CIN EUROPE - MEMORANDUM 2019 - EN

The Belgian health insurance funds ask for
greater social protection and stronger
health policies in Europe.
European elections 2019
Memorandum from the Belgian health insurance funds

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Memorandum from the Belgian health insurance funds - European elections

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I n t r o d u c t i o n
The core messages from the Belgian health insurance funds
The European elections will take place on 26 May 2019. Because of the fact that the federal and regional
elections fall on the same day in Belgium, European themes are often not sufficiently addressed. Unfortunately.
With this Memorandum, the Belgian health insurance funds want to call attention to a European Union that
focuses on the citizens, on health and on social protection.
More than ever, Europe has a significant impact on national and regional policies, even in domains such as
social protection, healthcare and health promotion. The federal and regional governments therefore have
every interest in proactively contributing to the shaping of European policy. But other domains also deserve
our attention. Consider the possible consequences of climate change and environmental pollution on our
health or the potential impact of free trade agreements on our healthcare and health insurance. In addition,
the European Member States must increasingly take into account the recommendations of the European
Semester regarding financially sustainable and efficient health insurance and healthcare systems.1
Given this context, it is difficult to understand why the existence of a European Commissioner for Health as
well as a full-fledged Directorate-General for Health and Food Safety (DG SANTE) is called into question
within the European Commission. Some have suggested to incorporate the health aspect in other domains.
Here, the Belgian health insurance funds are sounding the alarm: eliminating the DG SANTE would be a
grave error - ‘who’ then will be left to defend the health of the European citizens?
Don’t we run the risk that other interests will take precedence and that the health aspects will fade completely
into the background just as we are endeavouring to include them into all policy domains? Isn’t the need for
European cooperation in tackling the challenges increasing instead of decreasing? Consider rare diseases
and the European Reference Network, an initiative supervised by DG SANTE, whose continued expansion
and support can only be encouraged.
The Belgian health insurance funds also consider the following six themes related to healthcare and
social protection to be priorities in the coming years:
1. A social Europe that eliminates inequalities by concretising the European Pillar of Social Rights;
2. A strong social economy in Europe, including a recognition of the health insurance funds;
3. Trade agreements which are concluded in a transparent manner and which respect the European social
model and human rights;
4. A digital agenda which provides a solution to real public health challenges, encourages innovation and
supports efficient, accessible health systems;
5. A European policy that encourages the Member States to continue to strengthen public health by means
of prevention, environmental protection and health promotion;
6. A European cooperation directed at guaranteeing the financial accessibility of medicines.
In the coming months and years, the Belgian health insurance funds, in cooperation with AIM (International
Association of Mutual Benefit Societies), will dedicate itself to moving or keeping these priorities high on the
European agenda and to contributing to their realisation.

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C o n t e n t s
The core messages from the Belgian health insurance funds p. 04
A social Europe that eliminates inequalities by concretising
the European Pillar of Social Rights p. 06
A strong social economy in Europe, including a recognition
of the health insurance funds p. 08
Trade agreements which are concluded in a transparent manner and which
respect the European social model and human rights p. 10
A digital agenda which provides a solution to real public health challenges,
encourages innovation and supports efficient, accessible health systems p. 12
A European policy that encourages the Member States to continue to strengthen
public health by means of prevention, environmental protection and
health promotion p. 14
a
A European cooperation directed at guaranteeing
the financial accessibility of medicines p. 16
Footnotes p. 18
Presentation of the NIC p. 20
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A social Europe that eliminates inequalities by concre-
tising the European Pillar of Social Rights
On many fronts, Europe can create added value for public
health and for healthcare. However, if this is founded on
a unilateral and insufficiently nuanced application of the
free movement of goods and services and the right to
competition, this may also pose a threat to the social
model, to healthcare and to social services. Therefore,
the choices that have been and must still be made are
extremely important.
The prioritization of the public interest and the develop-
ment of the European social model must be the guiding
principles of European policy.
CORE CHALLENGES
In accordance with Article 3 of the Treaty on European
Union, one of the objectives of the Union is to promote
the well-being of the people and to work toward the sus-
tainable development of Europe on the basis of balanced
economic growth and price stability, a highly competitive
social market economy aimed at full employment and so-
cial progress and a high level of protection and improve-
ment of the quality of the environment. The Charter of
Fundamental Rights of the European Union guarantees
and promotes a number of fundamental principles which
are essential to the European social model.
Europe is confronted with disparities within and between
its different Member States. Seventeen percent (17%) of
Europeans live below the poverty line in their own coun-
tries. This proportion ranges from 12% in Finland to twice
that, 25%, in Romania.2
These disparities are further
intensified by current challenges including the conse-
quences of the austerity measures, the migration wave
and the new forms of work.
Although some progress has already been made, the
EU’s current system of economic governance with the
Semester for economic policy coordination does not
sufficiently integrate social objectives.
The European Pillar of Social Rights establishes the prin-
ciples and the fundamental rights required to guarantee
the proper functioning of the labour markets and the so-
cial protection systems. This Pillar consists of a roadmap
of twenty objectives. The chapter on social protection
and inclusion must lead to concrete achievements in or-
der to arrive at true social protection in Europe.
The objective to bring about a decrease in the poverty
rate and the social exclusion of 20 million Europeans (set
down in the “Europe 2020 Strategy”3
) must be realised,
and we are still a long way from achieving this goal.4
New forms of work from the platform economy, with pay-
ment per assignment or short-term and uncertain em-
ployment agreements, such as micro- and flexi-jobs, and
their inclusion in the social security systems challenge
the European Union to support the most wide-ranging,
inclusive social protection possible.
Healthcare must form an integral part of the social
services of general interest to which competition and
the free movement of goods and services must not
apply without restrictions. Due to their own unique
characteristics, they should indeed not be subject to the
same rules as commercial services.5
We note, however, in dossiers such as the free trade
agreements and the Directive on a proportionality test
before adoption of new regulation of professions that
these services are handled on the same footing as the
commercial services.6
What is needed is to find a good balance between the
will to open the borders (i.e. the removal of unjustified
obstacles to the freedom of services and the reduction
of the administrative barriers for those who want to
relocate or receive care abroad), on the one hand, and
the provision of the necessary social protection (i.e.
healthcare, citizen safety, the environment, consumer
interests, fair trade practices etc.), on the other hand.
THE HEALTH INSURANCE FUNDS EXPECT
EUROPE...
1 to support the Member States in the concrete reali-
sation of the principles of the European Pillar of Social
Rights.
The health insurance funds support the development of
an ambitious European framework for social protection
including:
• the access to high-quality (long-term) healthcare for all
Europeans,
• the implementation of an acceptable minimum wage
and benefits of at least 60% of the median standard of
living in each Member State,
• access to social services,
• the adoption of legislation for the implementation of the
Recommendation from the Council7
in order to guaran-
tee universal and non-discriminatory access to the so-
cial protection of all forms of work (micro- and flexi-jobs,
payment per assignment, short-term employment agree-
ments, ...);
1

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2 to reform the European economic governance
(European Semester) with the integration of a stronger
social dimension including social and environmental
indicators. This would allow the encouragement of long-
term investments in the provision of services to persons
(social services) and in the social infrastructures;
3 to replace the “gross domestic product” (GDP) as
the only measure for the economic situation with a series
of indicators that take into account the social dimension
and environmental elements, such as the “Better life” in-
dicator from the Organisation for Economic Cooperation
and Development (OECD);8
4 to develop a European directive concerning social
services of general interest which clarifies the concepts
and their areas of application and affirms the priority of
social objectives related to healthcare and to the assis-
tance to persons. The specificity of these services of
general interest must be respected in the realisation of
the internal market;
5 to recognise and accept the specific role of the
health insurance funds9
in the various European policy
sectors. The most important objective of Europe must be
the construction of a social Europe that guarantees every
individual access to healthcare and well-being;
6 to develop a European health policy which is sup-
ported by the fundamental values of universality, acces-
sibility, equality and inclusivity, quality and stability. The
European Union must create the conditions for its imple-
mentation and should ensure, among other things, that
the points at which the economic interests weigh too
heavily on the European healthcare system are adjusted.
The specificity of the healthcare and the welfare sectors
must be recognised. Maintaining a strong DG SANTE is
essential to being able to achieve these objectives in the
general interest;
7 to set up an even more ambitious European
cooperation regarding (ultra-)rare diseases in order to
simplify these patients’ access to diagnosis, treatment
and medicines:
• on the one hand, by concentrating the expertise for
ultra-rare disorders (less than one patient in 50,000)
within European expertise centres and by facilitating
patient mobility to these centres, and
• on the other hand, by establishing a European agency
whose specific goal is to guarantee access to medicines
for this broader patient group.

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A strong social economy in Europe, including
a recognition of the health insurance funds2
The health insurance funds form an integral part of the
social economy enterprises of all sizes; they are an
indisputable reality in the European area.
The social economy and the health insurance funds
offer a real alternative which must be taken into account.
In addition, they also offer a real perspective for the
construction of a more inclusive and human society
which protects the population from overexposure to the
dangers of uncontrolled globalisation.
This business model makes it possible, among other
things, to reconcile the values of solidarity with those of
good management and is a powerful proposition in the
realisation of a European Pillar of Social Rights, which
make up the basic values of the Union.
CORE CHALLENGES
The European Union and its Member States must ensure
and respect the diversity of the economic actors and the
abundance of different forms of enterprises within the
Union.
Due to the alternative they offer with respect to the domi-
nant economic model, social economy enterprises, when
viewed from this standpoint, are sources of prosperity,
because they offer sustainable solutions for our econo-
my. The social economy distinguishes itself by its pursuit
of social transformation for the purpose of improving the
well-being of the citizens.
The social economy enterprises, such as health insurance
funds, translate the need for an economy in which the
social, economic, ecological and financial dimensions
are in balance and which is capable of creating added
value that is measured not only on the basis of financial
capital, but also, and especially, on the basis of the social
capital generated.
Their activities are therefore not guided by market or
growth criteria but contribute to the public interest and
to social cohesion.
In order to survive, the social economy and the health
insurance funds must be able to develop all their potential
with appropriate legislative and operational conditions.
For the purposes of supporting, in general, the develop-
ment of the health insurance funds and the social econo-
my in the European Union, specific measures are needed
in the areas of tax law, access to loans and administrative
relaxations, all the more since these organisations want
to invest in human capital.
The lack of knowledge about or the institutional disregard
for the health insurance funds limits the role they could
play in the necessary diversification in the business
world and therefore in the development of an economic
democracy.
So, in order to promote their principles, their manner of
governance and their values, it is absolutely imperative
to support the development of the health insurance funds
in a broader context.
It is also essential to encourage the exchange of good
practices with other Member States which have longer
experience with the social economy.
EUROPE...
1 to study the most significant administrative and legal
obstacles with which social economy enterprises are
confronted and which limit their potential for developing
activities in the context of the Single Market;
2 to recognise the “limited profit” concept as this is
characteristic of the social economy enterprises in the
sense that they reinvest the majority of the profits in the
pursuit of their social aims and do not pay this out to the
shareholders.
This allows them to take greater account of their social
capital and not only of their financial capital;
3 to adapt the European financial instruments to the
needs of the large enterprises in the social economy.
Notably, this means leaving behind micro-financing and
social entrepreneurship as a pillar of the EaSI10
, which
provides guarantees for investments up to a maximum of
€ 500,000;
4 to develop satellite accounts for the social economy
at the level of the EU and its Member States in accord-
ance with the current efforts of Eurostat to illustrate the
effective contribution of the social economy to the most
important macroeconomic aggregates and to integrate
them into the European Semester;11
5 to develop an Erasmus+ programme for the
personnel of enterprises in the social economy to allow
them to exchange projects and good practices;

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6 to guarantee more significant participation of the
social economy enterprises in the priorities of the new
Multiannual Financial Framework 2021 - 2027 and more
specifically in the European Regional Development Fund;
7 to prioritise the use of the new European funds
(European Social Fund Plus - ESF+) for the support of
projects related to new technologies for the provision of
services to persons.

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Trade agreements which are concluded in a transparent manner
and which respect the European social model and human rights3
CORE CHALLENGES
The European trade agenda promotes the liberalisation
of healthcare within the internal European market, which
results in market forces having increased influence,
including in the organisation of the Belgian healthcare
sector.12
Increased deregulation and competition in the
healthcare sector places unacceptable pressure on
the healthcare itself, the personnel and the patients.
The protection of human rights, including access to
healthcare, and the European social model may not be
eroded by free trade and investment agreements or by
parallel jurisdiction of tribunals for settling trade disputes,
such as the Investor-State Dispute Settlement (ISDS),
the Investment Court System (ICS) or the Multilateral
Investment Court (MIC).
Within the internal European market, some social econo-
my actors, such as the health insurance funds, have the
advantage of an exemption regime, yet still more can be
done for these actors (Chapter 2).
However, in external European trade policy, there is a
lack of recognition of the specificity of such actors who
pursue the public interest – accessible, high-quality
healthcare – in a democratic manner and on the basis
of social or solidarity principles, whereby, as a result of
such trade agreements, they are put into an unfair com-
petitive position relative to the large market players.
“No two-speed healthcare” and “Health must not be a
privilege”: for the Belgian health insurance funds, these
pronouncements do not ring hollow.
In fact, for several years now they have been reasons,
in cooperation with AIM (International Association of
Mutual Benefit Societies) and other partners within the
Belgian social society, for raising the awareness of the
public and the politicians about the risks associated with
free trade agreements, such as CETA13
, TTIP14
and their
successors.
European commercial policy must not cause any harm to
the public interest15
or hinder access to healthcare.
That is why we advocate, in the first place, for greater
transparencyandforopportunitiesforgreaterinvolvement
from stakeholders, such as the health insurance funds,
in the development of trade agreements which may
have an impact on healthcare in order to pursue better
protections for the services of general interest and
accessible, affordable and high-quality healthcare.
In the public interest, the European Union assumes a
leading international role in the fight against climate
change. European commercial policy must therefore not
only be consistent with the objectives of the Paris Agree-
ment, as requested in the European Parliament Resolu-
tion, but the ratification and the implementation of this
Accord must also be a condition of future trade and in-
vestment agreements.16
EUROPE...
1 to guarantee transparency in the negotiations and
expect civil society to be involved in arriving at a support-
ed policy formulation:17
• the specification by the European Parliament of a clear
delimitation of the powers of the Commission in the
negotiations on free trade and investment agreements,
• in accordance with the transparency initiatives of the
European Commission, namely the Civil Society Dialogue
Network and the Citizens’ Dialogues, the establishment of
a “sustainable and fair trade” intergroup, where members
of the European Parliament can enter into dialogue with
interest groups and exchange standpoints,
• impact evaluations, such as the Sustainability Impact
Assessment18
, must verify whether and how trade
measures can be reconcilable with access to healthcare,
environmental protection and other human rights. These
evaluations must be available in a timely fashion and
must be also be undertaken at the national level,
• an ambitious continuation of the interinstitutional
negotiations on the upgrade of the compulsory lobby
register for employees of the European Parliament, the
Council and the Commission,
• timely access to negotiation proposals and texts for
members of Parliament at all levels. Trade and investment
agreements must first be submitted, before signing, to
the Parliaments, so that after discussion and evaluation
they may request adjustments;
2 to extend protection within the European Model and
the free trade agreements to public services and services
of general interest, such as health insurance and health
services:
• free trade agreements must work with a positive and
exhaustive list approach,
• the health insurance funds emphasise that their service
provision may not be categorised as financial services
and that the free trade agreements may not impair the
authority of the European Union and the Member States

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to organise and offer public services and services of
general interest, including services of general economic
interest;19
3 to allow health to take precedence over economic
interests;
4 to delay ratification of all trade and investment agree-
ments until the Belgian question to the European Court of
Justice regarding the reconciliation of ICS with other
agreements has been settled:20
• op 29 January 2019, an Advocate General of the
European Court of Justice (CJEU) delivered the
preliminaryconclusion-intheadvisoryprocedureinitiated
by Belgium - that the dispute resolution/ arbitration
mechanism in the EU-Canada Free Trade Agreement
can be reconciled with Union law.21
Surprisingly, this
contravenes an earlier judgement by the CJEU in 2018
in the Achmea v. Slovak Republic case which argues
that this type of dispute resolution runs counter to the
autonomy of EU legislation.22
It would be alarming should this earlier judgement be
overturned, and the EU would continue to include ar-
bitration mechanisms in free trade agreements thereby
consolidating a system of parallel jurisdiction in which
legal disputes – usually by multinational enterprises
against Member States – are placed outside the Euro-
pean courts,
• negotiations on the Multilateral Investment Court (MIC)
must proceed with the highest degree of transparency,
• increased vigilance which does not weaken the forum
for the regulatory cooperation for quality and product
standards in order to reduce trade barriers;
5 to perform an analysis of the impact on health and
the environment for each new proposal for any
international agreement (Health in all Policies - HiAP).

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A digital agenda which provides a solution to real public
health challenges, encourages innovation and supports
efficient, accessible health systems4
CORE CHALLENGES
Taking into account the major challenges facing the
European Union and its Member States (demographic
changes, the rise in non-communicable diseases, the
need for an integrated course of care and the shift away
from a purely curative approach to health care), the
digital transformation in healthcare and the innovation on
which this transformation rests are by no means an “end”
but instead are a “means” for the improvement of public
health by placing the patient at the centre of what occurs.
During the 2014 - 2019 legislative term, the European
Commission has taken a number of initiatives to make
“Digital Europe for all” a reality.
The strategy for the “Digital single market”, adopted in
2015, should maximise the growth potential of the digital
economy.23
A first evaluation in 2017 showed that many
proposals formulated by the European executive are still
in the negotiation phase.24
Confronted with these findings,
the initiatives were strengthened: the “Partnerships”
involved in artificial intelligence and blockchain
technology started an observatory forum, and several
health projects were started with special attention for the
fundamental ethical and legal guidelines.
By way of example, in December 2018 it was announced
that the “Member States and the Commission shall work
together to publish data - the raw material of artificial
intelligence - in sectors such as healthcare for the
purposes of improving the diagnosis and treatment of
cancer”.25
Secure, cross-border access to electronic health records
is promoted.
As a result of the Commission Recommendation (EU)
2019/243 concerning “a European exchange format for
electronic patient records”, including the annexes26
, the
European Commission encourages the Member States
to guarantee secure access to the computerised health
records at the national level, and the principles for a
cross-border exchange of these records have been set
down in several ‘health information domains’ (patient re-
cords, electronic prescription, ...).
The Belgian health insurance funds endorse the
objectives enumerated in the Communication from the
European Commission - “Digital transformation of the
healthcare sector”27
- whose aim is to position the citizens
at the heart of the healthcare system, including:
• the exchange of electronic health records across
borders,
• the roll-out of an infrastructure of shared European data
for the prevention of diseases, for the personalisation of
medical treatments and to better anticipate epidemics,
• the development of digital solutions which allow citizens
to manage their health in a more active manner within the
context of integrated care systems.28
In other words, they have a positive attitude toward the
actions taken by the European Commission and the
inclusion of digital healthcare in the European funding,
in particular the perspectives which were indicated in the
Multiannual Financial Framework 2021 - 2027.
In addition, however, a number of strict guidelines and
conditions must be met:
• the patient-centric health technologies must be seen as
a ‘tool’ for improving the accessibility and the quality of
the health services, both curative as well as preventive,
and for the promotion of health.
Innovation, after all, should contribute to more efficient
health systems which are accessible and adaptable
and which are based on the fundamental values stated
above,
• The specificity of the healthcare and the welfare sector
must be recognised.
The commercial digital industry may not dominate,
• the collective choice of the digital as leverage for the
activation of fundamental health rights (the “right” to
information, access to care, ...) must be guaranteed,
• a level of competency and knowledge of the digital
tools must be guaranteed by means of information cam-
paigns and adapted training opportunities.
The digital divide to which citizens, care professionals
and other actors in the health insurance system are
subject must be limited,
• each citizen must have access to his or her own data
and there must be voluntary, clear-cut and permanent
consent.
These are absolute conditions for the use of these data
for research purposes and for the improvement of public
health.
EUROPE...
1 to consolidate good governance at the European
level for the purpose of supporting the national
governments while respecting everyone’s competencies

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in order to successfully meet the challenges of the digital
revolution and to manage the associated risks by
protecting vulnerable persons and by offering extra
opportunities to all actors;
2 to ensure, together with this good governance, a
process that takes into account the “ecosystem” of digital
healthcare by, among other things, including the health
insurance funds in the negotiations, the observatories,
the networks and the process of ‘common coordination’
between the European Commission and the Member
States;
3 to prioritise investments in health systems in the con-
text of current and future European programmes, such as
Horizon 2020 and the European Social Fund Plus+
(ESF+).
The continued funding of innovative models for access
to care, including those which were implemented by the
social economy, must be guaranteed.
Any reductions to budgets and in medical personnel as a
result of the switch to new technologies must be rejected;
4 to develop ethical, legal and social frameworks at
the European and national levels for the protection of
health data which may never, under any circumstances,
be used in a discriminatory fashion (for example, for risk
selection or for publicity purposes, ...).
“The application of the General Data Protection
Regulation29
has not put an end to the vigorous debate
on the ownership of personal data. On the contrary, in the
context of the application of this new Regulation, many
issues remain subject to interpretation.
Citizens expect all actors to handle their health data with
the utmost care. Therefore, it is especially important to
prevent the re-identification of anonymous data”;30
5 to support the validation and certification of digital
solutions in order to implement these solutions in the
health systems by, among other things, introducing a
European labelling system for health applications;
6 to safeguard the effective implementation of the
Recommendation of the European Commission regarding
a “European exchange format for electronic patient
records”31
and the interoperability of the whole of the
digital architecture within the European Union which
arises from this.
In the case of social security, this also includes the
continuation of the implementation of the “electronic
exchange of social security information system” - EESSI -
and the cost/benefit analysis with a view to the launch of
a “European Social Security Number” - ESSN.

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A European policy that encourages the Member States to
continue to strengthen public health by means of prevention,
environmental protection and health promotion5
CORE CHALLENGES
In a modern Welfare State, good health is a fundamental
right for everyone. However, health is predominantly
dependent on factors other than healthcare, such as
personal lifestyle. As individuals, citizens have no hold on
several decisive elements, such as housing, education,
the employment situation - or being unemployed - and
traffic.
The evidence of the influence of the environment in which
we live on our health is also mounting (including with
regard to carcinogenic and endocrine-disrupting com-
pounds in our food, air quality and climate change).
Although an ounce of prevention is always worth a pound
of cure, only 3% of the health budget goes to preven-
tion.32
In light of the enormous challenges facing the various EU
countries in the areas of health and healthcare, it is of the
utmost importance that the DG SANTE continues to exist
as a full-fledged Directorate-General within the European
Commission and that its authorities are not transferred or
divided up.
EUROPE...
1 to include the improvement of health literacy and the
reduction of health disparities in the development of a
social Europe.
Health literacy is an essential instrument for the
elimination of health disparities. The level of health
literacy is closely linked to the socio-economic status of
an individual. Several studies have shown a correlation
between a low level of health literacy and high health
costs (more hospital admissions and re-admissions,
inappropriate use of medication, less frequent use of
prevention services, ...).
As a result, targeted initiatives are needed for the weakest
target groups, such as the elderly, pregnant women in
difficult psycho-social situations and single mothers.
Health education is therefore an enormous societal
challenge and, as a result, is a collective responsibility
in the EU;
2 to call on the Member States to invest more in
prevention and to provide support, if necessary, for the
national and regional prevention campaigns. Europe
should convince the Member States to increase their
prevention budgets to 5% of the health budget;
3 with regard to “HiAP” (Health in All Policies), to ask
the European Commission and the governments of the
EU Member States to provide a systematic assessment
of the repercussions of all policy measures and interna-
tional agreements on the health and on the living environ-
ment, and to do this at all policy levels.
Ideally, in the interest of improving public health and re-
ducing the health divide, the most important European
policy decisions in domains outside the health sector
should systematically take into account the implications
of decisions taken in the area of health. HiAP also implies
another method for measuring health and health welfare,
such as the concept of “Positive health”;33
4 to work on improving the air quality and on fighting
climate change.
Europe must play a leading role in the implementation
of the Paris Agreement on climate change. Handling air
pollution by means of strict air quality standards which
are in line with the recommendations of the WHO is
another important priority.
For fine particulate matter, for example, the threshold
value currently employed, 25 micrograms per m3 per year,
is more than double the WHO limit of 10 micrograms.34
Healthy air quality is, after all, one of the most important
measures for the prevention of illness and therefore for
the reduction in the cost of healthcare;
5 to improve the vaccination rates by means of setting
up an EU-wide vaccination action plan for the purpose of
protecting the public health.
The awareness of the citizens about the value of vaccines
must be raised in an objective manner;35
6 to develop a better regulatory framework for healthy
food.
In this area, the health insurance funds ask that Europe
work on stricter regulation of the advertising for unhealthy
products (tobacco and high-fat and high-sugar foods
and beverages), primarily when directed at children and
young people.36
Other necessary measures include the effective labelling
of food products and beverages;
7 to increase its work on banning endocrine-disrupting
compounds (EDCs) in food, clothing, packaging and hy-
giene products.
It is for this reason that we request the implementation of
the various measures outlined in the AIM Declaration of
201737
, including:

15
• the development of a series of criteria for the identifica-
tion of EDCs based on sound scientific evidence (toxico-
logical as well as epidemiological studies),
• the application of the precautionary principle, not only
for substances with proven negative effects but also for
those suspected of having negative effects.
In 2018, the European Commission published a strategy:
“A comprehensive EU framework for endocrine-disrupt-
ing compounds”.38
Europe must continue to make this framework more con-
crete, including a strict schedule for its implementation.

16
A European cooperation directed at guaranteeing
the financial accessibility of medicines6
CORE CHALLENGES
Pharmaceutical products are the third most important
expenditure item within healthcare. They accounted,
on average, for more than a sixth (16 %) of the
total expenditures in 2015 in the OECD countries.39
Furthermore, access to affordable medicines is one of
the greatest challenges in Europe.
In 2016 in the Conclusions of the European Council, the
Minsters of Health acknowledged that “new medicines
can also present new challenges to patients and public
healthcare systems, in particular with regard to the as-
sessment of their added value, their impact related to
pricing and reimbursement, the financial sustainability
of healthcare systems, post-market monitoring and their
access and affordability for the patient”.40
The European Parliament published a resolution on ac-
cess to medicines, with an important focus on the signifi-
cant price increase of new medicines and on the guaran-
tee of access for all citizens to these medicines.41
In 2017, AIM (International Association of Mutual Benefit
Societies) also published a “position paper” asking
Europe to also search for solutions to these challenges
on the European level.42
Important challenges include:
• fair prices: according to the World Health Organisa-
tion, the pricing of medicines is a “a global concern”.43
The pharmaceutical industry focuses on the value of the
treatment and the possible added value for society, while
other aspects, such as the actual costs of research and
development and the medical needs, must also be con-
sidered;
• therapeutic added value: this seems obvious, yet
medicines still often demonstrate too little added value or
relevant results, due, in part, to commercialisation which
occurs too rapidly without convincing hard evidence or
without a “Health Technology Assessment” (HTA).44
Wanting to shorten the official approval procedure, such
as the “adaptive pathways” of the European Medicines
Agency (EMA), is also a point of particular interest and
must be approached with the necessary caution;45
• sustainable and inclusive healthcare systems: high
prices for medicines for a few patients creates tensions
relative to the ambition to guarantee access to medical
care for all citizens.
The question arises of whether the budget allocated
for expensive medicines which only slow down the
progression of a disease or which offer little improvement
to the disease is the best way to use limited social
security resources.
More debate over these questions is needed, with regard
to the value of solidarity.
EUROPE...
1 to work on increasing the cooperation between
regulatory authorities and HTA agencies and amongst
the Member States. Furthermore, the HTA agencies do
not always have the necessary information at their
disposal. Additional efforts are needed to strengthen the
efforts of the HTA in the EU. “Horizon scanning” may also
be valuable at the European or at a broader level;
2 to strive toward more cooperation amongst the EU
Member States:
• A start was made with the BeNeLuxA initiative.46
This
cooperation between the Benelux and Austria, to which
Ireland later also became a party, would have a stronger
negotiating position in the future if other Member States
also acceded. The Interparliamentary Assembly of the
Benelux voted on a recommendation relevant to this in
2018,47
• The creation of a European agency for rare diseases
and disorders which, among other things, would play
the role of “watchdog”. This could, for example, prevent
medicines for rare disorders from being bought up by the
pharmaceutical industry after their patents expire to then
be sold again at a much higher price.
This agency could then also manage a European fund
which is funded by the pharmaceutical industry and
which can be used to finance the research and/or manu-
facturing of medicines without patents;
3 to work on greater transparency. There is a need for
more analysis of the share of public funding going to bio-
medical research.
The report of the European Parliament regarding access
to medicines indicates that pharmaceutical research is
financed to a significant degree by public funds.48
Greater transparency is therefore also needed with re-
spect to the prices that national governments pay for
medicines as well as with respect to the agreed upon
discounts to these prices.
The “Euripid Database” is a relevant tool at times when

17
Member States make use of external systems for refer-
ence prices. The report from the European Parliament,
however, rightly states that Euripid provides insufficient
information about the actual cost. Additional efforts at the
European level are therefore also needed;
4 to work on an adapted framework for the protection
of intellectual property. This plays an important role in the
regulation of the market prices. The protection of intellec-
tual property may not however lead to the pharmaceuti-
cal industry only opting for medicines for which it can
demand a high price. The revision of the definition of
“added therapeutic value” by the European Commission
is therefore also very welcome;
5 to organise greater reflection on the willingness of
society to pay. Up until now, there has been little discus-
sion of the “willingness to pay” and the “ability to pay”.
Europe should initiate and facilitate the debate on these
issues with the Member States. How willing is society to
pay, and are there limits to our solidarity? All these ques-
tions to be addressed;
6 to reflect more on pricing. It is interesting to think
about setting a “fair price” at the European level. This is a
maximum price for a new medicine, taking into account a
number of parameters, such as the costs of research and
development, the production, the target population etc.;
7 to consider alternative financing models: the social
security systems in Europe and, in particular, those of the
compulsory health insurance are under financial
pressure. Europe must consider alternative financing
models for medicines. In 2016, the Belgian Healthcare
Knowledge Centre published the study entitled “Future
scenarios for drug developments and drug prices” with
alternative scenarios, ranging from public-private
partnerships to the development of medicines with public
funds.49

18
F o o t n o t e s
1. European Commission - European semester thematic
factsheet - Health systems, see
https://ec.europa.eu/info/sites/info/files/file_import/european-
semester_thematic-factsheet_health-systems_en_0.pdf.
2. In French only - Observatoire des inégalités - La pauvreté
en Europe, see https://www.inegalites.fr/La-pauvrete-en-Eu-
rope.
3. European Commission - Europe 2020 strategy, see
https://ec.europa.eu/info/business-economy-euro/economic-
and-fiscal-policy-coordination/eu-economic-governance-
monitoring-prevention-correction/european-semester/fra-
mework/europe-2020-strategy_en.
4. Eurostat - Smarter, greener, more inclusive? Indicators to
support the Europe 2020 strategy - 2016 - pp.137-162.
5. In French only - Collège Intermutualiste National - CIN
(National Intermutuality College - NIC), « Le TTIP, un cheval
de Troie pour des soins de santé de qualité accessibles à
tous ? » (“The ‘Transatlantic Trade and Investment Partnership
- TTIP’, a Trojan horse for high-quality and accessible
healthcare?”) - 2016.
6. Directive (EU) 2018/958 of the European Parliament and of
the Council of 28 June 2018 on a proportionality test before
adoption of new regulation of professions.
7. Proposal of Council Recommendation on access to
social protection by employed and self-employed persons,
COM(2018) 132 final.
8. OECD - Better Life Initiative: Measuring Well-Being and
Progress, see https://www.oecd.org/statistics/better-life-ini-
tiative.htm.
9. In Belgium, the health insurance funds are mainly active in
the area of compulsory health insurance, although they also
offer services and contributions by way of complementary
insurance based on solidarity.
10. EaSI is an “EU programme for employment and social
innovation”.
11. This allows, among other things, for the employment
generated by the sector to also be taken into account. See:
“Manual for drawing up the satellite accounts of social econ-
omy enterprises: cooperatives and health insurance funds”,
CIRIEC, 2006.
12. Promotion of cross-border trade puts pressure on regula-
tion of healthcare providers- On the tacit application of CETA
and the EU Single Market Strategy, Rita Baeten, OSE.
13. Comprehensive Economic and Trade Agreement (CETA).
• Provisionally in force since 20 September 2017,
• European Commission, press release:
“Trade Agreement between the EU and Canada enters into
force”, see
http://europa.eu/rapid/press-release_IP-17-3121_en.htm.
• In French only - Ratification par la Chambre belge des
Députés le 19 juillet 2018, « Projet de loi portant assentiment
à l’Accord économique et commercial global (AECG) entre
le Canada, d’une part, et l’Union européenne et ses Etats
membres, d’autre part, fait à Bruxelles le 30 octobre 2016
» (Ratification by Belgian Chamber of Representatives on
19 July 2018 - “Draft bill approving the broad economic and
trade agreement - CETA between Canada and the European
Union and its Member States”, done at Brussels on 30
October 2016), 54K3086/001,
http://www.dekamer.be/FLWB/PDF/54/3086/54K3086001.
pdf.
N.B. The Federal government may only sign the agreement if
the regional Parliaments assent to the treaty.
14. Transatlantic Trade and Investment Partnership (TTIP)
between the European Union and the United States.
15. The Belgian health insurance funds frequently communi-
cated this message in press releases during the follow-up of
the progress of CETA and TTIP negotiations -
In French only:
• Communiqué de presse du CIN du 22 février 2016 : «
Mutualités et services d’intérêt général : nécessité d’une
exclusion explicite dans le TTIP ! » (NIC press release, 22
February 2016: “Health insurance funds and services of
general interest: need for explicit exclusion in TTIP!”);
• Communiqué de presse des mutualités belges du 25 avril
2016 : « Semaines critiques pour les dossiers TTIP et CETA:
Les mutualités appellent les autorités fédérales et régionales
à défendre les intérêts des citoyens ! » (Belgian health
insurance funds press release, 25 April 2016: “Crucial weeks
for the TTIP and CETA dossiers: Health insurance funds
call on the Federal and regional governments to defend the
interests of the citizens!”);
• Communiqué de presse du 8 juillet 2016 : « La politique
commerciale européenne: antidémocratique et malsaine ?
Les mutualités exigent des garanties concernant le CETA et
le TTIP » (Press release, 8 July 2016: “European trade policy:
undemocratic and unhealthy? Health insurance funds ask for
guarantees about CETA and TTIP”);
• Communiqué de presse du 13 octobre 2016 : « Les
mutualités belges sont unanimes : ne signez pas l’accord
de libre-échange entre l’UE et le Canada » (Press release,
13 October 2016: “Belgian health insurance funds are
unanimous: Do not sign the free trade agreement between
the EU and Canada”).
16. European Parliament Resolution of 3 June 2018, Article
37, see
http://www.europarl.europa.eu/doceo/document/TA-8-2018-
0280_EN.html.
17. In French only - « Le « Transatlantic Trade and Investment
Partnership (TTIP) », un cheval de Troie pour des soins de
santé accessibles et de qualité ? »,
Position des mutualités belges - Actualisée en février 2016
(The “Transatlantic Trade and Investment Partnership (TTIP)”,
a Trojan horse for high-quality and accessible healthcare?
Standpoint of the Belgian health insurance funds) - Updated
in February 2016), p.6.
18. “Sustainability Impact Assessment” (SIA).
19. Statement by the Commission concerning the Belgian
system of compulsory insurance and the health insurance
fundsaccordingtoBelgianlaw-StatementbytheCommission
concerning the public services, see https://eur-lex.europa.
eu/legal-content/EN/TXT/?uri=CELEX:22017X0114(02).

19
20. Kingdom of Belgium request for advice, 6 September
2017, from the European Court of Justice concerning the
legality of investor-State dispute settlement CETA (1/17).
21. Court of Justice of the European Union (29 January
2019), Press release no. 6/19: Conclusion of the Advocate
General in the advice procedure intimated by the Kingdom
of Belgium 1/17.
22. Court of Justice of the European Union (6 March 2018),
Press communiqué no. 26/18: Judgement in case C-284/16.
23. “A Digital Single Market for Europe: the Commission
establishes 16 initiatives to achieve this”, see http://europa.
eu/rapid/press-release_IP-15-4919_en.htm.
24. “Digital Single Market: Commission calls for swift adoption
of key proposals and maps out challenges ahead”, see http://
europa.eu/rapid/press-release_IP-17-1232_en.htm.
25. “Member States and Commission to work together to
boost artificial intelligence “made in Europe”, see https://
ec.europa.eu/commission/news/artificial-intelligence-2018-
dec-07_en.
26. Official Journal of the European Union, 11 February 2019.
27. Communication from the European Commission, “Digital
transformation of the healthcare sector”, April 2018, see http://
europa.eu/rapid/press-release_MEMO-18-3367_ en.htm.
28. From patient to actor.
29. Regulation (EU) 2016/679 of the European Parliament
and of the Council of 27 April 2016 on the protection of
natural persons with regard to the processing of personal
data and on the free movement of such data, and repealing
Directive 95/46/EC.
30. Memorandum from the International Association of
Mutual Benefit Societies (AIM) in the context of the European
elections 2019.
31. Recommendation of the European Commission regarding
a European exchange format for electronic patient records,
(C(2019)800) of 6 February 2019.
32. State of Health in the EU - Companion Report, 2017, p.
18.
33. In Dutch only -
http://www.allesisgezondheid.nl/content/positieve-
gezondheid.
34. AIM, Brussels declaration on Air Pollution and Health,
2018.
35. AIM, Recommendations on Vaccine Hesitancy, 2018.
36. AIM, Memorandum for the 2019 EU Elections, 2018, p.
6-8.
37. AIM, Declaration on endocrine-disrupting compounds,
2017.
38. Communication from the European Commission,
“Towards a comprehensive European Union framework on
endocrine disruptors”, COM(2018) 734 final, see
https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CE
LEX:52018DC0734from=en.
39. Health at a Glance 2017.
40. Conclusions of the European Council on strengthening
the balance in the pharmaceutical systems in the EU and its
Member States, 2016, see
https://www.consilium.europa.eu/en/press/press-
releases/2016/06/17/epsco-conclusions-balance-
pharmaceutical-system/.
41. European Parliament Resolution of 2 March 2017 on EU
options for improving access to medicines (2016/2057(INI)),
http://www.europarl.europa.eu/doceo/document/TA-8-2017-
0061_EN.html?redirect.
42. AIM, Position paper on fair medicines prices, 2017.
43. WHO Fair Pricing Forum, 2017, see
http://www.who.int/medicines/access/fair_pricing/fpf_report/
en/.
44. Health Technology Assessment (HTA).
45. See
http://www.ema.europa.eu/ema/index.jsp?curl=pages/
regulation/general/general_content_000601.jsp.
46. See http://www.beneluxa.org/collaboration.
47. In French only - Benelux, Recommandation, 2018, see
https://www.beneluxparl.eu/wp-content/uploads/2018/07/
BNL895-2.pdf.
48. European Parliament Resolution of 2 March 2017 on EU
options for improving access to medicines (2016/2057(INI)).
49. Future scenarios about drug development and drug
pricing, KCE Report 271.

20
P r e s e n t a t i o n o f N I C
The National Intermutuality College (NIC) is an association of health insurance funds (mutualities) comprised of
representatives from the 5 national health insurance fund federations, the Auxiliary Fund for Sickness and Invalidity
Insurance and the Fund for Medical Care from HR Rail. As a whole, the NIC represents all Belgians who are covered by
social insurance, which amounts to more than 10 million people.
The mission of the NIC:
• to organise consultation between the various health insurance funds concerning all issues which are of interest to
compulsory and supplemental health and disability insurance and to the health insurance fund sector in general;
• to take a position regarding these issues, taking into account the interests of all persons covered by social insurance;
• to advance joint actions or partnerships in the area of the management of insurance institutions.
CONTACT DETAILS
• Alliance Nationale des Mutualités Chrétiennes (National Federation of Christian Health Insurance Funds)
Agnès CHAPELLE
Chaussée de Haecht, 579 - B-1031 Brussels
Telephone: 02/246.26.22
E-mail: agnes.chapelle@mc.be
• Union Nationale des Mutualités Neutres (National Federation of Neutral Health Insurance Funds)
Anne VERHEYDEN
Chaussée de Charleroi, 145 - B-1060 Brussels
Telephone: 02/535.73.96
E-mail: Anne.VERHEYDEN@union-neutre.be
• Union Nationale des Mutualités Socialistes - Solidaris (National Federation of Socialist Health Insurance Funds)
Alain COHEUR
Rue Saint-Jean, 32-38 - B-1000 Brussels
Telephone: 02/515.05.87
E-mail: Alain.Coheur@solidaris.be
• Union Nationale des Mutualités Libérales (National Federation of Liberal Health Insurance Funds)
Ronny VAN HEE
Rue de Livourne, 25 - B-1050 Brussels
Telephone: 02/542.86.25
E-mail: ronny.vanhee@lm.be
• Union Nationale des Mutualités Libres (National Federation of Independent Health Insurance Funds)
Christian HOREMANS
Route de Lennik, 788A - B-1070 Brussels
Telephone: 02/778.94.18
E-mail: christian.horemans@mloz.be
• Caisse Auxiliaire d’Assurance Maladie-Invalidité (Auxiliary Fund for Sickness and Invalidity Insurance)
Alain VANCLOOSTER
Rue du Trône, 30 - B-1000 Brussels
Telephone: 02/504.66.43
E-mail: AVanclooster@caami-hziv.fgov.be
• Caisse des Soins de Santé de HR Rail (Fund for Medical Care from HR Rail)
Christine FRAIPONT
Rue de France, 85 (Section 71) - B-1060 Brussels
Telephone: 02/525.25.26
E-mail: christine.fraipont@hr-rail.be

21
Responsible publisher: The Belgian National Intermutuality College (NIC).

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