Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 1 ORIGINAL RESEARCH The relevance of ethics in the European Union’s second public health programme Nelly K. Otenyo1 1Department of International Health, School of Public Health and Primary Care (CAPHRI), Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands. Corresponding author: Nelly K. Otenyo, MSc Address: Department of International Health, Maastricht University, Postbus 616, 6200MD, Maastricht, The Netherlands; Email: nellyotenyo@gmail.com Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 2 Abstract Aim: The objective of this paper was to investigate whether ethical values were explicitly identified in the Second Public Health Programme (2008-2013) of the European Commission. Methods: A qualitative case study methodology of exploratory nature was followed. The data used were the summaries of the project proposals and Public Health Programme objectives and was retrieved from the publicly available Consumers, Health and Food Executive Agency database. Since the PHP was finalized during the study, the study only focused on the summaries of the fifty-five finalized project proposals while excluding the ongoing projects and those projects at the reporting stage. The full proposals for the projects are confidential and thus could not be retrieved. However, the project summaries were inarguably sufficient to conduct the study. Using a table, a content analysis method in addition to the ethical framework, was applied in order to analyze and categorise the project findings. Results: The results unfold that, out of the seven ethical principles, only ‘equity’ and ‘efficiency’ were explicitly considered in eighteen projects and four projects respectively. Moreover, from the shared health values, eight projects identified aspects pertaining to ‘accessibility to quality health care’ while ‘solidarity’ was only discussed in one project. Lastly, the ethical aspects ‘ethics’ and ‘values’ were identified in three projects and in one project respectively. Conclusions: From the results, there is a limited consideration of ethical principles within the projects. Therefore, future public health programmes could use this as an opportunity to emphasis on the inclusion and application of ethical principles in public health projects. Keywords: accessibility for quality health care, efficiency, equity, respect for human dignity, universality. Conflicts of interest: None. Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 3 Introduction In the recent years, there has been an increased focus on implementing policies that promote better health, that are cost effective and use targeted strategies against targeted ill-health worldwide. This interest has sparked an even greater concern for public health practices, as well as how ethics is observed with regards to health, especially since populations continue to suffer from emerging health challenges (1). It is also commonly known that human health is greatly influenced or affected by public health practices as well as socio-economic circumstances of individuals. In a response to solve this, researchers are constantly evaluating and checking their research work against ethical aspects of public health; assessing whether the recommendations that are or can be derived from their work can be ethically justified. Even though there has been a growing interest on how ethics applies to public health, it has not yet gained a prominent position in all public health research. With the increasing burden of disease and emergent public health programmes, it is important to emphasize the need for public health ethics and develop this interest into maturity in order for it to have benefits (2). Ethics is an academic discipline that questions what is required to be done, what is right, fair, just and good. Therefore, ethics clearly defined is the study of human values and reasoning, but also refers to the systematizing of these values or rules or moral conduct that guides human lives. Through the application of ethics, policy makers are able to frame policies and make critical decisions (3). The rise in the study of how public health and ethics are connected has been gradually developing in the past last years, due to human mal-practices, actions and problems in healthcare practice. Public health focuses on ways to detect and quantify factors that put the population’s health at risk, once these factors are quantified policies are formulated to tackle or reduce adverse health outcomes for the population (4). Public health ethics is concerned with the dissemination of health resources in a more equitable, efficient way and protecting the society (5). Numerous studies have been carried out on ethics and public health actions and these have led to normative frameworks of public health ethics. Hence, one could assume that ethical aspects are considered by researchers and public health professionals to be significant in enabling a functioning plan, execution and development of various public health programs. Within the European Commission, the 2007 Health Strategy ‘Together for Health’ is a better example of a health policy that considers values, as it is based on shared values. Moreover, founded on these values, the second PHP 2008-2013 was implemented (6). It therefore goes without saying that when ethics are considered, public health is safeguarded, particularly when the ethical aspects are predicted or recognized in advance through critical investigations and discussions (7). An example of how ethical values can be considered in different public health disciplines is through Gostin’s work. Gostin looks at public health ethics from three viewpoints. The first is ethics of public health, by which professionals need to work for the common good with regards to their public duty and trust from the society. The second, ethics in public health, involves examining the position of ethics in public health. It involves communal and individual interests in relation to the allocation of returns and harms in an equitable way, e.g. in decision making and implementation of public health policies. Ethics for public health, Gostin’s third point, mainly entails a healthy population where the needs of the vulnerable and marginalized populations are considered in a more practical manner (8). As outlined in Gostin’s perspectives, the ethical framework applied in this paper acts as an umbrella to ascertain whether the professionals carrying out the projects are working for the good of the Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 4 public, whether the allocation and distribution of resources is fair, and whether the needs of the minorities are taken into consideration to ensure a healthy population. Ethical principles and standards are not only important for public health, they are also considered important for other disciplines, institutions and they have been used in recent years to guide professional conduct and behaviour (9). The European Union (EU) is an example of such organizations, it does not only fund research through its framework programmes, but also monitors how health research is done or how projects are implemented (European Union, n.d). Through the health programme funding, the Directorate General for Health and Consumer Affairs (DG SANTE) oversees the health programme which is managed by the Consumers, Health and Food Executive Agency (CHAFEA) (Chafea, n.d). Every year, the European Commission through CHAFEA sends a call for proposal for operating grants, conferences as well as joint actions and sets the criteria for funding options available (Chafea, n.d). The European Commission has so far adopted three Public Health Programmes (hereafter referred to as PHP). In this work, we will focus on the second PHP 2008-2013 because of its significance in forming part of the Commission’s execution of the EU Health Strategy “Together for Health” (10). The objectives of PHP 2008-2013 were directed towards improving the health information and knowledge of EU citizens. This is done so as to increase the competences of how individuals respond to health threats or how they consider various determinants to stimulate better health or obviate disease (Chafea, n.d). Against this background, the PHP 2008-2013 was also aligned with the Health Strategy ‘Together for Health’. The first principle of shared health values emphasizes overarching values of solidarity, universality, access to good quality care and equity (6). For this paper, it is interesting to see how the funded projects of the PHP explicitly dealt with these ethical values and whether they used them as a foundation for setting their public health priorities. It is important to note that exploring the scope and the role of values in public health actions and strategies relates to the discipline of ethics. Thus, this paper explores whether ethical values, principles and aspects have been explicitly considered in the Second PHP objectives, proposals and its finalized projects. Theoretical framework In order to investigate whether ethical aspects or concerns were considered in the PHP objectives, projects funded by DG SANTE, a selection and combination of ethical appropriate principles, safeguarding and incorporating relevant values and aspects of human rights retrieved from studies addressing various aspects of public health ethics are proposed. There are five principles for public health ethics which are also known as ethical principles, these are: Health maximization, respect for human dignity, social justice, efficiency and proportionality (11), the principle of respect for autonomy (1), and finally equity as a principle proposed by Tannahill are also combined (12). To formulate the framework for this study, these ethical principles will be combined with the shared health values of the EU health Strategy namely: ‘universality’, ‘solidarity’, ‘accessibility for quality health care’. Respect for autonomy is targeted at various aspects, such as the decision-making power of individuals in relation to their health or the general public health. Additionally, it focuses on individual autonomy relating to self-domination, privacy, personal choice and free will (1). Respect for human dignity compliments respect for autonomy, it guards the various interests of an individual and his or her absolute value so that an individual is referred to with respect Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 5 especially for his or her liberties, such as self-control (11). It further emphasizes that an individual’s liberties should not be defiled unless it harmfully affects others (13). Health maximization is applied in practices where the monetary values of various projects are considered so as to give priority to the most cost effective project but also making sure that the public takes full advantage of all health benefits. The principle social justice guards against segregation and marginalization of vulnerable individuals. It ensures that individuals are treated fairly, particularly in matters of equity and maximization of health benefits, so as to minimize and avoid inequalities related to health care services. Due to the growing public health needs and the inadequate public health resources, the principle of efficiency is significant in public health ethics. It is viewed as a moral act that ensures benefits are maximized especially in the execution of public health strategies, done by promoting the dissemination of basic necessities in a resourceful way. The proportionality principle advocates for benefits to be considered and assessed alongside the harmful properties, especially when debates on individual liberty versus public good arise (11). Equity seeks to ensure that, the less privileged are not secluded in key public health actions that are important to them. In response to this, interventions and strategies that analyze the unfair allocation of services across different populations are implemented to target those at risk in a way to find the influencing factors and decrease inequalities (12). From the health strategy, shared values, Universality value ensures that every EU citizen has equal access to use the available healthcare and services and that no one is denied care. The value access to good quality care guarantees that the available health care and services are of high quality and no EU patient is denied any high-quality care. Equity as a value ensures that every EU patient is entitled to receive health care and services irrespective of their ethnic, gender or social economic backgrounds and status. Solidarity ensures that all the financial arrangements made by the respective Member States will promote the accessibility of health care and services to all citizens (6). Using this framework, this paper will explore whether ethical principles, values and the 2007 strategy’s shared values were sufficiently addressed in objectives, proposals and finalized projects of the Second PHP. Table 1. Overview of ethical principles and health strategy values (source: references 11-13) Ethical Aspect Description Health maximization Complete utilization of health benefits Respect for human dignity No violation of individual liberties Social justice Promotes fairness and guards against discrimination Efficiency Promotes cost effectiveness, maximizing of benefits and limits wastefulness Proportionality Considers the benefits alongside harm Respect of autonomy Promotes individual’s free will and privacy Equity Supporting the fair access with reference to the need but regardless of origin, sex, age, social or economic rank Universality No patient is denied access to health services and care Accessibility to quality health care Ensure accessibility of high quality health care for all Solidarity The financial organization of a Member States’ health system so as to ensure health is accessible for all. Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 6 Methods A qualitative study design was carried out to gain insights into the ethical concepts and determine whether they have a role in the funding allocation of PHPs and in the reported project results. The search items used, relate to the seven principles and basic terms of ethics: ‘equity’, ‘autonomy’, ‘health maximization’, ‘respect’, ‘dignity’, ‘social justice’, ‘justice’, ‘efficiency’, ‘proportionality’, ‘ethics’, ‘moral’, ‘value’, ‘ethic’, ‘ethical framework’. Including the shared health values ‘universality’, ‘solidarity’, ‘accessibility’ and ‘quality health care’. It is important to note that despite the fact that, a number of projects used ‘equity’ to imply the reduction of inequalities, the term ‘inequalities’ was still excluded used as a keyword. All data was retrieved from the Consumers, Health and Food Executive Agency (Chafea). The proposals were available as summaries which included the following sections: - general objectives, strategic relevance and contribution to the public health program, methods, means and expected outcomes (Chafea, n.d). The research focused on the summaries of the fifty-five finalized project proposals at the data collection time and excluded projects that were still ongoing as well as projects at the reporting stage. The study included all the projects from all the three strands of the CHAFEA project database: health information, determinants/health promotion, and health threats/health security. For the analysis, the individual project aims, goals and principles were compared against the ethical framework principles and the shared health values so as to show the overlapping concepts and which ethical gaps still need to be addressed. Moreover, the identified ethical aspects are further scrutinized to ascertain whether they were only mentioned as keywords or whether they were expected outcomes of the analyzed project. Methodological and theoretical limitations including other potential challenges The results from this study will indicate whether ethical concepts and public health ethics are already a constituent part of public health projects particularly with regard to the Second EU Public Health Programme. However, since this is a qualitative research, the study may encounter some limitations. To ensure validity as proposed by Bowling the researcher intends to organize, clustering the retrieved data into relevant and respective ethical themes (14). This study has looked into the PHP’s, assessing whether ethical aspects were explicitly considered in its objectives and the summaries of the project proposals. The study recognizes that, by focusing on the only the explicit role of ethics in PHP through the eyes of only the seven principles and the shared health values, other ethical relations and aspects which are still vital in PHPs may have been excluded. In addition, not all projects that implicitly discussed aspects related to the principles and shared values were reported due to the act that, out 55 finalized projects, ethical principles and related concepts were identified both explicitly and implicitly in 27 projects. Since the researcher used the given description of the principles to decide which ethical aspects and values were related to each other, there may be some form of interpretation bias. However, as discussed in the paper, it is inarguable that there are various definitions of ethics and ethical frameworks depending on different disciplines. This has led different ethical frameworks to be defined and applied to suit certain situations. The seven ethical principles proposed for the framework may therefore be exclusive in terms of excluding other significant values and concepts. Additionally, given different definitions, application and Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 7 descriptions of the principles, it is clear that some aspects may refer to various principles such as universality and accessibility to health care. The study recognizes that, by focusing on the explicit role of ethics in the PHP through the eyes of only the seven principles and the shared health values, other ethical relations and aspects which are still vital in PHPs may have been excluded. The results focusing on the project proposals show minimal external validity as they only apply to the 55 finalized projects and may perhaps not be adequately generalized to a broader setting. However, regarding the results focusing on the objectives of the PHP, the representativeness of the findings cannot be questioned since the objectives apply to all the projects funded during the 2008-2013 PHP. Thus, it can be generalized to improve the projects that are yet to be finalized and even aid in the drafting of the objectives of future PHP’s in the case of learning from best practices. Since most of the projects and proposals from the second PHP 2008-2013 were still in the final phase during the data collection, only the projects that were finalized by June 2014 were included and the projects submitted at any later date were excluded. The full proposals for the projects were also confidential and thus could not be retrieved. Therefore, it may be likely that some ethical principles and values might have been considered elsewhere in the full proposals hence resulting in limitations on the findings of this study. However, the project summaries were inarguably sufficient to conduct this study as they included a detailed executive summary of the project objectives in relation to the PHP objectives. Results After examining the summaries of the 55 project proposals and the EU Public Health Programme objectives, the findings were as follows. Out of the seven ethical principles from the theoretical framework, only two principles were identified. Other terminologies used in the analysis included ‘ethics’ and ‘values’ which were identified in three projects and in one project respectively. Since the second PHP was founded on values prioritized in the EU Health Strategy: Together for health, the keywords ‘universality’, ‘access’, ‘quality health care’ and ‘solidarity’ retrieved from the first principle of the health strategy were identified differently in nine projects. Eight projects identified aspects pertaining to accessibility to quality health care and solidarity was only discussed in one project. Additionally, out of the four shared health values, only ‘equity’, ‘solidarity’ and ‘access to quality health care’ was identified explicitly in the objectives of the PHP. The projects were analysed basing on the seven ethical principles, the four shared health values and the ethical concepts ethics, morals and values. The results will be analysed and presented in the following categories. The different research questions will be answered and discussed in their respective sub-sections below. Table 2. Presentation of the findings Categories used in analysis and how results are presented The terminologies used Those identified in project proposals and/or in PHP objectives Ethical concepts in PHP objectives & project proposals Morals, values, ethics, Ethics, values, Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 8 Shared health values identified in PHP objectives and project proposals Equity, accessibility to quality health care, universality and solidarity Solidarity, universality and accessibility to quality health care Ethical principles identified in PHP project proposals Health maximization, equity, proportionality, respect for human dignity, autonomy, efficiency, social justice. Efficiency and equity Ethical concepts and shared health values in the PHP-2008-2013 objectives Ethical concepts such as, ‘ethics’, ‘morals’ and ‘values’ were not identified in the PHP objectives. However, the shared health values equity, solidarity and access to quality health care were explicitly identified in the PHP objectives. From the general objectives of the PHP, the common goal evident is improving ways that will ensure and promote the health security of the EU citizens. This goal is in line with the shared health value of ensuring ‘accessibility to quality health care’. Even though ‘accessibility’ is not explicitly mentioned in the PHP objectives, it is one of the main objectives of the PHP because through the PHP, the EU Commission seeks to improve the Member State’s capacities of responding to all kinds of health threats and ensure that the health care services, treatment and medications, for example transplant organs, are of the highest quality. The PHP 2008-2013 also aims to promote the health of the EU citizens while reducing health inequalities. Solidarity ensures that all Member States commit to working in unity while supporting each other for the growth and development of the entire EU. Moreover, with regards to the solidarity value, the PHP was envisioned to complement, offer assistance and add value to the Member State’s policies by developing, distributing and sharing all information, evidence, best practices and expertise relating to health to all Member States. Since solidarity ensures that less capable countries are not left out in the development or growth, the PHP fully supports this value as it aims to see to it that prosperity in the European Union is increased, and as a counter effect public health is improved. Table 3. Shared health values in the PHP-2008-2013 objectives (source: adapted from reference no. 15) Shared health values of the EU Health Strategy Description as given in chapter 4 of this paper How the concept is used in the PHP objectives Equity Reduces inequalities among the minorities “promote health and reduce health inequalities” Solidarity Mutual support and commitment among the MS - “it is intended to complement, support and add value to the policies of the Member States and contribute to increasing solidarity and prosperity in the European Union” - “generate and disseminate health information and Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 9 knowledge, exchanging knowledge and best practice on health issues’’ Access to quality health care Safe and quality health care is made available to everybody “promoting actions related to patient safety through high quality and safe healthcare, scientific advice and risk assessment, safety and quality of organs, substances of human origin and blood” Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 10 Ethical principles in the PHP 2008-2013 project proposals From the 55 projects, only 6 projects explicitly discussed findings that related to equity, while efficiency was only identified in four projects. • Equity: The project ‘DAYSAFE- Improving patient safety of hospital care through day surgery’, recognized existing challenges health systems face while trying to ensure fair access to high quality and safe health care. The project therefore proposes to offer applicable solutions and as a result increase patient satisfaction, safety, equity and quality of health care. According to the ‘Chain of Trust’ project, increasing the awareness and understanding of the available recommendations regarding the perceptions, challenges and advantages resulting from the use of tele-health, will equip all the key stakeholders with knowledge and information that will add value and further promote the provision of health care equitable to all patients in the EU. The ‘HealthVent’ project discusses equity under the strategic relevance and contribution to the public health programme section of their proposal. It emphasizes that, its objectives will be aligned with those of the PHP as it aims to tackle environmental health determinants specifically those related to the use of energy in homes, schools and various public buildings so as to prevent chronic diseases and further decrease inequalities in health. ‘Crossing Bridges’ builds on the execution of article no. 168 of the EC Treaty to ensure that the HiAP vision is accomplished for equity across the EU. Moreover, ‘Crossing Bridges’ expects that through the project results, the respective stakeholders will be encouraged to implement policies that will result in health equity. By developing a suitable surveillance and information system for health the ‘EUMUSC.NET’ project expects to increase and harmonise the quality of care to allow for equity in care for rheumatic illnesses and musculoskeletal disorders across the member states. Through the consideration of structural aspects of gender inequality and gender stereotypes that openly affect men and women’s health, ‘ENGENDER’ project aims to ensure equity by creating an online inventory of good practice of policies and programmes that focus on promoting health. • Efficiency: ‘DAYSAFE’ expects to improve the technical efficiency of health services by ensuring that the policy-makers are well-informed and recognize the factors limiting the performance of DS, such as operational issues and incompetently designed structures. ‘HealthVent’ project: through establishing a health-related ventilation guideline focussing on buildings such as schools, homes, offices and nursery buildings among others, ‘HealthVent’ expects that inhabitants will utilize energy in a more reasonable manner so as to have more energy efficient buildings. BORDERNET project aims to improve the prevention, testing and treatment of HIV/AIDS/STIS by reducing obstacles related to practice, policies and cooperation between border countries and among member states though a more transparent and sustainable network. This will further improve the effectiveness and efficiency capacity of organizations of various sectors responding to AIDS/STIS. ‘ENGENDER’ expects that increasing the awareness and creating a platform for all stakeholders to be well informed through the online inventory of best practices, will result in effective, efficient policies and programs that focus on achieving gender equity in health. Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 11 Table 4. Efficiency aspects identified in project proposals Project title Aspects of efficiency/ efficient identified in the PHP project proposals Improving patient safety of hospital care through day surgery (DAYSAFE). "The project will enhance DS which represents a crucial strategic approach toward the improvement of health services safety and quality, including patient’s satisfaction, together with technical efficiency and, possibly, equity" Health-Based Ventilation Guidelines for Europe (HealthVent) The (guidelines) "will reconcile health and energy impacts by protecting people staying in these buildings against risk factors, and at the same time taking into account the need for using energy rationally and the need for more energy efficient buildings" Highly active prevention: scale up HIV/AIDS/STI prevention, diagnostic and therapy across sectors and borders in CEE and SEE (BORDERNETwork) "The improved effectiveness and efficiency on regional and cross-border level in interdisciplinary response to AIDS/STIs and scale up of HIV/STI- testing will put forward the practical implementation of HIV combination prevention" Inventory of good practices in Europe for promoting gender equity in health (ENGENDER) "Increased awareness and knowledge for all stakeholders including: policy makers, politicians, researchers, NGOs and citizens, within and outside the health sector about effective, efficient policies and programmes to achieve gender equity in health" Shared values of the 2007 EU Health Strategy in the PHP 2008-2013 project proposals? Out of the four shared health values, only accessibility to quality health care and equity were addressed in the summaries of the project proposals. Basing on the description given for universality, the value was in a way linked to the context used to describe accessibility. From this assessment, more principles are seen to be used in association such as, ‘accessibility and universality’, ‘universality and equity’. • Accessibility to quality health care: Accessibility was analyzed in the projects in two parts: first, those projects that promote high quality health care services and secondly, those that ensure high quality of health care are accessible to all. ‘COORENOR’, ‘DAYSAFE’ and ‘IMPLEMENT’ projects discuss ‘high quality of health care’ by stating that quality assurance models are present in their projects and will ensure safe and high quality of services across the EU. ‘Imp.Ac. T’ and ‘PROMOVOX’ projects promote actions that particularly focus on marginalized groups and migrants. ‘Imp.Ac. T’ aims to ensure that access to HIV/TB testing for marginalized groups is improved, and ‘PROMOVOX’ emphasizes the facilitation of better access of immunizations among the migrant population. ‘CARE-NMD’ relates accessibility of healthcare to reduced inequalities. The project believes that, by improving the access Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 12 to expert care, there will be a reduction of inequalities among member states and within a Member State. Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 13 Table 5. Accessibility to quality health care as identified in the summaries of the project-proposals Project title Accessibility to quality health care value as used in the PHP project proposals Coordinating a European initiative among national organizations for organ transplantation (COORENOR) "All requirements for ensure recipient safety and high quality of the treatment as well as running models for quality assurance will be considered and transferred to the EU institutions Improving patient safety of hospital care through day surgery (DAYSAFE) "The general objective of the project is to improve patient safety & quality of hospital care through the promotion of DS best practice and standards. Implementing Strategic Bundles for Infection Prevention and Management (IMPLEMENT) "Aims to improve patient safety through high quality and safe healthcare". Highly active prevention: scale up HIV/AIDS/STI prevention, diagnostic and therapy across sectors and borders in CEE and SEE. (BORDERNETwork) “BORDERNETwork' focuses both disease causes and underlying social determinants of health, aiming to improve responses to prevention offers and accessibility of care services”. Improving access to HIV/TB testing for marginalized groups (Imp.Ac.T) a) “Improving Access to HIV/TB Testing for marginalized groups b) “to increase the percentage of IDUs and migrants having access to HIV and TB testing” Promote Vaccinations among Migrant Populations in Europe (PROMOVAX) “Improve migrants understanding & acceptance of immunizations and facilitate their access to immunizations by identifying a network of relevant sites”. Dissemination and Implementation of the Standards of Care for Duchenne Muscular Dystrophy in Europe (including Eastern countries) (CARE-NMD) "Improved access to specialist care for DMD and reduction of inequalities between countries & within countries due to better trained health professionals" Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 14 Ethical concepts or aspects in the PHP 2008-2013 • Ethics: Under the strategic relevance and contribution to the PHP section, ‘Chain of Trust’ acknowledges that the consideration of ethical associated issues while developing recommendations related to the approval of telemedicine by patients and health professionals is important especially during the implementation of telemedicine. ‘APYN’ will assist in realizing the Work Plan priority 3.3.4 for preventing addiction and further contribute to the Alcohol strategy. The project proposes to consider “ethically sound actions” which, according to the priority areas for 2008 as stated in the 2008 work plan, refers to the ethical aspects outlined in the Charter of Fundamental Rights of the European Union. “Ethical considerations: Any proposal, which contravenes fundamental ethical principles particularly those set out in the Charter of fundamental Rights of the European Union may be excluded from the evaluation and selection process” (16). APYN’ and ‘Healthy Eco Life’ will support the work plan actions through the “Involvement of new (non-traditional) actors for health in sustained, co-operative and ethically sound actions, both at regional or local level and across participating countries” (Chafea, n.d). • Values: ‘ACTIVE’ intends to introduce a new method that will engage children between 5-8 years of age in Europe. It is evident from their title that the project aims to teach and inspire the children with values and views concerning healthy eating and physical activity- ‘Animation for Children to Teach and Influence Values and Views on healthy Eating and physical activity (ACTIVE)’. However, the project only mentions the term ‘values’ in its title. Discussion These ethical principles ensure that the individuals or professionals governed by them align their actions and conduct with the principles in order to uphold the society’s trust. Most of the ethical principles used in public health actions and research assist in making sure that researchers and public health professionals are held responsible by society. Moreover, ethical principles enable researchers to develop trust with the society, which often may cause them to receive funding or financial support for their research from the public because of their reliable and excellent work. Furthermore, upholding ethical principles in research will stimulate the consideration of significant moral and social values (9). Therefore, it is important for public health professionals and all stakeholders to abide by ethical principles in their duties. Additionally, ethical consideration is not limited to public health professionals only at a European level, it is also relevant for public health research and projects of the EU’s Public Health Programmes. With the PHP 2008-2013 being aligned with the Health strategy ‘Together for Health’, which was explicitly value based in setting priorities, ethics still plays a significant role in the explicit project proposals; yet, this role is not evident in all the PHPs. However, it is surprising to see that less than half of the projects considered the principle equity which is regarded as a public health and an EU strategy priority. It is clear from the projects, that the mention of equity in their objectives and expected outcomes is not a sufficient indication of ethical consideration, for example, by mentioning that project actions will promote the coordination of abilities from both Eastern and Western Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 15 Europe, COORENOR project justifies its role in reducing health inequalities. This is an example to show that the mere mention of ethical principle is not an indication for its consideration in the entire project implementation and therefore the project falls short of explicitly considering equity. In spite of this, various projects still gave relevance to ethical principles and values as they exhaustively discussed in their project summaries matters that related to ethics. ‘DAYSAFE’ recognizes that challenges exist which cause inaccessibility to quality and safe health care, hence they progress to propose methods that will promote equity in health. In discussing ‘efficiency’, the four projects, ‘BORDERNETwork’, ‘HealthVent’, ‘DAYSAFE’ and ‘ENGENDER’,only discussed how their activities and methods will result in efficient services and materials. They however fail to show in their methods how this will be attained and only limit it to mention that providing of policy guidelines will promote efficiency. Regarding ‘accessibility to quality health care’, the projects questioned the quality and safety of health care services offered in Europe and offered to foster a high level of surveillance and monitoring to further ensure that the quality health care is accessible to all patients. They linked quality assurance strategies to high quality services. Even though some projects did not explicitly mention ‘accessibility’, their objectives and method description matched the value ‘universality’ while also linking it to reduced inequalities, as they emphasized that no one particularly minorities such as, migrants, HIV/AIDS and TB patients, should be denied access to health care. Most of the projects had implicit discussions of how best practices should be shared across the EU and coordination among all different stakeholders should be supported in order to reduce inequalities in health instead of the explicit mention of solidarity. Ex-post evaluation of the health programme The aim of this evaluation was to assess the main results that were reached as well as recognize the key challenges and solutions especially after consideration of recommendations from preceding assessments. The post evaluation study was guided by four key themes that is programme management, dissemination methods, the effect of the health programme collaboration with other programmes and services. According to the assessment, the programme lacked proper management as monitoring data was not used, thus making follow- up a challenge. In order to increase the number of accepted and executed Health Programme funded actions, the main results of the health actions have to be made available to the relevant target groups. The 2nd Health Programme objectives were very broad, covering various significant needs of the Member States as well as those of the stakeholders. It was therefore recommended that the Health Programme ought to introduce more specific progress analysis as they have been defined in the 3rd Health Programme. With regard to the 2nd Health Programme’s objectives, the funded actions led to significant advancements such as, promoting cross-border partnerships. It is important to note that, the administrative duties of the programme were increasingly efficient. Moreover, the 2nd programme has shown major EU added value in recognizing best practices as well as networking (17). Even though, the objectives of the Health Programme are commendable as they seek good practices and also focus on national priorities while contributing to a healthy status for the European population, they are still very broad and only focus on the relevance of the action. Therefore, they may fail to explicitly address most of the ethical principles used in this study. Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 16 Since the study has examined only the explicit use of ethical principles and concepts in the project summaries and the PHP objectives, the ethical framework may therefore exclude implicit discussions of ethical principles and other significant ethical values especially those based on ethical definitions not considered in the descriptions provided for this study. Despite the fact that the ethical framework used for this assessment was based on seven principles, the study therefore doesn’t provide a full picture of this ethical role in PHP but provides a new mentality and platform that will enable the explicit rethinking and reconsidering of ethics and ethical aspects in public health. This new mentality and concern according to Callahan and Jennings will lead us to considering vital questions such as: - “What are the basic ethical issues of public health? What ethical orientations are most helpful in the clarification and resolution of these issues? How are ethical principles and concepts incorporated into decision making in public health agencies and programs? How adequately are ethical dimensions of public health policy identified and debated?” This is because as public health gains more prominence, the ethical aspects regarding health issues increase too (2). Conclusions This paper has presented and outlined ethical aspects that were explicitly identified in the 2008-2013 programme objectives and available project reports of the PHP. The projects were assessed, based on the theoretical framework consisting seven ethical principles. Furthermore, the four shared health values of the EU Health Strategy were considered as they were more general ethical concepts. From the analysis, the principle ‘equity’ was extensively discussed and considered by some of the projects, followed by the ‘efficiency’ principle and then the value ‘accessibility to quality health care’. The study recognizes that by focusing on the role of ethics in PHP through the eyes of only the seven principles and the shared health values, other ethical relations and aspects which are still vital in PHPs may have been excluded. Most commonly addressed values of the EU Health Strategy: ‘Together for health’ by the projects were, ‘equity’, ‘accessibility’ and ‘universality’ as it seemed expected from them since the PHP was based on values. It is encouraging to see that most of the shared health values were discussed in most of the projects. Even though vital principles such as- ‘respect for human dignity’, ‘autonomy’, and ‘health maximization’ were not addressed by any of the projects. It is clear from the projects, that the mere mention of a principle briefly such as ‘project will ensure equity’ in the project objectives and expected outcomes is not enough to justify that the principle will be adequately considered or that the project understands or acknowledges the significance of ethics in public health today. The project needs to consistently consider ethical aspects in its entire proposal, in this case a project summary, and not just mention it, since it is required and expected to be included under the ‘strategic relevance and contribution to public health programme’ section. This study has tried to paint a picture of the role of ethics in public health programmes. Even with its prominence, ethics in public health programmes and activities still needs to be encouraged. Moreover, more awareness in understanding ethics and ethical aspects in public health activities will further steer more ethical considerations not only amongst public health professionals and researchers, but also a more explicit and consistent consideration in PHPs and public health actions. In addition, basing on Gostin’s work, ethical values ought to be Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 17 considered firstly by professionals in order to guide them in working for the common good of the society. Secondly, in public health in terms of how decision making influences the balance between individual and communal interests especially in the implementation of public policies. Thirdly, ethics for public health where the needs of the population are met in practical ways, such as more emphasis on training and research to improve ethical knowledge, as well as applications. This study has therefore provided a new mentality and platform that will enable the explicit rethinking and reconsidering of ethics and ethical aspects in public health. References 1. Beauchamp TL, Childress JF. Principles of biomedical ethics: Oxford University Press; 2001. 2. Callahan D, Jennings B. Ethics and public health: forging a strong relationship. Am J Public Health 2002;92:169-76. 3. Preston N. Understanding ethics. The Federation Press; 2007. 4. Mann JM. Medicine and public health, ethics and human rights. Hastings Center Report 1997;27:6-13. 5. Kass NE. Public health ethics from foundations and frameworks to justice and global public health. J Law Med Ethics 2004;32:232-42. 6. Commission E. White paper–together for health: A strategic approach for the EU 2008–2013; 2007. 7. Coughlin SS. Ethical issues in epidemiologic research and public health practice. Emerg Themes Epidemiol2006;3:16. 8. Gostin LO. Public health, ethics, and human rights: A tribute to the late Jonathan Mann. J Law Med Ethics 2001;29:121-30. 9. Resnik DB. What is ethics in research & why is it important. Research Triangle Park, North Carolina: National Institute of Environmental Health Sciences/National Institute of Health; 2010. 10. Commission E. Together for health: a strategic approach for the EU 2008–2013. White paper, IP/07/1571; 2007;23. 11. Schröder-Bäck P, Brand H, Escamilla I, Davies JK, Hall C, Hickey K, et al. Ethical evaluation of compulsory measles immunisation as a benchmark for good health management in the European Union. Centr Eur J Public Health 2009;17:183. 12. Tannahill A. Beyond evidence—to ethics: a decision-making framework for health promotion, public health and health improvement. Health Promot Int2008;23:380-90. 13. Sørensen K, Schuh B, Stapleton G, Schröder-Bäck P. Exploring the ethical scope of health literacy: a critical literature review. Alban Med J 2013;2:71-83. 14. Bowling A. Research methods in health: investigating health and health services: McGraw-Hill International; 2009. 15. Council Directive. Decision 1350/2007EC of the European Parliament and of the Council of Europe; 23 October 2007. 16. Commission. E. Guide for the evaluation for proposals for action grants and operating grants, joint actions; 2008. 17. Directorate-General for Health and Consumers: The Second Health Programme 2008- 2013. http://ec.europa.eu/health/programme/policy/2008-2013_en. Accessed 13 July 2015. Otenyo NK. The relevance of ethics in the European Union’s second public health programme (Original research). SEEJPH 2017, posted: 10 March 2017. DOI:10.4119/UNIBI/SEEJPH-2017-138 18 ___________________________________________________________ © 2017 Otenyo; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction In the recent years, there has been an increased focus on implementing policies that promote better health, that are cost effective and use targeted strategies against targeted ill-health worldwide. This interest has sparked an even greater concern fo... Theoretical framework Methods Methodological and theoretical limitations including other potential challenges Results Ethical concepts and shared health values in the PHP-2008-2013 objectives Ethical principles in the PHP 2008-2013 project proposals Equity: The project ‘DAYSAFE- Improving patient safety of hospital care through day surgery’, recognized existing challenges health systems face while trying to ensure fair access to high quality and safe health care. The project therefore proposes to... Efficiency: ‘DAYSAFE’ expects to improve the technical efficiency of health services by ensuring that the policy-makers are well-informed and recognize the factors limiting the performance of DS, such as operational issues and incompetently designed s... Shared values of the 2007 EU Health Strategy in the PHP 2008-2013 project proposals? Ethical concepts or aspects in the PHP 2008-2013 Ethics: Under the strategic relevance and contribution to the PHP section, ‘Chain of Trust’ acknowledges that the consideration of ethical associated issues while developing recommendations related to the approval of telemedicine by patients and healt... ‘APYN’ will assist in realizing the Work Plan priority 3.3.4 for preventing addiction and further contribute to the Alcohol strategy. The project proposes to consider “ethically sound actions” which, according to the priority areas for 2008 as stated ... APYN’ and ‘Healthy Eco Life’ will support the work plan actions through the “Involvement of new (non-traditional) actors for health in sustained, co-operative and ethically sound actions, both at regional or local level and across participating countr... Values: ‘ACTIVE’ intends to introduce a new method that will engage children between 5-8 years of age in Europe. It is evident from their title that the project aims to teach and inspire the children with values and views concerning healthy eating and... Discussion Conclusions References