Mr Hasurdjiev said.

The barriers restricting access to Europe’s healthcare systems have been the focus of a great deal of academic and policy research, noted Clive Needle, Director and EU Policy Adviser, EuroHealthNet. “Now we have to move beyond describing, to how we overcome the obstacles”, Mr Needle said.

The discussions that led to the Vilnius Declaration have since informed EU action on access to healthcare and in particular to the development of an EU agenda for effective, accessible and resilient health systems, noted Andrzej Rys, Director Health Systems and Products at DG Health and Food Safety. While emphasising that healthcare is at all times under national control. Mr Rys outlined the actions that the EU is taking to support Member States and said, “I’m very happy to discuss with you what we can do to maintain the momentum.”

While the Commission has a broad perspective, the European Medicines Agency (EMA) is looking specifically at the issue of equitable access to innovative medicines. The Agency is testing ways in which access can be improved in its adaptive pathways pilot, said Guido Rasi, Principal Adviser in Charge of Strategy at EMA. The aim of the pilot is to approve products in small, defined sub-groups of patients and then expand the label as real world evidence is collected to show how a medicine performs in practice.

There should be a number of benefits, Mr Rasi said. “For investors, they know what evidence they need for approval and to access the market; for patients there is less exposure to clinical trials. Health technology assessment bodies and payers benefit because they get the evidence they need sooner,” he said.

Inequity in healthcare is “our biggest shame,” said Monika Kosinska, Programme Manager, Governance for Health WHO, describing how the WHO’s Health 2020 framework and its two underpinning values of equity and health as a human right forms the basis of all its work on health systems and access to healthcare.

“In Europe today, people are facing impoverishment due to their health,” said Mrs Kosinska. To change this, there needs to be empowerment of patients, new models of care innovation that are based on integrating health and social care, and health system quality improvements, she said.

Opening the session, Catherine Hartmann, EPHA board member and moderator asked the speakers to give their recommendations on political actions to make people-centred health service delivery a reality.

For Gunta Anca of the Disability Rights Group SUSTENTO the key is to weigh all decisions from the patients’ point of view. There is no denying the logic of this approach and the potential it holds to create more effective and sustainable healthcare systems, she said.

This does not all go one way – patients have a number of responsibilities in this model, of which, “Number one is to be involved, informed and educated about their health and the care that is provided, and to be actively involved in the development of treatment plans,” Mrs Anca said.

However, she added, “You can’t get patient responsibility just like that; you need preconditions.” These include education, trust in the healthcare system, non-discrimination and equal opportunities for good quality care.

Cancer provides a potent exemplar of how investment leads to better outcomes, with significant improvements in survival rates over the course of the past two decades, said Paul Cornes of the Clinical Outcomes Group, Bristol, UK. “There is a cost for cancer so we invest in it, and it’s a template for other diseases,” Mr Cornes. “Survival is going up – and new medicines account for 50 – 60 percent of what has been achieved.”

However, the cost of cancer drugs is rising five times faster than other medicines, while at the same time the incidence of cancer is increasing as people live longer. “We can’t afford the increases in the cost of each new innovation, but I need innovation to win the war on cancer,” Mr Cornes said, calling for money saved by switching to generic and biosimilar drugs to be reinvested in innovation.

“It is no longer in the realms of science fiction to talk about a cure for cancer,” said Stefan Oschmann, Vice President EFPIA and CEO Pharma of Merck KGaA. “We have the potential to reduce mortality in certain cancers by 90 percent in the next decade,” he said.

If the price of new drugs is going up, one reason is that there is a 10 percent year on year increase in the cost of research. At the same time many people argue that the current pricing model has reached the end of the road.

While patients demand faster access, the regulatory environment is still lagging. Adaptive pathways – underpinned by real world evidence – offer the prospect of a more flexible development and access pathway, Mr Oschmann said. “We can see what works and why; this will make it possible to focus on interventions that really work and drop those that don’t. There will be benefits all round,” he concluded.

Digital platforms will be a driving force behind the move to patient-centred care, providing the means to improve the collection, analysis and use of data of all kinds.

For Peteris Zilgalvis, Head of Unit, Health and Well-Being, DG Connect, European Commission, who is currently shaping the EU’s approach to mHealth, the potential is very great. There is the opportunity to empower patients, promote prevention measures and improve access to healthcare, whilst at the same time creating growth and jobs.

The EU approach to mHealth encompasses three perspectives:

• apps used in healthcare systems to deliver services such as ePrescriptions and appointments;
• apps that support social innovation and health literacy, helping patients and consumers to manage their health and wellbeing in the way they want;
• consideration of how commercial sector apps can be validated and the issues of trust and data protection can be overcome, allowing mHealth apps to become an asset in the move towards personalised healthcare.

Of the current catalogue of 120,000 mHealth apps, a few are regulated as medical devices. A few hundred others have been validated in some way, for example by patients groups or health systems. However, with most apps attracting and losing users within three months, there is a fast turnover. “It’s a market that is evolving rapidly so we have to address it in a way that does not hamper the development of the technology or the benefits, but addresses any negative impacts,” Mr Zilgalvis said.

Following on from the Green Paper on mHealth and the responses received, the EU is taking three steps to support evolution of the market:

• assisting industry in drawing up a voluntary code on privacy and security;
• convening a stakeholder meeting on the quality and reliability of mHealth apps;
• creating a pro-innovation framework for non-embedded software.

There will also be follow-up actions to support mHealth under Horizon 2020, in digital health literacy, big data for public health, digital security, and evidence gathering and exchange of best practice.

Zoltán Kaló, Professor of Health Economics and CEO of the Syreon Research Institute, told the conference big data platforms should be deployed to inform decisions about how to make the best use of healthcare resources and to monitor the impact of these decisions.

In Hungary for example, increasing expenditure on cancer drugs has had no impact on mortality rates. “Is that because the drugs are no good, or because the patient pathway is blocked? We don’t know,” Mr Kaló said. He believes the problem is caused by slow access rather than ineffective treatments and is hoping big data will unpick this.

“Currently, the financial decision makers are not impressed by the return on investment in health, so we need to show [investment] is generating health,” said Mr Kaló “Big data can show where the problems are and where to intervene to make better use of resources.”

For the pharmaceutical industry big data will underpin a shift towards its products being valued in terms of the outcomes they deliver, said Elizabeth Kuiper, Director of European Affairs at EFPIA.

One example is in the Innovative Medicines Initiative project ROADS (Roads to outcomes of Alzheimer’s Disease), which will build understanding of how to measure outcomes in the neurodegenerative disease. This will involve working in collaboration with national health authorities and health technology assessment bodies and pooling evidence of real world outcomes. “The impact should be better patient care from the early stages and better understanding of the natural history of the disease,” Mrs Kuiper said. “The goal is to support evolution towards outcomes-focussed and sustainable healthcare.”

Alignment on the outcomes that matter in Alzheimer’s Disease, and that as a result will be consistently measured and evaluated, will in turn promote faster access to innovation.

Mark Pearson, Deputy Director, Employment, Labour and Social Affairs at OECD, agreed that thus far big data has largely been a solution in search of an answer in the healthcare sphere. “It has been technology driven. There was not enough health input and focus on outcomes,” he said.

But while applications of big data in healthcare are still scratching the surface, there is some evidence of positive impacts in areas including better clinical decision-making, governance, care coordination, waste reduction, and in research.

There are also negative examples, such as a pilot in the UK that used big data to perform risk assessments in Accident and Emergency Departments. Although the quality of care improved, there were no cost savings, Mr Pearson observed. The big breakthrough in terms of healthcare will come when big data can be used at the patient/clinician interface, in the same way as interactions in other sectors, such as banking, are informed by the availability of personal data.

It was suggested that moves to make big data a standard tool for assessing healthcare issues must include looking at incentives and addressing cultural barriers to implementation. Currently, providers are paid for seeing patients in healthcare facilities. New payment mechanisms are needed to incentivise the use of digital platforms in which care is delivered remotely.

In addition, it is important that mHealth and other technologies do not create another divide, in which the digitally literate have improved access and people with no internet access who are really sick, cannot get the personal care they need.

Standards and interoperability remain as obstacles to the deployment of digital platforms, and this applies as much in different departments of the same hospital as between different levels of healthcare provision.

There are also issues of governance and accountability to be dealt with. In mHealth, for example, people will expect that if they take a measurement, the data submitted to healthcare professionals will be used. This raises questions of who will be responsible for data governance and deciding who is allowed to use patient-generated information.

Similarly, there is little point in conducting big data analyses if there no one is accountable for taking action on the basis of the findings.

Data protection is central to the application of digital platforms in health. After long debate, consultation and deliberation, health data has been enshrined as a separate category in the EU Data Protection Regulation, which is now in the final stages of approval. This will allow health data to be used for the benefit of the patient and to be applied in an ethical way for research, but will ensure access is controlled, information is anonymised and health data is protected.

Innovative pharmaceuticals must be affordable for healthcare systems whilst being priced at a level that incentivises innovators. However, at present, there is much nervousness among payers about the high cost of new drugs. This is despite the fact that expenditure on pharmaceuticals is stable or falling slightly.

For Gediminas Cerniauskas, Professor at the Department of Economics, Faculty of Economics and Financial Management, Mykolas Romeris University, Lithuania, sustainability for all stakeholders requires understanding of what each party is looking for. “The interest of patients is good health, of governments it is economic growth and reduced unemployment, of healthcare professionals, job satisfaction. The question is how to align these three,” Mr Cerniauskas said.

Differential pricing is one mechanism that could promote sustainability. Mr Cerniauskas suggested. If innovative drugs are sold at the same high prices everywhere, more economically advanced countries can afford them, but less advanced countries have to wait. Differential pricing gives all patients access sooner, promoting universal healthcare, while healthcare professionals have the satisfaction of being able to offer the most effective treatments, pharma companies benefit from bigger markets, and the national governments of countries where drugs are manufactured also benefit. “You get more health, more productivity, and so on,” said Mr Cerniauskas.

Elke Grooten, Director of Public Affairs, Sandoz Europe, speaking as a representative of the European Generic and Biosimilar Medicines Association, agreed it is important that sustainability is seen from the perspective of the different stakeholders. Since the financial crisis, more than half of Member States have reduced their healthcare budgets, making the uptake of generics and biosimilars an increasingly important contributor to sustainability.

“In hypertension, diabetes and other areas, generics have increased access, while the cost of drug treatment has gone down,” Mrs Grooten noted. With seven of the top ten best selling drugs now being biologics, the arrival of biosimilar versions is poised to have a big influence on equity. “Our industry can create competition and so increase access,” said Mrs Grooten.

At present, access to biologic treatments is far from being universal across Europe. Even in a world-class healthcare system like that of France, only 70 percent of rheumatoid arthritis patients have access to disease-modifying anti-tumour necrosis factor alpha biologic drugs. “It is very important policy makers put in place policies to drive uptake of generics, to ensure the maximum number of patients will obtain the maximum health outcomes,” Mrs Grooten said.

The key to ensuring treatments are sustainable for all stakeholders, is data, believes Harry Hemingway, Professor of Clinical Epidemiology, University College London and Director of the Farr Institute, a UK-wide organisation carrying out research into the application of big data in health. “We are in a new era: for a quarter of a century we have been talking about evidence-based medicines. Healthcare is now invited to be big data-driven,” Mr Hemingway said.

Europe has the opportunity to use its many data repositories to weave a rich ‘big data tapestry’ in which information from many sources is linked, integrated and analysed. A common platform is needed via which all the data that is currently locked away in departmental silos can be accessed. “If you put data at the centre, what can you do? You can do everything – not just mHealth or drug discovery, and so on. You can do all of these with greater facility,” Mr Hemingway said, noting that knowing where healthcare inequalities lie is the prelude to doing something about them.

“This is an important moment on an important topic”, said Monika Kosinska, Programme Manager, Governance for Health at WHO, in her closing keynote speech. “We need to ensure access to high quality healthcare systems in a sustainable manner.”

This is the motivation behind the WHO’s Health 2020 strategy, the European health policy framework created to support action across government and society, to improve health and wellbeing, reduce health inequalities, strengthen public health and ensure health systems are people-centred and sustainable.

Health 2020 should also be viewed in the context of the United Nations’ 17 post-2015 Sustainable Development Goals, and in particular Goal 3, which sets targets for universal health coverage. “This is an opportunity to monitor progress,” Mrs Kosinska said. “Equity is at the core.”

In addition, there is recognition that health is linked to other Sustainable Development Goals relating to poverty, education, gender equality, availability of water, and cities. “In other words, the UN sustainable development agenda is a very important one for health,” Mrs Kosinska said. The UN agenda also links back to Health 2020 objectives of improving health and reducing inequalities, pulling together health outcomes and social and development policies and highlighting the need for more inter-sectoral work to address the social determinants of health.

In terms of ensuring universal health coverage, in which everyone gets the healthcare they need, without paying more than they can afford, it is important to recognise this is not merely predicated on finance, but covers all aspects of healthcare delivery.

There are a number of challenges around the ambition of ensuring universal healthcare, Mrs Kosinka noted. These include addressing unmet need and ensuring that out of pocket payments do not prevent access.

Looking to the future, a multi-state agenda for pursuing universal health care is being finalised by WHO. This will act as a companion to the final report of the ‘Tallin Charter: Health Systems for Health and Wealth’, which will set out priorities for strengthening health systems, provide guidance on prioritising actions and give a focus for strengthening WHO’s support to countries.

A framework for action to ensure European health systems are efficient, sustainable and equitable – and deliver good health for all, was drawn together at the conclusion of the conference in Riga, with the aim of maintaining the momentum created by the Vilnius Declaration, in which stakeholders called on European Governments and the European Union to take action to stem the damage that austerity-era cuts have caused to our health systems.

Following on from the Vilnius Declaration, EU Health Commissioner Vytenis Andriukaitis has outlined three core principles for European health – of prevention, promotion and protection – and has emphasised the need to promote health across all stages of life.

To these three principles, the Riga Roadmap adds a fourth principle – of participation – and calls for patients and citizens to be placed at the centre of all aspects of European healthcare systems, from health promotion and disease prevention, to service delivery and research.

Taking such a holistic approach to healthcare and public health will inform moves to control healthcare costs and shift the perception that health services are an overheard. Instead, spending on health will be recognised as a vital investment to ensure a healthy, economically active population and to promote social cohesion.

The Riga Roadmap highlights the need to do more to identify appropriate and smarter ways of preventing unnecessary costs and burdens of ill health. Possible actions include smoking bans, effective food and alcohol information for consumers, promotion of physical activity and vaccination programmes. “We need smarter ways of preventing avoidable conditions,” said Nina Renshaw, Secretary General of the European Public Health Alliance.

Peter Wiessener, vice-president of the European Public Health Alliance called for more transparency and openness over drug pricing, saying the prices of some medicines are not justifiable. “Why aren’t price negotiations in public? Nobody knows who pays what for drugs at the end of the day.”

A second objective of the Riga Roadmap, Supporting sustainable healthcare systems by investment in valuable innovation, depends on a key starting point which is to develop a common definition of “valuable innovation”, based on patients’ needs and societal needs. Following this, principles should be developed to determine how valuable innovation should be encouraged and promoted.

This could include creating frameworks for meaningful patient involvement across the innovation chain, from setting priorities for research, to regulatory processes, cost-benefit assessments, pricing and reimbursement, and the ethical and consented use of patient data.

“There needs to be more patient involvement across the innovation chain, in particular in the last mile, when products are being considered by health technology assessment bodies and payers,” said Richard Bergstrom, Director General of EFPIA.

The third objective of the Riga Roadmap, of ensuring universal access to high quality people-centred health services, requires a clear European Union position that all people in Europe, whatever their position or vulnerabilities, should have continual access to basic healthcare services. This requires the development of a concrete strategy to ensure more equitable access to healthcare for all based on the principle of non-discrimination.

This should include efforts to ensure there is equitable access to innovative medicines and to promote the uptake of generics and biosimilars. To inform these objectives there is a need to develop common tools to measure access to healthcare and monitor outcomes and performance.

The promise of sustainable, high quality healthcare in Europe can be achieved, said Christoph Stoller, EGA executive member and Senior Vice President Commercial Operations Teva Europe. Generics can help by improving access to medicines. “It’s a solution we can use today, without any compromise in quality,” Mr Stoller said, noting typical price drops of 61 percent when medicines go generic. “The savings mean we can do more to make sure everyone has access to medicines, and so we have enough money for innovation.”

“We are all going to have to work a lot harder to defend universal healthcare; if we are not careful there will be exclusion.” said Adrian van den Hoven, Director General of EGA. “The EU needs a concrete strategy to ensure equality of access across the EU.”

To bring these three objectives into focus, Patient participation in healthcare will be a guiding principle. “I am gratified to see patient participation in healthcare given prominence,” said Anders Olauson, President of the European Patients’ Forum. “Meaningful involvement of patients is important: we patients are different from other stakeholders, because we know what the journey is like.”

Stakeholders representing patients, industry, academics and clinicians called on European Member States, European Institutions and the World Health Organization to work with them to promote the objectives emerging from the Riga Conference, and to take a holistic view to help ensure that European healthcare systems are people-centred, sustainable and deliver inclusive healthcare for all.

The Riga Roadmap aims to serve as a guiding thread of actionable points that will carry the four principles for European health – of prevention, promotion, protection, and participation – forward in the future.