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Part 1. “Fundamentals of a European Health Union” argues that the recent strengthening of European health policy, commonly referred to as a European Health Union (EHU), is an outcome of decades-long socioeconomic developments in Europe. The Covid-19 pandemic was a trigger but not a cause of the EHU, thus pan-European health policy should concentrate on all avenues promising European value added, not just preparedness for future crises.
- Europe has evolved from an industrial society to an economy where services predominate. The economic transformation was accompanied by a demographic transition, and the development of institutional protection. After WWII, social rights stimulated the expansion of health systems. As part of this transformation, the production of health services and goods combined became the largest sector in European economies.
- Today, almost 10% of value added is created by the production of health goods and services within the EU27. National and European market and non-market regulations, as well as international contracts, safeguard these value chains of production.
- Digitalisation of the single market is creating a European health data space, which, together with the further of artificial intelligence, generate new opportunities and challenges far beyond national capacities to govern them.
- The first practical steps towards European integration were partially inspired by the socially oriented Ventotene Manifesto. However, instead of prioritising social development, the European project was mainly aimed at the development of an internal market for goods.
- A solid post-war economic recovery demonstrated that national and pan-European policies that concentrated on agriculture and manufacturing in the 1950s were successful. This evidence contributed to the continuity of these policies in the following decades.
- The internal market of goods remains at the core of today’s European integration, but socio-economic transformation and shifting of national priorities in favour of health and other social sectors are contributing to the growth of the relevant importance of these sectors in pan-European politics. This is translated in the Treaty of Amsterdam (1997) and the 20 principles of the European Pillar of Social Rights (2017).
- Covid-19 undermined the notion that the European Union has very little to do with health and contributed to the European Commission’s pledge in 2020 to build “a stronger European Health Union”.
- Most breakthrough initiatives of the European project have been launched by Treaty changes and an implementation process. The strengthening of health policy, by contrast, started with policy documents. The greater role of the EU in health policy over time shows that member states and European institutions have an interest in moving towards a European Health Union. However, proponents of a more sustainable development of an EHU argue that without its legal framing in European Treaties, such a health union would be at risk in the long term. The unsuccessful project of the early 1950s regarding the creation of a “European Health Community” (Communauté européenne de la santé – CES) is a reminder of the risks that the EHU faces.
- The relationship between policymaking and public opinion on health is not straightforward in the European Union context. Public opinion evolved from being irrelevant to EU policies to an increasingly crucial factor in the EU integration process (from permissive consensus to constraining dissensus).
- According to Eurobarometer data, Europeans hold a positive perception of the EU, trust the EU more than their national institutions, and want their voice to be heard more within the EU. Moreover, health has consistently ranked among the primary concerns of EU citizens, and Europeans call on the European Union to prioritise public health and to have a common EU health policy.
- During the citizen-led Conference on the Future of Europe 2022, the panel recognised the necessity of revising Article 4 of the Treaty on the Functioning of the European Union to encompass health and healthcare as shared competencies between the member states and the EU.
- The evolution of the health role of the EU has been marked by a gradual recognition of the importance of health as a fundamental right and the need for coordinated action at the EU level to address health challenges. But the responsively established health institutions and the scattered capacities and competencies for policymaking on health systems and public health at the EU level are regarded as following the “failing forward” trend of European integration.
- Covid-19 presented the context and gathered the political will behind an enhanced EU role in health. It is in the interest of Europeans to seize this context to anchor a comprehensive EU health policy beyond the pandemic and address relevant health challenges in both communicable and non-communicable diseases.
- The EHU has many co-benefits and synergies with major policy frameworks both in Europe and around the world:
– The EHU can contribute to European sovereignty, economic prosperity, and promote peace in the continent. – The EHU would promote sustainability through its many interlinkages with the European Green Deal and the SDGs.
– The EHU can enhance the digitalisation objective of the EU.
- European health policy is not about substituting or overtaking the role of member states in health-related areas, nor about consolidating more power in Brussels. It is about equipping the EU with the necessary competence to support and complement the actions of every capital. It is about delivering the promise of ensuring a high level of human health. The EHU is about pursuing the EU’s commitment to put people first and to build a more resilient Union for the future.
Part 2. “Main avenues for pan-European cooperation for health” studies fields of pro-health actions that, according to the authors, are the most promising for the health and wellbeing of Europeans.
- Preparedness, or a lack thereof, was a major issue for EU countries during the Covid-19 pandemic. A lack of investment by national governments and patchy implementation of the 2013 decision on serious cross-border threats, meant that many countries’ health systems were overwhelmed by the disease. However, the pandemic resulted in greater coordination among EU institutions and the emergence of plans for a “stronger European Health Union”.
- The current reforms do not adequately address the problem of preparedness. Three paradigm shifts (joint procurement, scientific agency capacity, and recognition of interdependence) would offer an opportunity to integrate preparedness as a shared competence.
- Innovation in life sciences is the result of the interplay between academia, public institutions and private companies. The EU has a proven record of promoting progress in health technologies through a centralised process to approve new medicines, the orphan medicines regulation, the development of a Covid certificate, and fostering the development of Covid-19 vaccines by creating an EU buying club to invest broadly in a portfolio covering the four identified technology platforms.
- Universal health coverage (UHC) is one of the targets of the 2030 Agenda for Sustainable Development of the United Nations. It is affirmed by the EU as a principle of the European Pillar of Social Rights: “Everyone has the right to timely access to affordable, preventive and curative healthcare of good quality”.
- Improving people’s access to healthcare services has been a longstanding objective in European countries. It reflects the values and principles underpinning health systems in Europe – universality, access to good quality care, equity and solidarity. The level of social health protection in Europe is high in comparison with other parts of the world, even if the institutional arrangements to organise this financial protection and access to health services varies among countries within the EU.
- Available data already show that there is room for progress towards universal health coverage (UHC), and that there is wide variation and inequity between and within member states. To better understand the root causes of health gaps and to design policies to tackle them, additional tools are required, and the work of the Expert Group on Health System Performance Assessment provides a foundation to build upon.
- Claims that European high-income countries provide universal access to high quality healthcare mask huge gaps in coverage and marginalisation of particularly vulnerable groups in our societies, including people living with rare diseases (RD).
- In recognition of the extraordinary added value of cooperation between MS in the fi eld of rare diseases, the European Commission (EC) has taken decisive steps. Although the organisation of health systems is an autonomous field and the competence of every MS, in many cases, the EC has succeeded in achieving a constructive dialogue between countries.
- European-wide registries show large variations in service provision and gaps in adherence to existing care recommendations. Pan-European cooperation, in the form of European Reference Networks (ERNs), is starting to play a major role in increasing accessibility of highly specialised services and the spread of knowledge and expertise to countries with a less developed RD fi eld.
- The current initiatives of the EHU are mainly focused on preparedness and response to serious cross border health threats by agencies that coordinate, monitor, produce and procure medical countermeasures. It is questionable, however, whether these initiatives will address the structural inequalities in healthcare capacities across the Union, including inequalities in the sizes of the healthcare workforce.
- The number of doctors per 1000 population within the EU ranges between 2.4 and 5.4, and the number of practising nurses per 1000 population range from 4.4 to 15.4. This disbalance of healthcare workers within the EU is barely addressed at the EU level.
- The view that it is only free movement considerations which harm the centre of Europe that need a pan-European solution must be challenged. The need to address the unequal distribution of healthcare workforce capacities in Europe as part of an EHU is required if the EU is serious about access to healthcare for all. The Commission’s recognition of the problems in the EU Care Strategy and the explicit mention of the territorial gap in the proposed recommendation on affordable long term care can be seen as a prudential first step.
- Although EU competence in the fi eld of healthcare is, for now, limited, there are no reasons to exclude health workforce matters from the EHU. This includes suggestions on EU managed monitoring, regulation of minimum wages and working conditions, and fiscal solidarity addressing the equal distribution of healthcare workers.
- The EU Global Health Strategy (EU-GHS) is a major historic step in relation to the “external” health activities of the European Union. A strong global dimension is central to EU strategic health autonomy including, for example, supply chains, workforce and digital transformation.
- The EU-GHS gives very high priority to a “Team Europe” approach – this means joint action and pooling of resources, capacities and experience to reach common goals, and carries within it significant potential.
- The next few years will be decisive for the future global health order. In its implementation this EU Global Health Strategy must contribute to moving away from the undemocratic governance of global health where a few hegemonic players can still set the agenda.
Part 3. “Policies of transition towards a healthier and more socially inclusive Europe” describes pro-health political actions undertaken by European progressives and future scenarios of European health policy development.
- The EU paid with human lives and huge economic and social losses for the fact that, especially in the first phase of the pandemic, the development of a common European health policy progressed slowly. The S&D position paper of 12 May 2020 defi ned the possible components of an EHU concept.3
- There is a risk that the looming, overlapping energy, food, and financial crises associated with the protracted war in Ukraine are relegating health issues to the background. On the other hand, it is an encouraging sign that in January 2023 the European Parliament established its public health subcommittee (SANT).
- It is desirable that European progressives focus on the benefits of a unifying health policy. The growing nationalist and populist forces will claim that only nation states are able to provide quality healthcare. However, this is not true, as the challenges of healthcare (such as cost explosion, pandemic preparedness, rare diseases or health workforce shortage) can only be effectively responded to together.
- The European Commission’s competencies on health are currently restricted. While Article 168 of the Treaty on the Functioning of the EU provides a basis for the EU’s policies, it also leaves health policy as the responsibility of the member states.
- In its Communication on the results of the Conference on the Future of Europe, the European Commission stated: “just like constitutional texts of the Member States, the EU treaties are living instruments” and “new reforms and policies should not be mutually exclusive to discussions on Treaty change”.
- Covid-19 elevated health to the top of European politics, but proponents of a healthier Europe should not sleep on their laurels. Advocacy is needed to keep health high on the political agenda. Political debates focused on the scope, breadth, and criteria of maturity of the EHU and on bold proposals for a healthier Europe prior to elections to the European Parliament are of critical importance for transforming the EU from a mainly economic project, to one where social factors are treated equally to the internal market.
- The EU needs to speak explicitly about health as an aim of the EU. The health and wellbeing union should appear in the preamble of the TEU in parallel to the internal market and an economic and monetary union, inserting the words “Health” and “Social”. The amendment of the TEU by an explicit pledge to promote universal health coverage by establishing a European Health Union would greatly contribute to a healthier Europe, and to the maturity of the European project.
- The demands of Europeans regarding public health issues have been clear and unequivocal. Now, the responsibility lies in the hands of elected politicians to respond to the aspirations of citizens and take the necessary steps towards building a more comprehensive and cohesive European Health Union.
To build a strong and inclusive European Health Union, that has the means to deliver not only in boosting treatment but also prevention, it is recommended to:
- Think long term: No quick fixes but long-term vision to build sustainable partnerships, and innovative and caring institutions.
- A common protection: To protect from pandemics and public health emergencies, the European Union should be given more competencies.
- Connect policy initiatives: The EU Health Union will encompass many policies (care, employment, competition and internal market policy, ect.), and strategic consultations should be put in place with a wide range of stakeholders (national and local governments, insurance, patients’ organisations, medical and public health associations, etc.) to improve the proposed initiatives and regulations and ensure implementation.
- Support vulnerable groups: More attention needs to be paid to improving the health and care of underprivileged groups (ethnic minorities, the homeless, migrants and refugees), especially in relation to access to care.
- Define and evaluate healthcare minimum standards: Implement a timeline to reduce regional disparities when it comes to access, affordability and quality. Progress should be measured with thorough indicators and made public.
- Strengthen the EU’s role in primary prevention: Invest in people’s mental health early on and assess how to implement the WHO best buys to tackle commercial determinants of health, including uniform and strict regulations to curb smoking and drug use.
- Provide financial resources and invest in a skilled workforce: Launch several direct tenders to support the implementation of the programs of the European Health Union. As disease do not stop at borders, neither should policy-making. To deliver on the promise of well-being for its citizens and to upgrade the welfare system that makes our continent unique and resilient, the EU needs to take the next step and play a stronger role in securing health for all: an effective health integration is a prerequisite for a solid and social Union.