Position Paper on the Health Strand of ESF+
Introduction
At the end of May 2018, the European Commission published a set of proposals for the regulations of the next budget of the European Union (EU) for the 2021-2027 period. This is also known as the Multiannual Financial Framework (MFF). Compared to the current Financial Framework, which was agreed against the backdrop of the worst economic and financial crisis for generations, the focus for the 2021-2027 MFF has shifted to better align available financing with political priorities, emphasizing security and safety as top priorities for the Union of 27.
The proposals are currently being discussed by the European Parliament and Council of the European Union. They include many areas relevant to health, including mental health, but the main instrument for Health-related funding will be the European Social Fund Plus (ESF+) which will integrate the current Health Programme.
The proposed €413 million for the Health Strand in the ESF+ represents an 8% cut compared to the current funding period and misses out on one crucial element: adequately including mental health among its priorities. Overall, citizens’ well-being involves and depends on mental health and promoting positive mental health is key to social inclusion, participation, and cohesive societies. Mental Health Europe (MHE) calls on the EU to include mental health and well-being in the Health Strand of the ESF+ as mental health is an indispensable factor for delivering on the objectives of the ESF+.
ESF+ and Health Strand
The new ESF+ programme has a total budget of 101 billion euro for the seven years of its duration, and merges the following programmes: the European Social Fund (ESF) and the Youth Employment Initiative (YEI), the Fund for the European Aid to the Most Deprived (FEAD), the Employment and Social Innovation (EaSI) programme, and the programme for the Union’s action in the field of Health (Health Programme).
The new ESF+ aims to put into practice the European Pillar of Social Rights (Social Pillar) and is intended to be the ‘main financial instrument to strengthen Europe’s social dimension’. It therefore provides a path for the promotion of equal opportunities, non-discrimination, and social inclusion by committing to leave no one behind.
The proposed regulation divides the ESF+ into three strands:
- The ESF+ strand under shared management, covering for the current ESF and basic material assistance to the most deprived people. This strand has an allocation of 100 billion euro.
- The strand covering actions promoting employment and social innovation under direct and indirect management with an allocation of 761 million euro.
- The health strand incorporating the former Health Programme under direct and indirect management with an allocation of 413 million euro.
There is thus no longer a specific Health Programme, which is something that stakeholders have been concerned about since seeing the new proposal for EU funds 2021-2027. However, the merging of funds could also be seen as an interesting opportunity to ensure more integrated approaches within the ESF+ (which can help tackle some of the social determinants of mental ill health). The ESF+ will hopefully operate alongside other funds, such as Erasmus+, ERDF, InvestEU, or Horizon Europe, aiming to overcome the current fragmentation of funding instruments in the social policy arena.
Position of Mental Health Europe
MHE welcomes the fact that the new ESF+ will support the principles of the Social Pillar. These principles are structured around three categories: equal opportunities and access to the labour market, fair working conditions, and social protection and inclusion.
MHE also acknowledges the contribution of the ESF+ to the implementation of the United Nations Convention on the Rights of Persons with Disabilities (UN CRPD) and the need to promote the transition from institutional to family and community-based care, in addition to not supporting ‘any action that contributes to segregation or to social exclusion’.
Finally, MHE welcomes the reference to the United Nations Sustainable Development Goals (SDGs) and the need to apply sustainable development as an essential guiding principle for all Union policies, including through its financing instruments. MHE is pleased to see SDG 3, on the need to ‘Ensure healthy lives and promote well-being for all at all ages’ mentioned in the ESF+, including the reaffirmation from the Commission’s commitment to help Member States reaching this goal.
However, and despite the reference to SDG 3, mental health is completely absent from the main objectives of the Health Strand, which is a financial and political mistake. The economic consequences of mental health problems – including those due to the loss of productivity – are estimated to an average of 3-4% of gross national product in the European Union. Additionally, mental health problems constitute the greatest “burden” of disease after cardiovascular diseases in Europe and account for almost 40% of years lived with disability. One in four Europeans will experience mental health problems in their lifetime. Furthermore, the service provisions for persons with mental health problems are often inadequate, impacting other areas of society such as the economic, educational, justice and health care systems.
In its proposal, the European Commission mentions that the ESF+ should contribute to disease prevention and health promotion by addressing ‘health risk factors’, such as tobacco use and passive smoking, harmful use of alcohol, consumption of illicit drugs and reduction of drugs-related health damage, unhealthy dietary habits and physical inactivity. However, it fails to recognize that stress and anxiety are important key risk factors as well, omnipresent in today’s society, and with a disastrous impact on both the physical and mental health of EU citizens. In terms of economic loss, the cost of depression alone in the European Economic Area has been estimated at € 136,3 billion, of which around one third falls on the health care system. An emphasis on prevention measures regarding mental health is therefore crucial.
Article 3 of the Lisbon Treaty states that the Union’s aim is to promote peace, its values and the well-being of its people. Moreover, the definition of health in the Charter for the World Health Organization is that health is “not merely the absence of disease or infirmity but a complete state of physical, social and mental well-being.” The Treaty of Lisbon with the inclusion of article 3 has created policy priorities that need to be reflected in the MFF 2021-2027. Promoting well-being is an objective of the EU, and the WHO definition highlights the close link between well-being and health. The two are intrinsically entwined and the obligation for the European Union to promote well-being, including mental health, is clear and enforceable.
The Joint Action for Mental Health and Well-being (2013-2016) followed by the EU Compass for Action on Mental Health and Well-being (2015-2018), coordinated by the European Commission, recognised the need to contribute to the promotion of mental health and well-being, the prevention of mental health problems and the improvement of care and social inclusion of people with mental health problems in Europe, and that mainstreaming mental health in EU policies majorly benefits society as a whole. It is therefore regrettable that the European Commission omitted to streamline the conclusions of its own initiative in the 2021-2027 Multiannual Financial Framework.
Finally, the 413 million euro allocated for the Health Strand represents an 8% cut compared to the 449 million euro for the previous 7-year period. In addition, the use of funds for mental health under the current 2014-2020 Health programmes were minimal (2,8 % under 2008-2013 budget and, following information from the European Commission Consumers, Health, Agriculture and Food Executive Agency (CHAFEA), possibly even less under the current programme).
MHE calls on the EU to significantly increase the overall amount dedicated to health and to include mental health and well-being in the Health Strand of the ESF+ as mental health is an indispensable factor for delivering on the objectives of the ESF+. Mental health problems are wide-ranging, long-lasting and a source of discrimination that goes to the core of the European values. It is essential that the European Parliament and the Council mainstream mental health and well-being and put an emphasis on human capital if they really want to successfully get the results set by the proposal.
MHE proposals for amendments to the draft regulation
Amendment 1
Recital 18
EUROPEAN COMMISSION PROPOSAL
The ESF+ should support Member States’ efforts to tackle poverty with a view to breaking the cycle of disadvantage across generations and promote social inclusion by ensuring equal opportunities for all, tackling discrimination and addressing health inequalities. This implies mobilising a range of policies targeting the most disadvantaged people regardless of their age, including children, marginalised communities such as the Roma, and the working poor. […]
MHE PROPOSAL
The ESF+ should support Member States’ efforts to tackle poverty with a view to breaking the cycle of disadvantage across generations and promote social inclusion by ensuring equal opportunities for all, tackling discrimination and addressing health inequalities. This implies mobilising a range of policies targeting the most disadvantaged people regardless of their age, including children, marginalised communities such as the Roma, persons with disabilities, homeless persons and the working poor. […]
Justification: Persons with disabilities and homeless persons are, arguably, among the most socially excluded groups in Europe. Despite the obligation under the UNCRPD to mainstream disability rights related issues across EU and national policies, it is still crucial that targeted policies are in place that identify the root-causes of of disadvantage and the policy measures needed to address these effectively, taking into consideration the specific situation of persons with disabilities and other groups at risk
Amendment 2
Recital 22
EUROPEAN COMMISSION PROPOSAL
To ensure that the social dimension of Europe as set out in the European Pillar of Social Rights is duly put forward and that a minimum amount of resources is targeting those most in need Member States should allocate at least 25% of their national ESF+ resources of the ESF+ strand under shared management to fostering social inclusion.
MHE PROPOSAL
To ensure that the social dimension of Europe as set out in the European Pillar of Social Rights is duly put forward and that a minimum amount of resources is targeting those most in need Member States should allocate at least 30% of their national ESF+ resources of the ESF+ strand under shared management to fostering social inclusion.
Justification: The scope of the ESF+ will be broadened to include, for example, the socio-economic integration of third country nationals in the next programming period. It crucial that the earmarked 25% is increased to 30% to ensure that ESF+ will be allocated to foster the social inclusion of all disadvantaged groups. Additionally, as the current minimum benchmark for the European Social Fund (20% of the total resources) has been exceeded by most Member States in the current funding period, it is important to ensure that an adequate amount of resources are allocated to social inclusion. For more information on the Social inclusion 20% earmarking of the European Social Fund (ESF), see the policy paper on social inclusion indicators for ESF investments.
Amendment 3
Recital 28
EUROPEAN COMMISSION PROPOSAL
the ESF+ should also promote the transition from residential/institutional care to family and community-based care, in particular for those who face multiple discrimination. The ESF+ should not support any action that contributes to segregation or to social exclusion.
MHE PROPOSAL
the ESF+ should also promote the transition from institutional care to family and community-based care, in particular for those who face multiple discrimination. The ESF+ should not support any action that contributes to segregation or to social exclusion.
Justification: Some forms of community-based care may include residential services, which is why it is suggested that ‘residential’ is removed from the text. For more information, please see the Common European Guidelines on the Transition from Institutional to Community-based Care. Please also see Amendment 9 (Article 6 para 2).
Amendment 4
Recital 36 bis (new)
MHE PROPOSAL
Article 3 of the Lisbon Treaty states that the Union’s aim is to promote peace, its values and the well-being of its people. Moreover, the definition of health in the Charter for the World Health Organization is that health is “not merely the absence of disease or infirmity but a complete state of physical, social and mental well-being.”
In order to improve the health of the population in the Union and reduce health inequalities, it is essential not to focus only on physical health. According to the WHO, mental health problems account for almost 40 % of years lived with disability. Mental health problems are also wide-ranging, long- lasting and a source of discrimination, and contribute significantly to inequality in health.
Moreover, the economic consequences of mental health problems, mainly due to a loss of productivity, are estimated to be 3-4% of the gross national product in the EU. Social support, a healthy community and environment, having adequate employment and access to mental health services can prevent a person from developing mental health problems and increase productivity.
Justification: The Treaty of Lisbon with the inclusion of article 3 has created policy priorities that need to be reflected in the MFF. Promoting well-being is an objective of the EU, and the WHO definition highlights the close link between well-being and health. The two are intrinsically entwined and the obligation of the EU/EC to promote well-being, including mental health, is clear and enforceable.
The Council of the EU has recognized that there is significant evidence that a high-level of mental health of the population is an important factor for the economy and that mental disorders lead to economic loss.
Amendment 5
Recital 38
EUROPEAN COMMISSION PROPOSAL
The Health strand of the ESF+ should contribute to disease prevention throughout the lifetime of the Union’s citizens and to health promotion by addressing health risk factors such as tobacco use and passive smoking, harmful use of alcohol, consumption of illicit drugs and reduction of drugs-related health damage, unhealthy dietary habits and physical inactivity and foster supportive environments for healthy lifestyles in order to complement Member States action in line with the relevant strategies.
MHE PROPOSAL
The Health strand of the ESF+ should contribute to disease prevention throughout the lifetime of the Union’s citizens and to health promotion by addressing health risk factors such as tobacco use and passive smoking, harmful use of alcohol, consumption of illicit drugs and reduction of drugs-related health damage, depression and anxiety disorders, unhealthy dietary habits and physical inactivity and foster supportive environments for healthy lifestyles in order to complement Member States action in line with the relevant strategies.
Amendment 6
Article 4 – paragraph 1 – point 1
EUROPEAN COMMISSION PROPOSAL
Specific objectives
1. The ESF+ shall support the following specific objectives in the policy areas of employment, education, social inclusion and health and thereby also contributing to the policy objective for “A more social Europe – Implementing the European Pillar of Social Rights” set out in Article of the :
i. improving access to employment of all jobseekers, in particular youth and longterm unemployed, and of inactive people, promoting self-employment and the social economy;
ii. modernising labour market institutions and services to assess and anticipate skills needs and ensure timely and tailor-made assistance and support to labour market matching, transitions and mobility;
iii. promoting women’s labour market participation, a better work/life balance including access to childcare, a healthy and well–adapted working environment addressing health risks, adaptation of workers, enterprises and entrepreneurs to change, and active and healthy ageing;
iv. improving the quality, effectiveness and labour market relevance of education and training systems, to support acquisition of key competences including digital skills;
v. promoting equal access to and completion of, quality and inclusive education and training, in particular for disadvantaged groups, from early childhood education and care through general and vocational education and training, and to tertiary level, as well as adult education and learning, including facilitating learning mobility for all;
vi. promoting lifelong learning, notably flexible upskilling and reskilling opportunities for all taking into account digital skills, better anticipating change and new skills requirements based on labour market needs, facilitating career transitions and promoting professional mobility;
vii. fostering active inclusion with a view to promoting equal opportunities and active participation, and improving employability;
(…)
MHE PROPOSAL
Specific objectives
1. The ESF+ shall support the following specific objectives in the policy areas of employment, education, social inclusion, and health and thereby also contributing to the policy objective for “A more social Europe – Implementing the European Pillar of Social Rights” set out in Article of the :
i. improving access to employment of all jobseekers, in particular youth, women, persons with disabilities and longterm unemployed, and of inactive people, promoting self-employment and the social economy;
ii. modernising labour market institutions and services to assess and anticipate skills needs and ensure timely and tailor-made assistance and support to labour market matching, transitions and mobility;
iii. promoting women’s labour market participation, a better work/life balance including equal access to inclusive and non-segregated quality early childhood education and care and to other community-based care services for persons with disabilities and older people, a healthy and well–adapted working environment addressing health risks, adaptation of workers, enterprises and entrepreneurs to change, and active and healthy ageing;
iv. improving the quality, effectiveness and inclusiveness of education and training systems, to support acquisition of key competences including digital skills;
v. promoting equal access to and completion of, quality non-segregated and inclusive education and training, in particular for disadvantaged groups, from early childhood education and care through general and vocational education and training, and to tertiary level, as well as adult education and learning, including facilitating learning mobility for all;
vi. promoting lifelong learning, notably flexible upskilling and reskilling opportunities for all taking into account digital skills, better anticipating change and new skills requirements based on labour market needs, facilitating career transitions and promoting professional mobility;
vii. fostering active inclusion with a view to promoting equal opportunities, non-discrimination and active participation, and improving employability;
viii. (…)
Justification: Family and informal carers, providing care and support to persons with disabilities and older people are mostly women. Due to the lack of services (from childcare to care for older people and persons with disabilities) a large share of women are forced out of the employment or have to reduce their labour market participation. The ESF+, in order to achieve the specific objectives outlined, particularly those referring to women’s employment and work-life balance, should take into account all care services covering the life-cycle.
Amendment 7
Article 4 – paragraph 3
EUROPEAN COMMISSION PROPOSAL
3. Under the Health strand, the ESF+ shall support health promotion and disease prevention, contribute to effectiveness, accessibility and resilience of health systems, make healthcare safer, reduce health inequalities, protect citizens from cross-border health threats, and support EU health legislation.
MHE PROPOSAL
Under the Health strand, the ESF+ shall support health promotion and disease prevention, including the promotion of positive mental health and prevention of mental health problems, contribute to effectiveness, accessibility and resilience of health systems, make healthcare safer, reduce health inequalities, protect citizens from cross-border health threats, and support EU health legislation.
Justification: Mental health is a key risk factor and cross-cutting to other disease and health areas. A high number of mental health problems are preventable, yet countries spend only 3% of their total healthcare budgets on prevention.
Amendment 8
Article 6 – paragraph 1
EUROPEAN COMMISSION PROPOSAL
Equality between men and women and equal opportunities, and non-discrimination
1. All programmes implemented under the ESF+ strand under shared management, as well as the operations supported by the Employment and Social Innovation and Health strands shall ensure equality between men and women throughout their preparation, implementation, monitoring and evaluation. They shall also promote equal opportunities for all, without discrimination based on sex, racial or ethnic origin, religion or belief, disability, age or sexual orientation throughout their preparation, implementation, monitoring and evaluation.
MHE PROPOSAL
Equality between men and women and equal opportunities, and non-discrimination
1. All programmes implemented under the ESF+ strand under shared management, as well as the operations supported by the Employment and Social Innovation and Health strands shall ensure equality between men and women throughout their preparation, implementation, monitoring and evaluation. They shall also aim to promote equal opportunities for all, without discrimination based on sex, racial or ethnic origin, religion or belief, disability or health condition, age or sexual orientation throughout their preparation, implementation, monitoring and evaluation. They shall also aim to improve accessibility for persons with disabilities, as set out in Article 9 of the CRPD, including access to the labour market.
Justification: Although the provisions of the ESF + Regulation Proposal meet the requirements for non-discrimination based on disability, equal opportunities for persons with disabilities and other vulnerable groups and de-institutionalization, all references of the previous Regulation to the obligation to implement accessibility to persons with disabilities to all funded actions have been removed from it. Taking into account that accessibility concerns not only infrastructure but also services (that are mainly funded by the ESF+), procedures and goods, there is a clear need to include in the ESF+ Regulation an explicit reference to accessibility, which is the “key”, and one of the essential prerequisites to ensure the equal opportunities for all, which is one of the main goals of the ESF+
Amendment 9
Article 6 – paragraph 2
EUROPEAN COMMISSION PROPOSAL
Equality between men and women and equal opportunities, and non-discrimination
2. The Member States and the Commission shall also support specific targeted actions to promote the principles referred to in paragraph 1 within any of the objectives of the ESF+, including the transition from residential/institutional care to family and community-based care.
MHE PROPOSAL
Equality between men and women and equal opportunities, and non-discrimination
2. The Member States and the Commission shall also support specific targeted actions to promote the principles referred to in paragraph 1 within any of the objectives of the ESF+, including the transition from institutional care to family and community-based care.
Justification: Some form of community-based care may include residential services, wherefore it is suggested that ‘residential’ is removed from the text. For more information, please see the Common European Guidelines on the Transition from Institutional to Community-based Care.
Amendment 10
Article 7 – paragraph 3
EUROPEAN COMMISSION PROPOSAL
Consistency and thematic concentration
3. Member States shall allocate at least 25% of their ESF+ resources under shared management to the specific objectives for the social inclusion policy area set out in points (vii) to (xi) of Article 4(1), including the promotion of the socio-economic integration of third country nationals.
MHE PROPOSAL
Consistency and thematic concentration
Member States shall allocate at least 30% of their ESF+ resources under shared management to the specific objectives for the social inclusion policy area set out in points (vii) to (x) of Article 4(1), including the promotion of the socio-economic integration of third country nationals.
Justification: To ensure that the 2% allocation to FEAD (below) comes in addition to and not out of the min. allocation of ESF+ to social inclusion policy areas vii – x) We want to make it clear that point x) is managed under ESF strand and this point is confusing.
Amendment 11
Article 7 – paragraph 4
EUROPEAN COMMISSION PROPOSAL
Consistency and thematic concentration
4. Member States shall allocate at least 2% of their ESF+ resources under shared management to the specific objective of addressing material deprivation set out in point (xi) of Article 4(1).
In duly justified cases, the resources allocated to the specific objective set out in point (x) of Article 4(1) and targeting the most deprived may be taken into account for verifying compliance with the minimum allocation of at least 2% set out in the first subparagraph of this paragraph.
MHE PROPOSAL
Consistency and thematic concentration
4. In addition to the minimum allocation mentioned in point 3 above, Member States shall allocate at least 2% of their ESF+ resources under shared management to the specific objective of addressing material deprivation set out in point (xi) of Article 4(1).
In duly justified cases, the resources allocated to the specific objective set out in point (x) of Article 4(1) and targeting the most deprived may be taken into account for verifying compliance with the minimum allocation of at least 2% set out in the first subparagraph of this paragraph.
Justification: To ensure that the 2% allocation to FEAD (below) comes in addition to and not out of the min. allocation of ESF+ to social inclusion policy areas vii – x) We want to make it clear that point x) is managed under ESF strand and this point is confusing.
Amendment 12
Article 8 – paragraph 1
EUROPEAN COMMISSION PROPOSAL
Partnership
1. Each Member State shall ensure adequate participation of social partners and civil society organisations in the delivery of employment, education and social inclusion policies supported by the ESF+ strand under shared management.
MHE PROPOSAL
Partnership
1. Each Member State shall ensure the meaningful and inclusive participation of social partners, civil society organisations and service users in the management, programming, delivery, monitoring and evaluation of activities and policies supported by the ESF+ strand under shared management, including as relevant to employment, education, social inclusion and anti-discrimination policies and according to Article 6 of the proposed CPR Regulation and the “Commission Delegated Regulation (EU) No 240/2014.”
Justification:
· The proposed text is weaker than the provisions on involving partners in the 2014-2020 ESF Regulation (Article 6). Partnership must be ensured throughout programming, implementation, monitoring and evaluation of the funds, not just in the delivery of policies supported by those funds.
· To ensure the meaningful and inclusive participation of social partners and civil society instead of the adequate participation and to ensure implementation of the revised European Code of Conduct on Partnership (ECCP). For more information, see the review of the European Code of Conduct on Partnership developed by the Thematic Network of European Social Fund on Partnership.
Amendment 13
Article 8 – paragraph 2
EUROPEAN COMMISSION PROPOSAL
Partnership
2. Member States shall allocate an appropriate amount of ESF+ resources under shared management in each programme for the capacity building of social partners and civil society organisations.
MHE PROPOSAL
Partnership
Member States shall allocate the minimum amount of 2% of ESF+ resources under shared management in each programme for the capacity building of social partners and civil society organisations at European and national level.
Justification: Capacity building of social partners and civil society organisations is a key element to ensure the successful management of funds. For this reason, a minimum of 2% of ESF+ resources should be allocated to this purpose.
Amendment 14
Article 26 – paragraph 2 b
EUROPEAN COMMISSION PROPOSAL
2. The Health Strand has the following operational objectives:
(…)
b) Empower health systems
(i) Invest in health promotion and disease prevention(…)
d)Support integrated work (e.g. ERNs, HTA and implementation of best practices for the promotion of health, prevention and management of diseases)
MHE PROPOSAL
The Health Strand has the following operational objectives:
(…)
b) Empower health systems
(i) Invest in health promotion and disease prevention, including the prevention of mental health problems
(…)
d)Support integrated work (e.g. ERNs, HTA and implementation of best practices for the promotion of health, prevention and management of diseases, including mental health promotion and prevention)
Justification: Mental health is a key risk factor and cross-cutting to other disease and health areas. A high number of mental health problems are preventable, yet countries spend only 3% of their total healthcare budgets on prevention.
Amendment 15
Article 40 – paragraph 2
EUROPEAN COMMISSION PROPOSAL
Committee under Article 163 TFEU
2. Each Member State shall appoint one government representative, one representative of the workers’ organisations, one representative of the employers’ organisations and one alternate for each member for a maximum period of seven years.
(…)
MHE PROPOSAL
Committee under Article 163 TFEU
2. Each Member State shall appoint one government representative, one representative of the workers’ organisations, one representative of the employers’ organisations, one representative from civil society, one representative from a national human rights body and one alternate for each member for a maximum period of seven years. (…)
Justification: Inclusion of civil society organisations, including those representing rights holders and national human rights bodies is crucial to ensure good governance of the funds and they should be adequately represented in the ESF+ Committee.
Amendment 16
Annex I
EUROPEAN COMMISSION PROPOSAL
(…)
(1b) Other common output indicators
If data for these indicators is not collected from data registers, values on these indicators can be determined based on informed estimates by the beneficiary.
– participants with disabilities**,
– third country nationals*,
– participants with a foreign background*,
– minorities (including marginalised communities such as the Roma)**,
– homeless or affected by housing exclusion*,
– participants from rural areas*.
MHE PROPOSAL
(…)
(1b) Other common output indicators
If data for these indicators is not collected from data registers, values on these indicators can be determined based on informed estimates by the beneficiary.
– participants with disabilities**,
– third country nationals*,
– participants with a foreign background*,
– minorities (including marginalised communities such as the Roma)**,
– homeless or affected by housing exclusion*,
– participants from rural areas*,
– participants from geographical areas with high levels of poverty and social exclusion
– participants (children, persons with disabilities, persons experiencing mental health problems, homeless people) transitioning from institutional to family and community based care
– participants below 18 years of age*
Justification: In line with specific objective x in Article 4.1 on promoting social integration of people at risk of poverty or social exclusion, including the most deprived and children.
In line with Article 6 paragraph 2 of proposed regulations for ESF + Children should be also counted as beneficiaries.
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