This topic aims at supporting activities that are enabling or contributing to one or several expected impacts of destination 4 “Ensuring access to innovative, sustainable and high-quality health care”. To that end, proposals under this topic should aim for delivering results that are directed, tailored towards and contributing to several of the following expected outcomes:

• Decision- and policymakers, service providers, and health and care workers have better availability to and make use of knowledge on barriers to access to health and care services^[1] experienced by people in vulnerable situations and at risk of stigma or discrimination (from now on referred to as people in vulnerable situations)^[2].
• Decision- and policymakers, providers and health and care workers have access to innovative solutions to promote and improve access to health and care services for people in vulnerable situations.
• Decision- and policymakers and providers have access to reliable quantitative data on health inequalities in access to health and care services for people in vulnerable situations.
• People in vulnerable situations are better equipped in terms of health and digital literacy, knowledge about their rights etc. when it comes to access to health and care services.
• People in vulnerable situations are involved in the design and implementation of research and innovation activities concerning access to health and care services.

Equal and needs-based access to health and care services are important values of the EU, as well as central principles within the Member States (for example 2006 Council Conclusions on Common values and principles in European Union Health Systems, European Pillar of social rights). At the same time, plenty of evidence indicates that there is unmet need for health and care services. Although financial barriers are an important part of the explanation^[3], it is also evident that even in countries where co-payment is low or even zero, access to health and care services differs between groups. Certain groups are more at risk of not accessing all the health and care services they need, depending among other factors, on their socio-economic and legal status, age, sex and gender identity, (dis)ability, ethnicity and geographical location.

For example, the life expectancy for the Roma people – the largest ethnic minority in the EU – is on average ten years shorter than the general population. This is because, due to poor socio-economic conditions and ethnic segregation, many Roma people live in enclaves where equal opportunities to services including infrastructure are lacking. Due to these inequalities that are also rooted in antigypsysim^[4], Roma people are facing much greater difficulties accessing and receiving standard health and care services including prevention compared to other citizens^[5].

There are significant health inequalities between the LGBTIQ community and the population as a whole. One part of the explanation is reluctance to seek health and care services because they have experienced or fear hostile reactions. Trans- and intersex people still struggle to access quality and affordable medication and care, both related to general health services and specific health care relating to transition, such as a lack of relevant medication or surgical procedures^[6].

Compared to men, older women have a higher poverty risk also due to lower pay and lower pensions. They face a higher risk to live longer in poorer health, so their overall need for health and especially care services is therefore higher. People living in difficult socio-economic situations, such as homeless people or people at the risk of poverty may experience similar issues. For migrants and refugees, uncertain legal status, fear of public authorities, or language difficulties may cause additional barriers to seeking adequate health and care services.

Whilst factors outside the health and care sector also have an impact on people’s access to health and care services, health and care systems can influence and facilitate access through accessibility, costs, referrals and attitudes.

Another aspect concerns access to data regarding certain groups. Whereas data on access to health and care when it comes to factors related to socio-economic characteristics, geographical barriers, sex, and age is more accessible, data on people in vulnerable situations (often due to the problem of sensitivity of data) is often less accessible, contributing to making the situation of these groups less visible.

Activities under this call should focus on groups that are in vulnerable situations from a social, financial or health perspective, or at risk of discrimination, such as migrants, Roma people, trans and intersex people, specific age and gender groups (that intersects with other aspects of vulnerability, such as elderly women), indigenous people, homeless people, people in poverty or at risk of poverty, people with disabilities or patients with complex conditions. Where relevant, activities should use intersectional approaches to consider, inter alia, socioeconomic factors, geography, citizenship, age, sex and gender identity, and ethnicity.

Next to the above-mentioned, research and innovation activities under this topic should address several of the following:

• Different types of barriers - different barriers to study could be financial, geographic, social, marginalisation and discrimination. When relevant, health and digital literacy aspects should be analysed. The selection of factors should be context specific as groups suffering from access barriers vary a lot across EU countries and at subnational level. The principle of needs-based health and care should be taken into account.
• Access to what? – for example: what part of the health and care system (from prevention, primary care and long-term care to tertiary care, any specific services, e.g. mental care) do different groups have access to? Is integrated care provided for these groups taking into account their particular needs? How much health and care services do different groups access?
• Solutions - What measures are needed to counter inequalities in health and care access and make sure that vulnerable groups access health and care services and that access is based on needs (measures to educate, support and empower vulnerable groups can be included here)? What are the costs, at different levels, to develop these solutions? Piloting of measures could be included. Community-based and/or co-created initiatives and peer-support approaches: what works and how can these be supported, sustained and/or integrated in the wider service landscape.
• Better data – improving access and quality of data will contribute to identify people in vulnerable situations’ health needs and implement targeted measures corresponding to the challenges that each group experiences. The data could for example explore effectiveness of provided care (metrics helping to assess if provided care addresses the root causes of inequalities) or new valid methodologies to identify the unmet health related needs of people in vulnerable situations. Quantitative and qualitative data on inequalities in prevention, prevalence and treatment of different morbidities.
• Cost analyses - The cost of inequalities in access to health and care services: Quantitatively and/or qualitatively measure the negative impact on not taking measures for helping people in vulnerable situations have access to health and care services including prevention.

Proposals are expected to involve the people/groups studied in the design and implementation of the research and innovation activities and where relevant service providers and other stakeholders.

This topic requires the effective contribution of social sciences and humanities (SSH) disciplines and the involvement of SSH experts, institutions as well as the inclusion of relevant SSH expertise, in order to produce meaningful and significant effects enhancing the societal impact of the related research activities.

All projects funded under this topic are strongly encouraged to participate in networking and joint activities, as appropriate. Therefore, proposals should include a budget for the attendance to regular joint meetings and may consider covering the costs of any other potential joint activities without the prerequisite to detail concrete joint activities at this stage. The details of these joint activities will be defined during the grant agreement preparation phase.

When relevant, funded actions should build on the work done by the European Joint Action on Health Equity Europe (JAHEE) and the upcoming activities under the EU4Health Programme (Direct grants to international organisations (WHO): supporting Member States in improving access to healthcare and effectiveness of health coverage, taking into account vulnerabilities of specific groups and targeted intervention and access to mental health for people in vulnerable situations).

Also, when relevant, projects should build on, and are encouraged to consider how their proposals can contribute to, the Commission’s LGBTIQ Equality Strategy 2020-2025, the EU Strategy for the rights of persons living with disabilities, EU strategy on the rights of the child the Child Guarantee, the Gender Equality Strategy, the EU Roma Strategic Framework and the EU Strategy for the Rights of Persons with Disabilities 2021-2030^[7].

Projects are encouraged to coordinate their activities with the planned European Partnership on Transforming Health and Care Systems, the Cancer Mission, the Cancer Inequalities Registry and the EU Non-Communicable Diseases Initiative.

Projects may explore the Health Systems Performance Assessment (HSPA) Report on more effective ways of measuring access to healthcare, published in 2021. The report provides a collection of tools used on the ground to better understand needs of people in vulnerable situations and adapt the health coverage to ensure more effective care.

2021 Country Profiles published in the framework of the State of Health in the EU can be used as a source of basic comparable data on health inequalities.

Applicants invited to the second stage and envisaging to include clinical studies should provide details of their clinical studies in the dedicated annex using the template provided in the submission system. See definition of clinical studies in the introduction to this work programme part.

[1] “Health and care systems” implies a broader notion than “health systems” or “healthcare systems” notably encompassing all parts of health systems and health related parts of social care systems.

[2] Groups of people and/or patients vulnerable from a social, financial, or health perspective, or at risk of discrimination, such as migrants, Roma people, trans and intersex people, specific age and gender groups (that intersects with other aspects of vulnerability, such as elderly women), indigenous people, homeless people, people in poverty or at risk of poverty, people with disabilities or patients with complex conditions.

[3] See for example OECD Health at a glance 2021.

[4] Antigypsyism (a form of racism against Roma people) is a historically rooted structural phenomenon that appears at institutional, social and interpersonal levels.

[5] The EU Roma strategic framework for equality, inclusion and participation sets up the ambitious goal to lessen the life expectancy gap and ensure that by 2030 Roma women and men live 5 years longer. https://ec.europa.eu/info/sites/default/files/eu_roma_strategic_framework_for_equality_inclusion_and_participation_for_2020_-_2030_0.pdf

[6] stateofart_report_en.pdf (europa.eu) The Commission’s Health4LGBTI project concluded that trans and intersex-focused research is needed that addresses health inequalities and healthcare.

[7] (under the European Pillar of Social Rights) Delivering on the European Pillar of Social Rights - Employment, Social Affairs & Inclusion - European Commission (europa.eu) Union of equality: Strategy for the rights of persons with disabilities 2021-2030 - Employment, Social Affairs & Inclusion - European Commission (europa.eu) https://ec.europa.eu/social/BlobServlet?docId=23598&langId=en