Council of Europe: Recommendation Rec(2001)12 on the adaptation of health care services to the demand for health care and health care services of people in marginal situations  




Recommendation Rec(2001)12
of the Committee of Ministers to member states
on the adaptation of health care services to the demand 
for health care and health care services of people in marginal situations

(Adopted by the Committee of Ministers
on 10 October 2001
at the 768th  meeting of the Ministers' Deputies)



The Committee of Ministers, under the terms of Article 15.b of the Statute of the Council of Europe, 

Considering that the aim of the Council of Europe is to achieve a greater unity between its members and that this aim may be pursued, inter alia, in particular by the adoption of common rules in the health field; 

Noting that the number of persons living in marginal situations is constantly increasing in the member states; 

Considering that problems specific to persons living in marginal situations have serious consequences on their health and that this becomes a public health problem of growing importance and a serious and costly burden for the individual, the family, the community and the state; 

Recognising that due to the growth of inequalities in health in the European countries, any relevant and effective health policy should not only consider the health problems of the persons living in marginal situations but also those of the persons living in insecure conditions, health promotion being one of the key components of such a policy; 

Noting that it is now largely documented that psychological stress experienced by persons living in such insecure conditions has an effect on their physical and mental health; 

Recognising the need for policies designed to prevent health problems of persons living in marginal situations, while taking into account the need for protection of privacy of all persons concerned, and the respect of confidentiality; 

Recognising the right of persons living in insecure situations to live in conditions favourable to their proper development free from physical and psychological overload, social isolation, psychosomatic symptoms related to stress and other forms of handicap;

Recalling Article 11 of the European Social Charter on the right to health protection and Article 3 of the Convention on Human Rights and Biomedicine on the equitable access to health care; 

Referring to the 1994 Ljubljana Charter on Health reforms and the Copenhagen Declaration on Reducing the Social Inequalities in Health of  September 2000; 

Having regard to the recommendations of the Committee of Ministers to Member States, No. R (2000) 5 on the development of structures for citizen and patient participation in the decision-making process affecting health care, Recommendation No. R (97) 4 on securing and promoting the health of single parent families and Recommendation No. R (98) 7 concerning the ethical and organisational aspects of health care in prison; 

Aware that measures aimed at reducing the incidence of health problems of persons living in insecure conditions at primary level depend largely on situations outside the normal sphere of health and social services activities; 

Considering that the aim and duty of the state and society is to influence broad social and economic prerequisites to health, which finally determine the poorer health of persons living in marginal situations; 

Considering that it is also the responsibility of the state to ensure that policies affecting health are developed in a coherent way to increase the potential for health gain and to avoid adverse effects on health; 

Aware of the Council of Europe Project on Human Dignity and Social Exclusion and the proposals for action adopted at the 1998 Helsinki Conference; 

Aware of the WHO initiative on Partnership in Health and Poverty and aware of the communication of the European Commission on “Building an Inclusive Europe” and the programme of Community action to encourage co-operation between member states of the European Union to combat social exclusion; 

Aware of the Charter of Fundamental Rights of the European Union, 

Recommends the governments of member states to: 

i. develop a coherent and comprehensive policy framework that: 

- secures and promotes the health of persons living in insecure conditions;

- protects human dignity and prevents social exclusion and discrimination;

- ensures supportive environments for the social integration of persons living in marginal situations or in insecure conditions;

ii. strengthen and implement their legislation in order to ensure human rights protection, social solidarity and equity; 

iii. improve multisectoral co-operation to increase the ability of their social systems to participate in preventing health problems for persons living in insecure conditions. This approach should clearly specify the role, responsibilities and co-ordination of the various agencies and social institutions involved in order to prevent these persons from falling into marginal situations; 

iv. develop comprehensive, effective and efficient health systems for a timely and adequate response to health needs in order to ensure equity and equal access to health care services, taking into account health needs and available resources, and to be able to identify, assess and treat health problems of persons living in marginal situations; 

v. take to this end, whenever feasible, the measures presented in the appendix to this recommendation. 

Appendix to Recommendation Rec(2001)12 

I.            Principles 

Governments are encouraged to develop a social/health policy in the framework of the principles adopted by the World Health Organisation at the 1986 Ottawa Conference in order to prevent insecure conditions and therefore limit the risks of falling into marginal situations. 

When adapting the health care services to the needs of persons living in marginal situations or in insecure conditions, governments of member states should consider a certain number of principles: 

1.         The policy should be based on values propounded by the Council of Europe: human rights and patient's rights, human dignity, social cohesion, democracy, equity, solidarity, equal gender opportunity, participation, freedom of choice – balanced by the obligation to help strengthen one's own health. 

To be efficient, any health policy, especially if oriented towards the needs of persons living in marginal situations, should be based on an integrated approach and begin with social protection measures. A minimal regular income should be given to these persons.

2.         One of the best policies (apart from raising the standard of living) for improving their health and to prevent them from falling into marginal situations is to ensure equal access to social and health systems for everybody whatever his/her economic and legal status. It should take into account the fact that new groups and individuals may at any time find themselves in a marginal situation. 

3.         Social and economic prevention of the risk of falling into marginal situations should become a priority for governments and societies. 

4.         Long-term policies to improve social and health conditions for persons living in marginal situations or in insecure conditions cannot be implemented without their participation and agreement. They should, therefore, be considered as responsible persons, able to assume their own responsibilities and as much as possible involved in the decision process. 

5.         To ensure non-stigmatisation, member states, working in a long-term perspective, should endeavour to meet the needs of persons living in marginal situations within the existing health system. They should ensure an equal access for everybody to the national health  resources, which may require positive discrimination in the form of well targeted outreach measures, limited in time and scope and fully integrated into the normal health services. 

6.         There is no specific disease of the poor. Persons living in marginal situations suffer from the same diseases as the rest of the population but in a disproportionate way. 

7.         The social and health policies need to be grounded on aims to prevent impoverishment and ill-health, where other than merely health and social sectors matter. All policies need to be assessed and evaluated in terms of their impacts on social cohesion, social exclusion and health. This implies intersectoral action and accountability of all policies, including economic and trade policies, in terms of their implications for social well-being, health, equity and marginalisation of people. 

8.         The health systems have to be based on equity guaranteeing access to care according to need and financing of care regardless of the ability to pay. 

9.            Prevention, health promotion and health care measures for persons living in marginal situations or in insecure conditions should be an integral and integrated dimension of national and local social/health policy. 

10.            Children are particularly vulnerable in deprived conditions,  governments should pay particular attention to them in ensuring that they will benefit from specific social/health preventive policies.

11.            Governments should identify critical gaps and barriers in access to health care services: legal, social, economic, cultural, administrative and/or physical barriers. Initiatives and programmes should be implemented in order to reduce these obstacles, which often increase inequalities. 

12.            Appropriate policies should be developed to adapt the health system to the needs of persons living in marginal situations or in insecure conditions. Further elaboration and implementation of these policies should take into account the decisive role of civil society and NGOs in tackling social inequalities. 

II.            Development of an integrated and coherent social/ health policy 

Developing an integrated social/health policy in the framework of the Ottawa Charter includes measures which are obviously beyond the capacity of the health sector alone. (“The fundamental conditions and resources for health are peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity. Health promotion action means: build a healthy public policy, create supportive environments, strengthen community action, develop personal skills, reorient health services”.) These measures should depend on national and regional conditions and may include, among others: 

- compulsory education, including health education from early childhood;

- an environment which provides suitable jobs and professional activities;

- decent housing; and

- other measures which ensure a satisfactory social protection. 

Those issues are currently under study by the Social Cohesion Committee in order to develop a comprehensive recommendation on access to social goods and services. 

In health care, the priority aim should be to ensure that health services are available and financially accessible to everyone. 

The health policy should be formulated and implemented in order to improve the primary health care system so as to better respond to the needs of various social and cultural groups. It should also provide services of appropriate quality to everybody, including health promotion ones. 

A special effort should be made to develop a specific preventive health policy for the most vulnerable persons including unemployed persons and their families, young single parent households, disabled, refugees, migrants and prisoners. Special attention should be paid to mental health problems, which often affect people in conditions of socio-economic vulnerability, poverty and exclusion. 

Programmes for health promotion should reach people in marginal situations and should be planned in co-operation with them and be acceptable to them.

While all age groups should be considered for targeted action, special emphasis should be placed on the very early period in life, between conception and school age. 

All children should be offered a complete programme of immunisation and equal access to paediatric health services and all women should receive antenatal, birth and postnatal care in appropriate health facilities. 

Screening and rehabilitation should be offered to anyone regardless of his/her economic, social and cultural status. Physical access to all facilities for the disabled should be secured. 

Each person should have an equal access to curative services including secondary and tertiary hospital care, where most people in marginal situations usually end up due to emergencies. 

III.   Development of specific measures to guarantee a better equity 

When deciding on and implementing specific measures to improve access to health services to persons living in marginal situations or in insecure conditions, governments should pay particular attention to the risk of stigmatisation of these people. In addition, and because the objective is that everyone should have an equal access to health services, positive discrimination measures may be proposed for a limited period of time and be integrated into the normal health system. 

1.            Accessibility to preventive, promotional and curative health services and programmes 

- Regional/local systems for identifying people living in marginal situations should be developed. 

- Emphasis should be put on the primary health care network for providing affordable health services to persons living in marginal situations. 

- Health promotion and preventive services should be organised at local level with particular emphasis on outreach activities toward people living in marginal situations. 

- Provision and delivery of emergency health services should not depend on advance payment but be guaranteed irrespective of the ability to pay for it. 

- Innovative organisational approaches should be encouraged, aimed at increasing flexibility of health care provision (adjusted opening hours, telephone booking system, etc.). 

- Specific measures should be taken for financing basic health care services to persons living in illegal situations.

- Persons living in marginal situations or in insecure conditions are often poorly informed. Communication should be improved for informing them about existing programmes and services and how to reach them. 

- Health professionals should act as advocates for persons living in marginal situations who generally have a low access to health services. This role could include lobbying authorities, politicians, and international organisations for improving access to health services for these persons. 

- Health care of people living in illegal situations should be provided, with  respect for their anonymity. 

2.         Specific population groups  

Health services should be offered to everyone but special attention should be paid to persons living in insecure conditions, avoiding stigmatisation. 

- Women living in insecure conditions have a higher rate of premature birth and perinatal morbidity, so they should benefit from special social/health surveillance during pregnancy and the perinatal period. 

- Children with social/family risk factors should receive special attention from social/health services. 

- Families with economic and/or social difficulties should receive support in educating their children, with an emphasis on measures directly benefiting the recipient children (educational vouchers, food stamps, etc.). 

- Specific social/health services should be implemented at local level for young people having family/social risks factors with special emphasis on information on family planning, STD, HIV/Aids, traffic accidents, suicide, drug abuse, alcohol, etc. Their general physical and psychosocial well-being should be regularly assessed. 

- Social/health services should pay particular attention to the needs of disabled persons whatever the origin of the handicap. 

- Special attention should be paid to the needs of persons living in marginal situations with chronic diseases as well as with metabolic or neurological pathologies. 

- Occupational health should be developed in particularly exposed working places.

- People living in prison and their children living in collective institutions should benefit from health services of equally good quality as outside prison. 

- For underprivileged groups of population including refugees, recent migrants, etc., special attention should be paid to the specific cultural dimension of health. Some key social/health services should include professionals coming from such populations. 

- Health care for elderly persons living in insecure conditions should be developed within the community by specially trained social/health workers. 

- Specialised services should be available for alcohol and drug abusers. 

IV.            Improvement of knowledge on the health of persons living in insecure conditions 

Governments should pay particular attention to the improvement of knowledge on the health of persons living in insecure conditions and their specific health needs. There is a need for the routine collection of standardised and comparable data based on common definitions. Health and social indicators should be linked together. A monitoring and surveillance system should be developed, resulting in regular, if possible annual, reports at country and European levels. The following measures are recommended:

1.            Information system 

- An observatory of social/health development should be set up at national/regional level to collect, process and disseminate reliable information on social/health status of persons living in insecure conditions. 

- Data collected on a routine basis should include social and economic indicators as well as indicators of accessibility to health services. 

- In order to avoid discrimination and to ensure individual protection, anonymity of data should be fully respected. 

- Periodic and regular surveys should be conducted to better assess the use of services for specific problems. 

- Regional/local health conferences should be organised to collect and disseminate information. 

- Information should be made available to both social/health professionals and to the public. 

- Existing networks in the community should be identified in order to create supportive environments. 

2.            Research 

Research programmes should address the following issues: 

- Cost/utility, cost/benefit and cost/effectiveness evaluation of different health policies and programmes for improving access to health services for persons living in insecure conditions. 

- Selection of relevant indicators for monitoring and evaluation of policies, programmes and activities. 

- Health status and needs of people at risk and those living in marginal situations. 

- Qualitative surveys on health perception and obstacles to access to health care. 

- Longitudinal analysis of individual histories of how people get into marginal situations and of the strategies used to leave them.

- Health status and needs of young adults should receive particular attention. 

- Differences in values, social support networks, positive and negative experiences with health care services. 

- Social distance between various groups and health care professionals. 

- The role and impact of NGOs interventions. 

- Ways in which health facilities are modified to meet the needs of groups in marginal situations. 

V.        Change of behaviour of the administration and of health/ social professionals at the central and local level 

The following action areas are recommended to help the administration and health/social professionals at the national and local level to adapt their response to the health needs of persons living in insecure conditions:

1.         Policies 

- A policy paper on health protection and health promotion for persons living in marginal situations should be published. The formulation of such a policy should be based on a large consensus among all potential partners and when feasible with the community concerned. 

- Policy implementation should be based on a multisectoral approach and its impact systematically monitored and evaluated. 

- Re-assessment of the interface between health authorities and social services is encouraged . 

- NGOs experience and capacity should be used to implement policies at local level. 

- Instruments should be experimented with and developed with a view to involving people living in insecure conditions in the decision making process to design and organise health services. 

2.            Professional practices 

- Regular meetings should be organised at local level between administration staff, social/health professionals and NGOs to organise responses to health needs of groups/persons living in marginal situations. 

- New social professions should be created for young adults  in marginal situations to prepare them for working in  their own community. 

3.         Training 

- Disciplines like public health, epidemiology (in particular of non-communicable diseases), health promotion, social sciences, and health economy  should be reinforced in the undergraduate curriculum of health professionals and social workers and, particularly, future physicians. 

- National postgraduate programmes should be implemented with an emphasis on specific approaches to vulnerable social groups and individuals, preventive actions, outreach strategies and non-discriminatory identification methods of the health needs at community level. 

- Training programmes should be organised for both health and education personnel for an early detection of health problems at school. 

- Special programmes should be prepared for social/health/education staff for drawing their attention to the specific needs of the poor, unemployed people, refugees, etc. 

- Professionals working at grassroots level and NGOs should be encouraged to play an important role in such training programmes.




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